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Improving the quality of obstetric care for women with obstructed labour in the national referral hospital in Uganda: lessons learnt from criteria based audit
© The Author(s). 2016
Received: 22 April 2015
Accepted: 6 July 2016
Published: 11 July 2016
Obstructed labour remains a major cause of maternal morbidity and mortality whose complications can be reduced with improved quality of obstetric care. The objective was to assess whether criteria-based audit improves quality of obstetric care provided to women with obstructed labour in Mulago hospital, Uganda.
Using criteria-based audit, management of obstructed labour was analyzed prospectively in two audits. Six standards of care were compared. An initial audit of 180 patients was conducted in September/October 2013. The Audit results were shared with key stakeholders. Gaps in patient management were identified and recommendations for improving obstetric care initiated. Six standards of care (intravenous fluids, intravenous antibiotics, monitoring of maternal vital signs, bladder catheterization, delivery within two hours, and blood grouping and cross matching) were implemented. A re-audit of 180 patients with obstructed labour was conducted four months later to evaluate the impact of these recommendations. The results of the two audits were compared. In-depth interviews and focus group discussions were conducted among healthcare providers to identify factors that could have influenced the audit results.
There was improvement in two standards of care (intravenous fluids and intravenous antibiotic administration) 58.9 % vs. 86.1 %; p < 0.001 and 21.7 % vs. 50.5 %; P < 0.001 respectively after the second audit. There was no improvement in vital sign monitoring, delivery within two hours or blood grouping and cross matching. There was a decline in bladder catheterization (94 % vs. 68.9 %; p < 0.001. The overall mean care score in the first and second audits was 55.1 and 48.2 % respectively, p = 0.19. Healthcare factors (negative attitude, low numbers, poor team work, low motivation), facility factors (poor supervision, stock-outs of essential supplies, absence of protocols) and patient factors (high patient load, poor compliance to instructions) contributed to poor quality of care.
Introduction of criteria based audit in the management of obstructed labour led to measurable improvements in only two out of six standards of care. The extent to which criteria based audit may improve quality of obstetric care depends on having basic effective healthcare systems in place.
Obstructed labour is defined as failure of descent of the fetal presenting part in the birth canal in spite of adequate contractions. This is commonly due to cephalo-pelvic disproportion. If not managed promptly, obstructed labour may lead to maternal and fetal complications. Worldwide, obstructed labour occurs in an estimated 5 % of pregnancies and accounts for an estimated 8 % of maternal deaths . In a study conducted in six hospitals in the southwestern part of Uganda , the prevalence of obstructed labour was 10.5 %.
Of the 32,511 women who delivered at Mulago hospital, obstructed labour was the main contributor to maternal and fetal morbidity and mortality (Mulago hospital records 2012). For instance, obstructed labour and its complications (uterine rupture, puerperal sepsis, and postpartum hemorrhage) resulted in (40 out of 155) 26 % of all maternal deaths, and led to 266 out of 619 (40 %) admissions to the High Dependence Unit (HDU) (Mulago hospital records 2012). In addition, a review of 70 case files of patients managed for obstetric fistulas in 2012 in the Urogynaecology unit showed that 30 % of the patients had delivered in Mulago hospital following obstructed labour, prior to development of the obstetric fistula. These indicate poor quality of care for obstructed labour.
Poor quality of obstetric care was implicated in approximately 40 % of all maternal deaths in a Nigerian Teaching hospital . There were no local protocols or guidelines for the management of obstructed labour on the obstetric wards in Mulago hospital and clinical management did not depend on pre-determined standards of care. We hypothesized that lack of standardized management protocols for obstructed labour compromised the quality of obstetric care provided to women with obstructed labour, and that the quality of obstetric care could be improved through criteria based audit study. We assumed that when health workers adhered to pre-determined protocols, there would be early recognition of obstructed labour, and that institution of timely interventions could improve the quality of obstetric care . During implementation of the criteria based audit, we developed protocols for clinical management of obstructed labour with the aim of improving the quality of care for women with obstructed labour.
This study was conducted in the obstetric wards in Mulago Hospital, Uganda’s National Referral Hospital and teaching hospital for Makerere University College of Health Sciences.
Most of the patients are referred from satellite health facilities around Kampala City. Other patients are referred from Regional referral hospitals over 250 miles from Mulago hospital. Mulago hospital is a government-funded 2700-bed hospital, which currently serves more patients than 60,000 obstetric patients per annum. The hospital has 33,000 deliveries per year. The care is free to the public.
