title: Using clinical audit to improve the quality of obstetric care at the Tibetan Delek Hospital in North India: a longitudinal study.
abstract: BACKGROUND
  The Tibetan Delek Hospital is a small general hospital providing primary and secondary care for the Tibetan refugee community and the local Indian population in Dharamsala, Himachal Pradesh, North India. In a baseline clinical audit of intrapartum care at the Tibetan Delek Hospital in 1996, high levels of postpartum haemorrhage associated with poor medical management of the third stage of labour, plus inappropriate transfer of women in labour were observed. These audit findings prompted the implementation of changes in the delivery of intrapartum care and follow-up audit cycles to monitor the ongoing effect of these changes.
  
  
  METHODS
  The delivery of intrapartum care was modified in two ways. Firstly, nurses, midwives, and doctors were re-trained in the active management of the third stage of labour, which involved the administration of intramuscular syntocinon plus ergometrine with delivery of the anterior shoulder. Secondly partograms were introduced to help rationalise the management of labour, and in particular decisions about when to transfer women in labour. Follow up audits were conducted in 1997, 1998, and 2003 to quantify the effects of these changes. The key measures for improvement included the documented incidence of postpartum haemorrhage and the number of women transferred inappropriately for failure to progress in labour.
  
  
  RESULTS
  A sustained reduction of approximately 50% in the incidence of postpartum haemorrhage was observed after the introduction of active management of the third stage of labour. The introduction of the routine use of partograms was associated with a more rational decision-making process regarding transfer during labour.
  
  
  CONCLUSIONS
  Introducing and maintaining a clinical audit cycle can lead to improvements in the quality of obstetric care in a refugee population.
authors.affiliation: Section of General Practice and Primary Care, Division of Community-based Sciences, University of Glasgow, UK.
authors.forename: Stewart W
authors.initials: SW
authors.lastname: Mercer
authors.forename: Katherine
authors.initials: K
authors.lastname: Sevar
authors.forename: Tsetan D
authors.initials: TD
authors.lastname: Sadutshan