Table 4 Suboptimal care and its contribution to adverse perinatal outcome, level of delay and final grading by auditors
External 1 | External 2 | Internal | ||||
|---|---|---|---|---|---|---|
No | % | No | % | No | % | |
Suboptimal factor: | ||||||
Yes | 105 | 78.9 | 115 | 86.4 | 107 | 80.5 |
No | 19 | 14.3 | 15 | 11.3 | 16 | 12.0 |
No opinion | 9 | 6.8 | 3 | 2.3 | 10 | 7.5 |
Contribution of suboptimal factor to adverse outcome: | ||||||
Unlikely | 9 | 6.8 | 25 | 18.8 | 23 | 17.3 |
Possibly | 30 | 22.5 | 35 | 26.3 | 49 | 36.8 |
Likely | 71 | 53.4 | 58 | 43.6 | 58 | 43.6 |
No opinion | 23 | 17.3 | 15 | 11.3 | 3 | 2.3 |
Level of delay: | ||||||
Community/family level | 1 | 0.8 | 10 | 7.5 | 9 | 6.8 |
Infrastructure | 4 | 3.0 | 2 | 1.5 | 8 | 6.0 |
Care | 86 | 64.6 | 80 | 60.1 | 62 | 46.6 |
Infrastructure and care | 21 | 15.8 | 22 | 16.6 | 35 | 26.3 |
No comments | 21 | 15.8 | 19 | 14.3 | 19 | 14.3 |
Final grade: | ||||||
0 | 19 | 14.3 | 15 | 11.3 | 22 | 16.5 |
1 | 11 | 8.3 | 19 | 14.3 | 11 | 8.3 |
II | 54 | 40.6 | 42 | 31.6 | 65 | 48.9 |
III | 49 | 36.8 | 57 | 42.9 | 35 | 26.3 |
Was the information available sufficient to assign a final grade? | ||||||
Yes | 116 | 87.2 | 120 | 90.2 | 114 | 85.7 |
No | 15 | 11.3 | 12 | 9.0 | 18 | 13.5 |
No opinion | 2 | 1.5 | 1 | 0.8 | 1 | 0.8 |
Do you consider likely that this death was preventable? | ||||||
Yes | 101 | 75.9 | 69 | 51.6 | 105 | 78.9 |
No | 24 | 18.0 | 58 | 43.6 | 24 | 18.0 |
No opinion | 8 | 6.0 | 6 | 4.5 | 4 | 3.0 |
Avoidable factors detected by auditors: | ||||||
Inadequate foetal heart monitoring during labour | 57 | 42.9 | 55 | 41.4 | 62 | 46.6 |
Delayed operation | 18 | 13.5 | 22 | 16.5 | 15 | 11.3 |
Delayed referral | 20 | 15.0 | 18 | 13.3 | 31 | 23.3 |
Failure to diagnose | 4 | 3.0 | 10 | 7.5 | 7 | 5.3 |
Traumatic assisted delivery | 2 | 1.5 | 1 | 0.8 | 1 | 0.8 |
Failure to resuscitate a newborn | 0 | 0 | 0 | 0 | 3 | 2.3 |
Inadequate antenatal care | 3 | 2.3 | 2 | 1.5 | 3 | 2.3 |
Others | 10 | 7.5 | 17 | 12.8 | 4 | 2.8 |
None | 19 | 14.3 | 8 | 6.0 | 7 | 5.3 |
Total | 133 | 100 | 133 | 100 | 133 | 100 |