ABSTRACT
This study was the first assessment of a nationwide risk approach system to antenatal management introduced to Malaysia in 1989. Three rapid, record-based surveys on three different study groups were conducted to determine risk factor prevalence, accuracy of risk assignment, action after risk assignment and the relationship of risk level and place of delivery. The most frequent risk factors were short birth interval, high parity and first pregnancy. Accuracy of risk assignment was highest at the lowest levels of risk and poorest at the highest levels. Women at the lowest levels of risk were more likely to be seen by a doctor than women at highest risk. These was a trend to deliver in hospital, rather than at home, as level of risk increased; but many women at high risk still delivered at home. Recommendations are made on modifications to the system prior to future evaluation.
PIP: In 1990 in Malaysia, 3 distinct surveys were conducted as part of an assessment of a nationwide risk approach system to prenatal management introduced in 1989. After history-taking and examination, a health worker completed a risk checklist, then determined what risk category the pregnant woman belonged to and assigned her chart a color code. Red means a life-threatening condition and immediate labor ward admission. Yellow means risk factors requiring antenatal monitoring and treatment by a physician. White means no risk, so the midwife or the community nurse can monitor the pregnant women. Green means that complications may occur and a senior nurse should monitor the woman's progress. The first survey included all pregnant women attending prenatal clinics in Pasir Mas District, Kelantan State, for the first time. The second survey was a retrospective check of the prenatal cards of all pregnant women attending these clinics within the same area over a 1-week period in January 1990. The third retrospective, record-based survey included all women who delivered in the study area during February 1990. Both the clinic staff and the study team classified 75% of the women as high risk. Only 44.4% of antenatal cards had a completed risk checklist, more than 33% of which were completed after the clinic. The most common risk factors were short birth interval (47.5%) and high parity (i.e., gravida 6 or above) (27.2%). Almost 50% of women coded green delivered at home, when they should have delivered at the hospital, suggesting that they disregarded clinic advice. Sensitivity of the code approach was better at a lower level of risk than at higher levels (71.2% for green vs. 43.2% for yellow and 0 for red). Misunderstanding of risk criteria or coding to own clinical judgment accounted for the incorrect coding by health staff. Overall, midwives were knowledgeable and competent. They knew their communities and clients well. Based on these findings, the researchers suggest replacing the risk checklist with at least 1 laminated reference checklist displayed prominently in the clinic. Further evaluation is needed.
