The purpose of the review was to assign a cause of death, to ascertain the fac-tors that contributed to the death and to identify any systemic issues that could be addressed to prevent future similar deaths. The perinatal mortality audit process in 2019 provided important insights and evidence-based recommendations that can be used both to address system errors and barriers and to identify and praise points of strength. The aim is to pro-vide recommendations for better care for mothers and their infants during pregnancy, childbirth and the neonatal period and improve the quality of care provided throughout the health system.