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      Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania

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          Abstract

          Background

          Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR).

          Methods

          From 1 st August, 2007 to 31 st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient.

          Results

          The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors.

          Conclusion

          There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.

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          Most cited references23

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          The Measurement of Observer Agreement for Categorical Data

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            The epidemiology of adverse pregnancy outcomes: an overview.

            This paper provides an overview of the occurrence, etiology and temporal trends of adverse pregnancy outcomes. Disparities between developed and developing countries are highlighted for maternal mortality, infant mortality, stillbirth and low birth weight. The higher rate of low birth weight in developing countries is primarily due to intrauterine growth restriction rather than preterm birth. Much of the excess intrauterine growth restriction is caused by short maternal stature, low prepregnancy body mass index and low gestational weight gain (due to low energy intake). No important contribution has been established for micronutrient intake, nor have different fetal growth trajectories been demonstrated to reflect the timing of exposure to nutritional or other etiologic factors. Infant mortality has declined substantially over time both in developed and developing countries despite no decline (and even an increase) in low birth weight. Several developed countries have reported a temporal increase in fetal growth in infants born at term, a reduction in stillbirth rates and prevention of neural tube defects. More progress is required, however, in understanding the etiology and prevention of preterm birth.
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              No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths.

              Fewer than 3% of 4 million annual neonatal deaths occur in countries with reliable vital registration (VR) data. Global estimates for asphyxia-related neonatal deaths vary from 0.7 to 1.2 million. Estimates for intrapartum stillbirths are not available. We aimed to estimate the numbers of intrapartum-related neonatal deaths and intrapartum stillbirths in the year 2000. Sources of data on neonatal death included: vital registration (VR) data on neonatal death from countries with full (> 90%) VR coverage (48 countries, n = 97,297); studies identified through literature searches (> 4000 abstracts) and meeting inclusion criteria (46 populations, 30 countries, n = 12,355). A regression model was fitted to cause-specific proportionate mortality data from VR and the literature. Predicted cause-specific proportions were applied to the number of neonatal deaths by country, and summed to a global total. Intrapartum stillbirths were estimated using median cause-specific mortality rate by country (73 populations, 52 countries, n = 46,779) or the subregional median in the absence of country data. Intrapartum-related neonatal deaths were estimated at 0.904 million (uncertainty 0.65-1.17), equivalent to 23% of the global total of 4 million neonatal deaths. Country-level model predictions compared well with population-based data sets not included in the input data. An estimated 1.02 million intrapartum stillbirths (0.66-1.48 million) occur annually, comprising 26% of global stillbirths. Intrapartum-related neonatal deaths account for almost 10% of deaths in children aged under 5 years. Intrapartum stillbirths are a huge and invisible problem, but are potentially preventable. Programmatic attention and improved information are required.
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                Author and article information

                Journal
                BMC Pregnancy Childbirth
                BMC Pregnancy and Childbirth
                BioMed Central
                1471-2393
                2009
                19 September 2009
                : 9
                : 45
                Affiliations
                [1 ]Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
                [2 ]Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
                [3 ]Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences, Umeå University, Umeå, Sweden
                [4 ]Department of Obstetrics, Leiden University Medical Centre and Section of Health care and Culture, VU University Medical Centre, Amsterdam, The Netherlands
                [5 ]Department of Clinical Science, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden
                [6 ]Department of Women's and Children's Health, Academic Hospital, Uppsala, Sweden
                Article
                1471-2393-9-45
                10.1186/1471-2393-9-45
                2754979
                19765312
                d12a329c-1479-4903-93a1-2c7d756c337e
                Copyright © 2009 Kidanto et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 27 May 2009
                : 19 September 2009
                Categories
                Research Article

                Obstetrics & Gynecology
                Obstetrics & Gynecology

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