Assessment of quality of care among in-patients with postpartum haemorrhage and severe pre-eclampsia at st. Francis hospital nsambya: a criteria-based audit

Using the WHO individual near miss case review (NMCR) cycle to improve quality of emergency obstetric care and maternal outcome in Keren hospital, Eritrea: an interrupted time series analysis

BACKGROUND

In 2016, the WHO regional office for Europe prepared a manual for conducting routine facility based individual near miss case review cycle. This study evaluates the effectiveness of the individual near miss case review (NMCR) cycle in improving quality of emergency obstetric care and maternal outcome in Keren hospital.

METHODS

An interrupted time series design was used to achieve the objectives of this study. Monthly data on women with potentially life-threatening conditions (PLTCs) admitted between April 2018 and October 2022 (i.e. 33 months pre-implementation and 22 months post-implementation) were collected from medical records. Segmented regression analysis was used to assess the intervention's effect on three process and outcome measures, namely, SMO, delayed care, and substandard care. The intervention was expected a priori to show immediate improvements without time-lag followed by gradual increment in slope. Segmented regression analyses were performed using the "itsa' command in STATA.

RESULTS

During the entire study period, 4365 women with potentially life threatening conditions were identified. There was a significant reduction in the post-implementation period in the proportion of mothers with PLTC who experienced SMO (- 8.86; p <  0.001), delayed care (- 8.76; p <  0.001) and substandard care (- 5.58; p <  0.001) compared to pre-implementation period. Results from the segmented regression analysis revealed that the percentage of women with SMO showed a significant 4.75% (95% CI: - 6.95 to - 2.54, p <  0.001) reduction in level followed by 0.28 percentage points monthly (95% CI: - 0.37 to - 0.14, p <  0.001) drop in trend. Similarly, a significant drop of 3.50% (95% CI: - 4.74 to - 2.26, p <  0.001) in the level of substandard care along with a significant decrease of 0.21 percentage points (95% CI: - 0.28 to - 0.14, p < 0.001) in the slope of the regression line was observed. The proportion of women who received delayed care also showed a significant 7% (95% CI: - 9.28 to - 4.68, p < 0.001) reduction in post-implementation level without significant change in slope.

CONCLUSIONS

Our findings suggest that the WHO individual NMCR cycle was associated with substantial improvements in quality of emergency obstetric care and maternal outcome. The intervention also bears a great potential for scaling-up following the guidance provided in the WHO NMCR manual.

Acceptability of donated breast milk among pregnant women in selected hospitals in central Uganda: a cross-sectional study

BACKGROUND

Donated breast milk is considered beneficial to vulnerable infants. Thus, Uganda launched its first human milk bank in November 2021 to provide breast milk to preterm, low birthweight and sick babies. However, there is a scarcity of information on the acceptability of donated breast milk in Uganda. The study sought to assess the acceptability of using donated breast milk and associated factors among pregnant women at a private and a public hospital in central Uganda.

METHODS

This cross-sectional study enrolled pregnant women attending antenatal care at the selected hospitals between July and October 2020. All pregnant women recruited had already given birth to at least one child. Data were collected using a semi-structured questionnaire, and we recruited participants through systematic sampling. Used frequencies, percentages and means with standard deviations to summarize variables. Assessed the association between the acceptability of donated milk and selected factors by comparing their arithmetic means using a generalized linear model to allow for clustering at the health facility level. Used a normal distribution and an identity link and calculated the adjusted mean differences together with 95% CIs [generated using robust variance estimators to correct for model misspecification].

RESULTS

A total of 244 pregnant women with a mean age of 30 (± 5.25) years were enrolled. Sixty-one-point 5% (150/244) of the women reported that they would accept donated breast milk. Higher education (adjusted mean difference, technical versus primary level: 1.33; 95% CI 0.64, 2.02), being Muslim (adjusted mean difference, Muslim versus Christian: 1.24; 95% CI 0.77, 1.70), having heard of donated breast milk banking (adjusted mean difference, ever versus never: 0.62; 95% CI 0.18, 1.06) and presence of a serious medical condition (adjusted mean difference, preference of donated milk versus other feeds in a serious medical condition: 3.96; 95% CI, 3.28, 4.64) were associated with acceptability of donated breast milk.

