Evaluating Standards-Based Audit for Quality Improvement in Maternal and Newborn Care: Evidence from a multi-country implementation study

Background

Improving maternal and newborn health outcomes in low- and middle-income countries requires not only increased service coverage but also enhanced quality of care. Standards-based audits offer a structured, evidence-based approach to quality improvement; however, their implementation and effectiveness across diverse low- and middle-income country contexts remain underexplored.

Objectives

To assess the implementation and effectiveness of a quality improvement training programme using standards-based audit methodology across health facilities in Kenya, Nigeria, and Tanzania, and to evaluate its contribution to improvements in the quality of maternal and newborn care.

Methods

Between 2020 and 2024, 895 healthcare workers from 211 facilities, were trained using traditional and blended learning methods. One hundred and twenty-eight facilities were followed up, assessing the implementation of quality improvement. Facilities identified context-specific care gaps, audited baseline performance, implemented targeted interventions, and conducted follow-up audits to improve care.

Results

All facilities appointed a quality improvement champion, identified a care gap, and audited performance against an appropriate standard (n=137 audits/128 facilities). The average baseline audit scores across all three countries were 38.8%, with follow-up scores increasing to 77.4%, indicating a mean improvement of 38.2%. Over half (54%) of the facilities met or exceeded their improvement targets.

Key challenges include unrealistic target setting, resource constraints, and context-specific issues (staff shortages and supply disruptions). The approach was feasible across all facility levels. Contextualised standard selection enhanced local relevance and ownership of interventions, while the blended learning model increased the accessibility and cost-efficiency of the training.

Conclusion

Standards-based audit and quality improvement training is a scalable and effective approach to improve maternal and newborn care in low- and middle-income countries. The findings of this multi-country study support the broader adoption of low-tech, standards-driven methods and highlight the need for further research into cost-effectiveness and long-term health outcomes to inform national scale-up strategies.