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 Aug;23(4):456-63. doi: 10.1093/intqhc/mzr033. Epub 2011 Jun 13.


Purpose: Low-quality obstetric care in low- and middle-income countries contributes to high in-hospital maternal mortality. Criterion-based clinical audits are increasingly used to measure and improve obstetric care in these settings. This article systematically reviews peer-reviewed literature to determine if these audits are feasible, valid and reliable measurement tools for assessing the quality of obstetric care.

Data sources: PUBMED, Google Scholar and Web of Science databases were searched for peer-reviewed articles published between 1995 and 2009 and which used criterion-based clinical audits to measure the quality of obstetric care in low- and middle-income countries.

Study selection: Sixty-nine studies were identified by key terms and subsequently reviewed. Ten were retained based on inclusion/exclusion criteria.

Data extraction: (i) General characteristics of the study; (ii) compliance with expected standards of care and on maternal/child health outcomes; (iii) selection of the study population and sampling methods; and (iv) quality control and reliability.

Results of data synthesis: Criterion-based clinical audit is increasingly used in low- and middle-income countries. Most audits were conducted in sub-Saharan Africa. Studies had cross-sectional study or before-and-after designs. Sampling methods were poorly reported and selection bias was a concern. No studies compared audit against other measures of quality of care or against patient outcomes.

Methods: for quality control and assurance were generally not documented and reliability was mostly unaddressed.

Conclusions: Criterion-based clinical audit appears feasible. No studies have rigorously evaluated its measurement properties in low- and middle-income countries. Without such evaluation, measurement properties of the audit remain under question.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Developing Countries*
  • Female
  • Humans
  • Medical Audit*
  • Obstetrics / standards*
  • Quality of Health Care*