Table AI A summary of literature...

Table AI

A summary of literature synthesis

Author/year of publication	Title of the paper	Methodology	Aims of research	Summary
1. Abebe et al. (2017)	“We identify, discuss, act and promise to prevent similar deaths”: a qualitative study of Ethiopia’s maternal death surveillance and response system	A qualitative case study using key informants	The study interviewed frontline MDSR implementers in four largest zones in Ethiopia to find out their experiences of the first 2 years of MDSR, including perceptions of its introduction and outcomes for health services	In Ethiopia, the strong political support of MDSR with the broader health strategies and health systems was a facilitator to its implementation. Staff turnover, fear of legal repercussions and a lack of understanding of the purpose of MDSR were some of the barriers experienced at its onset
2. Agaro et al. (2016)	The conduct of maternal and perinatal death reviews in Oyam District, Uganda: a descriptive cross-sectional study	A cross-sectional mixed methods study	To examine the factors that influence the conduct of maternal and perinatal death reviews in Oyam District, Uganda	Findings showed a low participation of health workers in MPDR (34.8%). MPDR committees (p <0.001), attendance of review meetings (p <0.001), and lack of knowledge on the MPDR objectives (p<0.001), implementation of MPDR recommendations (p<0.001), observed improvement in maternal and new-born care (p<0.001) and provision of feedback (p<0.001) as enabling factors in enhancing audit meetings. Factors that hindered conducting MPDR included: lack of information among health workers about MPDR process, committee formation and training of MPDR committee, lack of supervision, and lack of financial motivation of MPDR committee members. Challenges to MPDR included: heavy workload to health workers, high number of perinatal deaths, and non-implementation of recommendations
3. Allanson and Pattinson (2015)	Quality-of-care audits and perinatal mortality in South Africa	Analysis of secondary data from 29 community health facilities, 105 district hospitals, 4 national central hospitals, 22 regional hospitals and three provincial tertiary hospitals	To determine how perinatal mortality rates had changed in health care facilities participating in the perinatal problem identification program	After five years of continuous audits in 163 facilities, findings revealed that there were reductions in perinatal mortality in 48 facilities. Facilities with high perinatal mortality rates attributed that to patient delay in seeking health care when the baby was sick, lack of use of antenatal steroids, lack of nursing personnel and data distress
4. Alexandre et al. (2009)	Improving obstetric care in low-resource settings: implementation of facility-based maternal death reviews in five pilot hospitals in Senegal	Qualitative approaches using multimethods	“[…] to explore and describe health workers’ perceptions of facility-based maternal death reviews and to identify barriers to and facilitators of the implementation of this approach in pilot health facilities of Senegal”	Using focus group discussions, participant’s observations of audit meetings, audit documents and interviews with staff, the study aimed to explore health professional’s barriers to and facilitators to the implementation of facility-based maternal death reviews. The study was conducted in varied hospitals context in Senegal where MDRs had been implemented in 2004–2015. Barriers to implementation of facility-based mortality audits were poor quality of information in the patient’s files, lack of feedback to non-attending staff, and senior managers lack of participation. Facilitators including experienced data professionals, the availability of maternity unit manager to participate as well as moderate the meetings and staff in attendance willing to participate in the discussions
5. Angelo et al. (2010)	Factors for change in maternal and perinatal audit systems in Dar as Salaam hospitals, Tanzania	Qualitative interviews	To assess the structure, process and impacts of maternal and perinatal death audit systems in clinical practice in order to provide insights on how they could be assessed	Maternal and perinatal audit systems existed only in 4 and 3 hospitals respectively, and key decision makers did not take part in audit committees. Sixty percent of care providers were not aware of even a single action which had ever been implemented in their hospitals because of audit recommendations. There were neither records of the key decision points, action plan, nor regular analysis of the audit reports in any of the facilities where such audit systems existed
6. Armstrong et al. (2014)	Strengths and weaknesses in the implementation of maternal and perinatal death reviews in Tanzania: perceptions, processes and practice	Reviewed the national MPDR guidelines and conducted a qualitative study using semi-structured interviews	To review national policy documentation and explore stakeholders’ involvement in, and perspectives of, the role and practices of MPDR in district and regional hospitals, and assessed current capacity for achieving MPDR	There are gaps in the current MPDR system. Responses showed differential understanding of the purpose of MPDR. Thus, the current MPDR do not function adequately or perform quality reviews. Facility-based maternal and perinatal death data are not sufficiently captured and appropriate challenges and solutions at the facility level that could inform learning are not well documented. Staff are committed to the process of maternal death review, with routine documentation and reporting, yet action and response are insufficient
