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5

Finding solutions to maternal and perinatal mortality

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Contents

Objectives

When you have completed this unit you should be able to:

Finding solutions

5-1 How can you find solutions to maternal and perinatal deaths?

There are a number of steps which are needed:

  1. Specific avoidable factors, missed opportunities and substandard care have to be identified.
  2. You need to know where and how to look for answers to these problems.
  3. Answers have to be found.
  4. Changes have to be introduced.

5-2 What is an avoidable factor?

An avoidable (or modifiable) factor is something which may have prevented the death, e.g. a woman not immediately going to a clinic or hospital when abdominal pain with vaginal bleeding occurs during pregnancy.

Many avoidable factors are due to missed opportunities.

An avoidable factor may have prevented a death.

5-3 What is a missed opportunity?

A missed opportunity is a chance to provide the correct care which was not taken. The opportunity was there to provide the correct management but the opportunity was missed, e.g. failing to measure the blood pressure at an antenatal visit or not screening for syphilis.

Note
A missed opportunity is when an action or omission by the patient, administration or health worker results in an adverse outcome for the mother or infant.

5-4 How can you recognise substandard care?

Substandard care means that the care that the patient received fell below the standard that should have been offered to her. It is necessary to know what correct care is before substandard care can be recognised. Care may be substandard because of any of the following:

  1. The patient did not go for care.
  2. The facilities were inadequate.
  3. Shortage of staffing or poor staff training.
  4. Staff did not provide the correct care needed.

Substandard care often leads to avoidable factors and missed opportunities. Therefore, substandard care, avoidable factors and missed opportunities are usually considered together as problems resulting in poor care. Typical examples of substandard care are not monitoring the fetal heart during labour and not suctioning the mouth of a meconium stained infant before delivering the shoulders.

5-5 How are problems and avoidable factors identified?

Answers cannot be found before the problems and avoidable factors are identified. As problems (i.e. causes of maternal and perinatal deaths) differ between different services, hospitals or clinics , the particular problems have to be identified for each service, hospital or clinic. The avoidable factors associated with each problem may also vary between services, hospitals or clinics.

Regular mortality meetings are an excellent way of identifying problems and avoidable factors.

5-6 How can avoidable factors be classified?

Avoidable factors can usually be classified into one of three groups:

  1. Patient related factors.
  2. Health worker related factors.
  3. Administrative related factors.

For example, if a fetus or newborn infant dies of congenital syphilis and the mother failed to attend antenatal care, then the avoidable factor would have been patient related. However, if the mother attended the antenatal clinic but the health care worker failed to screen her for syphilis or failed to collect the result and treat her, then the avoidable factor would have been health worker related. Finally, if the mother attended antenatal clinic and the health worker wanted to screen her for syphilis but either transport or the facilities to perform the test were not available, then the avoidable factor would have been administrative related.

Some avoidable factors are obviously the cause of a maternal or perinatal death while other avoidable factors may have contributed to the death. Therefore, avoidable factors can be divided into probable and possible factors. Probable avoidable factors are most important. Often more than one probably avoidable factor will be present.

In addition, some substandard care may not be related to the death of an infant. This poor care can still be discussed at a perinatal mortality meeting although it will not be included as an avoidable cause of infant death.

  1. An honest error, e.g. overestimating the gestational age.
  2. An oversight, e.g. forgetting to measure the blood pressure.
  3. A serious deviation from the accepted practice, e.g. failing to see the patient when called to do so.

5-8 Why is it important to identify the specific avoidable factor?

Only when the specific avoidable factor or missed opportunity has been identified can steps be taken to prevent similar deaths in future. If one does not know why the care was substandard, it would be very difficult to solve the problem. Finding avoidable factors is an important step in improving care.

5-9 Where can you look for answers?

There are many sources where answers can be found once the problem has been identified. Some answers are easy to find. Unfortunately some problems still do not have easy or effective answers, e.g. how to prevent pre-eclampsia.

Answers can usually be found:

  1. By consulting colleagues, especially those at referral hospitals.
  2. In standard textbooks or journals.
  3. In training programmes, such as the Perinatal Education Programme.
  4. By attending courses.
  5. In local management protocols.
  6. In provincial or national guidelines.
  7. On the internet.

5-10 What changes should be made to reduce mortality rates?

