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Professional responsibility in maternity care: Role of medical audit
Inf. J. Gynecol. Otwi.. 1989.30: 47-50 International Federation of Gynecology and Obstetrics
47
Professional responsibility in maternity care: role of medical audit R.V. Bhatt Medical College, Baroda (India)
Abstract
In 1965, Baroda Medical College initiated a process of medical audit of maternal andperinatal deaths occurring at this institution, and consultation in peripheral medical facilities providing antenatal and obstetric care. By 1984 maternal and perinatal mortality had declined and clinical judgment in maternity care had improved. Keywords:
Maternal audit; Peer review.
mortality;
Medical
If we agree that maternal and perinatal mortality rates are sensitive indices for judging the quality of obstetric services in any area, then surely we must declare unequivocally that the quality of maternity care in developing countries of South Asia is not at all satisfactory. It is sad but true that !XNoof maternal deaths take place in the Third World, and still more disturbing that 80% of them are preventable (Table I). The data from
those regions show that some antenatal care is available to 1545% of pregnant women and only 15% of the births take place in institutions (Table II). Obstetricians in developing countries have an obligation to participate in programs to correct this alarming situation. The dramatic fall in maternal mortality in industrial countries occurred long before the advent of such sophisticated equipment as fetal monitors, ultrasound, etc., demonstrating that expensive equipment and high technology are not the essential tools for reducing maternal deaths. Provision of basic maternity service8even in remote areas is what is wanted now, and available funds and resources must be diverted for this purpose. The role of teaching hospitals is important in developing good maternity services, and inquiry into every maternal death occurring in those facilities serves a very useful purpose in prevention of such deaths in the future. This is an account of the experience in our obstetric department after this system of inquiry and free discussion among the members of the staff andresidents was initiated.
and infant mortality in selected developing countries. T&kI. Maternal Country
Population in millions
Birth rate
Maternal mortality/lOO,OOO
Infant mortality/1000
India Pakistan Bangladesh Sri Lanka Ncaal
780 100 102 16 17
32 36 45 28 42
3OO-400 400-500 5cHI-700 SO-100 850
114 142 128 34.4 142
Source: World Bank, 1985.
oo2G7292/89/803.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
Corlference Proceedings
48
Ehatt
Table II.
Antenatal coverage and institutional deliveries in selected developing countries.
Country
Prenatal care coverage (To)
Delivery by trained attendant (@Jo)
Institutional Delivery Vo)
India Pakistan Bangladesh Sri Lanka Thailand Indonesia
45 30-40 20-25 60-65 33 35 IS
24-30 25 20 80 20-40 10-15 lo-15
10-15 lo-15 5-10 60-70 15-30 lo-20 5-10
Nepal
Source: World Demographic Yearbook. 1983.
Baroda, a small university town in the state of Gujurat in Western India, has a Medical College and an affiliated institution, Shree Sayajee General Hospital, which treats difficult obstetric cases from a catchment area within the vicinity of 40-60 km. The author assumed Chairmanship of the Department of Obstetrics and Gynaecology in 1964. Maternal mortality was high at the time; complicated cases with obstructed labor, severe hemorrhage or eclampsia frequently resulted in maternal death. Since these losses were accepted by the staff as inevitable, and proper obstetric records were not maintained, the idea of a system of inquiry or discussion into maternal death was not entertained. Error in the management of a pregnant woman never came to light because it had not been reported. In 1965, we initiated the following programs in the department. (1) Record forms were designed to document clinical management of all cases ending in maternal death. Record keeping was supervised by an assistant professor. (2) More than 80% of our obstetric cases are referred. There are three units in the department and each unit is on emergency labor room duty for 1 week. We organized weekly departmental meetings of all teaching staff and residents. The senior resident from the unit on emergency duty in the week under consideration presents vital data and information about the number of deliveries,
Int J Gynecol Obstet 30
