Quality-of-care audits and perinatal mortality in South Africa

PROBLEM: Suboptimal care contributes to perinatal mortality rates. Quality-of-care audits can be used to identify and change suboptimal care, but it is not known if such audits have reduced perinatal mortality in South Africa. APPROACH: We investigated perinatal mortality trends in health facilities that had completed at least five years of quality-of-care audits. In a subset of facilities that began audits from 2006, we analysed modifiable factors that may have contributed to perinatal deaths. LOCAL SETTING: Since the 1990s, the perinatal problem identification programme has performed quality-of-care audits in South Africa to record perinatal deaths, identify modifiable factors and motivate change. RELEVANT CHANGES: Five years of continuous audits were available for 163 facilities. Perinatal mortality rates decreased in 48 facilities (29%) and increased in 52 (32%). Among the subset of facilities that began audits in 2006, there was a decrease in perinatal mortality of 30% (16/54) but an increase in 35% (19/54). Facilities with increasing perinatal mortality were more likely to identify the following contributing factors: patient delay in seeking help when a baby was ill (odds ratio, OR: 4.67; 95% confidence interval, CI: 1.99–10.97); lack of use of antenatal steroids (OR: 9.57; 95% CI: 2.97–30.81); lack of nursing personnel (OR: 2.67; 95% CI: 1.34–5.33); fetal distress not detected antepartum when the fetus is monitored (OR: 2.92; 95% CI: 1.47–5.8) and poor progress in labour with incorrect interpretation of the partogram (OR: 2.77; 95% CI: 1.43–5.34). LESSONS LEARNT: Quality-of-care audits were not shown to improve perinatal mortality in this study.