Abstract

Perinatal deaths are devastating for families and staff involved. Failure to examine perinatal deaths for substandard care prevents learning and may lead to recurrence of events. We outlined issues with the classification of perinatal deaths and the different types of perinatal death reviews carried out in high-income countries. We reflected on the challenges that are encountered in the current processes and we then commented on how these may be overcome. Current literature showed that differences in classifications of perinatal deaths continue to impede important international comparisons. National perinatal mortality audits can provide reliable high-quality data. Confidential enquiries give expert assessment on anonymised information to initiate system-wide improvements, but to provide local information on perinatal deaths unit-based multi-disciplinary team reviews are required. There is a need to shift from a blame-culture to a focus on achieving best practice by learning from mistakes. Involving the bereaved parents in the perinatal death review process is important and ways to achieve this are progressing. To achieve a reduction in the number of stillbirths and neonatal deaths, it is crucial to ensure that the perinatal mortality audit and review cycle is completed with implementation and re-evaluation of recommended changes in maternity services.