maternal and perinatal deaths, operative deliveries and so forth. He also reports on abortions, hemorrhage, sepsis, and preeclamptic toxemia. The participants ask many searching questions and seek clarification on various points. The department chairman sees that the level of discussion is purely academic and does not degenerate into allegations and insinuations. However, residents and staff are encouraged to admit shortcomings and mistakes they have committed. In the first few years, the staff and residents were under tension and somewhat apprehensive during these weekly meetings. But soon they realized their purpose and utility. The senior teachers showed the way by admitting their own mistakes in the open meeting and then the residents followed. (3) A committee headed by the professor was formed to keep confidential records of all maternal deaths. The unit concerned was expected to complete all papers of the patient who died and then submit the data to the committee, comprised of two members from the teaching staff along with the professor. They raise questions and seek clarification on various points. Sometimes the resident who managed the case is also summoned for information before it is filed. (4) Some six to eight meetings of the staff and residents are held annually to discuss maternal and perinatal deaths in the department. The names of the consultant and the patient are not revealed, but it is true that
Medical audit of maternal deaths
total anonymity is difficult to secure in a small department. Even though the unit name is not announced, people do guess (more often correctly than not) who was responsible for the case. The staff and residents are encouraged to freely express their opinions. Emphasis is on evolving a policy to prevent recurrence of any mistake or error of judgment. We must admit in all fairness that in the earlier phase of this medical audit, attempts were made by staff and residents to alter the data on paper so that they could hide their follies. It was a natural reaction because there was fear of punitive action. Once they realized that none would be taken, the manipulation of data ceased. (5) Data on obstetric cases and maternal deaths were compiled and distributed to staff and residents. (6) The staff and the residents started visiting primary health centers (PHCs) periodically to provide antenatal care. Six PHCs were selected for this program with the help of the World Health Organization (WHO) and the United Nations Infants and Children Emergency Fund (UNICEF). A consultant, a resident and a technician would visit the center every week and help the local PHC doctor with difficult and high risk antenatal cases. Problems that had arisen in the previous week were also discussed. The outcome of cases referred to the teaching hospital was communicated to the PHC physician, who was encouraged to visit the department and spend time in our labor room and hospital to learn about management of pregnant women with complications. (7) In an effort to learn whether shortcomings in nursing care might have been responsible for maternal death, ward nurses also held fortnightly meetings to discuss nursing aspects of complicated obstetric cases. Analysis The data showed the following features that might have contributed to maternal deaths:
49
(1) Consultants attended 75% of the cases that resulted in maternal death. The residents managed 25% of the obstetric emergencies without consulting the attending obstetrician. (2) The common mistakes by residents include: (a) failure to diagnose presentation correctly. Shoulder and breech presentations were missed, resulting in obstructed labor; (b) failure to diagnose concealed accidental hemorrhage early. This resulted in disseminated intravascular coagulation (DIC) or renal failure causing death; (c) failure to call consultant at the time of surgery for rupture of the uterus. (3) There was delay in performing cesarean sections in 4% of maternal deaths. (4) The residents performed more obstetric procedures at night that resulted in maternal death than cases managed by consultants. (5) Maternal mortality was higher on weekends and during holidays when staff was inadequate. This was the picture in 1%7-l%& The impact of departmental meetings and detailed inquiry of every maternal death was seen from 1971 onwards. Individual staff members and residents became more vigilant while treating their patients. After all, the case might come up for discussion at departmental meetings! The consultants started seeing all high risk cases and remained present at the time of surgery to guide the resident. The residents began asking for a second opinion from other senior residents when dealing with women at risk. Obstetric emergencies occurring at night were also supervised by the consultant on duty. In the earlier phase, the departmental meetings and inquiries were looked upon with fear and apprehension by residents and staff. It was soon realized that their purpose was prevention rather than punishment . The data for 1983-1984 showed that error in judgment by members of the obstetric department was responsible for 1.5% of maternal mortality as compared to 10% in 1967-1968 (Table III).
