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The most common causes of pulmonary edema are the use of tocolytic agents, underlying cardiac disease, fluid overload, and preeclampsia.

Maternal and newborn mortality were reduced in a low-resource setting when appropriate models for continuous quality improvement were developed and employed.

A structured program of education and quality improvement led to an increase in the use of regional anesthesia for vaginal and cesarean deliveries. Achievements were sustained during periods of economic and political turmoil.

Topics: Systems-based Practice, Obstetric Complications R educing maternal mortality has been a challenge in Africa, mostly because of the disparity between known best practices and the availability of and access to care. Few collaborative efforts to improve health care quality have been undertaken in low-resource countries. Some quality improvement (QI) studies show positive results and the effects of QI are unpredictable. Kybele is a nonprofit humanitarian organization founded in 2001 to promote safe childbirth worldwide through collaboration; its teams include nurses, midwives, engineers, public health practitioners, organizational specialists, and physicians in obstetrics, anesthesia, and neonatology. In 2007, Kybele and the Ghana Health Service created a partnership to analyze systems and patient care processes at a regional hospital in Accra, Ghana. This study was undertaken to provide evidence on the effectiveness of a hospital-based QI collaboration in a low-resource country.The Kybele model employed a process map that tracked continuous assessment, implementation, advocacy, outputs, and outcomes. Problems were identified, solutions were recommended, and progress on improving the problems were tracked using a numeric correlated color-coded scoring system. The primary outcomes that were measured to examine effectiveness of the process included maternal and perinatal mortality and case fatality rates (CFRs) for hemorrhage and hypertensive disorders. The model identified 5 key outputs that were also measured: appropriate referrals, patient monitoring, standardized treatments, timely interventions, and improved client responsiveness as determinants of high-quality and primary outcomes. Key areas for improvement were grouped into "bundles" based on personnel, systems management, and service quality. Implementation and outcomes were evaluated triannually between 2007 and 2009.The leadership skills of obstetricians and key midwives were improved by coaching by team members and by employing a consultant who emphasized effective delegation and continuous QI methods, and provided feedback to the leadership. Corrective measures were undertaken to improve morale, motivation, and empowerment among the frontline staff; these included annual midwifery awards, dinner meetings, sponsorships to study at US hospitals, commendations, and positive debriefings. Numerous training modules were developed and used for neonatal resuscitation, obstetric ultrasound, and evidence-based management of obstetric complications. Poor patient flow and ineffective triage were identified and evidence-based guidelines for routine and complicated patient care were created. Needed equipment was either purchased or solicited by donations. Patient satisfaction was addressed and promoted through the right to respect, privacy, emotional support, pain relief, communication, and timely access to care. Improvements in communication enhanced cooperative efforts among the obstetric caregivers and departments. Collaboration with regional facilities was al...

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