Criteria-Based Audit of Quality of Care to Women with Severe Pre-Eclampsia and Eclampsia in a Referral Hospital in Accra, Ghana

Abstract

ObjectivesSevere pre-eclampsia and eclampsia are one of the major causes of maternal mortality globally. Reducing maternal morbidity and mortality demands optimizing quality of care. Criteria-based audits are a tool to define, assess and improve quality of care. The aim of this study was to determine applicability of a criteria-based audit to assess quality of care delivered to women with severe hypertensive disorders in pregnancy, and to assess adherence to protocols and quality of care provided at a regional hospital in Accra, Ghana.MethodsChecklists for management of severe preeclampsia, hypertensive emergency and eclampsia were developed in an audit cycle based on nine existing key clinical care protocols. Fifty cases were audited to assess quality of care, defined as adherence to protocols. Analysis was stratified for complicated cases, defined as (imminent) eclampsia, perinatal mortality and/or one or more WHO maternal near miss C-criteria.ResultsMean adherence to the nine protocols ranged from 15–85%. Protocols for ‘plan for delivery’ and ‘magnesium sulphate administration’ were best adhered to (85%), followed by adherence to protocols for ‘eclampsia’ (64%), ‘severe pre-eclampsia at admission’ (60%), ‘severe pre-eclampsia ward follow-up’ (53%) and ‘hypertensive emergency’ (53%). Protocols for monitoring were least adhered to (15%). No difference was observed for severe disease. Increased awareness, protocol-based training of staff, and clear task assignment were identified as contributors to better adherence.ConclusionA criteria-based audit is an effective tool to determine quality of care, identify gaps in standard of care, and allow for monitoring and evaluation in a health facility, ultimately resulting in improved quality of care provided and reduced maternal morbidity and mortality. In our audit, good adherence was observed for plan for delivery and treatment with magnesium sulphate. Substandard adherence to a number of protocols was identified, and points towards opportunities for targeted improvement strategies.

Effect of locally tailored clinical guidelines on intrapartum management of severe hypertensive disorders at Zanzibar's tertiary hospital (the PartoMa study)

“…Although evidence suggests that severe hypertension is a similarly important contributor to maternal mortality in sHDP, antihypertensives are not included in the signal functions, and this omission might have contributed to more than half of the women with sHDP at baseline not receiving antihypertensive treatment. A similar mismatch in pre‐eclampsia/eclampsia treatment was reported in Ghana, where health providers described how clinical guidelines were adhered to more closely if they were given more attention and if local adjustments were made . A second version of the brief and simple PartoMa pocket guide was launched in 2018, with the focal point broadened further by including additional essential intrapartum and postpartum care, and PartoMa seminars have now been conducted for nearly 4 years…”

“…A previous facility‐based survey in low‐ and middle‐income countries found that the likelihood of maternal near‐miss was eightfold and perinatal death threefold higher in a group of women with pre‐eclampsia than in a reference group without HDP . Although most cases are preventable, undiagnosed or suboptimally treated HDP is repeatedly reported in sub‐Saharan Africa . This violates human rights and is a key priority for safe motherhood …”

“…Lifesaving treatment includes induction and/or oxytocin augmentation of labor while stabilizing blood pressure (BP) and supporting vital organ functions . In high‐volume low‐resource hospitals, urgent intrapartum diagnosis, surveillance, and management of such complex diseases are challenging and need realistic practical guidance …”

“…In Tanzania, however, only one‐third of maternity units have emergency obstetric care guidelines available, and only one‐quarter have at least one birth attendant with adequate training in applying these . Even if available, guidelines are often not tailored to low‐resource settings . Unachievable international guidelines limit implementation and may demoralize staff.…”

“…2 Although most cases are preventable, undiagnosed or suboptimally treated HDP is repeatedly reported in sub-Saharan Africa. [3][4][5][6][7][8][9][10] This violates human rights and is a key priority for safe motherhood. 11,12 Hypertensive disorders in pregnancy can rapidly progress in severity, with increased risk of organ failure such as cerebral hemorrhage, coagulopathy, eclampsia, and pulmonary edema.…”