7. Belizan et al. (2011)	Neonatal death in low- to middle-income countries: a global network study	Observational study	To determine a population-based mortality rates in low and middle-income countries	Deaths were rampant in babies below 37 weeks or shortly after birth. Better access to medical care hospitalization in the intrapartum and early neonatal period could improve maternal and neonatal outcomes
8. Bakker et al. (2011)	Health workers’ perceptions of obstetric critical incident audit in Thyolo District, Malawi	Qualitative research entailing semi-structured interviews with 25 district health workers, a focus group discussion and observation of audit sessions in health facilities in Thyolo District, Malawi, between August 2009 and January 2010	To examine local health workers’ perceptions about obstetric audit and assess the impact of audit and feedback on their work satisfaction and motivation	Health workers were familiar with the concept of audit. Audit was deemed as a helpful tool to improve the quality of care. There is a need for audit to be performed in a manner that enhances motivation and on-the-job learning
9. Combs Thorsen et al. (2014)	Easier said than done! Methodological challenges with conducting maternal death review research in Malawi	Critical reflection	The aim of this paper is to critically reflect upon the process used to carry out a facility-based maternal death review study, while highlighting challenges and providing recommendations on how best to overcome these challenges	Challenges experienced were: (1) identification of cases: conflicting maternal death numbers, and missing medical charts, (2) data collection: poor record keeping, poor quality of documentation, difficulties in identifying and locating appropriate health care workers for interviews, the potential introduction of bias through the use of an interpreter, and difficulties with locating family and community members and recall bias; and (3) data analysis: determining the causes of death and clinical diagnoses
10. Hofman and Mohammed (2014)	Experiences with facility-based maternal death reviews in northern Nigeria	Mixed methods, including a review of MDR forms, health management information system data on maternal deaths (MDs), as well as semi-structured interviews with members of 11 MDR committees	To evaluate the effectiveness of the maternal death review (MDR) system and process in improving quality of maternal and new-born health care in northern Nigeria	Mortality death reviews were initiated in 75 emergency obstetric and new-born care facilities in northern Nigeria and were initially conducted in the 33 hospitals. Findings showed irregularity in conducting MDR in part due to transfer of key members of MDR committees. A lack of supervision and shortage of staff equally contributed to the poor MDR outcomes. Documentation was poor as only 93 (12.1%) of 768 identified MDs were recorded on MDR forms and 52 (6.7%) had been reviewed. Staff observed that MDRs resulted in improved quality of care
11. Kongnyuy and Van Den Broek (2008)	The difficulties of conducting maternal death reviews in Malawi	SWOT (strengths, weaknesses, opportunities and threats) analysis of the process of maternal death review during a workshop in Malawi	To explore the challenges encountered in the process of facility-based maternal death review in Malawi, and to suggest sustainable and logically sound solutions to these challenges	Findings showed that, the review was conducted by qualified staff, data were available from case notes, there was support from hospital management/DHMTs and hospitals had maternal death review forms. Barriers to conducting mortality reviews included: fear of blame, lack of knowledge and skills to properly conduct death reviews, inadequate resources and missing documentation. There were opportunities to improve the reviews through technical assistance from expatriates, support from the Ministry of Health and implementation of national protocols. Threats to improving audits included cultural practices, potential for lawsuit, demotivation due to the high maternal mortality and poor planning at the district level. There was need to improve documentation and the process of conducting maternal death review in a blame-free manner, encouraging good leadership, motivating staff, the need to used guidelines, proper stock inventory and community involvement
12. Kerber et al. (2015)	Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby	A review	To systematically review and capture the causes and avoidable factors linked to deaths, in order to affect change	Maternal audit has progressed globally and led to improved quality of care. The progress is slow in LMIC. Moving forward, good leadership and timely sharing of information is required
