Gunilla Lindmark

Criteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the use of a CBA to improve quality of care among eclampsia patients admitted at a University teaching hospital in Dar es Salaam Tanzania.

The functional referral system is important in backing-up antenatal, labour and delivery, and postnatal services in the primary level of care facilities. The aim of this study was to evaluate the effectiveness of the maternal referral system through determining proportion of women reaching the hospitals after referral advice, appropriateness of the referral indications, reasons for non-compliance and to find out if compliance to referrals makes a difference in the perinatal outcome.

The high rate of antenatal care attendance in sub-Saharan Africa, should facilitate provision of information on signs of potential pregnancy complications. The aim of this study was to assess quality of antenatal care with respect to providers' counselling of pregnancy danger signs in Rufiji district, Tanzania.

To describe the process of change and assess compliance and effect on maternal and infant outcome when the WHO package Effective Perinatal Care (EPC) was implemented at maternities in Ukraine. Intervention study comparing outcomes before and during 2.5 years after training. Three maternities in Donetsk, Lutsk and Lviv 2003-2006. Baseline data were collected for 652, 742 and 302 deliveries and 420, 381 and 135 infants, respectively, in Donetsk, Lutsk and Lviv. Follow-up data included 4,561, 9,865 and 7,227 deliveries and 3,829, 8,658 and 6,401 infants. Staff training on evidence-based guideline. Interventions during labor, maternal outcomes and hypothermia in the infants. EPC procedures were successfully implemented and adherence to the protocols was excellent. For most variables, the change occurred during the first three months but was well sustained. The use of partogram increased fourfold in Donetsk and from 0% to 60% in Lviv. Induction and augmentation of labor decreased to less than 1% and less than 5%, respectively. Cesarean section rate dropped significantly in two of the maternities. The proportion of hypothermic infants decreased from 60% (Donetsk), 85% (Lutsk) and 77% (Lviv) to 1% in all three maternities during the first three months and was stable throughout the study period. Admission to Neonatal Intensive Care Unit decreased significantly in two of the maternities and there was no effect on early neonatal mortality. The process of education and change was well anchored in the organization, and implementation of new procedures was quick and successful.

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).

Criteria-based audits have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the introduction of a criteria-based audit in a tertiary hospital in an African setting, assesses the quality of care among eclampsia patients and discusses possible interventions in order to improve the quality of care.

Awareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. The objectives of this study were to assess women's awareness of danger signs of obstetric complications and to identify associated factors in a rural district in Tanzania.

To estimate the effect of the severity of maternal anaemia on various perinatal outcomes. A cross-sectional study. Labour Ward, Muhimbili National Hospital, Dar es Salaam, Tanzania. The haemoglobin of eligible pregnant women admitted for delivery between 15 November 2002 and 15 February 2003 was measured. Data on socio-demographic characteristics, iron supplementation, malaria prophylaxis, blood transfusion during current pregnancy, and current and previous pregnancy outcomes were collected and analysed. Anaemia was classified according to the World Health Organization (WHO) standards: normal--Hb > or = 11.0 g/dl; mild--Hb 9.0-10.9 g/dl; moderate--Hb 7.0-8.9 g/dl; and severe--Hb < 7.0 g/dl. Logistic regression analysis was performed to estimate the severity of anaemia. The following outcome measures were used: preterm delivery (<37 weeks), Apgar score, stillbirth, early neonatal death, low birth weight (LBW) (<2500 g) and very low birth weight (VLBW) (<1500 g). A total of 1174 anaemic and 547 non-anaemic women were enrolled. Their median age was 24 years (range 14-46 years) and median parity was 2 (range 0-17). The prevalence of anaemia and severe anaemia was 68% and 5.8%, respectively. The risk of preterm delivery increased significantly with the severity of anaemia, with odds ratios of 1.4, 1.4 and 4.1 respectively for mild, moderate and severe anaemia. The corresponding risks for LBW and VLBW were 1.2 and 1.7, 3.8 and 1.5, and 1.9 and 4.2 respectively. The risks of preterm delivery and LBW increased in proportion to the severity of maternal anaemia.

Background. Traditionally, risk identification in early pregnancy in Swedish antenatal care [ANC] is performed by the midwife at booking, and confirmed by the doctor at a routine visit in early pregnancy, but this extra visit has been questioned. This study compared the risk assessment by the two professions. Methods. In a cluster randomised trial, a planning conference, where midwives reported new mothers to a doctor, replaced the routine consultation with the doctor. Ten ANC‐clinics with the new program (942 mothers) were compared to 10 clinics with standard care (758 mothers). Risk factors were registered independently by midwives and doctors. Degree of agreement in risk identification between midwives and doctors was estimated by the kappa coefficient. Results. The degree of agreement in risk registration was good for previous pregnancy complications (κ = 0.62; CI: 0.55–0.68), and recommendations for doctor's consultation (κ = 0.67; CI: 0.62–0.72); fair for social problems (κ = 0.29; CI: 0.03–0.55), and poor for registration of symptoms and problems in index pregnancy (κ = 0.09; CI: 0.03–0.21) and psychosocial aspects, such as anxiety (κ = 0.09; CI: 0.03–0.21). Significantly more risk factors were registered in the study group. Conclusions: Replacing the routine consultation with the doctor early in pregnancy with a planning conference had no negative impact on risk identification. The results support that the different perspectives of the two professions in combination are important for the safety of surveillance and the psychosocial support expected from antenatal care.

Background In order to assess the effectiveness of antenatal care for prevention of eclampsia, a retrospective case‐control study was performed at the Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania. All women with eclampsia seen at MNH during 1999–2000 and controls without eclampsia were included. Methods. The study used a labor ward database and antenatal cards of eclamptic women and non‐eclamptic controls. For each of the 741 eclamptic women who delivered at MNH, two non‐eclamptic controls were chosen from the database. For 399 of the eclampsia cases and 420 non‐eclamptic controls, the antenatal records could be traced and compared. Main outcome measures. Maternal and perinatal mortality, detection of antenatal risk factors, appropriate referrals, and incidence of eclampsia. Results. Hospital and population‐based incidences of eclampsia were 200/10 000 and 67/10 000, respectively. The case‐fatality rate for eclampsia was 5.0% for women who delivered at MNH and 16% for those referred to MNH after being delivered elsewhere. The risk of low birth weight and perinatal death was significantly increased in eclamptic women (odds ratio = 6 and 10, respectively). The screening coverage for signs of pre‐eclampsia was >85%, except for proteinuria (33%). Fewer than 50% of the women who developed eclampsia had been referred from the ANC clinic and Conclusions. The current practice of antenatal care is insufficient as a prevention strategy for eclampsia in a low‐resource setting with high incidence of eclampsia.