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Criteria-based audit on management of eclampsia patients at a tertiary hospital in Dar es Salaam, Tanzania
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
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2009 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, Vol. 9, no 13Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Criteria-based audits have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the introduction of a criteria-based audit in a tertiary hospital in an African setting, assesses the quality of care among eclampsia patients and discusses possible interventions in order to improve the quality of care.

METHODS: We conducted a criteria based audit of 389 eclampsia patients admitted to Muhimbili National Hospital (MNH), Dar es Salaam Tanzania between April 14, 2006 and December 31, 2006. Cases were assessed using evidence-based criteria for appropriate care.

RESULTS: Antepartum, intrapartum and postpartum eclampsia constituted 47%, 41% and 12% of the eclampsia cases respectively. Antepartum eclampsia was mostly (73%) preterm whereas the majority (71%) of postpartum eclampsia cases ware at term. The case fatality rate for eclampsia was 7.7%. Medical histories were incomplete, the majority (75%) of management plans were not reviewed by specialists in obstetrics, specialist doctors live far from the hospital and do not spend nights in hospital even when they are on duty, monitoring of patients on magnesium sulphate was inadequate, and important biochemical tests were not routinely done. Two thirds of the patient scheduled for caesarean section did not undergo surgery within agreed time.

CONCLUSION: Potential areas for further improvement in quality of emergency care for eclampsia relate to standardizing management guidelines, greater involvement of specialists in the management of eclampsia and continued medical education on current management of eclampsia for junior staff.

Place, publisher, year, edition, pages
2009. Vol. 9, no 13
National Category
Medical and Health Sciences
URN: urn:nbn:se:umu:diva-21826DOI: 10.1186/1471-2393-9-13PubMedID: 19323846OAI: diva2:211914
Available from: 2009-04-20 Created: 2009-04-20 Last updated: 2015-04-29Bibliographically approved
In thesis
1. Improving quality of perinatal care through clinical audit: a study from a tertiary hospital in Dar es Salaam, Tanzania
Open this publication in new window or tab >>Improving quality of perinatal care through clinical audit: a study from a tertiary hospital in Dar es Salaam, Tanzania
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Perinatal audit has been tested and proved an important tool for reduction of perinatal mortality and assessment of quality of perinatal care. At Muhimbili National Hospital (MNH), a tertiary hospital in Dar es salaam, Tanzania we performed a retrospective cross-sectional study using data from an obstetrics database to classify all perinatal deaths during 1999-2003. We also determined the prevalence of anaemia in pregnancy and its impact on perinatal outcome. Furthermore, we conducted a perinatal audit to study potential determinants and causes of perinatal and neonatal deaths and their avoidability. We also assessed the quality of care of patients admitted with eclampsia using a criteria based audit. Stillbirth, early neonatal and perinatal mortality rates (PMR) were 96, 27 and 124 respectively. A large proportion of foetuses (38%) had no audible foetal heart beat on admission at MNH labour ward and the majority of the neonatal deaths were asphyxiated at delivery. The PMR for multiples and singletons were 269 and 118 respectively resulting in a rate ratio of 2.4 (95%CI: 2.1-2.4). The prevalence of anaemia and severe anaemia was 68% and 5.8%, respectively. Severity of anaemia increased the risk of preterm delivery with ORs of 1.4, 1.4 and 4.1 for women with mild, moderate and severe anaemia as compared to women with normal haemoglobin levels. The corresponding risks for LBW and VLBW were 1.2, 1.7 and 3.8, and 1.5, 1.9 and 4.2 respectively. The prevalence of preterm delivery and LBW was 17% and 14% respectively. The hospital-based incidence of eclampsia was 504 per 10,000 women or 5.1 % of all mothers admitted. Suboptimal care were identified on criteria regarding management plan by senior staff, review of the plans by specialist obstetrician, delay on caesarean section, monitoring patients on magnesium sulphate and inadequate use of the laboratory. Two out of three patients requiring operation were not operated within set standards. Birth asphyxia was the main cause of intrapartum fresh stillbirth (47%) and early neonatal deaths (51%), whereas eclampsia (25%) and preeclampsia (8.3%) were main maternal medical conditions. The majority of stillbirths were fresh, indicating foetal demise during labour or just before delivery. The audit study identified suboptimal care in about 80% of audited cases out of which about 50% were found to be the likely cause of the adverse perinatal outcome. Inadequate maternal and foetal monitoring during labour were the main suboptimal factors, though delay in referral and operative interventions were also prominent. Based on these studies, we conclude that:

  • The perinatal mortality (PMR) in this study was higher than the national average.
  • About one in four perinatal deaths at MNH can be attributed to avoidable factors linked to obstetric care
  • Main causes of perinatal and neonatal deaths were intrapartum birth asphyxia, immaturity related and infections            Management of patients in labour needs to be improved
  • Suboptimal care that is essentially avoidable included: inadequate monitoring of patients during labour, delay of care,    e.g. long decision to surgery interval, and delayed referral of patients fromprimary hospitals
  • The prevalence of anaemia in pregnancy was very high; and low birth weight and preterm delivery was independently associated with severity of anaemia
  • The prevalence of eclampsia at MNH was high and the case management needs to be improved
Place, publisher, year, edition, pages
Umeå: Umeå university, 2009. 73 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1311
Perinatal mortality, perinatal audit, avoidable factors, anaemia in pregnancy, eclampsia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
urn:nbn:se:umu:diva-27638 (URN)978-91-7264-897-5 (ISBN)
Public defence
2009-12-04, Sal B, Rosa Salen, Tandläkarhögskolan, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Available from: 2009-11-13 Created: 2009-11-12 Last updated: 2015-04-29Bibliographically approved

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