Keywords
Perinatal mortality, stillbirth, neonatal death, review tool, surveillance and response, protocol
This article is included in the Maternal and Child Health collection.
Perinatal mortality, stillbirth, neonatal death, review tool, surveillance and response, protocol
Please see below detail on the changes and updates made to the manuscript on this updated version:
See the authors' detailed response to the review by Rachidatou Compaoré
See the authors' detailed response to the review by Ruby Barnard-Mayers and Collette N Ncube
“The day of birth is potentially the most dangerous day for both mothers and their babies” according to the World Health Organisation (WHO)1. While significant reductions have been made in neonatal mortality in the last two decades, there are still an estimated 2.7 million neonatal deaths every year. It is worth noting that there are also an estimated 2.6 million stillbirths every year, a fact that does not feature as prominently in the Sustainable Development Goals (SDG) published by the United Nations in 20162. Although the SDG 3.2 includes a target reduction in neonatal mortality to 12/1,000 livebirths by 2030, there is no clear reference to a reduction of stillbirth rates in this document2.
Perinatal mortality includes stillbirths (both antepartum and intrapartum stillbirths) and early neonatal deaths (death of a live born infant occurring within the first seven days of life). The perinatal mortality rate (PMR) of a country is a key indicator of the quality of maternity services available in that country3,4. In 2019, a stillbirth rate of 3.0/1000 livebirths and a neonatal death rate of 2.9/1000 livebirths was reported5,6. Perinatal death surveillance is a powerful approach towards monitoring and improving healthcare services4. A perinatal death is considered in many countries to be a sentinel event, which is defined in the United States (US) by the Joint Commission as a patient safety event that results in death, permanent harm, or severe temporary harm7. In an Irish context, a perinatal death is considered a serious reportable event, which is defined as a subset of incidents which are either serious or that should not occur if the available preventative measures have been effectively implemented by healthcare providers8. In recent years, there has been a greater focus on auditing and reviewing the circumstances surrounding the perinatal death with particular emphasis on the role of system factors in the death1,8–10.
In support of this, and to emphasise the importance of multi-factor review of perinatal deaths, the WHO published guidance on the establishment of maternal and perinatal death surveillance and response (MPDSR) committees at a local level in 20219. The value of comprehensive review of perinatal deaths has already been established in several high-income countries around the world10,11. This includes the United Kingdom (UK), where the perinatal mortality rate (PMR) has reduced by 18% from 2012–2018 with the introduction of several targeted measures, one of which is a perinatal mortality review tool (PMRT)12. Review tools, as part of this process, allow for a more streamlined approach to identification of risk factors and care-related issues. Similarly, the Netherlands established the Foundation National Perinatal Audit (PAN) programme in 2010 (now known as PERINED), which standardised the perinatal death review process, and helped to reduce their PMR by 18% during the years 2010 to 201513.
While it is extremely important to capture data on number and causes of perinatal deaths, it is also of vital importance that review of perinatal deaths encompasses the identification of modifiable factors in those deaths. Modifiable factors are defined by the WHO as a factor “that may have prevented the death had a different course of action been taken”1,9. Identification of remediable factors forms part of the WHO’s MPDSR cycle. It is only through reviewing quality of care that quality improvements and changes to clinical care can be enacted, thereby completing the cycle1. The importance of evaluating the quality of care through structured review has been highlighted repeatedly by MBRRACE-UK, whose confidential enquiry and national audit is often viewed internationally as a gold standard10. The quality of institutional review was more recently emphasised in the Ockenden Report, which reviewed the maternity services at a hospital group in the UK14. Recommendations from this report included strengthened accountability amongst senior maternity staff, timely implementation of changes in practice following review of care and improving family engagement in investigations.
There is no international consensus on the optimum way to conduct perinatal death reviews that factor in all of the above-mentioned aspects of the review cycle. A 2020 Cochrane systematic review of death audits for reducing maternal, perinatal and child mortality concluded that more research is required in order to identify how death reviews should be designed and implemented in order to achieve maximum effectiveness in different contexts globally3.
