TY - JOUR T1 - From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa JF - Global Health: Science and Practice JO - GLOB HEALTH SCI PRACT DO - 10.9745/GHSP-D-22-00213 AU - Mary V. Kinney AU - Asha S. George AU - Natasha R. Rhoda AU - Robert C. Pattinson AU - Anne-Marie Bergh Y1 - 2022/03/03 UR - http://www.ghspjournal.org/content/early/2023/03/02/GHSP-D-22-00213.abstract N2 - Key FindingsLessons learned from implementing a perinatal audit program in South Africa showed the importance of embedding the process within the health system, multiple structures with a continuity of actors and government ownership, demonstration of impact, local adaptation, and continuous efforts to institutionalization.Using a tool to measure the program’s implementation in 5 subdistricts in the Western Cape Province identified operational gaps in the perinatal audit program as well as possible gaps within the tool itself.Key ImplicationsEven in settings with wide uptake and use, such as South Africa, institutionalizing a national perinatal audit program requires continuous efforts to build the network of actors and governance structures, generate buy-in, and integrate into policy and guidelines.Measuring implementation of perinatal audit at the facility level using the existing tool is not sufficient for understanding sustainable and quality practice.Introduction:Maternal and perinatal death surveillance and response (MPDSR), or related forms of maternal and perinatal death audits, can strengthen health systems. We explore the history of initiating, scaling up, and institutionalizing a national perinatal audit program in South Africa.Methods:Data collection involved 56 individual interviews, a systematic document review, administration of a semistructured questionnaire, and 10 nonparticipant observations of meetings related to the perinatal audit program. Fieldwork and data collection in the subdistricts occurred from September 2019 to March 2020. Data analysis included thematic content analysis and application of a tool to measure subdistrict-level implementation. This study expands on case study research applied to 5 Western Cape subdistricts with long histories of implementation.Results:Although established in the early 1990s, the perinatal audit program was not integrated into national policy and guidelines until 2012 but was then excluded from policy in 2021. A network of national and subnational structures that benefited from a continuity of actors evolved and interacted to support uptake and implementation. Intentional efforts to demonstrate impact and enable local adaptation allowed for more ownership and buy-in. Implementation requires continuous efforts. Even in 5 subdistricts with long histories of practice, we found operational gaps, such as incomplete meeting minutes, signaling a need for strengthening. Nevertheless, the tool used to measure implementation may require revisions, particularly in settings with institutionalized practice.Conclusion:This article provides lessons on how to initiate, expand, and strengthen perinatal audit. Despite a long history of implementation, the perinatal audit program in South Africa cannot be assumed to be indefinitely sustainable or final in its current form. To monitor uptake and sustainability of MPDSR, including perinatal audit, we need research approaches that allow exploration of context, local adaptation, and underlying issues that support sustainability, such as relationships, leadership, and trust. ER -