Your Name / Leviticus Daniel
Date of audit / January to September 2012
Location where audit took place / Nkhotakota District Hospital (maternity and antenatal departments)
A CLINICAL AUDIT ON NEONATAL DEATHS, FRESH STILLBIRTHS DUE TO BIRTH ASPHYXIA AND FETAL DISTRESS
AUDIT AIMS
MAIN OBJECTIVE
  • To reduce neonatal deaths, fresh stillbirths due to birth asphyxias and fetal distress in Nkhotakota district health facilities.
INITIAL AUDIT SPECIFIC OBJECTIVES
  • To find out how big is neonatal deaths and fresh stillbirths due to birth asphyxia and fetal distress in Nkhotakota labour wards.
  • To detect major contributing factors to increasing birth asphyxia neonatal deaths and fetal distress fresh stillbirths.
  • To set standards and make recommendations against contributing factors to these deaths and let midwives, clinicians and community follow them for improvement.
  • To re-audit after 3 months and see if the established standards are improving health care quality to pregnant mothers in labour and if so sustain them.
RE-AUDIT SPECIFIC OBJECTIVES
  • To find out if the recommendations set in the first audit were successful.
  • To measure the gap between the current practice and the practice after introducing the audit standards (if there is any improvement in patient care).

OVERVIEW SUMMARY OF THE AUDIT
The World Health Organization (WHO) defines birth asphyxia as the failure to initiate and sustain breathing at birth and fetal distressis used to describe the signs that the baby is unwell or is not coping with demands of labour evaluated by fetal heart rate, meconium, and fetal stools in amniotic fluid. The initial audit was done in the month of January-March 2012 following data collection and analysis of 05 December 2010 to 05 December 2011. The standards were formulated from clinical guidelines in order to deal with the proposed factors to increased fresh stillbirths and birth asphyxia neonatal deaths in our district. The causes in this audit have been divided into hospital and community contributions to fresh stillbirths and birth asphyxia neonatal deaths. In order to make the attainment of standards easier the recommendations were made and some were implemented others are being implemented. This clinical audit was conducted noting that the increased number of fresh still birth and neonatal deaths due to birth asphyxia in our district. The data was collected in order to have base line data on current practice in quality of care and how big was the problem. The WHO treatment guidelines and Malawi Government Reproductive Health Treatment guidelines were used to find particular standards to improve quality of care. Five Standards were proposed which were thought could bring a change if their attainment successful. A number of recommendations were set to help attain the standards. The current practice was measured using improvement indicators against standards and results were compiled for comparison with re-audit findings.
The initial audit results, proposed standards and recommendations were presented to Nkhotakota District Hospital staff members and management team for their contribution and participation in this audit activity and it was successful. The period of 3months (April-June) allowed to pass for implementation of change. The re-audit was done in July-September 2012 to assess the progress and results again compared to standards. Interpretation of results was done in relation to the initial audit results and there was a significant improvement.
Challenges met were: difficulties to fully involve the health centers in an audit activity due to fuel shortages at our hospital. Most of the times we don’t have transport even for patients’ referrals from health centers. Frequent staff wards rotations, frequent transfer out of productive staff members and in of new staff members which pull back ward performance when the department is full of new staff for some time. The district nursing officer involvement in the audit activity will solve the staff rotation problems so that the ward (maternity) should not be full of new staff at any point in time.
SUMMARY OF FINDINGS
Findings in this audit really showed that a clinical audit improves quality of care to patients. The wide gaps between standards and current practice and those of re-audit results are good reasons to have hope for quality care improvement using an audit tool. See the table below for main findings:
Table C; Showing retrospective and prospective results of the audit.
STANDARDS / Initial score
(Current practice) / Score after introducing standards (Re-audit results)
Monitor fetal heart every 30 minutes during labour as per partograph / 4/40=10% / 26/40=65%