CONCLUSIONS

The acceptability of using donated breast milk for infant feeding was high among pregnant women. Public sensitization and education campaigns are indispensable for the acceptability of donated milk. These programs should be designed to include women with lower education levels.

Determinants of Obstetric Near Miss in a Tertiary Hospital in Kenya: A Retrospective Study

BACKGROUND

Kenya has a high burden of facility maternal deaths but there is scarce utilization of the near miss approach to understand facility related determinants of maternal mortality. The aim of this study was to investigate determinants of near miss in a major refferal hospital in Kenya using the World Health Organization near miss approach.

METHODS

A retrospective study design was used in a referral hospital in Kenya. Prevalence, direct and indirect causes of near miss were determined. Binomial logistic regression was used to determine associations between maternal characteristics and maternal near miss.

RESULTS

Maternal near miss ratio was 8.7 per 1000 live births. The most prevalent direct factors were: Severe post-partum hemorrhage (35%), eclampsia (18.9%) severe pre-eclampsia (17.4%), blood transfusion (79%), and hepatic dysfunction (3.7%). Anemia, previous ceaserean section and prolonged/obstructed labor were the most important contributory factors. The prevalence of organ dysfunction at admission was 39%. Only 74% of eclampsia cases had received magnesium sulphate on referral. Higher gestation at delivery (AOR = 0.640, 95% C.I =0.477–0.858) and those who received antenatal care from a level two or three facility (AOR = 0.190, 95% CI = 0.042–0.856) were less likely to experience a near miss.

CONCLUSION

Obstetric hemorrhage and pregnancy induced hypertension were the most important direct determinants of near miss, while anemia was the most important indirect determinant. Organ dysfunction on admission to the tertiary referral facility was high, suggesting delays in interventions at lower level facilities. Interventions addressing obstetric hemorrhage, pregnancy induced hypertension and pre-natal anemia may reduce the burden of near miss and mortality.

Introduction of Criterion-Based Audit of Postpartum Hemorrhage in a University Hospital in Eastern Ethiopia: Implementation and Considerations

With postpartum hemorrhage (PPH) continuing to be the leading cause of maternal mortality in most low-resource settings, an audit of the quality of care in health facilities is essential. The purpose of this study was to identify areas of substandard care and establish recommendations for the management of PPH in Hiwot Fana Specialized University Hospital, eastern Ethiopia. Using standard criteria (n = 8) adapted to the local hospital setting, we audited 45 women with PPH admitted from August 2018 to March 2019. Four criteria were agreed as being low: IV line-setup (32 women, 71.1%), accurate postpartum vital sign monitoring (23 women, 51.1%), performing typing and cross-matching (22 women, 48.9%), and fluid intake/output chart maintenance (6 women, 13.3%). In only 3 out of 45 women (6.7%), all eight standard criteria were met. Deficiencies in the case of note documentation and clinical monitoring, non-availability of medical resources and blood for transfusion, as well as delays in clinical management were identified. The audit created awareness, resulting in self-reflection of current practice and promoted a sense of responsibility to improve care among hospital staff. Locally appropriate recommendations and an intervention plan based on available resources were formulated.

Adherence to drug therapy for hypertensive disorders of pregnancy: a cross-sectional survey

Background

Hypertensive disorders of pregnancy (HDPs) are a major contributor to maternal mortality worldwide, and drug therapy for HDPs is complicated and special. Clinical guidelines help physicians optimize the care for HDPs, but little is known about whether physicians adhere to drug therapy guidelins well, especially in China. This study aims to evaluate adherence to the drug therapy guidelines of the Chinese Obstetricians and Gynecologists Association (COGA) for HDPs and to explore the corresponding associations with recommendation evidence.

Methods

A cross-sectional design was executed for 306 women with HDPs hospitalized in a maternity ward of a tertiary hospital from August 2014 to July 2015 in Hubei, China. Adherence to the COGA guidelines was evaluated according to six items: the time of use and route of administration and dosage of antihypertensive drugs, MgSO₄, and corticosteroids. Binary logistic regression was adopted to explore the associations between adherence to clinical decisions and recommendation evidence.

