Improving obstetric care in low-resource settings : implementation of facility-based maternal death reviews in five pilot hospitals in Senegal

Background: In sub-Saharan Africa, maternal and perinatal mortality and morbidity are major problems. Service availability and quality of care in health facilities are heterogeneous and most often inadequate. In resource-poor settings, the facility-based maternal death review or audit is one of the most promising strategies to improve health service performance. We aim to explore and describe health workers' perceptions of facility-based maternal death reviews and to identify barriers to and facilitators of the implementation of this approach in pilot health facilities of Senegal. Methods: This study was conducted in five reference hospitals in Senegal with different characteristics. Data were collected from focus group discussions, participant observations of audit meetings, audit documents and interviews with the staff of the maternity unit. Data were analysed by means of both quantitative and qualitative approaches. Results: Health professionals and service administrators were receptive and adhered relatively well to the process and the results of the audits, although some considered the situation destabilizing or even threatening. The main barriers to the implementation of maternal deaths reviews were: ( 1) bad quality of information in medical files; ( 2) non-participation of the head of department in the audit meetings; ( 3) lack of feedback to the staff who did not attend the audit meetings. The main facilitators were: ( 1) high level of professional qualifications or experience of the data collector; ( 2) involvement of the head of the maternity unit, acting as a moderator during the audit meetings; ( 3) participation of managers in the audit session to plan appropriate and realistic actions to prevent other maternal deaths. Conclusion: The identification of the barriers to and the facilitators of the implementation of maternal death reviews is an essential step for the future adaptation of this method in countries with few resources. We recommend for future implementation of this method a prior enhancement of the perinatal information system and initial training of the members of the audit committee - particularly the data collector and the head of the maternity unit. Local leadership is essential to promote, initiate and monitor the audit process in the health facilities