PMNCH Knowledge Summary #27 Death reviews: maternal, perinatal and child
Publisher: The Partnership for Maternal, Newborn and Child Health
Publication date: 2013
Language: English only
Many maternal, perinatal and child deaths are preventable and progress towards Millennium Development Goals 4&5, to reduce child mortality and improve maternal health, has been insufficient in many parts of the world. Well-implemented death reviews provide opportunities to examine the circumstances surrounding a woman’s or child’s death, and improve the delivery of health services to prevent such deaths in the future. Several types of review processes exist to evaluate deaths in diverse settings, given different data availability and levels of service delivery. Both consistent surveillance and effective response are needed to ensure that maternal, perinatal and child deaths are identified and reviewed, so that recommendations can be made, and action can be taken to prevent further deaths.
The majority of maternal, perinatal and child deaths occurring in low- and middle-income countries could be prevented through well established and cost-effective interventions delivered through a functioning health system. Death reviews provide opportunities to examine the circumstances surrounding, as well as the immediate and contributing causes leading to a mother’s or child’s death, and inform the delivery of health services to prevent such deaths in the future. The aim of death reviews is to take action at multiple levels to improve access to services and quality of health care for women and children during pregnancy and delivery, and ultimately to prevent future morbidity and mortality. At the national level, a death review process actively seeks to capture deaths and ensure lessons learned feed into actions at multiple levels, from communities to policies.1 It permits identification of deaths, analysis of their causes, and the use of this information to respond with actions to prevent future deaths. This knowledge summary describes the types of death reviews, the usage and benefits of different review processes, and gives some examples of death review implementation in high-, middle- and low-income countries.
Progress towards MDGs 4&5, to reduce child mortality and improve maternal health, has been insufficient in many parts of the world. In 2010, the United Nation’s Global Strategy for Women’s and Children’s Health was launched, and identified key areas where action is urgently required to enhance financing, strengthen policy and improve service delivery.2 One of these areas is improved monitoring and evaluation to ensure accountability for results. The Commission on Information and Accountability (CoIA) was formed to determine the most effective international institutional arrangements for global reporting, oversight, and accountability on women’s and children’s health.3 One of the key recommendations of CoIA is for countries to set up efficient health information systems to inform policies and practice to reduce maternal and child mortality. Maternal, perinatal and child death reviews can provide valuable information on causes of preventable deaths, and can help countries to meet the CoIA recommendation for accountability and reporting. The information guides actions to improve provision of quality healthcare to prevent future deaths.4 However, while some traction has been made in identifying deaths, there is still a significant gap in the implementation of response systems for corrective action. Participating in reviews, when response mechanisms are in place, can help generate a renewed and shared sense of commitment to prevent these deaths among community members, health care workers, and managers.
The guidelines on maternal death reviews “Beyond the Numbers,” outline five types of reviews depending on their level (community, facility, regional or national), methodological approach and sources of data.5 The “Maternal Death Surveillance and Response – technical guidance” emphasises the need for systematic and continuous surveillance of maternal deaths by linking the health information system, as well as standardised response systems and quality improvement processes from local to national levels, including the implementation and monitoring of recommendations which arise from death reviews.1,6,7 These guidelines support not only a systematic death review process, but outline structural ways to respond to death reviews for improvement in care.
