NEAR MISS STUDY RWANDA EMERGENCY OBSTETRIC CARE EFFICIENCY AT - - PowerPoint PPT Presentation

NEAR MISS STUDY RWANDA – EMERGENCY OBSTETRIC CARE EFFICIENCY AT NYAGATARE AND RWAMAGANA DISTRICT HOSPITAL.

Richard Supheert, co-assistent, Radboud University Nijmegen

NEAR MISS CASES

‘Women who almost died due to medical complications during pregnancy, giving birth

• r within 42 days after termination of pregnancy.’

A TYPICAL MATERNITY DEPT AT DISTRICT HOSPITALS

 11 deliveries per day on average, 3 C-sections  No obstetricians, only midwifes and 1 post-graduate doctor  Several uterine ruptures per week  Several fetal deaths per week  No knowledge about adequate resuscitation on newborns  No sterile environment or equipment to conduct a C-section  Not enough beds: ‘Floor beds’  No health insurance: €4,- per year  Low intrinsic motivation health workers

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

RESEARCH QUESTION

What is the difference in the management of emergency obstetric cases between near miss cases and women who delivered safely in November 2015 in the Nyagatare and Rwamagana district hospitals in Rwanda?

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

WORKING IN 2 DISTRICT HOSPITALS

Coverage indicators Process indicators Outcome indicators

• Rwamagana district hospital:
• Good coverage indicators
• Good process indicators
• Poor outcome indicators

T wo district hospitals included in this study:

• Nyagatare district hospital:
• Poor coverage indicators
• Poor process indicators
• Poor outcome indicators

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

PROSPECTIVE EXPLORATIVE CASE- CONTROL STUDY (PILOT STUDY)

 Haydom criteria  For every near miss case, two controls  A questionnaire was filled for every

identified near miss event and control

 Controls were matched by age, parity,

mode of delivery and time of delivery

Haydom near miss criteria Clinical criteria Acute cyanosis Gasping Repiratory rate >40 or < 6/min. Shock Oliguria non responsive to fluids or diuretics Failure to form clots Loss of consciousness lasting > 12 h Cardiac arrest Stroke Uncontrollable fit/total paralysis Jaundice in the presence of pre‐eclampsia Laboratory‐based criteria Oxygen saturation < 90% for ≥60 minutes Acute thrombocytopenia (<50,000 platelets/ml) Management‐based criteria Admission to intensive care unit Hysterectomy following infection or haemorrhage Transfusion of ≥1 unit of blood Intubation and ventilation for ≥60 minutes not related to anaesthesia Cardio‐pulmonary resuscitation Severe maternal complications Eclampsia Sepsis or severe systemic infection Uterine rupture INTRODUCTION - METHODS – RESULTS - CONCLUSIONS

NUMBER OF WOMEN INCLUDED

Nyagatare: 326 deliveries, November 2015 24 near miss cases 46 controls Rwamagana: 254 deliveries, November 2015 6 near miss cases 12 controls

T

• tal:

30 near miss cases 56 controls

PILOT study  Felix Sayinzoga (MD), Dr. Leon Bijlmakers,

• Prof. Koos van der

Velden, 4 districts, 215 NM cases, 400 controls (to be published)

INTRODUCTION - METHODS – RESULTS - CONCLUSIONS

RESULTS

Near miss cases versus controls High cesarean section rate (WHO 10-15% recommended on a population level) In 25% of all near miss cases in Nyagatare DH a laparotomy was necessary (uterine rupture)

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

DISTRIBUTION OF COMPLICATIONS

 Largest group:

Hemorrhage (38%)

 Included using

the Haydom criteria

38% 12% 3% 17% 12% 18%

Distribution of medical complications among near miss cases from Nyagatare and Rwamagana district hospital (N=30)

Hemorrhage (APH, IPH, PPH) Pre-eclampsia Eclampsia Sepsis or sever systemic infection Ruptured uterus Dysfunctional blood clotting

INTRODUCTION - METHODS – RESULTS - CONCLUSIONS

CASE MANAGEMENT – BLOOD PLATELETS

 Dysfunctional blood

clotting group: 18%

 18% of all near miss

cases had a low blood platelet level

 Invasive treatment or C-

section before correction of blood platelets

 Nyagatare: 2 hour one-

way drive to nearest bloodbank

38% 12% 3% 17% 12% 18%

Distribution of medical complications among near miss cases from Nyagatare and Rwamagana district hospital (N=30)

Hemorrhage (APH, IPH, PPH) Pre-eclampsia Eclampsia Sepsis or sever systemic infection Ruptured uterus Dysfunctional blood clotting

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

CASE MANAGEMENT – FETAL DEATH

 Of the 12 fetal

deaths recorded, 11 deaths were in Nyagatare DH

 Much lower

percentage of fetal deaths among the control group

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

CASE MANAGEMENT – TRANSPORT

 Overall duration of

transport is several hours (up till 10 hours)

 T

endency of the control group having a longer time of transport

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

PREVENTION: ANTE NATAL CARE CHECK-UPS

 The WHO recommends a

minimum of 4 ante natal care check-ups

 No significant difference

between the near miss group and control group was found (P = 0,565)

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

THE EDUCATIONAL GAP

 T

endency of women in the control group being higher educated than women in the near miss group

 No significant

difference was found (P = 0,122)

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

HEALTH INSURANCE: THE MUTUELLE DE SANTÉ

 10% of near miss

cases has no medical insurance

 Rwandan Social

Security Board (RSSB) gives better coverage than the Mutuelle

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

CONCLUSIONS

 Medical complications  Cesarean section rates too high  Dysfunctional blood clotting  Number of ante natal care check-ups too low  Emergency transportation time too long  The educational gap  No medical health insurance  Medical skills and knowledge not up to date  Low intrinsic motivation to improve

INTRODUCTION - METHODS - RESULTS - CONCLUSIONS

Antenatal care and management of women in labour leave room for improvement, especially at one of the two hospitals.

ACHIEVING LEARNING GOALS; GET YOUR EXPOSURE.

 Serious medical cases  Patients seek for help too late, no equipment  Maternal and fetal death, no money for the mortuary  Cardboard boxes

Questions?

‘We are all confronted with a bunch of great possibilities, beautifully disguised as unsolvable problems.’ (John W. Gardner) Stay in touch? richard_supheert@hotmail.com