Emergency obstetric care in developing countries: impact of guidelines implementation in a community hospital in Senegal

Abstract

Objective: To evaluate, with volunteer professionals in a resource-poor setting, an approach of audit and feedback to promote local implementation of emergency obstetric guidelines.

Design: Triple cohort observational time series study.

Setting: A 46-bed obstetric unit in an academic-affiliated community hospital in Senegal.

Population: All pregnant women with haemorrhagic and hypertensive complications who were admitted to the maternity unit during the study periods.

Methods: To assess the benefits of guidelines implementation, maternal outcomes during the intervention period were compared with those occurring in two one-year periods when staff daily supervision was the main potentially effective action on clinical management.

Main outcome measures: The intervention strategy was criteria-based audits with regular feedback over a one-year period. The clinical focus was haemorrhage and hypertension the most frequent causes of maternal death in the study population. Hospital charts were audited by external reviewers. The primary outcome was the case fatality rate (CFR) among patients with haemorrhage and hypertension.

Results: There was an increase in morbidity diagnoses during the intervention period. In addition, there was a marked increase in obstetric interventions, especially for transfusions and caesarean deliveries. Patients characteristic-adjusted case fatality decreased by 53% between baselines I and II and during the intervention period by 33% and 24%, compared with baseline periods I and II, respectively. Outcome improvements were different for haemorrhage and hypertension.

Conclusion: While staff daily supervision may have improved maternal outcome before the intervention period, audit and feedback produced marked effects on emergency obstetric care, specially for complications requiring highly trained management (e.g. pre-eclampsia). Audit and feedback are one of the potentially effective guidelines implementation strategies that should be considered for further studies in resource-poor health facilities.