Conjerence Proceedings
50
Bhatt
Impact of medical audit on obstetric Table Ill. performance. Baroda MedicalCollege, 1967-1968 and 198319g4. YW 1967-1968
Vital data
YCar 1983-1984
2968 43 342 41
Confinements Maternal deaths P&natal deaths Error in judgment or delay in treatment at department level Development of obstructed labor after admission Eclampsia deaths High risk and emergency cases attended by consultant
3125 36 315 7
14 6 114
2 2 206
Discwsion In many countries, quality control and peer review are mandatory for all institutions seeking recognition for training. Such supervision helps to improve the quality of service and prevent errors in management. This holds true for the incidence of maternal deaths, as is seen in all centers where inquiry in this mortality is mandatory. It affords opportunity to learn from one’s mistakes. It can,, be argued that self-assessment or introspection can achieve the same objective, but it is difficult to be objective in those circumstances. Colleagues can approach the situation with greater detachment and without bias. The obstetrician is more likely to be vigilant when he realizes that he is being watched and will be answerable to others for his actions. Unfortunately the systems of medical audit or peer review, or even open discussion on all
Int J Gynecol Obstet 30
maternal deaths, do not exist in all obstetric departments of the developing world. In fact it is in those very countries that they are most needed. Some institutions are reluctant to institute these practices because they see no need for them. Sometimes the inquiries do not serve their intended purpose if the attending doctor absents himself from these proceedings. Our data show the main drawbacks in teaching institutions in the developing world that lead to elevated maternal loss. These factors are: (1) Failure to supervise junior staff; (2) Failure of consultants to examine patients before prescribing treatment; (3) Allowing juniors to perform obstetric procedures in high risk cases without monitoring them; (4) Neglect of their hospital responsibilities by consultants and residents during weekends or holidays. It is incumbent on the leaders in the medical community to assume an aggressive role in dealing with this shameful state of affairs. Women must be assured of the active concern of those on whom they depend to care for them at the most vulnerable time of their lives. We physicians can do no less.
Address for reprints: R.V. Bhatt Vtjay Clinic Opposite Lakdi Pool Dandia Bazar Baroda 390401 India
47
Professional responsibility in maternity care: role of medical audit R.V. Bhatt Medical College, Baroda (India)
Abstract
In 1965, Baroda Medical College initiated a process of medical audit of maternal andperinatal deaths occurring at this institution, and consultation in peripheral medical facilities providing antenatal and obstetric care. By 1984 maternal and perinatal mortality had declined and clinical judgment in maternity care had improved. Keywords:
Maternal audit; Peer review.
mortality;
Medical
If we agree that maternal and perinatal mortality rates are sensitive indices for judging the quality of obstetric services in any area, then surely we must declare unequivocally that the quality of maternity care in developing countries of South Asia is not at all satisfactory. It is sad but true that !XNoof maternal deaths take place in the Third World, and still more disturbing that 80% of them are preventable (Table I). The data from
those regions show that some antenatal care is available to 1545% of pregnant women and only 15% of the births take place in institutions (Table II). Obstetricians in developing countries have an obligation to participate in programs to correct this alarming situation. The dramatic fall in maternal mortality in industrial countries occurred long before the advent of such sophisticated equipment as fetal monitors, ultrasound, etc., demonstrating that expensive equipment and high technology are not the essential tools for reducing maternal deaths. Provision of basic maternity service8even in remote areas is what is wanted now, and available funds and resources must be diverted for this purpose. The role of teaching hospitals is important in developing good maternity services, and inquiry into every maternal death occurring in those facilities serves a very useful purpose in prevention of such deaths in the future. This is an account of the experience in our obstetric department after this system of inquiry and free discussion among the members of the staff andresidents was initiated.
and infant mortality in selected developing countries. T&kI. Maternal Country
Population in millions
Birth rate
Maternal mortality/lOO,OOO
Infant mortality/1000
India Pakistan Bangladesh Sri Lanka Ncaal
780 100 102 16 17
32 36 45 28 42
3OO-400 400-500 5cHI-700 SO-100 850
114 142 128 34.4 142
Source: World Bank, 1985.
oo2G7292/89/803.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
Corlference Proceedings
48
Ehatt
Table II.
