TO THE PROJECT MANAGER, ETATMBA PROGRAM, WARWICK UNIVERSITY, UNITED KINGDOM.

Your Name Leviticus Daniel

Date of audit January to September 2012

Location where audit took place

Nkhotakota District Hospital (maternity and antenatal departments)

A CLINICAL AUDIT ON NEONATAL DEATHS, FRESH STILLBIRTHS DUE TO BIRTH ASPHYXIA AND FETAL DISTRESS

AUDIT AIMS

MAIN OBJECTIVE

To reduce neonatal deaths, fresh stillbirths due to birth asphyxias and fetal distress in Nkhotakota district health facilities.

INITIAL AUDIT SPECIFIC OBJECTIVES

To find out how big is neonatal deaths and fresh stillbirths due to birth asphyxia and fetal distress in Nkhotakota labour wards.

To detect major contributing factors to increasing birth asphyxia neonatal deaths and fetal distress fresh stillbirths.

To set standards and make recommendations against contributing factors to these deaths and let midwives, clinicians and community follow them for improvement.

To re-audit after 3 months and see if the established standards are improving health care quality to pregnant mothers in labour and if so sustain them.

RE-AUDIT SPECIFIC OBJECTIVES To find out if the recommendations set in the first audit were successful. To measure the gap between the current practice and the practice after introducing the audit standards

(if there is any improvement in patient care).

OVERVIEW SUMMARY OF THE AUDIT

The World Health Organization (WHO) defines birth asphyxia as the failure to initiate and sustain breathing at birth and fetal distress is used to describe the signs that the baby is unwell or is not coping with demands of labour evaluated by fetal heart rate, meconium, and fetal stools in amniotic fluid. The initial audit was done in the month of January-March 2012 following data collection and analysis of 05 December 2010 to 05 December 2011. The standards were formulated from clinical guidelines in order to deal with the proposed factors to increased fresh stillbirths and birth asphyxia neonatal deaths in our district. The causes in this audit have been divided into hospital and community contributions to fresh stillbirths and birth asphyxia neonatal deaths. In order to make the attainment of standards easier the recommendations were made and some were implemented others are being implemented. This clinical audit was conducted noting that the increased number of fresh still birth and neonatal deaths due to birth asphyxia in our district. The data was collected in order to have base line data on current practice in quality of care and how big was the problem. The WHO treatment guidelines and Malawi Government Reproductive Health Treatment guidelines were used to find particular standards to improve quality of care. Five Standards were proposed which were thought could bring a change if their attainment successful. A number of recommendations were set to help attain the standards. The current practice was measured using improvement indicators against standards and results were compiled for comparison with re-audit findings.

The initial audit results, proposed standards and recommendations were presented to Nkhotakota District Hospital staff members and management team for their contribution and participation in this audit activity and it was successful. The period of 3months (April-June) allowed to pass for implementation of change. The re-audit was done in July-September 2012 to assess the progress and results again compared to standards. Interpretation of results was done in relation to the initial audit results and there was a significant improvement.

Challenges met were: difficulties to fully involve the health centers in an audit activity due to fuel shortages at our hospital. Most of the times we don’t have transport even for patients’ referrals from health centers. Frequent staff wards rotations, frequent transfer out of productive staff members and in of new staff members which pull back ward performance when the department is full of new staff for some time. The district nursing officer involvement in the audit activity will solve the staff rotation problems so that the ward (maternity) should not be full of new staff at any point in time.

SUMMARY OF FINDINGS

Findings in this audit really showed that a clinical audit improves quality of care to patients. The wide gaps between standards and current practice and those of re-audit results are good reasons to have hope for quality care improvement using an audit tool. See the table below for main findings:

Table C; Showing retrospective and prospective results of the audit.

STANDARDS Initial score(Current practice)

Score after introducing standards (Re-audit results)

Monitor fetal heart every 30 minutes during labour as per partograph

4/40=10% 26/40=65%

Preparation in advance of newborn resuscitation equipment in delivery room.

2 out of 6 nurses=33%

10/10 nurses=100%

Initiate resuscitation within a minute of delivery and close monitoringto the baby after resuscitation.

2/10=20% 10/10=100%

Clinician must ideally attend to obstetric emergency within30 minutes after being called.

0/10=0% 10/10=100%

Antenatal clinic health talk/counseling about dangers and possible Outcome of a baby on homemade medicine use and home delivery on daily basis (to every woman).

1 nurse of 4 talked about it in 10 days

5 nurses out of 6 always find a chance to talk

assessment=25% about this=83%

CLINICAL GUIDELINES

This audit is relevant to clinical guidelines. Different but significant Obstetric books and manuals accepted in Malawi and recommended by WHO were used. All standards proposed were according to the guidelines recommendations in dealing with a particular contributing factor to the fresh stillbirths and birth asphyxia neonatal deaths. The guidelines were followed in whole but were applied to suit our setting without changing anything. Some ideas in this audit report were observations from actual practice of staff and community, collected data and analyzed which might be specific in our area (Nkhotakota). The guide lines which were used and their version number have been outlined below.

