Table 10

Impact of perinatal audit on stillbirths and perinatal mortality

Source

Location and Type of Study

Intervention

Stillbirth/Perinatal Outcomes


Reviews and meta-analyses


Mancey-Jones and Brugha 1997[124]

Zimbabwe, Guadeloupe, South Africa, Mozambique.

Systematic review. Before-and-after time series analyses. 7 studies included from low-/middle income countries.

Assessed the impact on perinatal mortality rates before and during a perinatal audit.

No pooled analysis done.

PMR (Guadeloupe): fell by 25% during audit.

PMR (Lebowa, South Africa): significant reduction.

PMR (Mozambique): no change (increase in high risk patients).

PMR (Port Elizabeth, South Africa): significant reduction.


Intervention studies


Biswas et al. 1995 [166]

Singapore. National University Hospital.

Comparison of perinatal mortality rates between two time periods. N = 26,173 mothers with N = 26,423 births during 1986–1992. N = 235 perinatal deaths, of which 145 (61.7%) were stillbirths and 90 (38.3%) were neonatal deaths.

Compared the perinatal mortality rate during a 7-year period (1986–1992) vs. baseline assessed in 1982 using perinatal audit. Compared to 1982, 1986–1992 were marked by improvements in antenatal and intrapartum fetal surveillance and improved neonatal care.

PMR: 8.9/1000 vs. 14.6/1000 in during perinatal audit period vs. baseline.

PMR (excluding lethal malformations): 5.7/1000 vs. 14.6/1000 in 1986–1992 vs. 1982


Cameron et al. 2001 [167]

Australia (Far North Queensland). Atherton Hospital.

Before-and-after study design. N = 5,879 births (N = 2996 during 1991–00, N = 2883 during 1981–90).

Analysed obstetric audit data collected from 1991–2000, comparing PMR during this period with the previous decade (1981–90). Was associated with increased public sector utilization and caesarean section rate (13% to 17.4%)

SBR: 12/2996 (4/1000) vs. 7/2883 (2.4/1000) after vs. before, respectively.

PMR: 16 (5.3/1000) vs. 15 (5.2/1000) after vs. before, respectively.

NMR: 4/2996 (1.3/1000 live births) vs. 8/2883 (2.8/1000) after vs. before, respectively.

No statistical significance data given.


Cameron 1998[168]

Australia (Far North Queensland). Atherton Hospital.

Descriptive study. N = 2883 deliveries during 1981–1990 (N = 1974 public confinements, N = 909 private confinements).

Analysed obstetric audit data collected from private vs. public facilities over the decade 1981–1990.

PMR: 5.2/1000.

PMR: 5.1/1000 vs. 5.5/1000 in public and private confinements, respectively.

PMR (corrected): 9.6/1000 vs. 13.5/1000 vs. 16.9/1000 in public patients, Queensland (1987) and the Far North Statistical Division (1987).


Dahl et al. 2000 [169]

Norway (Troms County). Medical Birth Registry of Norway and medical records.

Retrospective + prospective study design. N = 472 antenatal, neonatal and post neonatal deaths = 20 weeks of gestation from 1976– 1997.

Evaluation of deaths, including assessment of risk factors, mortality rates, cause of death, sub-optimal care and avoidable deaths, by medical audit to improve antenatal and neonatal care over a 22-year period.

Fetal death (miscarriage + SB) + NMR + IMR:

13.8/1000 in 1976–80

9.5/1000 in 1981–85

10.4/1000 in 1986–91

7.7/1000 in 1992–97 (P < 0.001)

Reduction attributable to reduced rate of pre-term birth (P < 0.001) and low birth weight (500–1995 g) (P < 0.001).


Hawthorne et al. 1997 [170]

United Kingdom. District general and teaching hospitals (Population data).

Prospective audit. N = 111 diabetic pregnant women booking in 1994.

To compare perinatal mortality associated with diabetic pregnancies with the background population (controls) to determine progress toward a specified target of diabetic pregnancy outcome approximating non-diabetic pregnancy outcome.

PMR: OR = 5.38 (95% CI: 2.27–12.70).

[48/1000 vs. 8.9/1000 in diabetic pregnancy and controls, respectively].

NMR: OR = 15.0 (95% CI: 6.77–33.10).

[59/1000 vs. 3.9/1000 in the diabetic pregnancies vs. controls, respectively].


Jansone and Lazdane 2006 [171]

Latvia (Riga). Tertiary referral perinatal care center.

Retrospective audit. N = 26,783 births, of which N = 494 were stillbirths and neonatal deaths during 1995–1999.

To analyze all perinatal deaths using the Nordic-Baltic classification system, and assess trends in perinatal mortality over the study period.

PMR: No decline during the study period.

