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Open Access Open Badges Research article

Effect of a facility-based multifaceted intervention on the quality of obstetrical care: a cluster randomized controlled trial in Mali and Senegal

Catherine M Pirkle123*, Alexandre Dumont4, Mamadou Traoré5, Maria-Victoria Zunzunegui23 and for the QUARITE group

Author Affiliations

1 Research Centre of the University Hospital Centre of Quebec (CHUQ), 2875 boulevard Laurier, Édifice Delta II, Bureau 600, 6e étage, Québec, Québec, GIV 2M2, Canada

2 Department of Social and Preventive Medicine, University of Montreal, Montreal, Canada

3 Research Centres of the University of Montreal Hospital Complex, Hôtel Dieu, Pavillon Masson, Montréal, Québec, Canada

4 Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France

5 URFOSAME, District health centre of Commun V, Bamako, Mali

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BMC Pregnancy and Childbirth 2013, 13:24  doi:10.1186/1471-2393-13-24

Published: 25 January 2013



Maternal mortality in referral hospitals in Mali and Senegal surpasses 1% of obstetrical admissions. Poor quality obstetrical care contributes to high maternal mortality; however, poor care is often linked to insufficient hospital resources. One promising method to improve obstetrical care is maternal death review. With a cluster randomized trial, we assessed whether an intervention, based on maternal death review, could improve obstetrical quality of care.


The trial began with a pre-intervention year (2007), followed by two years of intervention activities and a post-intervention year. We measured obstetrical quality of care in the post-intervention year using a criterion-based clinical audit (CBCA). We collected data from 32 of the 46 trial hospitals (16 in each trial arm) and included 658 patients admitted to the maternity unit with a trial of labour. The CBCA questionnaire measured 5 dimensions of care- patient history, clinical examination, laboratory examination, delivery care and postpartum monitoring. We used adjusted mixed models to evaluate differences in CBCA scores by trial arms and examined how levels of hospital human and material resources affect quality of care differences associated with the intervention.


For all women, the mean percentage of care criteria met was 66.3 (SD 13.5). There were significantly greater mean CBCA scores in women treated at intervention hospitals (68.2) compared to control hospitals (64.5). After adjustment, women treated at intervention sites had 5 points’ greater scores than those at control sites. This difference was mostly attributable to greater clinical examination and post-partum monitoring scores. The association between the intervention and quality of care was the same, irrespective of the level of resources available to a hospital; however, as resources increased, so did quality of care scores in both arms of the trial.

Trial registration

The QUARITE trial is registered on the Current Controlled Trials website under ISRCTN46950658

Maternal death review; Criterion based clinical audit; Quality of care; Obstetrics; West Africa