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Gondwe, Mtisunge (2022) Processes and outcomes of stillbirth and neonatal death audit as a quality improvement tool in the southern region of Malawi, Thesis (Doctoral), Liverpool School of Tropical Medicine.
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M Gondwe - Thesis Final.pdf - Accepted Version Download (4MB) | Preview |
Abstract
Stillbirth and neonatal death audits are suggested interventions to help meet the Sustainable Development Goals of reducing stillbirth and neonatal mortality. Many interventions aimed at improving treatment do not achieve their desired change, with few efficiently implemented and sustained due to health system constraints such as poor infrastructure, insufficient resources and poor leadership. To address these gaps, I assessed the quality, facilitators and barriers associated with stillbirth and neonatal death audit processes in seven public hospitals in Malawi. The ultimate goal was to provide evidence for recommendations on how the health system may better support staff so that the audit process can be improved.
The research approaches were guided by a conceptual framework which I developed based on health system strengthening, quality improvement theories, and a systematic literature review. I tested the framework in practice through three cross-sectional descriptive studies to evaluate its strengths and limitations.
In a systematic literature review, I evaluated ten studies from low and lower middle-income countries (LMICs) that implemented stillbirth and neonatal death audits. I found that audits improved structure, process and health outcomes in maternal and neonatal care. I identified 18 enablers and 23 barriers with the majority identified at the health provider and facility levels.
The first study assessed the resources available for neonatal care. I discovered that the hospitals' ability to provide newborn care was universally low due to inadequate Infrastructure, staff training, medications and supplies, clinical protocols and leadership support. The second study assessed the quality of stillbirth and neonatal death audits and discovered that they were of poor quality due to challenges in audit tools and guidelines, WHO audit cycle stages, action plans and patient load. In the last study, I used the conceptual framework to identify facilitators and barriers at system levels to performing death audits in practice. I discovered that the elements that influence staff engagement in audit meetings and the implementation of recommended solutions were interrelated.
In my research, I discovered that a number of structure and process factors contribute to low-quality audits. Rather than simply gathering information, I have emphasised that facility audits should aim at improving practice. This can be accomplished by implementing suggested actions and evaluating the process. However, this will only be possible if facility and national leadership provide adequate support in terms of resources, supervision and guidelines. A comprehensive approach guided by behavioural theory that tackles variables at all system levels is more likely to be successful. The findings contribute to the evidence base required to develop strategies that ensure the audit cycle is completed and contributes effectively to improving patient outcomes. The conceptual framework was deemed to be suitable for use in the Malawi context and should now be tried in other facilities across Malawi, as well as in other LMICs.
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