Reflection or correction? A qualitative study of health manager's experience of clinical audit activities in rural maternity units in KwaZulu-Natal, South Africa.

Clinical audit aims to improve maternal and newborn care by systematically reviewing clinical practices, identifying gaps, implementing corrective actions, and monitoring progress. Audit can improve outcomes but effective implementation requires strong teamwork, communication and trust. To explore how health professionals experience audit, individual semi-structured interviews were conducted with maternity managers in 11 rural health facilities in KwaZulu-Natal, South Africa, between November 2022 and February 2023. Participants included medical managers (5) and nursing managers (11). Analysis used inductive thematic analysis supported by Nvivo v15. Managers described the maternity team working together to systematically assess care across a range of clinical areas, suggesting that reflective practice was embedded in their work. Audit activities included auditing of clinical case records, caesarean sections, and perinatal and maternal deaths. However, managers reported that clinical audit was time consuming and required high level technical and facilitation skills. Feedback was often described as didactic, emphasising teaching rather than reflection and learning, and frequently involved elements of identifying and blaming individuals. It is important that maternity managers have skills to provide feedback in a safe, blame-free environment. Inappropriate or judgemental feedback could lead to a blame culture and negatively affect communication, teamwork and collaboration across the maternity team.