Part B: 8-step audit cycle

Step 1: Identify cases

A perinatal death audit should be undertaken as soon as results are available from initial investigations, so that it occurs within recent memory of those involved and enables information from the audit to be discussed with the parents, ideally at their routine hospital follow-up visit. Timely audit of the death may also facilitate appropriate counselling and support for staff.⁴⁰ If subsequent investigations change the findings of the initial investigations, further review of the death by the mortality committee may be required. 

Step 2: Engage and communicate with parents

Following hospital discharge, the PARENTS studies suggest that parents are contacted via post/email with information on how they can provide feedback.³⁴ This can be followed up with a phone call to discuss the feedback process and a home visit to go through their feedback.³⁴ If a home visit is declined, the option to receive feedback by telephone, email or post can be offered.³⁴ In the UK, this process is coordinated by the bereavement midwife/nurse⁴⁴ who will complete the feedback form with the parents.⁴⁴ Parents may opt to have the bereavement midwife or nurse represent them at the audit meeting.^34,44

Taking an individualised approach enables parents to contribute to the audit process if and as much as they wish.^32,34

Step 3: Collect information

Perinatal mortality audit should incorporate an evaluation of the medical notes,^46,47 clinical investigations,^12,48-58 input from the healthcare professionals involved in the case, and thorough history from the woman (and their partner) on the care they received and events leading to the death.^32-34 Healthcare professionals should ensure that all relevant clinical details are documented clearly and accurately in the medical record at the time of the event.¹¹ Notes should be obtained from private healthcare professionals, if applicable.

Transportation of the baby to a centre with appropriate perinatal pathology expertise may be warranted where this expertise does not exist in the birth facility, which may be the case in rural and remote settings.^59,60 Communication with a multidisciplinary team at tertiary centres should be established to ensure that any opportunities to gather information or investigations that can be performed locally are not missed. Refer to Section 6 for guidance on the appropriate investigations and parent-centred decision-making and communication around their options for investigations.

Standardised perinatal audit tools are recommended to facilitate the data collection process^4,36,40,55 and may overcome issues of inaccurate or incomplete reporting of clinical data and nonstandard audit methods.^3,4,61 The Australian Perinatal Mortality Audit Tool (APMAT) (Appendix 7A¹¹) and the New Zealand Mother and Baby Rapid Reporting Forms for a Perinatal Death (Appendix 7B) have been designed to capture a standardised dataset to facilitate the identification of causes of and factors contributing to perinatal deaths in Australia and Aotearoa New Zealand, respectively. Feedback from parents and healthcare professionals involved in the case should be recorded in the case summary sections of the APMAT and Rapid Reporting forms.

Death certificates

The Royal College of Pathologists of Australasia recommends that death certificates are issued or supervised by the lead healthcare professional responsible for care.⁶² A recent study in Russia recommends that a medical practitioner responsible for care around the time of death should complete the death certificate, and in their absence, a midwife or paramedic should complete the death certificate.⁶³ Healthcare professionals should familiarise themselves with local reporting requirements for death certificates.⁶⁴

Step 4. Review and analyse the information

Generally, perinatal mortality audit meetings should review all perinatal deaths occurring in that hospital. Maternity and newborn services (particularly smaller hospitals) may choose to combine audit meetings with another hospital committee or a regional mortality review committee.

Multidisciplinary participation 

Perinatal mortality committee members (see Part A Development of an Audit Framework) attend and oversee each Perinatal Mortality Audit meeting where individual perinatal deaths are reviewed in detail. In addition, healthcare professionals familiar with the circumstances of a particular perinatal death should be notified promptly of the perinatal mortality review meeting and invited to attend the case review.³⁴ At a minimum, the lead consultant, obstetrician, neonatologist, midwives, nurses, pathologist, and parent advocate should attend the perinatal mortality review meeting.^3,34

“No blame” principle

For perinatal mortality reviews to be effective, the system should function as a process to learn from mistakes to prevent future perinatal deaths rather than as a blame attribution process.^36,65,66 The chairperson should be skilled in chairing meetings of a highly sensitive nature.³⁴ While an experienced medical practitioner usually fulfils the role of chairperson, it is also important to involve nurses and midwives in this role.²

Having participants agree to a code of practice² that ensures confidentiality⁶⁵ can help ensure a blame-free environment (see Appendix 7C: Sample mortality audit meeting code of practice declaration).

