Emergency obstetric care in developing countries - Wiley Online Library

BJOG: an International Journal of Obstetrics and Gynaecology September 2005, Vol. 112, pp. 1264– 1269

DOI: 10.1111 /j .1471-0528 .2005.0 0604.x

Emergency obstetric care in developing countries: impact of guidelines implementation in a community hospital in Senegal Alexandre Dumont,a Alioune Gaye,b Patricia Mahe´,c Marie-He´le`ne Bouvier-Colled Objective To evaluate, with volunteer professionals in a resource-poor setting, an approach of audit and feedback to promote local implementation of emergency obstetric guidelines. Design Triple cohort observational time series study. Setting A 46-bed obstetric unit in an academic-affiliated community hospital in Senegal. Population All pregnant women with haemorrhagic and hypertensive complications who were admitted to the maternity unit during the study periods. Methods To assess the benefits of guidelines implementation, maternal outcomes during the intervention period were compared with those occurring in two one-year periods when staff daily supervision was the main potentially effective action on clinical management. Main outcome measures The intervention strategy was criteria-based audits with regular feedback over a one-year period. The clinical focus was haemorrhage and hypertension the most frequent causes of maternal death in the study population. Hospital charts were audited by external reviewers. The primary outcome was the case fatality rate (CFR) among patients with haemorrhage and hypertension. Results There was an increase in morbidity diagnoses during the intervention period. In addition, there was a marked increase in obstetric interventions, especially for transfusions and caesarean deliveries. Patients characteristic-adjusted case fatality decreased by 53% between baselines I and II and during the intervention period by 33% and 24%, compared with baseline periods I and II, respectively. Outcome improvements were different for haemorrhage and hypertension. Conclusion While staff daily supervision may have improved maternal outcome before the intervention period, audit and feedback produced marked effects on emergency obstetric care, specially for complications requiring highly trained management (e.g. pre-eclampsia). Audit and feedback are one of the potentially effective guidelines implementation strategies that should be considered for further studies in resource-poor health facilities.

INTRODUCTION Maternal mortality is a major public health problem, especially in West Africa where maternal mortality ratios are still very high.1 Most maternal deaths occur during —or few hours after — delivery. Haemorrhage, hypertension, obstructed labour and sepsis are the major direct obstetric

a

Department of Obstetrics and Gynaecology, Centre de Recherche de l’Hoˆpital Sainte-Justine, University of Montre´al, Montre´al, Quebec,Canada b Service de gyne´cologie-obste´trique, Centre de Sante´ Roi Baudouin, Gue´diawaye, Dakar, Se´ne´gal, Africa c Akar Fann, Se´ne´gal, Africa d Epidemiological Research Unit on Women and Children’s Health, National Institute of Health and Medical Research (INSERM), Paris, France Correspondence: Dr A. Dumont, Hoˆpital Sainte-Justine, 3175 Coˆte Sainte-Catherine, H3T-1C5 Montre´al, Que´bec, Canada. D RCOG 2005 BJOG: an International Journal of Obstetrics and Gynaecology

causes.2 The treatments for those obsterical complications are well known and appropriate emergency obstetric care should prevent most of these deaths.3 Situation analyses in various heath facilities in West Africa underlined problems related to health services management and to staff attitudes.4 The main factors identified as being responsible for poor quality of care were failure to offer 24-hour services, lack of drugs and supplies and low competence of birth attendants. Inadequate preservice and in-service training, lack of technical support and supervision and absence of standard treatment guidelines could explain the heterogeneous quality of care provided by midwifes in first line and referral hospitals.5 Furthermore, anthropological studies in West Africa pointed out that while both pregnant women and midwives are influenced by the same social rules (e.g. linguistic taboos, respect and shame), technical constraints force midwives to violate those rules, making the application of their technical skills very difficult.6 Thus, midwives and other staff involved in delivery management must learn how to implement modern obstetric guidelines within specific cultural environments. www.blackwellpublishing.com/bjog

