10 research outputs found
A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement
BACKGROUND: In 2007, 95% of women in Botswana delivered in health facilities with 73% attending at least 4 antenatal care visits. HIV-prevalence in pregnant women was 28.7%. The maternal mortality ratio in 2010 was 163 deaths per 100 000 live births versus the government target of 130 for that year, indicating that the Millennium Development Goal 5 was unlikely to be met. A root-cause analysis was carried out with the aim of determining the underlying causes of maternal deaths reported in 2010, to categorise contributory factors and to prioritise appropriate interventions based on the identified causes, to prevent further deaths. METHODS: Case-notes for maternal deaths were reviewed by a panel of five clinicians, initially independently then discussed together to achieve consensus on assigning contributory factors, cause of death and whether each death was avoidable or not at presentation to hospital. Factors contributing to maternal deaths were categorised into organisational/management, personnel, technology/equipment/supplies, environment and barriers to accessing healthcare. RESULTS: Fifty-six case notes were available for review from 82 deaths notified in 2010, with 0–4 contributory factors in 19 deaths, 5–9 in 27deaths and 9–14 in nine. The cause of death in one case was not ascertainable since the notes were incomplete. The high number of contributory factors demonstrates poor quality of care even where deaths were not avoidable: 14/23 (61%) of direct deaths were considered avoidable compared to 12/32 (38%) indirect deaths. Highest ranking categories were: failure to recognise seriousness of patients’ condition (71% of cases); lack of knowledge (67%); failure to follow recommended practice (53%); lack of or failure to implement policies, protocols and guidelines (44%); and poor organisational arrangements (35%). Half the deaths had some barrier to accessing health services. CONCLUSIONS: Root-cause analysis demonstrates the interactions between patients, health professionals and health system in generating adverse outcomes for patients. The lessons provided indicate where training of undergraduate and postgraduate medical, midwifery and nursing students need to be intensified, with emphasis on evidence-based practice and adherence to protocols. Action plans and interventions aimed at changing the circumstances that led to maternal deaths can be implemented and re-evaluated
Integration of HIV care into maternal health services: a crucial change required in improving quality of obstetric care in countries with high HIV prevalence
Use of oxytocin during Caesarean section at Princess Marina Hospital, Botswana : an audit of clinical practice
CITATION: Tsima, B., Madzimbamuto, F.D. & Mash, B. 2013. Use of oxytocin during Caesarean section at Princess Marina Hospital, Botswana: An audit of clinical practice. African Journal of Primary Health Care & Family Medicine, 5(1): 1-6, doi: 10.4102/phcfm.v5i1.418.The original publication is available at http://www.phcfm.orgBackground: Oxytocin is widely used for the prevention of postpartum haemorrhage. In the
setting of Caesarean section (CS), the dosage and mode of administrating oxytocin differs
according to different guidelines. Inappropriate oxytocin doses have been identified as
contributory to some cases of maternal deaths. The main aim of this study was to audit the
current standard of clinical practice with regard to the use of oxytocin during CS at a referral
hospital in Botswana.
Methods: A clinical audit of pregnant women having CS and given oxytocin at the time of
the operation was conducted over a period of three months. Data included indications for CS,
oxytocin dose regimen, prescribing clinician’s designation, type of anaesthesia for the CS and
estimated blood loss.
Results: A total of 139 case records were included. The commonest dose was 20 IU infusion
(31.7%). The potentially dangerous regimen of 10 IU intravenous bolus of oxytocin was used
in 12.9% of CS. Further doses were utilized in 57 patients (41%). The top three indications for
CS were fetal distress (36 patients, 24.5%), dystocia (32 patients, 21.8%) and a previous CS
(25 patients, 17.0%). Estimated blood loss ranged from 50 mL – 2000 mL.
Conclusion: The use of oxytocin during CS in the local setting does not follow recommended
practice. This has potentially harmful consequences. Education and guidance through evidence
based national guidelines could help alleviate the problem.http://www.phcfm.org/index.php/phcfm/article/view/418Publisher's versio
Adding a transversus abdominis plane block to parenteral opioid for postoperative analgesia following trans-abdominal hysterectomy in a low resource setting: a prospective, randomised, double blind, controlled study
Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study : a 7-day prospective observational cohort study
CITATION: Bishop, D. et al. Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study : a 7-day prospective observational cohort study. The Lancet Global Health, 7(2):e513-e522. doi:10.1016/S2214-109X(19)30036-1The original publication is available at https://www.thelancet.com/journals/langlo/issue/vol7no2/PIIS2214-109X(19)X0002-9Background: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes.
Methods: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery
in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years)
admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort
period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the
recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed
by local investigators. The study was registered on the South African National Health Research Database, number
KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899.
Findings: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were
included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality
analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and
anaesthetists totalling 0·7 per 100000 population (IQR 0·2–2·0). Maternal mortality was 20 (0·5%) of 3684 patients
(95% CI 0·3–0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2–18·6), which were predominantly
severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently
associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum
haemorrhage (odds ratio 4·47 [95% CI 1·46–13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99–17·34])
or anaesthesia complications (11·47 (1·20–109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7–5·0).
Interpretation: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income
countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the
global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage
might improve maternal and neonatal outcomes in Africa.https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30036-1/fulltextPublisher’s versio
Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.
BACKGROUND: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. METHODS: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. FINDINGS: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2-2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3-0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2-18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46-13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99-17·34]) or anaesthesia complications (11·47 (1·20-109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7-5·0). INTERPRETATION: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. FUNDING: Medical Research Council of South Africa.Medical Research Council of South Africa
The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications
Background:
The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.
Methods:
ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.
Results:
The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.
Conclusions:
This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.
© 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.Medical Research Council of South Africa gran