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Presentation Outline
Key definitions Audit cycle Uganda country experience Lessons learnt Challenges
KEY DEFINITIONS
Perinatal period surrounding birth, and includes the time from fetal viability of pregnancy up to 7 days of life.
The process of multi-disciplinary, no-fault review of care given to pregnant women, their unborn babies and their neonates after a death occurs with an aim to improve care.
Mortality audit can reduce deaths by up to 30% but only if data are used effectively and clearly linked to action. In 2008, maternal audit was a presidential directive Multifactorial etiology depending on SES, access to health care and quality of that health Care. Sub-optimal obstetric care is responsible for 75% of perinatal deaths in low Income Countries Avoidable causes of death are due simple errors or omissions in basic health care
Re-audit
Game changer
Effective audit
Confidential, no-fault An educational activity Promotes understanding Resource effective Raises standards Promotes change Source of information Peer led and multi-disciplinary ????? Involves patients and community
or improvements on Principles of : Focussing on the data-based problems and burden Focussing on systems and processes Using local data Multi-disciplinary teamwork/collaboration
One PNFP hospital lead introduction of audit but no wide-scale rollout MoH and SC introduced maternal and perinatal audit in a Ugandan district hospital in 2011 with an aim to scale up Trained 30 frontline HWs and support staff Formed a facility-based MPDR committee with a Chairman, Secretary and hospital administrator Formulated a date for the regular mortality review meetings (weekly)
Pilot phase: 20 out of 30 perinatal deaths were thoroughly audited within 3 months Created a file for case summaries and audit notes Recording, tracking and implementation of workable solutions Support supervision and mentorship done including partnering with PNFP hospital Paper-based system converted to electronic data can now be entered on cell phones and compiled centrally
Case summary
Causes of death
Case 1
Case 2
Patient factors
Poor history taking and examination Poor resuscitation skills Lack of knowledge on partograph use No early postnatal review of babies before discharge
Administrative factors
Antenatal records not linking to delivery Irregular requisition and supply of drugs and equipment Stationery not available
ACTIONS IMPLEMENTED
Patient factors
Link with VHT, create demand and knowledge of when to seek care
Continuous Medical Education, e.g. intrapartum care training, partograph refresher Improve targeted supervision
Administrative factors
maternity wards
In-charge was designated to facilitate stocking of drugs Audit endorsed as a routine activity of the hospital and supported by the district
Preliminary changes
Increase in timely caesarean section Improved documentation including history taking, noting time and actions taken Partograph use improved Improved knowledge and skills Administration more responsive Innovative processes to make meetings shorter fewer deaths audited with more concrete actions
Challenges
Fatigue of HWs Staff attrition and loss of audit champions Victimization key to maintain no-blame environment Inadequate utilization of audit data Lack of audit tools Lack of actions for administrative factors
Lessons learnt
Problem must be addressed, not the person Administrator participation is key Tools must be user friendly short, electronic Integrate with maternal near-miss audit Harmonization of ICD causes to identify true causes of death Avoidable factors should be modifiable Successes should also be discussed
Conclusion
Audit is a good starting point for improved quality of care but needs to link to action Mortality audit requires general health systems strengthening (including HMIS) Outstanding research questions:
Sustainable approaches to continuous mortality audit; Effective use of data; Community involvement