Facilitators and barriers to adoption of evidence-based perinatal care in Latin American hospitals: a qualitative study

Selective episiotomy and the active management of labor have been shown by numerous studies to benefit women's experience of labor as well as its outcomes. However, many Latin American public hospitals have not updated their clinical practices to reflect these findings. Limited access to new knowledge, limited time and physical resources and attitudes resistant to change are factors limiting the adoption of new practices in such hospitals. Interviews were conducted with three department heads, and focus groups were conducted with 31 physicians and midwives working in 10 public hospitals in Argentina and Uruguay. All were asked about facilitators and barriers to making changes in clinical practice. In addition, three focus groups were conducted with 16 pregnant women served by public hospitals. Responses were grouped according to stages of change in incorporating new evidence into practice. Numerous facilitators and barriers were identified by participants, as well as potential strategies for promoting change that could be incorporated into interventions. Barriers included limited access to information, negative attitudes toward changes in practice, lack of skills in performing new practices, lack of medical resources and explicit guidelines and a perceived need to practice defensive medicine. Changing long-standing clinical practice is difficult. Interventions must be adapted to translate evidence-based approaches to new cultures and contexts. Improving information access, use of role models, skill development and improved resources and support may be effective ways to overcome barriers to change in Latin American obstetric care.

Who cares for baby?

Divisions between maternal and child health services in the developing world, first reported 20 years ago, left services for newborns overlooked. Today, neonatal mortality is still unacceptably high. Hannah Brown reports on initiatives trying to bridge the gap

Quality of record keeping in the intrapartum period at the Provincial General Hospital, Kakamega, Kenya

OBJECTIVE

To assess the quality of recording critical events in the intrapartum period in Kakamega Provincial General Hospital (PGHK).

DESIGN

Retrospective comparative study.

SETTING

Provincial General Hospital, Kakamega, the referral hospital for Western Province, Kenya.

PARTICIPANTS

Two hundred women admitted at the labour ward during the six-month period between 1st September 2000 and 28th February 2001 were compared to two hundred women admitted between 1st July 2001 and 31st December 2001.

INTERVENTION

The Safe Motherhood Demonstration Project (SMDP) was introduced in four districts of Western Province, Kenya, in which PGHK is located. It included on job training in Safe Motherhood which emphasised, among others, collection and utilisation of maternal health care services data.

MAIN OUTCOME MEASURES

Comprehensiveness of recording of biodata, history taking and examination findings were assessed for women in labour before and during the implementation of the SMDP. The proportion of cases in labour managed by use of partograph and its appropriate use were also determined.

RESULTS

Retrieval rate of patients' notes was 86.9% and 89.6% before and during SMDP respectively. Information on sociodemographic characteristics, history taking, general and obstetric examination had a near universal recording in both groups but data on alcohol consumption, smoking, menarche, previous pregnancies and contraceptive use was poorly recorded. There was a significant improvement in recording of diagnosis and plan of management during the SMDP (p = 0.037). The partograph was used in only 11% of patients before SMDP as compared to 85% during SMDP (p = 0.000). Record on foetal condition and progress of labour were significantly improved during the SMDP (p = 0.000). Records on summary of labour likewise significantly improved during the SMDP (p = 0.02).

CONCLUSION

The quality of record keeping in the intrapartum period at the PGHK greatly improved during the implementation of the SMDP. It would be worthwhile to assess the sustainability of quality of intrapartum records and care a year or so after the SMDP ended.

Avoidable factors and causes of neonatal deaths from perinatal asphyxia-hypoxia in South Africa: national perinatal survey

BACKGROUND

Fetal or neonatal hypoxia owing to asphyxia can result in death or severe irreversible brain damage. To prevent this, factors contributing to the development of fetal or neonatal hypoxia must be identified.

AIMS

To determine the primary obstetric and neonatal causes or diagnoses and avoidable factors associated with death from asphyxia-hypoxia.

METHODS

Data from a computerised database from 142 hospitals using the Perinatal Problem Identification Program in South Africa from October 1999 to September 2003 were analysed. All records of deaths from asphyxia-hypoxia were retrieved and analysed. Primary obstetric and neonatal causes or diagnoses and factors associated with these deaths were identified. Each case identified as having died from asphyxia-hypoxia was analysed for possible and probable avoidable factors.

