Research is finding out what the right thing to do is, audit is seeing whether the right thing is being done. Audit is a potent method of identifying problems in the health service and enabling changes in the health service to occur. A Confidential Enquiry into Maternal Deaths is a well-established audit system that has led to major improvement in the care of pregnant women. This system has been introduced into South Africa and the method of assessing each case is described in this appendix. The results of the audit are presented in "Saving Mothers".
As health care workers involved in the care of pregnant women, we are aware of our own and the health systems shortcomings. We mostly aspire to improving the standard and quality of health care but are often at a loss at what to do.
One effective method for achieving an improvement in care and pointing us in the right direction is to identify problems in the care of pregnant women and devise solutions for these problems. It is very difficult to analyse the standard of care of every pregnant woman, therefore a sample of women needs to be taken. The sample should be easily defined and representative of the whole population. There should not be too many cases to overwhelm the investigators, but enough to get meaningful results. The sample should also comprise of cases where the problems are most likely to be identified. Maternal deaths clearly meet all these criteria. Maternal deaths as the criteria for admission to the sample has the added advantage in that by monitoring the Maternal Mortality Rate, the success of the solutions implemented can be measured.
This audit method of improving care can be summarised by reference to the tip of the iceberg theory, viz. by concentrating on a solving factors related to a small but important area of a problem, the ripple effects will be felt by a large number. For the "small but important area" read maternal deaths, for "problem" read standard and quality of care of pregnant women, and for "large number" read all pregnant women. Hence, by concentrating on solving factors related to maternal death with respect to the quality and standard of care of pregnant women, the ripple effects of these solutions will be felt by all pregnant women.
The effectiveness of this method has been clearly demonstrated in relation to the care of the fetus and newborn1,2. The basic philosophy rests on two assumptions:
There is compelling evidence that, provided there is a large enough sample, a relatively few cases can represent the picture for the population. There is also strong evidence that the problems of care in maternal deaths are similar to those where pregnant women suffered acute severe morbidity but survived3.
The Department of Health made maternal deaths notifiable medical condition in terms of the Health Act, 1977 (Act No. 63 of 1977). This was published in the Government Gazette (Government Notice No. 1307) on the 3rd October, 1997. It has also created a National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) to study all maternal deaths. The NCCEMD is tasked with making recommendations, based on the confidential study of maternal deaths, to the Department of Health such that the implementation of the recommendations will result in a decrease in maternal deaths. The inquiry is confidential and information regarding the identity of the patient or health personnel will not be available to anyone. The members appointed to the NCCEMD, have been appointed in their individual capacity and none of the members will be involved in any medico-legal case involving a maternal death. After any maternal death, the process to be followed is:
The aim of the Maternal Death Notification Form is to collect information on a maternal death. It is designed so that the story of what happened can be accurately recorded. Guidelines on completing the Maternal Death Notification Form are available from the Department of Health and are designed to help health workers fill in the form and also to discuss the death with the health personnel in their area. The process is summarised by the diagram A3.1.
The aims of each maternal death assessment are firstly to detect errors or omissions in the care of the woman such that these errors or omissions can be prevented in the future. It is not sufficient for an assessor to say the care was substandard, the assessor has to pinpoint what specifically in the care was substandard. The second objective for an assessor is that once a problem is identified in the care of a patient it must be described in such a way that it is logical, useable and readily understandable for the average health worker.
The NCCEMD adopted the definition of sub-standard care that is used by the United Kingdom.
"Substandard care
The term substandard care has been used in this report to take into account not only failure in clinical care, but also some of the underlying factors which may have produced a low standard of care for the patient. This includes situations produced by the action of the woman herself, or her relatives, which may be outside the control of the clinicians. It also takes into account shortage of resources for staffing facilities; and administrative failure in the maternity services and the back-up facilities such as anaesthetic, radiological and pathology services. It is used in preference to the term "avoidable factors" which was used previously in the England and Wales Reports until 1979 and has also been used in the Scottish and Northern Ireland reports. This was sometimes misinterpreted in the past, and taken to mean that avoiding these factors would necessarily have prevented the death. "Substandard" in the context of the report means that the care that the patient received, or care that was made available to her, fell below the standard which the authors considered should have been offered to her in this triennium." 5
It is extremely important to understand that in assessing the case, the assessor is looking at the care in totality. This includes how were the basic care was performed, e.g. during antenatal care was the haemoglobin level recorded, as well as the event that led to the woman's death.