13. Lewis (2014)	The cultural environment behind successful maternal death and morbidity reviews	A review	Aims to summarize many of the lessons learnt from the introduction of near-miss reviews in most areas of the world ranging from high-income countries to those in Africa, Asia and Central and Eastern Europe	Supportive cultural factors such as Individual responsibility and ownership; professionalism and “maternity conscience” provide an enabling environment for a successful review. A proactive institutional ethos, a supportive political and policy environment at both national and local levels are also central to the success of the conference
14. Madzimbamuto et al. (2014)	A root-cause analysis of maternal deaths in Botswana: toward developing a culture of patient safety and quality improvement	Maternal death case-notes analysis	To determine the underlying causes of maternal deaths using a root-cause analysis approach to guide interventions	The authors reviewed a total of 56 case notes from 82 deaths notified in 2010. The number of contributing factors were high, an indication of poor quality of care even where deaths were not avoidable. For example, “14/23 (61%) of direct deaths were considered avoidable compared to 12/32 (38%) indirect deaths.” Failure to recognize seriousness of patients’ condition (71% of cases); lack of knowledge (67%); failure to follow recommended practice (53%); lack of or failure to implement policies, protocols and guidelines (44%); and poor organizational arrangements (35%) were the highest-ranking categories contributing to deaths
15. Merali et al. (2014)	Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review	Systematic review	To identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle-income countries	Substandard care by health workers, patient delay and deficiencies in blood transfusion were the leading three factors that attributed to death
16. Musafili et al. (2017)	Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis	Case review	To assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals	Findings showed a higher rate for perinatal death. For example, from 8,424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1,000 births and a perinatal mortality rate of 32/1,000 births. A total of 250 perinatal deaths were audited. Factors contributing to mortality were ascertained for 79% of deaths. These included – delay in care-seeking (identified in 39% of deaths), delay in arriving at the health facility (identified in 10% of the deaths), and provision of suboptimal care at the health facility (identified in 37% of the deaths). Difficulties in reporting pregnancy-related danger signs and lack of money were a barrier in reaching the hospitals. Delay in referrals, diagnosis and management of emergency obstetric cases was the most prominent contributors affecting the provision of appropriate and timely care by health care providers
17. Nakibuuka et al. (2012)	Perinatal death audits in a peri-urban hospital in Kampala, Uganda	A retrospective descriptive study	Perinatal death audits were integrated in routine care, and its effect on perinatal mortality rate at Nsambya Hospital were described	Poor neonatal resuscitation skills, incorrect use of the partographs and delay in performing caesarean sections were the leading avoidable factors contributing to deaths. Three skills sessions of neonatal resuscitation, introduction of continuous positive airway pressure (CPAP) for babies with respiratory distress, updates on use of partographs were implemented. Perinatal mortality reduced after the introduction of audits (from 52.8 per 1,000 total births in 2007 to 47.9 deaths per 1,000 total births in 2008 following the introduction of mortality audits)
18. Owolabi et al. (2014)	Establishing cause of maternal death in Malawi via facility-based review and application of the ICD-MM classification	Qualitative interviews	To explore if international classification of Diseases Maternal Mortality (ICD-MM) classification is used during facility-based audit review in Malawi	To a certain degree, the MDR process and practice are well established in Malawi. Challenges faced entail completing the forms, analyzing the available data and using the information collected to improve practice. Practitioners, more often, do not understand the differences between primary and secondary causes of death. For instance, causes of death were sometimes reported as non-obstetric complications when it was not. Obstetric hemorrhage was the leading assigned cause of death. There is need for accurate classification of cause of death
19. Pattinson et al. (2009)	Perinatal mortality audit: counting, accountability and overcoming challenges in scaling up in low- and middle-income countries	Systematic review	Present the results of a systematic review of perinatal mortality audit in low- and middle-income settings to facilitate health system strengthening, particularly at the time of birth and examine the effect on perinatal outcomes, particularly intrapartum-related	Audit has the potential to decrease perinatal mortality rates and improve quality of care if solutions identified during the audit can be implemented. There is need for facilities to track intrapartum stillbirth and pre-discharge intrapartum-related neonatal mortality rates
20. Patrick and Stephen (2008)	Child PIP: making mortality meaningful by using a structured mortality review process to improve the quality of care that children receive in the South African health system	A descriptive paper	To describe the origins, growth and development of Child PIPP over the last 5 years, and provides an overview of the findings and recommendations to date	By allowing recommendations to arise out of the Child PIP information, Child PIP in South Africa generates information that can lead to improved quality of care