Changes may be needed in a number of different areas:

  1. Changes in the general community, e.g. better housing, education and income.
  2. Changes may be needed in antenatal care, e.g. better booking rates, improved screening for hypertension and proteinuria.
  3. Better patient education, e.g. the importance of being aware of fetal movements and danger signs in pregnancy.
  4. Improved facilities and staff numbers.
  5. More continuing training for health workers.
  6. Adequate public transport and ambulance services.

5-11 How can these changes be made?

Once answers are found, there are number of steps which can be taken to introduce changes:

  1. Notifying the health authorities.
  2. Altering protocols in clinics and hospitals.
  3. Improving the frequency and content of training programmes.
  4. Involving the community.

However, it is not always easy to introduce the changes needed to reduce mortality. A clear idea of what changes are needed together with the ability to win the co-operation of the authorities and colleagues are essential.

Avoidable factors associated with maternal deaths

5-12 Can maternal deaths be prevented?

Yes. In almost half of the maternal deaths there was a an avoidable factor (missed opportunity for preventing that death or substandard care). Avoidable factors were far more common for direct causes (e.g. postpartum haemorrhage) than indirect causes (e.g. AIDS). The maternal mortality rate is still far too high in South Africa.

Note
Information on causes of maternal death and avoidable factors is taken from the Saving Mothers 2002–2004: Third report on confidential enquiries into maternal deaths in South Africa.
  1. No, late or inadequate antenatal care.
  2. Delay in seeking help during labour.
  3. Not recognising danger signs and symptoms.
  4. Self-induced termination of pregnancy.
  1. Failure to follow management protocols.
  2. Failure to adequately resuscitate acutely ill women.
  3. Inadequate anaesthetic experience.
  4. Poor record keeping.
  5. Delay in referral to a level 1 or 2 unit.
  1. Lack or delay of transport.
  2. Lack of intensive care facilities and theatres.
  3. Lack of enough, well trained midwives and medical officers.
  4. Poor communication between health workers.
  5. Lack of management protocols.
  6. Inadequate supply of blood.

Every effort must be made to get women to attend an antenatal care clinic from the time that pregnancy is confirmed. They must also be educated to recognise danger symptoms and signs and report immediately to a clinic or hospital as soon as these present:

  1. All pregnant women should be referred to an antenatal clinic as soon as their pregnancy is confirmed. This message should be made known to all general practitioners and other health care professionals.
  2. Pregnant women should plan to be delivered by a skilled attendant and not at home by a family member.
  3. Schools, community organisations, radio, newspapers, magazines and TV should stress the importance of early antenatal care and the common danger signs in pregnancy.

Patient related factors often depend on the family and community. For example, a husband or mother-in-law may prevent a pregnant woman going to the clinic or hospital as soon as labour starts, or transport my not be available at night.

Every effort must be made to provide good, early antenatal care to all pregnant women.

5-17 What can be done to improve the care provided by health workers?

  1. Ensure patient access to adequately staffed and equipped maternity services.
  2. Easily understandable management protocols are essential.
  3. Simple referral guidelines are essential.
  4. A culture of ‘patient friendly’ care must be developed in all health services.
  5. A system of good record keeping is essential.
  6. Basic training must be improved and ongoing ‘in-service’ education provided.
  7. Adequately staffed facilities for termination of pregnancy, antenatal and labour care must be made available in all districts.
  8. Provide good patient transport and telephone or radio communication.

Preventing maternal deaths

5-18 What are the key recommendations to prevent maternal deaths?

  1. Clearly understood protocols are needed to manage conditions which commonly result in maternal deaths.
  2. A simple set of referral criteria is needed.
  3. Adequate staffing and equipment norms are needed and must be implemented.
  4. The partogram must be used to monitor every labour.
  5. Blood and regional anaesthesia must be available at all institutions where Caesarean sections are performed.
  6. Midwife Obstetric Clinics (nurse base primary care clinics) must be established in urban areas.
  7. Termination of pregnancy services must be expanded.
  8. Family planning services must be supported especially for women over 30 years or with five or more children.
  9. A national HIV/AIDS policy must be widely implemented.

5-19 Should every maternal death be reported?