While there are some support materials for maternal and perinatal death review included in the MPDSR guidance document published by the WHO in 2021, many of the examples given focus largely on maternal death reviews and surveillance9. Included information on perinatal death reviews, for example the sample stillbirth and neonatal death case review form, provides limited information and lacks the detail required to identify risk and contributory factors. which is possibly not as suited to countries who may have access to larger dataset and information on each perinatal death.. There is a need to identify what standardised tools (if any) are in use internationally for the review of perinatal deaths that may be more suitable for use in high-income, resource-rich settings.
The evidence for appraisal or comparison of review tools for perinatal deaths is lacking in the literature. This is particularly the case for review tools in use in high-income settings that incorporate the development and implementation of recommendations for clinical practice and governance. In addition, this analysis may aid policy-makers and stakeholders who seek to implement a standardised review tool to evaluate perinatal deaths in their own institution or country.
The primary aim of this systematic review is to examine standardised tools used to review perinatal deaths.
Identify tools or other standardised checklists, forms, frameworks or other documents that are currently in use or have been piloted for use in reviewing perinatal deaths.
Describe the structure of identified perinatal review tools and if they generate data or information on modifiable factors contributing to perinatal deaths.
Assess if identified facilitators and barriers to the implementation of standardised perinatal mortality review tool.
Examine evidence of validation or accreditation of the tool identified.
As part of this systematic review, we will also study the development of recommendations for clinical care generated as part of the use of standardised tools to review perinatal deaths and examine the evidence that employing these tools may contribute towards a reduction of perinatal mortality rates at institution, region or country-level.
This protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (protocol number: CRD42022326877) and is reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic review and Meta-Analysis – Protocols (PRISMA-P) 201515; the completed checklist is available as part of the extended data for this project.
The eligibility of review tools will be based on inclusion and exclusion criteria applied to the SPIDER framework (S: sample, PI: population of interest, D: study design, E: evaluation, R: research type), developed by Cooke et al. and outlined in Table 116.
SPIDER Framework | Eligibility Criteria |
---|---|
S: Sample | – Review of perinatal deaths (stillbirths and/or early neonatal deaths) occurring in maternity units or hospitals – Standardised review tools used, in use or piloted for use at local, regional or national level – Upper-middle-income to high-income countries as defined by the World Bank 2022 (N=135)18 |
PI: Phenomenon of Interest | – Perinatal mortality: stillbirths (antepartum and intrapartum) and early neonatal deaths – Definition according to each country |
D: Study Design | – Any study, report or other publication detailing the current use or trial of use of a standardised review tool to review individual perinatal deaths or perinatal mortality as a whole – No language restriction – No date restriction |
E: Evaluation | – Structure, content and format of perinatal mortality review tools – Standardisation or validation of the review tool – Development of recommendations based on identified remediable factors based on the review of perinatal deaths – Evidence of reduction in perinatal mortality rate (PMR) in the relevant institution, region or country – Facilitators and barriers encountered in the implementation of the perinatal mortality review process |
R: Research type | – All relevant study types involving the use of a standardised tool to review perinatal deaths will be included, including both quantitative and qualitative studies – Grey literature including publications from national or international scientific societies, professional colleges, charitable organisations, and government organisations |
The definition of stillbirth varies widely internationally. The WHO identifies the following definition for stillbirth: “death before birth, among fetuses that are, by order of priority, of at least 1000g birthweight, and/or at least 28 weeks gestation, and at least 35cm long.”9 Some countries use lower thresholds for both gestational age and weight at birth to define stillbirth (for example, a fetus that has reached greater than or equal to 24 weeks’ gestation or weighing greater than 500g at birth)17. As the term “perinatal mortality” is generally accepted to encompass stillbirths (antepartum and intrapartum) and early neonatal deaths, this definition also varies internationally. For the purposes of this systematic review, a country’s own definition of perinatal mortality, stillbirth and early neonatal death will be used when searching for tools used to review perinatal deaths.
Literature focused on tools form upper-middle-income to high-income countries to allow better comparability and ensure that the tools apply to settings with somewhat similar characteristics and level of resources.
