First south-eastern European “Beyond the numbers” workshop


The first south-eastern European "Beyond the numbers" (BTN) workshop was held in Skopje, the former Yugoslav Republic of Macedonia from 29 September to 2 October 2014. It was supported by the United Nations Population Fund (UNFPA) with the participation of delegates from Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Georgia, Kosovo (in accordance with United Nations Security Council resolution 1244 (1999)), Serbia and the former Yugoslav Republic of Macedonia.

The purpose of the meeting was to help countries introduce at national and/or facility level the BTN approaches to acquire experience and develop general recommendations for saving maternal and newborn lives, thus reducing the burden of severe maternal and neonatal morbidity.

The rule of Ps

The overall consensus of the meeting was defined as the rule of P's; i.e., the introduction of any technique for maternal and perinatal death reviews should be:

  • placed within a wider, comprehensive programme for quality improvement for maternal and newborn care;
  • planned and well prepared as some countries will need to undertake more preparatory work before introducing any BTN approaches;
  • practical and only use a BTN approach that will work due to the country's specific circumstances;
  • piloted since with any approach taken, a pilot study should be made and reviewed before roll out;
  • participative and involve the whole care team including doctors and midwives in the case review process;
  • supportive and not punitive as BTN-style case reviews will need to take into account country circumstances, which hinder the reporting of the true reasons for maternal deaths (currently some health workers are blamed unfairly);
  • supported politically, which means that the health ministry should be part of the process and lead the change to give greater strength to national guidelines and healthcare providers; and
  • partnership based and include all stakeholders to ensure longevity and implementation on local and national levels.

Further steps

National BTN approaches, such as confidential enquiries into maternal deaths or severe maternal morbidity, are extremely helpful in improving the quality of care for mothers and babies. However, in some countries, the point where they can be easily introduced has not been reached. Yet all countries could start by piloting near-miss case reviews at facility level. All methodologies should be piloted first and their quality reviewed before widespread and successful implementation.


Every year, many women suffer pregnancy-related complications and some die. WHO estimates that 20 million women suffer from severe complications in pregnancy, many of whom have long lasting consequences. Most of these deaths and complications can be averted with basic and effective low-cost interventions, even where resources are limited.

However, knowing the rates of maternal mortality is not enough; understanding the underlying factors that led to the deaths is essential, so that lessons can be learnt to help avoid such outcomes.

The WHO tool BTN presents a number of approaches that range from correctly counting the number of deaths to developing an understanding of why these occur and how they can be avoided.