Modifiable Factors and Delays Associated with Neonatal Deaths and Stillbirths in Jordan: Findings from Facility-Based Neonatal Death and Stillbirth Audits

Abstract

Objective This study employed the “three-delay” model to investigate the types of critical delays and modifiable factors that contribute to the neonatal deaths and stillbirths in Jordan. Study Design A triangulation research method was followed in this study to present the findings of death review committees (DRCs), which were formally established in five major hospitals across Jordan. The DRCs used a specific death summary form to facilitate identifying the type of delay, if any, and to plan specific actions to prevent future similar deaths. A death case review form with key details was also filled immediately after each death. Moreover, data were collected from patient notes and medical records, and further information about a specific cause of death or the contributing factors, if needed, were collected. Results During the study period (August 1, 2019–February 1, 2020), 10,726 births, 156 neonatal deaths, and 108 stillbirths were registered. A delay in recognizing the need for care and in the decision to seek care (delay 1) was believed to be responsible for 118 (44.6%) deaths. Most common factors included were poor awareness of when to seek care, not recognizing the problem or the danger signs, no or late antenatal care, and financial constraints and concern about the cost of care. Delay 2 (delay in seeking care or reaching care) was responsible for nine (3.4%) cases. Delay 3 (delay in receiving care) was responsible for 81 (30.7%) deaths. The most common modifiable factors were the poor or lack of training that followed by heavy workload, insufficient staff members, and no antenatal documentation. Effective actions were initiated across all the five hospitals in response to the delays to reduce preventable deaths. Conclusion The formation of the facility-based DRCs was vital in identifying critical delays and modifiable factors, as well as developing initiatives and actions to address modifiable factors. Key Points

Determinants of stillbirth among reviewed perinatal deaths in Ethiopia

“…Besides, a positive dose-response relation was observed between a score of delay three and stillbirth outcomes. The finding was parallel with studies conducted in Nigeria ( 89 ), Jordan ( 90 ), Brazil ( 91 ), and Sweden ( 92 ). This might be explained by the level of health service providers' capacity of identifying and managing obstetrics emergencies.…”

Facility-based stillbirth review processes used in different countries across the world: a systematic review

“…The included studies had one or more of the following aims when conducting a stillbirth review: to prevent stillbirth, to improve all aspects of care by making adequate and informed recommendation guided by clear local/national/international criteria or practices 3 , 15 , 17 , 25 , 36 , 39 , 43 , 46 , 51 , 52 , 55 , 56 , 57 , 64 , 65 , 69 , 73 , 75 ; to analyse cause/s of stillbirth and/or any suboptimal care during the pregnancy 3 , 10 , 11 , 15 , 16 , 19 , 20 , 21 , 22 , 23 , 24 , 26 , 28 , 29 , 30 , 31 , 32 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 45 , 47 , 50 , 53 , 54 , 58 , 59 , 61 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 77 ; to evaluate the current review process or tool implemented and what the facilitators or barriers were…”

“…For 29 out of 68 studies (43%), Government agencies (15 studies 3 , 14 , 17 , 18 , 24 , 25 , 30 , 32 , 34 , 35 , 36 , 38 , 39 , 72 , 75 ) or other funding bodies such as non-governmental organisations (9 studies 19 , 20 , 22 , 23 , 51 , 62 , 67 , 69 , 73 ), universities or professional associations (2 studies 26 , 47 ), and research grants (3 studies 10 , 11 , 77 ) were solely responsible for commissioning the review process. Fifteen studies 12 , 15 , 27 , 33 , 43 , 46 , 48 , 50 , 58 , 60 , 63 , 66 , 70 , 71 out of 68 received funding from two or more organisations (22%), but 24 out of the 68 studies (35%) received no funding or did not list any funding information for the stillbirth review process.…”

“…Routine data was used as at least one of the data sources to identify eligible stillbirths for review in 44 out of 68 included studies (65%). 10 , 11 , 12 , 16 , 19 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 38 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 50 , 52 , 55 , 57 , 59 , 61 , 62 , 63 , 64 , 65 , 67 , 69 , 71 , 72 , 73 , 74 , 75 , 77 Routine data included birth or death registry, hospital records, social care organisations' records, and obstetric records. Four studies (6%) used interviews with care providers as a supplementary source of data, in addition to routine records to identify stillbirths for review.…”

“…This means there was no interview or further additional information sought; 36 out of 68 studies (53%) used this method for data collection. 12 , 13 , 18 , 19 , 21 , 23 , 24 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 36 , 37 , 38 , 42 , 43 , 44 , 45 , 47 , 48 , 52 , 55 , 56 , 61 , 67 , 71 , 73 , 74 , 75 , 77 Twenty-six studies (38%) collected additional data for the purpose of the review 3 , 10 , 11 , 14 , 15 , 16 , 17 , 25 , 35 , 39 , 41 , 46 , 49 , 50 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 69 , 70 , 72 ; for example, by conducting interviews with mothers, health care providers, and family members, by requesting contextual background information about the facilities and mothers, and by carrying out additional tests (e.g. macroscopically examining placenta and cords) th...…”