In addition, the search will not be restricted by language, date of publication or type of study.
The identification of relevant perinatal mortality review tools will encompass a multi-tiered approach. Systematic bibliographic database searching will identify review tools that are in use or have been piloted for use at a local, regional or national level by individual hospitals, hospital groups or committees. This includes identifying review tools published in journals, through professional medical associations and organisations, or identified through searches of grey literature.
A systematic literature search will be performed to identify publications describing the use of perinatal mortality review tools using the following databases: PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and OpenGrey. Websites of international scientific institutes, organisations & professional societies, listed in Table 2, will also be searched. Other professional organisations will be added to this table if applicable as the search progresses.
A search strategy will be developed by the study investigators. The search strategy will include suitable keywords relating to perinatal mortality reviews. The terms will be followed by the truncation symbols * and will be refined using Boolean operators such as AND/OR. The initial search will be limited to screening titles and abstracts rather than full bibliographic records. The search strategy will be similar for all databases (with the same search terms and combinations) with exceptions for where a a specific database criteria requires a tailored approach. An example of search strategies developed for use in scientific databases is included in Supplementary File 1. The search strategy will be piloted before the final searches are executed.
For the bibliographic database search, two reviewers will screen titles and abstracts against the inclusion and exclusion criteria outlined below.
Inclusion criteria:
Perinatal mortality review tools from upper-middle- to high-income countries as classified by the World Bank Country and Lending Groups 2022 (N=135)18
Review tools for perinatal deaths currently in use or review tools that have been piloted for use in individual maternity units or hospitals, or in hospital groups
Review tools for perinatal deaths in use at local, regional or national level
Review tools for perinatal deaths that include a recommendation section for changes to clinical practice, guidelines, and/or governance
Tools that are used in the review of individual perinatal deaths or tools that are used for reviewing a grouping of perinatal deaths (e.g. intrapartum stillbirths or stillbirths caused by placental abruption)
Review tools available in any language
No date restrictions
Exclusion criteria:
Tools previously used to review perinatal deaths that are no longer in use or have been decommissioned or replaced
Lower-middle- and low-income countries as classified by the World Bank Country and Lending Groups 2022
Publication does not include the review or audit tool nor enough relevant information on this in the published material, or the review tool cannot be accessed by other means (e.g. direct contact with the study authors, or the governing group)
For screening of websites, two independent reviewers will screen the websites for the scientific institutes, organisations & professional societies outlined above. The titles and abstracts (where applicable) will be reviewed against the inclusion/exclusion criteria outlined above. The methodology for this website screening follows the process previously described by Hennessy et al. (2021) in their research19.
Results from both the scientific databases and the website screening will be imported using Rayyan software20 and duplicates will be removed. Title and abstract (or summary) screening will be carried out in this software using the blinding feature during the review period. When abstracts are not available, the summary of the document will be used. If summaries or preliminary information on the document is not available, a brief screening of the full record will be carried out. The SPIDER framework will be applied broadly during the initial screening to ensure relevant perinatal mortality review tools are not excluded. Full text articles of publications identified through screening of titles and abstracts will be retrieved and assessed independently for eligibility by the two reviewers. Disagreement between the two reviewers regarding the eligibility of any study will be resolved following discussion and consensus. If consensus on eligibility is not reached, the opinion of a third reviewer will be sought.
A PRISMA flow diagram will be used to illustrate the search process. This diagram will map out the process for review tool selection and the number of records identified at each stage based on the inclusion and exclusion criteria.
Once the review tools for inclusion have been obtained, all associated supplementary documents will be retrieved by the reviewer (EOC) prior to data extraction and quality assessment. If links to these documents are not provided within the article, website or other source, EOC will conduct a search to locate them. All supplementary documents will be verified by a second reviewer to ensure completeness and correct document pairing.
Data extraction will be completed by one reviewer (EOC) and will be independently verified by a second reviewer for accuracy and completeness. A standardised, pre-piloted form in Microsoft Excel will be used to extract data from the identified perinatal mortality review tools for assessment of quality and data synthesis. Discrepancies will be resolved through discussion and consensus. If consensus cannot be reached, the opinion of a third reviewer will be sought. Any missing information from the review tools will be recorded as ‘not described’ in the data extraction form.