Perinatal and child mortality reviews, while less commonly implemented and used, can also provide useful information and engage communities and health systems. Perinatal death reviews systematically review stillbirths and neonatal deaths to00%0A provide information on the quality of perinatal care; and child death reviews are a mechanism to describe the causes and circumstances of death among children. For example, in the US, multiagency child death review involves a systematic and multidisciplinary process to integrate data and resources from coroners, law enforcement, courts, child protective services, and health care providers.8 In England, each local authority has established a child death overview panel to review all deaths of children from birth to 18 years in their area.9
Maternal, perinatal and child death reviews allow healthcare staff and community members to draw lessons from preventable deaths and improve future practices, and can also be used to inform policies and programmes. Together, these three types of death reviews cover the continuum of care from pregnancy to childhood. At the national level, death reviews can provide general policy recommendations for the health sector and can inform development of guidelines for improving care.10
The United Kingdom has the world’s longest continuous system of maternal and perinatal death and severe morbidity reviews. In 2012, an improved UK wide programme was developed: Mothers and Babies Reducing Risks through Audit and Confidential Enquiries across the UK (MBRRACE-UK)11. It aims to deliver surveillance, audit and confidential case reviews for maternal and perinatal death and severe morbidities in order to assess the quality and safety of maternity and infant services, support improvements in quality and clinical practice through national and local learning and produce evidence based recommendations and good practice point.11
Low- and middle-income countries
In many low- and middle-income income countries, the routine process of death reviews has not been fully implemented, despite its potential to generate evidence and inform action to improve health. In these settings death reviews can be a valuable tool to inform, monitor and improve services to prevent maternal, perinatal and child deaths. In Latin America, one of the goals of the Latin American Centre for Perinatology (CLAP) is to improve maternal and perinatal surveillance to enable policy makers to focus efforts on high-priority problems.12 Perinatal mortality audit and child death reviews, outside of specific research studies, have been used even less frequently in low-income countries than maternal death reviews. The institutionalisation of the death reviews requires political commitment, a legal framework, national guidelines, financial support, capacity development and involvement of professional bodies.13,14,15
South Africa was the first country in sub-Saharan Africa to implement a confidential enquiry into maternal deaths occurring in health institutions. Maternal mortality is audited through the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD).16 In addition, the Perinatal Problem Identification Programme (PPIP) measures perinatal1 mortality rates and identifies avoidable factors associated with each death.17 Child mortality is recorded through the Child Healthcare Problem Identification Programme (Child PIP), which monitors deaths among infants and children admitted to paediatric wards of participating facilities. These three audits have demonstrated the potential of systematic death reviews to identify modifiable factors within the health system and beyond, identify local and national priorities, and make recommendations for action to reduce deaths.18,19
Death reviews can be challenging due in part to lack of knowledge and skills related to conducting reviews, as well as fear of blame and repercussions related to the findings. It is important to recognise that ownership of the process and engagement, within the community or health facilities, can help to identify timely and accurate information. Attention to training of both implementing and senior staff, within facilities, can ensure that the appropriate data are recorded and aggregated for use. Engagement with community members and leaders can also foster ownership and open participation. At all levels, understanding the aims and uses of death review information will support a functioning system. Policies protecting confidentiality and independence are important to protect those involved in death reviews, and ensure that accurate information is collected, without the risk of unjustified backlash or repercussions due to the results generated. To improve the uptake of death reviews and ensure ongoing review and response, the review process needs to be embedded within the health system.
Maternal, perinatal and child death reviews provide valuable information on the circumstances and causes of death, and guide actions at the community and health facility level, and at the level of national policy-making to prevent similar deaths in the future. From a human-rights and accountability perspective, death reviews can inform policies and practices which help ensure basic human rights to life, health, equity, confidentiality, participation and non-discrimination. In order to be effective, however, there must be a willingness to use the information generated from the reviews both locally and nationally to inform structural reforms to not only improve access to maternal and perinatal health services, but also the quality of these services. In order for death reviews to be most effective, the complete cycle must be enacted: identifying deaths, collecting data and analysing the information, and responding to the findings with recommendations, action and evaluation. Through this cycle, the death review process can positively impact focused health system improvements.
