Each year more than 536 000 women worldwide die from complications of pregnancy and childbirth.1 Many more survive but will suffer ill health and disability as a result of these complications. In addition, an estimated 4 million neonatal deaths occur each year, accounting for almost 40% of all deaths in children younger than 5 years.2 The key strategies that have been identified to reduce this global burden are the presence of skilled birth attendants,3 the availability of essential (or emergency) obstetric care4 and newborn care.
To have major effects on maternal outcomes, it is crucial that these elements are not just available but also of high quality. And assessment of quality requires effective clinical audit. However, anyone who has undertaken a clinical audit will realise that the practice is not as simple as the theory, and ‘closing the loop’ (to achieve the desired endpoint of improvements in clinical care) is often difficult. So the process of clinical audit itself must be critically evaluated. The paper by Richard et al.5 in this month’s BJOG is part of this process. They focus on the practical difficulties encountered when introducing clinical audit and the perceptions the healthcare providers have of the process. Although most health professionals (77%) agreed that audit had a positive influence on professional practice, they also highlighted a number of difficulties. Those in charge of audit used it almost as a disciplinary tool, staff felt that audit highlighted only the negative aspects of case management, anonymity was not respected, not all levels of healthcare providers were involved in the audits, and there was a perception that the selection of cases to be audited was biased. There was also a difficulty common to many resource-limited countries: a shortage of qualified staff to carry out the audit, with those present already working in difficult circumstances without much support or supervision. For them, audit was seen as simply a further burden, or as a form of inspection or criticism rather than support.
The assumption behind audit is that when health professionals receive feedback about the care given to patients and areas of suboptimal care, they will self-correct and improve their practice. A Cochrane systematic review on audit and feedback (72 studies, over 13 500 participants) concluded that although audit can improve professional practice, the effects are generally small to moderate.6,7 Audit was more likely to show significant improvement in the quality of care if the baseline compliance to good practice was poor; if the care was already reasonable or good, there is obviously less room for improvement.
The effectiveness of audit in improving the quality of care probably depends to a large extent on the method and intensity of feedback and whether this leads to the required actions, rather than on the specific audit process used. It can be difficult to introduce the concept of audit in such a way that it is embraced by the healthcare provider. In particular, failure to respect the basic principle of ‘no shame, no blame’ during the audit process can create a very threatening environment and generate conflict between individuals, departments and even health facilities, for example, the district hospital may blame the peripheral clinic for sending patients too late, midwives may blame traditional birth attendants for not referring the woman to a facility. Comparatively little is known about the practical difficulties of introducing audit into a healthcare system and the barriers to the implementation of audit and cost-effectiveness of audit, especially in a resource-limited setting. The paper by Richard et al. is therefore a welcome contribution.
Types of audit used in maternal and newborn care
Maternity audit, in a variety of forms, is now being implemented in many resource-poor countries. All essentially ask the same three questions: what was done well, what was not done well, and how can care be improved in future? (Table 1).8
Table 1. Different approaches to and levels of obstetric audit
Facility-based maternal death reviews
Case review of near miss
Local criterion- (or standards-) based audit
Confidential enquiry into maternal deaths
Confidential enquiry into near miss
National criterion- (or standards-) based audit
The longest running example of a confidential enquiry into maternal deaths (CEMD) is that of the UK. Initially, this began at subnational level and took the form of hospital/unit-based death reviews such as is now commonly practised in many resource-poor countries. In 1952, the decision was taken to undertake a national CEMD for England and Wales. The initial reports were short and focused only on three to four leading causes of maternal deaths. These reports helped to highlight the tragedy of maternal deaths, and the recommendations implemented played a major part in reducing maternal mortality. A number of low- or middle-income countries have introduced national CEMDs or are in process of doing so. Examples include Sri Lanka, Tunisia, Kenya, Malawi and the Republic of South Africa. Unfortunately, with some exceptions,9 reports are not usually published nor are they widely disseminated, so their message fails to have a major impact. In particular, the challenging process of moving from the level of audits at the hospital/unit level to establishing audit at a national level is not usually achieved. Ideally, all maternal deaths in a geographical area are recognised and audited, and factors contributing to the deaths are documented. Clearly, in many developing countries, this is not yet feasible due to the lack of death (and birth) registration systems. Furthermore, the technical expertise and systems are often not in place and there may be a reluctance to document the extent of the problems in detail. Despite these problems, CEMDs have been found to be useful when they have been implemented adequately.10,11
Similar to audit of maternal death, perinatal death audit is an important source of data on maternal and newborn health and can improve the quality of practice.12 Perinatal death is much more common than maternal death, and this makes analysis at a national level difficult because the numbers can become overwhelming. As with maternal deaths, it is often not known exactly how many stillbirths and early neonatal deaths occur. However, the underlying causes mirror those of maternal deaths; lack of appropriate and good quality clinical care. Audits at the hospital/unit level have been found to give a clear insight into how to make positive changes to the standard of care.13,14
For a variety of reasons, including the realisation that there is a need to actively identify ‘what went well’ as well as ‘what went badly’, obstetric audit has been expanded to include cases of ‘severe acute maternal morbidity’ or ‘near miss’.8,15 So far, definitions of such events have varied for different healthcare settings. Recently, however, the World Health Organization Working Group on Standardisation of Cause Identification of Maternal Death has begun work to agree on a standard definition. This would enable better comparisons between countries as well as across levels of care. ‘Near miss’ or severe morbidity audit can be helpful as there is less of a tendency to assign ‘blame’ (because the patient eventually recovers). In addition, it can be a valuable audit method in settings where maternal mortality is low, and it can be used alongside maternal death audit. In other settings, the number of maternal deaths in a particular hospital/unit may be low because severe cases are transferred out, or the number of cases seen is low, and then morbidity audit is also useful. The paper by Richard et al. in this journal relates to the introduction of a severe morbidity and stillbirth audit. It is clear from their description that even with this ‘positive’ form of audit, the familiar problems of blame and negativity can remain.
