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Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Department of Obstetrcs and Gynaecology, Muhimbili National Hospital, Tanzania. (Internationell kvinno- & mödrahälsovård och migration/Essén)ORCID iD: 0000-0003-3854-9085
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Internationell kvinno- & mödrahälsovård och migration/Essén)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Reproductive and Child Health section, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania. (Internationell kvinno- & mödrahälsovård och migration/Essén)
Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
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2016 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, 343Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: In Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting.

METHODS: During 2013-2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. The effect of the implementations was assessed by the differences in percentage of standard diagnosis and management between the baseline and re-audit, using Chi-square test or Fisher's exact test, when appropriate.

RESULTS: In the baseline audit and re-audit, 248 and 251 deliveries with a diagnosis of foetal distress were identified and audited, respectively. The standard of diagnosis increased significantly from 52 to 68 % (p < 0.001). Standards of management improved tenfold from 0.8 to 8.8 % (p < 0.001). Improved foetal heartbeat monitoring using a Fetal Doppler was the major improvement in diagnoses, while change of position of the mother and reduced time interval from decision to perform caesarean section to delivery were the major improvements in management (all p < 0.001). Percentage of cases with substandard diagnosis and management was significantly reduced in both referred public and non-referred private patients (all p ≤ 0.01) but not in non-referred public and referred private patients.

CONCLUSION: The criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.

Place, publisher, year, edition, pages
2016. Vol. 16, 343
National Category
Clinical Medicine
Identifiers
URN: urn:nbn:se:uu:diva-307491DOI: 10.1186/s12884-016-1137-zISI: 000387607600003PubMedID: 27825311OAI: oai:DiVA.org:uu-307491DiVA: diva2:1047129
Available from: 2016-11-16 Created: 2016-11-16 Last updated: 2017-03-31Bibliographically approved
In thesis
1. Improving the quality of caesarean section in a low-resource setting: An intervention by criteria-based audit at a tertiary hospital, Dar es Salaam, Tanzania
Open this publication in new window or tab >>Improving the quality of caesarean section in a low-resource setting: An intervention by criteria-based audit at a tertiary hospital, Dar es Salaam, Tanzania
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

A sharp increase in caesarean section (CS) rates at the Muhimbili National Referral Hospital (MNH) – a tertiary referral hospital in Tanzania – by 50% in 2000–2011, was associated with concomitant increase in maternal complications and deaths and inconsistent improvement in newborn outcomes. The aims of this thesis were to explore care providers’ in-depth perspective of the reasons for these high rates of CS, and to evaluate and improve standards of care for the most common indica-tions of CS, obstructed labour and fetal distress, which are also major causes of adverse maternal and neonatal outcomes.

This thesis reports an investigation performed at MNH, Tanzania. For Paper I, qualitative methods were employed and demonstrated how care providers dismissed their responsibility for the rising CS rate; and, instead, projected the causes onto factors beyond their control. Additionally, dysfunctinal teamwork, transparency, and previous poorly conducted clinical audits led to fear of blame among care providers in cases of poor outcome that subsequently encougared defensive practise by assigning unnecessary CS. Papers II and III evaluated stand-ards of care using a criteria-based audit (CBA) of obstructed labour and fetal dis-tress. After implementing audit-feedback recommendations, the standards of diag-nosis of fetal distress improved by 16% and obstructed labour by 7%. Similarly, the standards of management preceding CS improved tenfold for fetal distress and doubled for obstructed labour. The impact of the CBA process was evaluated by comparing the maternal and perinatal outcomes categorized into Robson groups (Paper IV) of all deliveries occurring before and after the audit process (n=27,960). After the CBA process, there was a 50% risk reduction of severe perinatal morbidi-ty/mortality for patients with obstructed labour. The overall CS rates increased by 10%, and this was attributed to an increase in the CS rate among breech, term preg-nancies (Robson group 6), and preterm pregnancies (Robson group 10) that specifi-cally had reduced risk of poor perinatal outcome. The overall neonatal distress rates were also reduced by 20%, and this was attributed to a decrease in the neonatal distress rate among low-risk, term pregnancies (Robson group 3). Importantly, the increased rates of poor perinatal outcomes were associated with referred patients that had higher risk of neonatal distress and PMR than non–referred patients, after CBA process. 

In conclusion, the studies managed to educate the care providers to take on their roles as decision-makers and medical experts to minimize unnecessary CS, using the available resources. Care providers’ commitment to achieve the best practice should be sustained and effort for stepwise upgrading quality of obstetric care should be supported by the hospital management from the primary to tertiary referral level.

Place, publisher, year, edition, pages
Acta Universitatis Upsaliensis, 2017. 91 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1325
Keyword
Caesarean section, Criteria-based audit, Fetal distress, Obstructed labour, Low resource setting, Robson classification
National Category
Medical and Health Sciences
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:uu:diva-319192 (URN)978-91-554-9890-0 (ISBN)
Public defence
2017-05-20, Rosénsalen, Akademiska sjukhuset, entrance 95/96, Uppsala, 10:15 (English)
Opponent
Supervisors
Available from: 2017-04-28 Created: 2017-03-31 Last updated: 2017-05-05

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