***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    Input: Background  Maternal mortality  in referral hospitals in Mali and Senegal surpasses 1 % of obstetrical admissions . Poor quality obstetrical care contributes to high maternal mortality ; however , poor care is often linked to insufficient hospital re sources . One promising method to improve obstetrical care is maternal death review . With a cluster r and omized trial , we assessed whether an intervention , based on maternal death review , could improve obstetrical quality of care . Methods The trial began with a pre-intervention year ( 2007 ) , followed by two years of intervention activities and a post-intervention year . We measured obstetrical quality of care in the post-intervention year using a criterion-based clinical audit ( CBCA ) . We collected data  from 32 of the 46 trial hospitals ( 16 in each trial arm ) and included 658 patients admitted to the maternity unit with a trial of labour . The CBCA question naire measured 5 dimensions of care- patient history , clinical examination , laboratory examination , delivery care and postpartum monitoring . We used adjusted mixed models to evaluate differences in CBCA scores by trial arms and examined how levels of hospital human and material re sources affect quality of care differences associated with the intervention . Results For all women , the mean percentage of care criteria met was 66.3 ( SD 13.5 ) . There were significantly greater mean CBCA scores in women treated at intervention hospitals ( 68.2 ) compared to control hospitals ( 64.5 ) . After adjustment , women treated at intervention sites had 5 points ’ greater scores than those at control sites . This difference was mostly attributable to greater clinical examination and post-partum monitoring scores . The association between the intervention and quality of care was the same , irrespective of the level of re sources available to a hospital ; however , as re sources increased , so did quality of care scores in both arms of the trial . Trial registration The QUARITE trial is registered on the Current Controlled Trials website under IS RCT INTRODUCTION Perinatal mortality rate is a sensitive indicator of quality of care provided to women in pregnancy , at and after child birth and to the newborns in the first week of life . Regular perinatal audit would help in identifying all the factors that play a role in causing perinatal deaths and thus help in appropriate interventions to reduce avoidable perinatal deaths . AIMS AND OBJECTIVES This study was carried out to determine perinatal mortality rate ( PMR ) and the factors responsible for  perinatal deaths at KMCTH in the two year period from November 2003 to October 2005 ( Kartik 2060 B.S. to Ashoj 2062 ) . METHODOLOGY This is a prospect i ve study of all the still births and early neonatal deaths in KMCTH during the two year period from November 2003 to October 2005 . Details of each perinatal death were filled in the st and ard perinatal death audit forms of the Department of Pediatrics , KMCTH . Perinatal deaths were analyzed according to maternal characteristics like maternal age , parity , type of delivery and fetal characteristics like sex , birth weight and gestational age and classify neonatal deaths according to Wigglesworth 's classification and comparison made with earlier similar study . RESULTS Out of the 1517 total births in the two year period , 22 were still births ( SB ) and 10 were early neonatal deaths ( ENND ) . Out of the 22 SB , two were of < 1 kg in weight and out of 10 ENND , one was of < 1 kg . Thus , perinatal mortality rate during the study period was 19.1 and extended perinatal mortality rate was 21.1 per 1000 births . The important causes of perinatal deaths were extreme prematurity , birth asphyxia , congenital anomalies and associated maternal factors like antepartum hemorrhage and most babies were of very low birth weight . According to Wigglesworth 's classification , 43.8 % of perinatal deaths were in Group I , 12.5 % in Group II , 28.1 % in Group III , 12.5 % in Group IV and 12.5 % in Group V. DISCUSSION The perinatal death audit done in KMCTH for 1 year period from September 2002 to August 2003 showed perinatal mortality rate of 30.7 and extended perinatal mortality rate of 47.9 per 1000 births . There has been a significant reduction in the perinatal mortality rate in the last 2 years at KMCTH . Main reasons for improvement in perinatal mortality rate were improvement in care of both the mothers and the newborns and the number of births have also increased significantly in the last 