Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania

Andrew H Mgaya; Hussein L Kidanto; Lennarth Nystrom; Birgitta Essén

doi:10.1371/journal.pone.0166619

Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania

PLoS One. 2016 Nov 28;11(11):e0166619. doi: 10.1371/journal.pone.0166619. eCollection 2016.

Authors

Andrew H Mgaya^{1

2}, Hussein L Kidanto^{2

3}, Lennarth Nystrom⁴, Birgitta Essén²

Affiliations

¹ Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania.
² Department of Women's and Children's Health/International Maternal and Child Health, Uppsala University, Uppsala, Sweden.
³ Reproductive and Child Health section, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania.
⁴ Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden.

Abstract

Objective: In low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting.

Methods: A baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit.

Results: Two hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01).

Conclusion: A criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.

MeSH terms

Adult
Cesarean Section
Female
Follow-Up Studies
Health Surveys
Humans
Labor, Obstetric*
Medical Audit*
Pregnancy
Referral and Consultation
Standard of Care
Tanzania
Young Adult

Grants and funding

All the funding received during this study was used to incur study activities costs. Laerdal Foundation for Acute Medicine funded the costs of stationary and audit criteria setting meetings. The audit evaluation meetings and the feedback workshop was co-funded by Muhimbili National Referral Hospital, Laerdal Foundation for Acute Medicine and the Faculty of Medicine, Uppsala University. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.