Every hospital should have a formal system of audit of pregnancy outcome on a monthly basis, according to a healthcare records review set up by the Health Service Executive.
It says that such audits would allow a pattern of adverse outcomes to be identified in a timely fashion, so that appropriate action could be taken.
It also says that each hospital should have in place a formal system of review of adverse outcomes and the results of the reviews should be shared with the patients in a timely fashion.
The review of 28 maternity case notes, mostly relating to the Midland Regional Hospital in Portlaoise, has been conducted by a team set up by the HSE.
The cases cover the period 1985 to 2013 and the families concerned have been issued with their individual reports which cover maternal as well as baby issues.
The report is by Dr Peter Boylan, chairman of the Institute of Obstetricians and Gynaecologists, and his clinical review team of six obstetricians.
The Boylan Report looked at 23 cases at the Midland Regional Hospital, three at the University Maternity Hospital in Limerick and two at the Midland Regional Hospital Mullingar.
It was set up after patients contacted the HSE or hospitals following the RTÉ Investigations Unit programme on Portlaoise hospital baby deaths in January 2014.
The review recommends that a representative from the HSE meets with each of the 28 patients, to relay the conclusions and recommendations in their individual cases.
None of the patient reports are published today by the HSE and only individual patients have received their own report.
Other recommendations in the Boylan Report are that each hospital should ensure the appointment of a number of midwives trained in ultrasoundography and hospitals should appoint bereavement counsellors to deal with perinatal deaths.
The report says that each hospital should have adequate midwifery and consultant obstetrician staffing and ongoing mandatory training programmes for all clinical staff.
It says that in the event of a perinatal death, every effort should be made to gain consent for a post-mortem examination.
The 28 case notes involved 14 stillbirths, or neonatal deaths, one infant death at ten months, two related babies with microcephaly, one case of cerebral palsy in a child who is quadriplegic, one related to a massive obstetric haemorrhage, one related to a retained swab and one related to a wound abscess.
In three cases, multiple questions were raised; one was of an undetermined neurological problem, in another case it was difficult to ascertain why a review of the case notes had been requested and in two cases, the outcome for the baby was unknown.
Meanwhile, the HSE says that a further separate review of 103 cases involving mostly Portlaoise hospital has been under way and patients should have received letters this week advising them of the ongoing process.
Of this group, 94 cases relating to Portlaoise have been reviewed and the HSE says that a report is in development.
Other hospitals will review the remaining 9 cases and those reports are due by the end of July.
The HSE says that due to the volume of cases, these 103 reviews are being conducted by the hospitals involved led by senior clinical staff.
The Boylan Review said that no definitive conclusions have been reached on the care provided in any of the 28 cases, as the review was only "a paper review" and the team did not meet patients, family or hospital staff.
The review identified "issues" to be addressed in ten cases, in six of which the baby was either stillborn, or died in the neonatal period.
