Background
LAMRN focal leads in Kenya, Uganda, Zambia and Zimbabwe identified clinical audit as an important next step, building on the success of a previous grant from THET which focused on strengthening midwives’ research skills.They recognised that audit training would help them champion use of research in practice in their clinical settings. In many cases, the projects midwives developed in the previous grant involved collecting data on problems that could be audited (e.g. causes of stillbirth (Zambia) and women’s experience of care during labour and birth (Kenya).

Research training has created additional benefits for midwives, evident in the success stories we collated as part of the monitoring and evaluation the original project. Some midwives have been appointed to: research leadership roles, coordinate institutional research training, and mentor colleagues to conduct research – which they indicated makes them well placed to be champions for clinical audit and practice change at their facilities.

The focal leads have the necessary research skills, emerging research leadership, and the determination to tackle maternity care standards in their facilities. This project will train midwives, who are rising champions for research in their workplaces, in clinical audit to improve the quality of maternity care.

Problem to be tackled
Governments in the four countries are already investing in audit programmes. In Uganda the Ministry of Health has prioritised maternal death audit, and has pursued clinical audit in modest programmes of work. The Kenyan government has developed the ‘Kenya Quality Model’, piloted clinical audit and developed maternity care standards, and produced a clinical audit manual. In Zambia, although quality of maternity care is a priority, audit is mostly carried out by hospital committees led by nursing officers and we are not aware of any coordinated government effort to establish routine audit. The Ministry of Health and Child Care in Zimbabwe is investing in maternal mortality audit (led by obstetricians) and uncoordinated clinical audit in maternity care programmes; no midwives are currently involved in clinical audit and there is a recognised need for training and skill development.In sub-Saharan Africa midwives provide most of the skilled care for women during birth. Given current concerns about low quality and disrespectful care we believe it is timely to work with midwives to strengthen their capacity to conduct clinical audit, in order to gauge how well they are doing in providing respectful and high quality, evidence-based intrapartum care for all women.

LAMRN midwives demonstrate capacity to identify auditable problems. In 2013 the Kenyan government introduced free maternity services in all public health facilities, but a year on there have been no audits to determine successes or failures of the programme. The LAMRN focal lead in Kenya highlighted this as an area where audit would help, to determine strengths and weaknesses in delivery of free maternity care and identify how the programme can improve. An audit of partograph use in nine facilities in Kenya found audit a useful tool to assess current practice, although it highlights a lack of regular audit of standards of care. In Uganda, midwives at Mulago National Referral Hospital were exposed to audit methods through Prof Andrew Weeks’ maternity audit project; we will involve volunteers from Mulago and other facilities who have experience of clinical audit to help support the training.

International evidence suggests audit and feedback is an effective monitoring and education tool. The Cochrane Review of audit and feedback suggests that it can lead to small but important improvements in practice. Available evidence from low and middle income countries suggests that it is a feasible, cheap, and simple method for identifying poor practice, prompting discussion about ways to address deficient care, and implementing change. We will incorporate elements of audit and feedback known to be effective, such as using senior colleagues to feedback audit results and having an action plan with targets for implementing change.

Objectives
The aim of the project is to strengthen capacity to conduct clinical audit among midwife practitioners in Kenya, Uganda, Zimbabwe and Zambia.

The project objectives are: a) to implement a series of workshops on principles of clinical audit, in order to: improve midwives’ understanding of the clinical audit process and its uses; strengthen midwives’ ability to identify, and collect and analyse data on, auditable problems; encourage midwives to act on audit findings; and help midwives establish audit as a routine activity in their facilities; and b) to share lessons and audit tools within country and with LAMRN midwives.

Activities
We will train teams of 12 midwives in each country in a series of four interactive workshops, adapted from an existing programme used by Weeks in Uganda. We will use a blended learning approach distributing materials, electronically via the LAMRN website, before workshops. UK partners from the University of Manchester will help facilitate all workshops and mentor the country teams. We intend to achieve at least one completed audit project per country; midwives in each country can work together on a single project or in teams on several audit projects.

We will hold a Network learning and sharing event to present audit project results to focal leads and deputies from the other LAMRN countries; this provides a platform to discuss sustainability and further projects in LAMRN countries. Each country team will hold a national sharing event to present the results of audit projects to key stakeholders, to showcase the achievements and discuss strategies to establish clinical audit as a routine activity. Materials will be made available as a maternity audit package (freely available pdfs of workshop presentations and audit tools).

Capacity strengthening
Our project approach is based on principles of good partnership working and research capacity strengthening. We recognise that capacity strengthening goes beyond individual skills, and involves institutions developing their capacity to support regular audit. Ultimately the goal is for audit to become routine; but we acknowledge this is unlikely in the short time frame of this project. We will build on a history of successful partnership between Manchester and LAMRN, and ensure we provide adequate platforms for sharing experiences with other LAMRN countries. We will encourage long term thinking, beginning with roundtable discussion about continuity and institutionalising audit as a routine activity at facilities in each country.