RESULTS

Among 4502 neonatal deaths weighing >999 g, 1459 (32.4%) were identified as being related to asphyxia-hypoxia. Intrapartum asphyxia was the most common diagnosis (72% of deaths). Hypoxic-ischaemic encephalopathy was identified as the main neonatal diagnosis in these deaths. The most common category of probable avoidable factors was health worker-related. Inadequate fetal monitoring was the most common health worker-related probable avoidable factor. Substandard care related to resuscitation was recorded infrequently, most likely because of inability to assess neonatal resuscitation.

CONCLUSIONS

Asphyxia-hypoxia is responsible for about one-third of neonatal deaths. Intrapartum asphyxia is the major primary obstetric cause of deaths from hypoxia. A third of the deaths were judged to be preventable.

Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However, in recent decades in hospitals worldwide, continuous support during labour has become the exception rather than the routine. Concerns about the consequent dehumanization of women's birth experiences have led to calls for a return to continuous support by women for women during labour.

OBJECTIVES

Primary: to assess the effects, on mothers and their babies, of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies in the birth environment that may affect a woman's autonomy, freedom of movement and ability to cope with labour; (2) whether the caregiver is a member of the staff of the institution; and (3) whether the continuous support begins early or later in labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2007).

SELECTION CRITERIA

All published and unpublished randomized controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. All authors participated in evaluation of methodological quality. One author and a research assistant independently extracted the data. We sought additional information from the trial authors. We used relative risk for categorical data and weighted mean difference for continuous data to present the results.

MAIN RESULTS

Sixteen trials involving 13,391 women met inclusion criteria and provided usable outcome data. Primary comparison: women who had continuous intrapartum support were likely to have a slightly shorter labour, were more likely to have a spontaneous vaginal birth and less likely to have intrapartum analgesia or to report dissatisfaction with their childbirth experiences. Subgroup analyses: in general, continuous intrapartum support was associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour and in settings in which epidural analgesia was not routinely available.

AUTHORS' CONCLUSIONS

All women should have support throughout labour and birth.

'Making a difference': A new care paradigm for pregnant and parenting Aboriginal people

OBJECTIVE

To describe community-based stakeholders' views of how safe and responsive care "makes a difference" to health and well-being for pregnant and parenting Aboriginal people. Community-based stakeholders included community members, providers of health and social care, and health care and community leaders.

METHODS

A postcolonial standpoint, participatory research principles and a case-study design were used to investigate two Aboriginal organizations' experiences improving care for pregnant and parenting Aboriginal people. Data were collected through researcher field notes, exploratory interviews and small group discussions with purposively selected community-based leaders, members and providers. Data were analyzed using an interpretive descriptive method.

RESULTS

Community participants' views of "making a difference" emphasized: recognizing relevant outcomes of care; acknowledging progress over time; and using a strengths-based approach in which providers appreciate individuals' efforts and the challenges of their contextual circumstances.

DISCUSSION

"Making a difference" to pregnant and parenting Aboriginal people would facilitate Aboriginal peoples' efforts to tackle the deeply embedded socio-historical determinants of well-being and capacity, and thus shift priorities for care upstream to focus on such determinants. Such a paradigm for care would integrate multiple perspectives on desirable outcomes within local frameworks based on values and priorities of Aboriginal parents, while also incorporating the benefits and wisdom of existing yet further downstream approaches to care.

CONCLUSION

Design and evaluation of care based on community values and priorities and using a strengths-based approach can improve early access to and relevance of care during pregnancy and parenting for Aboriginal people.