There was a wish to include some knowledge and information accessed through internet but was not possible due problems in accessing the internet. I thought of depending on internet books but due to financial problems many needed more airtime to download them. I am planning to buy my own laptop to minimize this and I think will solve a number of problems in accessing information. Still I did it using the literature I managed to find and I think are relevant materials. The following are reference materials used:

REFERENCES

1. Maternity Delivery Registers and Patients case files, Nkhotakota DHO (05/12/10 to 05/12/11): figures neonatal deaths, fresh still births and contributing factors.

2. HMIS data Nkhotakota DHO 05/12/10 to 05/12/11: figures of neonatal deaths and fresh still birth both district hospital and health centers.

3. HMIS, DIP Report Nkhotakota DHO 2011/2012: On Nkhotakota neonatal mortality rate and suggested associating factors.

4. MDHS, 2010: on neonatal mortality rate in Malawi and suggested associating factors5. http://www.biomedcentral.com/1471-2393/59- incidence of stillbirth and perinatal mortality and their

associated factors: antenatal care is very important.6. (i) WHO and Department of Reproductive Health and Research; Integrated Management of Pregnancy

and Childbirth, Managing complications in Pregnancy and Child Birth. A guide for mid wives and

doctors. C-65 Using the partograph.(ii)WHO and Department of Reproductive Health and Research; Integrated Management of Pregnancy and Childbirth, Managing complications in Pregnancy and Child Birth. A guide for mid wives and doctor. C-1, Rapid initial patient Assessment.

7. World Health Organization. Life Saving Skills Manual .Essential Obstetric and Newborn care. Revised 2007. (a) Neonatal resuscitation, pages 10-14 (b) partograph P. 105.

8. (i)Advanced Life Support in Obstetrics 4th Edition, Part 1 & 2. Neonatal resuscitation: E: intrapartum fetal surveillance. A: Pathophysiology of neonatal cardiorespiratory depression at birth. B: equipment needed for neonatal resuscitation. C: initial stabilization & evaluation of new born.(ii): World Health organization. Second edition, integrated management of pregnancy & Child Birth.-Pregnancy, Childbirth, postpartum & New born Care. A guide for essential practice.(a) C14 ;Develop a birth and & emergency plan.(b) K 11; New born resuscitation should start within a minute.(iii): Helping Babies Breathe Learner work book 2010 by American Academy of Pediatrics; Page 8, Preparing for a birth.

9. (i) The Merck Manual of Medical Information, Home Edition. Chapters 247-249. Labour and delivery (a) drug use during pregnancy: drugs used during labour and delivery (b) dangers on home delivery (c) Complications of labour & delivery: abnormal heart rate.(ii): World Health Organization; Second edition, Integrated Management of Pregnancy & Child Birth. -pregnancy, child birth, postpartum & newborn Care. Essential guide for practice. C18. Advise not to use local medications to hasten labour.(iii):WHO: Malawi Government, Ministry of Health. Focused Antenatal care and Prevention of Malaria June 2006. P40 Health Education, Avoidance of potentially harmful substances.

10. Moldenhauer 2008: definition of fetal distress.11. Malawi Ministry Of Health national Reproductive health Standards:

(i)Area 2.(a) SS.1, (b)SS.2,(c) SS.11, (d)SS.12, (e)SS.14,(f)SS.18.(ii)Area 10.(a) SS.12, (b)SS. 16.

A CLINICAL AUDIT REPORT ON NEONATAL DEATHS, FRESH STILLBIRTHS DUE TO BIRTH ASPHYXIA AND FETAL DISTRESS.

MAIN OBJECTIVE

To reduce neonatal deaths, fresh stillbirths due to birth asphyxias and fetal distress in Nkhotakota district health facilities.

Basing on data collected and interpreted, Nkhotakota district hospital maternity wards have not been spared from other districts in Malawi on increased neonatal deaths and fresh stillbirths. One of the major causes of this is birth asphyxia which sometimes is secondary to prolonged fetal distress.

INITIAL AUDIT SPECIFIC OBJECTIVES

To find out how big is neonatal deaths and fresh stillbirths due to birth asphyxia and fetal distress in Nkhotakota labour wards.

To detect major contributing factors to increasing birth asphyxia neonatal deaths and fetal distress fresh stillbirths.

To set standards and make recommendations against contributing factors to these deaths and let midwives, clinicians and community follow them for improvement.

To re-audit after 3 months and see if the established standards are improving health care quality to pregnant mothers in labour and if so sustain them. RE-AUDIT SPECIFIC OBJECTIVES

To find out if the recommendations set in the first audit were successful. To measure the gap between the current practice and the practice after introducing the

audit standards (if any improvement in patient care).