Yes. The routine reporting and a confidential enquiry into maternal deaths must be expanded to include all maternal deaths, especially in districts, regions and provinces where maternal deaths are still under reported. It is important to include all maternal deaths from private hospitals and the deaths that occur at home. Only when the majority of maternal deaths are reported can a reliable estimate of numbers, causes and avoidable factors be obtained.

5-20 What national HIV/AIDS policy is needed for pregnant women?

  1. Guidelines on how to manage pregnant women who are HIV positive must be implemented in all districts.
  2. HIV counselling, testing and prophylactic antiretrovirals must urgently be made available at all antenatal clinics in order to reduce the risk of mother-to-child transmission of HIV.
  3. Contraceptive advice and the option of terminating the pregnancy should be available.
  4. All clinics and hospitals have an obligation to their staff to ensure that the training and equipment is available to prevent HIV transmission to their staff (e.g. gloves, plastic aprons, glasses or masks, blunt-tipped needles, skin clips and sharps containers).
  5. CD4 screening must be done on all pregnant women who are HIV positive
  6. Combination antiretroviral treatment and prophylactic co-trimoxazole must be made available to all HIV positive pregnant women who meet the clinical or immunological criteria.

Avoidable factors associated with perinatal deaths

5-21 Can perinatal deaths be prevented?

Yes. In about a quarter of perinatal deaths there was a missed opportunity for preventing that death. The commonest avoidable factors are patient related. Unfortunately an avoidable factor often cannot be identified because of poor notes.

The commonest avoidable factors in perinatal death are patient related.

Note
n the 2003-6 Saving Babies report 16% of avoidable factors were patient related, 15% health worker related and 67% administrative related.

The commonest patient related factors are:

  1. No attendance, late attendance or irregular attendance for antenatal care.
  2. Inadequate response to decreased fetal movements.
  3. Inadequate response to rupture of the membranes.
  4. Inadequate response to antepartum haemorrhage.
  5. Delay in seeking medical attention in labour.

Failing to book early and then regularly attend antenatal care is the commonest patient related factor associate with perinatal death. Little understanding of the importance of antenatal care, long distances to the clinic and inadequate public transport all play an important role in poor attendance for antenatal care.

Inadequate antenatal care is the commonest patient related factor associated with perinatal death.

Because of poor antenatal clinic attendance, complications of pregnancy such as hypertension, decreased fetal growth and syphilis are not identified and managed.

  1. Transport delays in getting the patient between health institutions, e.g. getting a patient from a clinic to a hospital.
  2. Lack of adequate screening for syphilis.
  3. Too few staff or inadequately trained staff.
  4. Inadequate facilities, especially theatre and neonatal care facilities.

Inadequate transport to hospital is the commonest administrative related factor associated with perinatal death.

Health worker related factors may be divided into:

  1. Antepartum factors (during pregnancy).
  2. Intrapartum factors (during labour).
  3. Neonatal care factors (care of the infant after delivery).
  1. No response to a poor past obstetric history.
  2. Over or underestimating fetal size.
  3. No response to poor uterine growth.
  4. No response to poor fetal movement.
  5. No response to hypertension.
  6. Multiple pregnancy not diagnosed.
  7. No response to syphilis serology.
  8. No response to glycosuria.
  9. No response to postterm pregnancy.

No response by health workers to antenatal warning signs is a common avoidable factor associated with perinatal death.

  1. Partogram not used.
  2. Fetus not adequately monitored.
  3. Signs of fetal distress not interpreted correctly or ignored.
  4. No response to poor progress of labour.
  5. Prolonged second stage not managed correctly.
  6. Delay in calling a doctor or referring the patient.

Inadequate fetal monitoring is the commonest health worker related factor associated with perinatal death during labour.

  1. Inadequate resuscitation.
  2. Inadequate monitoring or management plan.
  3. Delay in calling for assistance or transferring the infant to a level 2 or 3 unit.

Inadequate resuscitation of the newborn is an important avoidable cause of perinatal death.

5-28 Which primary causes of neonatal mortality urgently need solutions?

The three main primary causes of neonatal mortality are:

  1. Spontaneous preterm delivery.
  2. Intrapartum hypoxia.
  3. Infection.

Preventing perinatal mortality

5-29 Can perinatal mortality be prevented?

