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      Death audits and reviews for reducing maternal, perinatal and child mortality

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          The United Nations' Sustainable Development Goals (SDGs) include reducing the global maternal mortality rate to less than 70 per 100,000 live births and ending preventable deaths of newborns and children under five years of age, in every country, by 2030. Maternal and perinatal death audit and review is widely recommended as an intervention to reduce maternal and perinatal mortality, and to improve quality of care, and could be key to attaining the SDGs. However, there is uncertainty over the most cost‐effective way of auditing and reviewing deaths: community‐based audit (verbal and social autopsy), facility‐based audits (significant event analysis (SEA)) or a combination of both (confidential enquiry).


          To assess the impact and cost‐effectiveness of different types of death audits and reviews in reducing maternal, perinatal and child mortality.

          Search methods

          We searched the following from inception to 16 January 2019: CENTRAL, Ovid MEDLINE, Embase OvidSP, and five other databases. We identified ongoing studies using and the World Health Organization (WHO) International Clinical Trials Registry Platform, and searched reference lists of included articles.

          Selection criteria

          Cluster‐randomised trials, cluster non‐randomised trials, controlled before‐and‐after studies and interrupted time series studies of any form of death audit or review that involved reviewing individual cases of maternal, perinatal or child deaths, identifying avoidable factors, and making recommendations. To be included in the review, a study needed to report at least one of the following outcomes: perinatal mortality rate; stillbirth rate; neonatal mortality rate; mortality rate in children under five years of age or maternal mortality rate.

          Data collection and analysis

          We used standard Cochrane Effective Practice and Organisation of Care (EPOC) group methodological procedures. Two review authors independently extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. We planned to perform a meta‐analysis using a random‐effects model but included studies were not homogeneous enough to make pooling their results meaningful.

          Main results

          We included two cluster‐randomised trials. Both introduced death review and audit as part of a multicomponent intervention, and compared this to current care. The QUARITE study (QUAlity of care, RIsk management, and TEchnology) concerned maternal death reviews in hospitals in West Africa, which had very high maternal and perinatal mortality rates. In contrast, the OPERA trial studied perinatal morbidity/mortality conferences (MMCs) in maternity units in France, which already had very low perinatal mortality rates at baseline.

          The OPERA intervention in France started with an outreach visit to brief obstetricians, midwives and anaesthetists on the national guidelines on morbidity/mortality case management, and was followed by a series of perinatal MMCs. Half of the intervention units were randomised to receive additional support from a clinical psychologist during these meetings. The OPERA intervention may make little or no difference to overall perinatal mortality (low certainty evidence), however we are uncertain about the effect of the intervention on perinatal mortality related to suboptimal care (very low certainty evidence).The intervention probably reduces perinatal morbidity related to suboptimal care (unadjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.40 to 0.95; 165,353 births; moderate‐certainty evidence). The effect of the intervention on stillbirth rate, neonatal mortality, mortality rate in children under five years of age, maternal mortality or adverse effects was not reported.

          The QUARITE intervention in West Africa focused on training leaders of hospital obstetric teams using the ALARM (Advances in Labour And Risk Management) course, which included one day of training about conducting maternal death reviews. The leaders returned to their hospitals, established a multidisciplinary committee and started auditing maternal deaths, with the support of external facilitators. The intervention probably reduces inpatient maternal deaths (adjusted OR 0.85, 95% CI 0.73 to 0.98; 191,167 deliveries; moderate certainty evidence) and probably also reduces inpatient neonatal mortality within 24 hours following birth (adjusted OR 0.74, 95% CI 0.61 to 0.90; moderate certainty evidence). However, QUARITE probably makes little or no difference to the inpatient stillbirth rate (moderate certainty evidence) and may make little or no difference to the inpatient neonatal mortality rate after 24 hours, although the 95% confidence interval includes both benefit and harm (low certainty evidence). The QUARITE intervention probably increases the percent of women receiving high quality of care (OR 1.87, 95% CI 1.35 ‐ 2.57, moderate‐certainty evidence). The effect of the intervention on perinatal mortality, mortality rate in children under five years of age, or adverse effects was not reported.