The following information will be extracted from identified perinatal mortality review tools:
Description of document provided by the authors (e.g. guideline, review tool, audit tool)
Composition of tool development group, if applicable
Evidence of peer review or validation
Target user of the review tool
Type of perinatal death reviewed by the tool (e.g. all perinatal deaths, intrapartum stillbirths only, or early neonatal deaths only)
Document structure (including subsections, type of data collected, length of document)
Development process (evidence based and/or consensus-based)
If a recommendation development section is included, data extraction will include the structure of the recommendation section
Appraisal of recommendations based on SMART principles (Specific, Measurable, Achievable, Relevant, Time-bound)21
Framework used for the development of recommendations, e.g. the Yorkshire framework22
Validity period, if specified
The quality of the included review tools will be appraised using the Appraisal of Guidelines Research and Evaluation Health Systems (AGREE-HS) tool23. This tool was developed by the AGREE research team to systematically appraise health systems guidance (or guideline) documents produced by countries, governing bodies or committees at national, regional or local level. Two reviewers will independently conduct the quality assessment of the review tools using AGREE-HS. This tool focuses on five key domains that form part of the development of health systems guidance:
Each domain is applied to the guidance document (in this case, the perinatal mortality review tool) and scored using a 7-point Likert scale, with scores ranging from 1 (lowest quality) to 7 (highest quality). A final score for the overall quality of the review tool will be calculated by totalling the individual scores for the five domains. If consensus cannot be research during appraisal (i.e., if individual scores from each reviewer differ more than 2 points), a third reviewer (KOD) will assist with the appraisal process. The final scores will be used to help interpret the guidance documents being appraised by identifying review tools of higher and/or lower quality. The quality appraisal outcomes will not affect the literature that will be included in the data synthesis.
Data synthesis will involve a descriptive approach to appraisal and examination of perinatal mortality review tools. The appraisal will be conducted using the AGREE-HS tool, as described above. There will be a narrative description of the data extracted from the perinatal mortality review tools, as well as a specific focus on those tools that include a section on the development of recommendations based on the review findings (if applicable).
The aim of this systematic review is to identify and appraise standardised review tools that are currently in use or have been piloted for use in reviewing perinatal deaths. Consistent review of the modifiable factors around perinatal deaths and implementation of recommendations developed from the review may help to prevent future perinatal deaths and reduce a country’s PMR. There is a need to identify what standardised review tools are being used to review perinatal deaths, particularly in a high-income, resource-rich setting and appraise and compare the tools. The findings from this systematic review may help in the implementation of a targeted perinatal death review program.
We plan for this systematic review of perinatal mortality review tools to be disseminated through peer-reviewed publication and presentation at relevant professional and scientific events.
Open Science Framework: A protocol for a systematic review of standardised tools used in perinatal death review programmes, https://doi.org/10.17605/OSF.IO/PVKX724.
This project contains the following extended data:
Open Science Framework: PRISMA-P checklist for “A protocol for a systematic review of standardised tools used in perinatal death review programmes”, https://doi.org/10.17605/OSF.IO/PVKX7.
Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Epidemiology, Maternal and Child Health
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Public health, sexual and reproductive health, quality of care, health policy and systems research, process evaluation
Is the rationale for, and objectives of, the study clearly described?
Partly
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Partly
Are the datasets clearly presented in a useable and accessible format?
Not applicable
References
1. Methley AM, Campbell S, Chew-Graham C, McNally R, et al.: PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews.BMC Health Serv Res. 2014; 14: 579 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed.
Reviewer Expertise: Epidemiology, Maternal and Child Health
Is the rationale for, and objectives of, the study clearly described?
Partly
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Partly
Are the datasets clearly presented in a useable and accessible format?
Not applicable
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Public health, sexual and reproductive health, quality of care, health policy and systems research, process evaluation
Alongside their report, reviewers assign a status to the article:
Invited Reviewers | ||
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Version 1 13 Jul 22 |
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