Results

The average adherence rate for drug therapy for HDPs was 48.22%. The adherence rate for the time of antihypertensive drug and corticosteroid use scored 95.65 and 86.75%, whereas the other four items of the time of MgSO₄ use and the routes of administration and dosages of antihypertensive drugs, MgSO₄, and corticosteroids scored < 50.00%. High- and low-evidence-based recommendations were followed in 40.00 and 54.70% of the decisions, respectively. Logistic regression revealed that recommendation evidence (OR = 0.588, P = 0.003) was associated with adherence.

Conclusions

Further improvement is still needed to achieve good adherence, especially regarding the time of MgSO₄ use and drug dosage. High-evidence-based management of drug therapy for HDPs should be strengthened.

Health facility readiness and provider knowledge as correlates of adequate diagnosis and management of pre-eclampsia in Kinshasa, Democratic Republic of Congo

BACKGROUND

Hypertensive disorders in pregnancy are the second most common cause of maternal mortality in the Democratic Republic of Congo (DRC), accounting for 23% of maternal deaths. This study aimed to assess facility readiness, and providers' knowledge to prevent, diagnose, and treat pre-eclampsia.

METHODS

A facility-based cross-sectional study was conducted in 30 primary health centres (PHCs) and 28 referral facilities (hospitals) randomly selected in Kinshasa, DRC. In each facility, all midwives and physicians involved in maternal care provision (n = 197) were included. Data on facility infrastructure and providers' knowledge about pre-eclampsia were collected using facility checklists and a knowledge questionnaire. Facility readiness score was defined as the sum of 13 health commodities needed to manage pre-eclampsia. A knowledge score was defined as the sum of 24 items about the diagnosis, management, and prevention of pre-eclampsia. The score ranges from 0 to 24, with higher values reflecting a better knowledge. The Mann-Witney U test was used to compare median readiness scores by facility type and ownership; and median knowledge scores between midwives in hospitals and in PHCs, and between physicians in hospitals and in PHCs.

RESULTS

Overall, health facilities had 7 of the 13 commodities, yielding a median readiness score of 53.8%(IQR: 46.2 to 69.2%). Although all provider groups had significant knowledge gaps about pre-eclampsia, providers in hospitals demonstrated slightly more knowledge than those in PHCs. Midwives in public facilities scored higher than those in private facilities (median(IQR): 8(5 to 12) vs 7(4 to 8), p = 0.03). Of the 197 providers, 91.4% correctly diagnosed severe pre-eclampsia. However, 43.9 and 82.2% would administer magnesium sulfate and anti-hypertensive drugs to manage severe pre-eclampsia, respectively. Merely 14.2 and 7.1% of providers were aware of prophylactic use of aspirin and calcium to prevent pre-eclampsia, respectively.

CONCLUSION

Our study showed poor availability of supplies to diagnose, prevent and treat pre-eclampsia in Kinshasa. While providers demonstrated good knowledge regarding the diagnosis of pre-eclampsia, they have poor knowledge regarding its prevention and management. The study highlights the need for strengthening knowledge of providers toward the prevention and management of pre-eclampsia, and enhancing the availability of supplies needed to address this disease.

How to improve the quality of care for women with postpartum haemorrhage at Onandjokwe Hospital, Namibia: quality improvement study

Background

Postpartum haemorrhage (PPH) is the leading direct cause of maternal morbidity and mortality worldwide. The sustainable development goals aim to reduce the maternal mortality ratio to 70 per 100,000 live births. In Namibia, the ratio was reported as 265 per 100,000 live births in 2015 and yet little is published on emergency obstetric care. The majority of deliveries in Namibia are facility-based. The aim of this study was to assess and improve the quality of care for women with PPH at Onandjokwe Hospital, Namibia.

Methods

A criterion-based audit cycle in all 82 women with PPH from 2015 using target standards for structure, process and outcomes of care. The audit team then planned and implemented interventions to improve the quality of care over a 10-month period. The audit team repeated the audit on all 70 women with PPH from the same 10-month period. The researchers compared audit results in terms of the number of target standards achieved and any significant change in the proportion of patients’ care meeting the predetermined criteria.

