1. Substandard Care and Harmful Practices

2. 2 Purpose of the session: The purpose of this session is to provide physicians with the different aspects of substandard care and harmful practices by the health care providers that contribute to maternal mortality. By the end of this session, trainees will be able to: Identify magnitude of the problem. Identify avoidable factors contributing to maternal death. Define Substandard Care. Explain totality of Care Identify Substandard Care in PPH and APH Identify Substandard Care in Hypertensive disorders with pregnancy Identify Substandard Care in Sepsis. Identify Substandard Care in Ruptured uterus. Identify Substandard Care in normal, abnormal labor and CS. Identify Substandard Care and Harmful Practices in the Private Sector.

3. 3 Problem in Egypt The ENMMS, 2000 estimated that The total MMR was 84/100,000. One or more avoidable factors contributed to 81% of maternal deaths

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7. 7 The maternal Mortality Stopwatch

8. 8 Avoidable Factors Health Facility Health Provider Women and Family

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10. 10 Health Facility Factors Health Facility Factors contributed to maternal death due to: Lack of blood (16%) distance of care(4%) lack of drug(2%) lack of supplies(2%) and equipment (5%).

11. 11 Women and family Failure to recognize problems [27%] and delay in seeking medical care [21%]

12. 12 Health provider Factors Substandard care by health provider was the leading avoidable cause of death contributing to 36 maternal death per100,000 live birth.

13. 13 Definition of Substandard Care It includes: The use of practices which are clearly harmful or ineffective. Practices where insufficient evidence exists to support a clear recommendation Practices which are frequently used inappropriately.

14. 14 Standard Care… The need of ‘Standardized Clinical Guidelines’ Clinical guidelines are: ‘Systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions’ Developed using a standardised methodology

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16. 16 u NICE guidelines u USAID Recommendations for Updating Selected Practices in Contraceptive Use u JHPIEGO Infection Prevention reference manual u CPI guidance documents u RCOG green top guidelines Evidence Based and Updated Guidelines

17. 17 - Ila Evidence obtained from at least one well- designed controlled study without randomization. - Ilb Evidence obtained from at least one other type of well-designed quasi- experimental Evidence obtained from well-designed non- experimental descriptive studies, such as comparative studies, correlation studies. Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities 1 - Ia Evidence obtained from meta-analysis of randomized controlled trials. - Ib Evidence obtained from at least one randomized controlled trial. 2 3 4 Classification of Evidence Levels

18. 18 Forms of Care… Beneficial Forms of care. Forms of care likely to be beneficial. Forms of care with a trade off. Forms of care with unknown effectiveness. Forms of care likely to be ineffective. Forms of care likely to be harmful.

19. 19 Grades of Recommendation AAt least one controlled trialLevel Ia, Ib BRequires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations. Level IIa, IIb, III CRequires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality Level IV

20. 20 Totality of Care 1.Check that all the basic steps were followed. 2.Monitor the patient throughout the entire care process : Antenatal care period Intrapartum care period postpartum care period. Emergency events or admission Anesthesia and recovery

21. 21 Skilled Attendant.. Is a professional caregiver Has the knowledge and skills to: Manage labor, childbirth and postpartum period Recognize complications Diagnose, manage or refer woman or newborn to higher level of care if complications occur that require interventions beyond caregiver’s competence Performs all basic obstetric interventions WHO 1999.

22. 22 Substandard Care … A Cause of Maternal Deaths Let’s examine instances where substandard care by providers is one of the major contributing causes of maternal death in Egypt.

23. 23 Major Maternal Killers Bleeding Hypertension Sepsis

24. 24 Postpartum Hemorrhage (PPH) Substandard care by obstetricians contributed to 50% of deaths due to PPH. Antenatal care Lack of or poor antenatal care Failure to recognize the predisposing factors for PPH, e.g. previous history of PPH Emergency room Failure to provide appropriate first aid management e.g. not giving fluid replacement while waiting for blood

25. 25 Pre-delivery and delivery room Incorrect use of oxytocin in high doses with no titration Failure to recognize predisposing factors of PPH as in cases were there is APH or when there is twin pregnancy or overdistension Absence of a senior specialist Pushing on the abdomen to force delivery that leads to a ruptured uterus, laceration or tears Not following a protocol for PPH management Packing the vagina during atonic PPH, thus masking the condition Ignoring the active management of the third stage of labor

26. 26 Operating room Delaying decision of hysterectomy Waiting for a senior obstetrician or surgeon to perform other life-saving interventions for which providers do not have skills or which are inappropriate. Recovery room or postoperative follow-up There is a lack of monitoring of the patient post-labor or postoperatively, resulting in unnoticed bleeding and rapid deterioration. Early discharge of patients from the hospital, without complete treatment.

27. 27 Antepartum Hemorrhage (APH) Substandard care by obstetricians contributed to 61% of deaths due to APH. Antenatal care Failure to recognize the problem, e.g. attributing the blood to delayed menstruation or local causes without confirming the diagnosis Failure to admit a patient who needs admission Emergency room Failure to provide appropriate first aid management by not giving fluid replacement while awaiting blood Digital examination of patients with APH before excluding placenta previa

28. 28 Pre-delivery room Failure to request or assess a coagulation profile Delivering patients with APH without considering the high probability of PPH Operating room Delaying interventions until blood is available Absence of senior specialist Recovery room or postoperative follow-up Antepartum hemorrhage is the main cause of PPH, and lack of close observation could easily miss early diagnosis of the condition.