Proportion of preventable perinatal deaths: 36.4% vs.14.7% in 1999 vs. 1995, respectively (P = 0.01).


Korejo et al. 2007 [172]

Pakistan (Karachi). Government teaching hospital.

Prospective review. N = 7743 deliveries in 2001, of which N = 753 were perinatal deaths (N = 569 stillbirths and N = 184 early neonatal deaths).

To review the extent and determinants of perinatal mortality using the Aberdeen classification system, which analyses cause of death as well as preventive factors, comparing the PMR in 2001 with previous data.

SBR: 73.4/1000 total births.

PMR: 97.2/1000 total births.

No change in PMR over 40 years due to higher patient influx and incoming referrals.

Perinatal deaths associated with poor care and education and low socio-economic status.


Krebs et al. 2002 [136]

Denmark (Copenhagen). University hospital.

Blinded controlled perinatal audit). N = 12 non-malformed, breech infants with intrapartum/early neonatal death in the period 1982–92. N = 23 controls matched by presentation and planned mode of delivery.

11 obstetricians reviewed the data (derived from maternity records) and narratives of cases and controls, subsequently completing questionnaires in which they guessed whether the baby had died based on the data (for both cases and controls), and whether suboptimal care had been provided during pregnancy and delivery, indicating a potentially avoidable death.

Suboptimal ANC: 17% vs. 4% in cases and controls, respectively.

Suboptimal intrapartum care: 25% vs. 26% in cases and controls, respectively.

When death was assumed, obstetricians asserted it was potentially avoidable in 7/12 (58%) of cases and 4/23 (17%) of controls (P = 0.02).


Krue et al. 1999 [173]

Denmark (Viborg County).

Perinatal audit (county-wide).

Compared perinatal mortality over a three-year perinatal audit period from 1994–1996. The mortality rate in 1995 was also compared to data from the Danish National Birth Register (1995).

PMR: 6.5/1000 vs. 9.4/1000 in 1996 vs. 1994, respectively [NS].

NMR: 2.4/1000 vs. 3.2/1000 in 1996 vs. 1994, respectively [NS].

PMR: No difference between county and national rates in 1995.


Papiernik et al. 2005 [174]

France (Paris).

Perinatal audit. All deaths from 1989 to 1992 in the Perinatal Enquiry.

Assessed the impact of audit of obstetrical practices and the analysis of perinatal deaths on perinatal mortality.

PMR: Major reduction after a 10-year period.


Tay et al. 1992 [137]

Singapore. Tertiary referral hospital.

Caesarean audit. N = 16, 875 deliveries during the 4 year period.

Assessed the impact on perinatal mortality of an intradepartmental audit (critical review of indications for cesarean delivery).

PMR: 8.25, 7.05, 9.39 and 5.38 in 1987, 1988, 1989 and 1990, respectively for infants weighing ≥ 500 g

Caesarean section rate: 12.3%, 11.1%, 11.2% and 11.4% for 1987, 1988, 1989 and 1990, respectively.


Wilkinson et al. 1997 [135]

South Africa (rural). Hlabisa Maternity Service, comprising Hlabisa Hospital, 8 village clinics, and 20 mobile clinic points.

Perinatal audit with subsequent interventions. N = 21,112 consecutive births between May 1991 and December 1995.

To assess the impact of the perinatal audit on the quality of care, along with the design of interventions informed by the audit results. The interventions employed consisted of structural and functional rearrangement of the maternity service district-wide, writing and implementing protocols of care for local use, and regular in-service education.

PMR: 27/1000, 42/1000 and 26/1000 in 1991, 1992 and 1995, respectively (40% reduction from the peak in 1992; P = 0.002).

PMR: 653/21,112 (31/1000) from 1991 to 1995.

Proportion of perinatal deaths occurring in clinics (vs. at home/outside of clinics): 6.3% vs. 17% in 1995 vs. 1991, respectively.


Observational studies


King et al. 2006 [120]

Australia (Victoria). Maternity hospitals.

Perinatal death audit. A cohort of N = 3485 perinatal deaths over a 5-year period, 2000–2004. Live births: N = 312651; stillbirths: N = 242; neonatal deaths: N = 1057

To assess the impact of a systematic audit of stillbirths and neonatal deaths via application of the classification systems developed by the Perinatal Society of Australia and New Zealand (PSANZ).

Causes of perinatal deaths: congenital abnormality (24.5%), followed by spontaneous preterm birth (17.0%), unexplained antepartum death (15.9%), and maternal conditions (14.8%).

Causes of stillbirths: unexplained antepartum death was the main cause of death (22.9%), followed by congenital abnormality (20.3%) and maternal conditions (20.4%).


Bhutta et al. BMC Pregnancy and Childbirth 2009 9(Suppl 1):S7   doi:10.1186/1471-2393-9-S1-S7

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