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      Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby

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          While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking.


          We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality.


          Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed.


          Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

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          Most cited references 33

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          Too far to walk: maternal mortality in context.

           S Thaddeus,  D Maine (1994)
          The Prevention of Maternal Mortality Program is a collaborative effort of Columbia University's Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care. The literature clearly indicates that while distance and cost are major obstacles in the decision to seek care, the relationships are not simple. There is evidence that people often consider the quality of care more important than cost. These three factors--distance, cost and quality--alone do not give a full understanding of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors, such as severity. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.
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            Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer.

             Gwyneth Lewis (2002)
            Avoiding maternal deaths is possible, even in resource-poor countries, but requires the right kind of information on which to base programmes. Knowing the level of maternal mortality is not enough; we need to understand the underlying factors that led to the deaths. Each maternal death or case of life-threatening complication has a story to tell and can provide indications on practical ways of addressing its causes and determinants. Maternal death or morbidity reviews provide evidence of where the main problems in overcoming maternal mortality and morbidity may lie, produce an analysis of what can be done in practical terms and highlight the key areas requiring recommendations for health sector and community action as well as guidelines for improving clinical outcomes. The information gained from such enquiries must be used as a prerequisite for action.
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              Impacts of e-health on the outcomes of care in low-and middle-income countries: where do we go from here?

              E-health encompasses a diverse set of informatics tools that have been designed to improve public health and health care. Little information is available on the impacts of e-health programmes, particularly in low-and middle-income countries. We therefore conducted a scoping review of the published and non-published literature to identify data on the effects of e-health on health outcomes and costs. The emphasis was on the identification of unanswered questions for future research, particularly on topics relevant to low-and middle-income countries. Although e-health tools supporting clinical practice have growing penetration globally, there is more evidence of benefits for tools that support clinical decisions and laboratory information systems than for those that support picture archiving and communication systems. Community information systems for disease surveillance have been implemented successfully in several low-and middle-income countries. Although information on outcomes is generally lacking, a large project in Brazil has documented notable impacts on health-system efficiency. Meta-analyses and rigorous trials have documented the benefits of text messaging for improving outcomes such as patients' self-care. Automated telephone monitoring and self-care support calls have been shown to improve some outcomes of chronic disease management, such as glycaemia and blood pressure control, in low-and middle-income countries. Although large programmes for e-health implementation and research are being conducted in many low-and middle-income countries, more information on the impacts of e-health on outcomes and costs in these settings is still needed.

                Author and article information

                BMC Pregnancy Childbirth
                BMC Pregnancy Childbirth
                BMC Pregnancy and Childbirth
                BioMed Central
                11 September 2015
                : 15
                : Suppl 2
                : S9
                [1 ]Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
                [2 ]Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
                [3 ]Institute for Women's Health, University College London, 74 Huntley Street, London WC1E 6AU, United Kingdom
                [4 ]Translating Research Into Practice Centre, Mater Research Institute, University of Queensland, Aubigny Place, South Brisbane, Qld 4101, Australia
                [5 ]Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Homepostcode CB20, PO Box 30 001, 9700 RB Groningen, The Netherlands
                [6 ]Evidence for Action, 19B Jimmy Carter Street, Asokoro, Abuja, Nigeria
                [7 ]Save the Children, Plot 68/70 Kira Road, Kampala, Uganda
                [8 ]JHPIEGO, 1776 Massachusetts Ave., NW, Washington, DC 20036, USA
                [9 ]School of Women's and Infants' Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia
                [10 ]UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland
                [11 ]University of Cape Town, Groote Schuur Hospital, Main Road, Observatory, 7925, South Africa
                [12 ]Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
                [13 ]Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
                [14 ]SAMRC Maternal and Infant Health Care Strategies Unit, Obstetrics and Gynaecology Department, University of Pretoria, PO Box 323 Arcardia, 0007, South Africa
                Copyright © 2015 Kerber et al.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.



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