Objectives Improvement activities, surveillance and research in maternal and neonatal health in Afghanistan rely heavily on medical record data. This study investigates accuracy in delivery care records from three hospitals across workshifts.

Design Observational cross-sectional study.

Setting The study was conducted in one maternity hospital, one general hospital maternity department and one provincial hospital maternity department. Researchers observed vaginal deliveries and recorded observations to later check against data recorded in patient medical records and facility registers.

Outcome measures We determined the sensitivity, specificity, area under the receiver operator characteristics curves (AUROCs), proportions correctly classified and the tendency to make performance seem better than it actually was.

Results 600 observations across the three shifts and three hospitals showed high compliance with active management of the third stage of labour, measuring blood loss and uterine contraction at 30 min, cord care, drying and wrapping newborns and Apgar scores and low compliance with monitoring vital signs. Compliance with quality indicators was high and specificity was lower than sensitivity. For adverse outcomes in birth registries, specificity was higher than sensitivity. Overall AUROCs were between 0.5 and 0.6. Of 17 variables that showed biased errors, 12 made performance or outcomes seem better than they were, and five made them look worse (71% vs 29%, p=0.143). Compliance, sensitivity and specificity varied less among the three shifts than among hospitals.

Conclusions Medical record accuracy was generally poor. Errors by clinicians did not appear to follow a pattern of self-enhancement of performance. Because successful improvement activities, surveillance and research in these settings are heavily reliant on collecting accurate data on processes and outcomes of care, substantial improvement is needed in medical record accuracy.