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Safe Motherhood

Role play of birth with birth attendants in Ecuador,

QAP conducted a four-country operations research study that examined determinants of skilled attendance of birth and the quality of maternal care. Data were collected in Benin, Ecuador, Jamaica, and Rwanda in three areas: 1) measuring competency of skilled birth attendants; 2) in-facility delays occurring during labor, delivery, and postpartum care that contribute to maternal complications and poor outcomes; and 3) factors other than competency that affect the quality of maternal care and immediate newborn care:

Enabling factors affecting the performance of skilled birth attendants
A wide variety of factors might affect the performance of skilled birth attendants, including provider competence and motivation, various patient characteristics, hospital leadership and supervision, availability of equipment, drugs and supplies, policies, time of day and week, and support team. This study examined the relationships between such factors and performance during labor, delivery and immediate postpartum maternal and newborn care. Data were obtained from 5 referral hospitals, 12 smaller hospitals, and 4 health centers in four countries (Benin, Ecuador, Jamaica, Rwanda). Performance was defined as compliance according to international standards and measured by direct observation of all births and retrospective record review of obstetric emergencies. The enabling factors were measured by a variety of instruments, measurements of the competency of birth attendants obtained from a related study.

Measuring competency of skilled birth attendants
This study developed instruments for measuring knowledge and skills of birth attendants. It was tested in four countries: Benin, Ecuador, Jamaica and Rwanda. The instruments measured competency during labor, delivery, postpartum maternal care, and postpartum newborn care. Knowledge was measured with a 55-item test derived from several well-known sources, such as the WHO IMPAC guidelines. The skills test included two partograph exercises and six skill stations using mannekins and attended by expert clinicians. Locally appropriate standards were added to the tests in each country.

Measuring in-facility delays during emergency obstetric care
This study developed and tested a method for measuring delays in the treatment of selected obstetrical emergencies within facilities in four countries: Benin, Ecuador, Jamaica, and Rwanda. Emergencies addressed included eclampsia/pre-eclampsia, sepsis, obstructed labor, postpartum hemorrhage, and post-abortion complications. The method included observing patient flow in the obstetrical ward and/or the emergency room, and record review of obstretrical emergencies. Patient flow data were obtained on 856 maternal cases, and 329 records of obstetrical cases were reviewed by a physician. The study found that patient flow observation is feasible and necessary to measure delays in initial evaluation. Record reviews by physicians also yielded usable information on delays in obstetrical emergencies.

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Case management maps for pregnancy-induced hypertension and postpartum hemorrhage
This study developed, implemented and measured the impact of a case management map on the management of pregnancy-induced hypertension (PIH) and postpartum hemorrhage (PPH) in Jinja Hospital, Uganda. The maps served as a job aid and a permanent record of the care provided. The map development process within the hospital was an integral part of the intervention, including the steps of team selection, current process description, developing the job aid map, define monitoring indicators, and implementation. The development team also worked to solve barriers to good performance such as missing equipment or drugs. This process was undertaken twice in the same ward, first for PIH and six months later for PPH. A third maternal condition, pelvic inflammatory disease (PID), was used as a control. Impact was measured by quality of care and by health outcome. To measure quality of care, three key tasks (one each for assessment, monitoring and treatment) were measured for six months pre-intervention and six months post intervention for all three conditions. The average of the three quality tasks performed to standard in 86 PIH cases increased from 0.33 to 2.3 (significant), and the average for 30 PPH cases increased from 0.45 to 1.1 (not significant), while the performance in 66 PID cases increased only slightly (0.46 pre, 0.62 post, not significant). Health outcomes improved for PIH cases (stillbirths and women progressing to eclampsia both dropped but not significantly), but did not improve for PPH cases (maternal deaths increased). The study concluded that the case management maps contributed to increased quality of care under ideal conditions.

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Improving the Management of Obstetric Emergencies in Uganda through Case Management Maps

Improved quality of care reduces pregnancy-induced hypertension costs in Tver Oblast, Russia
QAP helped Tver Oblast redesign its system of care for pregnancy-induced hypertension (PIH) in three hospitals, including the introduction of new, evidence-based guidelines. Under the new guidelines, fewer women were admitted for PIH care, and those admitted received more aggressive care to prevent progression to eclampsia, including mono-drug therapy (magnesium sulfate) and early induced delivery if the drug therapy did not work. The new system resulted in no progressions to eclampsia, no PIH deaths, and a 60% drop in newborn complications to PIH mothers in the 19 months following the introduction of the new guidelines. This study focused on measuring the cost of the new and old systems in two of the hospitals. The direct cost of drugs, laboratory tests and hospitalization (nurse and clinician time, food) for PIH inpatient and outpatient care was estimated for PIH patients in similar 6-month periods before and after the new guidelines. Total costs dropped by 87% following the introduction of the new guidelines. Four factors contributed most to this reduction: a 76% drop in the number of cases admitted, a 13% reduction in the length of hospitalization, an 81% reduction in the number of women given additional PIH outpatient care over and above normal antenatal care, and more rationale use of drugs, resulting in a 63% reduction in the drug cost per inpatient.

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Improving the Quality of Care for Women with Pregnancy-Induced Hypertension Reduces Costs in Tver, Russia

Redesign of obstetric records
This study redesigned the obstetric patient record process in four Ecuadorian hospitals using a standard QA redesign approach. As part of this process, eight key indicators of patient record quality were defined: (1) complete set of forms, (2) correct chart headers, (3) complete discharge form, (4) complete delivery record, (5) signed patient consent and release forms, (6) identification on admit and discharge forms, (7) legible, (8) coherent and consistent. A random sample of about 200 records from each hospital (about 100 before the redesign and 100 after) were audited. The percentage of indicators meeting the standard in the sample improved significantly in all four hospitals. Overall, quality increased by an average of 27 percentage points, from 41% compliant with quality standards before redesign to 69% compliant afterwards. The biggest gains were in legibility, coherency and consistency, complete set of forms, discharge form, and delivery record. Further work is required to assess whether the increase in quality reduced medical errors, and whether the records are now of sufficient quality to use as a data source for monitoring quality assurance activities.

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Redesigning Hospital Documentation Systems to Improve the Quality of Patient Obstetric Records in Ecuador


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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development (USAID) under Contract Number GPH-C-00-02-00004-00.