Strengths and limitations
Criterion-based audits are a pragmatic and low-cost approach to address quality of intrapartum care and birth outcomes in low-resource crisis settings, where attention to providing care is prioritized above more time- and resource-consuming study designs. Yet, the study’s sample size limits its ability to detect smaller differences in birth outcomes, and the absent differences found between the two periods studied may be due to lack of power. However, similarities across the periods in achieving the audit criteria for intrapartum care argue against this.
The results are limited to the two months studied and cannot be used to predict the possible effect of high work-pressure on quality of care and birth outcomes for a lengthy time period. Furthermore, the assumption that any practice not documented was not performed could bias the results towards showing poorer intrapartum care than actually provided. Conversely, there is also a risk of non-performed care being documented as performed.
While the comparable background characteristics among labouring women are reassuring, external confounding factors may have affected the quality of intrapartum care and birth outcomes. Notably, women in the low-volume month had a significantly higher attendance of at least one ANC visit, which might have improved birth outcomes. Moreover, additional characteristics of the background population and socioeconomic data of women seeking care would have allowed a better understanding of the access to care. Unfortunately, no data was available on women failing to access care after introduction of the restriction policy.
As in other FCAS, the humanitarian response in Yemen operates under very difficult conditions, and the decision to scale up or down on intake of beneficiaries served is dependent on multiple factors beyond quality of care, which we were not able to include in this study (e.g. occupational health, supplies, funding and security risks).