Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review

Abstract

BackgroundAudits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries.MethodsWe performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews.ResultsThirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified.ConclusionsAudits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2393-14-280) contains supplementary material, which is available to authorized users.

Assessment of infant mortality surveillance: case study

“…It is critical to improving the quality of investigations in order to build a chain of events that supports death notifications and provides a better understanding of the socioeconomic, cultural, and care determinants. 5,11,17 National and international discussions of deaths occur in committees by a group of experts from universities, health departments, councils, and nongovernmental organizations. 11,27,28 The studied municipalitydiffers when it that adds social services, inspection, and management workers into the discussion.…”

“…3,4 Several nations have acknowledged the need to associate the epidemiological profile of mortality with quality assessments of care provided to women and children during their trajectory, and have perfected strategies to facilitate greater understanding of social and care-related determinants of the deaths, including the mortality surveillance. 5,6 In the inspection and investigation of child deaths, international experiences have produced several configurations based on availability of information and the supply of more or less complex health services. 5,7,8 The investigation of deaths can explain the circumstances in which they occurred and the results should be notified to managers and any interested people so they may act on various levels of the health system to improve access and quality of care provided during pregnancy, labour, childbirth, and child and mother follow-up.…”

“…5,6 In the inspection and investigation of child deaths, international experiences have produced several configurations based on availability of information and the supply of more or less complex health services. 5,7,8 The investigation of deaths can explain the circumstances in which they occurred and the results should be notified to managers and any interested people so they may act on various levels of the health system to improve access and quality of care provided during pregnancy, labour, childbirth, and child and mother follow-up. 5,7,8 In Brazil, a similar strategy was implemented by the Ministry of Health (MH) in 2010, with the publication of a normative base of Infant Death and Foetal Surveillance, 9 although municipal and state initiatives with different conformations have existed for some years.…”

“…5,7,8 The investigation of deaths can explain the circumstances in which they occurred and the results should be notified to managers and any interested people so they may act on various levels of the health system to improve access and quality of care provided during pregnancy, labour, childbirth, and child and mother follow-up. 5,7,8 In Brazil, a similar strategy was implemented by the Ministry of Health (MH) in 2010, with the publication of a normative base of Infant Death and Foetal Surveillance, 9 although municipal and state initiatives with different conformations have existed for some years. [10][11][12][13][14][15] In Recife, since 2003, infant mortality surveillance was implemented to investigate and discuss all infant deaths (except those caused by congenital malformations) of mothers living in Brazil.…”

Death surveillance as an instrument to reduce invisibility from social and assistance exclusion of women and children

“…The visibility conceded to maternal and child death by monitoring the MDG supported the reduction of the problem, yet not evenly in all countries which, even in those who had advanced the most, still indebted with specific populations such as indigenous, quilombolas, gipsy, riverside and homeless. 2,3 In order to develop effective public policies directed to women and children, the adequate knowledge regarding the relevance of problems, its determinants and circumstances of its occurring is indispensable. Countries which own complete continuous registry information systems can measure safely the mortality range, although sometimes information are insufficient to apprehend facts related to death, as well as identifying socially marginalized groups.…”