          We did not find any studies that evaluated child death audit and review or community‐based death reviews or costs.

          Authors' conclusions

          A complex intervention including maternal death audit and review, as well as development of local leadership and training, probably reduces inpatient maternal mortality in low‐income country district hospitals, and probably slightly improves quality of care. Perinatal death audit and review, as part of a complex intervention with training, probably improves quality of care, as measured by perinatal morbidity related to suboptimal care, in a high‐income setting where mortality was already very low.

          The WHO recommends that maternal and perinatal death reviews should be conducted in all hospitals globally. However, conducting death reviews in isolation may not be sufficient to achieve the reductions in mortality observed in the QUARITE trial. This review suggests that maternal death audit and review may need to be implemented as part of an intervention package which also includes elements such as training of a leading doctor and midwife in each hospital, annual recertification, and quarterly outreach visits by external facilitators to provide supervision and mentorship. The same may also apply to perinatal and child death reviews. More operational research is needed on the most cost‐effective ways of implementing maternal, perinatal and paediatric death reviews in low‐ and middle‐income countries.

          Plain language summary

          Reviewing deaths to prevent mothers and children from dying in the future

          What was the aim of this review?

          This Cochrane Review aimed to assess if 'death audits and reviews' (exploring why people have died and what could have been done to prevent these deaths) can prevent mothers and children from dying. The review authors collected and analysed all relevant studies to answer this question and found two studies.

          Key messages

          In a study from West African hospitals, where death rates among women and babies were high, reviewing deaths probably led to fewer deaths among pregnant women, new mothers and newborn babies. In French hospitals, where death rates among babies were low, it may have made little or no difference to death rates among newborn babies .

          What did the review study?

          Every year, millions of babies and children die. Many women also die while they are pregnant or giving birth, or shortly afterwards. More than half of these deaths happen in sub‐Saharan Africa.

          In many settings, health facilities or communities carry out 'death audits and reviews'. Here, people explore why a person died, what could have been done to avoid this death and what could be done better in the future.

          Death audits and reviews could potentially help improve the quality of care and prevent new deaths among mothers and children. But they could also cost money, be based on wrong information and take health workers away from other important tasks. If they are done badly, they could also make health workers feel blamed and humiliated, which could lead to poorer care. We need to find out if audits and reviews work and which approach works best.

          The review authors searched for studies where people from health facilities or the community carried out audits or reviews of deaths of pregnant women, women who had recently given birth, newborn babies or children under five years of age. The studies had to compare places or times where death audits and reviews were used to places or times where they were not.

          What were the main results of the review?

          The review authors found two relevant studies. Both studies assessed death audits at health facilities.

          The first study took place in West African hospitals with high death rates among women and babies. In this study, doctors and midwives were given extra training in pregnancy and childbirth care. This included one day of training in how to carry out death audits of women who had died during pregnancy or childbirth. They then returned to their hospitals and held audits at monthly meetings, with support from an expert from a different hospital. These hospitals were compared to hospitals without the training and audit meetings. For mothers and babies who were in hospital, this approach:

          ‐ probably led to fewer pregnant women and new mothers dying, and probably led to slightly better care for mothers;

          ‐ probably led to fewer babies dying during the first 24 hours. However, it may have made no difference to the number of babies who died after their first 24 hours, although the range where the actual effect may be (the "margin of error") includes both an increase and a decrease in the number of babies who died.

          ‐ probably made no difference to the number of stillbirths.

          The second study took place in French hospitals that already had very few deaths among newborns. In this study, doctors and midwives were given information about pregnancy and childbirth guidelines. They then held audit meetings in their hospitals where they discussed stillbirths and newborn babies who had become sick or died. These hospitals were compared to hospitals without the information and the meetings. This approach:

          ‐ may have made little or no difference to the number of babies who died during their first week

          ‐ probably reduced the number of babies who were sick because they received poor quality care.