21. Rhoda et al. (2014)	Experiences with perinatal death reviews in South Africa – the perinatal problem identification program: scaling up from program to province to country	A review	To understand strengths and challenges of PIPP	PPIP is user friendly and has the potential to be used in many facilities with minimum requirements for installation. It has the potential to facilitate the rapid expansion of data collection, analysis and review ultimately leading to quality of care
22. Smith et al. (2017)	Implementing maternal death surveillance and response: a review of lessons from country case studies	A secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement	A review	Review revealed that MDR is accepted and ongoing at subnational level in many countries. However, it is not institutionalized, there is need for a shift from facility-based MDR to continuous MDSR to inform wider health system. There is need for team processes at facility level. No shame culture must be adapted. There governments must allocate resources toward this course
23. Van Hamersveld et al. (2012)	Barriers to conducting effective obstetric audit in Ifakara: a qualitative assessment in an under-resourced setting in Tanzania	Qualitative study – participant observation and interviews	To explore barriers to and solutions for effective implementation of obstetric audit at Saint Francis Designated District Hospital in Ifakara, Tanzania	Audit sessions were inconsistent, often, happened only when the head of department of obstetrics and gynecology were available. Cases with evident substandard care factors were audited. Participants regarded obstetric audit as useful in improving quality, yet they lacked adequate knowledge of the purpose of audit. Staff were not committed, there was a lack of managerial support, low staffing ratios and lack of financing. Audit meetings were not recommended by action plans. Conclusively, there is need to encourage staff and managers to attend the meetings
24. Vink et al. (2013)	Maternal death reviews at a rural hospital in Malawi	Retrospective study	To analyze maternal deaths at Nkhoma Church of Central Africa Presbyterian (CCAP) Hospital and identify factors causing delays in care	Findings showed that most deaths were indirect (n=34 (58.6%)). Non-pregnancy-related infections were the leading cause of indirect death (n=22), with meningitis the most common (n=13). Most of the patients experienced a delay in seeking care (n=37 (63.8%)), a transport delay (n=43 (74.1%)) or a delay in receiving adequate care (n=34 (58.6%))

Author/year of publication	Title of the paper	Methodology	Aims of research	Summary
1. Abebe et al. (2017)	“We identify, discuss, act and promise to prevent similar deaths”: a qualitative study of Ethiopia’s maternal death surveillance and response system	A qualitative case study using key informants	The study interviewed frontline MDSR implementers in four largest zones in Ethiopia to find out their experiences of the first 2 years of MDSR, including perceptions of its introduction and outcomes for health services	In Ethiopia, the strong political support of MDSR with the broader health strategies and health systems was a facilitator to its implementation. Staff turnover, fear of legal repercussions and a lack of understanding of the purpose of MDSR were some of the barriers experienced at its onset
2. Agaro et al. (2016)	The conduct of maternal and perinatal death reviews in Oyam District, Uganda: a descriptive cross-sectional study	A cross-sectional mixed methods study	To examine the factors that influence the conduct of maternal and perinatal death reviews in Oyam District, Uganda	Findings showed a low participation of health workers in MPDR (34.8%). MPDR committees (p <0.001), attendance of review meetings (p <0.001), and lack of knowledge on the MPDR objectives (p<0.001), implementation of MPDR recommendations (p<0.001), observed improvement in maternal and new-born care (p<0.001) and provision of feedback (p<0.001) as enabling factors in enhancing audit meetings. Factors that hindered conducting MPDR included: lack of information among health workers about MPDR process, committee formation and training of MPDR committee, lack of supervision, and lack of financial motivation of MPDR committee members. Challenges to MPDR included: heavy workload to health workers, high number of perinatal deaths, and non-implementation of recommendations
3. Allanson and Pattinson (2015)	Quality-of-care audits and perinatal mortality in South Africa	Analysis of secondary data from 29 community health facilities, 105 district hospitals, 4 national central hospitals, 22 regional hospitals and three provincial tertiary hospitals	To determine how perinatal mortality rates had changed in health care facilities participating in the perinatal problem identification program	After five years of continuous audits in 163 facilities, findings revealed that there were reductions in perinatal mortality in 48 facilities. Facilities with high perinatal mortality rates attributed that to patient delay in seeking health care when the baby was sick, lack of use of antenatal steroids, lack of nursing personnel and data distress