Preparation in advance of newborn resuscitation equipment in delivery room. / 2 out of 6 nurses=33% / 10/10 nurses=100%
Initiate resuscitation within a minute of delivery and close monitoring
to the baby after resuscitation. / 2/10=20% / 10/10=100%
Clinician must ideally attend to obstetric emergency within
30 minutes after being called. / 0/10=0% / 10/10=100%
Antenatal clinic health talk/counseling about dangers and possible
Outcome of a baby on homemade medicine use and home delivery on daily basis (to every woman). / 1 nurse of 4 talked about it in 10 days assessment=25% / 5 nurses out of 6 always find a chance to talk about this=83%
CLINICAL GUIDELINES
This audit is relevant to clinical guidelines. Different but significant Obstetric books and manuals accepted in Malawi and recommended by WHO were used. All standards proposed were according to the guidelines recommendations in dealing with a particular contributing factor to the fresh stillbirths and birth asphyxia neonatal deaths. The guidelines were followed in whole but were applied to suit our setting without changing anything. Some ideas in this audit report were observations from actual practice of staff and community, collected data and analyzed which might be specific in our area (Nkhotakota). The guide lines which were used and their version number have been outlined below.
There was a wish to include some knowledge and information accessed through internet but was not possible due problems in accessing the internet. I thought of depending on internet books but due to financial problems many needed more airtime to download them. I am planning to buy my own laptop to minimize this and I think will solve a number of problems in accessing information. Still I did it using the literature I managed to find and I think are relevant materials. The following are reference materials used:
REFERENCES
  1. Maternity Delivery Registers and Patients case files, Nkhotakota DHO (05/12/10 to 05/12/11): figures neonatal deaths, fresh still births and contributing factors.
  2. HMIS data Nkhotakota DHO 05/12/10 to 05/12/11: figures of neonatal deaths and fresh still birth both district hospital and health centers.
  3. HMIS, DIP Report Nkhotakota DHO 2011/2012: On Nkhotakota neonatal mortality rate and suggested associating factors.
  4. MDHS, 2010: on neonatal mortality rate in Malawi and suggested associating factors
  5. of stillbirth and perinatal mortality and their associated factors: antenatal care is very important.
  6. (i) WHO and Department of Reproductive Health and Research; Integrated Management of Pregnancy and Childbirth, Managing complications in Pregnancy and Child Birth. A guide for mid wives and doctors. C-65 Using the partograph.
(ii)WHO and Department of Reproductive Health and Research; Integrated Management of Pregnancy and Childbirth, Managing complications in Pregnancy and Child Birth. A guide for mid wives and doctor. C-1, Rapid initial patient Assessment.
  1. World Health Organization. Life Saving Skills Manual .Essential Obstetric and Newborn care. Revised 2007. (a) Neonatal resuscitation, pages 10-14 (b) partograph P. 105.
  2. (i)Advanced Life Support in Obstetrics 4th Edition, Part 1 & 2. Neonatal resuscitation: E: intrapartum fetal surveillance. A: Pathophysiology of neonatal cardiorespiratory depression at birth. B: equipment needed for neonatal resuscitation. C: initial stabilization & evaluation of new born.
(ii): World Health organization. Second edition, integrated management of pregnancy & Child Birth.-Pregnancy, Childbirth, postpartum & New born Care. A guide for essential practice.(a) C14 ;Develop a birth and & emergency plan.(b) K 11; New born resuscitation should start within a minute.
(iii): Helping Babies Breathe Learner work book 2010 by American Academy of Pediatrics; Page 8, Preparing for a birth.
  1. (i) The Merck Manual of Medical Information, Home Edition. Chapters 247-249. Labour and delivery (a) drug use during pregnancy: drugs used during labour and delivery (b) dangers on home delivery (c) Complications of labour & delivery: abnormal heart rate.
(ii): World Health Organization; Second edition, Integrated Management of Pregnancy & Child Birth. -pregnancy, child birth, postpartum & newborn Care. Essential guide for practice. C18. Advise not to use local medications to hasten labour.
(iii):WHO: Malawi Government, Ministry of Health. Focused Antenatal care and Prevention of Malaria June 2006. P40 Health Education, Avoidance of potentially harmful substances.
  1. Moldenhauer 2008: definition of fetal distress.
  2. Malawi Ministry Of Health national Reproductive health Standards:
(i)Area 2.(a) SS.1, (b)SS.2,(c) SS.11, (d)SS.12, (e)SS.14,(f)SS.18.
(ii)Area 10.(a) SS.12, (b)SS. 16.