29. 29 Hypertensive disorders with pregnancy Substandard care by obstetricians contributed to 47% of deaths due to hypertensive diseases of pregnancy. Antenatal care failure to recognize hypertension, as in some cases the blood pressure is not correctly taken. If the problem is detected, some physicians adopt what they think is conservative management and delay delivery, which can put both the mother and fetus at risk. In some instances the physician tends to postpone delivery

30. 30 Emergency room and pre-delivery room Prescribing sedation and anti-hypertensive drugs for patients with severe cases who are not in labor and discharging them Inability to provide correct first aid management for patients with convulsions because IV access was not established Failure to control convulsions immediately by administering correct doses of MgSO4 Waiting for delivery to occur spontaneously even though it may take a long period of time

31. 31 Delivery room Administering Methergine Prolonging the second stage of labor Absence of a senior specialist Operating room Failure to inform the anesthesiologist of the patient’s medical history Patient not stabilized before the operation Failure to request the presence of a neonatologist Recovery room or postoperative follow-up Failure to monitor the toxic effects of MgSO4 Failure to continue MgSO4 for48hrs in sever cases.

32. 32 Sepsis Substandard care by obstetricians contributed to 38% of sepsis deaths. Antenatal care Severe deficiencies in or lack of quality care, especially with regard to health education, e.g. hygiene

33. 33 Emergency room and pre-delivery room Lack of infection control precautions Little or no hand washing between patients Failure to use sterile instruments Failure to isolate patients with puerperal sepsis Frequent vaginal examinations of patients with PROM Delivery room Lack of infection control precautions

34. 34 Operating room Lack of infection control precautions, e.g., inadequate cleaning of the table and instruments between patients Antibiotic prophylaxis in CS done with incorrect timing and wrong dose Recovery room Poor or no monitoring of cases for signs of infection Early discharge of patients with mild fever Early discharge of patients with PROM

35. 35 Ruptured uterus Substandard care by obstetricians contributed to 64% of ruptured uterus deaths. Antenatal care Poor quality of care Patients with a previous history of uterine scars not counseled on the importance of a hospital delivery

36. 36 Emergency room and pre-delivery room Poor history taking, which results in missing high-risk cases of previous operations or previous obstructed deliveries Delay in diagnosis due to lack of experience Delay in infusing fluids while waiting for blood Inappropriate use of oxytocin

37. 37 Emergency room and pre-delivery room Using drugs still under trial to induce labor, with no known dose for induction of labor, e.g., Misoprostol Not using a partograph to monitor labor Trial of a scar with incorrect judgment or essential pre-requisites Lack of knowledge of signs of a ruptured uterus

38. 38 Delivery room Pushing on the abdomen to force delivery Obstructed labor not diagnosed early or dealt with properly Operating room Delaying intervention until blood is available Delaying a hysterectomy to save the uterus Senior obstetricians not attending in time Recovery room Lack of any postoperative follow

39. 39 Clinical Conduct of Labor Instances of substandard care can occur in the following: Antenatal Care No care or poor quality of care Emergency and pre-delivery care No proper history taking, thus missing the opportunity to anticipate possible problems or complications that may have occurred before High-risk patients not identified Low risk patients are NOT properly followed up General examination incorrectly done or omitted Vaginal examination only procedure performed in the emergency room

40. 40 FHS not monitored Partograph not used to monitor labor Oxytocin used inproperly High enema and catheterization still used as a routine Patients allowed to bear down early before full cervical dilation

41. 41 Delivery room Forceps or vacuum extractor used inappropriately due to incorrect evaluation of cases from the start Late intervention in prolonged or obstructed labor Methergine routinely used Recovery room No postpartum care or follow-up Patients discharged too early

42. 42 Abnormal labor and CS Substandard care by obstetricians contributed to 68% of CS deaths. Antenatal care Poor quality of care Emergency room Medical history not taken properly Admission procedures too slow

43. 43 Pre-delivery No proper history taking, thus missing the opportunity to anticipate possible problems that may have occurred before High-risk patients not identified General examination not performed

44. 44 Investigations not ordered Patients inappropriately referred due to lack of blood With a history of a previous CS, an attempt at labor occurs without proper preparation CS done without proper indication Oxytocin used with a previous CS scar with the incorrect dosage and poor or no follow-up

45. 45 Operating room Anesthesia administered to patients by obstetricians Complete hemostasis not reached CS done by inexperienced providers with no supervision Delay in intervention due to absence of appropriate personnel Delivery of fetal malpresentations by inexperienced staff Applying forceps if vacuum extraction fails Recovery room No postoperative follow-up

46. 46 Substandard Care and Harmful Practices in the Private Sector A considerable number of deliveries are performed outside of hospitals at home, private sector hospitals or clinics. Different types of service providers are usually involved When the process of delivery is complicated, the woman is referred to a nearby health facility.

47. 47 The most common forms of substandard care that may lead to maternal mortality or morbidity outside health facilities are: Poor quality of antenatal care Failure or delay in recognizing problems Delay in correctly managing cases Late referral of complicated cases Operations sometimes performed by inexperienced persons Drugs given in the wrong way or in an incorrect dose

48. 48 To sum it up… Most substandard care is due to : Not being aware of the latest knowledge and techniques or no following the proper guideline A failure to supervise and train new providers in order to ensure that appropriate standards are maintained A failure to observe and implement the protocols for management.