DOI: 10.1111/1471-0528.12904
Commentary
www.bjog.org
Towards greater effectiveness of perinatal death audit in low- and middle-income countries EJ Buchmann Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa Correspondence: Prof EJ Buchmann, Department of Obstetrics and Gynaecology, Room 31, First floor, Maternity and Gynaecology, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Soweto, Johannesburg, South Africa. Email [email protected] Accepted 16 April 2014. Please cite this paper as: Buchmann EJ. Towards greater effectiveness of perinatal death audit in low- and middle-income countries. BJOG 2014; 121 (Suppl. 4): 134–136.
Perinatal death audit is a powerful tool for measuring, assessing and managing perinatal mortality. Low- and middle-income countries (LMICs) suffer a disproportionate burden of perinatal deaths, and in low-income countries both stillbirths and neonatal deaths are frequently attributable to intrapartum causes, such as obstructed labour, birth asphyxia and uterine rupture.1 In such settings, the quality of obstetric health care needs evaluation and improvement, primarily to prevent these unnecessary deaths, but also to ensure delivery of better obstetric care. Clinical audit is founded on the classic Donabedian model, where the aim is to evaluate quality of care, by identifying the poor outcomes (perinatal deaths) and then looking for failures in health system structures and clinical care processes.2 In the LMIC context, an important addition to the model is the question of access to and utilisation of health care, as auditing structure and process alone have limited value when pregnant women cannot reach or do not use local health facilities.3 A perinatal audit is performed by collecting and analysing information, with presentation and discussion at an audit meeting, and then planning and making improvements in quality of care. The goal is closure of the audit loop by finally re-auditing and showing positive changes. In general, outcomes audit is continuous, supported by regular audit meetings, while structure and process audits are done ad hoc, as so-called topic audits, to concentrate on identified problem areas.
Outcomes audit Outcomes audit starts by identifying perinatal deaths and assigning clinical causes according to a classification system. In some middle-income countries, perinatal deaths may be infrequent, so that perinatal near-miss could be a more appropriate audited outcome. Finding perinatal
134
deaths or near-misses is followed by a systematic assessment of deficiencies (avoidable factors) in access, structure and process for each death. Two frameworks are commonly used for this assessment—the ‘three delays’ model of Thaddeus and Maine,3 and the ‘patient–administrative– healthcare provider’ model used in the Perinatal Problem Identification Programme (PPIP).4 The three delays model is perhaps best suited to low-income countries, where access to health care is an important issue. The first delay is the pregnant woman delaying the decision to seek care, the second is delayed arrival at a facility, and the third is the delay in the provision of adequate care. The PPIP model combines the first and second delays into ‘patient’ factors, and splits the third delay into ‘administrative’ failures and ‘healthcare provider’ failures. With greater emphasis on health system capacity, the PPIP model is more appropriate for middle-income countries. Whichever model is used, each perinatal death undergoes an overall assessment of whether the suboptimal care, if any, was such that it contributed to the death and to what extent (not at all, possibly, or probably). Outcomes audit has its limitations. Selection bias is an obvious problem, where perinatal deaths are missed, for administrative reasons such as lost files, or because some categories of deaths do not occur in the health facilities, for example newborns discharged and dying in their homes. Many published reports of audits do not question the validity of the avoidable factor assessments. One study has shown that inter-rater agreement between expert assessments was only poor to moderate.5 Outcomes audits need to be regularly monitored for validity and reliability, so that decisions on quality improvement are not based on incorrect data. Finally, care should be taken in using perinatal death audits as epidemiological community surveys. Audits will give biased information on mortality rates and causes if they cover
ª 2014 Royal College of Obstetricians and Gynaecologists
Perinatal audit in low- and middle-income countries
births and deaths only at health facilities or at high-level referral centres and exclude home births or births at lower levels of care.
