Social Audit in Obstetrics

Definition

• Park's Textbook of Preventive and Social Medicine states: "Maternal death audit, both facility and community based, is an important strategy to improve the quality of obstetric care and reduce maternal mortality and morbidity."

Purpose and Importance

1. Identify preventable deaths - Most maternal deaths are preventable; audits quantify the proportion that are avoidable.
2. Uncover systemic failures - Beyond clinical error, audits reveal gaps in health infrastructure, referral pathways, staffing, drugs, and equipment.
3. Improve obstetric care quality - Recommendations feed back into local, district, and national policy.
4. Monitor progress - Serial audit cycles (like the UK's triennial CEMD reports, running since 1952) track whether interventions are working.
5. Accountability - Health facilities, districts, and states become accountable for outcomes.

Types / Approaches to Social Audit in Obstetrics

1. Facility-Based Maternal Death Review (FBMDR)

• Audits deaths that occur inside health facilities.
• A multidisciplinary committee reviews all clinical notes, nursing records, partographs, laboratory results, and antenatal records.
• Includes interviews of health personnel who attended the deceased (and may extend to family members).
• Non-judgmental to encourage cooperation of health workers.
• Provides data to improve institutional obstetric care.

2. Community-Based Maternal Death Review (Verbal Autopsy)

• In-depth investigation of deaths that occur outside health facilities (at home, in transit).
• A community informant notifies local authorities when a woman of reproductive age dies.
• An interviewer (usually not a health worker) interviews family members who cared for the deceased, sensitively probing circumstances.
• A team of physicians then reviews the interview notes to determine cause of death.
• When combined with facility-based review, gives a more complete picture of all maternal deaths in a locality.

3. Confidential Enquiries into Maternal Deaths (CEMD)

• A national or subnational multidisciplinary committee periodically reviews maternal deaths systematically and anonymously.
• The UK CEMD is the gold-standard model, achieving near-100% ascertainment and publishing triennial reports since 1952.
• The anonymity and confidentiality of the process removes fear of personal consequences and encourages honest reporting.
• Findings are used to issue national recommendations.
• India's Kerala state implemented a Confidential Review of Maternal Deaths (CRMD) modeled on the UK system, led by KFOG (Kerala Federation of Obstetrics & Gynaecology) from 2004.

4. Clinical Audit of Obstetric Care

• Reviews whether standards of care were met in specific cases (e.g., use of magnesium sulfate for eclampsia, correct PPH management).
• Focuses on processes and clinical decision-making.

5. Near-Miss (Severe Acute Maternal Morbidity) Audit

• Audits women who nearly died but survived due to medical intervention.
• More frequent events than deaths - provides greater statistical power to identify avoidable factors.
• Complements maternal death review.

The Three Delays Framework

• Miller's Anesthesia describes how this framework "has been used to describe factors delaying timely access to safe health care services" in maternal health and surgery.

The WHO Maternal Death Surveillance and Response (MDSR) Cycle

1. IDENTIFY & NOTIFY maternal deaths
         ↓
2. MATERNAL DEATH REVIEW (MDR)
         ↓
3. ANALYSE findings & formulate RECOMMENDATIONS
         ↓
4. RESPOND - implement changes & MONITOR impact
         ↓ (feeds back to Step 1)

India's Maternal Death Review Programme

• Mandatory notification: All maternal deaths - whether at home, in facility, or in transit, rural or urban - must be reported.
• Two levels of review:
  1. Community-level review (verbal autopsy by ANM/ASHA)
  2. Facility-level review (by the obstetric team and medical officer)
• Confidential Review of Cases (CCR): State-level expert committee conducts a deeper confidential review of facility deaths to assess clinical management.
• Implementation: Guidelines and tools for MDR developed by the Ministry of Health and Family Welfare; piloted with FOGSI, WHO, and state governments.
• Under NHM, PHCs are mandated to conduct facility-based MDR as a desirable standard activity.
• JSSK (Janani-Shishu Suraksha Karyakram) and PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan) are complementary programmes that reduce barriers to institutional delivery and antenatal care, addressing the first and second delay.

Process of Conducting a Maternal Death Audit (Facility Level)

1. Death notification - Any maternal death is reported immediately to the audit committee.
2. Data collection - All records collected: antenatal card, partograph, delivery notes, operation notes, investigation reports, nursing notes.
3. Verbal autopsy (for community deaths) - Structured interview with family.
4. Case summary preparation - Anonymised case summary prepared.
5. Committee review - Multidisciplinary meeting (obstetrician, physician, nurse, administrator).
6. Determination of cause - Primary obstetric cause + contributing factors classified.
7. Avoidability assessment - Was this death preventable? Were standards of care met?
8. Recommendations - Specific, actionable recommendations drafted.
9. Feedback and action - Findings shared with facility staff; changes implemented.
10. Re-audit - Next cycle checks whether recommendations were acted upon.

Causes Targeted by Social Audit

• Postpartum haemorrhage (PPH) - most common cause of maternal death globally
• Hypertensive disorders (pre-eclampsia/eclampsia)
• Sepsis and infection
• Obstructed labour
• Unsafe abortion complications
• Venous thromboembolism

Outcomes and Impact

• The UK CEMD reduced MMR to approximately 8-9 per 100,000 live births - substantially lower than the US (14-17/100,000) - largely attributed to the confidential enquiry system.
• Countries with functioning MDR systems (South Africa, UK, Kenya, India-Kerala) show improved quality of obstetric care over time.
• A systematic review of 140 trials (PMC5513145) found that audit and feedback generally leads to small but clinically important improvements in provider practice.

