Through mortality audit, we have identified a key problem in the South African health system where newborns are failing to receive appropriate care within child health services.

Improving quality of care on the front lines: the case of newborn deaths in South Africa’s child mortality audit system

Photo: Mats Lignell/Save the Children

“The best time to plant a tree is ten years ago, the next best time is now”

Ten years ago, this African proverb inspired us to plant a tree. It’s nice to be in a position 10 years later, looking at the fruit of the tree and reflecting that it was indeed the best time to plant. The tree I’m talking about is South Africa’s Child Healthcare Problem Identification Programme (Child PIP), a South African mortality audit tool and system. Since 2003, Child PIP has contributed to improving knowledge regarding child deaths and to reducing the levels of these deaths. Child PIP is designed to support healthcare workers to conduct mortality reviews or audits of in-hospital deaths of children by:

  • Ensuring that all deaths are identified;
  • Determining the social, nutritional and HIV context of each child who dies;
  • Assigning a cause to each death; and
  • Determining modifiable factors, which identify instances where failure to meet specific standards of care contributed or may have contributed to the child’s death.

The strength of Child PIP lies in the fact that it encourages teams of healthcare workers to reflect on the quality of health care and other services that children in their care receive. Child PIP also encourages them to identify gaps or deficiencies in this care, and to find solutions that will improve care in the future. But it is also more than that. It is a philosophy built around a network of dedicated individuals wanting to do better for newborns and children.

One of the gaps that Child PIP has helped us to identify was the number of newborns dying in children’s wards, instead of under the care of those trained to handle them.  Newborn deaths represent 11% of child deaths audited in 2011; a proportion that has increased from 7% in 2009. Fourty-two percent of newborn deaths captured in Child PIP took place in the first week of life – a particularly vulnerable time where specific needs such as extra warmth (e.g., Kangaroo Mother Care), special feeding requirements (e.g., breastmilk) and protection from infectious diseases (e.g., diarrhoeal disease and acute respiratory infections), must be meet. The proportion of newborn deaths is increasing but more worryingly, the in-hospital mortality rate for neonates has also increased, reflecting deteriorating care for newborns in the South African health system.

Mortality audit data has shown that many of these deaths are preventable but the time to act for newborns in our care is short. Nearly half of all neonates dying in children’s wards died within 24 hours of admission, which is much higher than that recorded for child deaths after the first month of life (30%). About half of all modifiable factors identified in neonatal deaths were attributed to clinical personnel, about one fifth to administrators, and the remainder to caregivers. Poor monitoring (respiratory rate, O2 saturation, blood glucose), both in the ward and in the emergency department were the leading modifiable factor at hospitals. Delay in recognising danger signs and seeking care was noted in nearly half of all deaths.

Based on the compiled audit findings from sites across the country, the following recommendations were identified to improve newborn care:

  • Strengthen antenatal and primary obstetric care, with particular emphasis on maternal HIV and TB, and integrate these services with newborn care.
  • Ensure skilled birth attendants are present at delivery and are also competent in neonatal resuscitation.
  • Newborn care after delivery must include:
    • Full examination and assessment of the newborn;
    • Early detection and referral of complications;
    • Discharge 24 hours or more post-delivery; and
    • Pre-discharge education of mothers regarding feeding and care, recognition of illness in their babies, and where to access help.
  • Develop a national uniform guideline for postnatal care and early follow-up of discharged newborn babies during the first week of life. 
  • Define and implement a formal policy on the principles of care for hospitalised newborns. 

Through mortality audit, we have identified a key problem in the South African health system where newborns are failing to receive appropriate care within child health services. The solutions to this problem requires policy makers, health managers as well as families and communities, to know that it is their problem too and that we can and must act together to make change happen. While the best time to make this change may have been ten years ago, the next best time is now. 


This blog is part of four-part series introducing the Healthy Newborn Network’s Mortality Audits topics page. This new page seeks to give maternal and newborn health practitioners the latest tools, guidelines, resources, news and blogs on death auditing.

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