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Quality Indicators and Outcomes of Emergency Caesarean Deliveries at a District-level Maternity Hospital

Melike Harfouche, Mina Hosseinipour, Stephen Kaliti, Jeffrey Wilkinson


The objective of this research study is to identify quality indicators of cesarean deliveries and determine their relationship to neonatal and maternal morbidity and mortality in one high volume maternity hospital in Lilongwe, Malawi. Demographic, perioperative, and postoperative data were collected on all cesarean deliveries over three months. Indicators of quality (antibiotic administration, use of oxytocin, decision-to-incision time, and uterine incision type) were compared to maternal morbidities (postpartum hemorrhage, fistula and wound infection) and neonatal mortality. Causes of delays in decision to incision time were identified. 513 cesarean deliveries were performed during the study period, with no maternal deaths and 39 neonatal deaths. Adherence to oxytocin and antibiotic administration was high but not complete, with greater adherence to the former (97.1% vs 82.6%). The decision to incision time between women with and without neonatal deaths was similar (1.62 hours vs 1.49 hours, p=0.41). Most delays were attributed to a busy operating theatre (49.1%) and delayed transfer to the operating theatre (26.9%). Uterine rupture and cesarean hysterectomy were associated with an outcome of neonatal death (p<0.001). Infrastructure and personnel limitations are major barriers to the improvement of quality of cesarean deliveries. Future endeavors towards quality improvement must address these deficiencies. (Afr J Reprod Health 2015; 19[3]: 61-67).

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Bailey P, Lobis and Maine D (2009) Monitoring emergency obstetric care: A handbook, Geneva, Switzerland: World Health Organization, p. 5-7.

Goodburn E, Hussein J, Lema V, Damisoni H and

Graham W (2001) Monitoring obstetric services: putting the UN guidelines into practice in Malawi. 1: developing the system. International Journal of Gynecology & Obstetrics 74 (2): 105-117

Hussein J, Goodburn E, Damisoni H, Lema V and

Graham W (2001) Monitoring obstetric services: putting the 'UN Guidelines' into practice in Malawi: 3 years on. International Journal of Gynecology & Obstetrics 75(1): 63-73.

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat

AHS, Dellinger EP, et al (2009) A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine 360(5): 491-499.

Berwick DM, Calkins DR, McCannon CJ and Hackbarth

AD (2006) The 100 000 Lives Campaign - Setting a goal and a deadline for improving health care quality. Journal of the American Medical Association 295(3): 324-327.

Graham WJ (2009) Criterion-based clinical audit in

obstetrics: bridging the quality gap? Best Practice & Research in Clinical Obstetrics & Gynaecology 23(3): 375-388.

Dumont A, Tourigny C, Fournier P (2009) Improving

obstetric care in low-resource settings: implementation of facility-based maternal death reviews in five pilot hospitals in Senegal. Human Resources for Health 7: 61.

Fauveau V, De Bernis L (2006) "Good obstetrics"

revisited: Too many evidence-based practices and devices are not used. International Journal of Gynecology & Obstetrics 94(2): 179-184.

Dogba M, Fournier P (2009) Human resources and the

quality of emergency obstetric care in developing countries: a systematic review of the literature. Human Resources for Health 7: 7.

Duff P (2010) A Simple Checklist for Preventing Major

Complications Associated With Cesarean Delivery. Obstetrics and gynecology 116(6): 1393-1396.

Berghella V, Baxter J, Chauhan S (2005) Evidence

based surgery for cesarean delivery. American Journal of Obstetrics and Gynecology

(5): 1607-1617.

Helmy, W., Jolaoso, A., Ifaturoti, O., Afify, S., & Jones, M. (2002) The decision-to-delivery interval for emergency caesarean section: Is 30 minutes a realistic target? Bjog-an International Journal of Obstetrics and Gynaecology, 109(5): 505-508.

Van Den Akker T, Mwagomba B, Irlam J and Van

Roosmalen J (2009) Using audits to reduce the incidence of uterine rupture in a Malawian district hospital. International Journal of Gynecology & Obstetrics 107(3): 289-294.

Makoka MH, Miller WC, Hoffman IF, Cholera R,

Gilligan PH, Kamwendo D, et al (2012) Bacterial infections in Lilongwe, Malawi: aetiology and antibiotic resistance. Bmc Infectious Diseases 12: 67.

Hema, K., & Johanson, R. (2001) Techniques for

performing caesarean section. Best Practice & Research in Clinical Obstetrics & Gynaecology, 15(1): 17-47.

Kelly J (1992) Vesicovaginal and Rectovaginal Fistulas.

Journal of the Royal Society of Medicine 85(5): 257-258.

Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D,

Faundes A, et al (2007) Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. British medical journal 335(7628): 1025-1029.

Fawcus, S., & Moodley, J. (2013) Postpartum

haemorhage associated with caesarean section and caesarean hysterectomy. Best Practice & Research Clinical Obstetrics & Gynaecology 27(2): 233-249.

Hofmeyr G, Say L, Gulmezoglu A (2005) WHO

systematic review of maternal mortality and morbidity: the prevalence of uterine rupture. Bjog-an International Journal of Obstetrics and Gynaecology 112(9): 1221-1228.

Chilopora GC, Pereira C, Kamwendo F (2007)

Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Human Resources for Health 5(17): 1-6.

Wilson A, Lissauer D, Thangaratinam S, Khan KS,

MacArthur C, and Coomarasamy A (2011) A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: meta-analysis of controlled studies. British medical journal 342: 1-8.


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