Resultados da assistência ao parto no Centro de Parto Normal Dr. David Capistrano da Costa Filho em Belo Horizonte, Minas Gerais, Brasil

A qualidade da assistência prestada em Centro de Parto Normal (CPN) por enfermeira obstetra é amplamente questionada. Foi realizado um estudo descritivo e retrospectivo de 2.117 partos ocorridos entre janeiro de 2002 e julho 2003, no CPN Dr. David Capistrano da Costa Filho, em Belo Horizonte. Entre os principais resultados da assistência, destacam-se a taxa de transferência materna com 11,4%; a taxa de cesárea com 2,2%; a taxa de admissão em Centro de Tratamento Intensivo (CTI) neonatal de 1,2%; e a taxa de Apgar < 7 no 5º minuto de 1%. Distocias de trabalho de parto e o desejo por analgesia peridural foram as maiores causas para a transferência materna, enquanto o distúrbio de desconforto respiratório foi a causa principal para admissão dos recém-nascidos no CTI. A mortalidade neonatal corrigida foi de 2 casos em mil nascidos vivos. Percebe-se que os resultados do CPN em estudo não diferem dos dados referidos na literatura internacional. A baixa taxa de cesárea é talvez o resultado mais evidente. Estudos comparativos nacionais são necessários.

Consensus statement on perinatal care

While there is general agreement with the framework of the consensus statements, it is at the margins of the 'grey zone', particularly at 23 weeks of gestation, that practice in other states appears to differ from practice in New South Wales (NSW)/Australian Capital Territory (ACT). This is evidenced by the lower regional survival in NSW/ACT at 23 weeks compared with other contemporaneous regional Australian cohorts, reflecting the discouragement of active intervention in NSW/ACT at this gestation. At the other end of the 'grey zone', surely active intervention, including prenatal transfer to a tertiary obstetric centre, should always be given to an otherwise uncomplicated 25-week infant? At any of these gestations, where infants survive, the majority are not severely disabled, leading us in this state to support initiation of intensive care to infants of marginal gestations where informed parents wish us to do so. The consensus conference questions and response rates by professional group should be published in full.

Impact of service changes on neonatal transfer patterns over 10 years

INTRODUCTION

Many changes have been made to the staffing and organisation of neonatal care in the UK in the past 10 years. This study assessed the extent to which these changes had affected the transfer of babies between different parts of the service.

METHODS

Data from the Trent Neonatal Survey, an ongoing study of neonatal intensive care activity in the former Trent Health Region of the UK, were used to evaluate neonatal inter-hospital transfers over a 10-year period, from 1 January 1995 to 31 December 2004. The number of transfers and the types of transfer were analysed and trends in gestation and disease severity over the study period were assessed. Rates of "inappropriate transfer" were also identified.

RESULTS

8105 babies were transferred over the period; 2294 babies underwent urgent postnatal transfer and this equates to approximately two such transfers every three days. The maximum number of journeys by any one baby was eight. Intensive care activity rose during the 10 years but the number of inappropriate transfers remained persistently high.

CONCLUSIONS

Organisational changes in neonatal care during the 10-year period have been insufficient to deal with the rising demand, as reflected by the persistently high rate of inappropriate transfers.

Neonatal transfers--a thin layer of glue to keep the service network together?

Perspective on the papers by Cusack et al (see page F181 ) and Kempley et al (see page F185 )

Reducing infant mortality in Chile: success in two phases

Latin America, and especially Chile, has done well in reducing infant mortality, with rates of around twenty-five per thousand live births. There are two clear phases of declining mortality: one largely influenced by poverty reduction, primary health care, and environmental and demographic factors; and a second one more sensitive to focused health care interventions. In 2000 Chile reached 8.9 infant deaths per 1,000, using interventions that represent an increase in the provision of services related to perinatal risks, acute respiratory diseases, congenital heart conditions, and certain vaccine-preventable infections. Chile, with per capita income near 5,000 US dollars in 2000, has infant mortality that compares with that of wealthier countries.

Do panels vary when assessing intrapartum adverse events? The reproducibility of assessments by hospital risk management groups

INTRODUCTION

A national audit project, Scotland-wide Learning from Intrapartum Critical Events (SLICE), included local assessment of quality of care in cases of perinatal death and neonatal encephalopathy due to intrapartum events. Concerns had been raised about interobserver variation in case assessment by different panels. We therefore studied the extent of agreement and disagreement between assessment panels, and examined the areas in which agreement and disagreement tended to occur.