2 years without appropriate increase in perinatal deaths . CONCLUSION Good and regular antenatal care , good care at the time of birth including appropriate and timely intervention and proper care of the sick neonates are important in reducing perinatal deaths . Prevention of preterm births , better care and monitoring during the intranatal period and intensive care of low birth weight babies would help in further reducing perinatal deaths . Key words : Perinatal mortality rate ( PMR ) , still births , early neonatal death ( ENND ) , Total perinatal death ( PND ) BACKGROUND Maternal mortality is higher in west Africa than in most industrialised countries , so the development and validation of effective interventions is essential . We did a trial to assess the effect of a multifaceted intervention to promote maternity death review s and onsite training in emergency obstetric care in referral hospitals with high maternal mortality rates in Senegal and Mali . METHODS We did a pragmatic cluster-r and omised controlled trial , with hospitals as the units of r and omisation and patients as the unit of analysis . 46 public first-level and second-level referral hospitals with more than 800 deliveries a year were enrolled , stratified by country and hospital type , and r and omly assigned to either the intervention group ( n=23 ) or the control group with no external intervention ( n=23 ) . All women who delivered in each of the participating facilities during the baseline and post-intervention periods were included . The intervention , implemented over a period of 2 years at the hospital level , consisted of an initial interactive workshop and quarterly educational clinical ly-oriented and evidence -based outreach visits focused on maternal death review s and best practice s implementation . The primary outcome was reduction of risk of hospital-based mortality . Analysis was by intention-to-treat and relied on the generalised estimating equations extension of the logistic regression model to account for clustering of women within hospitals . This study is registered with Clinical Trials.gov , number IS RCT N46950658 . FINDINGS 191,167 patients who delivered in the participating hospitals were analysed ( 95,931 in the intervention groups and 95,236 in the control groups ) . Overall , mortality reduction in intervention hospitals was significantly higher than in control hospitals ( odds ratio [ OR ] 0·85 , 95 % CI 0·73 - 0·98 , p=0·0299 ) , but this effect was limited to capital and district hospitals , which mainly acted as first-level referral hospitals in this trial . There was no effect in second-level referral ( regional ) hospitals outside the capitals ( OR 1·02 , 95 % CI 0·79 - 1·31 , p=0·89 ) . No hospitals were lost to follow-up . Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals . INTERPRETATION Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions . Maternal death review s , combined with best practice s implementation , are effective in reducing hospital-based mortality in first-level referral hospitals . Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals . FUNDING Canadian Institutes of Health Research Lars Åke Persson and colleagues conduct a  cluster r and omised control in northern Vietnam to analyze the effect of the activity of local community-based maternal- and -newborn stakeholder groups  on neonatal mortality . Please see later in the article for the Editors ' Background In Mali and Senegal , over 1 % of women die giving birth in hospital . At some hospitals , over a third of infants are stillborn . Many deaths are due to subst and ard medical practice s. Criterion-based clinical audits ( CBCA ) are increasingly used to measure and improve obstetrical care in re source -limited setting s , but their measurement properties have not been formally evaluated . In 2011 , we published a systematic review of obstetrical CBCA highlighting insufficient considerations of validity and reliability . The objective of this study is to develop an obstetrical CBCA adapted to the West African context and assess its reliability and validity . This work was conducted as a sub- study within a cluster r and omized trial known as QUARITE . Methods Criteria were selected based on extensive literature review and expert opinion . Early 2010 , two auditors applied the CBCA  to identical sample s at 8 sites in Mali and Senegal ( n = 185 ) to evaluate inter-rater reliability . In 2010–11 , we conducted CBCA at 32 hospitals to assess construct validity ( n = 633 patients ) . We correlated hospital characteristics ( re source availability , facility