Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review

BMC Pregnancy and Childbirth

Jonathan Spector⁶  Priya Agrawal⁴  Angela Lashoher⁵  Atul A Gawande³  Nathanael Hevelone¹  Stuart Lipsitz¹  Hasan S Merali² 

[1] Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA;The Hospital for Sick Children, 555 University Avenue, Toronto ON M5G 1X8, Canada;Ariadne Labs: A Joint Center at Brigham and Women’s Hospital and Harvard School of Public Health, Boston, MA, USA;Harvard School of Public Health, Boston, MA, USA;World Health Organization, Geneva, Switzerland;MassGeneral Hospital for Children, Boston, MA, USA

关键词: Mortality;    Death;    Factors;    Avoidable;    Perinatal;    Neonatal;    Fetal;    Maternal;   

Others  :  1125628
DOI  :  10.1186/1471-2393-14-280

 received in 2013-12-17, accepted in 2014-08-05,  发布年份 2014

【 摘 要 】

Background

Audits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries.

Methods

We performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews.

Results

Thirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified.

Conclusions

Audits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five.

【 授权许可】

   
2014 Merali et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

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