Dr. Merlene Fredericks

Chief Medical Officer

Sis. Smith Layne Departmental Sister, VH

September 14, 2015

Population: 165 000

Life expectancy: 72 M: 79 F

Fertility rate: 3.5 in 1985 to 1.5 in 2012

Range annual births: 1882-2233

Range annual infant deaths: 33-43 (neonatal deaths 60%)

Range annual maternal deaths:0-2

Organization of Health system

◦ Strong Primary Care focus

◦ Government owned hospitals

◦ Free/highly subsidized care to pregnant women

Free midwifery and doctors clinics

Free STI screening – public sector

(other diagnostics – out of pocket)

WHY WAS A PERINATAL AUDIT REQUESTED?

Central Statistics Office St. Lucia WHO: Life expectancy

Infant Mortality per 1000 live births

Maternal Mortality per 100,000 live births

0

50

100

150

200

250

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

Rate

Year

0

5

10

15

20

25

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

Rate

Year

Erosion of national image

Erosion of public trust

National

◦ Potential failure to meet MDGs

MDG 4 (reduction in child mortality) and 5 (reduction in maternal mortality)

◦ Human Development index compromised

◦ Cost to society

Institution Increased cost of care

- Complications increase complexity and cost of care

- Litigation costs: emotional and financial

- Increases strain on healthcare workers and affects morale

Family and individual

- Emotional - Immediate financial

challenges - Long term financial &

psychological

Goal: To identify any gaps which can be addressed to improve outcomes of mother and child

PAHO/CLAP and St. Lucia team ◦ Public

◦ private

WHO Near miss approach

Review situational analysis for maternal and perinatal outcomes

Critically review selected individual patient’s documentation

Complete the audit questionnaires (manually)

Add “free text” comments to the evaluation tool, as warranted

Identify and record those situations that were either best practices or critical and need of remedial actions

Collate information, and discuss findings

Document and present findings

Participate in related discussions

Between the years January 2012 to June 2014 The cases were included if they were classified (and selected) by the health institution as: Stillbirth Neonatal death (before 7 days) Near-Miss maternal death

A sample of antenatal health records were selected from three(3) clinics

Maternal deaths were included for the years 2009 to June 2014

Assessment of the Quality of Care Structure (Hospitals)

Assessment of the Quality of Care Process (Antenatal clinics)

Severe Maternal Outcomes

Maternal near-miss case- “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy”

Maternal death - death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes

Still births and early neonatal deaths

Title of the Presentation 10

Quality of Care Variables by Hospitals

Components St. Jude Victoria Hospital Tapion Hospital Comments

Quality of the environment

Satisfactory Satisfactory Satisfactory

Organization and management of the facility

Satisfactory Satisfactory Satisfactory Unit wide meetings not routinely held

Procedural documentation

Satisfactory Needs improvement

Adequate (needs to be customized for the institution)

Manuals not approved and some incomplete

Staff orientation

Satisfactory Satisfactory Satisfactory No specific orientation package

Supplies and equipment

Inadequate equipment

Inadequate equipment

Satisfactory Basic equipment such as blood gas machine, portable –x-ray are needed. Need structured mechanism for monitoring

Infection control

Satisfactory Satisfactory Satisfactory

Monitoring of the health status of staff

Needs improvement

Needs improvement

Satisfactory To be addressed

Title of the Presentation 11

Quality of Care Process Variables by Primary Care Clinics

Components Vieux Fort Castries Soufriere Comments

SOPs and guidelines

Basic Basic Basic Being updated

Initial Assessment Satisfactory Satisfactory Satisfactory The assessment card does not capture all variables of interest.

Follow-up assessment

Needs improvement

Needs improvement

Needs improvement

Quality of documentation needs improvement; inconsistency in documenting patient information. Nature of counselling not defined

Identification of high risk pregnancies

Needs improvement

Satisfactory Referral of HR cases to private sector can be barrier to care

Satisfactory Poor follow-up of cases; no definite mechanism in place. Needs further in-depth assessment

Support in Antenatal Period

Inadequate Inadequate Inadequate No emphasis for involvement of father in ANC. Organization of the delivery process does not support inclusion of fathers

MATERNAL MORTALITY

NEAR MISS

LIFE THREATENING CONDITIONS

LIVE BIRTH AND

MOTHER IN GOOD HEALTH

MATERNAL NEAR MISS

St Jude N=18

Eclampsia 3

Severe pre-eclampsia 12

Severe PPH 2

Pulmonary embolism 1

Victoria Hospital N=13

Severe pre-eclampsia 3

Eclampsia 3

Sepsis 1 Ectopic 1

PPH 5

Severe

preeclampsiaeclampsia

sepsis

severe

preeclampsia

severe PPH

pulmonary

embolism

Distribution of Selected Variables for Maternal Mortality (N=8)

