Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review

Background: Audits provide a rational framework for quality improvement by systematically assessing clinical practices against accepted standards with the aim to develop recommendations and interventions that target modifiable deficiencies in care. Most childbirth-associated mortality audits in developing countries are focused on a single facility and, up to now, the avoidable factors in maternal and perinatal deaths cataloged in these reports have not been pooled and analyzed. We sought to identity the most frequent avoidable factors in childbirth-related deaths globally through a systematic review of all published mortality audits in low and lower-middle income countries. Methods: We performed a systematic review of published literature from 1965 to November 2011 in Pubmed, Embase, CINAHL, POPLINE, LILACS and African Index Medicus. Inclusion criteria were audits from low and lower-middle income countries that identified at least one avoidable factor in maternal or perinatal mortality. Each study included in the analysis was assigned a quality score using a previously published instrument. A meta-analysis was performed for each avoidable factor taking into account the sample sizes and quality score from each individual audit. The study was conducted and reported according to PRISMA guidelines for systematic reviews. Results: Thirty-nine studies comprising 44 datasets and a total of 6,205 audited deaths met inclusion criteria. The analysis yielded 42 different avoidable factors, which fell into four categories: health worker-oriented factors, patient-oriented factors, transport/referral factors, and administrative/supply factors. The top three factors by attributable deaths were substandard care by a health worker, patient delay, and deficiencies in blood transfusion capacity (accounting for 688, 665, and 634 deaths attributable, respectively). Health worker-oriented factors accounted for two-thirds of the avoidable factors identified. Conclusions: Audits provide insight into where systematic deficiencies in clinical care occur and can therefore provide crucial direction for the targeting of interventions to mitigate or eliminate health system failures. Given that the main causes of maternal and perinatal deaths are generally consistent across low resource settings, the specific avoidable factors identified in this review can help to inform the rational design of health systems with the aim of achieving continued progress towards Millennium Development Goals Four and Five. Electronic supplementary material The online version of this article (doi:10.1186/1471-2393-14-280) contains supplementary material, which is available to authorized users

Perspectives in quality: designing the WHO Surgical Safety Checklist

The World Health Organization's Patient Safety Programme created an initiative to improve the safety of surgery around the world. In order to accomplish this goal the programme team developed a checklist with items that could and, if at all possible, should be practised in all settings where surgery takes place. There is little guidance in the literature regarding methods for creating a medical checklist. The airline industry, however, has more than 70 years of experience in developing and using checklists. The authors of the WHO Surgical Safety Checklist drew lessons from the aviation experience to create a safety tool that supports essential clinical practice. In order to inform the methodology for development of future checklists in health care, we review how we applied lessons learned from the aviation experience in checklist development to the development of the Surgical Safety Checklist and also discuss the differences that exist between aviation and medicine that impact the use of checklists in health car

Improving Quality of Care for Maternal and Newborn Health: Prospective Pilot Study of the WHO Safe Childbirth Checklist Program

Background: Most maternal deaths, intrapartum-related stillbirths, and newborn deaths in low income countries are preventable but simple, effective methods for improving safety in institutional births have not been devised. Checklist-based interventions aid management of complex or neglected tasks and have been shown to reduce harm in healthcare. We hypothesized that implementation of the WHO Safe Childbirth Checklist program, a novel childbirth safety program for institutional births incorporating a 29-item checklist, would increase delivery of essential childbirth practices linked with improved maternal and perinatal health outcomes. Methods and Findings A pilot, pre-post-intervention study was conducted in a sub-district level birth center in Karnataka, India between July and December 2010. We prospectively observed health workers that attended to women and newborns during 499 consecutively enrolled birth events and compared these with observed practices during 795 consecutively enrolled birth events after the introduction of the WHO Safe Childbirth Checklist program. Twenty-nine essential practices that target the major causes of childbirth-related mortality, such as hand hygiene and uterotonic administration, were evaluated. The primary end point was the average rate of successful delivery of essential childbirth practices by health workers. Delivery of essential childbirth-related care practices at each birth event increased from an average of 10 of 29 practices at baseline (95%CI 9.4, 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6, 25.3; p<0.001). There was significant improvement in the delivery of 28 out of 29 individual practices. No adverse outcomes relating to the intervention occurred. Study limitations are the pre-post design, potential Hawthorne effect, and focus on processes of care versus health outcomes. Conclusions: Introduction of the WHO Safe Childbirth Checklist program markedly improved delivery of essential safety practices by health workers. Future study will determine if this program can be implemented at scale and improve health outcomes.

