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Perinatal mortality audits and reviews: Past, present and the way forward

To achieve a reduction in the number of stillbirths and neonatal deaths, it is crucial to ensure that the perinatal mortality audit and review cycle is completed with implementation and re-evaluation of recommended changes in maternity services.

Authors

Änne Helps, Sara Leitao, Keelin O'Donoghue

Year
2020
Journal Name
European Journal of Obstetrics, Gynecology, and Reproductive Biology (EJOG)
Category
Journal Article
Keywords
Audit / Service evaluation, Neonatal death, Perinatal mortality, Stillbirth
Project

Perinatal death reviews, inquiries and audits

Full Citation

Helps Ä, Leitao S, Greene R, O'Donoghue K. Perinatal mortality audits and reviews: Past, present and the way forward. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2020;250:24-30. https://doi.org/10.1016/j.ejogrb.2020.04.054.

Link to Publication
https://doi.org/10.1016/j.ejogrb.2020.04.054

Abstract

Perinatal deaths are devastating for families and staff involved. Failure to examine perinatal deaths for substandard care prevents learning and may lead to recurrence of events. We outlined issues with the classification of perinatal deaths and the different types of perinatal death reviews carried out in high-income countries. We reflected on the challenges that are encountered in the current processes and we then commented on how these may be overcome. Current literature showed that differences in classifications of perinatal deaths continue to impede important international comparisons. National perinatal mortality audits can provide reliable high-quality data. Confidential enquiries give expert assessment on anonymised information to initiate system-wide improvements, but to provide local information on perinatal deaths unit-based multi-disciplinary team reviews are required. There is a need to shift from a blame-culture to a focus on achieving best practice by learning from mistakes. Involving the bereaved parents in the perinatal death review process is important and ways to achieve this are progressing. To achieve a reduction in the number of stillbirths and neonatal deaths, it is crucial to ensure that the perinatal mortality audit and review cycle is completed with implementation and re-evaluation of recommended changes in maternity services.

Pregnancy Loss Research Group

Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University College Cork, Fifth Floor, Cork University Maternity Hospital, Wilton, Cork, T12 YE02, Ireland,

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