Full Report - Research for Development - Department for ...

Synthesis results
Training and audit
Nine papers focused on training and audit. Several studies evaluated the impact of
training and/or audit (or death review) on maternal and neonatal deaths. These
facility-based quality improvement measures seemed to be associated with improved
maternal health outcomes (Bugalho and Bergstrom, 1993 (-)/(-); Dumont et al., 2005
(++)/(++); Dumont et al., 2006 (++)/(++); Kongnyuy et al., 2008 (+)/(+)).
Audit was the most frequently reported service intervention for reducing maternal
mortality. A study by Awan et al. (1989) (+)/(-) in Lahore, Pakistan, evaluated a
complex intervention (staff increases, peer review and feedback), and used trend
analysis with before-intervention and during- and post-intervention outcomes for a
range of reproductive health outcomes, including IMR and MMR. They demonstrated
how audits can be used to develop professional responsibility. Comprehensive audit
systems with periodical checks were also found to be significant in reducing waiting
times, emergency cases and ultimately maternal mortality. A pre- and post-test
study in urban Angola by Strand et al. (2009) (-)/(+) specifically considered the audit
of obstetric emergencies. A substantial decline in the number of maternal deaths
occurred alongside the use of improved partogrammes, reduced waiting times,
improved vigilance and increased awareness of the birthing process, but the study
design was unable to show causality. De Muylder and Thiery (1989) (-)/(-) reported
time trend analyses of rates of C-section following the introduction of guidelines for
the management of dystocia, previous C-section, foetal distress and breech
presentation in Zimbabwe. They showed a decline in rates of C-section and maternal
mortality over two years, and attributed this to implementation of the guidelines, in
the absence of any new technology introduced over the same period. Bhatt (1989) (-
)/(-) considered how a drop in maternal deaths from 1967-8 to 1983-4 at a teaching
hospital in Baroda, India, might have been due to the initiation of medical audit and
maternal death review. The paper showed a decline in maternal deaths from 43 in
1967-8 to 36 in 1983-4 despite a growing case load over that period. The audit was
able to highlight problems such as lack of supervision for junior staff and high-risk
times when senior staff were away at weekends and holidays. In general, audit
meetings appeared to be low-cost interventions to identify avoidable deaths and
gaps in the human resource performance.
A note of caution must be introduced, however, regarding the impact of audits and
reviews. Although not one of our included papers, Filippi et al. (2004), based on a
four-country study (Benin, Côte d'Ivoire, Ghana and Morocco), demonstrate the
difficulties involved in sustaining this kind of initiative. The majority of papers in our
review did not consider the sustainability of the intervention and we can only
speculate that they would be sustainable due to the reported low cost in some
studies.
Training is the focus of an intervention in Guatemala (O’Rourke, 1995) (+)/(-). The
programme's goals were to institute standards of care for obstetric and neonatal
patients as well as to improve relations between hospital staff and TBAs in both rural
and urban areas. Despite increasing referral and improving satisfaction, the
programme did not result in a statistically significant reduction in mortality.
Provider models
Only one paper (de Bernis et al., 2000) (+)/(+) looked specifically at the link
between service delivery and maternal mortality and morbidity in urban populations
with contrasting availability of health care. This study, from Senegal, showed that
an area where women were more likely to deliver in hospitals with trained midwives
had lower levels of maternal mortality than an area where most women gave birth in
district health centres, usually assisted by TBAs, implying that access to skilled
health care is fundamental. Given that the distribution of women by socio-economic
What are the effects of different models of delivery for improving maternal and infant health
outcomes for poor people in urban areas in low income and lower middle income countries? 35