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

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. 

Consensus-based recommendation 7.5

The Perinatal Mortality Audit Committee should arrange for review of perinatal death to occur in a timely manner, aiming to have results in time for the initial follow-up visit with parents.

  • If test results are delayed, it may be necessary to re-review and arrange additional follow-up meetings with the parents to provide final results.

Step 2: Engage and communicate with parents

When a baby is stillborn or dies soon after birth, parents generally place a high value on information about the causes of and contributors to their baby’s death.42

Often, parents are not actively involved in the audit process,43 despite many parents indicating that they are willing to provide feedback on their care and want to know the audit cycle is taking place. In the UK, the PARENTS studies provide a model for how parents may be involved in the process.32-34

The PARENTS studies recommend that parents are provided with a face-to-face explanation of the audit process, supported by a written information leaflet, prior to hospital discharge.34 In the UK, this meeting is led by the senior healthcare professional responsible for care (such as an obstetrician, midwife or paediatrician) and/or a contact person such as a bereavement midwife/nurse who supports them through the audit process.44

Parents whose baby have died have the greatest stake in understanding why their baby died and what contributed to their baby’s death.42

“It really focussed the meeting on discussing what was important to the parents, which is not always what the healthcare professional would perceive is important to discuss.”

Healthcare professional.1

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

“I think having the support is crucial, but also having a voice to give your feedback on a process that you have been through is also really powerful, and it feels like you’ve been listened to…

Nothing can change the situation, but at least you think you might be able to help improve things in the future for other people, and that’s important”

Bereaved parent.1

The Australian Open Disclosure Framework can support open communication between healthcare professionals and parents during perinatal audit.45 Additional co-designed parent engagement materials to support healthcare professionals during this step of the audit cycle are currently under development. For further information, the Stillbirth CRE can be contacted via email: stillbirthcre@mater.uq.edu.au.

Consensus-based recommendation 7.6

Discuss the audit process with parents including how parents may be involved, and when, and how the results of the audit will be provided.

  • This should be conducted by an experienced healthcare professional, ideally the lead healthcare professional involved in the parents’ care or the known point of contact for each family/whānau (such as a bereavement midwife).

Consensus-based recommendation 7.7

Offer parents the option of providing a summary of events for presentation at the audit meeting either through a written summary using the Australian Perinatal Mortality Audit Tool, or local equivalent, and/or a healthcare professional presenting information on their behalf.

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 process4,36,40,55 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.

Evidence-based recommendation 7.8

Evidence quality: High confidence

Perinatal mortality audit committees should ensure the classification of causes and associated factors for stillbirths and neonatal deaths use the best available information from a comprehensive history and appropriate investigation (see Section 6: Investigations for perinatal death).

Consensus-based recommendation 7.9

The Australian Perinatal Mortality Audit Tool (or local equivalent) or the New Zealand Mother and Baby Rapid Reporting Forms for a Perinatal Death should be completed for each perinatal death in Australia and Aotearoa New Zealand, respectively, for purposes of committee review of the death and for relevant local and jurisdictional reporting requirements.

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

Consensus-based recommendation 7.10

The Medical Certificate of Perinatal Death should be completed by (or supervised by) the lead/experienced healthcare professional responsible for care around the time of the death in accordance with local requirements.

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

Evidence-based recommendation 7.11

Evidence quality: Moderate confidence

The perinatal mortality audit process should be overseen by a multidisciplinary committee including medical staff (obstetric and neonatal), midwives, nurses, a perinatal pathologist (where possible), and parent advocate.

“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).

Evidence-based recommendation 7.12

Evidence quality: Moderate confidence

The perinatal mortality committee chair must ensure audits are conducted in a no-blame environment.

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.

Evidence-based recommendation 7.13

Evidence quality: High confidence

Perinatal mortality audit committees should use the PSANZ Classification system to assign the underlying cause of death and up to two associated conditions for every perinatal death after consideration of all relevant clinical information.

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.

Consensus-based recommendation 7.14

The maternity service (ideally through a designated bereavement service) should ensure the death certificate is revised, when necessary, based on the outcome of the perinatal mortality audit meeting and ensure a revised copy is sent to the parents.

