Improving the quality of record keeping
Individual patient files were missing for more than 20% of all CSs at five of the nine sites. For certain key quality of care indicators, such as partograph monitoring, time of decision to perform CS, prophylactic antibiotic administration, and maternal and fetal outcomes, 10% or more of the data were missing from more than three sites. However, CS indication data were found in nearly all of the cases reviewed. Most of the women who had been referred arrived without notes or a partograph. Incomplete, inaccurate, and inaccessible medical records have the potential to adversely impact decision making and care. Improved record keeping could facilitate routine monitoring, reporting, and clinical audits that might help facility staff identify deficiencies in care [21, 22]. Findings from this study indicate a pressing need to improve record keeping across study sites and referring facilities.
The decision-to-delivery (DTD) interval was not recorded in most files, and more than one-third of files at three sites did not include information about whether the CS was emergency or elective. The time interval between the decision to do a CS and the intervention is critical in obstetric emergencies, particularly in low-resource settings, as delays in care are a significant contributor to maternal and newborn morbidity and mortality [23]. Existing DTD guidelines target high-resource settings and are unlikely to be feasible in low-resource settings [24, 25]. To improve CS record keeping, we recommend the inclusion of the DTD interval in standardized patient records to better estimate the magnitude of delays and to establish attainable DTD standards in this context. Patient flow analyses can identify sources of delay, and obstetric “emergency drills” and case simulations can help prepare and motivate staff while improving performance [26, 27].
Poor record keeping raises critical questions about the care provided: if there is no documentation, was care provided? Or did staff believe that the care provided was not significant enough to document? The quality of record keeping (and care) suffers when providers are overburdened and facilities are understaffed. Key informants acknowledged the need to train and motivate staff in the importance of recording keeping for improving quality of care. To be effective, training will need to be supported with ongoing facilitative supervision.
Documentation found in our study was often duplicative and lengthy. Computerization of patient records is a long-term goal for many facilities to improve quality and access to patient information [21, 22]. In the meantime, improvements to paper-based systems can be achieved by developing a standardized individual patient maternity and CS record, including the partograph. A “tick box” format could be used to record information and care given, similar to WHO’s Safe Childbirth Checklist [27]. This would be easier and quicker to complete, avoid duplication, and act as a useful teaching job aid for providers, prompting them to perform essential elements of care while facilitating retrieval of data for routine review.
Improving the quality of labor monitoring—use of the partograph
Our findings indicate that partograph use is disappointingly low. The high numbers of incomplete and incorrectly completed partographs suggest that many providers do not understand how to use it properly or are unable to do so because of workload demands. In 1.5% to 46.5% of cases, when the action line was crossed, partograph findings did not translate into action. It is possible that these were completed after the delivery, a practice that has been reported in the literature [28, 29]. However, we cannot corroborate this from our data.
A recent Cochrane review of the effect of partograph use on clinical outcomes concludes that there is no evidence that it has any effect on intrapartum care. However, the review also stated that partograph use may be of some benefit in settings with poorer access to health care resources. Additionally, studies have shown that partograph use and early interventions for women experiencing a delay in the progress of labor have contributed to some reduction in CS rates [30].
In low-resource settings such as our study sites, we suggest the partograph remain an important (and often the only available) clinical decision-making tool for labor monitoring and management [31]. In particular, it is valuable for diagnosing prolonged and obstructed labor, leading indications for CS in our review. Further research to determine effective approaches for partograph training and implementation may be a valuable investment in improving the quality of labor monitoring and clinical decision making.
Provision of care
Data on CS type and indications have the potential to reveal important information about the quality of procedures performed [6, 19] and provide insights that are masked by institutional CS rates alone. The institutional CS rates for Bangladesh, Guinea B, and Niger B were relatively similar (49%, 53%, 49%, respectively) but had different indication profiles—at the Guinea and Niger sites, the leading indications were obstructed labor, uterine rupture, previous CS, and eclampsia/severe preeclampsia. In Bangladesh, one-third of the CS indications were listed as “other, not enough information”, suggesting that some CSs may not have been medically justified, potentially exposing women to greater risk of adverse outcomes.
None of the study sites employed a formal CS classification system. Clinicians at study sites used a wide range of terminology to describe CS indications. For example, conditions resulting in obstructed labor were described in a multitude of ways, including deformed or contracted pelvis, big baby, and failed trial of labor. The variety of overlapping terminology shown by our study echoes the multiple codes listed in the WHO International Classification of Disease for causes of prolonged and obstructed labor and draws attention to the need for agreement on a simplified and standardized global terminology to describe these common conditions [32]. Standardized terminology for CS indications would also facilitate clinical audit and monitoring of trends. Multiple classification systems have been proposed, based on clinical indications, “degree of urgency”, or patient characteristics, but none have been extensively implemented [33].