Yes. Many perinatal deaths can be prevented:

  1. We know that the perinatal mortality rate in South Africa is far too high.
  2. We know what the major causes are.
  3. We have identified many of the avoidable factors.
  4. We know how to manage most of these problems.

All that we now need is a clear plan of action and the will to make the plan work.

With simple, good management many of the perinatal deaths can be prevented.

5-30 What should be done to reduce the perinatal mortality rate during pregnancy?

There are many avoidable factors which can be addressed to reduce the perinatal mortality. The most important are:

  1. Early booking, preferably at the time that pregnancy is diagnosed.
  2. On-site screening for syphilis and early treatment.
  3. Clear protocols for good routine antenatal care and indications for referral.
  4. Fetal growth monitoring using symphysis-fundal height measurements correctly.
  5. Teaching mothers to monitor fetal movements.
  6. Teaching mothers the danger signs of complications.

5-31 What should be done to reduce the perinatal mortality rate during labour?

  1. Correct use of the partogram in all labours.
  2. Correct method of monitoring the fetal heart rate.
  3. Clear protocols of management.
  4. Indications for referral.
  5. Adequate equipment that is maintained in good working order.

5-32 What should be done to reduce the perinatal mortality rate after delivery:

  1. Early diagnosis of birth asphyxia (not breathing well after delivery).
  2. Knowledge, skills and equipment for good resuscitation.
  3. Keep infants dry and warm.
  4. Kangaroo mother care.
  5. Weigh all infants to identify low birth weight infants.
  6. Good basic newborn care.
  7. Breastfeeding (preferably exclusive breastfeeding).

It is essential that the facilities, necessary equipment, management protocols and adequate numbers of well trained health workers are available at each clinic and hospital. It is every woman’s right to have a safe delivery.

5-33 Why do some infants die of intrapartum hypoxia?

Intrapartum hypoxia means that the fetus did not receive enough oxygen before delivery (usually during labour). The main reasons for fetal hypoxia are:

  1. Placental abruption.
  2. Prolonged or obstructed labour.
  3. Fetal growth restriction or wasting (poor fetal growth or weight loss).
  4. Maternal disease, e.g. pre-eclampsia, diabetes and syphilis.
  5. Prolapsed umbilical cord.

The infant may also developed hypoxia after delivery if they breathe poorly and are not well resuscitated.

5-34 What can be done to reduce the risk of fetal hypoxia?

Every effort should be made to prevent fetal hypoxia, and detect fetal distress as soon as it develops. Careful monitoring of the fetal condition and the progress of labour is essential. The partogram must be used correctly to detect poor progress of labour.

Fetal hypoxia presents with the signs of fetal distress, i.e. meconium stained liquor and late fetal heart rate decelerations (and poor beat-to-beat variability on the cardiotocogram).

Correct use of the partogram with careful fetal monitoring is essential.

5-35 How can monitoring of the fetal heart rate during labour be improved?

It is impractical to have a cardiotocograph (CTG) recorder in every labour ward. Therefore, the fetal heart must be monitored with an ordinary stethoscope, a fetal stethoscope or a hand held Doppler ultrasound fetal heart rate monitor (a ‘Doptone’). An ultrasound fetal heart rate monitor is by far the best as the fetal heart is often difficult to hear with an ordinary stethoscope or fetal stethoscope.

The fetal heart rate must be counted before contractions (to determine the baseline heart rate) and again during and at the end of a contraction (to detect any early or late decelerations). Late decelerations are caused by fetal hypoxia and indicate fetal distress. In a low risk labour, the fetal heart should be monitored every at least every hour.

Late decelerations must be carefully listened for.

5-36 What can be done to prevent hypoxia after delivery?

The most important cause of hypoxia in the newborn infant is failure to establish good respiration after birth (neonatal asphyxia). This results in a 1 minute Apgar score of less than 7. It is essential to detect neonatal asphyxia early and to resuscitate the infant well. Everyone delivering a newborn infant must be able to provide basic resuscitation, especially bag and mask ventilation. Oxygen is not necessary for resuscitation.

The most important step in newborn resuscitation is bag and mask ventilation.

5-37 What can be done to decrease the mortality of preterm infants?