The labour ward receives about 60–80 admissions, delivers about 50–70 mothers by vaginal delivery and 20–25 mothers by emergency caesarean delivery daily in 12-h duty shifts. Most of patients get spinal anesthesia. General anesthesia is only given in cases were spinal anesthesia fails to take or incase of obstetric complications such as HELLP syndrome. Operative vaginal delivery is less than 10 % at this facility.
The study units included the labour ward, postnatal ward, Operating theatre and HDU, which units are adjacent to each other on the same floor of the hospital.
The medical care is provided via a 24-h duty shift team comprised of two specialist obstetricians (as team leaders), seven residents (trainee obstetricians), three Intern doctors, eight midwives, one records officer and three Anesthetic Officers / Anesthesiologist. This translates into provider: patient ratio of 1:5.
Indicators, their set targets and Action points following presentation of first audit results
Currents status (At the initial audit)
Target (By the end of the second audit)
Action points during implementation
Contact Person and level of Achievement of target
23.3 % had reasons in patient notes for not delivering within the expected 2 h. 85.1 % of the reasons were theatre related
Increase the number of women accessing theatre within two hours from 32 to 64 %.
Scaling up the number of mothers having assisted vaginal delivery. Assigning mothers to midwives for closer observation.
Labour Suite in charge
IV fluids assessment prior to delivery
41 % had IV access line 28 % received at least 1 L
100 % for IV access and I litre of IV fluid administration
Better documentation of all IV fluids given. Have a checklist in all patients’ charts
Team on duty. Almost achieved
IV Antibiotic assessment Receiving d IV antibiotics pre-operatively
22 % of mothers.
All mothers to have pre-operative antibiotics
Doctors to prescribe in all patient files
Labour suite weekly rotation Team leader
Indicators, their set targets and Action points following presentation of first audit results
Currents status (At the initial audit)
Target (By the end of the second audit)
Action points during implementation
Contact Person and level of Achievement of target
Ω Blood grouping and cross matching for all patients prior to caesarean delivery
13 % had blood taken off
A target of 100 % was set.
Blood group & CBC were to be sent on.
Labour suite weekly rotation Team leader Target not achieved.
Mothers to have urinary catheters inserted before delivery.
94 % of the mothers Preoperatively
100 % bladder catheterization pre-operatively.
Avail sundries. Avail Obstructed labour management protocol
Labour suite Area manager & Protocol team Protocol developed
Vital sign monitoring Done both on admission and at least once in 4 h in the labour ward.
15 % had a BP 17 % had their pulse rate measured No participant had a single temperature reading taken
100 % monitoring of vital signs (BP, PR, Temperature).
Midwives to take the vital signs CME was to be conducted The labour ward to be zoned into sections.
Labour Suite in-charge CMEs conducted (achieved) Other targets not achieved
Upon making a diagnosis of obstructed labour by the obstetric team on duty, patients who consented to participate in the study were followed prospectively to the point of discharge from the facility. The quality of obstetric care given to them was analyzed from their charts. Participants were interviewed for details where there was need for clarity in cases of under or over documentation of clinical findings.
All women with obstructed labour managed in Mulago hospital during the study period that consented to participate in the study.
Women managed for obstructed labour in other facilities but referred to Mulago hospital for further care following delivery.
Women with more than one obstetric emergency not related to each other e.g., Eclampsia + Obstructed labour.
Very sick women with obstructed labour unable to give informed consent or participate in patient interviews.
The study participants were 180 women with obstructed labour in each audit that was conducted within 24 h of admission. The criteria used for diagnosis of obstructed labour included having three adequate uterine contractions in ten minutes lasting 45–60 s with no cervical progression in two hours or progression less than 1 cm/h or presence of clinical signs of obstructed labour (impending uterine rupture, Bandl’s ring, blood-stained urine, severe caput or molding of fetal head) or clinical signs of shock (hypotension or tachycardia with a pulse of >110/min).
Maternal outcome variables
The maternal outcomes, which were considered in the study included; hospital stay of the participants, mode of delivery, maternal morbidities like puerperal sepsis, uterine rupture, fistula formation, and whether mother died or was alive at discharge.
Fetal outcome variables
Fetal outcomes that were considered included; admission to a NICU (special care Unit), rationale for admission to the NICU, and whether the baby died or was alive at discharge from hospital.
Study procedure and data collection
An initial one-week pilot study of ten participants diagnosed and managed for obstructed labour was conducted to pretest the instruments. After revising the instruments, audit participants were recruited from the labour ward and informed consent obtained prior to enrollment into the study.
