Perinatal death reviews, inquiries and audits

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Perinatal death reviews, inquiries and audits

What is this project about?

Study of methods, systems, recommendations and bereaved parents’ involvement in perinatal death reviews, inquiries and audits

An estimated 5.3 million perinatal deaths occur worldwide each year. In Ireland, there were 335 perinatal deaths reported in 2019. These deaths are devastating for the parents, families and, if unexpected, for the healthcare staff involved, with long-lasting emotional consequences. Some of these deaths are unavoidable, but many are preventable. To investigate these deaths and identify contributory factors, local hospital-based perinatal death reviews as well as national perinatal mortality audits are carried out. In certain circumstances an external inquiry may be commissioned to investigate events of public concern. Reports with recommendations are published after local perinatal death reviews, perinatal audits and external inquiries.

In Ireland, there is currently no standardised format to the recommendations or their implementation. Further, the involvement of bereaved parents in local maternity hospital-based perinatal death reviews is poorly explored. The aim of this thesis was to analyse the methodology and structure of perinatal mortality audits, local reviews and inquiries, as well as recurrent themes in the recommendations of the published reports and the inclusion of bereaved parents in reviews.

What was involved?

  • An integrative literature search was carried out focussing on the types and evolution of perinatal mortality audits and reviews in high-income countries.
  • An integrative review using quantitative and qualitative methods to identify established national perinatal mortality audits in four high-income countries and national initiatives addressing recommendations from these audits was undertaken. Content analysis of the audits’ recommendations was performed.
  • A service evaluation of the local maternity hospitals’ perinatal death reviews in Ireland was carried using an electronic survey. The quantitative and qualitative data collected from all 19 maternity units were analysed to identify and compare current local review processes.
  • In the analyses of the ten Irish inquiry reports relating to perinatal deaths and pregnancy loss services in the maternity services, quantitative and qualitative data were collected by two clinicians using a specifically designed review tool. Descriptive analyses of the main characteristics of the reports gave an overview of the terms of reference and inquiry review process, and identified recurring themes in the recommendations.
  • Semi-structured interviews with bereaved parents in Ireland to examine how parents may be appropriately involved in the local hospital-based review in a way that is beneficial to them and the review process itself. 

Who was involved?

Project team

Name Affiliation Role
Dr Änne Helps Pregnancy Loss Research Group  PhD Student
Professor Keelin O'Donoghue Pregnancy Loss Research Group  Primary Supervisor
Dr Sara Leitao National Perinatal Epidemiology Centre, UCC; Pregnancy Loss Research Group Co-supervisor
Professor Richard Greene National Perinatal Epidemiology Centre, UCC Co-supervisor



Name Affiliation
Dr Arlene Gutman Pregnancy Loss Research Group 
Dr Laura O'Byrne INFANT Research Centre, UCC
Orla O'Connell Pregnancy Loss Research Group 

Dissemination activities

Journal articles

Policy briefs

Radio interviews

Project status

Completed: July 2018 to July 2021

Further information

Please email Dr Änne Helps:


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,