Criterion-based clinical audit Process audit is more specific than outcomes audit, and is necessitated by recurrent perinatal adverse events often discovered in routine outcomes audit. An example would be a facility auditing intrapartum-related perinatal death in term babies, where poor labour management and substandard neonatal resuscitation may be contributory. Criterion-based clinical audit (CBCA) is a method currently popular for scrutinising such processes. CBCA involves the setting of criteria (standards) for, in this example, quality of care for women in labour, and neonatal resuscitation. Using evidence from randomised trials where possible, and local expertise, standards are set and introduced for audit in that facility. Each criterion is part of the process (intrapartum care and neonatal resuscitation) being audited, for example partograph use, emergency caesarean section started within 30 minutes of deciding to operate, or Apgar scores at 1 and 5 minutes being assigned. Any number of criteria (but not hundreds) can be included on the audit sheet, but all should be easy to assess on reviewing the clinical notes. CBCA is a rewarding method of identifying problems, and can be followed by root-cause analysis (why? why?), to better understand underlying deficiencies.6 With growing interest in CBCA in obstetric care, Pirkle et al.7 performed a systematic review of CBCA in LMICs to assess validity and reliability of these audits. They could not assess validity and reliability in the ten included audits because of selection bias, poor quality control, and missing information. The same authors then used data from the cluster randomised QUARITE Trial in West Africa to evaluate the CBCA that was part of the trial.8 They showed good inter-rater reliability between assessors in their clinical reviews. There was also concordance between the clinical processes and the underlying health system structure, and the processes and the subsequent clinical outcomes, confirming the validity of the Donabedian structure– process–outcome model. The findings are reassuring about CBCA, and should provide confidence in its use for evaluation of perinatal care. The authors also provided useful recommendations for developing clinical audit in obstetric care, with safeguards to prevent biased data collection and review. Audit of structure is often necessary to identify deficiencies in facilities, equipment or staffing, and may be integrated in a CBCA. The principle is similar to process audit, with standards being set from research evidence and experience. An example would be basic equipment needed for neonatal resuscitation and numbers of qualified staff that
ª 2014 Royal College of Obstetricians and Gynaecologists
should be immediately available for neonatal resuscitation. While clinical processes can often be modified by clinicians, structural deficiencies are a greater challenge. Personal experience from working in low- and middle-income settings is that administrators may be unwilling or unable to commit budgets to new equipment or staff. Repairs and renovations may themselves be substandard or delayed. Pleas for equipment and improved facilities may result in conflicts with administrators, and also with clinician colleagues who may be competing for scarce funds to have other parts of the health facility improved.
Perinatal audit effecting change Perinatal audits are carried out to reduce perinatal mortality, not merely to collect data. However, linking reduced perinatal mortality to the introduction of audit is difficult. A systematic review of perinatal audits from LMICs identified seven reports with before-and-after designs, and found perinatal mortality reductions of about 30% after introducing perinatal audit.1 The review noted that the studies were of low quality, and acknowledged a likelihood of publication bias towards reporting of successful audits. Proof of effect from randomised trials should be the benchmark for any healthcare intervention, but a Cochrane review on the topic could find no trials that tested perinatal death audit.9 The Cochrane reviewers concluded, however, that perinatal death reviews should be continued, ‘until further information is available’. For ethical reasons, it is unlikely that trials comparing audit with no audit will be done. The need for and potential value of perinatal audits is not in doubt, but different approaches can still be tested in randomised comparisons. There is a strong research agenda on perinatal audit. In a priority-setting exercise on research to reduce stillbirths, the question of how best to undertake perinatal audit and quality improvement ranked in the top ten lists of research priorities for both low- and middle-income countries.10 A step back from preventing perinatal deaths is the ability of perinatal audit to effect change in structures or processes. With no noticeable changes resulting from audit, even enthusiasts driving the process can easily become demoralised. Nyamtema et al.11 investigated eight hospitals in Dar es Salaam, Tanzania, a city in which perinatal audit had become well established, and found that only 50% of the hospitals had audit committees and that some had discontinued clinical audit, attributed in one case to ‘failure of the hospital administration to implement audit recommendations’. Pattinson et al.10 pointed out the importance of involving all interfaces or contacts in the health system (healthcare providers, healthcare managers, health promotion managers, heads of health, and health policy makers) to ensure sustainable change. Beliza´n et al.4 reported on a
135
Buchmann
South African qualitative study on overcoming such barriers, in which ‘stages of change’ were identified in implementing audit programmes. The first stages were creation of awareness and commitment to implement, followed by implementation, then integration into routine practice and finally sustaining new practices. The authors described audit as a package with four essentials: (1) motivated drivers with teams, (2) outreach and clinical supervision in the facilities, (3) regular perinatal review meetings, and (4) communication and networking involving all levels of care including administrative management. An important point made was that ‘conducting audit and giving feedback at morbidity and mortality meetings and other educational and review meetings still does not mean that quality of care will improve automatically’. The ‘package’ nature of change is well demonstrated in the QUARITE trial, where a multifaceted intervention was tested in a number of hospitals.12 The intervention involved developing local leadership, empowering obstetric teams through interactive workshops, and establishing multidisciplinary audit committees to undertake maternal death reviews and CBCAs. Four years into the trial, first-level referral hospitals allocated to the intervention arm of the trial had reduced maternal mortality, while neonatal mortality at less than 24 hours after birth decreased for all hospitals combined. The simultaneous improvement in both maternal and neonatal survival illustrates the mutualistic relationship between perinatal and maternal mortality audit. Perinatal death and maternal death audits should be performed by the same team using similar processes and discussed at the same review meetings.