In addition, participants’ case files were extracted and the quality of care the participants received audited, to assess the clinical management particularly data related to six standards of care (administration of intravenous fluids, intravenous antibiotics, monitoring of maternal vital signs, bladder catheterization, delivery within two hours, and blood grouping and cross matching). Interviewer-administered questionnaires were used to assess socio-demographic data, referral status and other relevant obstetric history related to the clinical management. Participants were interviewed for details where there was need for clarity in cases of under or over documentation of clinical findings. For each participant, the management received was compared to the recommended practice of the set standard of care.
The study criteria (standard of care) for managing mothers with obstructed labour included; delivery by emergency caesarean delivery, destructive vaginal or assisted vaginal delivery within two hours of making a diagnosis of obstructed labour, intravenous access and at least one litre, Intravenous fluids to be given to correct metabolic derangement before delivery, Intravenous antibiotics to be administrated pre-operatively within one hour before any intervention to relieve the obstruction, blood grouping and cross-matching, monitoring temperature, fetal heart rate, pulse rate, blood pressure in an observation chart at least every four hours and bladder catheterization.
Focus group discussions and in-depth interviews
To explore healthcare providers’ perceptions of the audit findings, ten semi-structured in-depth interviews (with one specialist obstetrician, one resident, the in-charge of the labour ward, the in-charge of theatre and the in-charge of the postnatal ward) and three focus group discussions (FGDs) (separately with midwives, intern doctors and residents) were conducted after each audit. Each FGD had ten participants and lasted about 40–80 min. The questions were thematically related to the criteria-based audit and were open ended. The interviews and FGDs were transcribed, coded and analyzed by thematic analysis.
Sample size calculation for the audit
Using Kish Leslie formula (1965) for sample size estimation, a mean care score in the initial P1 and second audit P2 of 81.7 and 93.5 % respectively (from a study conducted in South-western Nigeria , an acceptable error margin M of 5 %, a power of 80 % and using the formula n = (Τ 2[Ρ 1(1 − Ρ 1) + P2(1 − Ρ 2)])/ Μ 2 with as the standard value of 1.96, the minimum sample size of 324 participants for both audits was computed.
Data entry was performed with EPI-DATA 3.1 and analyzed using STATA version 12. Results from initial and second audits were compared using chi square (χ 2) for categorical variables and the Student t-test for numerical variables, and odds ratios computed. The level of statistical significance was set at p < 0.05. The performance score was computed as the number of participants that received the recommended divided by the total number of participants ×100.
Baseline characteristics of 360 participants managed for obstructed labour in Mulago Hospital in two Audits 4 months apart
Audit 1 (n = 180)
Re-audit (n = 180)
≤ 20 years
> 35 years
Complications in previous pregnancy
Not applicable (PG)
aComplications in previous pregnancy
aOutcome of last pregnancy (non PGs)
Fresh still birth
Early neonatal deaths
Fetal heart status at admission
Present and recorded
When the diagnosis of O.L was made
Comparison of 3 Standards of care that changed between Audit 1 and Audit 2
Audit 1 N (%)
Audit 2 N (%)
95 % CI
Intravenous access achieved
IV fluids given before delivery
How much fluid before delivery?
< 1 l
≥ 1 l
IV fluids given after delivery
How much IV fluid after delivery?
IV antibiotics administered after diagnosis of O.L?
Catheter was in situ post-op
How long was the catheter in situ?
≤ 3 days
More than 3 days
Comparison of parameters that did not change between Audit 1 and Audit 2
Audit 1 N (%)
Audit 2 N (%)
95 % CI
Delivery within 2 h of diagnosis of obstructed labor.
< 2 h
≥ 2 h
Grouping and Cross matching done before intervention
Maternal blood pressure taken at admission & at least once
Partograph used to monitor labor
Fetal and Maternal outcome parameters of the Participants in the two Audits
Baby admitted in Special care Unit after delivery
Reason for admission to Special care Unit
Baby alive at discharge
If baby not alive, is it any of the following?
Fresh still birth
Macerated Still birth
Early neonatal death
Mode of delivery
Post spinal headache
Duration of hospital stay
≤ 3 days
> 14 days
Qualitative study findings
Several issues emerged from the in-depth interviews and focus groups, the following key themes were categorized as; a) healthcare provider, b) health facility and c) patient factors.
Healthcare provider factors
“We are few but does it need many midwives to measure blood pressure? You can have 4 midwives and yet not a single Blood Pressure reading is taken any patient for the whole day! …another example, a shift may have 25 patients with 4 midwives but no single partograph is plotted.”
