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.

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.

Read the full abstract...
Background: 

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).

Objectives: 

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

Search strategy: 

We searched the following from inception to 16 January 2019: CENTRAL, Ovid MEDLINE, Embase OvidSP, and five other databases. We identified ongoing studies using ClinicalTrials.gov 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.

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