Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis

Background

Perinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals.

Methods

Perinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model.

Results

Out of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths.

Conclusions

Factors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1269-9) contains supplementary material, which is available to authorized users.

The burden of bone, native joint and soft tissue infections on orthopaedic emergency referrals in a city hospital

Introduction Bone, native joint and soft tissue infections are frequently referred to orthopaedic units although their volume as a proportion of the total emergency workload has not been reported previously. Geographic and socioeconomic variation may influence their presentation. The aim of this study was to quantify the burden of such infections on the orthopaedic department in an inner city hospital, determine patient demographics and associated risk factors, and review our current utilisation of specialist services. Methods All cases involving bone, native joint and soft tissue infections admitted under or referred to the orthopaedic team throughout 2012 were reviewed retrospectively. Prosthetic joint infections were excluded. Results Almost 15% of emergency admissions and referrals were associated with bone, native joint or soft tissue infection or suspected infection. The cohort consisted of 169 patients with a mean age of 43 years (range: 1-91 years). The most common diagnosis was cellulitis/other soft tissue infection and the mean length of stay was 13 days. Two-thirds of patients (n=112, 66%) underwent an operation. Fifteen per cent of patients were carrying at least one blood borne virus, eleven per cent were alcohol dependent, fifteen per cent were using or had been using intravenous drugs and nine per cent were homeless or vulnerably housed. Conclusions This study has shown that a significant number of patients are admitted for orthopaedic care as a result of infection. These patients are relatively young, with multiple complex medical and social co-morbidities, and a long length of stay.

Differences in severity at admission for heart failure between rural and urban patients: the value of adding laboratory results to administrative data

BACKGROUND

Rural/urban variations in admissions for heart failure may be influenced by severity at hospital presentation and local practice patterns. Laboratory data reflect clinical severity and guide hospital admission decisions and treatment for heart failure, a costly chronic illness and a leading cause of hospitalization among the elderly. Our main objective was to examine the role of laboratory test results in measuring disease severity at the time of admission for inpatients who reside in rural and urban areas.

METHODS

We retrospectively analyzed discharge data on 13,998 hospital discharges for heart failure from three states, Hawai'i, Minnesota, and Virginia. Hospital discharge records from 2008 to 2012 were derived from the State Inpatient Databases of the Healthcare Cost and Utilization Project, and were merged with results of laboratory tests performed on the admission day or up to two days before admission. Regression models evaluated the relationship between clinical severity at admission and patient urban/rural residence. Models were estimated with and without use of laboratory data.

RESULTS

Patients residing in rural areas were more likely to have missing laboratory data on admission and less likely to have abnormal or severely abnormal tests. Rural patients were also less likely to be admitted with high levels of severity as measured by the All Patient Refined Diagnosis Related Groups (APR-DRG) severity subclass, derivable from discharge data. Adding laboratory data to discharge data improved model fit. Also, in models without laboratory data, the association between urban compared to rural residence and APR-DRG severity subclass was significant for major and extreme levels of severity (OR 1.22, 95% CI 1.03-1.43 and 1.55, 95% CI 1.26-1.92, respectively). After adding laboratory data, this association became non-significant for major severity and was attenuated for extreme severity (OR 1.12, 95% CI 0.94-1.32 and 1.43, 95% CI 1.15-1.78, respectively).

CONCLUSION

Heart failure patients from rural areas are hospitalized at lower severity levels than their urban counterparts. Laboratory test data provide insight on clinical severity and practice patterns beyond what is available in administrative discharge data.