dr. merlene fredericks sis. smith layne departmental
TRANSCRIPT
Dr. Merlene Fredericks
Chief Medical Officer
Sis. Smith Layne Departmental Sister, VH
September 14, 2015
Population: 165 000
Life expectancy: 72 M: 79 F
Fertility rate: 3.5 in 1985 to 1.5 in 2012
Range annual births: 1882-2233
Range annual infant deaths: 33-43 (neonatal deaths 60%)
Range annual maternal deaths:0-2
Organization of Health system
◦ Strong Primary Care focus
◦ Government owned hospitals
◦ Free/highly subsidized care to pregnant women
Free midwifery and doctors clinics
Free STI screening – public sector
(other diagnostics – out of pocket)
WHY WAS A PERINATAL AUDIT REQUESTED?
Central Statistics Office St. Lucia WHO: Life expectancy
Infant Mortality per 1000 live births
Maternal Mortality per 100,000 live births
0
50
100
150
200
250
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
Rate
Year
0
5
10
15
20
25
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
Rate
Year
Erosion of national image
Erosion of public trust
National
◦ Potential failure to meet MDGs
MDG 4 (reduction in child mortality) and 5 (reduction in maternal mortality)
◦ Human Development index compromised
◦ Cost to society
Institution Increased cost of care
- Complications increase complexity and cost of care
- Litigation costs: emotional and financial
- Increases strain on healthcare workers and affects morale
Family and individual
- Emotional - Immediate financial
challenges - Long term financial &
psychological
Goal: To identify any gaps which can be addressed to improve outcomes of mother and child
PAHO/CLAP and St. Lucia team ◦ Public
◦ private
WHO Near miss approach
Review situational analysis for maternal and perinatal outcomes
Critically review selected individual patient’s documentation
Complete the audit questionnaires (manually)
Add “free text” comments to the evaluation tool, as warranted
Identify and record those situations that were either best practices or critical and need of remedial actions
Collate information, and discuss findings
Document and present findings
Participate in related discussions
Between the years January 2012 to June 2014 The cases were included if they were classified (and selected) by the health institution as: Stillbirth Neonatal death (before 7 days) Near-Miss maternal death
A sample of antenatal health records were selected from three(3) clinics
Maternal deaths were included for the years 2009 to June 2014
Assessment of the Quality of Care Structure (Hospitals)
Assessment of the Quality of Care Process (Antenatal clinics)
Severe Maternal Outcomes
Maternal near-miss case- “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”
Maternal death - death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes
Still births and early neonatal deaths
Title of the Presentation 10
Quality of Care Variables by Hospitals
Components St. Jude Victoria Hospital Tapion Hospital Comments
Quality of the environment
Satisfactory Satisfactory Satisfactory
Organization and management of the facility
Satisfactory Satisfactory Satisfactory Unit wide meetings not routinely held
Procedural documentation
Satisfactory Needs improvement
Adequate (needs to be customized for the institution)
Manuals not approved and some incomplete
Staff orientation
Satisfactory Satisfactory Satisfactory No specific orientation package
Supplies and equipment
Inadequate equipment
Inadequate equipment
Satisfactory Basic equipment such as blood gas machine, portable –x-ray are needed. Need structured mechanism for monitoring
Infection control
Satisfactory Satisfactory Satisfactory
Monitoring of the health status of staff
Needs improvement
Needs improvement
Satisfactory To be addressed
Title of the Presentation 11
Quality of Care Process Variables by Primary Care Clinics
Components Vieux Fort Castries Soufriere Comments
SOPs and guidelines
Basic Basic Basic Being updated
Initial Assessment Satisfactory Satisfactory Satisfactory The assessment card does not capture all variables of interest.
