Please cite this paper as: Kongnyuy E, van den Broek N. Audit for maternal and newborn health services in resource-poor countries. BJOG 2009;116:7-10. Each year more than 536 000 women worldwide die from complications of pregnancy and childbirth. 1 Many more survive but will suffer ill health and disability as a result of these complications. In addition, an estimated 4 million neonatal deaths occur each year, accounting for almost 40% of all deaths in children younger than 5 years. 2 The key strategies that have been identified to reduce this global burden are the presence of skilled birth attendants, 3 the availability of essential (or emergency) obstetric care 4 and newborn care.To have major effects on maternal outcomes, it is crucial that these elements are not just available but also of high quality. And assessment of quality requires effective clinical audit. However, anyone who has undertaken a clinical audit will realise that the practice is not as simple as the theory, and 'closing the loop' (to achieve the desired endpoint of improvements in clinical care) is often difficult. So the process of clinical audit itself must be critically evaluated. The paper by Richard et al. 5 in this month's BJOG is part of this process. They focus on the practical difficulties encountered when introducing clinical audit and the perceptions the healthcare providers have of the process. Although most health professionals (77%) agreed that audit had a positive influence on professional practice, they also highlighted a number of difficulties. Those in charge of audit used it almost as a disciplinary tool, staff felt that audit highlighted only the negative aspects of case management, anonymity was not respected, not all levels of healthcare providers were involved in the audits, and there was a perception that the selection of cases to be audited was biased. There was also a difficulty common to many resource-limited countries: a shortage of qualified staff to carry out the audit, with those present already working in difficult circumstances without much support or supervision. For them, audit was seen as simply a further burden, or as a form of inspection or criticism rather than support.The assumption behind audit is that when health professionals receive feedback about the care given to patients and areas of suboptimal care, they will self-correct and improve their practice. A Cochrane systematic review on audit and feedback (72 studies, over 13 500 participants) concluded that although audit can improve professional practice, the effects are generally small to moderate. 6,7 Audit was more likely to show significant improvement in the quality of care if the baseline compliance to good practice was poor; if the care was already reasonable or good, there is obviously less room for improvement.The effectiveness of audit in improving the quality of care probably depends to a large extent on the method and intensity of feedback and whether this leads to the required actions, rather than on the specific audit process used...
