Criterion-based clinical audit to assess quality of obstetrical care in low- and middle-income countries: a systematic review

Abstract

Low-quality obstetric care in low- and middle-income countries contributes to high in-hospital maternal mortality. Criterion-based clinical audits are increasingly used to measure and improve obstetric care in these settings. This article systematically reviews peer-reviewed literature to determine if these audits are feasible, valid and reliable measurement tools for assessing the quality of obstetric care. PUBMED, Google Scholar and Web of Science databases were searched for peer-reviewed articles published between 1995 and 2009 and which used criterion-based clinical audits to measure the quality of obstetric care in low- and middle-income countries. Sixty-nine studies were identified by key terms and subsequently reviewed. Ten were retained based on inclusion/exclusion criteria. (i) General characteristics of the study; (ii) compliance with expected standards of care and on maternal/child health outcomes; (iii) selection of the study population and sampling methods; and (iv) quality control and reliability. Criterion-based clinical audit is increasingly used in low- and middle-income countries. Most audits were conducted in sub-Saharan Africa. Studies had cross-sectional study or before-and-after designs. Sampling methods were poorly reported and selection bias was a concern. No studies compared audit against other measures of quality of care or against patient outcomes. for quality control and assurance were generally not documented and reliability was mostly unaddressed. Criterion-based clinical audit appears feasible. No studies have rigorously evaluated its measurement properties in low- and middle-income countries. Without such evaluation, measurement properties of the audit remain under question.