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Audit-Identified Avoidable Factors In Global Maternal, Fetal, and Newborn Deaths

Saturday, October 20, 2012
Room 346-347 (Morial Convention Center)
Hasan Merali, MD1, Stuart Lipsitz, ScD2, Priya Agrawal, MD, MPH3, Angela Lashoher, MD, MPH4, Atul Gawande, MD, MPH3 and Jonathan Spector, MD, MPH5, (1)MassGeneral Hospital for Children, Boston, MA, (2)Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, (3)Harvard School of Public Health, Boston, MA, (4)Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, (5)Neonatology, MassGeneral Hospital for Children, Boston, MA


The major causes of maternal deaths, newborn deaths, and intrapartum-related stillbirths globally are well described. Significantly less well established, though equally as important for developing effective interventions, are the specific avoidable human and administrative factors that directly contribute to childbirth-associated mortality.  Clinical audits provide a rational framework for quality improvement by assessing existing practices against accepted standards. The majority of childbirth-related audits in lower income countries have been conducted at the facility level and, up to now, these data have not been systematically pooled and analyzed. We sought to (1) comprehensively review all existing reports of facility-based, audit-identified avoidable factors in maternal, fetal, and newborn deaths in low and middle income countries; (2) identify trends (i.e., factors that repeatedly account for high proportions of avoidable deaths); and (3) develop intervention recommendations likely to be widely applicable in this context.


We performed a systematic search of published literature from 1970 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. The search returned 3,775 results and an additional 16 papers were added from reference lists. There were 691 duplicate entries and 2,975 were subsequently removed after abstract screening. The full texts of the 125 remaining articles were reviewed and 44 met inclusion criteria. We summarized the remaining papers and categorized them by type of measure examined.


Of the 44 papers included in the analysis, 23 (52%) demonstrated patient-related factors, 23 (52%) demonstrated transport- or referral-related factors, 24 (55%) demonstrated administrative- and supply-related factors at facilities, and 40 (91%) demonstrated health worker-related factors. The most common factor overall was a delay in or lack of maternal transport to the facility. The next most common factors were poor blood transfusion capacity, medication shortages, and a delay in care after admission. More than 30 avoidable factors were catalogued. 


Most childbirth-related deaths are clustered around the time of birth and enhancing safety during this period is essential to optimizing maternal and newborn survival. This study highlights the existence of a high number of avoidable factors that exist across the continuum of childbirth (antenatal to delivery to postpartum/natal) as well as across orientation (patient-, administrative-, and health worker-related). Avoidable health worker-oriented factors were found in most studies. Further analyses on this dataset will further determine, quantitatively, the specific contribution of each avoidable factor and enable the development of informed intervention recommendations.