Standards-based Audit to Improve Quality of Maternal and Newborn Care-A Stepped-wedge Cluster Randomised Trial in Malawi

Overview

Journal PLoS One

Specialties General Medicine
Science

Date 2024 Sep 30

PMID 39348372

Authors

Sarah Ann White

Florence Mgawadere

Somasundari Gopalakrishnan

Nynke van den Broek

Affiliations

Soon will be listed here.

Abstract

Background: Audit is a quality improvement approach used in maternal and newborn health. Our objective was to introduce the practice of standards-based audit at healthcare facility level, and to examine if this would improve quality of care assessed by compliance with standards developed and agreed with healthcare providers. Our focus was on emergency obstetric and newborn care (EmONC).

Methods: A multidimensional incomplete stepped-wedge cluster randomised trial with 8 steps was conducted in 44 healthcare facilities in Malawi. A total of 25 standards of care were developed. At each healthcare facility one (health centres) or two (hospitals) standards were audited per cycle with two consecutive audit cycles conducted. Each cycle consisted of five steps: (i) select standard to be audited, (ii) measure compliance with standard (measurement 1), (iii) review findings and identify what changes are required to increase compliance (iv) implement changes, (v) re-measure compliance (measurement 2). Each compliance measurement assessed 25 women. Multilevel mixed effects logistic regression models were used to analyse data for all standards.

Results: The crude overall compliance rate rose from 45% in the control phase (measurement 1) to 63% in the intervention phase (measurement 2) (from 51.6% to70.6% at Basic and from 34.5% to 50.8% at Comprehensive EmONC healthcare facilities. When adjusted for standard, facility type, month, and healthcare facility by month, the adjusted OR (95% CI) was 2.80 (1.65, 4.76). Actions taken to improve compliance with standards included improving staff performance of clinical duties and general conduct through re-orientation and staff meetings as well as improved supervision, and, ensuring basic equipment and consumables were available on site (thermometers, rapid diagnostic tests, partograph).

Conclusion: The introduction of standards-based audit helped healthcare providers identify problems with service provision, which when addressed, resulted in a measurable and significant improvement in quality of care.

Trial Registration: ISRCTN registration number: 59931298.

References

van den Broek N, Graham W . Quality of care for maternal and newborn health: the neglected agenda. BJOG. 2009; 116 Suppl 1:18-21. DOI: 10.1111/j.1471-0528.2009.02333.x. View

Dogba M, Fournier P . Human resources and the quality of emergency obstetric care in developing countries: a systematic review of the literature. Hum Resour Health. 2009; 7:7. PMC: 2645357. DOI: 10.1186/1478-4491-7-7. View

Kongnyuy E, van den Broek N . Audit for maternal and newborn health services in resource-poor countries. BJOG. 2008; 116(1):7-10. DOI: 10.1111/j.1471-0528.2008.01994.x. View

Raven J, Tolhurst R, Tang S, van den Broek N . What is quality in maternal and neonatal health care?. Midwifery. 2011; 28(5):e676-83. DOI: 10.1016/j.midw.2011.09.003. View

Johnston G, Crombie I, Davies H, Alder E, Millard A . Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care. 2000; 9(1):23-36. PMC: 1743496. DOI: 10.1136/qhc.9.1.23. View

Raven J, Hofman J, Adegoke A, van den Broek N . Methodology and tools for quality improvement in maternal and newborn health care. Int J Gynaecol Obstet. 2011; 114(1):4-9. DOI: 10.1016/j.ijgo.2011.02.007. View

Hemming K, Kasza J, Hooper R, Forbes A, Taljaard M . A tutorial on sample size calculation for multiple-period cluster randomized parallel, cross-over and stepped-wedge trials using the Shiny CRT Calculator. Int J Epidemiol. 2020; 49(3):979-995. PMC: 7394950. DOI: 10.1093/ije/dyz237. View

Hemming K, Taljaard M, Forbes A . Analysis of cluster randomised stepped wedge trials with repeated cross-sectional samples. Trials. 2017; 18(1):101. PMC: 5336660. DOI: 10.1186/s13063-017-1833-7. View

Kruk M, Gage A, Arsenault C, Jordan K, Leslie H, Roder-DeWan S . High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018; 6(11):e1196-e1252. PMC: 7734391. DOI: 10.1016/S2214-109X(18)30386-3. View

10.

van den Broek N, Ameh C, Madaj B, Makin J, White S, Hemming K . Effects of emergency obstetric care training on maternal and perinatal outcomes: a stepped wedge cluster randomised trial in South Africa. BMJ Glob Health. 2019; 4(6):e001670. PMC: 6861119. DOI: 10.1136/bmjgh-2019-001670. View

11.

White S, Mgawadere F . A multi-dimensional incomplete stepped-wedge trial design to estimate the impact of standards-based audit. PLoS One. 2023; 18(11):e0294352. PMC: 10688679. DOI: 10.1371/journal.pone.0294352. View

12.

Ivers N, Jamtvedt G, Flottorp S, Young J, Odgaard-Jensen J, French S . Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012; (6):CD000259. PMC: 11338587. DOI: 10.1002/14651858.CD000259.pub3. View

13.

Madaj B, Smith H, Mathai M, Roos N, van den Broek N . Developing global indicators for quality of maternal and newborn care: a feasibility assessment. Bull World Health Organ. 2017; 95(6):445-452I. PMC: 5463814. DOI: 10.2471/BLT.16.179531. View

14.

Colquhoun H, Michie S, Sales A, Ivers N, Grimshaw J, Carroll K . Reporting and design elements of audit and feedback interventions: a secondary review. BMJ Qual Saf. 2016; 26(1):54-60. DOI: 10.1136/bmjqs-2015-005004. View

15.

Pattinson R, Say L, Makin J, Bastos M . Critical incident audit and feedback to improve perinatal and maternal mortality and morbidity. Cochrane Database Syst Rev. 2005; (4):CD002961. PMC: 4171456. DOI: 10.1002/14651858.CD002961.pub2. View

16.

Smith H, Ameh C, Roos N, Mathai M, van den Broek N . Implementing maternal death surveillance and response: a review of lessons from country case studies. BMC Pregnancy Childbirth. 2017; 17(1):233. PMC: 5513145. DOI: 10.1186/s12884-017-1405-6. View

17.

Siassakos D, Fox R, Bristowe K, Angouri J, Hambly H, Robson L . What makes maternity teams effective and safe? Lessons from a series of research on teamwork, leadership and team training. Acta Obstet Gynecol Scand. 2013; 92(11):1239-43. DOI: 10.1111/aogs.12248. View

18.

van den Broek N, Lewis G, Mathai M . Guest editors' choice. BJOG. 2014; 121 Suppl 4:2-3. DOI: 10.1111/1471-0528.13011. View

19.

Ameh C, Kerr R, Madaj B, Mdegela M, Kana T, Jones S . Knowledge and Skills of Healthcare Providers in Sub-Saharan Africa and Asia before and after Competency-Based Training in Emergency Obstetric and Early Newborn Care. PLoS One. 2016; 11(12):e0167270. PMC: 5179026. DOI: 10.1371/journal.pone.0167270. View

20.

Adegoke A, Hofman J, Kongnyuy E, van den Broek N . Monitoring and evaluation of skilled birth attendance: a proposed new framework. Midwifery. 2011; 27(3):350-9. DOI: 10.1016/j.midw.2011.03.006. View