Traumatic injury mechanisms and severity in Karachi, Pakistan: a single center prospective study

Background: Traumatic injury is a leading cause of morbidity and mortality in the developing world. Etiology and outcomes may differ substantially across regions and gender. Objective: We sought to describe the patterns of injury mechanism, treatment and outcomes in patients of all ages presenting at a major trauma center in Karachi, Pakistan. Methods: All patients presenting for emergency treatment of moderate-to-severe acute traumatic injury between January 1, 2011 and December 31, 2011 were eligible for study. Injury Severity Scores (ISS) were calculated for each patient based on injury descriptions. Descriptive statistical methods, including Student’s t-tests and Wilcoxon rank-sum tests, as well as Chi-square tests were used to compare differences between genders and across age groups. Inpatient treatment intensity and mortality were examined across patient factors. Results: A total of 678 individuals were eligible for study, of whom 89.2% were male. Median age was similar for male and female patients (29 vs. 27 years respectively; p=0.262). The vast majority of patients incurred road traffic injuries (RTI) with 58.7% of all injuries among males and 82.2% among females. Among males, 27.8% of admissions were related to gunshot wounds compared with 4.1% among females (p\u3c0.001). Falls represented 6.1 % of admissions and were evenly distributed across genders. Pedestrian injury was the most common trauma for patients aged 65 years or older encompassing 57.7% of all injuries in this age group. Overall, more than half of the patients were transferred to ICU care (30.2%) or to the OR (20.9%). Patient mortality was 4.0% and did not differ by gender (p=0.489). Conclusion: The majority of patients presenting with moderate-to-severe trauma had suffered RTI. Over half of all patients were treated with ICU and/or or surgical care and 4% of all patient died in-hospital. Injury patterns across age and gender suggest possible subpopulation-specific areas for Keywords: Truama, Injury, Karachi, Pakista

Designing the WHO Safe Childbirth Checklist program to improve quality of care at childbirth.

BACKGROUND: Poor-quality care during institutional births in low- and middle-income countries is a major contributing factor to preventable maternal and newborn harm, but progress has been slow in identifying effective methods to address these deficiencies at scale. Based on the success of checklist programs in other disciplines, WHO led the design and field testing of the WHO Safe Childbirth Checklist-a 29-item tool that targets the major causes of maternal and newborn mortality globally. METHODS: The development process consisted of comprehensive evidence and guideline review, in-person consultation with content experts and other key stakeholders, iterative refinement through ongoing discussions with a wide collaborator network, and field evaluation for usability in 9 countries, primarily in Africa and Asia. Pilot testing in South India demonstrated major improvement in health workers' delivery of essential safety practices after introduction of the program. RESULTS: WHO has launched a global effort to support further evaluation of the program in a range of contexts, and a randomized trial is underway in North India to measure the effectiveness of the program in reducing severe maternal, fetal, and newborn harm. CONCLUSION: A novel checklist program has been developed to support health workers in low-resource settings to prevent avoidable childbirth-related deaths

Observed in-facility mortality before and after intervention.

<p>Observed in-facility mortality before and after intervention.</p

Changes in rates of delivery of specific childbirth practices before and after intervention; (2a) On admission; (2b) From pushing until delivery; (2c) Soon after birth (within one hour); (2d); Before discharge (*P value = 0.052; all others p≤0.001).

<p>Changes in rates of delivery of specific childbirth practices before and after intervention; (2a) On admission; (2b) From pushing until delivery; (2c) Soon after birth (within one hour); (2d); Before discharge (*P value = 0.052; all others p≤0.001).</p

Demographic characteristics of women and newborns before and after intervention.

a<p>Referred to study facility from another facility after labor started.</p>b<p>Attended fewer than 3 antenatal appointments.</p

Average rate of successful delivery of essential childbirth practices before and after intervention (p<0.001).

<p>Average rate of successful delivery of essential childbirth practices before and after intervention (p<0.001).</p