Editor's Comment

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Self-assessment leads to self-improvement. At least that's the idea. The papers in the July issue are all about different aspects of self-assessment. All 3 describe introducing self-assessment in settings where there was previously none in place.

The first paper by Hussein et al. [1] from Immpact at the University of Aberdeen focuses on modifying the traditional confidential inquiries into maternal deaths, which started nearly 100 years ago in the United Kingdom and continues [2]. The modifications include introducing positive aspects of care (identifying the elements of care done particularly well) and the inclusion of serious complications, sometimes called “near misses.” Confidential inquiries sometimes run into resistance because of the implied blame. Indeed, in one introduction with which I was associated the effort was doomed to failure when “confidential inquiries” was translated into the local language as “secret investigations”! Yet confidential inquiries have, from the beginning, intended to identify where improvements in care could have been made and are explicitly “no name, no blame.” Confidential inquiries are credited with large declines in maternal mortality in England and Wales and have been introduced into quite a few countries. The modifications developed by Immpact are intended to make confidential inquiries less threatening and are likely to increase their acceptance in yet more countries, some of which may have previously resisted implementing them.

The Tanzanian team adapted a method of assessment used for maternal deaths and applied it to perinatal deaths. Mbaruku et al. [3] used the 3-delays concept developed by Thaddeus and Maine [4], and reviewed perinatal deaths in terms of the contributions made by delay in receiving appropriate treatment once the mother arrived at the district hospital (the “third delay”). Although delay and mismanagement are usually viewed as two separate problems, they can, in practice, amount to much the same thing—delay in getting appropriate care. The shortcomings identified by this assessment are being addressed.

Pearson et al. [5] describe the efforts of 3 UN agencies to get all Sub-Saharan African countries to implement some form of maternal death review as a national policy; the UN offered assistance in various forms to facilitate the process. Ministries of Health could choose 1 of 5 types of self-assessment. At least 30 of the 46 Sub-Saharan countries made some progress toward maternal death reviews as a means of identifying areas for improvement, and several made very significant progress.

There are many kinds of institutional self-assessment methods including those developed by airlines (on matters of safety) and manufacturing. To those offered by Pearson et al. [5] we can add criterion-based audit of any part of the clinical process, from cleanliness to complying with treatment protocols. Examples include Wagaarachchi et al. [6] in Malawi using a method developed by Immpact, and Bailey et al. [7] in Vietnam using a method developed by the Averting Maternal Death and Disability program at Columbia University [8].

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References 

1. Hussein J, D'Ambruoso , Armar-Klemesu M, Achadi E, Arhinful D, Izati Y, et al. Confidential enquiries into maternal death: modifications and adaptations in Ghana and Indonesia. Int J Gynecol Obstet. 2009;106(1):80–84
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2. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers' Lives: reviewing maternal deaths to make motherhood safer – 2003-2005. In:  Lewis G editors. The Seventh Report on Confidential Enquiries in Maternal Deaths in the United Kingdom. London: CEMACH; 2007;
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3. Mbaruku G, van Roosmalen J, Kimondo C, Bilango P, Bergstrom S. Perinatal audit using the three delays model in Western Tanzania. Int J Gynecol Obstet. 2009;106(1):
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4. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38(8):1091–1110
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5. Pearson L, deBernis L, Shoo R. Maternal death review in Africa. Int J Gynecol Obstet. 2009;106(1):89–94
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6. Wagaarachchi PT, Graham WJ, Penney GC, McCaw-Binns A, Yeboah Antwi K, Hall MH. Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries. Int J Gynecol Obstet. 2001;74(2):119–130
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7. Bailey PE, Binh HT, Bang HT. Promoting accountability in obstetric care; Use of criteria-based audit in Viet Nam. Glob Public Health. 2009;1–12[Electronic publication ahead of print]
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8. Bailey P, Fortney J, Freedman L, Goodburn E, Kwast B, Mavalankar D, et al. Improving Emergency Obstetric Care through Criterion-Based Audit. Mailman School of Public Health, Columbia University; December 2002;
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