Classification system

More than 80 classification systems for causes of perinatal death have been reported globally,⁶⁷ none of which is clearly superior (see Section 7: Technical report for perinatal mortality audit and classifications for further information). The WHO recommends the use of the WHO–ICD for perinatal mortality (ICD-PM),² which uses ICD rules and classifies a single underlying cause of perinatal death based only on death certificate data. While the ICD-PM holds promise for consistent global reporting of causes of perinatal death, the system has limitations,^50,68,69 particularly for well-resourced settings where more information is available to allow more specific classification of causes.⁶⁷

The PSANZ Classification System for Stillbirths and Neonatal Deaths (Appendix 7D and 7E) is currently used across Australia and Aotearoa New Zealand to classify causes of perinatal death.^19-27 The PSANZ Classification System was first released in 2003, and subsequently revised in 2004, 2009, and 2018. The current version for use is version 4. Version 5 has been finalised and is intended for use across Australia and Aotearoa New Zealand for perinatal deaths occurring for births from 1 January 2025. The PSANZ Classification System performs well against other systems⁷⁰ and until further enhancements are made to the ICD system, the PSANZ Classification System remains the recommended system for causes of perinatal deaths in Australia and Aotearoa New Zealand.

The key principles of the PSANZ Classification System are:

• to identify an underlying cause of death for stillbirths and neonatal deaths
• to identify up to two associated conditions for stillbirths and neonatal deaths.

Determining the cause of death and presence of contributing factors relating to care

A standardised approach to data collection, using tools such as the Australian Perinatal Mortality Audit Tool (APMAT) (Appendix 7A) and the New Zealand Mother and Baby Rapid Reporting Forms (Appendix 7B), may facilitate the identification of causes and contributing factors for perinatal deaths during audit meetings.^4,8,39The APMAT also contains a “Contributory Factors Relating to Care” component to systematically classify the types of contributing factors present and their relation to the death. Use of the APMAT in Queensland has found that the tool is helpful in identifying the underlying causes of stillbirths¹¹ and identifying contributing factors relating to care (substandard care factors).⁸ Contributory factors were found to have significantly likely contributed to 35% of perinatal deaths audited using the APMAT in one of the study cohorts (n=56).⁸ The review of contributing factors should consider recommendations of a facility-based root cause analysis, if one was conducted.^71,72

Refer to Consensus-based recommendation 7.9.

Revision of perinatal death certificates

Perinatal death certificates are often issued prior to the results of investigations becoming available,³⁹ which may result in significant error in cause-of-death data. In a recent cross-sectional audit in the UK, almost 80% of medical certificates of stillbirth contained errors and 43% were registered as “unknown cause of death”.⁷³ Review of autopsy and placental histopathology during perinatal audit can provide additional information on the cause of death.^{48-54,56,57,74} This guideline recommends that death certificates are reviewed during perinatal mortality audit meetings and revised if required.⁶³ As the process of revising death certificates varies across Australia and Aotearoa New Zealand, each Perinatal Mortality Committee should become familiar with the process within their region and implement a process that ensures that a revised death certificate is submitted if required, and that parents are advised of this.

Step 5: Recommend solutions to improve quality of care

The development of recommendations linked to action plans with clear targets is an important step of the audit cycle that is often missed.^3,4,31 The WHO Making every baby count: audit and review of stillbirths and neonatal deaths guideline recommends the development of SMART solutions (specific, measurable, action-orientated, realistic, and time-bound) to help ensure the proposed actions are achievable.⁷⁵

Step 6: Communicate and feedback to parents

• Where possible, someone with specific expertise in interpreting the results of perinatal death investigations and providing feedback on the outcome of the audit review should also attend the meeting with parents.
• Schedule the meetings after all relevant test results are available and following perinatal mortality audit meeting review.
• Inform parents if the results of key investigations (such as autopsy) will not be available at the time of the scheduled meeting and offer them an additional or alternative time to receive those results.

