PERINATAL AUDITS FOR IMPROVED CARE

Dr Naamala Hanifah Sengendo Save the Children

Global Newborn Conference Johannesburg April 2013

Ministry of Health

Presentation Outline

Key definitions Audit cycle Uganda country experience Lessons learnt Challenges

KEY DEFINITIONS

Audit is a well-described method of systematic, critical analysis of quality of medical care

Perinatal period surrounding birth, and includes the time from fetal viability of pregnancy up to 7 days of life.

Perinatal deaths include stillbirths and early neonatal deaths.

What is Perinatal mortality audit?

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.

Perinatal Mortality Audit

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

THE AUDIT CYCLE

Problem or objective identified Criteria agreed and standards set Audit (Data collected) Identify areas for improvement

Re-audit

Make necessary changes

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

How does mortality audit improve care?

Caregivers are informed of their deficiencies

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

Uganda perinatal audit experience

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)

Audit experience (contd)

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

Perinatal reporting dashboard example

Avoidable factors Action planned By whom By When Comments on pending actions

Case summary

Causes of death

Case 1

Case 2

Major gaps identified through audit leading to avoidable deaths

Patient factors

Delay in deciding to seek care / reaching the health facility

Health worker 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

Health worker factors

Continuous Medical Education, e.g. intrapartum care training, partograph refresher Improve targeted supervision

Administrative factors

Internal organization changes e.g Duty Rota for Drs coverage of

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