METHODS

8 cases were randomly selected from all 42 cases identified during a 6-month period (1 January-1 July 2005). Each case was independently reviewed by three panels: the local hospital clinical risk-management group and two specially convened external panels. Panels assessed quality of care in three areas: admission assessment, recognition of incident, and method and timing of delivery. Predefined standards of care were provided for these three areas. Panels were also asked to assess the overall quality of care.

RESULTS

For each area of care, agreement between the two external panels was lowest. The lowest levels of agreement between panels were seen in assessment of overall care (50% crude agreement between external panel 1 and the hospital (kappa = 0.24, AC(1) = 0.36); 29% crude agreement between external panels 1 and 2 (kappa = -0.11, AC(1) = 0.1); 47% crude agreement between external panel 2 and the hospital (kappa = 0.36, AC(1) = 0.46). The lowest level of agreement among all three panels was also in the assessment of overall care (crude agreement 48%; kappa = 0.16, AC(1) = 0.34).

CONCLUSION

Moderate to substantial agreement among the three panels was achieved for the three areas in which explicit standards were provided. Therefore, a systematic approach to analysis of adverse events in perinatal care improves reproducibility.

[Clinical practice in looking after breastfeeding women and the new-born in some hospitals in Bogotá, Colombia]

OBJECTIVE

Evaluating the frequency of 17 practices being used in managing the main causes of maternal and perinatal morbidity and mortality in some hospitals in Bogotá between August 2004 and March 2005.

METHODS

A cross-sectional study was carried out. The data related to 3,108 women who gave birth at gestational age greater than 24 weeks.

RESULTS

The following percentages were obtained for each variable evaluated: having a perinatal record card (79.4%), taking iron and folic acid supplement (87.3%), syphilis screening (69.5%), bacteriuria screening (69.7%), constant accompaniment during giving birth (42.0%), not taking enemas (99.4%), not shaving the perinea (93.0%), selective episiotomy in first-time mothers (56.5%), adopting a squatting or seated position when giving birth (7.9%), active management of birth in gestation greater than 41 weeks (14.7%), active management of birth (73.5%), administering prophylactic antibiotics during a caesarean birth (61.2%), treating severe pre-eclampsia (76.5%) and eclampsia (20.0%) with magnesium sulphate, administering corticoids for inducing foetal maturation in mothers having a high risk of predetermined birth (51.6%), exclusive maternal lactation, having no restrictions (99.1%) and joint mother-newborn accommodation (91.2%).

CONCLUSIONS

Effective methodologies are required for guaranteeing adherence to maternal and perinatal attention regulations and guidelines and those administrative and management decisions facilitating compliance with them.

[Perinatal care in Croatia. Yesterday, today, tomorrow]

The indicators and determinants of perinatal care in Croatia are presented. The maternal mortality is low, less than 10/100.000, at a level of developed countries. The perinatal mortality, following stagnation during 10 years at a level of around 9.0%o, since 2001 started to decrease for all perinatally dead up to the rate of 7.8%, and for those > or =1000 grams or > or =27 weeks up to 5.8%. The fetal mortality continues to be stagnant at a rate of about 4.0%, while the early neonatal mortality continues to decrease up to the rate of 1.9%. The determinants of perinatal care and mortality are analyzed. The pre-term deliveries and the births of low birthweight infants (4-6%), of very low birthweight infants (0.6%) and of extremely low birthweight infants (0.4%) are at the level of developed countries. The antenatal care is continuously improving: the average number of antenatal visits increased to 8.1, over 50% of pregnant patients had 9 or more visits; the average number of ultrasound examinations increased to 3.97, 59% of them had 4 or more US examinations; these values do not correspond to the values in very developed countries with very low perinatal mortality. The rate of Cesarean sections increased to 15.5%. In neonatal care during last 10 years the early mortality of infants > or =2500 grams was continuously low , the early mortality of infants 1000-1499 grams and of 1500-2499 grams is remarkably decreased, but the decrease in those of 500-999 grams was not substantial. In neonatal care the lack of equipment and of specialists neonatologists, especially in NICU-s is registered. Regional organization of perinatal care is voluntary, it is not legally instituted. During 2004, 67.7% of all infants and 73.4% of live-born infants with birthweight <1500 grams in the 3rd level materity wards with NICU were delivered. The causes and regional differences in perinatal mortality are analyzed. With the aim to continue in the future the positive trend, and to achieve a very low perinatal mortality (<5.0%), regional organization of perinatal care, functioning of NICU with adequate equipment, and further education of specialists in neonatology and fetal-maternal medicine should be institutionally established.