  • Parents should be informed by the lead carer (ideally a bereavement midwife) that they will receive a revised death certificate including the reasons for the revision.

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

Consensus-based recommendation 7.15

The perinatal mortality audit committee should consider areas for practice improvement in relation to every perinatal death and develop recommendations and an accompanying implementation plan where relevant. This should also include any recommendations for care of the woman in a subsequent pregnancy.

Step 6: Communicate and feedback to parents

The PARENTS studies recommend that parents are given a plain language summary of the outcome of the review conducted by the perinatal mortality audit committee.34 This feedback should be provided during a face-to-face follow-up meeting with the lead healthcare professional involved in the woman’s care (such as an obstetrician, midwife, paediatrician) and, where applicable, the specialised bereavement midwife/nurse who supported the family/whānau during the audit process.34 Early feedback to the woman’s general practitioner and other relevant healthcare professionals may also be important.41 Other key considerations in communication with parents at the face-to-face follow-up meeting include the following.

“I remember feeling that I couldn’t follow everything the doctor was saying about the possible reasons our baby died. I was able to ask her to explain it again in a way that made sense. And it was good to have the short summary that didn’t use all the complicated medical words”

Parent quote from the Guiding Conversations Booklet.

  • 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.

Consensus-based recommendation 7.16

A follow-up meeting with the parents, ideally with the lead healthcare professional involved in the woman’s care and the healthcare professional managing the perinatal mortality audit process (for example bereavement midwife or nurse), should be offered to discuss the outcome of the review by the perinatal mortality audit committee. More than one follow-up meeting may be required, depending on when the final results of investigations become available, and the audit committee finalises the review.

Evidence-based recommendation 7.17

Evidence quality: Moderate confidence

Parents should be offered a plain language summary of the outcome of the review of their baby’s case by the perinatal mortality audit committee. Ideally, this should occur during a face-to-face follow-up meeting with the lead healthcare provider, the bereavement midwife, and other relevant members of the health care team.

Consensus-based recommendation 7.18

A comprehensive clinical summary should be sent to the woman’s general practitioner and all care providers nominated to the parents after review by the perinatal mortality committee.

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).

Table 1. Questions for reflection on the implementation and maintenance of the audit system
  • How can review meetings be improved and used more effectively?
  • How often and to whom is feedback given?
  • What are the gaps in the feedback procedures?
  • How can the feedback to service providers and senior management in the facility be improved?
  • How can engagement in the audit process, the use of the findings and the application of recommendations be improved?
  • How can feedback outside the facility be improved, e.g. district or provincial levels, and community?
  • How can involvement from each of these levels be improved?
  • Who is responsible for keeping the audit system together, e.g. one person, a team, formally or informally designated?
  • Who is leading the audit?
  • Who takes responsibility when the leader(s) is/are not there?
  • What kind of succession plan do we have?
  • How do staffing issues such as rotations and turnovers influence the audit activities?
  • If lacking, how can staff stability be improved?
  • What is the facility’s responsibility in reaching out to another facility or facilities to introduce and establish an audit program?

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

Evidence-based recommendation 7.19

Evidence quality: Moderate confidence

Following the completion of the review by the perinatal mortality audit committee, the chair of the perinatal mortality audit committee or delegate should ensure a summary of the classification of causes and contributing factors relating to care is provided to the jurisdictional perinatal mortality committees for regional and national reporting.

Evidence-based recommendation 7.20

Evidence quality: Moderate confidence

The assigned classifications for causes and contributing factors relating to care should be included in the routine perinatal data collections across jurisdictions for every perinatal death to enable comprehensive reporting of perinatal deaths.

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.   

Consensus-based recommendation 7.21

National definitions for statistical reporting of perinatal deaths should be used to ensure consistency and comparability in perinatal death data across Australia and Aotearoa New Zealand. Reports of perinatal deaths should present data with and without the inclusion of perinatal deaths resulting from termination of pregnancy.

Part A: Audit framework
Section 7 references
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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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