EMERGENCY OBSTETRIC CARE IN DEVELOPING COUNTRIES

The movement to develop and disseminate clinical practice guidelines (CPGs) has been well established in industrialised countries for more than a decade.7 Practice guidelines, however, although useful as one component in quality assurance programme, do not by themselves appear to change professional behaviour, which has proven resistance to outside directives.8 Supplementary local activities are needed for implementing CPGs. In resource-high settings, audits and feedback, opinion leaders, reminder systems and academic detailing were shown to be moderately or strongly effective.9 In developing countries, the audit approach is a promising strategy that could be applied at the local level to change obstetric practice.10 – 14 Few studies have shown the impact of this complex intervention on maternal mortality. This ‘before-and-after’ study evaluates, with community hospital midwives and physicians, criteria-based audits with feedback for encouraging local implementation of emergency obstetric guidelines. The clinical focus was haemorrhage and hypertension the most frequent causes of maternal death in the study population. The objective was to evaluate whether this strategy would, under usual clinical circumstances with volunteer professionals, lead to changes in obstetric practices and to a decrease in maternal mortality.

METHODS We conducted an observational study with two baseline periods and an intervention period. The study was approved by the local committee on clinical research in the Centre de Sante´ Roi Baudouin, Gue´diawaye, Dakar, Senegal. The intervention had a one-year duration (1 March 2001 through 28 February 2002). Two baseline periods of equal duration were used for comparison of clinical outcomes. Baseline

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period I was selected as an appropriate time interval after the opening of the surgical unit (1 January 1998, to 31 December 1998), and baseline period II was selected to evaluate possible time-related changes in outcomes before the study intervention (1 January 1999, to 31 December 1999). Year 2000 was the preintervention period for the elaboration and dissemination of CPGs and thus was neither baseline period nor an intervention period. All pregnant women with haemorrhagic and hypertensive complications who were admitted to the maternity unit during the study period were included. The following complications were examined: placental abruption, haemorrhagic placenta previa, postpartum haemorrhage, preeclampsia and eclampsia. Women who were referred from other health facilities were included in the study unless they met predefined inclusion criteria. The patients with haemorrhage or hypertensive disorders who were transferred from the study site to other hospitals were included in the study and information was obtained by telephone within six weeks after the transfer. We excluded women with first trimester complications (unsafe abortion, septic or haemorrhagic miscarriage, ectopic pregnancy) because the CPGs focussed on second and third trimester complications and women admitted after 24 hours following delivery because care of unit was not concerned at the beginning. The study site was a surgical maternity unit in a 72-bed academic-affiliated district hospital located in the suburb of Dakar, Senegal’s capital. The surgical unit was built in 1997. Three residents, four nurse – anesthesists and one gynaecologist – obstetrician provided 24-hour surgical obstetric care. Labour management and normal deliveries were attended by 19 midwifes. At the daily meeting with staff, the senior gynaecologist –obstetrician reviewed all patients’ charts to control for clinical data and assist with triage issues. During the study periods, he identified

Fig. 1. Example of the 11 objective criteria that the external reviewers used to evaluate the clinical management of antepartum eclampsia. When the process of care met all the 11 criteria, the management was classified as ‘standard care’, and ‘substandard care’ in the other cases.

D RCOG 2005 BJOG: an International Journal of Obstetrics and Gynaecology 112, pp. 1264 – 1269

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Table 1. Demographic and obstetric characteristics of the patient population. Values are presented as mean [SD] or n (%).

Patients (no.) Age Parity 0 1–2 3 and more

Baseline I Baseline II Intervention

P

446 520 27.8 [7.3] 28.1 [6.9]

0.58

712 27.8 [7.2]

131 (29) 90 (20) 225 (50)

128 (25) 132 (25) 260 (50)

223 (31) 150 (21) 339 (48)

0.06

9 (2)

4 (1)

22 (3)

0.02

Antenatal visits 0 1–2 3 and more

80 (18) 291 (65) 175 (39)

55 (11) 256 (49) 209 (40)

49 (7) 315 (44) 348 (49)