INTRODUCTION

The World Health Organization (WHO) defines birth asphyxia as the failure to initiate and sustain breathing at birth and fetal distress is used to describe the signs that the baby is unwell or is not coping with demands of labour evaluated by fetal heart rate, meconium, fetal stools in amniotic fluid10. Due to an increase in number of neonatal deaths and fresh stillbirths in our district (Nkhotakota) I have thought it wise to conduct an audit on above topic. Basing on data collected from Health Management Information System Office Nkhotakota (HMIS), maternity registers, patients’ case files, safe motherhood coordinator, kangaroo mother care coordinator and many more, babies are losing their lives during labour and soon after birth due to birth asphyxias. The data reveals that from 5th December 2010 to 5th

December 2011 we had 24 fresh stillbirths per 1000 live births and 13 neonatal deaths per 1000 live births from different causes2. These were only from health facility deliveries excluding home/traditional birth attendants’ deliveries. According to data collected from maternity registers and patients case files within this mentioned period (excluding health centers) we had about 122 birth asphyxia cases of which

16% of it died1. 81 total fresh stillbirths from both district hospital and health centers about 74% had positive fetal heart for some time after admission in labour ward. After collecting and analyzing the above data I proceeded to collect the already existing data to see how big the problem was from existing HMIS reports was.

In Nkhotakota neonatal death rate is at 44 deaths per 1000 live births3.This DIP report includes home delivery neonatal deaths and fresh stillbirths plus hospital delivery deaths. According to this source of data one of the contributing factors is that only a small number of deliveries are conducted by health workers3. By June 2010 only 42% of pregnant women were delivering at health facility the rest at traditional birth attendants3. For the whole country Malawi only 57.1% of pregnant mothers deliver at health facility4.Neonatal deaths and fresh stillbirths is still a challenge countrywide although there is some improvement as compared to the years before 2005. According to Malawi Demographic and health survey (2010) results; there were 40 perinatal deaths per 1000 pregnancies and 31 neonatal deaths per 1000 live births country wide4. Taking part in Millennium Development Goal 4, this audit will help to reduce neonatal mortality due to birth asphyxia in our district. Birth asphyxia is a number 2 cause of neonatal deaths, the number 1 being those related to prematurity according to this audit in our health facilities.

In Nkhotakota many women give birth outside health facilities (at traditional birth attendants). The people in this district believe that if they take home made medicine which is denied in health facilities to induce or augment labour they will deliver fast and easy. They indeed develop aggressive uterine contractions before the cervix is favorable for induction and start pushing before full cervical dilatation. Homemade medicine being a substance which has no dosage affect the unborn baby in different ways possibly after crossing the placentae8A 9a. Many end up giving birth to a fresh stillbirth or very asphyxiated baby. After failing to deliver the baby vaginally they go to the hospital where most of the times it’s too late and we find:

The already dead fetus inside the uterus with or without ruptured uterus. Severe signs of fetal distress but urgent assisted vaginal delivery possible as a result the

baby is born with very low Apgar score, despite effective resuscitation the baby dies. Severe signs of fetal distress no urgent vaginal delivery, taken to theatre for caesarian

section only to end up with fresh still birth or very low Apgar score baby who dies despite effective resuscitation. (homemade medicine is one contributing factor to increased caesarian sections at our hospital).

Or the already delivered baby some hours ago at traditional birth attendant, brought to the hospital because did not cry after birth but showed some signs of life. It is always too late, the baby is already dead.

Many health facility neonatal deaths and fresh stillbirths occur due to poor quality of care by nurse mid wives and clinicians in addition to those contributed by community. The evidence of this was found on 20 case notes of those ended up in fresh stillbirths and neonatal deaths shown below;

Table: A showing

Factors that contributed to increased neonatal deaths and fresh stillbirths due to birth asphyxia and fetal distress in Nkhotakota health facilities

Poor monitoring of fetal condition during labour resulted in late discovery of severe fetal distress.

Poor preparation of resuscitation equipment before conducting a baby delivery. Delays in initiating resuscitation of a newborn and conducting it far from delivery room. Delayed action when the problem detected (severe fetal distress) from the time midwife nurse

called the clinician to the time the clinician attended to the patient (transport problem / Poor transport system of the hospital and affects much the health center referrals.

Tendency of pregnant women in use of homemade medicine for induction/ augmentation of labour.

Pregnant mothers’ late reporting to the hospital when in labour and increased home deliveries (TBA).

Lack of team work among staff members and poor attitude of staff members. Combination of staff members in postnatal and labour ward which affect quality of services to

one department when the other department is very busy.

I decided to investigate in order to see what the problem was so that at the end we could set the relevant recommendations and standards for care quality improvement during antenatal, labour and soon after delivery.

NOTE: In this audit it has been thought wise only to audit:

The fresh stillbirths which had positive fetal heart upon admission in our labour ward. Birth asphyxias and fetal distress of term pregnancy (not related to prematurity).

And

Fetal distress has been combined with birth asphyxias because of audit results. Many babies who were diagnosed to have fetal distress during labour, after birth had asphyxia and to those the action delayed after diagnosis of fetal distress was made were born dead as fresh stillbirths.

