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Care Around Stillbirth and Neonatal Death (CASaND) Clinical Practice Guideline

Perinatal mortality audit and classification

Background

Understanding the causes of and factors contributing to perinatal deaths (stillbirths and neonatal deaths) is essential to prevent these deaths from occurring in the future and to help parents understand why their baby died and plan future pregnancies.1

Perinatal mortality audit captures information on the causes of deaths and analyses quality of care, in a no-blame interdisciplinary setting.2 Local perinatal mortality audit carried out within the hospital setting can improve care of women and their babies.3 Perinatal mortality audit programs including in-depth analyses of contributory factors (substandard care factors), can identify important areas for practice improvement to inform policy and clinical practice.4-13

National perinatal mortality audit programs have been implemented in Aotearoa New Zealand14, the UK15, the Netherlands,16 and Ireland.17 Contributory factors relating to access to care, the professional care received, and organisational/management factors were identified in 25% of perinatal deaths (excluding termination of pregnancies) in Aotearoa New Zealand during 2018.18 Approximately 13% of perinatal deaths were likely avoidable.18 Of the contributing factors identified, ‘barriers to access and/or engagement with care’ was the most common factor cited and was more frequent among Māori and Pacific mothers.18 

Australia is yet to establish a national perinatal audit program; however, state and territory committees produce regular reports on rates and causes of perinatal mortality.19-26 Around half the states and territories also conduct in-depth analyses of contributory factors at the jurisdictional level to inform practice improvements.27 Results from perinatal mortality classification and audit are included in national reporting by the Australian Institute of Health and Welfare.

In 2017–18, 37% of perinatal deaths in Australia had results from jurisdictional audits of contributory factors included in national reporting.27 Contributory factors relating to the woman, family/whānau, and social situation, relating to access to care and the professional care received, were identified in 21% of cases. Those factors were likely to have significantly contributed to the outcomes in 8% of cases. The proportion of perinatal deaths with contributing factors was much higher in an audit of deaths ≥34 gestational weeks in Queensland in 2018,8 contributing factors were identified in 71% of deaths and likely to have significantly contributed to the outcome in 30% of deaths.

Objective

This section provides guidance for frontline healthcare professionals and maternity services on optimal perinatal mortality audit, including classification of causes, associated conditions, and contributing factors relating to care.

A note about terminology

This guideline uses parent-centred language that is intended to be inclusive of all affected by loss. We use the term ‘woman’ throughout the guideline to refer to the person who is pregnant and gives birth.28 We acknowledge diverse gender identities and that not all individuals who become pregnant and give birth identify as a woman. The term ‘parent’ is used to refer to expectant and bereaved mothers, fathers, and partners. It is important to recognise individuals who identify themselves as parents. However, we also acknowledge that not all individuals who experience perinatal loss consider themselves to be parents.29

For perinatal mortality reviews to be effective, the system should not function as a blame process, but a process to learn from mistakes to prevent future perinatal deaths. 31

This guideline uses ‘baby’ when referring to stillbirth and neonatal death because these terms are preferred by many bereaved parents. Terms such as ‘fetus’ may add to parents’ distress because this language denies personhood30 and is inconsistent with recognition of parenthood that is crucial to providing respectful and supportive care. This guideline uses ‘healthcare professional’ to denote all those working with bereaved parents and family/whānau. Many healthcare professionals may be familiar with the term ‘audit’ when applied to perinatal deaths and mortality, while others are more familiar with the term ‘review’. This guideline uses both terms interchangeably.2 (see Glossary).

Resources

  • Appendix 7A: Australian Perinatal Mortality Audit Tool
  • Appendix 7B: New Zealand Baby and Mother Rapid Reporting Forms for a Perinatal Death
  • Appendix 7C: Sample mortality audit meeting code of practice declaration
  • Appendix 7D: PSANZ Classification System for Stillbirths and Neonatal Deaths (version 4)
  • Appendix 7E: PSANZ Classifications quick reference sheet (version 4)
  • Appendix 7F: PSANZ Classification System for Stillbirths and Neonatal Deaths (version 5)
  • Appendix 7G: PSANZ Classifications quick reference sheet (version 5)
  • Appendix 7H: Definitions of Australian state and territory and Aotearoa New Zealand reports on rates and causes of stillbirths and neonatal deaths

Section 6 appendices
Part A: Audit framework
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Western Pacific Regional Office of the International Stillbirth Alliance
Coordinating Centre, Stillbirth and Neonatal Death Alliance, Perinatal Society of Australia and New Zealand

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Mater Research Institute
Raymond Terrace,
South Brisbane QLD 4101
The University of Queensland Faculty of Medicine

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