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).