title: Quality of care, risk management, and technology in obstetrics to reduce hospital-based maternal mortality in Senegal and Mali (QUARITE): a cluster-randomised trial.
abstract: BACKGROUND
  Maternal mortality is higher in west Africa than in most industrialised countries, so the development and validation of effective interventions is essential. We did a trial to assess the effect of a multifaceted intervention to promote maternity death reviews and onsite training in emergency obstetric care in referral hospitals with high maternal mortality rates in Senegal and Mali.
  
  
  METHODS
  We did a pragmatic cluster-randomised controlled trial, with hospitals as the units of randomisation and patients as the unit of analysis. 46 public first-level and second-level referral hospitals with more than 800 deliveries a year were enrolled, stratified by country and hospital type, and randomly assigned to either the intervention group (n=23) or the control group with no external intervention (n=23). All women who delivered in each of the participating facilities during the baseline and post-intervention periods were included. The intervention, implemented over a period of 2 years at the hospital level, consisted of an initial interactive workshop and quarterly educational clinically-oriented and evidence-based outreach visits focused on maternal death reviews and best practices implementation. The primary outcome was reduction of risk of hospital-based mortality. Analysis was by intention-to-treat and relied on the generalised estimating equations extension of the logistic regression model to account for clustering of women within hospitals. This study is registered with ClinicalTrials.gov, number ISRCTN46950658.
  
  
  RESULTS
  191,167 patients who delivered in the participating hospitals were analysed (95,931 in the intervention groups and 95,236 in the control groups). Overall, mortality reduction in intervention hospitals was significantly higher than in control hospitals (odds ratio [OR] 0·85, 95% CI 0·73-0·98, p=0·0299), but this effect was limited to capital and district hospitals, which mainly acted as first-level referral hospitals in this trial. There was no effect in second-level referral (regional) hospitals outside the capitals (OR 1·02, 95% CI 0·79-1·31, p=0·89). No hospitals were lost to follow-up. Concrete actions were implemented comprehensively to improve quality of care in intervention hospitals.
  
  
  CONCLUSIONS
  Regular visits by a trained external facilitator and onsite training can provide health-care professionals with the knowledge and confidence to make quality improvement suggestions during audit sessions. Maternal death reviews, combined with best practices implementation, are effective in reducing hospital-based mortality in first-level referral hospitals. Further studies are needed to determine whether the benefits of the intervention are generalisable to second-level referral hospitals.
  
  
  BACKGROUND
  Canadian Institutes of Health Research.
authors.affiliation: Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France. alexandre.dumont@ird.fr
authors.forename: Alexandre
authors.initials: A
authors.lastname: Dumont
authors.forename: Pierre
authors.initials: P
authors.lastname: Fournier
authors.forename: Michal
authors.initials: M
authors.lastname: Abrahamowicz
authors.forename: Mamadou
authors.initials: M
authors.lastname: Traoré
authors.forename: Slim
authors.initials: S
authors.lastname: Haddad
authors.forename: William D
authors.initials: WD
authors.lastname: Fraser
mesh_terms: D002983:Clinical Competence / Q000592:standards; D016000:Cluster Analysis; D004638:Emergency Treatment / Q000592:standards*; D005260:Female; D006282:Health Personnel / Q000193:education / Q000592:standards; D006280:Health Workforce; D017052:Hospital Mortality; D006767:Hospitals, District / Q000706:statistics & numerical data; D006801:Humans; D007318:Inservice Training; D008302:Mali; D008428:Maternal Mortality; D009774:Obstetrics / Q000193:education / Q000592:standards*; D009775:Obstetrics and Gynecology Department, Hospital / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011248:Pregnancy Complications / Q000401:mortality / Q000517:prevention & control; D011256:Pregnancy Outcome; D011295:Prenatal Care / Q000592:standards*; D011787:Quality of Health Care; D012308:Risk Management / Q000379:methods; D012675:Senegal