International Journal of Gynecology and Obstetrics
International Journal of Gynecology and Obstetrics
International Journal of Gynecology and Obstetrics
a r t i c l e i n f o a b s t r a c t
Keywords: Objective: To audit intrapartum fetal and early neonatal deaths of infants weighing ≥ 2000 g in a regional
Perinatal audit hospital in western Tanzania. Methods: The 3-delays methodology was applied to a cohort of perinatal deaths
Substandard care from July 2002 to July 2004. Results: The overall perinatal mortality rate in the hospital was 38 per 1000 live
Tanzania
births, and in just over half of these cases the birth weight was ≥ 2000 g. The leading clinicopathologic causes
3-delays model
of death were birth asphyxia (19.0%), prolonged or obstructed labor (18.5%), antepartum hemorrhage
(11.5%), and uterine rupture (9.0%). First delays occurred in 19.0% of the cases, second delays occurred in
21.5%, and third delays occurred in 72.5%. Conclusion: For women who delivered in this hospital, most of the
substandard care occurred after admission to the health facility. The improvement of institutional health care
may have a significant impact on the decision to attend health institutions and, thereby, reduce first delays.
© 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2009.04.008
86 G. Mbaruku et al. / International Journal of Gynecology and Obstetrics 106 (2009) 85–88
backgrounds (age, marital status, and place of residence) and com- Table 2
plete medical, obstetric, family, and social histories. To ascertain the First delaysa among intrapartum fetal and early neonatal deaths in which birth weight
was ≥2000 g (n = 200).
duration of labor, attention was paid to the details of parturition that
took place prior to admission to the regional hospital. Attention was First delays No. (%)
also paid to fetal viability on admission and the care given from the Wanted to deliver at home, attended after complication occurred 26 (13.0)
onset of labor. Information included the time taken to get from home Advised to have hospital delivery, but attended only after 9 (4.5)
complication occurred
to the institution after the onset of labor, the type and cost of tran-
Refused intervention 2 (1.0)
sport, whether the mother was referred from a lower-level health No prenatal care 1 (0.5)
facility, and the diagnosis made at the lower-level health facility (if Total 38 (19.0)
applicable). The care provided during labor was noted, including a
Thaddeus and Maine [23].
institutional delays, type of attendant, decisions on management,
mode of delivery, complications, and resuscitation. Partogram use was
also assessed. All neonates were examined immediately after birth in Medical Research in Tanzania. Written consent was obtained from
the hospital and details were recorded, including weight, sex, pre- each participant.
sence of congenital anomalies, and most importantly whether fetal
death had occurred prior to or during labor. All neonatal deaths (up to 3. Results
7 days) that occurred in the hospital were recorded; no autopsies
were performed. Sick neonates received standard care according to During the study period, 385 perinatal deaths occurred in 10 200
the hospital protocols. hospital births (38 per 1000 live births). Birth weight was less than
The questionnaire was filled in by one of the authors (CK) after 2000 g in 185 (48%) of these cases, leaving 132 intrapartum fetal deaths
interviewing the mother and checking the records. Counterchecking and 68 early neonatal deaths in which the birth weight was ≥2000 g
was done by another author (GM). In addition to the completed (52%) to be included in the audit. The leading cause of death was birth
questionnaires, prenatal cards and clinical records were studied in asphyxia (n= 38; 19.0%); followed by prolonged or obstructed labor
detail when available. The data were analyzed by a local team (n = 37; 18.5%); antepartum hemorrhage (n = 23; 11.5%); uterine
consisting of a consultant obstetrician, a consultant pediatrician, rupture (n = 18; 9.0%); cord prolapse (n = 15; 7.5%); and breech
2 medical officers, and 2 nurse–midwives. delivery (n= 14; 7.0%) (Table 1). Congenital anomalies accounted for
All intrapartum fetal and early neonatal deaths in which the birth only 7 cases (3.5%). Most infants (n= 161; 80.5%) weighed ≥2500 g.
weight was ≥2000 g were audited using the 3-delays methodology. There was 1 set of twins, and 3 mothers out of 199 (1.5%) died.
This methodology classifies delays as follows: (1) first delay refers to Analysis of the care received in terms of the 3-delays model is
the time spent at home before a decision is made to seek health care; provided in the following sections.
(2) second delay refers to the inability to get to a health facility after
having made the decision to go there (due to problems with transport,
3.1. First delays
money, or poor roads); and (3) third delay refers to the time spent
waiting for adequate management after arrival at a health facility. In
First delays occurred in 38 cases (19.0%) (Table 2). Most women
addition to the Thaddeus and Maine model, we considered “misman-
were admitted for delivery only after labor had started. Nine women
agement or incorrect treatment” as a third delay in that it delayed
who had been advised to deliver in hospital attended only after com-
appropriate management.
plications had occurred at home. In another 38 cases, pregnancy was
For each perinatal death, a “process audit” was undertaken,
unwanted and its prevention could have avoided these perinatal
whereby actual practice was compared with standard practice, based
deaths.
on evidence or expert consensus. Fetal monitoring was conducted
mainly through intermittent auscultation, and resuscitation of
asphyxiated neonates involved clearing the airway, simple drying, 3.2. Second delays
ventilation with bag and mask, and immediate skin-to-skin contact
with the mother. Neonatal care comprised use of the “Kangaroo Second delays occurred in 43 cases (21.5%) (Table 3). The major
method,” breastfeeding and close observation of early signs and issues here were unspecified problems with transport after labor had
symptoms of infection. Sick neonates were seen by a consultant started (27 cases). Six women had long waiting times before em-
pediatrician. barking on a boat, 5 were transported on a stretcher, and 3 arrived by
The research protocol was approved by the Ethics Committee of bus or lorry. In 1 case, a car breakdown caused serious delay and
the Karolinska Institute in Sweden and the National Institute of another woman had no money for transport.
An example of first and second delays was the case of a grand-
multiparous woman with 5 previous stillbirths (1 after cesarean
delivery). She had a 13-hour first stage of labor at home, experienced
Table 1
Clinicopathologic causes of intrapartum fetal and early neonatal deaths in which birth
weight was ≥ 2000 g (n = 200).
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