Can hospital audit teams identify case management problems, analyse their causes, identify and implement improvements? A cross-sectional process evaluation of obstetric near-miss case reviews in Benin.

BACKGROUND: Obstetric near-miss case reviews are being promoted as a quality assurance intervention suitable for hospitals in low income countries. We introduced such reviews in five district, regional and national hospitals in Benin, West Africa. In a cross-sectional study we analysed the extent to which the hospital audit teams were able to identify case management problems (CMPs), analyse their causes, agree on solutions and put these solutions into practice. METHODS: We analysed case summaries, women's interview transcripts and audit minutes produced by the audit teams for 67 meetings concerning one woman with near-miss complications each. We compared the proportion of CMPs identified by an external assessment team to the number found by the audit teams. For the latter, we described the CMP causes identified, solutions proposed and implemented by the audit teams. RESULTS: Audit meetings were conducted regularly and were well attended. Audit teams identified half of the 714 CMPs; they were more likely to find managerial ones (71%) than the ones relating to treatment (30%). Most identified CMPs were valid. Almost all causes of CMPs were plausible, but often too superficial to be of great value for directing remedial action. Audit teams suggested solutions, most of them promising ones, for 38% of the CMPs they had identified, but recorded their implementation only for a minority (8.5%). CONCLUSIONS: The importance of following-up and documenting the implementation of solutions should be stressed in future audit interventions. Tools facilitating the follow-up should be made available. Near-miss case reviews hold promise, but their effectiveness to improve the quality of care sustainably and on a large scale still needs to be established.

Validity and reliability of postpartum morbidity questionnaires in Benin.

We describe the validity and reliability of midwife-administered postpartum questionnaires in home and clinic settings. Women identified prospectively before or following hospital delivery (n = 476), September 2004-January 2005, were re-contacted at 6 months postpartum for home interview and medical examination. Reliability was measured by comparing women's responses to the same questions at home and in clinic interviews. Validity was measured by comparing questionnaire responses with results of medical examination. Reliability of responses to questions comparing home and clinic interview was very good (κ > 0.6) for resumption of menstruation and occurrence of hemorrhoids, moderate (0.4 < κ ≤ 0.6) for weight loss and incontinence, and poor (κ ≤ 0.4) for burning sensation or pain on urination and exhaustion or fatigue. The home and clinic interviews had poor validity for detecting common postpartum morbidities: anaemia (sensitivity 33.7%, specificity 65.7%), urinary incontinence (5.1, 98.1%), urinary tract infection (2.1, 94.5%), prolapse (18.2, 91.2%); but good validity for hemorrhoids (71.4, 86.9%). In this setting, questionnaire-based interviews were neither reliable nor valid tools for measuring morbidity at 6 months postpartum. A medical examination is required to identify and measure the levels of morbidity up to 6 months postpartum.

Effects of severe obstetric complications on women's health and infant mortality in Benin.

OBJECTIVE: To document the impact of severe obstetric complications on post-partum health in mothers and mortality in babies over 12 months in Benin and to assess whether severe complications associated with perinatal death are particularly likely to lead to adverse health consequences. METHODS: Cohort study which followed women and their babies after a severe complication or an uncomplicated childbirth. Women were selected in hospitals and interviewed at home at discharge, and at 6 and 12 months post-partum. Women were invited for a medical check-up at 6 months and 12 months. RESULTS: The cohort includes 205 women with severe complications and a live birth, 64 women with severe complications and perinatal death and 440 women with uncomplicated delivery. Women with severe complications and a live birth were not dissimilar to women with a normal delivery in terms of post-partum health, except for hypertension [adjusted OR = 5.8 (1.9-17.0)], fever [adjusted OR = 1.71 (1.1-2.8)] and infant mortality [adjusted OR = 11.0 (0.8-158.2)]. Women with complications and perinatal death were at increased risk of depression [adjusted OR = 3.4 (1.3-9.0)], urine leakages [adjusted OR = 2.7 (1.2-5.8)], and to report poor health [adjusted OR = 5.27 (2.2-12.4)] and pregnancy's negative effects on their life [adjusted OR = 4.11 (1.9-9.0)]. Uptake of post-natal services was poor in all groups. CONCLUSION: Women in developing countries face a high risk of severe complications during pregnancy and delivery. These can lead to adverse consequences for their own health and that of their offspring. Resources are needed to ensure that pregnant women receive adequate care before, during and after discharge from hospital. Near-miss women with a perinatal death appear a particularly high-risk group.

