Abstract
BackgroundIn Mali and Senegal, over 1% of women die giving birth in hospital. At some hospitals, over a third of infants are stillborn. Many deaths are due to substandard medical practices. Criterion-based clinical audits (CBCA) are increasingly used to measure and improve obstetrical care in resource-limited settings, but their measurement properties have not been formally evaluated. In 2011, we published a systematic review of obstetrical CBCA highlighting insufficient considerations of validity and reliability. The objective of this study is to develop an obstetrical CBCA adapted to the West African context and assess its reliability and validity. This work was conducted as a sub-study within a cluster randomized trial known as QUARITE.MethodsCriteria were selected based on extensive literature review and expert opinion. Early 2010, two auditors applied the CBCA to identical samples at 8 sites in Mali and Senegal (n = 185) to evaluate inter-rater reliability. In 2010–11, we conducted CBCA at 32 hospitals to assess construct validity (n = 633 patients). We correlated hospital characteristics (resource availability, facility perinatal and maternal mortality) with mean hospital CBCA scores. We used generalized estimating equations to assess whether patient CBCA scores were associated with perinatal mortality.ResultsResults demonstrate substantial (ICC = 0.67, 95% CI 0.54; 0.76) to elevated inter-rater reliability (ICC = 0.84, 95% CI 0.77; 0.89) in Senegal and Mali, respectively. Resource availability positively correlated with mean hospital CBCA scores and maternal and perinatal mortality were inversely correlated with hospital CBCA scores. Poor CBCA scores, adjusted for hospital and patient characteristics, were significantly associated with perinatal mortality (OR 1.84, 95% CI 1.01-3.34).ConclusionOur CBCA has substantial inter-rater reliability and there is compelling evidence of its validity as the tool performs according to theory.Trial registrationCurrent Controlled Trials ISRCTN46950658
Highlights
In Mali and Senegal, over 1% of women die giving birth in hospital
Description of the Criterion-based clinical audits (CBCA) questionnaire From 2008 to 2010, we developed a CBCA adapted to the West African context to measure intrapartum quality of care
We looked at the correlation between hospital CBCA scores and hospital rates of maternal and perinatal mortality
Summary
In Mali and Senegal, over 1% of women die giving birth in hospital. At some hospitals, over a third of infants are stillborn. The objective of this study is to develop an obstetrical CBCA adapted to the West African context and assess its reliability and validity. An estimated three million babies are stillborn every year; stillbirths account for the majority of perinatal deaths in developing countries [2]. Experts agree that one way to reduce maternal and perinatal mortality is to encourage women to routinely deliver in health facilities [1,4,5]. For such a strategy to work, women must have confidence in the health system [6] and the system itself should not contribute to mortality
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