|11. What is the Evidence for the Role of Audits to Improve the Quality of Obstetric Care|
The use of defined standards of medical care is the hallmark of audit. Their primary purpose is to highlight deficiencies, by comparing the care that was given to the care that ought to have been given. Standards are explicit statements of how a patient should be managed, taking into account the resource context of the care that is under review. Since ownership of the findings is crucial, standards are usually negotiated internally within the audit group, although external bodies such as the government or the World Health Organisation might also set standards. Standards are usually developed through a combination of clinical experience and a review of the available evidence. Clinical judgement can be used as an implicit standard, and can be sufficient when deficiencies are so large as to be self-evident. Where possible however, published research should be used to back up clinical judgement and expert opinion.
One of the main advantages of audits in obstetric care is that evidence-based practice guidelines have been developed based on scientific literature (Chalmers et al. 1989). The Cochrane Pregnancy and Childbirth Database, for example, provides access to systematic reviews of randomised trials of interventions in pregnancy and childbirth that are updated on a six-monthly basis (Cochrane Collaboration 1997). In addition, explicit criteria of quality of obstetric care have been established for those processes for which we have sound scientific evidence or a formal consensus of experts that the criteria, when applied, lead to an improvement in health (Benhow et al. 1997). Such process criteria have been developed in a number of countries, including more recently in two developing countries (Graham et al. 2000). Although these criteria are by no means exhaustive, they are certainly a useful starting point for establishing criteria of best practice in obstetric care. Based on these external criteria internal standards can be negotiated within the audit group taking into account local circumstances.
Standards are not always made explicit, and a team of experts may ultimately decide whether the care is to be considered as substandard or not. In the Confidential enquiries into Maternal Deaths in England and Wales, for example, a team of experts initially assessed all maternal deaths for their avoidability (Department of Health and Social Security 1982). After considering the circumstances of each individual death, the assessors decided whether an alternative choice of action by any individual would have prevented or reduced the likelihood of death. The factors were classified as avoidable or not avoidable according to whether there was a departure from generally accepted standards of care (Department of Health and Social Security 1982). Responsibility for the death was sought at the individual level and factors were classified by the type of person responsible (i.e. patient, general practitioner, obstetrician, midwife, anaesthetist, other hospital staff, other community staff, service manager and politician) and time of occurrence (antenatal period, labour or operative procedure, and puerperium or post-operative period). In 1980, the term avoidable was replaced by substandard care, because the avoidable factors were often wrongly interpreted as meaning that avoiding these factors would necessarily have prevented the death. Substandard, on the other hand, meant that the care that the patient received, or that was made available to her, fell below the standard which the authors considered should have been offered to her (Department of Health and Social Security 1986). Substandard care takes into account not only failure in clinical care, but also actions by the woman herself or her relatives, and factors outside the control of physicians such as shortage of resources or administrative failures.