While it is difficult to prevent preterm delivery, a lot can be done to prevent the early neonatal death of preterm infants:

1. Anticipation

2. Early recognition of neonatal asphyxia and good resuscitation

3. Initial newborn care

4. Ongoing care

As the prevention of preterm labour is often not possible, every effort must be made to give preterm infants better care.

5-38 How can Kangaroo Mother Care prevent neonatal deaths?

Kangaroo Mother Care (skin-to-skin care) keeps the infant warm, promotes bonding and breast feeding, reduces the risk of serious infection, and allows for earlier discharge. It is a simple, natural and cheap way of caring for small infants. It is very effective and significantly reduces the neonatal mortality of small infants, especially in poorly equipped facilities.

5-39 How can infection of the fetus be prevented?

  1. On-site screening all pregnant women for syphilis at their first antenatal visit. Usually the syphilis rapid test or RPR card test is used to screen for syphilis. Treatment must be started immediately.
  2. All young girls must be immunised against rubella before they reach puberty.
  3. Every effort must be taken to prevent the heterosexual spread of HIV. There is a particularly high risk of spread of HIV to the fetus if the mother becomes infected during pregnancy.
  4. Aseptic technique must be used during vaginal examinations.
  5. Prolonged rupture of the membranes should be avoided if possible.

5-40 What can be done to prevent infection during labour?

  1. Using an aseptic technique during vaginal examinations.
  2. Do not perform unnecessary vaginal examination in labour.
  3. Antiretroviral drugs for HIV positive women.

5-41 How can bacterial infection of the newborn infant be prevented?

  1. Breast feeding, especially exclusive breast feeding from the time of delivery.
  2. Wash or spray hands before handling an infant.
  3. Kangaroo mother care.
  4. Good cord care.
  5. Prophylactic eye care with chloramphenicol (Chloromycetin) ointment after birth.
  6. Discharge the infant home as soon as possible.

5-42 How can the risk of mother-to-child transmission of hiv be reduced?

  1. Antiretrovirals (AZT plus nevirapine) can reduce the risk of HIV transmission to less than 5%. Use antiretroviral treatment when indicated.
  2. The risk of passing on HIV after delivery can be prevented with formula feeds and significantly lowered with exclusive breast feeding.
  3. HIV negative women must be warned against the danger of HIV infection during pregnancy and while they are still breast feeding.
  4. Elective Caesarean section reduces the risk of HIV transmission during labour and delivery. This is usually not necessary with good antiretroviral prophylaxis.
  5. Avoid prolonged rupture of the membranes when possible.
  6. Avoid unnecessary episiotomies.

5-43 What can health administrators do to reduce perinatal mortality?

  1. Ensure accessible maternity care facilities.
  2. Basic equipment and facilities must be made available.
  3. Adequate numbers of staff are essential.
  4. Staff rotation must be stopped to build up a core of experienced midwives.
  5. Doctors and nurses should work as a team with clear management protocols.
  6. Midwives’ opinions should be respected.
  7. Continuing staff training is essential.
  8. A minimal data set must be collected and regular perinatal audit meetings arranged.
  9. A good transport and referral system must be set in place.

An adequate number of well trained staff are essential to reduce both maternal and perinatal mortality.

Case study 1

A young women presented at an antenatal clinic for the first time at 36 weeks of gestation, complaining of severe headache for two days. She was told to wait her turn but an hour later had a generalised convulsion. When she was found to be hypertensive, eclampsia was diagnosed. She was given an injection of phenobarbitone and an ambulance was ordered to transfer her to hospital. The referral hospital was not contacted. Unfortunately the ambulance was delayed. While waiting for the ambulance she had another convulsion and died.

The women booked very late for antenatal care. If she attended antenatal care from early in her pregnancy, she may have learned that severe headache was a danger sign and that she should have reported immediately to the clinic. Hypertension and proteinuria may also have been detected at an earlier visit.

2. What errors did the staff make?

There were a number of health worker related factors which were associated with this woman’s death. She should have been seen immediately but her severe headache was not recognised as a danger sign. The correct management protocol for convulsions was not followed and phenobarbitone was given instead. The staff should have discussed the problem with the referral hospital.

Yes. Transport was inadequate. The staff may also have been inadequately trained and there may not have been a management protocol for eclampsia.

4. How can early attendance for antenatal care be encouraged?

Schools, community organisations, radio, newspapers, magazines and TV should be used to inform the general public, and young women especially, about the important of antenatal care.