VARIABLE NUMBER

Age 17-41 years

Place Health facility

Referral Yes (but some missing data)

Marital status and occupation All unmarried and unemployed

Primigravida 3

Preterm 5

Prepartum 1

Outcome 3 Stillbirth 1 Neonatal death 4 Live birth

More than 3 antenatal care visits 4

High risk pregnancies 6

Main Characteristics of Neonatal Deaths

St. Jude Hospital Victoria Hospital

Extreme premature

47% 47%

Extremely LBW

53% 47%

Deaths within the first day

59% 47%

Related to Congenital Birth Defects

41% 26%

Severely depressed at birth

24% 32%

Mostly male 2/1

2/1 2.3/1

Mid maternal age 30% >24

5% <20 y. and 30% >24

Neonatal Deaths by Gestational Age at Birth

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

St. Jude - Neonatal deaths Victoria H. Neonatal deaths

term

37-38

29-36w

<28 w

Neonatal Deaths by Birthweight

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

St. Jude Victoria

3000 or more

2500-2999g

1500-2499g

1000-1499g

<1000g

Neonatal Deaths by Causes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

St. Jude Victoria

unknown

other

hemorragic disease

Asphyxia

Cong. Deffect

Prematurity

Stillbirth by Gestational Age at Birth

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

St. Jude - Neonatal deaths Victoria H. Neonatal deaths

term

37-38

29-36w

<28 w

Stillbirths by Causes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

St. Jude Victoria

unknown

other

Fresh

Cong. Deffect

Macerated

Other: dystocia, abruptio placentae, IUGR

Qualitative Evaluation

Improvement needed in documentation

Infections and sepsis listed as secondary cause of death in some cases

In some cases, excellent report for case referral

From a neonatal perspective, most of the cases were related to extreme clinical conditions, but the obstetric condition resulting in the poor neonatal outcome still might have been preventable

Some newborns with an apparently good prognosis had unexpectedly poor outcomes

Neonatal Themes to be Addressed

1. Asphyxia and training on neonatal resuscitation

2. Oxygen provision and prevention, diagnosis and

treatment of Retinopathy of Premature (ROP)

3. Neonatal transport – opportunity and conditions

4. Prevention, diagnosis and treatment of sepsis

5. Specific follow up to moderate to extreme premature

6. Warning signs at hospital discharge and at community

level

7. Early skin-to-skin contact and early initiation of

breastfeeding

8. Identify risk conditions during pregnancy in order to

prevent premature births

National

Perinatal Committee and plan; protocols; surveillance system

System related

Trigger high risk cases; adopt SIPS; increase access to

diagnostics

Institution

Increased collaboration and communication between and within

facilities and care levels; training and re-training

Patient

Education, promotion of antenatal care

National

National Perinatal Committee

Training in neonatal resuscitation

Pipeline: ◦ Full implementation plan + M&E framework

◦ Health promotion campaign

◦ Finalization of maternal and child health protocol

◦ Introduction of SIPS and incorporation into national pregnancy passport

◦ HR - OBGYN, Neonatologist

◦ Strengthen surveillance

◦ Integrate community and hospital high risk clinics

Institution Primary Care: ◦ Re-training and sensitization of midwives, DMOs ◦ Community outreach increased

Secondary-Hospitals ◦ Monthly perinatal meetings instituted ◦ Plans for simulations developed ◦ SJH- Trained in neonatal resuscitation ◦ Protocols and guidelines shared ◦ VH- procurement of ventilators, CPAP machines ◦ Dedicated physician to delivery suite ◦ Patient information leaflets provided

Eager participants from all sectors, public and private

Willingness to accept ownership of problems and gaps

Have started to make changes and eager to continue improving

Opportunities for enhanced collaboration between patients, community, health care providers and institutions

Desire for further research into perinatal outcomes and their causes

Ms. Kathleen Albert, Nurse/Midwife (MOH) Dr. Alicia Aleman, Obstetrician/Gynaecologist

(CLAP) Dr. Gillian Birchwood, Neonatologist (Barbados) Dr. Lucilla Charles, Obstetrician/Gynaecologist

(MOH) Dr. Pablo Duran, Advisor on Perinatal Health (CLAP) Dr. Margaret Hazlewood, Public Health Specialist

(PAHO - BAR Dr. Beryl Irons, Advisor, Family, Gender and Life

Course (PAHO –BAR) Ms. Frances Lesmond, Nurse Practitioner (MOH) Ms. Judith Solomon, Nurse/Midwife (MOH)

References: ◦ Report of Perinatal Audit in St. Lucia (PAHO /WHO

Office of Eastern Caribbean )

◦ Maternal/Perinatal Audit presentation: October 13-17, 2014: PAHO/WHO Centre for Perinatology (CLAP)

◦ Central Statistics Unit of St. Lucia

◦ WHO Life Expectancy figures

◦ Epidemiology Unit of the Ministry of Health, St. Lucia