Stages of change: a qualitative study on the implementation of a perinatal audit programme in South Africa

In this article, published in 2011 by the BMC Health Services Research, Belizan and colleagues set out to examine the implementation and management of the Perinatal Problem Identification Programme (PPIP) in South Africa. The authors conducted two workshop sessions to draw on the experiences of clinical care providers. An analytical framework was applied, divided into three phases: ‘pre-implementation’, ‘implementation’ and ‘institutionalisation’. Each phase has two stages of change.

The authors identified four themes that are key to sustaining the implementation of an audit system across the stages of change. These include:

  • Drivers of change and teamwork
  • Outreach visits and supervisory meetings
  • The review of perinatal deaths and feedback meetings
  • Communicating and networking

The six stages that correspond to the three phases – before implementation, during implementation and the institutionalisation of the audit programme – include:

  • Building awareness
  • Committing to audit implementation
  • Preparing for audit implementation
  • Implementing the audit programme
  • Making audit routine practice
  • Sustaining the programme

These findings may be applied to other low- and middle-income settings that have high neonatal mortality and are planning on adapting a perinatal audit system. The authors also provide a comprehensive tool to reflect on the implementation and management of a perinatal audit system.