Apart from death and severe morbidity audit, there are also examples of successful criterion- (or standard-) based audit from a number of resource-poor countries.16–19 These reports show that the process can be immensely rewarding for the healthcare providers who generally find this form of audit easy to conduct and can see immediate improvements in practice. A multidisciplinary approach is key to this approach as well as a need to agree standards that are locally feasible and relevant.
Scaling up the use of audit
There is no doubt that audit is a valuable tool for addressing the quality of care and is relevant at all levels of healthcare facilities in both resource-poor and resource-rich settings. The introduction of audit as a tool for improving quality of care should be a major priority internationally. But how should this now be scaled up internationally?
In many low- and middle-income countries, the focus has largely been on audits of adverse outcomes. Less is known about the introduction of standards- or criterion-based audit in resource-poor settings, but it is likely that such audit can be seen as less threatening and can be used to complement adverse events audit. Also, in many cases, the changes needed to improve practice to meet the given standards can be easier to bring about in a short time period.
It is currently common practice in many low- and middle-income countries to introduce audit by starting with a process of maternal death audit at hospital/unit and sometimes at community level. This directly brings to the attention of everyone concerned the high priority that needs to be given to reducing maternal deaths globally. Where the concept of maternal death audit is not yet accepted, this will require time and sensitivity with a strong emphasis on the ‘no-shame, no-blame’ principle. Training in how to conduct audit and subsequent supervision is needed and preferably conducted in a multidisciplinary group.
Where maternal death audit has already been introduced, the basic concepts can be expanded to include perinatal death audit, near-miss or severe maternal morbidity audit, as well as standards- or criterion-based audit. From experience, it is important that such standards are locally agreed and accepted and are in line with current evidence-based medicine as well as being ‘women and baby friendly’.
In those countries where the concept of maternal death audit is continuing and attempts are being made to proceed to a national (or subnational) confidential enquiry, it is important that the results are compiled and translated into recommendations that will improve the healthcare delivery system of the whole region or country. In addition, lessons learnt usually have wider application and relevance and can be used to inform plans for improved maternal and newborn healthcare delivery in the region and even internationally.
It is difficult, and probably unjustified, to make a direct causative link between the implementation of audit and a reduction in maternal and perinatal mortality. Use of the UN process indicators, which include increased uptake of services, reduction in case fatality rate and achieving at least the minimum levels of population-based caesarean section rates are probably more realistic outcome measures (Figure 1). Beyond this, audit is also useful for evaluating and documenting shortages of personnel, skills, equipment and drugs. Adequate provision of these is critical if the minimum acceptable levels of care of skilled attendance at birth and essential (or emergency) obstetric care for those 15% or so of women who need it are to be achieved.20
The success of audit largely depends on the motivation of the healthcare providers themselves. If they are able to evaluate the care they are giving, and willing and able to give praise where this is due, as well as make amendments where needed, then this should lead to improved motivation, ownership and sense of responsibility for delivering good quality care. Audit, especially in maternal and newborn care, has a solid base, but it is important that more lessons about how to do it well are learnt and documented.
Disclosure of interests
The authors are staff members of the Liverpool School of Tropical Medicine and are involved in helping sub-Saharan countries implement maternal and perinatal death audit as well as criterion- (or standards-) based audit as part of general programs of work to improve maternal and neonatal health. The authors are responsible for the views expressed in this publication.