Approaches, enablers, barriers and outcomes of implementing facility-based stillbirth and neonatal death audit in LMICs: a systematic review

Abstract

PurposeTo identify approaches, enablers, barriers and outcomes of facility stillbirth and neonatal death audit in low-income and middle-income countries (LMICs).Data sourcesWe searched MEDLINE, CINAHL Complete, Academic Search Index, Science Citation Index, Complementary index and Global health electronic databases.Study selectionStudies were considered eligible when reporting the approaches, enablers, barriers and outcomes of facility-based stillbirth and neonatal death audit in LMICs.Data extractionTwo authors independently performed the data extraction using predefined templates made before data extraction.Results of data synthesisA total of 10 articles from 7 countries were included in the final analysis. Facility or external multidisciplinary teams performed death audits on a weekly or monthly basis. A total of 1018 stillbirths and neonatal deaths were audited. Of 18 audit enablers identified, nine were at the health provider level while 18 of 23 barriers to audit that were identified occurred at the facility level. The facility-level barriers cited by more than one study included: failure to implement change; inadequate training; limited time; increased workload; too many cases and poor documentation. Six studies reported that death audits resulted in structural improvements in physical structure, training, service organisation, supplies and equipment in the wards. Five studies reported that death audits improved the standard of care, with one study showing a significant improvement in measured standards. One study reported a significant reduction in newborn mortality rate of 29.4% (95% CI 0.6% to 2.4%; p=0.0015) and one study a reduction in perinatal mortality of 4.9% (52.8% in 2007 to 47.9% in 2008) before and after perinatal audit implementation.ConclusionStillbirth and neonatal death audit improves facility structures, processes of care and health outcomes in neonatal care. There is a need to enhance enablers and address barriers identified at both health provider and facility levels to improve the audit process.

Resource availability and barriers to delivering quality care for newborns in hospitals in the southern region of Malawi: A multisite observational study

“…Our finding regarding nursery ward space is inconsistent with the WHO 2020 standards for providing high-quality care to small and sick newborns [20]. Limited nursery beds resulted in nursing more than one baby in a single cot increasing the risk of infection and overburdening staff [24][25][26][27]. Hospital-acquired infections among neonates cause about 30-40% of neonatal deaths [28].…”

‘There is trauma all round’: A qualitative study of health workers’ experiences of caring for parents after stillbirth in Kenya and Uganda

“…Fear and distrust amongst health workers, characteristic of this culture, act to supress openness, practice learning and innovation and result in increasing errors and poor-quality health care [29] . For example, the existence of blame culture has recently been acknowledged as a barrier to perinatal death reviews, advanced as an important strategy to reduce stillbirth in sub-Saharan Africa settings [30] . In HIC settings, organisations are increasingly encouraged to move away from a focus on blaming individuals, towards acknowledging systems factors, alongside individual responsibility, and learning [31] .…”

Factors influencing maternal death surveillance and review implementation in Dodoma City, Tanzania. A qualitative case study

“…Data from Sierra Leone reported that stakeholders' involvement allows a direct confrontation with the reaching of targets, increases the readiness to support the implementation of MDSR activities in the community and it helps the user of the services to provide new ideas and inputs that could improve the process. 21 Moreover, the study conducted by Adrian et al ( 2016) in Sub-Saharan Africa also reported that the involvement of individuals in the implementation process promotes individual accountability towards implementing the intervention 22 . Other studies emphasized the role of multilevel involvement of stakeholders in the prompt correction of mistakes, wherever a supportive supervision is put in place.…”

“…20 The inclusion of different professional figures in the team has been considered as a positive element of the implementation process in previous studies. 22 Multidisciplinary teams should include various cadres not only at the facility level, but also external stakeholders from ministries of health and other implementing partners at subnational and national levels. 20 Because of cultural differences usually present within an organization across ranks, occupation, clinical specialties and operating units, 19 in an environment favouring inclusion and confrontation a multidisciplinary team can act as a catalyzer for collective learning.…”