“At times there is one BP machine, I need to walk around and look for it but another clinician with a poor attitude will not be bothered. It is challenging but we have to work with the few resources available, so that attitude change is needed.”
“Patients don’t receive drugs because no one seems to care. There was a patient who had a fresh stillbirth following obstructed labour and she had a C-section and was taken to postnatal ward. When I found this patient had not taken a shower for a while and did not receive antibiotics just because she had no IV access [cannula]. I bathed her and gave the drugs myself”.
“Doctors are too proud especially when called upon to review some mothers with complications, which discourages us from consulting them, leading to delays… Both nurse midwives and doctors do separate rounds instead of working together. There is an ‘I know it all!’ mentality”.
“There is some teamwork but it’s difficult, and apparently teamwork may not seem to work. When we have a doctor, midwife, and an intern, we can’t move as a team to do the work, as we may need to separate to do the work promptly. We allow the team to disintegrate but we keep communicating to each other.”
“There are constant stock outs of supplies, the pay is so low yet the patients are too many. … I am disgusted with the whole system and I feel like leaving. The work is constantly frustrating and I’m no longer excited about work.”
Health facility factors
“There are supervision issues as there are few specialists who show up on the wards to provide guidance so we can better manage the patients.”
“As the financial year closes we suffer marked shortage of supplies because of the delay of release of funds, and the situation has kept worsening over time. On a typical day we do 20-25 Caesarean sections, but when I requisition for Foley’s catheters for the week, I am given 30 to cover a week, which can only last one day.”
“Sometimes documentation is less because there is lack of appropriate stationery in patient files. For example, when you have no partograph, how do you plot?”
“In the theatre, one team member may be unavailable. Some members may be there, but when another comes and finds one (key) person is missing on the team, they also disappear!
“The challenge starts with the lower health centres as most of the mothers are referrals; the people make a wrong diagnosis and usually refer to it as prolonged labour or delay in second stage, making it difficult to manage in time. The system does not separate levels of complications and emergencies.”
“Most of the time, we encounter problems like the drugs are out of stock. We tell them to buy but they have no money delaying and compromising the care given, and this causes other complications like ruptured uterus and sepsis.”
“Nurses are the ones who stay on the bedside 24 hours yet the patients are too many for these nurses to handle adequately. (To manage obstructed labour, you need a midwife to mother ratio of 1:3 but we receive a tune of up to 100 patients in a day and out of that number we deliver about 80 per day for both spontaneous vaginal delivery and caesarean section. This is a high number compared to the midwives who are about 2-3 in the delivery suite. This makes it hard to do key vital sign monitoring for the patients.”
“Mothers first try to seek help elsewhere till they are referred to us. They come in late when there are other priority cases already on the theatre list; yet each delay worsens the situation.”
“The patient also contributes. Some have a negative attitude on bladder catheterization. Some pressurize medical workers or pay money for the catheters to be removed before the scheduled removal time.”
This study aimed at assessing extent to which criteria-based audit improves the quality of obstetric care given to women with obstructed labour. The results show that introduction of criteria-based audit in the management of obstructed labour led to measurable improvements in only two out of six standards of care. Healthcare factors, facility factors and patient factors contributed to failure of quality improvement on the recommended standard of care. Though there was a decline in the overall mean performance score from 55.1 % in audit one to 48.2 % in second audit, there was a slight improvement in some parameters assessed in the second audit.
The value of criteria-based clinical audit in improving quality of obstetric care could be assessed objectively in terms of the change in the proportion of cases where management met the criteria for good quality care . There is no stipulated duration of time that must be observed between the two audits. In Weeks et al. audit study , improvements were seen over a period of six months. Crombie, however, noted that effecting quality takes time; thereby emphasizing that even the most likely outcome of a well conducted audit study is only partial success . In this study, there were limited funds to allow a wider time interval between the first and second audit. Given more time, and if provider and facility concerns had been addressed, the results of the second audit could have been different.
The findings show that improvement in quality of obstetric care without strengthening health systems may have minimal success. In the midst of scarcity of resources in sub-Saharan countries, Kidanto et al.  found that efforts to improve maternal and newborn quality of care were self-driven without mobilizing external resources. This called for reorganization of available human resources (physicians and nurses) in all levels accompanied by self-motivation to combat the unacceptably high maternal and child morbidity and mortality in the Sub-Saharan countries . Efforts to improve the outcomes of the second audit like re-organization of the labour ward (like supervision, team work, motivation and task allocation) to ensure maximum utilization of the available human resources were not implemented. This could explain the poor results of the second audit.
