OBJECTIVES When you have completed this unit you should be able to: Find solutions to the common causes of maternal and perinatal deaths. List the potentially avoidable causes of maternal death. Take steps to prevent maternal death. List the potentially avoidable causes of perinatal death. Take steps to avoid the primary causes of perinatal death. Improve the care of newborn infants.

COPYRIGHT

All rights reserved. No part of this Perinatal Education Programme may be altered in any way without the written permission of the editorial board of the Perinatal Education Trust. To facilitate the improvement of perinatal care, the Programme may be reproduced for teaching purposes provided due acknowledgement is given and the material is not sold for financial profit. While the advice and information in the Programme is believed to be accurate, the editorial board cannot accept responsibility or liability for any errors or omissions that may have been made.

ISBN 0 7992 2141 4

FINDING SOLUTIONS

50-1 HOW CAN YOU FIND SOLUTIONS TO MATERNAL AND PERINATAL DEATHS?

There are a number of steps which are needed to find solutions:

1. Specific avoidable factors, missed opportunities and substandard care have to be identified.
2. You need to know where and how to look for answers to these problems.
3. Answers have to be found.
4. Changes have to be introduced.

50-2 WHAT IS AN AVOIDABLE FACTOR?

An avoidable factor is something which may have prevented the death, e.g. not immediately going to a clinic or hospital when abdominal pain with vaginal bleeding occurs during pregnancy.

Many avoidable factors are due to missed opportunities.

50-3 WHAT IS A MISSED OPPORTUNITY?

A missed opportunity is a chance to provide the correct care which was not taken. The opportunity was there to provide the correct management but the opportunity was missed, e.g. failing to measure the blood pressure at an antenatal visit or not screening for syphilis.

*** A missed opportunity is when an action or omission by the patient, administration or health worker results in an adverse outcome for the mother or infant.

50-4 HOW CAN YOU RECOGNISE SUBSTANDARD CARE?

Substandard care means that the care that the patient received fell below the standard that should have been offered to her. It is necessary to know what correct care is before substandard care can be recognised. Care may be substandard because of any of the following:

1. The patient did not go for care.
2. The facilities were inadequate.
3. Shortage of staffing or poor staff training.
4. Staff did not provide the correct care needed.

Substandard care often leads to avoidable factors and missed opportunities. Therefore, substandard care, avoidable factors and missed opportunities are often considered together as problems resulting in poor care. Typical examples of substandard care are not monitoring the fetal heart during labour and not suctioning the mouth of a meconium stained infant before delivering the shoulders.

*** The Perinatal Education Programme is often used as the basis of what primary or secondary level care should be provided.

50-5 HOW ARE PROBLEMS AND AVOIDABLE FACTORS IDENTIFIED?

Answers cannot be found before the problems and avoidable factors are identified. As problems (i.e. causes of maternal and perinatal deaths) differ between different services, hospitals or clinics , the particular problems have to be identified for each service, hospital or clinic. The avoidable factors associated with each problem may also vary between services, hospitals or clinics.

The method of identifying problems using the method of audit is discussed fully in Unit 49.

50-6 HOW CAN AVOIDABLE FACTORS BE CLASSIFIED?

Avoidable factors can usually be classified into one of three groups:

1. Patient related factors.
2. Health worker related factors.
3. Administrative related factors.

For example, if a fetus or newborn infant dies of congenital syphilis and the mother failed to attend antenatal care, then the avoidable fector would have been patient related. However, if the mother attended antenatal care and the health care worker failed to screen her for syphilis or failed to collect the result and treat her, then the avoidable factor would have been health worker related. Finally, if the mother attended antenatal clinic and the health worker wanted to screen her for syphilis but either transport or the facilities to perform the test were not available, then the avoidable factor would have been administrative related.

Some avoidable factors are obviously the cause of a maternal or perinatal death while other avoidable factors may have contributed to the death. Therefore, avoidable factors can be divided into probable and possible factors.

In addition, some substandard care may not be related to the death of an infant. This poor care can still be discussed at a perinatal mortality meeting although it will not be included as an avoidable cause of infant death.

50-7 HOW CAN AVOIDABLE FACTORS RELATED TO HEALTH WORKERS BE SUBDIVIDED?

1. An honest error, e.g. overestimating the gestational age.
2. An oversight, e.g. forgetting to measure the blood pressure.
3. A serious deviation from the accepted practice, e.g. failing to see the patient when called to do so.

50-8 WHY IS IT IMPORTANT TO IDENTIFY THE SPECIFIC AVOIDABLE FACTOR?

Only when the specific avoidable factor or missed opportunity has been identified can steps be taken to prevent similar deaths in future. If one does not know why the care was substandard, it would be very difficult to solve the problem. Finding avoidable factors is an important step in improving care.

50-9 WHERE CAN YOU LOOK FOR ANSWERS?

There are many sources where answers can be found. Some answers are easy to find. Unfortunately some problems still do not have easy or effective answers, e.g. how to prevent pre-eclampsia.

Answers can usually be found:

1. By consulting colleagues, especially those at referral hospitals.
2. In standard textbooks.
3. In training programmes, such as the manuals of the Perinatal Education Programme.
4. By attending courses.
5. In local management protocols.
6. In provincial or national guidelines.
7. On the internet.

50-10 WHAT CHANGES SHOULD BE MADE TO REDUCE MORTALITY RATES?

Changes may be needed in a number of different areas:

1. Changes in the general community, e.g. better housing, education and income.
2. Changes may be needed in antenatal care, e.g. better booking rates, improved screening for hypertension and proteinuria.
3. Better patient education, e.g. the importance of being aware of fetal movements and danger signs in pregnancy.
4. Improved facilities and staff numbers.
5. More continuing training for health workers.
6. Adequate public transport and ambulance services.

50-11 HOW CAN THESE CHANGES BE MADE?

Once answers are found, there are number of steps which can be taken to introduce changes:

1. Notifying the health authorities.
2. Altering protocols in clinics and hospitals.
3. Improving the frequency and content of training programmes.
4. Notifying and involving the community.

However, it is not always easy to introduce the changes needed to reduce mortality. A clear idea of what changes are needed together with the ability to win the co-operation of the authorities and colleagues.

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