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

Int J Gynaecol Obstet. 2009 Oct:107 Suppl 1:S113-21, S121-2. doi: 10.1016/j.ijgo.2009.07.011.


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.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Developing Countries*
  • Female
  • Fetal Death / epidemiology*
  • Fetal Death / prevention & control
  • Humans
  • Maternal Health Services / organization & administration
  • Medical Audit / organization & administration*
  • Obstetric Labor Complications / epidemiology*
  • Obstetric Labor Complications / prevention & control
  • Perinatal Care / organization & administration
  • Perinatal Mortality*
  • Pregnancy