Photo: Caroline Trutmann Marconi/Save the Children
South Africa’s stillbirth and neonatal death audit system – The Perinatal Problem Identification Programme (PPIP) – has been in operation since 1999, and since that time has recorded information on over 100,000 stillbirths and neonatal deaths. In 2011, over 73% of the nation’s public sector births were captured and 94% of the hospitals contributed data to PPIP in 2011– an impressive accomplishment for a system that has up until now been mainly voluntary and user-driven.
PPIP relies on regular (in most cases every week) institutional review meetings to discuss perinatal deaths and possible shortcomings in care in a no-fault environment. A clinical classification of perinatal deaths is used since access to post-mortems and placental histology is scarce, and avoidable factors are recorded and discussed. The data are used for local quality improvement, and also entered into databases in every facility with software that is freely available from PPIP.
Data collection, reporting, and entry into the software can be done by midwives. Data are collated nationally and summarised in a biennial report that is linked to national and provincial Departments of Health, providing recommendations for action on the basis of the data.
The newborn deaths captured in PPIP are mainly those that take place in the first week of life – around 90% since 2000. A number of hospitals are finding ways to link PPIP and the child mortality audit system, Child PIP, to get a better sense of the whole picture for newborn care and fill the gaps in care for these vulnerable children. The main causes of death identified are those that are common amongst stillbirths and early neonatal deaths in developing settings, including intrapartum-related deaths, complications of prematurity and infections, but PPIP becomes more than just a data collection tool in the identification of avoidable factors at different levels of care – the things that could be changed at different levels in order to prevent the death.
Whereas Child PIP has seen a drastic reduction in the in-hospital mortality rate in many facilities across the country, and while there are pockets of improvement and individual facilities where PPIP shows that mortality rates have been impressively reduced, we haven’t seen a similar reduction across the country in perinatal deaths. So what are those few facilities doing differently? All facilities using PPIP are identifying deaths. They are assigning a cause of death and exploring the background characteristics of each stillbirth or neonatal death. They are looking at the avoidable factors. Recommendations are made based on the avoidable factors and actions are identified. But those facilities that are making a difference are those with individuals who feel empowered to that close the audit loop and effect change based on the recommendations made and the actions identified.
A core difference between Child PIP and PPIP is that doctors run Child PIP and most midwives run PPIP. This has meant that although the problems have been identified, no action has been taken as midwives often feel less empowered to affect change. Involving administrators in the action steps if not the meetings themselves is also a powerful step for accountability.
An in-depth analysis of the factors associated with closing the audit loop demonstrated that implementing recommendations is a two-step process that requires making the necessary preparations (e.g. changing schedules, acquiring equipment, conducting a skills improvement session) to putting the solutions in place. When implementation is evaluated and further refined, the solutions becoming routine practice. When a quality improvement mindset underpins the solutions recommended on the basis of the audit findings, a practice can become sustainable.
PPIP users, sometimes under extremely difficult conditions, continue to support the programme and directly contribute to saving the lives of mothers and babies. This group of dedicated people is tirelessly working to improve the healthcare services with an aim to make South Africa’s future brighter. We aim to reach a place where perinatal mortality is so uncommon that PPIP can be used to look at the avoidable factors of near-miss cases rather than struggling to audit each stillbirth and neonatal death. But we must act now in order to reach that point.
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.