A CLINICAL AUDIT REPORT ON NEONATAL DEATHS, FRESH STILLBIRTHS DUE TO BIRTH ASPHYXIA AND FETAL DISTRESS.

MAIN OBJECTIVE

  • To reduce neonatal deaths, fresh stillbirths due to birth asphyxias and fetal distress in Nkhotakota district health facilities.

Basing on data collected and interpreted, Nkhotakota district hospital maternity wards have not been spared from other districts in Malawi on increased neonatal deaths and fresh stillbirths. One of the major causes of this is birth asphyxia which sometimes is secondary to prolonged fetal distress.

INITIAL AUDITSPECIFIC OBJECTIVES

  • To find out how big is neonatal deaths and fresh stillbirths due to birth asphyxia and fetal distress in Nkhotakota labour wards.
  • To detect major contributing factors to increasing birth asphyxia neonatal deaths and fetal distress fresh stillbirths.
  • To set standards and make recommendations against contributing factors to these deaths and let midwives, clinicians and community follow them for improvement.
  • To re-audit after 3 months and see if the established standards are improving health care quality to pregnant mothers in labour and if so sustain them.

RE-AUDIT SPECIFIC OBJECTIVES

  • To find out if the recommendations set in the first audit were successful.
  • To measure the gap between the current practice and the practice after introducing the audit standards (if any improvement in patient care).

INTRODUCTION

The World Health Organization (WHO) defines birth asphyxia as the failure to initiate and sustain breathing at birth and fetal distressis used to describe the signs that the baby is unwell or is not coping with demands of labour evaluated by fetal heart rate, meconium, fetal stools in amniotic fluid10. Due to an increase in number of neonatal deaths and fresh stillbirths in our district (Nkhotakota) I have thoughtitwisetoconductanauditonabovetopic. Basing on data collected from Health Management Information System Office Nkhotakota (HMIS), maternity registers, patients’ case files, safe motherhoodcoordinator, kangaroo mother care coordinatorand many more, babies are losing their lives during labour and soon after birth due to birth asphyxias. The data reveals that from 5th December 2010 to 5th December 2011 we had 24 fresh stillbirths per 1000 live births and 13 neonatal deaths per 1000 live births from different causes2. These were only from health facility deliveries excluding home/traditional birth attendants’ deliveries. According to data collected from maternity registers and patients case files within this mentioned period (excluding health centers) we had about 122 birth asphyxia cases of which 16% of it died1. 81 total fresh stillbirths from both district hospital and health centers about 74% hadpositive fetal heart for some time after admission in labour ward. After collecting and analyzing the above data I proceeded to collect the already existing data to see how big the problem was from existing HMIS reports was.

In Nkhotakota neonatal death rate is at 44 deaths per 1000 live births3.This DIP report includes home delivery neonatal deaths and fresh stillbirths plus hospital delivery deaths. According to this source of data one of the contributing factors is that only a small number of deliveries are conducted by health workers3. By June 2010 only 42% of pregnant women were delivering at health facility the rest at traditional birth attendants3. For the whole country Malawi only 57.1% of pregnant mothers deliver at health facility4.Neonatal deaths and fresh stillbirths is still a challenge countrywide although there is some improvement as compared to the years before 2005. According to Malawi Demographic and health survey (2010) results; there were40 perinatal deaths per 1000 pregnancies and 31 neonatal deaths per 1000 live births country wide4. Taking part in Millennium Development Goal 4, this audit will help to reduce neonatal mortality due to birth asphyxia in our district. Birth asphyxia is a number 2 cause of neonatal deaths, the number 1 being those related to prematurity according to this audit in our health facilities.

