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Table 1 Challenges and potential solutions to scaling up perinatal mortality audit by health system building blocks.

From: Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby

Health system building block Challenges Potential solutions
Leadership and governance • Absence of a national policy or strategy on audit • Lack of data collection tools mortality audit meeting guidelines • Lack of prioritisation of audit by policymakers • Culture of blame and fear of potential legal ramifications • Lack of awareness and use of data by government officials • No champions • National policy with clear implementation plan and decision-tree based on entry-points and system capacity • Standardised tools (paper-based and electronic) available for adaptation at global level • Training for facilitators both integrated into intrapartum care training and stand-alone • Legal protection • High level buy-in for collection and use of data (e.g. from President or Minster of Health)
Health finance • Lack of funding for audit tool development locally • Training and supervision not currently budgeted • Software and electronic platforms may pose additional financial burden • Opportunity cost of audit committee meetings • Advocate for inclusion of audit in budget for national and sub-national quality improvement processes • Cost the additional benefit of removing avoidable factors in comparison to extra time spent dealing with missed opportunities
Health workforce • Overburdened staff do not have time for meetings • Fear of blame, inter-disciplinary mistrust and professional power hierarchies • Identify champions to lead and participate in the audit committee who will engage not antagonise • Legal protection and confidentiality
Essential medical products and technologies • Stationery not available for patient records necessary to complete audit • Lack of electronic system means paper-based forms lost, or data not aggregated and shared • Prioritise stationery procurement • Develop easy to complete patient charts and checklists • More effective records management and retrieval
Health service delivery • Administration is responsible for many of the necessary changes outside of health worker control • Ensure facility administrators are members of the audit committee with responsibility to attend meetings periodically if not always • District administrators receive specific, actionable requests from the audit committee
Health information system • Lack of a centralised database for compiling audit results • No system for notification of perinatal deaths at any level • Poor capacity to use and interpret statistics and create actionable recommendations • Where practical, consider the use software that generates run chart data, simple graphs, and provides prompts and checklists for addressing recommendations arising from audit
Community ownership and partnership • Community representatives are rarely engaged in the audit process or informed of the findings • Only facility deaths captured; inequitable representation of true burden of disease and avoidable factors in the community • Engage a community liaison as a standing member of the audit committee with appropriate confidentiality requirements • Consider community surveillance to inform about perinatal deaths that occur outside the facility and conduct verbal and social autopsy, where feasible