METHODS

STUDY SETTING

This criterion based audit was conducted to improve the quality of care in maternity patients in order to reduce perinatal neonatal mortality and morbidity in our hospitals. Nkhotakota is one of the 5 districts in central region of Malawi. Nkhotakota district has a population of more than 300 000 people. There is one district hospital and 18 health centers including mission hospitals which refer their obstetric emergencies to it. A small number of maternity patients prefer to be referred to St Annes mission hospital (paying hospital) which is just at a few kilometers from the district hospital. At this period of an

audit the district hospital has two ambulances. Most of the times we use one ambulance or no ambulance to take obstetric emergencies from health centers and to take clinicians on call during weekends, public holidays and nights to attend to these emergencies due to fuel crisis in the country. The transport problem becomes worse when the only existing ambulance escorts emergency case to Kamuzu central hospital and the clinician on call stays far from the hospital. That means the hospital has no ambulance to pick clinician for other emergencies at the hospital. The care in the government hospital of maternity cases is free. There are 4 nurse midwives during the day in labour ward and 3 during the night at this hospital. At least 3 clinical officers are allocated to this ward. One clinical officer covers the department at night, weekends and public holidays. The whole hospital has about 5 clinical officers which rotates in maternity and other departments every 3months. Many reside far from the hospital and their urgent attention to obstetric emergencies is easily affected by transport problems when on call. Other challenges include undedicated nurse midwives and clinicians due to low incomes, lack of resources like drugs, gloves, sutures, intravenous fluids and few resuscitation equipment of a newborn.

CLINICAL AUDIT CYCLE

The first audit was done in January to March 2012 after data collection and analysis of neonatal deaths and fresh stillbirths from 5th December 2010 to 5th December 2011. The re-audit was done from July to September 2012. In between the audits the period of 3months was allowed to go (April, May and June) for implementation of changes.

Step 1: Establishment of standards for birth asphyxia neonatal deaths and fresh stillbirths

The Malawi national treatment guidelines (safe motherhood protocols) and World Health Organization manuals were used to establish the recommended standards in management of woman in labour in order to come out with a healthy baby from antenatal, perinatal and postnatal period. After analyzing the data on major contributing factors to these deaths I looked into the important criteria in management of asphyxiated baby and how to monitor and identify fetal distress in labour then the five management criteria guidelines were proposed. Our maternity team of nurse midwives, nurse midwives from other departments, clinicians and some hospital management team members played a very important role and contributed some facts relevant to our treatment guidelines.

STANDARDS

• Monitor fetal condition and plot on partograph every 30 minutes(fetal heart rate). (The provider uses the partograph to monitor labor and make adjustments to care)11ic/6i.

• Prepare for newborn resuscitation before conducting any delivery in our labour ward and resuscitate the new born in the same delivery room. (The provider prepares equipment, supplies and the environment to conduct clean and safe deliveries)11ia.

• Resuscitation efforts have to be started within a minute after delivery, done correctly and the baby should be closely monitored after. (The provider properly conducts a rapid initial

assessment of the newborn and provides immediate resuscitation if needed8iib/11ie.) (The provider properly monitors the newborn in immediate postpartum period)

• The emergency obstetric cases from health centers must not be delayed and clinician must not take more than 30 minutes before attending to maternity emergency after being called. (The facility manager organizes a referral system that keeps tracking of clients transferred to/from other health units)6ii/11iia.

• Community sensitization on dangers of using homemade medicine and home deliveries on outcome of the baby through antenatal clinic health talks/counseling. (The provider properly conducts individualized care based on findings and protocols e.g. Counseling on drug abuse, delivery by skilled birth attendant).9ii/iii

Step 2: MEASUREMENT OF CURRENT PRACTICE It has been highlighted in introduction that there were about 81 fresh stillbirths both from our health centers and district hospital and 19 neonatal deaths from district hospital labour ward alone due to birth asphyxia1. In order to detect contributing factors the following investigations were done:

Monitoring fetal condition during labour every 30 minutes as per partograph: Fetal heart rate is supposed to be monitored every 30 minutes some literatures recommend every 15 minutes but none of the 20 partographs in reviewed fresh stillbirths and asphyxia neonatal deaths case notes was checked every 30 minutes (0%) while other 20 case notes partographs which ended in health babies only 4 partographs out of 20 cases the fetal heart was monitored every 30 minutes (20%). Some were taking 6, 4, 2hours respectively before they were rechecked. The ones suffered the most were those in labour ward during the night, weekends and public holidays and it was found that many neonatal deaths due to birth asphyxias occur during these times.

Preparation of resuscitation equipment in advance before any delivery and in the same delivery room: On initial assessment it was observed from 6 nurse midwives conducting a baby delivery before preparing the equipment for new born resuscitation .Only 2 nurse midwives managed to prepare well for new born resuscitation. After the baby was born and needed resuscitation it was when many nurse midwives were busy looking for equipment which was happening to be in opposite delivery room. This contributed a lot in delays in starting resuscitation. It was also observed that many nurses and midwives were used to resuscitating the new born in nursery room which is at approximately 11 meters from delivery room. Concerning the actual resuscitation procedure many midwives were good at it with minor problems like mixing steps and unnecessary delays that might be collected with repeated teachings in resuscitation of a new born.

Resuscitation has to be started within a minute and close monitoring of the baby after delivery: Out of 10 resuscitation procedures observed only 2 were initiated with knowledge of golden minute importance in newborn resuscitation; otherwise many had un necessary delays. Many clinicians and nurse midwives seemed not aware of importance of a golden minute in

resuscitation of a new born. Cascading a teaching with a practical session to them can solve this problem.

