From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa

Area of Science:

• Public Health
• Health Systems Strengthening
• Maternal and Child Health

Background:

• Maternal and perinatal death surveillance and response (MPDSR) and audits are vital for improving health systems.
• South Africa's national perinatal audit program, initiated in the 1990s, has a complex history of policy integration and exclusion.

Purpose of the Study:

• To explore the historical trajectory of initiating, scaling up, and institutionalizing South Africa's national perinatal audit program.
• To identify lessons learned for the initiation, expansion, and strengthening of perinatal audit programs.

Main Methods:

• Qualitative study employing 56 individual interviews and a systematic document review.
• Semistructured questionnaires and 10 nonparticipant observations of audit meetings.
• Thematic content analysis and a tool to measure subdistrict-level implementation in 5 Western Cape subdistricts.

Main Results:

• The perinatal audit program was integrated into national policy in 2012 but excluded in 2021, highlighting policy volatility.
• A network of national and subnational structures, with actor continuity, supported program uptake.
• Despite long-standing practice, operational gaps persist, indicating a need for continuous strengthening and potential tool revision.

Conclusions:

• Perinatal audit programs require ongoing effort and cannot be assumed to be sustainable without continuous monitoring and adaptation.
• Research approaches exploring context, local adaptation, relationships, leadership, and trust are essential for monitoring MPDSR uptake and sustainability.