Maternal outcomes
Data on postoperative maternal complications were missing from one-third or more of the records at five sites. While it may be possible that women did not experience any complications, given that many other variables were also missing from patient records, it is possible that this information was not recorded. Delivery by CS is major surgery, and one would expect to see complications, even minor ones (such as wound infection, adverse reactions to medications, or abnormal bleeding), to be recorded in patient files. In addition, data on whether the woman survived or died were missing in more than 10% of the files at three study sites.
The majority of the recorded maternal deaths occurred at four sites (n = 40); most of the women had been referred but without notes. These data suggest that the women experienced delays in reaching the referral center and/or after arrival. The large number of women in the study population who experienced uterine rupture is further evidence of severe delay in taking the necessary action. Overall, the maternal case fatality rates in this sample are high. We do not have data to ascertain how generalizable these rates are compared to other low resource settings. We strongly recommend increased investment in strengthening the capacity of peripheral facilities and referring providers to properly and efficiently diagnose, refer and transfer women to emergency obstetric care.
Fetal outcomes
Perinatal outcomes (stillbirth and early newborn death) have been proposed as a facility indicator of CS quality of care [6]. In this study, data on birth outcomes were missing in 10% or more of the files at three sites. The majority of fetal deaths (48% or more) were classified as stillbirths at five sites; early neonatal deaths ranged from 3.6% to 52.9% at six sites. The small number of early neonatal deaths, compared with the much larger number of stillbirths, suggests that some early neonatal deaths may have been misclassified to conceal substandard care at birth, a relatively common phenomenon in low-resource settings [34]. Information was not available on how many CSs were performed on diagnosed intrauterine fetal deaths. The authors acknowledge the principle that to avoid greater risk to the mother, if the baby is already dead then it should be delivered vaginally where possible, while also bearing in mind that the specific characteristics of the case influences delivery. Nearly three-quarters of the files had no information on cause of perinatal death.
Follow-up actions
Following the presentation of study results at each study site, stakeholders developed quality improvement action plans. Similar themes emerged, including the need to develop structured patient record forms; standardize CS indications; implement/improve partograph use, especially at referring centers; train and support staff in record-keeping practices; improve record room management; and streamline record-keeping systems. Since the completion of the study, partograph training has been implemented across all study sites. In Uganda, a coaching and mentoring program to improve partograph use has begun, where health personnel with partograph competencies help other providers develop skills through training and ongoing monitoring and feedback [35]. In Bangladesh, efforts are underway to conduct routine reviews of CS and to reinforce its appropriate use for valid clinical reasons (A.J. Faisel, personal communication, January 8, 2013).
Methodological considerations
This study’s main limitation is the generalizability of results, as sites were not randomly selected. Thus, study sites may not be representative of similar sites in their respective countries. The data presented here are from a mix of private rural facilities and urban public hospitals. An advantage of data from a variety of facilities is that they highlight common deficits as well as priority areas for improving the quality of record keeping and care. A disadvantage of the heterogeneity of these data is that they are harder to interpret, hindering us from drawing firm conclusions about factors that contribute to service quality.
While retrospective record reviews are relatively less expensive to conduct than observational studies, this approach has limitations. The AMDD data collection tool that we adapted has been widely used as part of larger needs assessments for emergency obstetric services [15] in a variety of country settings, including Afghanistan [26], Angola, Ethiopia, Ghana, Guyana, and Malawi [P. Bailey, personal communication, January 13, 2013]; however, it has not been formally validated [26]. While data were missing on key variables, we were able to describe CS practices and identify areas needing improvement, such as partograph use and standardized terminology for CS indications. During chart reviews, one is obliged to accept at face value the information contained in the chart. However, it can be assumed that clinicians know what to write to make a procedure sound “medically justified”. Alternatively, appropriate care may have been provided but not recorded due to high work load. Ideally, data from chart reviews should be compared with observations of practices [26].
We did not collect detailed information about intrapartum care. Also, because we did not collect data about the availability of and capacity for providing emergency obstetric in each of the study site’s catchment areas, it is difficult to interpret institutional CS rates. Any future studies using this type of record review methodology to assess quality of care could be strengthened by including intrapartum care variables, as well as a review of all obstetric services available in the study site’s catchment area.