Development of the Perinatal Concerns Program: care of mothers after diagnosis of fatal infant anomalies

Care of the grieving mother in the labor and delivery setting is a complex phenomenon requiring collaboration of professionals and designing sensitive care based on theory and compassion. This article describes The Perinatal Concerns Program, which was developed to make available a complete range of care for women whose pregnancies are complicated by fetal abnormalities. Development of this program required collaboration of several services, coordination of protocols, and establishment of clear lines of communication. It was born after a particularly difficult case in labor and delivery that alerted a staff nurse to the fact that coordination of care for this patient could have resulted in enhanced ability of all the staff to meet this woman's physical and emotional needs. The development of this program demonstrates that a motivated staff nurse with effective leadership skills can make major changes in an institution which can make a difference in the care of grieving patients.

Rapid point-of-care HIV testing in pregnant women: a systematic review and meta-analysis

Rapid, point-of-care human immunodeficiency virus (HIV) testing has the potential to enhance strategies to prevent mother-to-child transmission (MTCT) of HIV infection. Rapid tests need minimal laboratory infrastructure and can be performed by health workers with minimal training. In our systematic review and meta-analysis, we aimed to summarize the overall diagnostic accuracy of rapid HIV tests in pregnancy, and outcomes such as acceptability, patient preference, feasibility and impact of rapid testing. We searched four major databases, identified and screened 1377 citations, and included 17 studies that met our eligibility criteria. Analyses of these studies suggested that the overall sensitivity and specificity of blood-based rapid tests was high compared with oral rapid tests. A two-step testing strategy, particularly parallel testing, was found to be superior to single-test strategy in labour and delivery settings. Acceptability of rapid tests and patient preference was variable across studies. Overall, rapid HIV testing was highly accurate compared with conventional tests and offer a clear advantage of enabling the implementation of timely interventions to reduce MTCT of HIV. To improve diagnostic accuracy and to reduce false-positive results, it may be necessary to use two rapid tests during labour and delivery.

Suboptimal care in stillbirths – a retrospective audit study

BACKGROUND

Stillbirth rates have decreased radically over the last decades. One reason for this is improved perinatal care. The aim of this study was to explore whether sub-optimal factors in stillbirths were more frequent among non-western than western women.

METHODS

Population-based perinatal audit of 356 stillbirths after gestational week 23, in 2 Norwegian counties during 1998-2003 (4.2 per 1,000 deliveries); of these 31% were born to non-western women. By audit, the stillbirths were attributed to optimal or sub-optimal care factors. Multivariate methods were used to analyse the data.

RESULTS

Sub-optimal factors were identified in 37% of the deaths. When compared to western women, non-western women had an increased risk of stillbirth (OR: 2.2; 95% CI: 1.3-3.8), and an increased risk of sub-optimal care (OR: 2.4; 95% CI: 1.5-3.9). More often, non-western women received sub-optimal obstetric care (p<0.001), as e.g. failure to act on non-reassuring fetal status or incorrect assessment of labour progression. A common failure in antenatal care for both groups was unidentified or inadequate management of intrauterine growth restriction or decreased fetal movements. Non-western women were less prone to attend the program for antenatal care or to take the consequences of recommendations from health professionals. Inadequate communication was documented in 47% of non-western mothers; an interpreter was used in 29% of these cases.

CONCLUSIONS

Non-western women constituted a risk group for sub-optimal care factors in stillbirths. Possibilities for improvements include a reduction of language barriers, better identification and management of growth restriction for both origin groups, and adequate intervention in complicated vaginal births; with increased vigilance towards non-western women.

A clinical evaluation of evidence-based maternity care using the Optimality Index

The Optimality Index-US (OI-US) reflects the use of evidence-based practices in obstetrics. This paper's objective is to apply the OI-US to a "typical" nurse-midwifery service data set to demonstrate its use outside of a research context. The OI-US score for the sample practice was 80%. The OI-US can be used by obstetric and gynecologic nurse clinicians to demonstrate the relationship of various care practices to optimal outcomes.