5. What can be done to improve the care provided at an antenatal clinic?

The clinic staff must be well trained and must develop a culture of ‘patient friendly’ care. Clear management protocols and referral criteria are essential, and they must communicate with their referral hospital if patients need to be referred.

6. How can the administration prevent similar maternal deaths at clinics?

Adequate staffing and facilities, good communication and transport must be provided. Ideally, each community should be within reach of a clinic.

Case study 2

In a review of potentially avoidable causes of perinatal death in an urban health service, a case study is discussed. The woman presented in labour and reported poor fetal movements for the past two days. A partogram was not used as a short labour was expected. The fetal heart was recorded every 4 hours. After a prolonged second stage with meconium stained liquor, a fresh stillborn infant was delivered by the midwife. The doctor had not been called.

Yes. The mother should have come to the clinic when she first noticed that the fetal movements had suddenly decreased. Failure to report important danger signs in pregnancy remains a common patient related factor in perinatal deaths.

2. Should a partogram have been used to monitor labour?

Yes. A partogram should always be used. Not using a partogram at all, or failing to use a partogram correctly, is common health worker related factor in potentially avoidable perinatal deaths. The condition of the mother and fetus, as well as the progress of labour, should have been carefully assessed at regular intervals. If this had been done correctly the stillbirth may have been avoided.

With meconium stained labour and a history of poor fetal movements, the fetal heart rate should have been very closely monitored (every half hour). In addition, the second stage of labour should not have been allowed to become prolonged. The doctor should also have been called. Important health worker related factors during labour, which are associated with perinatal deaths, include poor monitoring of the fetus, failure to detect fetal distress and poor response to fetal distress. Inadequate monitoring during labour is the commonest health worker related factor associated with perinatal deaths.

Inadequate resuscitation, poor monitoring of the infant, no management plan and a delay in calling for help. Inadequate resuscitation is a major preventable cause of early neonatal death.

5. What are the three primary causes of neonatal death which urgently need to be addressed in South Africa.

Spontaneous preterm labour, intrapartum hypoxia and infection. The case is an example of intrapartum hypoxia.

Case study 3

After reading the summary of early neonatal deaths in a large teaching hospital, the doctor in charge of newborn care decided that something drastic had to be done to reduce the unacceptably high early neonatal mortality rate. He called all the nursing and medical staff together to discuss the problem and make suggestions to prevent further deaths.

1. Can early neonatal deaths be prevented?

Yes. With simple, good management many early neonatal deaths can be prevented.

2. What is needed to prevent most early neonatal deaths?

Common causes of death and the important avoidable factors need to be identified. Then a clear plan to manage these common problems must be drawn up. As these are already available, all that is now required is the will to make the plan work.

3. What can be done during pregnancy to reduce the early neonatal death rate?

  1. Encourage early booking and practice good antenatal care.
  2. Screen for and treat syphilis.
  3. Monitor fetal growth and fetal movements.
  4. Teach pregnant women the danger signs.

Good antenatal care to prevent, detect and manage problems with the fetus should be made available to all pregnant women. It is better and cheaper to prevent than to treat a neonatal problem.

4. What should be done after delivery to reduce the early neonatal mortality rate?

  1. Diagnose and treat asphyxia.
  2. Keep infants warm and dry, preferably with kangaroo mother care.
  3. Weigh all infants to identify low birth weight infants who may need extra care.
  4. Promote exclusive breastfeeding.
  5. Provide good basic newborn care.

5. How can monitoring the fetal heart during labour be improved?

Staff must be taught to listen to and count the fetal heart rate between and immediately after the end of contractions in order to detect late decelerations. The fetal heart must be clearly heard, with a Doptone if necessary.

6. What simple steps can be done after delivery to prevent infection in the newborn infant.

  1. Encourage exclusive breastfeeding.
  2. Wash or spray hands before examining an infant.
  3. Promote kangaroo mother care.
  4. Give prophylactic cord and eye care.

7. How can the mother-to-child transmission of HIV be reduced?

  1. Offer HIV screening to all pregnant women.
  2. Antiretroviral drugs can halve the risk of HIV transmission to the infant.
  3. Exclusive breast or exclusive formula feed.