There are two broad dimensions of quality of maternity care, namely quality of health outcomes and quality as experienced by women receiving the care [1]. Both dimensions are crucial in measuring and improving the quality of care which in turn affects utilisation of maternal health services. In some settings women's experience of care may be more important than the health outcomes because childbirth is a culturally and emotionally sensitive area [2]. This is particularly true since most users of maternity care are healthy women who need only basic care, although some users will develop conditions requiring a higher level of care [3].
There are many tools used to improve the quality of care in maternity units. These include maternal death audit, criterion-based audit, training, dissemination of practice guidelines, plan-do-study-act (PDSA) cycles, tools for process description (client flow analysis, process mapping, and cause-effect analysis), tools for data collection (direct observation, exit interviews, and focus group discussion), tools for collaborative work (nominal group technique, facilitative supervision, force-field analysis, benchmarking, and SWOT analysis), and combined models involving a combination of these tools [4–11].
Criterion-based audit (also called clinical audit) is a well known approach for improving the quality of maternity care. It is strongly supported by expert opinion as well as national and international organisations including the World Health Organisation (WHO) and the National Institute of Clinical Excellence (NICE) in the United Kingdom [2, 12]. NICE defines audit as: "A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and implementation of change. Aspects of structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery" [12].
The five classic steps of the clinical audit cycle are presented in Figure 1. The first step is the development of standards. Traditionally standards have been developed by systematic reviews to identify sets of criteria that constitute optimal care. Once standards have been developed, actual practice is measured and compared with standards (best practice). Gaps in current practice are identified, recommendations are made and implemented, and progress is evaluated
Previous studies on criterion-based audit in maternity units have focused on improving the outcomes of emergency obstetric complications, ignoring quality as perceived by clients [13–15]. Criterion based audit for emergency obstetric complications has just recently been introduced in a few developing countries, including Uganda, Ghana and Jamaica [13–15]. To the best of our knowledge there are no published studies on the use of criterion based audit to improve women friendly care in a developing country setting.
Developing standards for women-friendly care is complex because (a) acceptable and valued behaviour may not be documented and (b) cultural values vary between countries or ethnic groups. Therefore systematic reviews may not capture what women consider good quality of care. This is particularly challenging in settings were traditional values strongly shape how quality of care is perceived by clients. Unfortunately this important area has been given very little attention especially in developing countries. The high maternal mortality in resource-limited settings is partly due to the poor attitudes of health providers which lead to reduced utilisation of maternity care services [16].
As part of a collaborative programme to reduce maternal mortality in Malawi, we sought to introduce criterion based audit to improve women friendly care in maternity units. This paper describes how standards for women friendly care were developed in Malawi, and attitudes of health care providers that could influence the implementation of criterion based audit.