Social Audit in Obstetrics

Definition

Purpose and Objectives

1. Reduce maternal mortality and morbidity by identifying avoidable factors in deaths
2. Improve quality of obstetric care at all levels - community, primary, secondary, tertiary
3. Promote accountability of health providers and institutions
4. Identify three delays that contribute to maternal deaths:
   • Delay in recognizing danger signs and deciding to seek care (community/family level)
   • Delay in reaching appropriate care (transport/access)
   • Delay in receiving adequate care (facility level)
5. Empower communities to participate in health care monitoring
6. Track national program implementation (e.g., JSY, JSSK, LaQshya in India)

Types of Audit in Obstetrics

1. Maternal Death Review (MDR)

• Facility-based MDR: Review of every maternal death occurring in a health facility. A structured proforma (MoHFW MDR form) is filled, and the death is discussed in a multidisciplinary review committee.
• Community-based MDR: Verbal autopsy conducted by field workers (ASHA, ANM) for deaths occurring at home or outside facilities. Identifies community-level delays.
• District-level MDR committee: Reviews all maternal deaths in the district. Generates an action taken report (ATR).

2. Confidential Enquiry into Maternal Deaths (CEMD)

• Anonymous peer review of all maternal deaths
• Classifies deaths as avoidable, partially avoidable, or unavoidable
• Identifies substandard care
• UK's MBRRACE-UK (formerly CEMACH) is the model; India has adopted this at state and national level

3. Near-Miss Audit (Severe Acute Maternal Morbidity - SAMM)

• Studies cases of women who nearly died from severe obstetric complications (e.g., eclampsia, severe hemorrhage, septic shock, ruptured uterus)
• WHO defines near-miss as: a woman who nearly died but survived a severe life-threatening complication during pregnancy, childbirth, or within 42 days of termination
• Near-miss: maternal death ratio should be >1:1 (ideally >5:1), indicating more women are being saved
• Advantage: larger numbers, survivors can provide firsthand accounts

4. Criterion-Based Clinical Audit (CBCA)

• Compares actual practice against pre-defined evidence-based standards or criteria
• Example criteria: percentage of eclampsia patients receiving MgSO4, percentage of PPH managed with oxytocin within 1 minute
• Identifies gaps between standard care and actual care

5. Clinical Audit (Process and Outcome Audit)

• Reviews processes of care: antenatal care coverage, institutional delivery rates, skilled birth attendance
• Outcome audit: maternal mortality ratio (MMR), perinatal mortality rate, stillbirth rate, neonatal mortality rate

Key Indicators Monitored (Vital Statistics)

The "Three Delays" Model (Thaddeus and Maine, 1994)

• Phase 1 - Delay in seeking care: Poor recognition of danger signs, cultural/social barriers, financial constraints, low status of women
• Phase 2 - Delay in reaching care: Distance, lack of transport, poor road conditions, cost of travel
• Phase 3 - Delay in receiving care: Shortage of skilled staff, lack of blood/drugs/equipment, poor quality of EmOC

Social Autopsy / Verbal Autopsy

• Used for community-based deaths
• Conducted by trained personnel (ANM/ASHA) using standardized questionnaire
• Gathers information from family, community members, healthcare workers
• Identifies social determinants: poverty, illiteracy, gender inequity, lack of decision-making power
• Distinguishes medical cause of death (e.g., PPH, eclampsia) from social/systemic causes

National Frameworks in India

Janani Suraksha Yojana (JSY)

• Cash incentive scheme to promote institutional delivery
• Social audit ensures cash transfers reach beneficiaries
• Community monitoring by Gram Panchayat/Mahila Arogya Samiti (MAS)

LaQshya (Labour Room Quality Improvement Initiative)

• Audits quality of intrapartum and immediate postpartum care
• Certification of labour rooms and operation theatres in government hospitals

Maternal Death Surveillance and Response (MDSR)

• WHO-recommended framework
• Real-time notification of maternal deaths → investigation → response
• Notification within 24 hours mandatory in India since 2017

PNDT Act and Sex Ratio at Birth

• Social audit of sex-selective practices
• Monitoring sex ratio at birth (SRB) at district level

Process of Conducting a Social Audit

1. Notification: Every maternal death notified within 24 hours to Block Medical Officer
2. Data collection: MDR proforma filled; verbal autopsy done
3. Review meeting: District MDR committee meets monthly; case discussed confidentially
4. Analysis: Avoidable factors identified - medical, systemic, socio-demographic
5. Action Taken Report (ATR): Specific corrective actions recommended
6. Feedback loop: Action implemented; next audit cycle monitors impact
7. Community dissemination: Findings shared with Gram Panchayat, health committees

Role of Community in Social Audit

• ASHA workers: First responders, verbal autopsy, referral facilitation
• Mahila Arogya Samiti (MAS): Village-level women's health committee; monitors JSY, JSSK, institutional delivery
• Gram Sabha: Formal community meeting where audit findings are presented
• Rogi Kalyan Samiti (RKS): Hospital management committee; reviews facility-level deaths

Limitations of Social Audit in Obstetrics

1. Underreporting of maternal deaths (community deaths often unnotified)
2. Fear of blame and legal action leads to under-disclosure
3. Lack of trained personnel for verbal autopsy
4. Delayed notification reduces quality of information
5. Action taken reports not regularly implemented or followed up
6. Limited data from private sector
7. Confidentiality breaches reduce cooperation of providers

International Models

• UK: MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) - gold standard; confidential peer review of all maternal deaths and near-misses
• WHO MDSR framework: Global standard for LMIC
• FIGO Safe Motherhood and Newborn Health Committee: Promotes audit globally

Summary Points for Exam

• Social audit = accountability + quality improvement tool for maternal health
• Core components: MDR (facility + community), near-miss audit, criterion-based audit
• Three delays model is the analytical framework
• India mandates real-time MDSR since 2017; MDR committee at district level
• Key programs: JSY, LaQshya, MDSR, Surakshit Matritva Aashwasan (SUMAN)
• Goal: Every maternal death should be reviewed, and every preventable death should be prevented
• MMR target India: <70 per 100,000 live births by 2030 (SDG 3.1)
• Near-miss to maternal death ratio is a quality of care indicator