Making practice perfect - clinical audit for better maternal health

What is the best way to improve hospital services for pregnant women in developing countries? Are measures of best practice from wealthy countries relevant to poorer nations? Researchers co-ordinated by Scotland's Aberdeen University are testing the use of criterion-based clinical audit for obstetric services in Ghana and Jamaica.

In this first stage, expert teams, including local health professionals, collaborated to develop locally-relevant criteria for assessing the management of five major obstetric complications. They stress the importance of using local expertise and repeating the audit cycle to achieve continued improvements in practice.

Deaths during pregnancy and childbirth are major problems in developing countries. Good quality obstetric care for pregnant women is essential to help prevent these deaths and improve maternal health. Providing such care represents a huge challenge for over-stretched health systems in poorer countries.

To improve obstetric care, existing practice must be monitored, evaluated and changed. This principle underlies a major new research project bringing together expertise from Ghana, Jamaica and Scotland. Researchers are using a monitoring and evaluation technique known as ‘criterion-based audit’. Clinical audit is defined as the systematic and critical analysis of the quality of care. In criterion-based audit, healthcare professionals agree on a list of criteria for best practice. These are then used to evaluate current practice in hospitals.

The process involves five steps:

• establish the criteria for best practice using a literature review and the opinions of expert panels
• review case records and administer a staff questionnaire to assess current hospital practice, then compare this with best practice criteria
• pass findings back to hospital staff and set new local standards
• implement changes in practice
• re-start the cycle of evaluation and feedback.

This research formed the first step of the audit cycle. Expert teams in Scotland, Ghana and Jamaica agreed on 37 criteria of best practice for life-threatening obstetric complications, including haemorrhage, eclampsia, obstructed labour, genital tract sepsis and uterine rupture. Two hospitals each in Ghana and Jamaica have been chosen for evaluation.

Criterion-based audit can be adapted and applied to resource-poor settings. The researchers emphasise that health planners considering a similar approach should:

• identify clinical rather than laboratory criteria
• seek local expert opinion in addition to research evidence to ensure that criteria are relevant
• monitor structural factors, such as staffing and facilities.

It is important to distinguish between current practices and those that should be aspired to, particularly in developing countries. The potential for improvement is lost if best practice criteria are set according to current practice.

Source(s):
'Criteria for clinical audit of the quality of hospital-based obstetric are in developing countries' by W. Graham et al., Bulletin of the World Health Organisation 78 (2000)
'Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries' by P. Wagaarachchi et al., International Journal of Gynecology & Obstetrics 74 (2001)

Funded by: UK Department for International Development

id21 Research Highlight: 23 November 2001

Further Information:
Wendy Graham
Dugald Baird Centre for Research on Women's Health
Department of Obstetrics and Gynaecology
Aberdeen Maternity Hospital
Cornhill Road
Aberdeen AB25 2ZL Scotland

Tel: +44 (0)1224 553924 / 553621
Fax: +44 (0)1224 404925
Contact the contributor: w.graham@abdn.ac.uk

University of Aberdeen, Scotland

Kojo Yeboah Antwi
Kintampo Health Research Centre
PO Box 2000
Kintampo
Ghana

Tel: +233 61 7304
Fax: +233 61 7304
Contact the contributor: parthur@ghana.com

Other related links:
JSI's Mothercare Programme has lots of experience of working in maternal health.

Find details of research and other initiatives on the WHO's safer motherhood site.

The International Confederation of Midwives has a new website.