Results

In the baseline audit 12/19 structural, 0/9 process and 0/3 outcome target standards were achieved. On follow up 19/19 structural, 6/9 process and 2/3 outcome target standards were met. There was one maternal death in the baseline group and none in the follow up group. Overall 6/9 process and 2/3 outcome criteria significantly improved (p <  0.05) from baseline to follow up. Key interventions included training of nursing and medical staff in obstetric emergencies, ensuring that guidelines and standard operating protocols were easily available, reorganising care to ensure adequate monitoring of women postpartum and ensuring that essential equipment was available and functioning.

Conclusion

The study demonstrates that the quality of care for emergency obstetrics can be improved by audit cycles that focus on the structure and process of care. Other hospitals in Namibia and the region could adopt the process of continuous quality improvement and similar strategies.

Effect of locally tailored clinical guidelines on intrapartum management of severe hypertensive disorders at Zanzibar's tertiary hospital (the PartoMa study)

Objective

To estimate the effect of locally tailored clinical guidelines on intrapartum care and perinatal outcomes among women with severe hypertensive disorders in pregnancy (sHDP).

Methods

A pre–post study at Zanzibar's low‐resource Mnazi Mmoja Hospital was conducted. All labouring women with sHDP were included at baseline (October 2014 to January 2015) and at 9–12 months after implementation of the ongoing intervention (October 2015 to January 2016). Background characteristics, clinical practice, and delivery outcomes were assessed by criterion‐based case file reviews.

Results

Overall, 188 of 2761 (6.8%) women had sHDP at baseline, and 196 of 2398 (8.2%) did so during the intervention months. The median time between last blood pressure recording and delivery decreased during the intervention compared with baseline (P=0.015). Among women with severe hypertension, antihypertensive treatment increased during the intervention compared with baseline (relative risk [RR] 1.37, 95% confidence interval [CI] 1.14–1.66). Among the neonates delivered (birthweight ≥1000 g), stillbirths decreased (RR 0.56, 95% CI 0.35–0.90) and Apgar scores of seven or more increased during the intervention compared with baseline (RR 1.17, 95% CI 1.03–1.33).

Conclusion

Although health system strengthening remains crucial, locally tailored clinical guidelines seemed to help work‐overloaded birth attendants at a low‐resource hospital to improve care for women with sHDP.

ClinicalTrials.org

NCT02318420.

Among women with severe hypertensive disorders at Zanzibar's referral hospital, locally tailored intrapartum guidelines were associated with care improvements and 44% risk reduction of stillbirth.

Effectiveness of the facility-based maternal near-miss case reviews in improving maternal and newborn quality of care in low-income and middle-income countries: a systematic review

OBJECTIVES

The maternal near-miss case review (NMCR) has been promoted by WHO as an approach to improve quality of care (QoC) at facility level. This systematic review synthesises evidence on the effectiveness of the NMCR on QoC and maternal and perinatal health outcomes in low-income and middle-income countries (LMICs).

METHODS

Studies were searched for in six electronic databases (MEDLINE, Index Medicus, Web of Science, the Cochrane library, Embase, LILACS), with no language restrictions. Two authors independently screened papers and selected them for inclusion and independently extracted data. Maternal mortality was the primary outcome. Secondary outcomes included any outcome informing on any of the six dimensions of QoC: efficacy, safety, efficiency, equity, accessibility and timely care, acceptability and patient-centred care.

RESULTS

Out of 24 822 papers retrieved, 17 studies from 11 countries were included. Maternal mortality measured before and after the implementation of the NMCR cycle significantly decreased (OR 0.77, 95% CI 0.61 to 0.98, eight studies, 55 573 043 women; I2=39%). A statistically significant reduction in the incidence of uterine rupture, postpartum haemorrhage and maternal sepsis was observed in three out of six studies. Ten studies reporting on maternal care process all showed some significant improvement when measured against predefined standards. All studies reported that the NMCR resulted in some amelioration of the facility structure (physical structure, staffing, equipment, training, organisation of care). Newborn outcomes were overall poorly reported; four studies showed no significant difference in perinatal mortality. Patient satisfaction and equity were also poorly reported.

CONCLUSIONS

Policy makers may consider implementing the maternal NMCR cycle approach among strategies aiming at improving QoC and reducing maternal mortality and morbidity in LMIC. Future studies should better document the effectiveness of the NMCR cycle particularly on outcomes reflecting patient-centred care and cost-effectiveness.