Article Text

Exploring the sustainability of perinatal audit in four district hospitals in the Western Cape, South Africa: a multiple case study approach
  1. Mary Kinney1,
  2. Anne-Marie Bergh2,
  3. Natasha Rhoda3,4,
  4. Robert Pattinson2,
  5. Asha George1
  1. 1School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Bellville, South Africa
  2. 2Maternal and Infant Health Care Strategies Research Unit, Medical Research Council of South Africa, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
  3. 3Department of Neonatology, Mowbray Maternity Hospital, Cape Town, South Africa
  4. 4Department of Paediatrics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
  1. Correspondence to Mary Kinney; mkinney{at}


Introduction Maternal and perinatal death surveillance and response (MPDSR) is an intervention process that uses a continuous cycle of identification, notification and review of deaths to determine avoidable causes followed by actions to improve health services and prevent future deaths. This study set out to understand how and why a perinatal audit programme, a form of MPDSR, has sustained practice in South Africa from the perspectives of those engaged in implementation.

Methods A multiple case study design was carried out in four rural subdistricts of the Western Cape with over 10 years of implementing the programme. Data were collected from October 2019 to March 2020 through non-participant observation of seven meetings and key informant interviews with 41 purposively selected health providers and managers. Thematic analysis was conducted inductively and deductively adapting the extended normalisation process theory to examine the capability, contribution, potential and capacity of the users to implement MPDSR.

Results The perinatal audit programme has sustained practice due to integration of activities into routine tasks (capability), clear value-add (contribution), individual and collective commitment (potential), and an enabling environment to implement (capacity). The complex interplay of actors, their relationships and context revealed the underlying individual-level and organisational-level factors that support sustainability, such as trust, credibility, facilitation and hierarchies. Local adaption and the broad social and structural resources were required for sustainability.

Conclusion This study applied theory to explore factors that promote sustained practice of perinatal audit from the perspectives of the users. Efforts to promote and sustain MPDSR will benefit from overall good health governance, specific skill development, embedded activities, and valuing social processes related to implementation. More research using health policy and system approaches, including use of implementation theory, will further advance our understanding on how to support sustained MPDSR practice in other settings.

  • Health systems
  • Maternal health
  • Obstetrics
  • Qualitative study
  • Health policies and all other topics

Data availability statement

Data are available upon reasonable request. The data (case study reports and transcripts) are available from the corresponding author on request.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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Data availability statement

Data are available upon reasonable request. The data (case study reports and transcripts) are available from the corresponding author on request.

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  • Handling editor Seye Abimbola

  • Twitter @maryvkinney, @ashageorge72

  • Contributors MK and AG conceived and designed the study. A-MB, NR and RP served as an advisory group for the study, providing inputs throughout the process. MK conducted the data collection and analysis, with oversight from AG, and wrote the first draft of the paper with inputs from all authors. All authors edited the manuscript and approved the final version. MK and AG act as guarantor to this article.

  • Funding AG and MK are supported by the South African Research Chair’s Initiative of the Department of Science and Technology and National Research Foundation of South Africa (grant number 82769), the South African Medical Research Council and the Countdown 2030 project funded by the Bill and Melinda Gates Foundation. Any opinion, finding and conclusion or recommendation expressed in this material is that of the authors, and funders do not accept any liability in this regard. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

  • Disclaimer The funders played no role in the design, data collection, analysis, interpretation or writing of this study.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.