perinatal and maternal mortality ) with mean hospital CBCA scores . We used generalized estimating equations to assess whether patient CBCA scores were associated with perinatal mortality . Results Results demonstrate substantial ( ICC = 0.67 , 95 % CI 0.54 ; 0.76 ) to elevated inter-rater reliability ( ICC = 0.84 , 95 % CI 0.77 ; 0.89 ) in Senegal and Mali , respectively . Re source availability positively correlated with mean hospital CBCA scores and maternal and perinatal mortality were inversely correlated with hospital CBCA scores . Poor CBCA scores , adjusted for hospital and patient characteristics , were significantly associated with perinatal mortality ( OR 1.84 , 95 % CI 1.01 - 3.34 ) . Conclusion Our CBCA has substantial inter-rater reliability and there is compelling evidence of its validity as the tool performs according to theory . Trial registration Current Controlled Trials IS RCT OBJECTIVE Suboptimal care contributes to  perinatal morbidity and mortality .  We investigated the effects of a multifaceted program design ed to improve obstetric practice s and outcomes . STUDY DESIGN A cluster-r and omized trial was conducted from October 2008 to November 2010 in 95 French maternity units r and omized either to receive an information intervention  about published guidelines or left to apply them freely . The intervention combined an outreach visit with a morbidity/mortality conference ( MMC ) to review perinatal morbidity/mortality cases . Within the intervention group , the units were r and omized to have MMCs with or without clinical psychologists . The primary outcome was the rate of suboptimal care among perinatal morbidity/mortality cases . The secondary outcomes included the rate of suboptimal care among cases of morbidity , the rate of suboptimal care among cases of mortality , the rate of avoidable morbidity and /or mortality cases , and the incidence of , morbidity and /or mortality . A mixed logistic regression model with r and om intercept was used to quantify the effect of the intervention on the main outcome . RESULTS The study review ed 2459 cases of morbidity or mortality among 165,353 births . The rate of suboptimal care among morbidity plus mortality cases was not significantly lower in the intervention than in the control group ( 8.1 % vs. 10.6 % , OR [ 95 % CI ] : 0.75 [ 0.50 - 1.12 ] , p=0.15 . However , the cases of suboptimal care among morbidity cases were significantly lower in the intervention group ( 7.6 % vs. 11.5 % , 0.62 [ 0.40 - 0.94 ] , p=0.02 ) ; the incidence of perinatal morbidity was also lower ( 7.0 vs. 8.1‰ , p=0.01 ) . No differences were found between psychologist-backed and the other units . CONCLUSIONS The intervention reduced the rate of suboptimal care mainly in morbidity cases and the incidence of morbidity but did not succeed in improving morbidity plus mortality combined . More clear-cut results regarding mortality require a longer study period and the inclusion of structures that intervene before and after the delivery room . ( Clinical Trials.gov ID : NCT02584166 ) OBJECTIVES To explore the differential effect of a multifaceted intervention on hospital-based maternal mortality  between patients with cesarean and vaginal delivery in low-re source setting s. STUDY DESIGN We reanalyzed the data from a major cluster-r and omized controlled trial , QUARITE ( Quality of care , Risk management and technology in obstetrics ) . These subgroup analyses were not pre-specified and were treated as exploratory . The intervention consisted of an initial interactive workshop and quarterly educational clinical ly oriented and evidence -based outreach visits focused on maternal death review s ( MDR ) and best practice s implementation . The trial originally recruited 191,167 patients who delivered in each of the 46 participating hospitals in Mali and Senegal , between 2007 and 2011 . The primary endpoint was hospital-based maternal mortality . Subgroup-specific Odds Ratios ( ORs ) of maternal mortality were computed and tested for differential intervention effect using generalized linear mixed model between two subgroups ( cesarean : 40,975 ; and vaginal delivery : 150 
    Output:
    
Authors ' conclusions A complex intervention including maternal death audit and review , as well as development of local leadership and training , probably reduces inpatient maternal mortality in low‐income country district hospitals , and probably slightly improves quality of care .
However , conducting death review s in isolation may not be sufficient to achieve the reductions in mortality observed in the QUARITE trial .