Elsevier

Women and Birth

Volume 21, Issue 4, December 2008, Pages 149-155
Women and Birth

Effect of audit and feedback on the availability, utilisation and quality of emergency obstetric care in three districts in Malawi

https://doi.org/10.1016/j.wombi.2008.08.002Get rights and content

Summary

Background

Facility-based maternal death reviews and criterion-based clinical audit, were introduced in three districts in Malawi in 2006.

Research question

Can audit and feedback improve the availability, utilisation and quality of emergency obstetric care (EmOC)?

Participants and methods

Observational study in which emergency obstetric care offered to women who gave birth in 73 health facilities (13 hospitals and 60 health centres) in three districts in Malawi in 2005 (baseline, 41,637 women) was compared to 2006 (43,729 women) and 2007 (51,085 women).

Results

The number of comprehensive and basic EmOC facilities did not change over the 3-year period (p for trend = 1.000). Although institutional delivery rate decreased in 2006, overall it increased over 3 years (p for trend < 0.001) – 31.8% (2005), 31.1% (2006) and 34.7% (2007), and Caesarean section rate was low and did not change (p for trend = 0.257) – 1.7% (2005), 1.6% (2006) and 1.5% (2007). There was a significant increase in the met need for EmOC (p for trend < 0.001) – 15.2% for 2005, 17.0% for 2006 and 18.8% for 2007. Maternal mortality decreased significantly from 250 per 100,000 women in 2005 to 222 in 2006 and 182 in 2007 (p for trend < 0.001). Similarly, the case fatality rate decreased monotonically (p for trend < 0.001) – 3.7% (2005), 3.0% (2006) and 1.5% (2007).

Discussion

Audit and feedback can improve availability, utilisation and quality of emergency obstetric care in countries with limited resources.

Conclusion

There is need to increase availability of emergency obstetric care by upgrading some health centres to EmOC level through training of staff and provision of equipment and supplies.

Introduction

Malawi is a sub-Saharan African country with a population of 14,000,000 and 20.8% live below US$ 1 per day. In the world ranking, Malawi is number 164 out of 177 countries with a human development index of 0.439.[1], [2], [3] The life expectancy at birth is low (46.3 years), the literacy rate of 15–24-year-olds is 76.0% and the HIV prevalence among the adult population (15–49 years) is currently estimated as 12%.[2], [3], [4]

Poor socio-economic indicators are reflected in maternal and neonatal health status. Malawi has one of the highest Maternal Mortality Ratios (MMR) in the world.5 The unadjusted MMR is 984 per 100,000 live births.2 The MMR increased from 620 per 100,000 live births in 1992 to 1120 per 100,000 live births in 2000 before dropping slightly to 984 per 100,000 in 2005.2 These could reflect actual changes in MMR as well as changes in changes in data collection.

Reducing maternal mortality in Malawi is a challenge because the facility delivery rate is low (57%) and there are many barriers to accessing health care.2 Seljeskog et al. identified three major barriers namely, (a) sub-optimal quality of care which includes communication, attitudes and cooperation, (b) cultural barriers such as traditional view of pregnancy and perception of danger signs and (c) unsatisfactory availability and accessibility of skilled delivery care in terms of transport, distance, costs and critical shortage of skilled attendants.6

In 2005 the Malawi Ministry of Health developed a Road Map for reducing maternal and neonatal mortality and morbidity. One of the objectives of the Road Map was to improve the quality of emergency obstetric care (EmOC) throughout the country. In order to achieve this objective two types of audit namely, facility-based maternal death reviews and criterion-based clinical audit, were introduced in three districts (Lilongwe, Kasungu and Salima) in the Central Region of Malawi in August 2006. Since then maternal death case reviews have been conducted in the three districts to identify sub-optimal care associated with maternal deaths and make recommendations for change. In addition, local standards for emergency obstetric care were developed and criterion-based audits used to identify deviations from standards and make recommendations for change.

We sought to answer the question: can audit and feedback improve the availability, utilisation and quality of emergency obstetric care? We hypothesized that maternal death reviews and criterion-based audit would improve the availability, utilisation and quality of emergency obstetric care in Malawi.

Audit and feedback is a broad term which has been defined as “any summary of clinical performance of health care over a specified period of time”.7 In maternity care audit and feedback may refer to either maternal death audit, perinatal death audit, near-miss case review or criterion-based audit. The term maternal death audit is a broad term that describes different approaches used to study maternal deaths with view to reducing future maternal mortality and morbidity by improving the quality of care. These approaches are confidential enquiries into maternal deaths, maternal death surveillance, facility-based death reviews and community-based death reviews (also called verbal autopsy).8

Criterion-based clinical audit on the other hand is a more specific term which has been defined as “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and implementation of change. Aspects of structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery”.9 Criteria-based audit consists of five steps that form the classic audit cycle: establish standards of good practice, measure current practice, feedback findings and set local targets, implement changes in practice where indicated, and re-evaluate practice and feedback.8

Both maternal death review and criterion-based clinical audit are supported by expert opinion and have recently been endorsed by the World Health Organisation.8 A Cochrane systematic review that included 118 randomized controlled trials concluded that criterion-based audits can bring about improvements in professional practice.7 A second Cochrane review set out to evaluate the effect of maternal and perinatal death reviews on maternal and perinatal mortality, but did not find any randomized controlled trials.10 However, observational studies have shown that maternal death reviews can improve practice and reduce maternal mortality.11

Section snippets

Design

We conducted an observational study in which the availability, utilisation and quality of emergency obstetric care at baseline (2005) was compared with Year 1 (2006) and Year 2 (2007). Maternal death review and criterion-based audit were introduced in the three districts in 2006.

Setting

The study was conducted in three districts (Lilongwe, Kasungu, Salima) with a total population of 2,944,360. There were a total of 92 health facilities in the three districts – this includes 13 hospitals, 60 health

Availability of EmOC services

There were seven comprehensive emergency obstetric care (CEmOC) facilities in Lilongwe, one CEmOC facility in Kasungu and one CEmOC facility in Salima and this number did not change during the 3-year period (p for trend = 1.000). The number of CEmOC facilities was adequate in two districts and slightly below the minimum recommended (1 per 500,000 population) in the third district. The distribution of CEmOC facilities was unequal with poor access in some rural areas.

There were 0.2 basic emergency

Discussion

The paper describes the availability, utilisation and quality of EmOC services before and after the introduction of maternal death reviews and criterion-based clinical audit in three districts in Malawi. The availability of both BEmOC and CEmOC facilities did not change over 3 years, but utilisation of EmOC services increased slightly, while maternal deaths and case fatality rate decreased over 3 years.

The study revealed that the three districts have a fairly adequate number of CEmOC

Conclusion

Combining maternal death reviews and criteria-based audit improved the quality and utilisation (but not availability) of emergency obstetric care in Malawi. In order to significantly reduce maternal and neonatal mortality in Malawi and other countries with similar socio-economic profiles, there is need to increase availability and accessibility of skilled birth attendants and EmOC services. This can be achieved by upgrading some health centres to BEmOC level through training of staff and

Competing interests

None declared.

Authors’ contribution

EJK designed the study, wrote the protocol, collected the data, analysed and interpreted the data, and wrote all versions of the manuscript. BL and NVDB reviewed the manuscript for important intellectual content.

Ethical approval

The study was approved by the Reproductive Health Unit of the Malawi Ministry of Health.

Acknowledgement

We wish acknowledge the Health Foundation for providing support for this study.

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