Clinical audit to enhance safe practice of skilled birth attendants for the fetus with nuchal cord: evidence from a refugee and migrant cohort

Abstract

BackgroundCurrent evidence for optimal management of fetal nuchal cord detected after the head has birthed supports techniques that avoid ligation of the umbilical cord circulation. Routine audit found frequent unsafe management of nuchal cord by skilled birth attendants (SBAs) in migrant and refugee birth centres on the Thai-Burmese border.MethodThe audit cycle was used to enhance safe practice by SBA for the fetus with nuchal cord. In the three birth centres the action phase of the audit cycle was initially carried out by the doctor responsible for the site. Six months later a registered midwife, present six days per week for three months in one birth facility, encouraged SBAs to facilitate birth with an intact umbilical circulation for nuchal cord. Rates of cord ligation before birth were recorded over a 24 month period (1-July-2011 to 30-June-2013) and in-depth interviews and a knowledge survey of the SBAs took place three months after the registered midwife departure.ResultsThe proportion of births with nuchal cord ligation declined significantly over the four six monthly quarters from 15.9% (178/1123) before the action phase of the audit cycle; to 11.1% (107/966) during the action phase of the audit cycle with the doctors; to 2.4% (28/1182) with the registered midwife; to 0.9% (9/999) from three to nine months after the departure of the registered midwife, (p < 0.001, linear trend). Significant improvements in safe practice were observed at all three SMRU birth facilities. Knowledge of fetal nuchal cord amongst SBAs was sub-optimal and associated with fear and worry despite improved practice. The support of a registered midwife increased confidence of SBAs.ConclusionThe audit cycle and registered midwife interprofessional learning for SBAs led to a significant improvement in safe practice for the fetus with nuchal cord. The authors would encourage this type of learning in organizations with birth facilities on the Thai-Burmese border and in other similar resource limited settings with SBAs.

A tool to improve competence in the management of emergency patients by rural clinic health workers: a pilot assessment on the Thai-Myanmar border

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“…As the aim was to improve competence in assessment and management, previous training tools involving clinical skills and past experiences at SMRU were discussed regarding their advantages and disadvantages [ 15 , 16 ]. Several of the physicians had attended various emergency courses in developed countries and certain aspects of these courses were discussed.…”

Strategies for the prevention of perinatal hepatitis B transmission in a marginalized population on the Thailand-Myanmar border: a cost-effectiveness analysis

“…Mae La refugee camp grew significantly in 1995–6 after additional conflict led to the merger of Shoklo, Bono Klo, Mae La and several other smaller camps. The population at the time of this analysis included an estimated 45,000 refugees [ 32 ]. Approximately 5–10% of those who attend the clinic at Mae La refugee camp are migrants or Karen minorities from surrounding villages [ 31 ].…”

“…Significant encouragement by clinic staff and free service provision has reduced home birth to 10–15% [ 34 ]. Women who deliver at the clinic are cared for by locally trained skilled birth attendants who can administer vaccinations and will refer women for caesarean sections at Thailand public hospitals if required [ 32 , 34 ]. Care at the clinic is free and basic public health programmes including routine vaccinations are supported in part by external agencies, including the Thailand Department of Public Health.…”

Audit of the quality of medical care as a way to improve the efficiency of medical organizations

“…Нередко про-водимые в таких условиях аудиты имеют низкую эффек-тивность [66][67][68][69][70][71][72].…”