4. Alexandre et al. (2009)	Improving obstetric care in low-resource settings: implementation of facility-based maternal death reviews in five pilot hospitals in Senegal	Qualitative approaches using multimethods	“[…] to explore and describe health workers’ perceptions of facility-based maternal death reviews and to identify barriers to and facilitators of the implementation of this approach in pilot health facilities of Senegal”	Using focus group discussions, participant’s observations of audit meetings, audit documents and interviews with staff, the study aimed to explore health professional’s barriers to and facilitators to the implementation of facility-based maternal death reviews. The study was conducted in varied hospitals context in Senegal where MDRs had been implemented in 2004–2015. Barriers to implementation of facility-based mortality audits were poor quality of information in the patient’s files, lack of feedback to non-attending staff, and senior managers lack of participation. Facilitators including experienced data professionals, the availability of maternity unit manager to participate as well as moderate the meetings and staff in attendance willing to participate in the discussions
5. Angelo et al. (2010)	Factors for change in maternal and perinatal audit systems in Dar as Salaam hospitals, Tanzania	Qualitative interviews	To assess the structure, process and impacts of maternal and perinatal death audit systems in clinical practice in order to provide insights on how they could be assessed	Maternal and perinatal audit systems existed only in 4 and 3 hospitals respectively, and key decision makers did not take part in audit committees. Sixty percent of care providers were not aware of even a single action which had ever been implemented in their hospitals because of audit recommendations. There were neither records of the key decision points, action plan, nor regular analysis of the audit reports in any of the facilities where such audit systems existed
6. Armstrong et al. (2014)	Strengths and weaknesses in the implementation of maternal and perinatal death reviews in Tanzania: perceptions, processes and practice	Reviewed the national MPDR guidelines and conducted a qualitative study using semi-structured interviews	To review national policy documentation and explore stakeholders’ involvement in, and perspectives of, the role and practices of MPDR in district and regional hospitals, and assessed current capacity for achieving MPDR	There are gaps in the current MPDR system. Responses showed differential understanding of the purpose of MPDR. Thus, the current MPDR do not function adequately or perform quality reviews. Facility-based maternal and perinatal death data are not sufficiently captured and appropriate challenges and solutions at the facility level that could inform learning are not well documented. Staff are committed to the process of maternal death review, with routine documentation and reporting, yet action and response are insufficient
7. Belizan et al. (2011)	Neonatal death in low- to middle-income countries: a global network study	Observational study	To determine a population-based mortality rates in low and middle-income countries	Deaths were rampant in babies below 37 weeks or shortly after birth. Better access to medical care hospitalization in the intrapartum and early neonatal period could improve maternal and neonatal outcomes
8. Bakker et al. (2011)	Health workers’ perceptions of obstetric critical incident audit in Thyolo District, Malawi	Qualitative research entailing semi-structured interviews with 25 district health workers, a focus group discussion and observation of audit sessions in health facilities in Thyolo District, Malawi, between August 2009 and January 2010	To examine local health workers’ perceptions about obstetric audit and assess the impact of audit and feedback on their work satisfaction and motivation	Health workers were familiar with the concept of audit. Audit was deemed as a helpful tool to improve the quality of care. There is a need for audit to be performed in a manner that enhances motivation and on-the-job learning
9. Combs Thorsen et al. (2014)	Easier said than done! Methodological challenges with conducting maternal death review research in Malawi	Critical reflection	The aim of this paper is to critically reflect upon the process used to carry out a facility-based maternal death review study, while highlighting challenges and providing recommendations on how best to overcome these challenges	Challenges experienced were: (1) identification of cases: conflicting maternal death numbers, and missing medical charts, (2) data collection: poor record keeping, poor quality of documentation, difficulties in identifying and locating appropriate health care workers for interviews, the potential introduction of bias through the use of an interpreter, and difficulties with locating family and community members and recall bias; and (3) data analysis: determining the causes of death and clinical diagnoses