Clinician must not take more than ideally 30 minutes before attending to obstetric emergencies after being called: 10 emergency obstetric case notes were reviewed and it was detected that out of 10 only 3cases were attended to within an hour the rest it took more than an hour before they were seen after the clinician was called by the midwife for help.

Community sensitization on dangers of using homemade medicine and home delivery on possible outcome to the baby: 15 caesarian section patients were provided with a questionnaire to write 1 if took homemade medicine to induce or augment labour or write 0 if no. 10 patients out of 15 accepted to have taken homemade medicine. Out of 15 vaginal deliveries provided with the same questionnaire only 4 of them accepted to have taken homemade medicine. 80 spontaneous vaginal delivery patients’ case files were audited to detect if Pregnant mothers report in labour ward in good time when labour starts. 36 patients out of 80 cases partographs were seen in second stage of labour and after few minutes delivered; some with good Apgar score babies, some asphyxiated babies, some fresh stillbirths. Many pregnant mothers report late to labour ward from traditional birth attendants and home. This means that they go through first stage of labour after taking homemade medicine and no fetal condition monitoring. Antenatal clinic health talks were attended to in order to find out if the issue of homemade medicine use and home delivery was talked about. Only 1 nurse out 4 nurses talked about this in 10 days assessment.

Table: B. Showing measurement of current practice.

STANDARDS Initial score(Current practice)

Score after introducing standards (Re-audit results)

Monitor fetal heart every 30 minutes during labour as per partograph

4/40=10%

Preparation in advance of newborn resuscitation equipment in delivery room.

2 out of 6 nurses=33%

Initiate resuscitation within a minute of delivery and close monitoring to the baby after resuscitation.

2/10=20%

Clinician must ideally attend to obstetric emergency within30 minutes after being called by the midwife.

0/10=0%

Antenatal clinic health talk/counseling about dangers and possible Outcome of a baby on homemade medicine and home delivery on daily basis (to every woman).

1 nurse of 4 talked about it in 10 days assessment=25%

Step 3: Analysis of findings

Performance on current practice was measured against standards and documented in percentage for comparison with the re-audit results. In order to come up with the better results in re-audit results there was a need to come up with reasonable recommendations that will make it possible to attain the standards.

Step 4: Recommendation and implementation of change

The difference between the standards and current practice allowed identification of the gap that had to be filled for improved services to patients. Therefore some recommendations were suggested and presented to nurse midwives, clinicians and hospital management team for suggestions and reconstruction in order to implement the standards. In order to convince the mentioned staff to take part in the audit activity the recommendations were presented as follows:

First the midwives and clinicians were interviewed on why taking this long time intervals in between fetal heart checks instead of every 30 minutes on partograph. This monitoring also reflect the monitoring of post -operative cases BP, PR, PV bleeding, eclampsia cases, monitoring of babies who have been resuscitated successfully after delivery. Everyone on data collecting tool believed that the set-up of Nkhotakota maternity ward was confusing in-terms of staff allocation and therefore was one of the factors:

(A)Combination of postnatal ward and labour ward staff was suggested to be one of the major contributing factors to this problem at our hospital.

(B)Negligence of staff in monitoring and documenting the observations.

Recommendations (A)• If we can allocate staff to labour ward and post natal ward as different but related wards in terms

of staff as it is in other districts, improved quality services can be predicted. • Infection prevention will be of high standard and monitoring of patients both during perinatal

and postnatal period will be of good quality.

But how will that improvement be achieved? Post natal ward staff will organize the ward as theirs and so will do the labor ward staff. The

problem with current setting is that when labour ward is busy affects services in post natal ward because it is the same staff supposed to work there and vice versa.

• There will be regular monitoring of vital signs so neonatal and maternal sepsis , post op complications like PPH, post vaginal delivery complications will be detected earlier by staff on duty but also after being called by guardians to see their patients.

• Post natal ward will have a nurse midwife during the night who will attend to the patients’ problems unlike now when the guardians find it difficult to go to labor ward to complain to

nurses when their patient has a problem. There will be improved documentation in case notes

by staff and this will cover them up if sued or if complaints are raised as it will be easy to defend themselves.

• Labor ward staff will concentrate on managing pregnant mothers in labor and monitoring their condition and that of their unborn babies and comply to prior preparation of resuscitation equipment.

• The labor ward staff will easily address the Infection prevention problem which is currently of very low quality in labor ward due to lack of soap for hand washing, sometimes no delivery packs which leads to midwives using unsterilized instruments for delivery and suturing tears as a result neonatal sepsis cases and deaths will be reduced.

Note 1: It is us who can change this for improved quality services to the patients. Doing this today can allow other babies who would end in FSBs and birth asphyxia related deaths to survive, therefore this is an emergency change.

Can shortage of staff be an excuse?• NO: Shortage of staff is not an excuse. It is just a matter of re-organizing our system at our

institution.

• Labor ward is a factory which manufactures people and our factory is a busy one. Wherever there is maternity ward after delivery whether C/S or SVD, labour ward staff gives the hand over to post natal ward staff who monitor the mother and baby for any complication and it works. Here after delivery the woman and the baby are dumped into post natal ward especially during the night where there is no nurse and the 3 nurses on duty are busy with deliveries in labor ward. No wonder many complications are detected too late than we can save life.

