Reducing Intrapartum Stillbirth: Could Standards-Based Audit Hold the Secret to Successful Improvement in Quality of Care?

By Mamuda Aminu

Internationally, a stillbirth is any baby born with no sign of life after 28 weeks of pregnancy. However, the duration of pregnancy used for the definition of stillbirth varies from one country to another. For example, in the UK, 24 weeks of pregnancy is considered to be the cut-off point. Every year, an estimated 2.6 million stillbirths occur worldwide, with up to 98% occurring in low- and middle-income countries (LMIC). Of these deaths, about 1.3 million (50%) occur during the intrapartum period, i.e. during labour and birth.

The World Health Assembly (2014) has endorsed reducing the stillbirth rate in each country to 12 per 1,000 birth by 2030. To achieve this target, at least 56 countries, mostly in sub-Saharan Africa, will need to more than double their present annual rate of reduction in stillbirth. 

A systematic review of 142 publications from LMIC shows that the most common causes of intrapartum stillbirth are asphyxia, cord-related conditions and birth trauma. Since these causes are in principle preventable, it follows that most stillbirths that occur during labour and birth must be considered preventable if evidence-based good quality care for mothers and babies is provided. Stillbirth rate is considered a marker of the quality of care during pregnancy, labour and birth.

Moreover, as intrapartum stillbirths happen at a specific period (i.e. during labour and childbirth), it is feasible to consider interventions at this crucial time that will make a difference. With an increasing number of women in LMIC giving birth in a healthcare facility, there is potential to prevent many stillbirths by using interventions that improve the quality of care during labour and birth.

There are only a handful of approaches that have any empirical evidence suggesting that they could improve the quality of care during the intrapartum period. One such approach is the use of standards-based audit. In fact, quality of care can be measured by assessing the degree of compliance with standards. An example of a standard could be: every emergency Caesarean section should be conducted within 30 minutes of the decision.

What is a standards-based audit?

Standards-based audit (SBA) is a quality improvement method used by healthcare providers to measurably improve the quality of care. It is likely, but not proven, to improve health outcomes based on the premise that increased compliance with the relevant and appropriate standards of care is a marker of improved quality of care, which, in turn, will improve health outcomes and reduce mortality and morbidity.

SBA is commonly implemented in 3-6-month cycles following five stages:

(1)    Selection of standards for audit based on the most frequent problems, and their severity.

(2)    Baseline measurement of compliance with the standards.

(3)    Feedback and analysis of what needs to change in practice to fully comply with the standard. This also includes planning for implementation of changes.

(4)    Implementation of changes required.

(5)    Reassessment to check if there has been a change in compliance compared to the baseline.

How effective is SBA in reducing stillbirths?

The short answer to the above question is: we don’t know for sure. Currently, there is a paucity of literature on the effectiveness of SBA in improving perinatal outcomes. However, there are good reasons to believe that it holds great potential. For example, a Cochrane review shows that audit, in general, leads to important improvements in professional practice.  

Another indication that SBA could be effective in reducing stillbirth comes from an implementation study on the use of SBA in maternal, newborn and child health. Researchers implemented SBA in 30 low-resource countries and found that the method facilitates rapid action to correct service gaps and promotes a culture of standardisation, continuous measurement, and recognition of achievements.

Although the above-mentioned study also reported a small decrease in maternal complications and maternal deaths, the numbers were too small to generalise the results, and this reduction was only reported from a single health facility. However, 24 of 30 participating countries successfully implemented SBA, showing that the method has a high level of system-wide acceptability across different levels of the healthcare system. This indicates the potential of the method as an effective intervention for improving the quality of care.

Nevertheless, more rigorous studies are needed to assess if and how SBA works to improve quality and whether this affects health outcomes.

At the Centre for Maternal and Newborn Health at LSTM, we are committed to improving quality of the care that mothers and babies receive by working with healthcare providers, governments and other stakeholders to implement the most effective interventions where they are needed most. We deliver quality improvement interventions across multiple countries in Africa and Asia.

We conduct research on quality improvement, producing high-quality research outputs. Our research also informs our teaching of the various quality improvement methods, including standards-based audit, which is part of our postgraduate diploma and MSc programmes.

You can learn more about our previous work or visit our news page for up-to-date information on our current work.

About the author

Dr Mamuda Aminu (MD, MSc, PhD) is a Senior Clinical Research Associate at the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine. He has research interests in quality improvement in healthcare and perinatal epidemiology.