For cases of a congenital anomaly, it may be appropriate to discuss the need for genetic counselling with a geneticist prior to the follow-up appointment with the lead healthcare professional who provided the woman’s care. The geneticist can either attend the follow-up consultation or offer a genetic counselling consultation. Depending on the results of the initial investigation, it may also be necessary to arrange further tests. See Section 6: Investigations for perinatal deaths.

Step 7: Implement changes into clinical practice

Systematic reviews report failure to implement change as a common reason for healthcare professionals’ reluctance to participate in the audit process, and a major challenge to effective perinatal audit.^3,4,66 The perinatal mortality audit cycle needs to be completed by implementing and re-evaluating recommended changes to reduce perinatal deaths.³¹

A process of feedback to healthcare professionals should be established, to ensure recommendations from perinatal audit inform clinical practice and hospital policy.^4,36 Educational meetings, in addition to the perinatal mortality audit meetings, which engage a wider group of healthcare professionals across the hospital service may be helpful in translating findings from the audit into practice. The Australian Commission on Safety and Quality in Health Care recommends using the plan-do-study-act (PDSA) cycle to improve clinical practice.⁷⁶

Step 8: Evaluate and refine the process

The WHO Making every baby count: Audit and review of stillbirths and neonatal deaths guideline² recommends a final step in the audit cycle to evaluate the success of the audit processes undertaken. An electronic data system can enable easy access to aggregate data to assess time trends in rates and causes of perinatal deaths and contributing factors.⁴⁴ The WHO guideline² has questions to help users assess and reflect on progress (Table 1).

National and international reporting considerations

Hospital-based perinatal audit programs should be supported by, and feed into, regional and national audit programs to inform high-level changes in national policy and clinical practice.^31,77 In Aotearoa New Zealand, the Perinatal and Maternal Mortality Review Committee has produced annual reports with national recommendations for raising public awareness of perinatal mortality risk factors, detecting fetal growth restriction, preventing preterm birth, and resources for data collection and review.¹⁴ The Perinatal and Maternal Mortality Review Committee has also conducted in-depth reviews of the investigation and management of cases of neonatal encephalopathy. From 1 July 2023, the National Mortality Review Committee will be responsible for reviewing and reporting on perinatal mortality in Aotearoa New Zealand. In Australia, a national audit program is yet to be established; however, state and territory committees report on rates and causes of perinatal mortality. Some state and territory committees also conduct in-depth reviews of a sample of defined cases to identify possible contributing factors relating to care to inform practice improvements.^19-27

Definitions

Differences in definitions impede comparable national and international reporting of perinatal deaths.^4,52,78-80 The WHO defines stillbirth as a baby born with no signs of life at ≥22 weeks of pregnancy but recommends 28 weeks’ gestation as the lower limit for international comparison of stillbirth rates.⁸¹ However, only including stillbirths from 28 weeks gestation may underestimate the true burden of stillbirth,⁸² and countries continue to use their own definitions.^31,80 Differences in the lower limit of gestation for classification of stillbirth and the inclusion/exclusion of late termination of pregnancies, affects national perinatal mortality rates.^31,80 In Australia, gestational age and birth weight cut offs, and the inclusion/exclusion of terminations in reported rates of perinatal mortality is inconsistent across states and territories;^19-26 some jurisdictions report fetal deaths of at least 20 weeks gestational age or at least 400g birthweight, other jurisdictions report fetal deaths of at least 20 weeks gestational, or if gestational age is unknown, at least 400g birthweight. Inclusion of perinatal deaths resulting from termination of pregnancy in perinatal mortality statistics is also variable. Please refer to Appendix 7F for regional definitions reported across Australia and New Zealand.  To ensure consistency and comparability within Australia and Aotearoa New Zealand, these guidelines recommend that reporting of stillbirths and neonatal deaths adhere to the recommended definitions from the Australian Institute of Health and Welfare⁸³ and the Perinatal and Maternal Mortality Review Committee.¹⁴

It should be noted that the definitions for the registration of perinatal deaths across the different perinatal data collections in Australia may differ from that recommended for statistical purposes. Healthcare professionals should be aware of the definitions for registration of perinatal deaths and of their requirements for reporting a perinatal death in their jurisdiction.