Conclusion Perinatal death audit is an essential element of all obstetric services. Routine outcomes audit supported by perinatal review meetings forms the foundation of audit activities, based on frameworks for understanding avoidable factors. Perinatal death audit in LMICs can be improved with special attention to data quality and reliability of assessments. The flow of information must lead to closure of the audit loop to address deficiencies in obstetric care so prevalent in LMICs, to reduce perinatal deaths. There is a need for well-designed prospective research on perinatal audit, on its own or as part of a package of obstetric service improvement.
Disclosures of interests The author has no conflicts of interest in writing this commentary.
136
Contribution to authorship The author wrote the commentary.
Details of ethics approval Not applicable.
Funding No funding was applied for or received to write this commentary.
Acknowledgements None. &
References 1 Pattinson R, Kerber K, Waiswa P, Day LT, Mussell F, Asiruddin S, et al. Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries. Int J Gynecol Obstet 2009;107:S113–22. 2 Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44:166–203. 3 Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38:1091–110. 4 Beliz an M, Bergh AM, Cilliers C, Pattinson RC, Voce A. Stages of change: a qualitative study on the implementation of a perintal audit programme in South Africa. BMC Health Serv Res 2011;11:243. 5 Kidanto HL, Mogren I, van Roosmalen J, Thomas AN, Massawe SN, Nystrom L. Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. BMC Pregnancy Childbirth 2009;9:45. 6 Weeks AD, Alia G, Ononge S, Mutungi A, Otolorin EO, Mirembe FM. Introducing criteria based audit into Ugandan maternity units. BMJ 2003;327:1329–31. 7 Pirkle CM, Dumont A, Zunzunegui MV. Criterion-based clinical audit to assess quality of obstetrical care in low- and middle-income countries: a systematic review. Int J Qual Health Care 2011;23:456– 63. 8 Pirkle CM, Dumont A, Traore M, Zunzunegui MV. Validity and reliability of criterion based clinical audit to assess quality of care in West Africa. BMC Pregnancy Childbirth 2012;12:118. 9 Pattinson RC, Say L, Makin JD, Bastos MH. Critical incident audit and feedback to improve perinatal and maternal mortality and morbidity. Cochrane Database Syst Rev 2005;(4):CD002961. 10 Pattinson RC, Kerber K, Buchmann EJ, Friberg IK, Beliz an M, Lansky S, et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011;377:1610–23. 11 Nyamtema AS, Urassa DP, Pembe AB, Kissanga F, van Roosmalen J. Factors for change in maternal and perinatal audit systems in Dar es Salaam hospitals, Tanzania. BMC Pregnancy Childbirth 2010;10:29. 12 Dumont A, Fournier P, Abrahamowicz M, Traor e M, Haddad S, Fraser WD; for the QUARITE research group. Quality of care, risk management and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial. Lancet 2013;382:146–57.