10. Hofman and Mohammed (2014)	Experiences with facility-based maternal death reviews in northern Nigeria	Mixed methods, including a review of MDR forms, health management information system data on maternal deaths (MDs), as well as semi-structured interviews with members of 11 MDR committees	To evaluate the effectiveness of the maternal death review (MDR) system and process in improving quality of maternal and new-born health care in northern Nigeria	Mortality death reviews were initiated in 75 emergency obstetric and new-born care facilities in northern Nigeria and were initially conducted in the 33 hospitals. Findings showed irregularity in conducting MDR in part due to transfer of key members of MDR committees. A lack of supervision and shortage of staff equally contributed to the poor MDR outcomes. Documentation was poor as only 93 (12.1%) of 768 identified MDs were recorded on MDR forms and 52 (6.7%) had been reviewed. Staff observed that MDRs resulted in improved quality of care
11. Kongnyuy and Van Den Broek (2008)	The difficulties of conducting maternal death reviews in Malawi	SWOT (strengths, weaknesses, opportunities and threats) analysis of the process of maternal death review during a workshop in Malawi	To explore the challenges encountered in the process of facility-based maternal death review in Malawi, and to suggest sustainable and logically sound solutions to these challenges	Findings showed that, the review was conducted by qualified staff, data were available from case notes, there was support from hospital management/DHMTs and hospitals had maternal death review forms. Barriers to conducting mortality reviews included: fear of blame, lack of knowledge and skills to properly conduct death reviews, inadequate resources and missing documentation. There were opportunities to improve the reviews through technical assistance from expatriates, support from the Ministry of Health and implementation of national protocols. Threats to improving audits included cultural practices, potential for lawsuit, demotivation due to the high maternal mortality and poor planning at the district level. There was need to improve documentation and the process of conducting maternal death review in a blame-free manner, encouraging good leadership, motivating staff, the need to used guidelines, proper stock inventory and community involvement
12. Kerber et al. (2015)	Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby	A review	To systematically review and capture the causes and avoidable factors linked to deaths, in order to affect change	Maternal audit has progressed globally and led to improved quality of care. The progress is slow in LMIC. Moving forward, good leadership and timely sharing of information is required
13. Lewis (2014)	The cultural environment behind successful maternal death and morbidity reviews	A review	Aims to summarize many of the lessons learnt from the introduction of near-miss reviews in most areas of the world ranging from high-income countries to those in Africa, Asia and Central and Eastern Europe	Supportive cultural factors such as Individual responsibility and ownership; professionalism and “maternity conscience” provide an enabling environment for a successful review. A proactive institutional ethos, a supportive political and policy environment at both national and local levels are also central to the success of the conference
14. Madzimbamuto et al. (2014)	A root-cause analysis of maternal deaths in Botswana: toward developing a culture of patient safety and quality improvement	Maternal death case-notes analysis	To determine the underlying causes of maternal deaths using a root-cause analysis approach to guide interventions	The authors reviewed a total of 56 case notes from 82 deaths notified in 2010. The number of contributing factors were high, an indication of poor quality of care even where deaths were not avoidable. For example, “14/23 (61%) of direct deaths were considered avoidable compared to 12/32 (38%) indirect deaths.” Failure to recognize seriousness of patients’ condition (71% of cases); lack of knowledge (67%); failure to follow recommended practice (53%); lack of or failure to implement policies, protocols and guidelines (44%); and poor organizational arrangements (35%) were the highest-ranking categories contributing to deaths
15. Merali et al. (2014)	Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review	Systematic review	To identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle-income countries	Substandard care by health workers, patient delay and deficiencies in blood transfusion were the leading three factors that attributed to death
16. Musafili et al. (2017)	Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis	Case review	To assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals	Findings showed a higher rate for perinatal death. For example, from 8,424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1,000 births and a perinatal mortality rate of 32/1,000 births. A total of 250 perinatal deaths were audited. Factors contributing to mortality were ascertained for 79% of deaths. These included – delay in care-seeking (identified in 39% of deaths), delay in arriving at the health facility (identified in 10% of the deaths), and provision of suboptimal care at the health facility (identified in 37% of the deaths). Difficulties in reporting pregnancy-related danger signs and lack of money were a barrier in reaching the hospitals. Delay in referrals, diagnosis and management of emergency obstetric cases was the most prominent contributors affecting the provision of appropriate and timely care by health care providers
