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National systems, reviews and audits

Maternity staff views on implementing a national perinatal mortality review tool: understanding barriers and facilitators

Our study demonstrated a perinatal mortality review system that is not standardised or transparent. Institutional culture influences how reviews are conducted and perceived by staff. Implementing a standardised review system is viewed positively though barriers must be addressed.

Authors

Emily O'Connor, Änne Helps, Keelin O'Donoghue, Sara Leitao

Year
2025
Journal Name
Journal of Perinatal Medicine
Category
Journal Article
Keywords
Neonatal death, Perinatal mortality, Stillbirth
Project

ACHIEVE

Full Citation

O'Connor E, Helps Ä, Greene R, O'Donoghue K, Leitao S. Maternity staff views on implementing a national perinatal mortality review tool: understanding barriers and facilitators. Journal of Perinatal Medicine. 2025. https://doi.org/10.1515/jpm-2024-0601.

Link to Publication
https://doi.org/10.1515/jpm-2024-0601

Abstract

Perinatal death reviews investigate the reasons behind perinatal deaths and identify avoidable causes of perinatal deaths. In this study, we aimed to identify anything that might hinder or help the introduction of a standardised tool, or checklist, that would be used in Irish maternity units to review the causes of perinatal deaths. We spoke with staff members working in the Irish maternity services to discuss their opinions about perinatal death reviews and what they think about changing this system. We held individual interviews with 32 staff members between May and December 2022. Four main themes were generated from these discussions: (1) The review process itself, (2) The time challenges associated with reviews, (3) The impact of a maternity unit’s culture on reviews, and (4) The needs of staff members during the review process. We found that reviews were not structured similarly between maternity units and staff were not always involved in reviews. Reviews can have a big impact on the health and wellbeing of staff members who are involved in reviews, and staff require support during this time. Changing the review system to be more structured was generally supported by staff. Using a standardised review tool may help to improve reviews.

Pregnancy Loss Research Group

Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University College Cork, Fifth Floor, Cork University Maternity Hospital, Wilton, Cork, T12 YE02, Ireland,

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