Perinatal mortality audit: Counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries

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Abstract
Background: In high-income countries, national mortality audits are associated with improved quality of care, but there has been no previous systematic review of perinatal audit in low- and middle-income settings. Objectives: To present a systematic review of facility-based perinatal mortality audit in low- and middle-income countries, and review information regarding community audit. Results: Ten low-quality evaluations with mortality outcome data were identified. Meta-analysis of 7 before-and-after studies indicated a reduction in perinatal mortality of 30% (95% confidence interval, 21%-38%) after introduction of perinatal audit. The consistency of effect suggests that audit may be a useful tool for decreasing perinatal mortality rates in facilities and improving quality of care, although none of these evaluations were large scale. Few of the identified studies reported intrapartum-related perinatal outcomes. Novel experience of community audit and social autopsy is described, but data reporting mortality outcome effect are lacking. There are few examples of wide-scale, sustained perinatal audit in low-income settings. Two national cases studies (South Africa and Bangladesh) are presented. Programmatic decision points, challenges, and key factors for national or wide scale-up of sustained perinatal mortality audit are discussed. As a minimum standard, facilities should track intrapartum stillbirth and pre-discharge intrapartum-related neonatal mortality rates. Conclusion: The effect of perinatal audit depends on the ability to close the audit loop; without effectively implementing the solutions to the problems identified, audit alone cannot improve quality of care. (C) 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.