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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
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).
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 [en]
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: urn:nbn:se:uu:diva-319192ISBN: 978-91-554-9890-0 (print)OAI: oai:DiVA.org:uu-319192DiVA: diva2:1086307
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
List of papers
1. Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting
Open this publication in new window or tab >>Fear, Blame And Transparency: Obstetric caregivers' rationales for high caesarean section rates in a low-resource setting
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2015 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 143, 232-240 p.Article in journal (Refereed) Published
Abstract [en]

In recent decades, there has been growing attention to the overuse of caesarean section (CS) globally. In light of a high CS rate at a university hospital in Tanzania, we aimed to explore obstetric caregivers' rationales for their hospital's CS rate to identify factors that might cause CS overuse. After participant observations, we performed 22 semi-structured individual in-depth interviews and 2 focus group discussions with 5-6 caregivers in each. Respondents were consultants, specialists, residents, and midwives. The study relied on a framework of naturalistic inquiry and we analyzed data using thematic analysis. As a conceptual framework, we situated our findings in the discussion of how transparency and auditing can induce behavioral change and have unintended effects. Caregivers had divergent opinions on whether the hospital's CS rate was a problem or not, but most thought that there was an overuse of CS. All caregivers rationalized the high CS rate by referring to circumstances outside their control. In private practice, some stated they were affected by the economic compensation for CS, while others argued that unnecessary CSs were due to maternal demand. Residents often missed support from their senior colleagues when making decisions, and felt that midwives pushed them to perform CSs. Many caregivers stated that their fear of blame from colleagues and management in case of poor outcomes made them advocate for, or perform, CSs on doubtful indications. In order to lower CS rates, caregivers must acknowledge their roles as decision-makers, and strive to minimize unnecessary CSs. Although auditing and transparency are important to improve patient safety, they must be used with sensitivity regarding any unintended or counterproductive effects they might have.

Keyword
Tanzania; Caesarean section; Low-resource setting; Attitudes; Caregivers; Transparency
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-238477 (URN)10.1016/j.socscimed.2015.09.003 (DOI)000364245600027 ()26364010 (PubMedID)
Funder
Swedish Research Council
Available from: 2014-12-15 Created: 2014-12-12 Last updated: 2017-03-31Bibliographically approved
2. 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
Open this publication in new window or tab >>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
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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.

National Category
Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-307491 (URN)10.1186/s12884-016-1137-z (DOI)000387607600003 ()27825311 (PubMedID)
Available from: 2016-11-16 Created: 2016-11-16 Last updated: 2017-03-31Bibliographically approved
3. Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania
Open this publication in new window or tab >>Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania
2016 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 11, e0166619Article in journal (Refereed) Published
Abstract [en]

Objective In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting. Methods A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit. Results Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01). Conclusion A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.

National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-312977 (URN)10.1371/journal.pone.0166619 (DOI)000389472400035 ()27893765 (PubMedID)
Note

Contributed equally to this work with: Andrew H. Mgaya, Hussein L. Kidanto, Lennarth Nystrom, Birgitta Essén

Available from: 2017-02-10 Created: 2017-02-10 Last updated: 2017-03-31Bibliographically approved
4. Optimizing the use of cesarean section in a low resource setting: Criteria-Based Audit at a tertiary referral hospital in Tanzania.
Open this publication in new window or tab >>Optimizing the use of cesarean section in a low resource setting: Criteria-Based Audit at a tertiary referral hospital in Tanzania.
(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
Cesarean section, criteria-based audit, fetal distress, obstructed labour, low resource setting, Robson classification
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-319055 (URN)
Available from: 2017-03-31 Created: 2017-03-31 Last updated: 2017-03-31

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