Antenatal coverage and institutional deliveries in selected developing countries.
Country
Prenatal care coverage (To)
Delivery by trained attendant (@Jo)
Institutional Delivery Vo)
India Pakistan Bangladesh Sri Lanka Thailand Indonesia
45 30-40 20-25 60-65 33 35 IS
24-30 25 20 80 20-40 10-15 lo-15
10-15 lo-15 5-10 60-70 15-30 lo-20 5-10
Nepal
Source: World Demographic Yearbook. 1983.
Baroda, a small university town in the state of Gujurat in Western India, has a Medical College and an affiliated institution, Shree Sayajee General Hospital, which treats difficult obstetric cases from a catchment area within the vicinity of 40-60 km. The author assumed Chairmanship of the Department of Obstetrics and Gynaecology in 1964. Maternal mortality was high at the time; complicated cases with obstructed labor, severe hemorrhage or eclampsia frequently resulted in maternal death. Since these losses were accepted by the staff as inevitable, and proper obstetric records were not maintained, the idea of a system of inquiry or discussion into maternal death was not entertained. Error in the management of a pregnant woman never came to light because it had not been reported. In 1965, we initiated the following programs in the department. (1) Record forms were designed to document clinical management of all cases ending in maternal death. Record keeping was supervised by an assistant professor. (2) More than 80% of our obstetric cases are referred. There are three units in the department and each unit is on emergency labor room duty for 1 week. We organized weekly departmental meetings of all teaching staff and residents. The senior resident from the unit on emergency duty in the week under consideration presents vital data and information about the number of deliveries,
Int J Gynecol Obstet 30
maternal and perinatal deaths, operative deliveries and so forth. He also reports on abortions, hemorrhage, sepsis, and preeclamptic toxemia. The participants ask many searching questions and seek clarification on various points. The department chairman sees that the level of discussion is purely academic and does not degenerate into allegations and insinuations. However, residents and staff are encouraged to admit shortcomings and mistakes they have committed. In the first few years, the staff and residents were under tension and somewhat apprehensive during these weekly meetings. But soon they realized their purpose and utility. The senior teachers showed the way by admitting their own mistakes in the open meeting and then the residents followed. (3) A committee headed by the professor was formed to keep confidential records of all maternal deaths. The unit concerned was expected to complete all papers of the patient who died and then submit the data to the committee, comprised of two members from the teaching staff along with the professor. They raise questions and seek clarification on various points. Sometimes the resident who managed the case is also summoned for information before it is filed. (4) Some six to eight meetings of the staff and residents are held annually to discuss maternal and perinatal deaths in the department. The names of the consultant and the patient are not revealed, but it is true that
Medical audit of maternal deaths
total anonymity is difficult to secure in a small department. Even though the unit name is not announced, people do guess (more often correctly than not) who was responsible for the case. The staff and residents are encouraged to freely express their opinions. Emphasis is on evolving a policy to prevent recurrence of any mistake or error of judgment. We must admit in all fairness that in the earlier phase of this medical audit, attempts were made by staff and residents to alter the data on paper so that they could hide their follies. It was a natural reaction because there was fear of punitive action. Once they realized that none would be taken, the manipulation of data ceased. (5) Data on obstetric cases and maternal deaths were compiled and distributed to staff and residents. (6) The staff and the residents started visiting primary health centers (PHCs) periodically to provide antenatal care. Six PHCs were selected for this program with the help of the World Health Organization (WHO) and the United Nations Infants and Children Emergency Fund (UNICEF). A consultant, a resident and a technician would visit the center every week and help the local PHC doctor with difficult and high risk antenatal cases. Problems that had arisen in the previous week were also discussed. The outcome of cases referred to the teaching hospital was communicated to the PHC physician, who was encouraged to visit the department and spend time in our labor room and hospital to learn about management of pregnant women with complications. (7) In an effort to learn whether shortcomings in nursing care might have been responsible for maternal death, ward nurses also held fortnightly meetings to discuss nursing aspects of complicated obstetric cases. Analysis The data showed the following features that might have contributed to maternal deaths:
