Scaling up clinical audits of obstetric cases in Morocco.

OBJECTIVES To follow-up on the process of implementing clinical audits of obstetric cases in Morocco as recommended by the Ministry of Health (2001) and to explore both the barriers to and factors facilitating sustainability of clinical audits. METHOD Questionnaires were sent to heads of all 61 Moroccan health provinces (response rate 69%) to ask if their maternity units had implemented clinical audits between 1998 and 2003. Twenty of the 42 public maternities which responded had performed so. Thirteen of these 20 hospitals were visited and 56 semi-structured interviews held with administrators and health professionals. Locally available audit registers were consulted to triangulate data. RESULTS Eleven of 13 maternities visited conducted an average of 6.8 case reviews per year with a total average of 16.7 cases per hospital (range 4-38). Although interviewees confirmed that audits resulted in better quality of care, five hospitals had ceased performing audits altogether and the remainder did them less frequently, because of audit teams encountering staff resistance, insufficient understanding of the audit concept, difficulties in organizing sessions, and lack of administrative support. Insufficient training and external assistance hindered the implementation of complete audit loops, resulting in a loss of staff motivation. CONCLUSION Implementing clinical audits as a means to improving quality of care requires a significant investment in training and various kinds of on-going assistance--factors which decision-makers should be aware of.