• Recommendation (B): Labor ward staff should make sure that they check and fill in fetal monitoring areas on partographs every 30 minutes, and other vital signs according to Malawi national guidelines protocols11ic. Negligence is not good; remember we vowed to take care of

patients before almighty God. All of us have to be willing to change our attitudes towards improving the quality of services we offer to our patients. Remember this is our responsibility.

• We all have to show leadership spirit in this change. And the DHO, DMO, DNO, Safe motherhood coordinator should make sure that clinicians and nurses know where to find the clinical guidelines where recommended protocols in cases management are found. Many of us just operate on knowledge we got from school but for the clinical guidelines on how we can manage several obstetric cases to meet the required standards we don’t know.

• The DHO, DMO, DNO: there is a need for them to strengthen the polices/clinical guidelines by advising those who are not acting according to the required standards11iib.

All of us have to strengthen the required standards and advise each other when something is wrong BUT remember with respect and no embarrassment to each other.

• Recommendation (C): Resting period by nurse midwives during the night should be reviewed to ensure that monitoring of patients is not compromised. In this study many FSBs and birth asphyxia NNDs occurred during the night.

Recommendation (D): Drivers and transport officer briefing in labor ward on what we mean when we say there is obstetric emergency we need a clinician/anesthetist in labor ward/theater or an ambulance wanted at a certain H/C to pick obstetric emergency11iia.

Recommendation (E): Hospital management team to urgently look into empowering labour ward midwives to directly be in touch with ambulance drivers and control them not through switchboard (telephone operator).

Recommendation (F): Health center obstetric calls to be through both switch board and labour ward staff (this is not very new many hospitals do this). Helps in early preparation for health center emergency obstetric cases management.

Recommendation (G): clinicians on cover, call or during working hours must notify midwives about their whereabouts and must not be very far from the hospital.

Recommendation (H): Hospital management team if it can provide the clinicians lounge/room for resting to keep them within maternity ward after ward round during working hours as it is with other wards at this hospital it might reduce the incidents of nurses struggling to find a clinician to review the patient during working days and hours after ward round.

Recommendation (I): Clinician on call including during the night should be within the hospital compass. There should be a room for clinicians on call to sleep if they live far away, not this system of being picked from home by an ambulance when there is patient for review.

Recommendation (J): Before conducting a delivery nurse midwife must make sure that newborn resuscitating equipment has already been prepared and tested11ia. Maintenance department has to fix our resuscitation equipment including suction machines so that we do not run with asphyxiated babies to nursery for suction wasting baby’s chances to survive.

COMMUNITY CONTRIBUTION

• Recommendation (k): Every pregnant woman in antenatal clinic/ward should be briefly taught the very possible outcome if she will take home made medicine during labor9ii,iii (she might be done C/S or end in FSB both preventable) and dangers of reporting late to labour ward after labour starts.

NOTE: If this can be everyday music to these mothers despite gestational age for we don’t know may be she will not come again to ante natal clinic until delivery may help.

Table C: Key recommendations made, implemented and those in progress during the audit

Labour ward and post natal ward should respectively have different staff and during the night there should be nurses in post natal ward as it is with labour ward and other wards at the hospital= Implemented few days after audit report presentation .

Nurses and clinicians all individually should change their attitudes, they should work to improve health services to patients and improve in documentation of patients’ monitoring=Progressing well.

District health Officer, District Medical officer, District nurses Officer should strengthen the policies/clinical guidelines by making sure their clinicians and nurses know the required clinical guidelines and protocols in managing different obstetric cases, they should kindly advise those workers acting contrary to the required standards=In progress.

Labour ward staff should make sure they monitor their patients according to the required standards on partograph and fill in=Progressing well but with some resistance.

Before conducting any newborn delivery in our labour ward the midwife should make sure has prepared for resuscitation and the equipment is ready, maintenance department should fix our resuscitation equipment urgently =progressing very well, equipment was fixed.

Resting period during the night by nurse mid wives should be revised so that patients monitoring is not compromised =there is good progress.

There should be a sleeping room for Clinicians on call those stay away from the hospital in order to reduce the time it takes to review emergency obstetric cases after being called during the night, weekends and public holidays (Clinician on call must see the patient after being called within 30 minutes)=Done and going on well 3 rooms for second and first on call clinicians the other one for laboratory technician on busy nights were identified and are being used.

Ambulance drivers, hospital cars and health center calls should be handled by labour ward staff during the night, weekends and public holidays=Agreed-done and going on well when fuel is available.

Community/pregnant mothers should be counseled during antenatal

period on every visit about possible outcome of the baby if they will take homemade medicine to induce or augment labour (she might be done C/S or end in ruptured uterus and fresh stillbirth both preventable) and dangers of reporting late to labour ward after labour starts=Progressing well.

Step 5: A re-audit of Standards to assess progress

3 months after the initial audit a re- audit was done to assess the progress. The same investigations as in the first audit were done and results were measured against the standards. Retrospective and prospective results are shown in audit results.

