Abstract:
INTRODUCTION : Maternal and perinatal death surveillance and response
(MPDSR), or related forms of maternal and perinatal
death audits, can strengthen health systems. We explore the history
of initiating, scaling up, and institutionalizing a national
perinatal audit program in South Africa.
METHODS : Data collection involved 56 individual interviews, a systematic
document review, administration of a semistructured
questionnaire, and 10 nonparticipant observations of meetings
related to the perinatal audit program. Fieldwork and data collection
in the subdistricts occurred from September 2019 to
March 2020. Data analysis included thematic content analysis
and application of a tool to measure subdistrict-level implementation.
This study expands on case study research applied to 5 Western
Cape subdistricts with long histories of implementation.
RESULTS : Although established in the early 1990s, the perinatal
audit program was not integrated into national policy and guidelines
until 2012 but was then excluded from policy in 2021. A
network of national and subnational structures that benefited
from a continuity of actors evolved and interacted to support uptake
and implementation. Intentional efforts to demonstrate impact
and enable local adaptation allowed for more ownership
and buy-in. Implementation requires continuous efforts. Even in
5 subdistricts with long histories of practice, we found operational
gaps, such as incomplete meeting minutes, signaling a need for
strengthening. Nevertheless, the tool used to measure implementation
may require revisions, particularly in settings with institutionalized
practice.
CONCLUSION : This article provides lessons on how to initiate, expand,
and strengthen perinatal audit. Despite a long history of
implementation, the perinatal audit program in South Africa cannot
be assumed to be indefinitely sustainable or final in its current
form. To monitor uptake and sustainability of MPDSR, including
perinatal audit, we need research approaches that allow exploration
of context, local adaptation, and underlying issues that
support sustainability, such as relationships, leadership, and trust.