17. Nakibuuka et al. (2012)	Perinatal death audits in a peri-urban hospital in Kampala, Uganda	A retrospective descriptive study	Perinatal death audits were integrated in routine care, and its effect on perinatal mortality rate at Nsambya Hospital were described	Poor neonatal resuscitation skills, incorrect use of the partographs and delay in performing caesarean sections were the leading avoidable factors contributing to deaths. Three skills sessions of neonatal resuscitation, introduction of continuous positive airway pressure (CPAP) for babies with respiratory distress, updates on use of partographs were implemented. Perinatal mortality reduced after the introduction of audits (from 52.8 per 1,000 total births in 2007 to 47.9 deaths per 1,000 total births in 2008 following the introduction of mortality audits)
18. Owolabi et al. (2014)	Establishing cause of maternal death in Malawi via facility-based review and application of the ICD-MM classification	Qualitative interviews	To explore if international classification of Diseases Maternal Mortality (ICD-MM) classification is used during facility-based audit review in Malawi	To a certain degree, the MDR process and practice are well established in Malawi. Challenges faced entail completing the forms, analyzing the available data and using the information collected to improve practice. Practitioners, more often, do not understand the differences between primary and secondary causes of death. For instance, causes of death were sometimes reported as non-obstetric complications when it was not. Obstetric hemorrhage was the leading assigned cause of death. There is need for accurate classification of cause of death
19. Pattinson et al. (2009)	Perinatal mortality audit: counting, accountability and overcoming challenges in scaling up in low- and middle-income countries	Systematic review	Present the results of a systematic review of perinatal mortality audit in low- and middle-income settings to facilitate health system strengthening, particularly at the time of birth and examine the effect on perinatal outcomes, particularly intrapartum-related	Audit has the potential to decrease perinatal mortality rates and improve quality of care if solutions identified during the audit can be implemented. There is need for facilities to track intrapartum stillbirth and pre-discharge intrapartum-related neonatal mortality rates
20. Patrick and Stephen (2008)	Child PIP: making mortality meaningful by using a structured mortality review process to improve the quality of care that children receive in the South African health system	A descriptive paper	To describe the origins, growth and development of Child PIPP over the last 5 years, and provides an overview of the findings and recommendations to date	By allowing recommendations to arise out of the Child PIP information, Child PIP in South Africa generates information that can lead to improved quality of care
21. Rhoda et al. (2014)	Experiences with perinatal death reviews in South Africa – the perinatal problem identification program: scaling up from program to province to country	A review	To understand strengths and challenges of PIPP	PPIP is user friendly and has the potential to be used in many facilities with minimum requirements for installation. It has the potential to facilitate the rapid expansion of data collection, analysis and review ultimately leading to quality of care
22. Smith et al. (2017)	Implementing maternal death surveillance and response: a review of lessons from country case studies	A secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement	A review	Review revealed that MDR is accepted and ongoing at subnational level in many countries. However, it is not institutionalized, there is need for a shift from facility-based MDR to continuous MDSR to inform wider health system. There is need for team processes at facility level. No shame culture must be adapted. There governments must allocate resources toward this course
23. Van Hamersveld et al. (2012)	Barriers to conducting effective obstetric audit in Ifakara: a qualitative assessment in an under-resourced setting in Tanzania	Qualitative study – participant observation and interviews	To explore barriers to and solutions for effective implementation of obstetric audit at Saint Francis Designated District Hospital in Ifakara, Tanzania	Audit sessions were inconsistent, often, happened only when the head of department of obstetrics and gynecology were available. Cases with evident substandard care factors were audited. Participants regarded obstetric audit as useful in improving quality, yet they lacked adequate knowledge of the purpose of audit. Staff were not committed, there was a lack of managerial support, low staffing ratios and lack of financing. Audit meetings were not recommended by action plans. Conclusively, there is need to encourage staff and managers to attend the meetings
24. Vink et al. (2013)	Maternal death reviews at a rural hospital in Malawi	Retrospective study	To analyze maternal deaths at Nkhoma Church of Central Africa Presbyterian (CCAP) Hospital and identify factors causing delays in care	Findings showed that most deaths were indirect (n=34 (58.6%)). Non-pregnancy-related infections were the leading cause of indirect death (n=22), with meningitis the most common (n=13). Most of the patients experienced a delay in seeking care (n=37 (63.8%)), a transport delay (n=43 (74.1%)) or a delay in receiving adequate care (n=34 (58.6%))

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