Box 1 – Human-rights and accountability perspectives on death reviews
Preventable deaths represent violations of a basic human right and thus are unacceptable. The 2009 UN Human Rights Council resolution “Preventable maternal mortality and morbidity and human rights” acknowledged maternal health as a human rights issue and stressed the need to develop effective accountability mechanisms at facility, regional and national levels.20,21 Maternal and child death reviews have the potential to provide evidence of existing inequalities and to trigger system-wide action to reduce inequalities and address gaps in quality of care. A human rights-based approach would guide national policies on maternal and child health to align with the principles of accountability, transparency and monitoring. The CoIA accountability framework of 2011 is based on the right to health, equity in health and gender equity, and report that strengthening accountability is an essential but neglected strategy for improving women’s and children’s health and reducing mortality.3
1. Maternal Death Surveillance and response – Technical Guidance. Information for action to prevent maternal death, World Health Organization, 2013. 2. United Nations Secretary-General. Global Strategy for Women’s and Children’s health: The Partnership for Maternal, Newborn and Child Health, 2010. 3. Commission on Information and Accountability for Women’s and Children’s Health. Keeping promises, measuring results. Geneva, Switzerland: World Health Organization, 2011. 4. Graham WJ, Hussein J. Universal reporting of maternal mortality: an achievable goal? International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2006; 94(3): 234-42. 5. World Health Organization. Beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. Geneva, Switzerland: World Health Organization, 2004. 6. Hounton S, De Bernis L, Hussein J, et al. Towards elimination of maternal deaths: maternal deaths surveillance and response. Reproductive health 2013; 10: 1. 7. Danel I, Graham WJ, Boerma T. Maternal death surveillance and response. Bulletin of the World Health Organization 2011; 89(11): 779-A. 8. Durfee M, Gellert G, Tilton-Durfee D. Origins and clinical relevance of child death review teams. JAMA 1992; 267(23): 3172-5. 9. Sidebotham P, Fox J, Horwath J, Powell C. Developing effective child death review: a study of ‘early starter’ child death overview panels in England. Inj Prev; 17 Suppl 1: i55-63. 10. Pattinson R, Kerber K, Waiswa P, et al. Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middleincome countries. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2009; 107 Suppl 1: S113-21, S21-2. 11. MBRRACE-UK. MBRRACE-UK; Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK, 2012. https://www.npeu.ox.ac.uk/mbrrace-uk 12. Belizan J, Cafferata M, Belizan M, Tomasso G, Chalmers B. Goals in maternal and perinatal care in Latin America and The Caribbean. Birth 2005; 32: 210-8. 13. Pearson L, deBernis L, Shoo R. Maternal death review in Africa. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2009; 106(1): 89-94. 14. Dumont A, Gaye A, de Bernis L, et al. Facility-based maternal death reviews: effects on maternal mortality in a district hospital in Senegal. Bulletin of the World Health Organization 2006; 84(3): 218-24. 15. Kongnyuy EJ, van den Broek N. The difficulties of conducting maternal death reviews in Malawi. BMC pregnancy and childbirth 2008; 8: 42. 16. South Africa Every Death Counts Writing G, Bradshaw D, Chopra M, et al. Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa. Lancet 2008; 371(9620): 1294-304. 17. Belizan M, Bergh AM, Cilliers C, Pattinson RC, Voce A, Synergy G. Stages of change: A qualitative study on the implementation of a perinatal audit programme in South Africa. BMC health services research 2011; 11: 243. 18. UNFPA. making 1 billion count: investing in adolescents’ health and rights: UNFPA, 2003. 19. Bergh AM, Pattinson R, Belizan M, et al. Completing the audit cycle for quality care in perinatal, newborn and child health. Pretoria, South Africa: MRC Research Unit for Maternal and Infant Health Care Strategies, University of Pretoria, 2011. 20. United Nations Human Rights Council. Resolution 11/8. Preventable maternal mortality and morbidity and human rights. In: United Nations Human Rights Council, eleventh session, New York, 17 June 2009. New York: UN Human Rights Council, 2009. 21. United Nations Human Rights Council. Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality: United Nations General Assembly, A/HRC/21/22, 2012.
Scientific writers: Katherine Theiss-Nyland and Boika Rechel. Contributors to development and review: Bilal Avan, Oona Campbell, Rachel Coghlan, Simon Cousens, Isabella Danel, Pat Doyle, Sue England, Andres de Francisco, Jennifer Franz-Vasdeki, Stefan Germann, Wendy Graham, Shyama Kuruvilla, Ana Langer, Joy Lawn, Gwyneth Lewis, Elizabeth Mason, Matthews Mathai, Affette McCaw-Binns, Lori McDougall, Bob Pattinson, Carole Presern, Roger Rochat, Joanna Schellenberg, Ann Starrs, Mary Nell Wegner. Coordination team: Bilal Avan, Agnes Becker, Shirine Voller at the London School of Hygiene & Tropical Medicine. Design by Roberta Annovi.