Effectiveness of facility-based audits to improve the responsiveness of West African district hospitals to obstetric emergencies: a three-country cluster randomised controlled trial
Identifying and implementing sustainable interventions to improve the
quality of hospital care in sub-Saharan Africa is challenging. Maternal
and perinatal mortality ratios stagnate at a high level; improving hospitals'
responsiveness to obstetric emergencies is thought to be an important
potential contribution to decrease them. WHO has launched an initiative
to promote a range of quality assurance strategies, including several
types of facility-based audits. While audits certainly hold promise,
the evidence for their effectiveness is mixed. All randomised controlled
trials of audits have been undertaken in industrialised countries, but
the effectiveness of health services intervention is likely to vary
according to context.
We shall carry out a cluster-randomised controlled trial in West African
district hospitals to assess the effectiveness of two types of facility-based
audits, criterion-based clinical audits (CBCA) and patient-centred case
reviews (PCCR). WHO guidelines on the management of obstetric complications
and enhanced routine documentation including the WHO partograph will
be introduced in all 36 participating hospitals, while CBCA or PCCR
will be set up in 12 hospitals each. The primary outcome variable is
a quality of care score, designed to measure technical and organisational
management of obstetric emergencies. Co-primary outcome measures include
the delay between decision and start of emergency caesarean section,
and hospital based perinatal mortality.
A concurrent anthropological study will improve our understanding of
how audits work or why they fail and identify barriers and facilitators
for their successful integration into routine practice. An economic
evaluation will assess the cost-effectiveness of both interventions.
We are confident that the trial results will not only provide essential data for policy making in safe motherhood, but will provide lessons for quality assurance in district hospital in developing countries in general.