Substandard Care Substandard Care and and Harmful PracticesHarmful Practices

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Purpose of the session:

The purpose of this session is to provide physicians with the different aspects of

substandard care and harmful practices by the health care providers that contribute to

maternal mortality.

By the end of this session, trainees will be able to:

Identify magnitude of the problem .

Identify avoidable factors contributing to maternal death.

Define Substandard Care .

Explain totality of Care

Identify Substandard Care in PPH and APH

Identify Substandard Care in Hypertensive disorders with pregnancy

Identify Substandard Care in Sepsis.

Identify Substandard Care in Ruptured uterus.

Identify Substandard Care in normal, abnormal labor and CS.

Identify Substandard Care and Harmful Practices in the Private Sector.

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Problem in Egypt

The ENMMS, 2000 estimated that The total MMR was 84/100,000.

One or more avoidable factors contributed to 81% of maternal deaths

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The maternal Mortality Stopwatch

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Avoidable Factors

Health Facility

Health ProviderWomen and Family

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54%

24%

22%

Health Facility Woman & Family Health Provider

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Health Facility Factors

Health Facility Factors contributed to maternal

death due to:

Lack of blood (16%)

distance of care(4%)

lack of drug(2%) lack of supplies(2%) and

equipment (5%).

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Women and family

Failure to recognize problems [27%]

and delay in seeking medical care [21%]

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Health provider Factors

Substandard care by health provider was the leading avoidable cause of death contributing to 36 maternal death per100,000 live birth.

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Definition of Substandard Care

It includes: The use of practices which are clearly harmful or ineffective.

Practices where insufficient evidence exists to support a clear recommendation

Practices which are frequently used inappropriately.

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Standard Care…The need of ‘Standardized Clinical Guidelines’

Clinical guidelines are:

‘Systematically developed statements which

assist clinicians and patients in making decisions

about appropriate treatment for specific

conditions’

Developed using a standardised methodology

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NICE guidelines

USAID Recommendations for

Updating Selected Practices

in Contraceptive Use

JHPIEGO Infection

Prevention reference manual

CPI guidance documents

RCOG green top guidelines

Evidence Based and Updated Guidelines

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- Ila Evidence obtained from at least one well- designed controlled study without randomization. - Ilb Evidence obtained from at least one

other type of well-designed quasi- experimental

Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies .

Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

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- Ia Evidence obtained from meta-analysis of randomized controlled trials. - Ib Evidence obtained from at least one randomized controlled trial.

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Classification of Evidence Levels

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Forms of Care…

Beneficial Forms of care.

Forms of care likely to be beneficial.

Forms of care with a trade off.

Forms of care with unknown effectiveness.

Forms of care likely to be ineffective.

Forms of care likely to be harmful.

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Grades of Recommendation

AAt least one controlled trialLevel

Ia, Ib

BRequires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations.

Level

IIa, IIb, III

CRequires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality

Level

IV

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Totality of Care

1. Check that all the basic steps were followed.

2. Monitor the patient throughout the entire care process :

Antenatal care periodIntrapartum care period

postpartum care period.Emergency events or admission Anesthesia and recovery

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Skilled Attendant..Is a professional caregiver

Has the knowledge and skills to:Manage labor, childbirth and postpartum period

Recognize complications

Diagnose, manage or refer woman or newborn to higher level of care if complications occur that require interventions beyond caregiver’s competence

Performs all basic obstetric interventions

WHO 1999.

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Substandard Care …A Cause of Maternal Deaths

Let’s examine instances where substandard care by providers is one of the major contributing causes of maternal death in Egypt.

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Major Maternal Killers

Bleeding

Hypertension

Sepsis

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Postpartum Hemorrhage (PPH)

Substandard care by obstetricians contributed to 50% of deaths due to PPH.

Antenatal careLack of or poor antenatal care

Failure to recognize the predisposing factors for PPH, e.g. previous history of PPH

Emergency roomFailure to provide appropriate first aid management e.g. not

giving fluid replacement while waiting for blood

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Pre-delivery and delivery room

Incorrect use of oxytocin in high doses with no titrationFailure to recognize predisposing factors of PPH

as in cases were there is APH or when there is twin pregnancy or overdistension

Absence of a senior specialistPushing on the abdomen to force delivery that leads to a ruptured uterus, laceration or tearsNot following a protocol for PPH managementPacking the vagina during atonic PPH, thus masking the conditionIgnoring the active management of the third stage of labor

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Operating roomDelaying decision of hysterectomy

Waiting for a senior obstetrician or surgeon to perform other life-saving interventions for which providers do not have skills or which are inappropriate.

Recovery room or postoperative follow-upThere is a lack of monitoring of the patient post-labor or postoperatively, resulting in unnoticed bleeding and rapid deterioration.

Early discharge of patients from the hospital, without complete treatment.

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Antepartum Hemorrhage (APH)

Substandard care by obstetricians contributed to 61% of deaths due to APH.

Antenatal careFailure to recognize the problem, e.g. attributing the blood to delayed menstruation or local causes without confirming the diagnosisFailure to admit a patient who needs admission

Emergency roomFailure to provide appropriate first aid management by not giving fluid replacement while awaiting bloodDigital examination of patients with APH before excluding placenta previa

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Pre-delivery room

Failure to request or assess a coagulation profile

Delivering patients with APH without considering the high probability of PPH

Operating room

Delaying interventions until blood is available

Absence of senior specialist

Recovery room or postoperative follow-up

Antepartum hemorrhage is the main cause of PPH, and lack of close observation could easily miss early diagnosis of the condition.