When performing an assessment of a maternal death, the spirit that pervades the assessor's enquiry is how could we have done better? The basic guidelines that the assessor employs are those commonly used in the country and those that are applicable to the level of care. The Maternal Manual of the Perinatal Education Programme is used as a basis for assessing care at a primary level, and local protocols are used for tertiary level care.
The basic structure of the assessment of care system devised for the confidential enquiry is to analyse
Analysis in these three categories has the obvious advantage that information gained in these areas can be fed back immediately to the relevant sectors for action.
1. Patient related problems. (The woman and her environment)
Assessing avoidable factors or missed opportunities related to the woman and her environment is divided into three sections:
Clearly much of this information may not be currently available in patient's case notes, but hopefully it will be discussed in the meeting where the Maternal Death Notification Form is filled in. One of the purposes of widely distributing the method of assessment of maternal deaths is to raise awareness in professionals and in this way begin getting more information regarding each case. However, when collecting and interpreting the information it is important not to victim blame. The full story tends to be complicated, and often circumstances dictate the behaviour and not neglect or desire to do damage on the side of the woman.
2. Administrative problems.
Administrative problems are easier to classify and the information easier to obtain. The problems are classified as:
3. Standard of health care
The assessment of the standard of care given to the woman by the health workers is divided into distinct periods and the care is assessed in each period where applicable. The periods are:
| A. Antenatal care | } | |
| B. Intrapartum care | } | these refer to the routine care of the patient. |
| C. Postpartum care | } | |
| D. Emergency event/admission | } | |
| E. Resuscitation | } | these refer to the event that lead to the death |
| F. Anaesthesia | } |
The assessment of each section is based on how the following were performed in each case:
(Assessment of the resuscitation follows the ABCD protocol - airways, breathing, circulation, drugs).
This system is used because it is the way each patient should be managed and is consistent with the way that the medical staff has been taught.
Cases where a death might not be able to be assessed because of lack of notes or missing notes are also recorded. Valuable information is obtained here. The very fact there are no notes indicates substandard care, also cases of missing files indicates a major administrative problem. The assessors also look at the behaviour of the health personnel and record areas where they think there are problems. For example, was the patient seen regularly or not.
In the South African Confidential Enquiry into Maternal Deaths, the assessors have a checklist which covers all aspects of the case as described above. The checklist is used to ensure a uniform approach to case assessment. The areas where sub-standard care are thought to be present are recorded and subsequently all the information is computerised. The cause of each death is recorded and the assessment of care in each case is linked. In this way disease specific information is obtained and specifically where the problems lie in a particular disease can be identified. Consequently, it is easier to formulate solutions.
For example, information from the confidential enquiry shows that maternal deaths due to septic abortion are in the top five of the major causes of death. In three-quarters of the cases the diagnosis of septic shock was initially missed and only diagnosed too late. In less than one-fifth a hysterectomy was performed.
Clearly the message needs to go out bringing attention of the profession to this. It was also apparent that in two thirds of cases the women herself or people from outside the health service induced the abortion. In the areas where these women came from there were no Provincial termination of pregnancy services. This indicates a lack of accessibility of a health service for women and this has been brought to the attention of the authorities.
For the first time a national assessment of the standard and quality of care of the pregnant woman has being undertaken. From this ongoing survey, (the Confidential Enquiry into Maternal Deaths), many important messages are emerging. It will be essential that practitioners involved in the care of pregnant women take cognisance of the findings, examine the recommendations in relation to their practice and change their practice where necessary. In this way the objective, of improving the quality and standard of care for all pregnant women, will be achieved.