Emma Allanson

Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby

BackgroundWhile there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking.MethodsWe reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality.ResultsMaternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed.ConclusionsHealth workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

The WHO application of ICD‐10 to deaths during the perinatal period (ICD‐PM): results from pilot database testing in South Africa and United Kingdom

To apply the World Health Organization (WHO) Application of the International Classification of Diseases, tenth revision (ICD‐10) to deaths during the perinatal period: ICD‐Perinatal Mortality (ICD‐PM) to existing perinatal death databases.

Umbilical lactate as a measure of acidosis and predictor of neonatal risk: a systematic review

Umbilical cord lactate is one approach to measuring acidosis and intrapartum hypoxia, knowledge of which may be helpful for clinicians involved in the care of women and newborns.

Seeking order amidst chaos: A systematic review of classification systems for causes of stillbirth and neonatal death, 2009-2014

BackgroundEach year, about 5.3 million babies die in the perinatal period. Understanding of causes of death is critical for prevention, yet there is no globally acceptable classification system. Instead, many disparate systems have been developed and used. We aimed to identify all systems used or created between 2009 and 2014, with their key features, including extent of alignment with the International Classification of Diseases (ICD) and variation in features by region, to inform the World Health Organization’s development of a new global approach to classifying perinatal deaths.MethodsA systematic literature review (CINAHL, EMBASE, Medline, Global Health, and PubMed) identified published and unpublished studies and national reports describing new classification systems or modifications of existing systems for causes of perinatal death, or that used or tested such systems, between 2009 and 2014. Studies reporting ICD use only were excluded. Data were independently double-extracted (except from non-English publications). Subgroup analyses explored variation by extent and region.ResultsEighty-one systems were identified as new, modifications of existing systems, or having been used between 2009 and 2014, with an average of ten systems created/modified each year. Systems had widely varying characteristics: (i) comprehensiveness (40 systems classified both stillbirths and neonatal deaths); (ii) extent of use (systems were created in 28 countries and used in 40; 17 were created for national use; 27 were widely used); (iii) accessibility (three systems available in e-format); (iv) underlying cause of death (64 systems required a single cause of death); (v) reliability (10 systems tested for reliability, with overall Kappa scores ranging from .35–.93); and (vi) ICD alignment (17 systems used ICD codes). Regional databases were not searched, so system numbers may be underestimated. Some non-differential misclassification of systems was possible.ConclusionsThe plethora of systems in use, and continuing system development, hamper international efforts to improve understanding of causes of death. Recognition of the features of currently used systems, combined with a better understanding of the drivers of continued system creation, may help the development of a truly effective global system.

Characteristics of a global classification system for perinatal deaths: a Delphi consensus study

BackgroundDespite the global burden of perinatal deaths, there is currently no single, globally-acceptable classification system for perinatal deaths. Instead, multiple, disparate systems are in use world-wide. This inconsistency hinders accurate estimates of causes of death and impedes effective prevention strategies. The World Health Organisation (WHO) is developing a globally-acceptable classification approach for perinatal deaths. To inform this work, we sought to establish a consensus on the important characteristics of such a system.MethodsA group of international experts in the classification of perinatal deaths were identified and invited to join an expert panel to develop a list of important characteristics of a quality global classification system for perinatal death. A Delphi consensus methodology was used to reach agreement. Three rounds of consultation were undertaken using a purpose built on-line survey. Round one sought suggested characteristics for subsequent scoring and selection in rounds two and three.ResultsThe panel of experts agreed on a total of 17 important characteristics for a globally-acceptable perinatal death classification system. Of these, 10 relate to the structural design of the system and 7 relate to the functional aspects and use of the system.ConclusionThis study serves as formative work towards the development of a globally-acceptable approach for the classification of the causes of perinatal deaths. The list of functional and structural characteristics identified should be taken into consideration when designing and developing such a system.

Giving a voice to millions: developing the WHO application of ICD-10 to deaths during the perinatal period: ICD-PM

application of ICD-10 to deaths during the perinatal period: ICD-PM ER Allanson, Ӧ Tunçalp, J Gardosi, RC Pattinson, JP Vogel, JJHM Erwich, VJ Flenady, JF Frøen, J Neilson, A Quach, A Francis, D Chou, M Mathai, L Say, AM Gülmezoglu a Faculty of Medicine, Dentistry and Health Sciences, School of Women’s and Infants’ Health, University of Western Australia, Crawley, WA, Australia b Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland c Perinatal Institute, Birmingham, UK d Department of Obstetrics and Gynaecology, SAMRC Maternal and Infant Health Care Strategies unit, University of Pretoria, Pretoria, South Africa e Department of Obstetrics, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands f Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Qld, Australia g International Stillbirth Alliance, Bristol, UK h Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway i Centre for Intervention Science for Maternal and Child Health, University of Bergen, Bergen, Norway j Centre for Women’s Health Research, University of Liverpool, Liverpool, UK k Pacific Northwest University of Health Sciences, Yakima, WA, USA l Maternal & Perinatal Health, Department of Maternal, Newborn Child & Adolescent Health, World Health Organization, Geneva, Switzerland Correspondence: ER Allanson, Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland. Email allansone@who.int

Making stillbirths visible: a systematic review of globally reported causes of stillbirth

Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD‐PM) aims to improve data on stillbirth to enable prevention.

Application of ICD-PM to preterm-related neonatal deaths in South Africa and United Kingdom

We explore preterm‐related neonatal deaths using the WHO application of the International Classification of Disease (ICD‐10) to deaths during the perinatal period: ICD‐PM as an informative case study, where ICD‐PM can improve data use to guide clinical practice and programmatic decision‐making.

Optimising the International Classification of Diseases to identify the maternal condition in the case of perinatal death.

The WHO application of the tenth edition of the International Classification of Diseases (ICD‐10) to deaths during the perinatal period (ICD Perinatal Mortality, ICD‐PM) captures the essential characteristics of the mother–baby dyad that contribute to perinatal deaths. We compare the capture of maternal conditions in the existing ICD‐PM with the maternal codes from the WHO application of ICD‐10 to deaths during pregnancy, childbirth, and the puerperium (ICD Maternal Mortality, ICD‐MM) to explore potential benefits in the quality of data received.

Global, regional and national levels and trends of preterm birth rates for 1990 to 2014: protocol for development of World Health Organization estimates.

BackgroundThe official WHO estimates of preterm birth are an essential global resource for assessing the burden of preterm birth and developing public health programmes and policies. This protocol describes the methods that will be used to identify, critically appraise and analyse all eligible preterm birth data, in order to develop global, regional and national level estimates of levels and trends in preterm birth rates for the period 1990 – 2014.MethodsWe will conduct a systematic review of civil registration and vital statistics (CRVS) data on preterm birth for all WHO Member States, via national Ministries of Health and Statistics Offices. For Member States with absent, limited or lower-quality CRVS data, a systematic review of surveys and/or research studies will be conducted. Modelling will be used to develop country, regional and global rates for 2014, with time trends for Member States where sufficient data are available. Member States will be invited to review the methodology and provide additional eligible data via a country consultation before final estimates are developed and disseminated.DiscussionThis research will be used to generate estimates on the burden of preterm birth globally for 1990 to 2014. We invite feedback on the methodology described, and call on the public health community to submit pertinent data for consideration.Trial registrationRegistered at PROSPERO CRD42015027439Contact: pretermbirth@who.int