In Nkhotakota many women give birth outside health facilities (at traditional birth attendants). The people in this district believe that if they take home made medicine which is denied in health facilities to induce or augment labour they will deliver fast and easy. They indeed develop aggressive uterine contractions before the cervix is favorable for induction and start pushing before full cervical dilatation. Homemade medicine being a substance which has no dosage affect the unborn baby in different ways possibly after crossing the placentae8A 9a. Many end up giving birth to a fresh stillbirth or very asphyxiated baby. After failing to deliver the baby vaginally they go to the hospital where most of the times it’s too late and we find:

  • The already dead fetus inside the uterus with or without ruptured uterus.
  • Severe signs of fetal distress but urgent assisted vaginal delivery possible as a result the baby is born with very low Apgar score, despite effective resuscitation the baby dies.
  • Severe signs of fetal distress no urgent vaginal delivery, taken to theatre for caesarian section only to end up with fresh still birth or very low Apgar score baby who dies despite effective resuscitation. (homemade medicine is one contributing factor to increased caesarian sections at our hospital).
  • Or the already delivered baby some hours ago at traditional birth attendant, brought to the hospital because did not cry after birth but showed some signs of life. It is always too late, the baby is already dead.

Many health facility neonatal deaths and fresh stillbirths occur due to poor quality of care by nurse mid wives and clinicians in addition to those contributed by community. The evidence of this was found on 20 case notes of those ended up in fresh stillbirths and neonatal deaths shown below;

Table: A showing

Factors that contributed to increased neonatal deaths and fresh stillbirths due to birth asphyxia and fetal distress in Nkhotakota health facilities

  • Poor monitoring of fetal condition during labour resulted in late discovery of severe fetal distress.
  • Poor preparation of resuscitation equipment before conducting a baby delivery.
  • Delays in initiating resuscitation of a newborn and conducting it far from delivery room.
  • Delayed action when the problem detected (severe fetal distress) from the time midwife nurse called the clinician to the time the clinician attended to the patient (transport problem / Poor transport system of the hospital and affects much the health center referrals.
  • Tendency of pregnant women in use of homemade medicine for induction/ augmentation of labour.
  • Pregnant mothers’ late reporting to the hospital when in labour and increased home deliveries (TBA).
  • Lack of team work among staff members and poor attitude of staff members.
  • Combination of staff members in postnatal and labour ward which affect quality of services to one department when the other department is very busy.

I decided to investigate in ordertosee what the problem was so that at the end we could setthe relevant recommendations and standards for care quality improvement during antenatal, labour and soon after delivery.

NOTE: In this audit it has been thought wise only to audit:

  • The fresh stillbirths which had positive fetal heart upon admission in our labour ward.
  • Birth asphyxias and fetal distress of term pregnancy (not related to prematurity).

And

Fetal distress has been combined with birth asphyxias because of audit results. Many babies who were diagnosed to have fetal distress during labour, after birth hadasphyxia and to those the action delayed after diagnosis of fetal distress was made were born dead as fresh stillbirths.

METHODS

STUDY SETTING

This criterion based audit was conducted to improve the quality of care in maternity patients in order to reduce perinatal neonatal mortality and morbidity in our hospitals. Nkhotakota is one of the 5 districts in central region of Malawi. Nkhotakota district has a population of more than 300 000 people. There is one district hospital and 18 health centers including mission hospitals which refer their obstetric emergencies to it. A small number of maternity patients prefer to be referred to St Annes mission hospital (paying hospital) which is just at a few kilometers from the district hospital. At this period of an audit the district hospital has two ambulances. Most of the times we use one ambulance or no ambulance to take obstetric emergencies from health centers and to take clinicians on call during weekends, public holidays and nights to attend to these emergencies due to fuel crisis in the country. The transport problem becomes worse when the only existing ambulance escorts emergency case to Kamuzu central hospital and the clinician on call stays far from the hospital. That means the hospital has no ambulance to pick clinician for other emergencies at the hospital. The care in the government hospital of maternity cases is free. There are 4 nurse midwives during the day in labour ward and 3 during the night at this hospital. At least 3 clinical officers are allocated to this ward. One clinical officer covers the department at night, weekends and public holidays. The whole hospital has about 5 clinical officers which rotates in maternity and other departments every 3months. Many reside far from the hospital and their urgent attention to obstetric emergencies is easily affected by transport problems when on call. Other challenges include undedicated nurse midwives and clinicians due to low incomes, lack of resources like drugs, gloves, sutures, intravenous fluids and few resuscitation equipment of a newborn.