ª 2014 Royal College of Obstetricians and Gynaecologists
Commentary
www.bjog.org
Towards greater effectiveness of perinatal death audit in low- and middle-income countries EJ Buchmann Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa Correspondence: Prof EJ Buchmann, Department of Obstetrics and Gynaecology, Room 31, First floor, Maternity and Gynaecology, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Soweto, Johannesburg, South Africa. Email [email protected] Accepted 16 April 2014. Please cite this paper as: Buchmann EJ. Towards greater effectiveness of perinatal death audit in low- and middle-income countries. BJOG 2014; 121 (Suppl. 4): 134–136.
Perinatal death audit is a powerful tool for measuring, assessing and managing perinatal mortality. Low- and middle-income countries (LMICs) suffer a disproportionate burden of perinatal deaths, and in low-income countries both stillbirths and neonatal deaths are frequently attributable to intrapartum causes, such as obstructed labour, birth asphyxia and uterine rupture.1 In such settings, the quality of obstetric health care needs evaluation and improvement, primarily to prevent these unnecessary deaths, but also to ensure delivery of better obstetric care. Clinical audit is founded on the classic Donabedian model, where the aim is to evaluate quality of care, by identifying the poor outcomes (perinatal deaths) and then looking for failures in health system structures and clinical care processes.2 In the LMIC context, an important addition to the model is the question of access to and utilisation of health care, as auditing structure and process alone have limited value when pregnant women cannot reach or do not use local health facilities.3 A perinatal audit is performed by collecting and analysing information, with presentation and discussion at an audit meeting, and then planning and making improvements in quality of care. The goal is closure of the audit loop by finally re-auditing and showing positive changes. In general, outcomes audit is continuous, supported by regular audit meetings, while structure and process audits are done ad hoc, as so-called topic audits, to concentrate on identified problem areas.
Outcomes audit Outcomes audit starts by identifying perinatal deaths and assigning clinical causes according to a classification system. In some middle-income countries, perinatal deaths may be infrequent, so that perinatal near-miss could be a more appropriate audited outcome. Finding perinatal
134
deaths or near-misses is followed by a systematic assessment of deficiencies (avoidable factors) in access, structure and process for each death. Two frameworks are commonly used for this assessment—the ‘three delays’ model of Thaddeus and Maine,3 and the ‘patient–administrative– healthcare provider’ model used in the Perinatal Problem Identification Programme (PPIP).4 The three delays model is perhaps best suited to low-income countries, where access to health care is an important issue. The first delay is the pregnant woman delaying the decision to seek care, the second is delayed arrival at a facility, and the third is the delay in the provision of adequate care. The PPIP model combines the first and second delays into ‘patient’ factors, and splits the third delay into ‘administrative’ failures and ‘healthcare provider’ failures. With greater emphasis on health system capacity, the PPIP model is more appropriate for middle-income countries. Whichever model is used, each perinatal death undergoes an overall assessment of whether the suboptimal care, if any, was such that it contributed to the death and to what extent (not at all, possibly, or probably). Outcomes audit has its limitations. Selection bias is an obvious problem, where perinatal deaths are missed, for administrative reasons such as lost files, or because some categories of deaths do not occur in the health facilities, for example newborns discharged and dying in their homes. Many published reports of audits do not question the validity of the avoidable factor assessments. One study has shown that inter-rater agreement between expert assessments was only poor to moderate.5 Outcomes audits need to be regularly monitored for validity and reliability, so that decisions on quality improvement are not based on incorrect data. Finally, care should be taken in using perinatal death audits as epidemiological community surveys. Audits will give biased information on mortality rates and causes if they cover
ª 2014 Royal College of Obstetricians and Gynaecologists
Perinatal audit in low- and middle-income countries
births and deaths only at health facilities or at high-level referral centres and exclude home births or births at lower levels of care.