          We don't know what the effect was on stillbirths or on the number of mothers or older babies and children who died because the study did not measure this.

          How up‐to‐date was this review?

          The review authors searched for studies that had been published up to 16 January 2019.

          Related collections

          Most cited references 62

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          Is Open Access

          Validation of the theoretical domains framework for use in behaviour change and implementation research

          Background An integrative theoretical framework, developed for cross-disciplinary implementation and other behaviour change research, has been applied across a wide range of clinical situations. This study tests the validity of this framework. Methods Validity was investigated by behavioural experts sorting 112 unique theoretical constructs using closed and open sort tasks. The extent of replication was tested by Discriminant Content Validation and Fuzzy Cluster Analysis. Results There was good support for a refinement of the framework comprising 14 domains of theoretical constructs (average silhouette value 0.29): ‘Knowledge’, ‘Skills’, ‘Social/Professional Role and Identity’, ‘Beliefs about Capabilities’, ‘Optimism’, ‘Beliefs about Consequences’, ‘Reinforcement’, ‘Intentions’, ‘Goals’, ‘Memory, Attention and Decision Processes’, ‘Environmental Context and Resources’, ‘Social Influences’, ‘Emotions’, and ‘Behavioural Regulation’. Conclusions The refined Theoretical Domains Framework has a strengthened empirical base and provides a method for theoretically assessing implementation problems, as well as professional and other health-related behaviours as a basis for intervention development.
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            Audit and feedback: effects on professional practice and healthcare outcomes.

            Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact. To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library., including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011). Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included. All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors. We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention. Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.
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              Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

              Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success. We generated updated estimates of child mortality in early neonatal (age 0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (1-4 years), and under-5 (0-4 years) age groups for 188 countries from 1970 to 2013, with more than 29,000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030. We estimated that 6·3 million (95% UI 6·0-6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1-18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6-177·4) in Guinea-Bissau to 2·3 (1·8-2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from -6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000-13 than during 1990-2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only -1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone. Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030. Bill & Melinda Gates Foundation, US Agency for International Development. Copyright © 2014 Elsevier Ltd. All rights reserved.

                Author and article information

                Cochrane Database Syst Rev
                Cochrane Database Syst Rev
                The Cochrane Database of Systematic Reviews
                John Wiley & Sons, Ltd (Chichester, UK )
                25 March 2020
                March 2020
                30 March 2020
                25 March 2020
                : 2020
                : 3
                University of Southampton, Aldermoor Health Centre deptDepartment of Primary Care and Population Sciences Aldermoor CloseSouthamptonHampshireUKSO16 5ST
                University of Oxford deptNuffield Department of Primary Care Health Sciences OxfordUK
                University of Southampton deptPrimary Care and Population Sciences, Faculty of Medicine SouthamptonUKSO16 5ST
                University of Oxford deptBodleian Health Care Libraries Knowledge Centre, ORC Research Building, Old Road CampusOxfordOxfordshireUKOX3 7DQ
                Liverpool School of Tropical Medicine deptCentre for Maternal and Newborn Health Pembroke PlLiverpoolUKL3 5QA
                Mbarara University of Science and Technology (MUST) deptFamily medicine and community practice MUST, PLOT 10‐18, KABALE ROADMbararaUganda1410, Mbarara
                Institut de recherche pour le développement, Paris Descartes University deptUMR 196 CEPED Faculté de Pharmacie, 4 avenue de l?ObservatoireParisFrance75006
                CD012982.pub2 CD012982
                Copyright © 2020 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.

                This is an open access article under the terms of the Creative Commons Attribution‐Non‐Commercial Licence, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                Implementation strategies
                Child health
                Effective practice & health systems
                Neonatal care
                Pregnancy & childbirth


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