Identification and collection of quality indicators for perinatal care

We describe the development of a database of quality indicators and outcomes for perinatal care as part of a multi-institutional collaborative quality improvement project, Neonatal Intensive Care Quality 2002. Important principles of developing such a database are also discussed including eligibility criteria that identify high-risk patients without burdening data collectors, clinically important and well-defined measures, development of systems within each hospital to ensure identification of all eligible patients, use of data collectors with knowledge of perinatal care, appropriate design of paper and electronic data-collection tools, multiple pilot tests, and periodic feedback of data to participating hospitals.

Stability of Nevirapine Suspension in Prefilled Oral Syringes Used for Reduction of Mother-to-Child HIV Transmission

OBJECTIVE

To reduce mother-to-child transmission (MTCT) of HIV, we assessed the stability of nevirapine suspension in an oral dosing syringe over a range of storage conditions.

DESIGN

A mother-to-child transmission dosing kit, containing a maternal nevirapine tablet and infant nevirapine suspension in an oral syringe that can be dispensed to the pregnant woman to use at delivery. However, the manufacturer only packages nevirapine in 240 mL, multidose containers and there are no published stability data for nevirapine suspension repackaged in an oral syringe.

METHODS

Nevirapine suspension 6 mg/0.6 mL in 3 mL amber BAXA Exacta-Med Oral Dispensers (Baxa Corporation, Englewood, CO) were stored under the following conditions: 26 degrees C/high relative humidity (RH), 40 degrees C/low RH, 40 degrees C/high RH, refrigerated and frozen -30 degrees C for 6 months. The samples were assayed monthly for nevirapine by HPLC-UV. At 3, 4, and 6 months the samples were cultured for pathogens.

RESULTS

: There were no significant decreases in nevirapine concentrations in the prefilled syringes compared with baseline. Nevirapine became more concentrated in syringes incubated at 40 degrees C/low RH due to evaporation resulting in the suspension becoming more viscous. No pathogens were cultured.

CONCLUSIONS

Nevirapine suspension is stable and pathogen free at varying conditions for 6 months in Baxa Exacta-Med Oral Dispensers.

A comparison of perinatal mortality in Korea on holidays and working days

OBJECTIVE

To examine whether the perinatal mortality of infants born during holidays differs from that of infants born on workdays, and to elucidate its cause.

DESIGN

Cross-sectional study. Setting Vital statistics linked to the National Infant Mortality Survey data for 1999 births in Korea.

POPULATION

In all, 628 485 births in 1999 in Korea.

METHODS

Number of births and perinatal mortality were classified according to the day of the week using the occurrence index. After adjusting for confounding factors, the odds ratios (ORs) for increased holiday mortality were estimated using logistic regression.

MAIN OUTCOME MEASURE

Birthweight-adjusted perinatal mortality.

RESULTS

Births on holidays were 33% fewer and perinatal deaths 24% higher than expected (PMR, Perinatal Mortality Rate, 16.4 versus 12.8; OR, 1.3; 95% CI, 1.2-1.4). After the adjustment of birthweight, gender, plurality and congenital anomalies, the odds ratio for death of infants born during holidays was 1.2 (95% CI, 1.1-1.3).

CONCLUSIONS

The higher perinatal mortality during holidays in Korea appears to be due to different qualities of perinatal care, rather than difference in case-mix.

Regionalization reigns--but is care being delivered accordingly? An evaluation of perinatal care delivery in a regionalized child health network

The Child Health Network for the Greater Toronto Area (CHN), a network of 20 hospitals and 9 community care access centres, assessed one component of its early progress in building a regionalized system of perinatal care. Focusing on the relationship between hospital level of care and gestational age, the study showed that most births occurred at appropriately designated facilities. However, a quarter of newborns of gestational age <32 weeks were delivered at a lower level of care than is considered optimal. CHN's ongoing research will offer opportunities to assess the impact of regional models on their foremost goal--quality clinical care.