Criterion-based clinical audit Process audit is more specific than outcomes audit, and is necessitated by recurrent perinatal adverse events often discovered in routine outcomes audit. An example would be a facility auditing intrapartum-related perinatal death in term babies, where poor labour management and substandard neonatal resuscitation may be contributory. Criterion-based clinical audit (CBCA) is a method currently popular for scrutinising such processes. CBCA involves the setting of criteria (standards) for, in this example, quality of care for women in labour, and neonatal resuscitation. Using evidence from randomised trials where possible, and local expertise, standards are set and introduced for audit in that facility. Each criterion is part of the process (intrapartum care and neonatal resuscitation) being audited, for example partograph use, emergency caesarean section started within 30 minutes of deciding to operate, or Apgar scores at 1 and 5 minutes being assigned. Any number of criteria (but not hundreds) can be included on the audit sheet, but all should be easy to assess on reviewing the clinical notes. CBCA is a rewarding method of identifying problems, and can be followed by root-cause analysis (why? why?), to better understand underlying deficiencies.6 With growing interest in CBCA in obstetric care, Pirkle et al.7 performed a systematic review of CBCA in LMICs to assess validity and reliability of these audits. They could not assess validity and reliability in the ten included audits because of selection bias, poor quality control, and missing information. The same authors then used data from the cluster randomised QUARITE Trial in West Africa to evaluate the CBCA that was part of the trial.8 They showed good inter-rater reliability between assessors in their clinical reviews. There was also concordance between the clinical processes and the underlying health system structure, and the processes and the subsequent clinical outcomes, confirming the validity of the Donabedian structure– process–outcome model. The findings are reassuring about CBCA, and should provide confidence in its use for evaluation of perinatal care. The authors also provided useful recommendations for developing clinical audit in obstetric care, with safeguards to prevent biased data collection and review. Audit of structure is often necessary to identify deficiencies in facilities, equipment or staffing, and may be integrated in a CBCA. The principle is similar to process audit, with standards being set from research evidence and experience. An example would be basic equipment needed for neonatal resuscitation and numbers of qualified staff that
ª 2014 Royal College of Obstetricians and Gynaecologists
should be immediately available for neonatal resuscitation. While clinical processes can often be modified by clinicians, structural deficiencies are a greater challenge. Personal experience from working in low- and middle-income settings is that administrators may be unwilling or unable to commit budgets to new equipment or staff. Repairs and renovations may themselves be substandard or delayed. Pleas for equipment and improved facilities may result in conflicts with administrators, and also with clinician colleagues who may be competing for scarce funds to have other parts of the health facility improved.
Perinatal audit effecting change Perinatal audits are carried out to reduce perinatal mortality, not merely to collect data. However, linking reduced perinatal mortality to the introduction of audit is difficult. A systematic review of perinatal audits from LMICs identified seven reports with before-and-after designs, and found perinatal mortality reductions of about 30% after introducing perinatal audit.1 The review noted that the studies were of low quality, and acknowledged a likelihood of publication bias towards reporting of successful audits. Proof of effect from randomised trials should be the benchmark for any healthcare intervention, but a Cochrane review on the topic could find no trials that tested perinatal death audit.9 The Cochrane reviewers concluded, however, that perinatal death reviews should be continued, ‘until further information is available’. For ethical reasons, it is unlikely that trials comparing audit with no audit will be done. The need for and potential value of perinatal audits is not in doubt, but different approaches can still be tested in randomised comparisons. There is a strong research agenda on perinatal audit. In a priority-setting exercise on research to reduce stillbirths, the question of how best to undertake perinatal audit and quality improvement ranked in the top ten lists of research priorities for both low- and middle-income countries.10 A step back from preventing perinatal deaths is the ability of perinatal audit to effect change in structures or processes. With no noticeable changes resulting from audit, even enthusiasts driving the process can easily become demoralised. Nyamtema et al.11 investigated eight hospitals in Dar es Salaam, Tanzania, a city in which perinatal audit had become well established, and found that only 50% of the hospitals had audit committees and that some had discontinued clinical audit, attributed in one case to ‘failure of the hospital administration to implement audit recommendations’. Pattinson et al.10 pointed out the importance of involving all interfaces or contacts in the health system (healthcare providers, healthcare managers, health promotion managers, heads of health, and health policy makers) to ensure sustainable change. Beliza´n et al.4 reported on a
135
Buchmann
South African qualitative study on overcoming such barriers, in which ‘stages of change’ were identified in implementing audit programmes. The first stages were creation of awareness and commitment to implement, followed by implementation, then integration into routine practice and finally sustaining new practices. The authors described audit as a package with four essentials: (1) motivated drivers with teams, (2) outreach and clinical supervision in the facilities, (3) regular perinatal review meetings, and (4) communication and networking involving all levels of care including administrative management. An important point made was that ‘conducting audit and giving feedback at morbidity and mortality meetings and other educational and review meetings still does not mean that quality of care will improve automatically’. The ‘package’ nature of change is well demonstrated in the QUARITE trial, where a multifaceted intervention was tested in a number of hospitals.12 The intervention involved developing local leadership, empowering obstetric teams through interactive workshops, and establishing multidisciplinary audit committees to undertake maternal death reviews and CBCAs. Four years into the trial, first-level referral hospitals allocated to the intervention arm of the trial had reduced maternal mortality, while neonatal mortality at less than 24 hours after birth decreased for all hospitals combined. The simultaneous improvement in both maternal and neonatal survival illustrates the mutualistic relationship between perinatal and maternal mortality audit. Perinatal death and maternal death audits should be performed by the same team using similar processes and discussed at the same review meetings.
