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

Abstract

BackgroundIn 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.MethodsDuring 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.ResultsIn 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.ConclusionThe criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.

Use of a criteria‐based audit to optimize uptake of cesarean delivery in a low‐resource setting

“…after implementation of audit‐feedback recommendations) was conducted from July 1 to December 30, 2015. Two main sources of information were used in the present study: previously published CBA data from MNH and the MNH obstetric database (2013–2016).…”

“…Using Epi Info version 7 (CDC, Antanta, Georgia, USA), the minimum required sample size for CBA was calculated based on the number deliveries at MNH in 2012 (n=110 433), with a cesarean delivery rate of 49% . The minimum required sample size for baseline CBA of obstructed labor was 256, assuming that 767 had undergone cesarean delivery.…”

“…Therefore, the minimum sample size for baseline CBA of fetal distress was 248. To detect a 10% improvement in care, 250 parturients were required for re‐audit . Patients with obstructed labor and fetal distress were conveniently sampled by selecting eligible participants until the required sample size was reached.…”

“…Patients with obstructed labor and fetal distress were conveniently sampled by selecting eligible participants until the required sample size was reached. The sample size of studied patients with obstructed labor and fetal distress were predetermined from the previously published studies . Participants with both obstructed labor and fetal distress were included in the obstructed labor group.…”

“…Inadequate emergency obstetric and neonatal care (EmONC) during delivery and within the first 48 hours after delivery is an appreciable contributor to substandard care in both rural and urban health facilities in Tanzania . Other factors include non‐evidence‐based obstetric practice, limited skills and use of vacuum extraction, poor organization and teamwork among staff during care, and substandard management before cesarean delivery …”