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

Male Involvement in Child Care Activities: A Review of the Literature in Botswana

Engaging men as partners in childrearing is critical because of the positive aspects on the child’s development and reduction of childhood illnesses. The paper presents findings from a literature review whose aim was to assess the extent to which males are involved in child care activities. Findings revealed a limited number of studies conducted in the area of male involvement. Socio-cultural factors have a negative influence on men’s participation on child care activities. In addition, some laws were prohibitive to male involvement. It was difficult to assess the extent to which males were involved due to inadequate data collection tools. Recommendations include a study on male involvement, review of the existing Sexual and Reproductive Health data collection tools, development of a policy on paternity leave, strengthening training on male involvement; community sensitization on cultural stereotypes and harmonization of customary and common laws.L'engagement des hommes en tant que partenaires dans l'éducation des enfants est essentiel en raison des aspects positifs sur le développement et la réduction des maladies infantiles de l'enfant. L’article montre les résultats d'une revue de la documentation dont l'objectif était d'évaluer jusqu’à quel point les hommes participent dans des activités d’assistance à l'enfant. Les résultats ont révélé un nombre limité d'études menées dans le domaine de la participation des hommes. Les facteurs socio- culturels ont une influence négative sur la participation des hommes aux activités d’assistance à l'enfant. En outre, certaines lois avaient interdit la participation des hommes. Il était difficile d'évaluer à quel point les hommes ont été impliqués en raison de l’insuffisance d'outils de collecte de données. Les recommandations comprennent une étude sur la participation des hommes, la révision des outils de collecte de données existants sur la santé sexuelle et de reproduction, le développement d'une politique sur le congé de paternité, le renforcement de la formation sur la participation des hommes, la sensibilisation de la communauté sur les stéréotypes culturels et l'harmonisation des lois coutumières et communes

High Levels of Post-Abortion Complication in a Setting Where Abortion Service Is Not Legalized.

BACKGROUNDMaternal mortality due to abortion complications stands among the three leading causes of maternal death in Botswana where there is a restrictive abortion law. This study aimed at assessing the patterns and determinants of post-abortion complications.METHODSA retrospective institution based cross-sectional study was conducted at four hospitals from January to August 2014. Data were extracted from patients' records with regards to their socio-demographic variables, abortion complications and length of hospital stay. Descriptive statistics and bivariate analysis were employed.RESULTA total of 619 patients' records were reviewed with a mean (SD) age of 27.12 (5.97) years. The majority of abortions (95.5%) were reported to be spontaneous and 3.9% of the abortions were induced by the patient. Two thirds of the patients were admitted as their first visit to the hospitals and one third were referrals from other health facilities. Two thirds of the patients were admitted as a result of incomplete abortion followed by inevitable abortion (16.8%). Offensive vaginal discharge (17.9%), tender uterus (11.3%), septic shock (3.9%) and pelvic peritonitis (2.4%) were among the physical findings recorded on admission. Clinically detectable anaemia evidenced by pallor was found to be the leading major complication in 193 (31.2%) of the cases followed by hypovolemic and septic shock 65 (10.5%). There were a total of 9 abortion related deaths with a case fatality rate of 1.5%. Self-induced abortion and delayed uterine evacuation of more than six hours were found to have significant association with post-abortion complications (p-values of 0.018 and 0.035 respectively).CONCLUSIONAbortion related complications and deaths are high in our setting where abortion is illegal. Mechanisms need to be devised in the health facilities to evacuate the uterus in good time whenever it is indicated and to be equipped to handle the fatal complications. There is an indication for clinical audit on post-abortion care to insure implementation of standard protocol and reduce complications

Bivariate analysis of factors associated with abortion complications.

<p>Bivariate analysis of factors associated with abortion complications.</p

Background and reproductive characteristics of the patients admitted to hospitals.

<p>Background and reproductive characteristics of the patients admitted to hospitals.</p