Conclusion Perinatal death audit is an essential element of all obstetric services. Routine outcomes audit supported by perinatal review meetings forms the foundation of audit activities, based on frameworks for understanding avoidable factors. Perinatal death audit in LMICs can be improved with special attention to data quality and reliability of assessments. The flow of information must lead to closure of the audit loop to address deficiencies in obstetric care so prevalent in LMICs, to reduce perinatal deaths. There is a need for well-designed prospective research on perinatal audit, on its own or as part of a package of obstetric service improvement.
Disclosures of interests The author has no conflicts of interest in writing this commentary.
136
Contribution to authorship The author wrote the commentary.
Details of ethics approval Not applicable.
Funding No funding was applied for or received to write this commentary.
Acknowledgements None. &
References 1 Pattinson R, Kerber K, Waiswa P, Day LT, Mussell F, Asiruddin S, et al. Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries. Int J Gynecol Obstet 2009;107:S113–22. 2 Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44:166–203. 3 Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994;38:1091–110. 4 Beliz an M, Bergh AM, Cilliers C, Pattinson RC, Voce A. Stages of change: a qualitative study on the implementation of a perintal audit programme in South Africa. BMC Health Serv Res 2011;11:243. 5 Kidanto HL, Mogren I, van Roosmalen J, Thomas AN, Massawe SN, Nystrom L. Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. BMC Pregnancy Childbirth 2009;9:45. 6 Weeks AD, Alia G, Ononge S, Mutungi A, Otolorin EO, Mirembe FM. Introducing criteria based audit into Ugandan maternity units. BMJ 2003;327:1329–31. 7 Pirkle CM, Dumont A, Zunzunegui MV. Criterion-based clinical audit to assess quality of obstetrical care in low- and middle-income countries: a systematic review. Int J Qual Health Care 2011;23:456– 63. 8 Pirkle CM, Dumont A, Traore M, Zunzunegui MV. Validity and reliability of criterion based clinical audit to assess quality of care in West Africa. BMC Pregnancy Childbirth 2012;12:118. 9 Pattinson RC, Say L, Makin JD, Bastos MH. Critical incident audit and feedback to improve perinatal and maternal mortality and morbidity. Cochrane Database Syst Rev 2005;(4):CD002961. 10 Pattinson RC, Kerber K, Buchmann EJ, Friberg IK, Beliz an M, Lansky S, et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011;377:1610–23. 11 Nyamtema AS, Urassa DP, Pembe AB, Kissanga F, van Roosmalen J. Factors for change in maternal and perinatal audit systems in Dar es Salaam hospitals, Tanzania. BMC Pregnancy Childbirth 2010;10:29. 12 Dumont A, Fournier P, Abrahamowicz M, Traor e M, Haddad S, Fraser WD; for the QUARITE research group. Quality of care, risk management and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial. Lancet 2013;382:146–57.
ª 2014 Royal College of Obstetricians and Gynaecologists
