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

PURPOSE: 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. DATA SOURCES: 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. STUDY SELECTION: Sixty-nine studies were identified by key terms and subsequently reviewed. Ten were retained based on inclusion/exclusion criteria. DATA EXTRACTION: (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. RESULTS OF DATA SYNTHESIS: 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. METHODS: for quality control and assurance were generally not documented and reliability was mostly unaddressed. CONCLUSIONS: 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.