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Optimizing the use of cesarean section in a low resource setting: Criteria-Based Audit at a tertiary referral hospital in Tanzania.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania. .
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Reproductive and Child Health, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania.
Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Introduction. Substandard intrapartum care contributes to maternal and perinatal morbidity in low-resource settings. The aim was to estimate the impact of a criteria-based audit (CBA) of obstructed labour (OL) and fetal distress (FD), at a tertiary referral hospital in Tanzania. Material and Methods. The CBA included a baseline audit (December 2013-June 2014) followed by implementation of audit recommendations (March-June 2015). A before-and-after survey of maternal and perinatal outcomes included 499 patients with FD (baseline audit n=248; re-audit n=251) and 510 with OL (baseline n=260; re-audit n=250). Patients with OL and FD were grouped as OL (baseline audit n=82; re-audit n=76). The maternal and perinatal outcomes of 27,960 deliveries were analysed in 10 Robson groups, which are mutually exclusive and reproducible, unlike CS indications, FD and OL. Bivariate and multivariate logistic regression estimated the likelihood of CS, neonatal distress rate and perinatal mortality rate (PMR) after the CBA. Results. Perinatal morbidity and mortality decreased (16% vs. 8.8%; p=0.01) for the OL group. The likelihood of CS increased for nulliparous, singleton, breech, term pregnancies (Robson group 6) (adjusted odds ratio (aOR) 5.2, 95% confidence interval (CI); 1.4-19) and singleton, preterm pregnancies (Robson group 10) (aOR 1.6, 95%CI; 1.4-2.0). Similarly, the overall likelihood of CS increased (aOR 1.1, 95%CI; 1.1-1.2). The neonatal distress rate decreased for multiparas (excluding previous CS), singleton, term pregnancies (Robson group 3) (aOR 0.76, 0.62-0.95) and singleton, preterm pregnancies (aOR 0.30, 95%CI; 0.25-0.36). The singleton, preterm pregnancies also had a decreased PMR (aOR 0.58, 95%CI; 0.46-0.78). The overall neonatal distress and PMR were comparable before and after the CBA process. Conclusion: With the use of Robson classification we could demonstrate that CBA is a feasible and reliable tool that improved perinatal outcome of OL and optimized benefits of CS in relatively high- and low-risk pregnancies.

Keyword [en]
Cesarean section, criteria-based audit, fetal distress, obstructed labour, low resource setting, Robson classification
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-319055OAI: oai:DiVA.org:uu-319055DiVA: diva2:1086008
Available from: 2017-03-31 Created: 2017-03-31 Last updated: 2017-03-31
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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