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Background: Implementation of quality maternal death audits requires good programming, good communication and compliance with core principles. Studies on compliance with core principles in the conduct of maternal death audits (MDAs) exist but were conducted in urban areas, at the 2nd or 3rd level of the healthcare system, in experimental situations, or in a context of skills-building projects or technical platforms with an emphasis on the review of “near miss”. This study aims to fill the gap of evidence on the implementation of MDAs in rural settings, at the first level of care and in the routine care situation in Burkina Faso. Methods: We conducted a multiple-case study, with seven cases (health districts) chosen by contrasted purposive sampling using four criteria: (i) the intra-hospital maternal mortality rates for 2013, (ii) rural versus urban location, (iii) proofs of regular conduct of maternal death audits (MDAs) as per routine health information system, and (iv) the use of district hospital versus regional hospital for reference when the first mentioned does not exist. A review of audit records and structured and semi-structured interviews with staff involved in MDAs were conducted. The survey was conducted from 27 April to 30 May of 2015. Results: The results showed that maternal death audits (MDAs) were irregularly scheduled, mostly driven by critical events. Overall, preparing sessions, communication and the conduct of MDAs were most of the time inadequate. Confidentiality was globally respected during the clinical audit sessions. The principle of “no name, no shame, and no blame” was differently applied and anonymity was rarely preserved. Conclusion: Programming, communication, and compliance with the basic principles in the conduct of maternal death audits were inadequate as compared to the national standards. Identifying determinants of such shortcomings may help guide interventions to improve the quality of clinical audits. Resume: La mise en œuvre d’audits de décès maternels de qualité nécessite une bonne programmation, une bonne communication et le respect des principes fondamentaux. Des études sur le respect des principes fondamentaux existent mais ont été menées dans les zones urbaines, le 2ème ou 3ème niveau du système de santé, dans des situations expérimentales, un contexte de projets de renforcement des compétences ou de plates-formes techniques, en mettant l’accent sur la revue des «near miss». Cette étude vise à combler le manque d’information sur la programmation et le respect des principes fondamentaux concernant le milieu rural, le niveau du système de santé qui est. le district sanitaire et la situation de routine au Burkina Faso. Méthodologie: Nous avons mené une étude de cas multiple dans 7 établissements de santé sélectionnés par échantillonnage raisonné contrasté selon 4 critères: milieu urbain ou rural, taux de mortalité maternelle dans les établissements de santé en 2013 (les données de l’année 2014 n’étant pas complètes à la rédaction du protocole), la déclaration des audits de décès maternels dans le système de surveillance nationale, le recours ou non par le district choisi à un centre hospitalier régional pour les soins complémentaires de premier niveau (normalement offerts à l’hôpital de district s’il existe). Une revue des dossiers d’audits, ainsi que des entretiens directifs, semi-directifs auprès du personnel impliqué dans les soins de maternité ont été réalisés. L’enquête s’est. déroulée du 27 Avril au 30 Mai 2015. Résultats: Les résultats montrent que les revues des décès maternels ont été irrégulièrement programmées, de façon espacée et très souvent au gré des évènements. La préparation, la conduite des séances et la communication après les séances ont été défaillantes. La confidentialité au sein du groupe d’auditeurs a été respectée tandis que le niveau de respect du principe de « no name, no shame, no blame » a varié d’une structure à une autre. Enfin, l’anonymat a été le moins respecté. Conclusion: La programmation, la communication et le respect des principes fondamentaux ont connu des défaillances par rapport aux normes mais de façon variable d’une structure à une autre. L’identification des déterminants de ces insuffisances pourront aider à l’orientation des interventions visant l’amélioration de l’activité des audits de décès maternels au niveau district de santé.