AUDIT RESULTS The results of the initial audit showed wide gaps between current practice and the five standards as follows: Monitoring fetal condition during labour every 30 minutes as per partograph: Initial audit

scored 10% (total score for 4 cases of 40= 10%). Re-audit results showed an improvement to 65% on the similar data collection and analysis.

Preparation of resuscitation equipment in advance before any delivery and in the same delivery room: On initial assessment it was observed from 6 nurse midwives conducting a baby delivery before preparing the equipment for new born resuscitation .Only 2 nurse midwives managed to prepare well for new born resuscitation (33%). After implementing the recommendations and introducing the standards it was assessed on 10 nurse midwives. The re-audit results showed an improvement to 100%.

Resuscitation has to be started within a minute (resuscitation efforts in golden minute) and close monitoring of the baby after resuscitation: Out of 10 newborn resuscitation procedures observed only 2 were initiated within a minute (20%). After implementing the recommendations like cascading teachings on neonatal resuscitation, equipment fixing and also each delivery room was given ambu bags and masks to always be kept there and clean after use, the re-audit results showed the great improvement to 100% on the same measurement criteria.

Clinician must not take more than ideally 30 minutes before attending to obstetric emergencies after being called: 10 emergency obstetric case notes were reviewed and it was detected that out of 10 only 3cases were attended to within an hour not within 30 minutes the rest took more than an hour before they were seen after the clinician was called (0%). After the standards were introduced and recommendations (see recommendations on this standard) were carried out the re-audit results showed an improvement to 100%.

Community sensitization on dangers of homemade medicine and home delivery and possible outcome on the baby: 15 caesarian section patients were provided with a questionnaire to write 1 if took home made medicine to induce labour or write 0 if no. 10 patients out of 15 accepted to have taken homemade medicine (66.7%). And out of 15 vaginal deliveries provided with the same

questionnaire only 4 of them accepted to have taken homemade medicine (26.7%). Total mothers who took home made medicine 14 out of 30 (46.7%). In the course of implementing the recommendations in order to attain the standards the re-audit results showed an improvement to 26.7%. This is great, this recommendation is more challenging, will be improving slowly because not all pregnant mothers go to antenatal clinic. 80 spontaneous vaginal delivery patients’ case files were audited to detect if pregnant mothers report in labour ward in good time when labour starts. 36 patients out of 80 cases partographs were seen in second stage of labour (45%). After introducing the recommendations and standards the re-audit results showed an improvement to 30%. Antenatal clinic health talks were attended to in order to find out if the issue of homemade medicine use and home delivery were talked. Only 1 nurse out 4 nurses talked about this in 10 days assessment (25%). After carrying out the recommendations and introducing the standards re-assessment was done on 6 nurses, the results showed an improvement to 83%

Table C; Showing retrospective and prospective results of the audit.

STANDARDS Initial score(Current practice)

Score after introducing standards (Re-audit results)

Monitor fetal heart every 30 minutes during labour as per partograph

4/40=10% 26/40=65%

Preparation in advance of newborn resuscitation equipment in delivery room.

2 out of 6 nurses=33%

10/10 nurses=100%

Initiate resuscitation within a minute of delivery and close monitoringto the baby after resuscitation.

2/10=20% 10/10=100%

Clinician must ideally attend to obstetric emergency within30 minutes after being called.

0/10=0% 10/10=100%

Antenatal clinic health talk/counseling about dangers and possible Outcome of a baby on homemade medicine use and home delivery on daily basis (to every woman).

1 nurse of 4 talked about it in 10 days assessment=25%

5 nurses out of 6 always find a chance to talk about this=83%

CHALLENGES

There were few problems encountered in this audit.

Health Centers Involvement in Implementing the Audit recommendations and Standards.

Health centers were partially involved and supervised in implementing these standards. The main problem has been fuel for transport. Most of the times our hospital has no fuel for health center patients’ referrals, health centers routine visits and other supervisions. Shortage of fuel for health centers patients’ referrals has been a big drawback to improved health services. The main problem being lack of money for buying fuel. Few opportunities met to brief the audit results and proposed standards to the health centers’ clinicians and nurses when they came to the district hospital for other activities. Despite all staff members awareness of the audit activity frequent change of staff in the departments and transfers in and out of staff have been noted as other drawbacks for sustainability of improved practice especially in maternity ward. This is so because you find that improved services are going on well with current staff and has to be passed on to new staff joining the department but come tomorrow you find totally a different staff with only one or two old staff which takes them sometime to change the new staffs’ practice.

ATTITUDE OF STAFF: The problem was found in changing fellow staff in improving documentation on case files partograph which is still a problem and I don’t know what to do. Monitoring and documenting fetal heart every 30 minutes during labour was not successful as I thought would be. Slowly I think we will succeed I am still thinking on how to go about it.

