From: Impact of maternal death reviews at a rural hospital in Zambia: a mixed methods study
Core area | Challenges | Opportunities |
---|---|---|
Standards of practice | Health Center • Absent or incomplete screening during antenatal care visits (e.g. hemoglobin, urinalysis, rapid plasma reagin, CD4 testing for mothers with human immunodeficiency virus [HIV] infection) • Late initiation of antiretroviral therapy (ART) among those with HIV infection • Mothers with high risk pregnancies who should have been advised to deliver in a hospital but were not • Measuring and recording of vital signs not done in some cases • Slow to recognize criteria for referral to higher level of care • Preliminary care not provided prior to referral • Incomplete or unclear documentation Hospital • Partograph use and/or interpretation errors • Missed or delayed diagnosis • Oxytocin errors • Unnecessary fundal pressure • Antibiotic prophylaxis not given when indicated • Inadequate investigation of postpartum fever • Inadequate wound care • Poor sterilization procedure • Incomplete or unclear documentation | • Routine training by district hospital and Ministry of Health (MOH) of rural health facility providers regarding antenatal screening procedures and approach to high-risk pregnancies, including prevention of mother-to-child HIV transmission • Universal application of partograph monitoring of labor • Ensuring adequate staffing to enable reliable monitoring of contractions when oxytocin is administered • Recruitment during obstetric emergencies of non-obstetric nursing staff to assist midwives • Wound care by providers rather than students or patients’ caregivers for postoperative infections • Shorten laboratory investigation lead-times through clear assignment of responsibilities • Reviews of patient charts by senior staff and feedback to providers to improve good charting practices • Reassign sterilization to theater nurses exclusively and provide training and monitoring by nurse supervisors |
Health systems | Personnel • Shortage of skilled staff at some rural health centers • Insufficient provider-to-patient ratio • Poor retention of medical doctors at adjacent district hospitals Communication/managerial • Absence of radio or other means of communication between health centers and hospital • Ambiguity of provider work schedules and shift coverage • No backup provider schedule for evacuation emergencies requiring nurse accompaniment • Health centers with no motorcycle ambulance or other means of transportation • Delayed ambulance or delayed referral Availability of health services • Lack of basic emergency obstetric and neonatal care (BEmONC) services in peripheral health centers due to lack of trained staff and/or equipment • Absence of sufficiently staffed district hospitals in two adjacent districts Hospital resources • Blood product stock-outs • Limited oxygen supply and pulse oximetry • Inadequate number of manual vacuum extractor sets • Inoperable or insufficient anesthetic equipment • Power outages and lack of generator backup for labor and delivery ward • Traditional birth attendant-related delays | • Increase number of obstetric care providers (nurses, midwives, birth attendants) • Training of personnel to identify and respond to obstetric emergencies and scheduling backup staff in such cases • Create incentives for medical doctor retention by improving the work environment • Establish communication channels with 24/7 monitoring at the hospital level • Assign a member of staff to oversee scheduling and disseminate schedules 5 days prior to the start of each month by posting in workspaces • Establish a schedule for nurses assigned to emergency transfers to level-one center • Training and provision of BEmONC equipment for rural health center • Establish a system for recording blood stock-outs and petitioning to provincial Ministry of Health to ensure steady inventories • Lobby MOH and/or donors for additional equipment • Engagement and training of traditional birth attendants |
Accessibility | • Long distances from patient village to health center • No district hospital in adjacent districts • Poor road conditions and lack of reliable transport • Ambulance not available to transport patient from health center to hospital • Water transport for island-dwelling patients unreliable | • Infrastructure and transportation improvements by the government • Increase availability of ambulances and emergency boat transport |
Patient factors | • Poor antenatal care clinic attendance and late booking • Delay in seeking care • Preference for home delivery • Prioritization of ethnomedical care over biomedical care | • Conduct sensitization activities in the local communities on issue related to health-seeking behavior, home delivery, use of herbal medicines, and antenatal care clinic attendance |