In the national reference documents related to clinical audits (including the review of cases of maternal deaths in health facilities), the following points stand for standards: confidentiality of information during the clinical audits, anonymity (“No name”) of the cases audited by the audit committee members, no accusation (“no shame”), and no punishment (“no blame”). Principles and rules of good conduct of clinical audit (mutual respect, openness, active participation, acceptance of discussion and questioning of practices …) have been specified in an “Audit Charter” whose reading and approval is required prior to participating in any audit sessions. Audits or reviews are meant to be regularly scheduled with an interval of one to three months. The process should involve the maximum of stakeholders involved with the case management and/or by the decision making in order to facilitate the implementation of the recommendations. Communication between the different actors of maternal health before and after audits is also important. Feedback of maternal audits to stakeholders for finding solutions to the problem should be carried out and has been advocated for by the Direction of Family Health of the Ministry of Health. An outline for good conduct of the session of MDAs was established. It emphasizes the need for an environment ensuring confidentiality, role sharing, good management of discussions in compliance with the principles and rules stated in the charter [3–5]. The study was conducted in Burkina Faso, a landlocked developing country in West Africa. Its public health system includes an administrative and operational organization. Administratively we have a central level (constituted by the minister’s office, the general secretariat and the central directorates), an intermediate level composed of the Regional Directorates of Health and the Regional Hospitals, and a peripheral level with 70 health districts, 63 of which are headed by district teams. Healthcare provision is equally organized in three levels. The first level is composed of two echelons (the first echelon with 1643 primary health care facilities and the second echelon with 47 Medical Centers with Surgical Antenna (MCSA) or District Hospitals). The first and the second echelons are under the responsibility of the health district. Some health districts do not have district hospital as referral center and would refer patients requiring additional care directly to the corresponding regional hospital that stands for their district hospital. A total of nine health districts are in the latter described situation, referring directly to the regional hospital, which pertains in the health care system to the second level. A total of nine functioning regional hospitals are in the country. The third level of care consists of one national hospital and three university teaching hospitals. In the context of health district, maternal deaths may occur in the community, in primary health care facilities, in MCSU or in Regional hospitals when the latter stand for direct referral centre for the health district. To date, the country has 63 functioning health districts headed by health district management teams [12–14]. We carried out a cross sectional qualitative multiple cases study from 27 April to 30 May of 2015. The cases are health districts purposely chosen between those that reported carrying out MDAs. Cases selection was carried out in a way to have a mix of rural and urban location health districts, districts with high, average and low intra-hospital maternal mortality rates and districts using district hospitals and regional hospitals for reference. We analyze all maternal deaths that occurred from January 1st to December 31st 2014 and we selected a sample of the staff members involved with healthcare provision to women in the maternity wards in all type of health facilities in the selected health districts. The health districts were selected using contrasted purposive sampling based on the declarations of the MDAs performed in 2013, the intra-hospital maternal mortality rates for the year 2013, and the location area of the health district (urban vs rural). Five groups of health districts were constructed based on the reported intra-hospital maternal mortality rates (close to the minimum national rate, close to the national average rate and close to the maximum national rate) and the location area. The regional hospitals were considered also if the selected health districts did not have a MCSU as referral center. We selected 5 health districts with district hospitals as referral center (Djibo, Tougan, Dafra, Tenkodogo, Ouahigouya) and 2 health districts that use regional hospitals as referral centers (Tenkodogo and Ouahigouya) to be included in the study. In the selected districts, all maternal deaths that occurred in healthcare facilities in 2014 and for which a review was carried out were included in the study. Reviews conducted should have a minimum of proof documents (charter, attendance list, clinical case summary, case analysis or discussion summary sheet, micro-planning for implementing solutions, change evaluation sheet) available regardless their completeness or nature (soft and/or hard copies). Documents (memos, posters, activity reports, etc.) in paper or electronic form related to maternal deaths and/or audits were also reviewed. Participants were selected among the staff involved in the maternity unit (delivery room, chirurgical ward, and postoperative care units), staff of pharmacy, staff of laboratory, and staff from administration and management sections at the MCSU or regional hospitals levels in each selected health district. The heads of the previous mentioned departments were systematically included in the study. When an audit committee was in place and functioning, all the members of such committee were included in the study. Additional respondent selection in each unit was conducted in a way to represent all available qualifications in the health facility. The number of respondents to be included in the study and their respective qualifications for each health district was informed by a quick review of the general information obtained on human resources and the organization in place for the conduct of MDAs. the data collection took place from 27 April to 30 May of 2015. General information on health facilities were obtained through face-to-face interviews with key respondents at each health facility level using a questionnaire. An interview guide (see Table 1) was used to assess the compliance with known standards in the conduct of MDAs using in-depth individual interviews (IDIs). The IDIs were conducted by a medical doctor who was a public health student at the time of the study and was previously trained on MDAs. Full information on the themes and sub-themes that were investigated during the IDIs and the targets for each question are available in Table 1. In addition to the previous mentioned techniques, data extraction from relevant data sources (patients ‘charts, audits records etc.) was performed to complete the information gathered through IDIs. The interviews were conducted in French and tape recorded using a Dictaphone. Interview guide The data recorded were transcribed and enter into MS Word. The data were thereafter render anonymous using codes. Health facilities were numbered from 1 to 7. The number of health facility followed by and order number was used for interviewees. We performed a framework analysis in accordance with the four dimensions of the principles of maternal death audits: general conditions of conduct of audits, principles of audits, stages of the audit cycle, overall appraisal of the practice of audits. Each dimension was declined into subdimensions (Table 2). Following these dimensions and subdimensions, we developed an analysis frame with MS Excel 2010 to code the data. To do this, an analysis frame (based on the basics principles of maternal death audit was developed, theme by theme. Themes, sub-themes and levels used in the analysis of data The National Ethics Committee for Health Research in Burkina Faso in its statement n° 2015-5-058 authorized this study. The interviews were only conducted after obtaining an informed and written consent. During the data collection and analysis the anonymity and confidentiality of study participants were safeguarded and all informations are stored on laptops protected by passwords. Access and utilization of the data collected was limited to the research team.
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