• Park's Textbook of Preventive and Social Medicine (chapters on RCH-II, MDR, NRHM)
• Creasy & Resnik's Maternal-Fetal Medicine, 8e - Chapter 47: Maternal Morbidity and Mortality
• Miller's Anesthesia, 10e - Three Delays Framework
• World Bank: Maternal Death Audit as a Tool for Reducing Maternal Mortality
• India MDSR Guidelines (NHM)
• WHO MDSR Technical Guidance (UNFPA)

Prenatal Counselling

Definition

• Preconception counselling - ideally before conception
• Antenatal counselling - during each trimester of an ongoing pregnancy
• Genetic counselling - when heritable conditions or fetal anomalies are suspected

Objectives

1. Identify risk factors before they cause harm to mother or fetus.
2. Provide evidence-based education about healthy pregnancy practices.
3. Optimize management of pre-existing medical conditions.
4. Reduce risk of congenital anomalies, maternal morbidity, and perinatal mortality.
5. Support informed, autonomous decision-making.
6. Offer emotional and psychological support.

Components of Prenatal Counselling

1. History Taking and Risk Assessment

• Medical history: Diabetes mellitus, hypertension, epilepsy, thyroid disorders, cardiac disease, renal disease, SLE - all must be optimized before and during pregnancy.
• Obstetric history: Previous preterm deliveries, recurrent abortions, stillbirths, fetal anomalies, operative deliveries, or Rh isoimmunization.
• Family history: Hereditary conditions (Down syndrome, thalassaemia, cystic fibrosis, neural tube defects, fragile X syndrome).
• Medication history: Teratogenic drugs must be identified and alternatives prescribed (e.g., replace warfarin with heparin, replace ACE inhibitors, avoid valproate where possible).
• Social history: Alcohol, tobacco, substance use, domestic violence, socioeconomic status, consanguinity.

2. Nutritional Counselling

• Folic acid 400-5000 mcg/day started at least 1 month before conception and continued through the first trimester - reduces neural tube defect risk by up to 70%.
• Iron and calcium supplementation throughout pregnancy.
• Balanced diet rich in proteins, fresh vegetables, and fruits.
• Avoidance of unpasteurized dairy, raw meat, and unwashed produce (risk of Listeria, Toxoplasma).
• Adequate weight: Pre-pregnancy BMI and gestational weight gain targets to be discussed.

3. Screening and Testing Counselling

4. Genetic Counselling

• Advanced maternal age (≥35 years) - increased risk of trisomies.
• Previous child with chromosomal anomaly or neural tube defect.
• Family history of heritable condition.
• Consanguineous marriage.
• Abnormal screening test result.
• Known carrier status in either parent.

• Explains inheritance patterns (autosomal dominant/recessive, X-linked, multifactorial).
• Quantifies recurrence risk (e.g., 25% for autosomal recessive if both parents are carriers).
• Presents options: continuation, termination, donor gametes, preimplantation genetic testing (PGT-IVF).
• Provides psychosocial support - grief, guilt, and anxiety are common reactions.

5. Vaccination and Infection Counselling

• Rubella: Women should be immune; vaccinate if non-immune before conception (MMR is live - do not give in pregnancy).
• Hepatitis B, Varicella: Screen and vaccinate pre-pregnancy.
• Influenza, Tdap (whooping cough): Recommended during pregnancy.
• Avoid TORCH infections: Toxoplasma (avoid cat litter, undercooked meat), Cytomegalovirus (hygiene), Rubella (check immunity), Herpes (partner screening).

6. Lifestyle and Environmental Counselling

• Smoking cessation: Increases risk of IUGR, placental abruption, preterm labour, stillbirth.
• Alcohol abstinence: No safe level established - fetal alcohol spectrum disorder.
• Recreational drugs: Cocaine, heroin, and cannabis are associated with fetal harm.
• Occupational hazards: Radiation exposure, heavy metals, solvents, extreme physical exertion.
• Travel advice: Malaria prophylaxis, Zika virus precautions in endemic areas.
• Exercise: Moderate exercise (30 min/day) is beneficial; avoid contact sports and supine position in late pregnancy.

7. Chronic Disease Management

8. Birth Planning and Preparedness Counselling

• Danger signs to watch for: vaginal bleeding, severe headache, visual disturbance, reduced fetal movements, leaking PV.
• Institutional delivery: Benefits emphasized; birth plan discussed including mode of delivery preferences.
• Birth preparedness: Nearest facility, transport arrangements, emergency funds, blood donor identification.
• Complication readiness: Signs of preterm labour, PROM, pre-eclampsia.
• Postpartum care: Breastfeeding, contraception after delivery, postnatal depression awareness.

9. Psychological and Social Support

• Address anxiety and fear about pregnancy, labour, and fetal outcome.
• Screen for domestic violence (routine enquiry recommended by ACOG and WHO).
• Identify mental health disorders: Depression, anxiety, PTSD, eating disorders.
• Social support mapping: Partner support, family involvement, financial aid schemes.

Principles of Effective Prenatal Counselling

1. Non-directive - Counsellor presents information objectively without imposing personal values.
2. Confidentiality - Sensitive information is kept strictly private.
3. Autonomy - Patient's right to make her own informed decision is respected.
4. Beneficence and Non-maleficence - Actions aim to help and not harm.
5. Justice - Services should be accessible equitably.
6. Empathy - Acknowledgment of emotional impact; active listening.

Summary Table