The study findings demonstrate constraints and challenges that may hinder quality improvement through criteria-based audit. Of the constraints described by Ronsmans  for successful implementation of audits in low resource countries, this study faced challenges of low motivation from the health care providers, short time between the first and second audits because of limitations in the study funding, poor documentation of clinical findings in patients’ case files, stock outs of medical sundries and equipment and the short duration residents and intern doctors rotate in the labour ward. The latter necessitates regular training and updating on management protocols.
Ten very sick patients were excluded because they were too sick to consent and also participate in the interview. They also had other co-morbidities that could have altered the study findings.
Being a national referral and teaching hospital, the intern doctors and residents (trainee obstetricians) rotate in the labour ward for one week every one to two months, thereafter shifting to other wards. The specialist obstetricians/gynecologists rotate in the labour ward once every fortnight. These changes in the staff make it hard to ensure supervision or maintain consistent quality of care in the labour ward.
As in other studies , compliance to the patient management protocol was still low for all cadres. Most of the parameters that did not change in the second audit seemed to depend more on health systems strengthening efforts than the individual staff efforts. Such challenges are not unique to this study alone, and have been reported by other researchers [5, 6, 12–14].
Amidst all the constraints, in this study it has been found that promotion of the audit cycle is feasible and a useful strategy to improve professional practice in under-resourced settings where adherence to recommended practice is low . This because as health care providers come together to solve health problems as part of the audit cycle, they can formulate practical solutions that may improve their patient care within their setting thereby enriching and improving their professional practice.
The introduction of criteria-based audit in the management of obstructed labour was well received and led to measurable improvement in two standards of care provided to the study participants, though overall improvement in practice was minimal. Putting management guidelines and protocols in place to streamline patient management, without having a well-motivated team and constant supply of materials, may be inadequate to improve patient care. The extent to which criteria-based audit may improve the quality of care provided to patients is therefore dependent on having effective health systems even in low resource settings.
BP, Blood pressure; CME, Continuing Medical Education; C-section, Caesarean section; FGDs, Focus Group Discussions; HDU, High Dependency Unit; HELLP syndrome, Hemolytic Anemia Elevated liver enzymes and Low Platelets; IV, Intravenous; NICU, Neonatal (Special care) Intensive Unit; OL, Obstructed labour; PR, Pulse Rate
We want to thank Prof Meg Autry, and Felicia Lester, Dr. Jolly Beyeza, Sematta Andrew and Dr. Andrew Edielu for their contribution towards the critiquing the manuscript for intellectual content and data analysis. A vote of thanks goes also to Prof Karamagi and Associate Prof Joan Kalyango for the constant encouragement during the preparation of this manuscript. We wish to acknowledge the Belgian Technical Cooperation for funding this study.
The Belgian Technical Corporation (BTC) made contribution towards the development and implementation of this study. There were no competing commercial interests from the Corporation.
Availability of data and materials
All the necessary data and materials are within this manuscript. In case any more data or materials are needed, they are readily accessible in the Directorate of Obstetrics and Gynecology library, and Albert Cook library archives, College of Health sciences, Makerere University.
HK developed the study’s concept, designed the study methodology, and also participated in data analysis and interpretation. JA revised critically the manuscript and made amendments for important intellectual content; KP and DKK contributed significantly to the intellectual content of the manuscript and also gave the final approval of the version submitted for publication. All of the authors have agreed to be accountable for all aspects of the work in this study.
HK is as an obstetrician/gynecologist who completed both his Undergraduate and postgraduate training in Makerere University and currently a lecturer in the Directorate of Obstetrics and Gynecology, Makerere University College of Health Sciences. JA is an Obstetrician/Gynecologist at Mulago hospital. KP and DKK are Associate Professors in the Directorate of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala-Uganda.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the participants prior to data collection. Both the mothers and healthcare providers who participated in the study were informed that the study findings were to be published in a reputable journal. They were also informed that participating in the study was optional and that they could opt out if they wished to. They clarified that they were comfortable having their views published as long as the end result was to improve the quality of care within and outside of the facility.
Ethics approval and consent to participate
We received ethical approval for this study from the Directorate of Obstetrics and Gynecology, Makerere University, and School of Medicine Research and Ethics Committee of the College of Health Sciences, Makerere University. Written informed consent was obtained from the participants. The study participants included women with obstructed labour that fulfilled the study criteria and also healthcare providers who participated in the focus group discussions and the In depth interviews.
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