The Value Of Staff Meetiings To Discuss Perinatal Morbidity And Mortality

THE VALUE OF STAFF MEETINGS TO DISCUSS PERINATAL MORBIDITY AND MORTALITY BY DR. D.O. ALLAGOA

THE CONCEPT OF AUDIT In its original sense, audit implies a critical review of events, particularly economic events.

It has been DEFINED: As a numerical review by an outside investigator directed at among other things, the prevention of fraud.

Clinical audit does not aim at the prevention of fraud but rather at detecting mismanagement and the avoidability of adverse out comes of clinical management.

Clinical audit can rightly be considered an action – orientated research, aimed at putting findings into operation in order to correct mismanagement and to improve norms with a focus on avoidability issues.

PERINATAL MORTALITY AUDIT VERSUS PERINATAL CARE AUDIT.

PERINATAL MORTALITY AUDIT Audit used for reviewing deaths and events related to fatal development of certain morbidities.

PERINATAL CARE AUDIT Audit aimed at reviewing existing ward routines Nursing care principles and adherence to norms for referral of severely ill cases. Also at looking at “near misses”.

AUDIT IN OBSTETRICS Aims at  Monitoring mortality rates is one of the most basic ways of checking the effectiveness of a clinical service. 

Rates of intervention



Non fatal adverse outcome



Satisfaction among women



Long-term health outcomes of interventions.

Note In developing countries maternal and perinatal mortality rates are the main indicators of the quality of maternity services, a measure of reproductive loss in any community and it serves as an indicator of women’s health status.

DEFINITION OF TERMS 

Perinatal deaths

All still births, plus deaths in the first week after birth. 

Still birth:

This is any foetus born with no signs of life after 24 weeks gestation. This definition was changed in 1992 before this time only death after 28 weeks gestation were included. 

Early neonatal death

This denotes death in the first week after birth.

PERINATAL MORTALITY RATE (PMR) Perinatal mortality is the total number of still births and deaths occurring during the first week of life per 1000 live births.

The gestational age and the fetal weight at birth recognized as still birth varies in different regions of the world. Whilst 28 weeks and above or fatal weight of 700g and above is accepted in developing countries, twenty weeks gestation or fatal weight of 500g and above is recognized as still birth in developed countries.

Note LATE NEONATAL DEATH: Death from age 7 days to 27 completed days of life.

POST NEONATAL DEATH Death at age 28 days and over but under one year. These are not part of perinatal mortality.

GLOBAL PICTURE World Health Organization: Data for world perinatal mortality rate is 53 per 1000 births. For

advanced countries

11 per 1000 births

For

developing countries

57 per 1000 births

North America

-

9 per 1000 births

Europe

-

13 per 1000 births

Latin America

-

39 per 1000 births

Caribbean countries

-

39 per 1000 births

Asia

-

55 per 1000 births

Africa

-

75 per 1000 births

PERINATAL MORTALITY IN AFRICA In Nigeria PMR Between 90 and 120 per 1000 deliveries Algeria Benin Republic

14 -

No data

Burkina faso

62

Cameroon

38

Congo

54

Ethiopia

68

Gambia

46

Guinea Bissau

52

Lesotho

63

Madagascar

25

Mauritius

29

Namibia

21

Senegal

183

Sudan

43

South Africa

45

Sierra-leone

97

Togo

78

PERINATAL MORTALITY IN NIGERIA Benincity

57 per 1000

Ibadan

98 per 1000

Ilorin

60 per 1000

Lagos

46 per 1000

Ile-Ife

54 per 1000

Sokoto

131 per 1000

Zaria

86 per 1000

Uyo

57 per 1000

Port Harcourt

1991

90 per 1000

2004

34.7 per 1000

REASONS FOR DEATHS  Reasons for these deaths differ from country to country but include.  Lack of access to contraception  Lack of primary care or transport facilities  Lack of electricity  Inadequate water supply  Economic hardship  Poor communication facilities  Race  Poor nutrition  Unfavourable cultural practices  Religious beliefs  Exposure to toxins.  Age <16yrs >35yrs.  Best perinatal outcome is obtained in mothers between 2o and 24 years of age.

