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Improving quality of perinatal care through clinical audit: a study from a tertiary hospital in Dar es Salaam, Tanzania
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
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.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1311
Keyword [en]
Perinatal mortality, perinatal audit, avoidable factors, anaemia in pregnancy, eclampsia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-27638ISBN: 978-91-7264-897-5 (print)OAI: oai:DiVA.org:umu-27638DiVA: diva2:276843
Public defence
2009-12-04, Sal B, Rosa Salen, Tandläkarhögskolan, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2009-11-13 Created: 2009-11-12 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Analysis of perinatal mortality at a teaching hospital in Dar es Salaam, Tanzania, 1999-2003
Open this publication in new window or tab >>Analysis of perinatal mortality at a teaching hospital in Dar es Salaam, Tanzania, 1999-2003
2006 (English)In: African Journal of Reproductive Health, ISSN 1118-4841, Vol. 10, no 2, 72-80 p.Article in journal (Refereed) Published
Keyword
Apgar Score, Female, Health Surveys, Hospitals; University/*statistics & numerical data, Humans, Infant Mortality, Infant; Newborn, Pregnancy, Pregnancy Outcome/epidemiology, Retrospective Studies, Tanzania/epidemiology
Identifiers
urn:nbn:se:umu:diva-14156 (URN)17217119 (PubMedID)
Available from: 2007-05-23 Created: 2007-05-23 Last updated: 2017-12-14Bibliographically approved
2. Risks for preterm delivery and low birth weight are independently increased by severity of maternal anaemia
Open this publication in new window or tab >>Risks for preterm delivery and low birth weight are independently increased by severity of maternal anaemia
Show others...
2009 (English)In: SAMJ South African Medical Journal, ISSN 0256-9574, E-ISSN 2078-5135, Vol. 99, no 2, 98-102 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To estimate the effect of the severity of maternal anaemia on various perinatal outcomes. DESIGN: A cross-sectional study. SETTING: Labour Ward, Muhimbili National Hospital, Dar es Salaam, Tanzania. METHODS: The haemoglobin of eligible pregnant women admitted for delivery between 15 November 2002 and 15 February 2003 was measured. Data on socio-demographic characteristics, iron supplementation, malaria prophylaxis, blood transfusion during current pregnancy, and current and previous pregnancy outcomes were collected and analysed. Anaemia was classified according to the World Health Organization (WHO) standards: normal--Hb > or = 11.0 g/dl; mild--Hb 9.0-10.9 g/dl; moderate--Hb 7.0-8.9 g/dl; and severe--Hb < 7.0 g/dl. Logistic regression analysis was performed to estimate the severity of anaemia. The following outcome measures were used: preterm delivery (<37 weeks), Apgar score, stillbirth, early neonatal death, low birth weight (LBW) (<2500 g) and very low birth weight (VLBW) (<1500 g). RESULTS: A total of 1174 anaemic and 547 non-anaemic women were enrolled. Their median age was 24 years (range 14-46 years) and median parity was 2 (range 0-17). The prevalence of anaemia and severe anaemia was 68% and 5.8%, respectively. The risk of preterm delivery increased significantly with the severity of anaemia, with odds ratios of 1.4, 1.4 and 4.1 respectively for mild, moderate and severe anaemia. The corresponding risks for LBW and VLBW were 1.2 and 1.7, 3.8 and 1.5, and 1.9 and 4.2 respectively. CONCLUSION: The risks of preterm delivery and LBW increased in proportion to the severity of maternal anaemia.

Identifiers
urn:nbn:se:umu:diva-25330 (URN)19418670 (PubMedID)
Available from: 2009-08-12 Created: 2009-08-12 Last updated: 2017-12-13Bibliographically approved
3. Criteria-based audit on management of eclampsia patients at a tertiary hospital in Dar es Salaam, Tanzania
Open this publication in new window or tab >>Criteria-based audit on management of eclampsia patients at a tertiary hospital in Dar es Salaam, Tanzania
Show others...
2009 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-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.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-21826 (URN)10.1186/1471-2393-9-13 (DOI)19323846 (PubMedID)
Available from: 2009-04-20 Created: 2009-04-20 Last updated: 2017-12-13Bibliographically approved
4. Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania
Open this publication in new window or tab >>Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania
Show others...
2009 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 9, 45- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR).

METHODS: From 1st August, 2007 to 31st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient.

RESULTS: The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors.

CONCLUSION: There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-27629 (URN)10.1186/1471-2393-9-45 (DOI)19765312 (PubMedID)
Available from: 2009-11-12 Created: 2009-11-12 Last updated: 2017-12-12Bibliographically approved

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