DISCUSSION

The findings in this clinical audit are giving evidence on how such type of audits can improve health care services to women in labour and new born babies in order to reduce their mortality and morbidity. This matches objectives (aims) and expectations of this clinical audit. It shows that with the available resources and by using the already existing guidelines recommended by World Health Organization, safe motherhood department (Reproductive health Unit) in Malawi we can improve our health services in patient care. In this audit only in 3 months’ time some of the standards namely; fetal heart monitoring

every 30 minutes, preparation of new born resuscitation materials in advance, initiating resuscitation within a minute after delivery in the same delivery room, pregnant mothers antenatal clinic counseling on use of homemade medicine during labor and home delivery disadvantages and clinician attendance to obstetric emergency within 30 minute had already started showing a big improvement in health service. The letter has just been designed for parents waiting for the baby during antenatal period which has a message on dangers and possible outcomes of a baby in using homemade medicine and home deliveries on the baby to be born. This letter if accepted by the DHO will be given to each antenatal mother to read with the husband at home. I think it will improve things because parents will have knowledge and understand on why are we against such practice.

CONCLUSION AND RECOMMENDATIONS

It has been observed in this audit that criteria based audit can improve health care in fetal monitoring during labour, asphyxiated newborn resuscitation, antenatal clinic counseling on dangers of using homemade medicine and home delivery on possible baby outcome and urgent clinician review of emergency obstetric cases despite limited resources. I think if our District Health Officer can encourage and give support to clinical officers and nurses to conduct several clinical audits, there can be a great improvement in health care services using the already available but just ignored standards of care at a low cost in Nkhotakota hospitals. Teaching fellow staff on how to conduct a clinical audit will make nurse midwives and clinicians realize its importance and how interesting it is in improving clinical health services. For future improved patient care there is a need to work as a team and conduct several clinical audits, implement and sustain them.

There is a need to own the audit activity for its sustainability and keep on reminding each other. As earlier said factors like frequent staff transfers (both in and out), departmental frequent rotations of staff members and some situations where by the staff members feel demoralized due to lack of being appreciated on their efforts to improve health services by the community and hospital management team. These factors interrupt the progress of improved services when you have totally a new staff in the department. This time I can be sure that the new practice according to standards will be passed on to new staff members joining each concerned department for sustainability. The already implemented recommendations will make it easier for the new staff to catch up with the recommended practice. For the health centers I am still looking forward at how best they can be handled so that we move together. The main problem with health centers is transport issue due to persistent fuel shortages. The hospital most of the times has no money to buy fuel.

REFERENCES1. Maternity Delivery Registers and Patients case files, Nkhotakota DHO (05/12/10

to 05/12/11): figures neonatal deaths, fresh still births and contributing factors.2. HMIS data Nkhotakota DHO 05/12/10 to 05/12/11: figures of neonatal deaths

and fresh still birth both district hospital and health centers.

3. HMIS, DIP Report Nkhotakota DHO 2011/2012: On Nkhotakota neonatal mortality rate and suggested associating factors.

4. MDHS, 2010: on neonatal mortality rate in Malawi and suggested associating factors

5. http://www.biomedcentral.com/1471-2393/59- incidence of stillbirth and perinatal mortality and their associated factors: antenatal care is very important.

6. (i)WHO and Department of Reproductive Health and Research; Integrated Management of Pregnancy and Childbirth, Managing complications in Pregnancy and Child Birth. A guide for mid wives and doctors. C-65 Using the partograph.

(ii)WHO and Department of Reproductive Health and Research; Integrated Management of Pregnancy and Childbirth, Managing complications in Pregnancy and Child Birth. A guide for mid wives and doctor. C-1, Rapid initial patient Assessment.

7. World Health Organization. Life Saving Skills Manual .Essential Obstetric and Newborn care. Revised 2007. (a) Neonatal resuscitation, pages 10-14 (b) partograph P. 105.

8. (i)Advanced Life Support in Obstetrics 4th Edition, Part 1 & 2. Neonatal resuscitation: E: intrapartum fetal surveillance. A: Pathophysiology of neonatal cardiorespiratory depression at birth. B: equipment needed for neonatal resuscitation. C: initial stabilization & evaluation of new born.

(ii): World Health organization. Second edition, integrated management of pregnancy & Child Birth.-Pregnancy, Childbirth, postpartum & New born Care. A guide for essential practice.(a) C14 ;Develop a birth and & emergency plan.(b) K 11; New born resuscitation should start within a minute.(iii): Helping Babies Breathe Learner work book 2010 by American Academy of Pediatrics; Page 8, Preparing for a birth.

9. (i) The Merck Manual of Medical Information, Home Edition. Chapters 247-249. Labour and delivery (a) drug use during pregnancy: drugs used during labour and delivery (b) dangers on home delivery (c) Complications of labour & delivery: abnormal heart rate.

(ii): World Health Organization; Second edition, Integrated Management of Pregnancy & Child Birth. -pregnancy, child birth, postpartum & newborn Care. Essential guide for practice. C18. Advise not to use local medications to hasten labour.(iii):WHO: Malawi Government, Ministry of Health. Focused Antenatal care and Prevention of Malaria June 2006. P40 Health Education, Avoidance of potentially harmful substances.

10. Moldenhauer 2008: definition of fetal distress.11. Malawi Ministry Of Health national Reproductive health Standards:

(i)Area 2.(a) SS.1, (b)SS.2,(c) SS.11, (d)SS.12, (e)SS.14,(f)SS.18.(ii)Area 10.(a) SS.12, (b)SS. 16

Leviticus Daniel ETATMBA STUDENT