Obstetric/Medical Conditions DEVELOPING 

Prolonged obstructed labour



Anaemia and malnutrition



Hypertensive disease of pregnancy



Haemorrhage (Antepartum Haemorrhage).



Diabetes mellitus in pregnancy

 Birth trauma (CPD, macrosornia, shoulder dystocia, prolonged or difficult labour/precipitous delivery/abnormal presentation and instrumental delivery 

Infections



Prematurity



IUGR

 Intrapartum asphyxia, (prolonged cord, abruption placenta, intrapartum bleeding from placental praevia, post maturity prolonged obstructed labour, breech delivery, congenital malformation Post maturity Maternal disease eg malaria, sickle cell disease.

DEVELOPED COUNTRIES 

Prematurity

 Congenital malformation 

Antepartum fetal death



Birth asphyxia

OTHER REASONS FOR STAFF AUDITING 

Out dated knowledge



Inadequate skills



Scarcity of Health Care Providers



Over crowding



Inadequate hygiene



Lack of essential medicines, supplies and equipment.

CRITICAL INCIDENT REPORTING OR PERINATAL MORTALITY MEETINGS.  For many years it has been standard practice for hospitals to hold perinatal mortality meeting to review cases or perinatal death.  Clinical features and the pathological findings are examined and the implication for management of similar cases are discussed.  If audit meetings are too infrequent the staff involved tend to forget about details, findings and circumstances important for the correct interpretation of the events. 

The mailbox Syndrome:

 Crucial information are mailed to regional data collation centers instead of locally from where they are generated for enhancement of quality care.



Audit sessions should focus on



Deaths



Near misses



Twin deliveries.



Post partum haemorrhage



Eclamptic



Convulsions



Caesarean sections



Asphyxiated newborns



Knowledge content/skills



Infrastructure



Equipment etc.

PRERQUISITES FOR PERINATAL AUDIT Since audit ultimately aims at analyzing avoidability, mismanagement, it thus appears threatening to staff involved. Hence it is important that clinical audit is carried out as an internal activity. 

Emphasis on local control.

 Reasonably ambitious and an achievable objectives should be set. 

Emphasis on the value of present and past practices.



Identification of current review activities.



It should not produce anxiety and tachycardia.



It should not be threatening to any one present.



Have a process of feedback of data to staff.



Sustainability of the feedback system is also important.

 Privacy, confidentiality, informed choice, concern, empathy, honesty, tact and sensitivity.  Successful audit – routine is dependent on a competent chairperson.  The most important prerequisite is the competence of the perinatal team. 

A good audit spirit is crucial for maintenance of quality and for

PROBLEMS IN PERINATAL STAFF AUDIT N/B Audits can be confidential or non confidential.  Those who feel threatened by audit may resist sharing information or block progress. 

Some may seek attention from the group by being aggressive towards others.

 Other members of the audit team may try to focus proceedings upon their particular interest.  Those who feel anxious in the group meetings may with draw or divert attention towards other topics. 

Some devalue others expertise and work practices.



Reject others ideas and proposals without acknowledging their value.



Blame or intimidate others



Distract discussions into personal interest or previously discussed issues.



Encourage conflict between others.

 These issues if not properly handled will reduce motivation of staff and fragment the entire group.

CONCLUSION  A key part of reducing antepartum and intrapartum still births will be the presence of senior staff on labour wards and the appointment, of more consultants and their active involvement in management of parturient.  More involvement of senior staff in terms of number in monitoring and delivery of babies.  Perinatal mortality audit can reduce perinatal mortality if properly handled.  Improvement of knowledge and skill will ultimately improve perinatal outcome.