Skip to main content


Perinatal mortality audits and reporting of perinatal deaths: Systematic review of outcomes and barriers

Incomplete data, lack of standardised methods &classifications, inadequate training - identified as main barriers for perinatal mortality audit. To reduce perinatal mortalities, audit cycles must be completed, implementing recommendations with continuous re-evaluation of changes.


Arlene Gutman, Tommy Harty, Keelin O'Donoghue, Sara Leitao

Journal Name
Journal of Perinatal Medicine
Journal Article
Audit / Service evaluation, Neonatal death, Perinatal mortality, Stillbirth
Full Citation

Gutman A, Harty T, O’Donoghue K, Greene R, Leitao S. Perinatal mortality audits and reporting of perinatal deaths: systematic review of outcomes and barriers. Journal of Perinatal Medicine. 2022;50(6):684-712.

Link to Publication


Perinatal deaths (stillbirth or neonatal death) are a devastating experience for families and healthcare professionals involved. Perinatal mortality (PNM) audit is essential to understand the factors associated with perinatal death, identify key deficiencies in healthcare provision and improve the quality of perinatal care. However, barriers exist to successful audit implementation and few countries have implemented national perinatal audit programs. We searched five scientific databases for articles evaluating PNM audits or audit implementation, identifying risk or care factors of PNM through audits, in middle and/or high-income; we included 20 articles. Barriers to PNM reporting and audit implementation were identified: incomplete data, lack of standardised audit methods and classifications, and inadequate training. The most common substandard care factors identified through audit were failure in timely detection and management of antenatal maternal and fetal conditions, and late presentation or failure to escalate care. Overall, the implementation of audit recommendations remains unclear. Recommendations for perinatal audit focused on standardised audit tools and training of staff. This review emphasises the need for adequately trained staff to participate in standardised and thorough regular audit. To reduce perinatal mortalities, it is crucial that the audit cycle is completed, recommendations implemented with continuous re-evaluation of recommended changes.

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,