When to start supplementary iron to prevent iron deficiency in early childhood in sub-Saharan Africa setting.

BACKGROUND: To study the efficacy of oral ferrous fumarate, an inexpensive, readily available preparation on iron deficiency in infants in Africa. PROCEDURE: Four months old (group 1, n = 252) and 6-18 months old (group 2, n = 360) healthy infants attending four primary health care centers (PHC) for vaccination/well-child visits in Benin were studied. Ninety-six pregnant women (PW) over 36 weeks gestational age attending the same PHC during the study period were also studied. Infants were offered 2 months supplementation with oral powdered generic ferrous fumarate (GFF), that is, 5 mg/kg/day of elemental iron, given twice and were reevaluated 2 months later for hematological indices. The prevalence of anemia and iron deficiency among pregnant women was assessed using hematological indices and transferrin saturation. RESULTS: The prevalence of anemia was 42.0%, 61.9%, and 37.5% in groups 1, 2, and PW, respectively. All anemic PW were iron deficient. Hemoglobin level shifted towards high values after supplementation. In addition, 24 infants from group 1 whose mothers interrupted the treatment, showed a significant decrease in hemoglobin level values, and similar improvement after two additional months of supplementation. CONCLUSION: Programs to prevent iron deficiency in Africa should utilize inexpensive preparations, start during pregnancy, continue in infants at 3 months of age and address problems of noncompliance.

Distribution of causes of maternal mortality during delivery and post-partum: results of an African multicentre hospital-based study.

OBJECTIVE: To assess the maternal mortality ratio in maternity units of reference hospitals in large west African cities, and to describe the distribution of complications and causes of maternal deaths. STUDY DESIGN: Prospective descriptive study in twelve reference maternities located in three African countries (Benin, Ivory Coast, Senegal). Data (clinical findings at hospital entry, medical history, complications, type of surgery, vital status of the women at discharge) were collected from obstetrical and surgical files and from admission hospital registers. All cases of maternal deaths were systematically reviewed by African and European staff. RESULTS: Of a total of 10,515 women, 1495 presented a major obstetric complication with dystocia or inappropriate management of the labour phase as the leading cause. Eighty-five maternal deaths were reported, giving a global hospital-based maternal mortality ratio of 800/100,000. Hypertensive disorders were involved in 25/85 cases (29%) and post-partum haemorrhage in 13/85 cases (15%). Relatively few cases (14) of major sepsis were reported, leading to three maternal deaths. CONCLUSION: The results of this multicentre study confirm the high rates of maternal mortality in maternity units of reference hospitals in large African cities, and in addition to dystocia the contribution of hypertensive disorders and post-partum haemorrhage to maternal deaths.

Obstetric audit in resource-poor settings: lessons from a multi-country project auditing 'near miss' obstetrical emergencies.

This paper outlines the practical steps involved in setting up and running multi-professional, in-depth case reviews of 'near miss' obstetrical complications. It draws on lessons learned in 12 referral hospitals in Benin, Côte d'Ivoire, Ghana and Morocco. A range of feasibility indicators are presented which measured the implementation and frequency of audit activities, the quality of participation, adherence to the planned protocol for the near-miss audits, the quality of audit discussions and the sustainability of the project. Although the principles of the audit approach were well accepted and implemented everywhere, near-miss audits appeared most successful in first referral level hospitals. Contextual factors that determine the successful implementation of near-miss audit include staff finding adequate time for audit activities, financial incentives to groups rather than individuals, involvement of senior staff and hospital managers, the ease of communication in smaller units, the employment of social workers for the incorporation of women's views at audits, and the strength of external support provided by the research team. The poor quality of information recorded in case notes was recognized everywhere as a deficiency, but did not present a major obstacle to effective case reviews. Ownership and leadership within the hospital, more easily achieved in the first-level referral hospitals, were probably the most important determinants of successful implementation. Sustainability requires a commitment to audit from policy makers and managers at higher levels of the health system and some devolution of resources for implementing recommendations.

Costs of near-miss obstetric complications for women and their families in Benin and Ghana.