49
(1) Consultants attended 75% of the cases that resulted in maternal death. The residents managed 25% of the obstetric emergencies without consulting the attending obstetrician. (2) The common mistakes by residents include: (a) failure to diagnose presentation correctly. Shoulder and breech presentations were missed, resulting in obstructed labor; (b) failure to diagnose concealed accidental hemorrhage early. This resulted in disseminated intravascular coagulation (DIC) or renal failure causing death; (c) failure to call consultant at the time of surgery for rupture of the uterus. (3) There was delay in performing cesarean sections in 4% of maternal deaths. (4) The residents performed more obstetric procedures at night that resulted in maternal death than cases managed by consultants. (5) Maternal mortality was higher on weekends and during holidays when staff was inadequate. This was the picture in 1%7-l%& The impact of departmental meetings and detailed inquiry of every maternal death was seen from 1971 onwards. Individual staff members and residents became more vigilant while treating their patients. After all, the case might come up for discussion at departmental meetings! The consultants started seeing all high risk cases and remained present at the time of surgery to guide the resident. The residents began asking for a second opinion from other senior residents when dealing with women at risk. Obstetric emergencies occurring at night were also supervised by the consultant on duty. In the earlier phase, the departmental meetings and inquiries were looked upon with fear and apprehension by residents and staff. It was soon realized that their purpose was prevention rather than punishment . The data for 1983-1984 showed that error in judgment by members of the obstetric department was responsible for 1.5% of maternal mortality as compared to 10% in 1967-1968 (Table III).
Conjerence Proceedings
50
Bhatt
Impact of medical audit on obstetric Table Ill. performance. Baroda MedicalCollege, 1967-1968 and 198319g4. YW 1967-1968
Vital data
YCar 1983-1984
2968 43 342 41
Confinements Maternal deaths P&natal deaths Error in judgment or delay in treatment at department level Development of obstructed labor after admission Eclampsia deaths High risk and emergency cases attended by consultant
3125 36 315 7
14 6 114
2 2 206
Discwsion In many countries, quality control and peer review are mandatory for all institutions seeking recognition for training. Such supervision helps to improve the quality of service and prevent errors in management. This holds true for the incidence of maternal deaths, as is seen in all centers where inquiry in this mortality is mandatory. It affords opportunity to learn from one’s mistakes. It can,, be argued that self-assessment or introspection can achieve the same objective, but it is difficult to be objective in those circumstances. Colleagues can approach the situation with greater detachment and without bias. The obstetrician is more likely to be vigilant when he realizes that he is being watched and will be answerable to others for his actions. Unfortunately the systems of medical audit or peer review, or even open discussion on all
Int J Gynecol Obstet 30
maternal deaths, do not exist in all obstetric departments of the developing world. In fact it is in those very countries that they are most needed. Some institutions are reluctant to institute these practices because they see no need for them. Sometimes the inquiries do not serve their intended purpose if the attending doctor absents himself from these proceedings. Our data show the main drawbacks in teaching institutions in the developing world that lead to elevated maternal loss. These factors are: (1) Failure to supervise junior staff; (2) Failure of consultants to examine patients before prescribing treatment; (3) Allowing juniors to perform obstetric procedures in high risk cases without monitoring them; (4) Neglect of their hospital responsibilities by consultants and residents during weekends or holidays. It is incumbent on the leaders in the medical community to assume an aggressive role in dealing with this shameful state of affairs. Women must be assured of the active concern of those on whom they depend to care for them at the most vulnerable time of their lives. We physicians can do no less.
Address for reprints: R.V. Bhatt Vtjay Clinic Opposite Lakdi Pool Dandia Bazar Baroda 390401 India