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Hypertensive disorders with pregnancy

Substandard care by obstetricians contributed to 47% of deaths due to hypertensive diseases of pregnancy.

Antenatal carefailure to recognize hypertension, as in some cases the blood pressure is not correctly taken.

If the problem is detected, some physicians adopt what they think is conservative management and delay delivery, which can put both the mother and fetus at risk.

In some instances the physician tends to postpone delivery

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Emergency room and pre-delivery room

Prescribing sedation and anti-hypertensive drugs for patients with severe cases who are not in labor and discharging them

Inability to provide correct first aid management for patients with convulsions because IV access was not established

Failure to control convulsions immediately by administering correct doses of MgSO4

Waiting for delivery to occur spontaneously even though it may take a long period of time

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Delivery roomAdministering MethergineProlonging the second stage of laborAbsence of a senior specialist

Operating roomFailure to inform the anesthesiologist of the patient’s medical historyPatient not stabilized before the operationFailure to request the presence of a neonatologist

Recovery room or postoperative follow-upFailure to monitor the toxic effects of MgSO4Failure to continue MgSO4 for48hrs in sever cases.

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Sepsis

Substandard care by obstetricians contributed to 38% of sepsis deaths.

Antenatal careSevere deficiencies in or lack of quality care, especially with regard to health education, e.g. hygiene

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Emergency room and pre-delivery room

Lack of infection control precautions

Little or no hand washing between patients

Failure to use sterile instruments

Failure to isolate patients with puerperal sepsis

Frequent vaginal examinations of patients with PROM

Delivery roomLack of infection control precautions

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Operating roomLack of infection control precautions, e.g., inadequate cleaning of the table and instruments between patientsAntibiotic prophylaxis in CS done with incorrect timing and wrong dose

Recovery roomPoor or no monitoring of cases for signs of infectionEarly discharge of patients with mild feverEarly discharge of patients with PROM

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Ruptured uterus

Substandard care by obstetricians contributed to 64% of ruptured uterus deaths.

Antenatal care

Poor quality of care

Patients with a previous history of uterine scars not counseled on the importance of a hospital delivery

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Emergency room and pre-delivery room

Poor history taking, which results in missing

high-risk cases of previous operations or

previous obstructed deliveries

Delay in diagnosis due to lack of experience

Delay in infusing fluids while waiting for blood

Inappropriate use of oxytocin

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Emergency room and pre-delivery room

Using drugs still under trial to induce labor, with no known dose for induction of labor, e.g., Misoprostol

Not using a partograph to monitor labor

Trial of a scar with incorrect judgment or essential pre-requisites

Lack of knowledge of signs of a ruptured uterus

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Delivery room

Pushing on the abdomen to force delivery

Obstructed labor not diagnosed early or dealt with properly

Operating room

Delaying intervention until blood is available

Delaying a hysterectomy to save the uterus

Senior obstetricians not attending in time

Recovery room

Lack of any postoperative follow

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Clinical Conduct of Labor Instances of substandard care can occur in the

following:Antenatal Care

No care or poor quality of care Emergency and pre-delivery care

No proper history taking, thus missing the opportunity to anticipate possible problems or complications that may have occurred beforeHigh-risk patients not identifiedLow risk patients are NOT properly followed upGeneral examination incorrectly done or omittedVaginal examination only procedure performed in the emergency room

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FHS not monitored

Partograph not used to monitor labor

Oxytocin used inproperly

High enema and catheterization still used as a

routine

Patients allowed to bear down early before full

cervical dilation

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Delivery roomForceps or vacuum extractor used inappropriately due to incorrect evaluation of cases from the startLate intervention in prolonged or obstructed laborMethergine routinely used

Recovery roomNo postpartum care or follow-upPatients discharged too early

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Abnormal labor and CS

Substandard care by obstetricians contributed to 68% of CS deaths.

Antenatal care

Poor quality of care

Emergency room

Medical history not taken properly

Admission procedures too slow

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Pre-delivery

No proper history taking, thus missing the

opportunity to anticipate possible problems

that may have occurred before

High-risk patients not identified

General examination not performed

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Investigations not ordered

Patients inappropriately referred due to lack of

blood

With a history of a previous CS, an attempt at

labor occurs without proper preparation

CS done without proper indication

Oxytocin used with a previous CS scar with

the incorrect dosage and poor or no follow-up

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Operating roomAnesthesia administered to patients by obstetriciansComplete hemostasis not reachedCS done by inexperienced providers with no supervisionDelay in intervention due to absence of appropriate personnelDelivery of fetal malpresentations by inexperienced staffApplying forceps if vacuum extraction fails

Recovery roomNo postoperative follow-up

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Substandard Care and Harmful Practices in the Private Sector

A considerable number of deliveries are

performed outside of hospitals at home,

private sector hospitals or clinics. Different

types of service providers are usually involved

When the process of delivery is complicated,

the woman is referred to a nearby health

facility.

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The most common forms of substandard care that may lead to maternal mortality or morbidity outside health facilities are:Poor quality of antenatal careFailure or delay in recognizing problemsDelay in correctly managing casesLate referral of complicated casesOperations sometimes performed by inexperienced persons Drugs given in the wrong way or in an incorrect dose

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To sum it up…

Most substandard care is due to:Not being aware of the latest knowledge and techniques or no following the proper guideline

A failure to supervise and train new providers in order to ensure that appropriate standards are maintained

A failure to observe and implement the protocols for management.