Follow-up assessment
Needs improvement
Needs improvement
Needs improvement
Quality of documentation needs improvement; inconsistency in documenting patient information. Nature of counselling not defined
Identification of high risk pregnancies
Needs improvement
Satisfactory Referral of HR cases to private sector can be barrier to care
Satisfactory Poor follow-up of cases; no definite mechanism in place. Needs further in-depth assessment
Support in Antenatal Period
Inadequate Inadequate Inadequate No emphasis for involvement of father in ANC. Organization of the delivery process does not support inclusion of fathers
MATERNAL MORTALITY
NEAR MISS
LIFE THREATENING CONDITIONS
LIVE BIRTH AND
MOTHER IN GOOD HEALTH
MATERNAL NEAR MISS
St Jude N=18
Eclampsia 3
Severe pre-eclampsia 12
Severe PPH 2
Pulmonary embolism 1
Victoria Hospital N=13
Severe pre-eclampsia 3
Eclampsia 3
Sepsis 1 Ectopic 1
PPH 5
Severe
preeclampsiaeclampsia
sepsis
severe
preeclampsia
severe PPH
pulmonary
embolism
Distribution of Selected Variables for Maternal Mortality (N=8)
VARIABLE NUMBER
Age 17-41 years
Place Health facility
Referral Yes (but some missing data)
Marital status and occupation All unmarried and unemployed
Primigravida 3
Preterm 5
Prepartum 1
Outcome 3 Stillbirth 1 Neonatal death 4 Live birth
More than 3 antenatal care visits 4
High risk pregnancies 6
Main Characteristics of Neonatal Deaths
St. Jude Hospital Victoria Hospital
Extreme premature
47% 47%
Extremely LBW
53% 47%
Deaths within the first day
59% 47%
Related to Congenital Birth Defects
41% 26%
Severely depressed at birth
24% 32%
Mostly male 2/1
2/1 2.3/1
Mid maternal age 30% >24
5% <20 y. and 30% >24
Neonatal Deaths by Gestational Age at Birth
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
St. Jude - Neonatal deaths Victoria H. Neonatal deaths
term
37-38
29-36w
<28 w
Neonatal Deaths by Birthweight
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
St. Jude Victoria
3000 or more
2500-2999g
1500-2499g
1000-1499g
<1000g
Neonatal Deaths by Causes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
St. Jude Victoria
unknown
other
hemorragic disease
Asphyxia
Cong. Deffect
Prematurity
Stillbirth by Gestational Age at Birth
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
St. Jude - Neonatal deaths Victoria H. Neonatal deaths
term
37-38
29-36w
<28 w
Stillbirths by Causes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
St. Jude Victoria
unknown
other
Fresh
Cong. Deffect
Macerated
Other: dystocia, abruptio placentae, IUGR
Qualitative Evaluation
Improvement needed in documentation
Infections and sepsis listed as secondary cause of death in some cases
In some cases, excellent report for case referral
From a neonatal perspective, most of the cases were related to extreme clinical conditions, but the obstetric condition resulting in the poor neonatal outcome still might have been preventable
Some newborns with an apparently good prognosis had unexpectedly poor outcomes
Neonatal Themes to be Addressed
1. Asphyxia and training on neonatal resuscitation
2. Oxygen provision and prevention, diagnosis and
treatment of Retinopathy of Premature (ROP)
3. Neonatal transport – opportunity and conditions
4. Prevention, diagnosis and treatment of sepsis
5. Specific follow up to moderate to extreme premature
6. Warning signs at hospital discharge and at community
level
7. Early skin-to-skin contact and early initiation of
breastfeeding
8. Identify risk conditions during pregnancy in order to
prevent premature births
National
Perinatal Committee and plan; protocols; surveillance system
System related
Trigger high risk cases; adopt SIPS; increase access to
diagnostics
Institution
Increased collaboration and communication between and within
facilities and care levels; training and re-training
Patient
Education, promotion of antenatal care
National
National Perinatal Committee
Training in neonatal resuscitation
Pipeline: ◦ Full implementation plan + M&E framework
◦ Health promotion campaign
◦ Finalization of maternal and child health protocol
◦ Introduction of SIPS and incorporation into national pregnancy passport
◦ HR - OBGYN, Neonatologist
◦ Strengthen surveillance
◦ Integrate community and hospital high risk clinics
Institution Primary Care: ◦ Re-training and sensitization of midwives, DMOs ◦ Community outreach increased
Secondary-Hospitals ◦ Monthly perinatal meetings instituted ◦ Plans for simulations developed ◦ SJH- Trained in neonatal resuscitation ◦ Protocols and guidelines shared ◦ VH- procurement of ventilators, CPAP machines ◦ Dedicated physician to delivery suite ◦ Patient information leaflets provided
Eager participants from all sectors, public and private
Willingness to accept ownership of problems and gaps
Have started to make changes and eager to continue improving
Opportunities for enhanced collaboration between patients, community, health care providers and institutions
Desire for further research into perinatal outcomes and their causes
Ms. Kathleen Albert, Nurse/Midwife (MOH) Dr. Alicia Aleman, Obstetrician/Gynaecologist
(CLAP) Dr. Gillian Birchwood, Neonatologist (Barbados) Dr. Lucilla Charles, Obstetrician/Gynaecologist
(MOH) Dr. Pablo Duran, Advisor on Perinatal Health (CLAP) Dr. Margaret Hazlewood, Public Health Specialist
(PAHO - BAR Dr. Beryl Irons, Advisor, Family, Gender and Life
Course (PAHO –BAR) Ms. Frances Lesmond, Nurse Practitioner (MOH) Ms. Judith Solomon, Nurse/Midwife (MOH)
References: ◦ Report of Perinatal Audit in St. Lucia (PAHO /WHO
Office of Eastern Caribbean )
◦ Maternal/Perinatal Audit presentation: October 13-17, 2014: PAHO/WHO Centre for Perinatology (CLAP)
◦ Central Statistics Unit of St. Lucia
◦ WHO Life Expectancy figures
◦ Epidemiology Unit of the Ministry of Health, St. Lucia