This paper estimates the total cost to women and their families associated with a spontaneous vaginal delivery and five types of 'near-miss' obstetric complication in Benin and Ghana, and assesses affordability in relation to household cash expenditure. A retrospective evaluation of costs was carried out among 121 mothers in three hospitals in Ghana. A prospective evaluation of costs was undertaken among 420 pregnant women in two hospitals in Benin. Information was collected on the cost of travel to the facilities and of direct medical and non-medical costs incurred during their stay in hospital. In Benin, costs ranged from an average of 15 US dollars for a spontaneous delivery to 256 US dollars for a near-miss complication caused by dystocia. In Ghana, average costs ranged from 18 US dollars for a spontaneous vaginal delivery to 115 US dollars for a near-miss complication caused by haemorrhage. Medical costs accounted for the largest share of total costs, mainly drugs and medical supplies in Ghana and costs of the delivery and any surgical intervention in Benin. Payments associated with a spontaneous vaginal delivery amounted to at least 2% of annual household cash expenditure in both countries. In the case of severe obstetric complications, costs incurred reached a high of 34% of annual household cash expenditure in Benin. The economic burden of hospital-based delivery care in Ghana and Benin is likely to deter or delay women's use of health services. Should a woman develop severe obstetric complications while in labour, the relatively high costs of hospital care could have a potentially catastrophic impact on the household budget.

Effect of a comprehensive clinical care program on disease course in severely ill children with sickle cell anemia in a sub-Saharan African setting.

Clinical severity of sickle cell anemia (SS) in Africa may not be solely determined by genetic factors. This study evaluated the effects of intensive parental education and adequate clinical care on the course of SS in children in Benin. SS children referred to the National Teaching Hospital in Cotonou were included in the study. Teaching about SS was repeated frequently, emphasizing the importance of keeping clinic appointments, improving the nutrition of the affected children, and instituting antipneumococcal and antimalarial prophylaxis. Frequency and severity of SS-related events, changes in physical growth, frequency of malarial attacks, causes of transfusion, and causes of death were the principal variables assessed. 236 young children with repeated SS-related acute complications were studied from July 1, 1993, to December 31, 1999 (983 patient-years). A marked reduction in the frequency and severity of SS-related acute events was observed. Improvement in general status and physical growth was noted in 184 patients (78%); in addition, 22 of the remaining 52 patients showed similar improvement after remotivating the parents for compliance. There were 10 deaths, primarily in this cohort of 52 patients. Intensive sociomedical intervention can produce sustained clinical improvement in many severely ill SS children in sub-Saharan Africa.

[Effect of antenatal gymnastics on childbirth: a study on 50 sedentary women in the Republic of Benin during the second and third quarters of pregnancy]. / L'effet de la gymnastique prénatale sur l'accouchement: étude sur 50 femmes béninoises sédentaires au cours des deuxième et troisième trimestres de grossesse.

Antenatal gymnastics is a form of non-pharmacological childbirth preparation methods. It helps maintain rachidian statics and to relieve painful syndromes (joints, lumbar pains) during pregnancy. It also helps correct gravidic problems (leg cramps, back ache, weight increase, etc.). It is both a physical and psychological training method in accordance with the natural mechanisms of childbirth, implying personal involvement on the part of the parturient. Fifty (50) pregnant women of Benin (apart from pathological pregnancies) divided into two groups of 25 subjects (experimental group) and 25 subjects (control group) voluntarily took part in the study after having given their written assent. Each involved subject is paired with a counterpart of control following the same criteria: age of the gestante, parity, characteristic of the pelvis. Subjects aged from 17 to 42 trained twice a week with a minimum of 24 hours rest between two sessions; the training period intensity of exercise is limited to 60% of the maximum heart frequency and each training session lasts 45 min. The results show a lower number of caesareans and a significant lower number of untorn perineas in the experimental group. Apgar scores are also statistically higher in the children of trained women. This study confirms that sedentary pregnant women without any medical counter-indications (repetitive miscarriages, premature births, placenta praevia, cervical gaping, cardiac diseases, hypertension, narrow pelvis) can participate in antenatal gymnastics at a moderated rhythm, for their own benefit and that of their babies. Muscular force improvement (quality of the abdominal pushing), psychological control (absence of stress and panic), and good body form, can be noticed in trained mothers. However, abnormal presentation of baby, fetal suffering and the inherent characteristics of the pelvis (narrow) are factors requiring a caesarean. On the whole, antenatal gymnastics is an effective non-pharmacological means to avoid complications in childbirth. This method might be one of the solutions which could benefit pregnant women in Africa, considering its low cost compared to the exorbitant cost of medicines and hospitalisation.