A critical analysis of the implementation of obstetric management guidelines on common causes of maternal death, as applicable to midwives

Abstract

Background Despite interventions by the United Nations which formulated the Sustainable Development Goals (SDGs), to replace the unmet targets of the Millennium Development Goals, the maternal mortality ratio (MMR) remains high in low-andmiddle income countries including South Africa (SA). The goal 3 of the SDG aims to achieve less than 70 maternal deaths per 100 000 live births by 2030, globally. The slow but steady decline in the number of maternal deaths in SA with 339 deaths over the last 2014-2016 triennium falls short of the SDG targets (National Department of Health, 2017). The institutional MMR for potentially preventable maternal deaths in South Africa was 83.3 over the last triennium. The management of obstetric emergencies in SA is based on the interventions laid out in the Essential Steps in Managing Obstetric Emergencies (ESMOE) which was adapted from internationally recognised obstetric management guidelines that have proven to reduce MMR’s if effectively implemented. The availability of a good clinical guideline is only part of the solution but ensuring effective implementation in the clinical environment is of greater significance to reduce preventable maternal deaths. Aim The aim of this study was to analyse the impact of the implementation of the ESMOE guidelines by midwives on the management of the common causes of maternal deaths. This included identifying gaps, challenges and successes of its implementation by the midwife at the different levels of health care facilities with the ultimate aim of developing a practice framework to implement the interventions into midwifery training, to improve relevant knowledge and skills in providing quality emergency obstetric care. Methodology A multi method data collection approach using quantitative and qualitative designs was implemented in four phases. This study was conducted in two of the eleven districts of KwaZulu-Natal. All level of hospitals and CHCs (eleven) in eThekwini (District A) and Ugu (District B) were chosen based on purposive sampling including the districts health system’s referral pattern. Data was collected by the researcher using self-designed data capturing sheets. Quantitative data was collected on resources and ESMOE training at all eleven selected facilities, as well as a retrospective chart review on a total of 17 maternal deaths that occurred over a specified period to assess the implementation of ESMOE interventions. Face to face interviews were conducted by the researcher with 14 ESMOE trained midwives to determine the barriers and challenges they experience that impedes successful implementation of the ESMOE interventions. To test for significant trends in the quantitative data, inferential statistics was applied, including Pearson’s correlation, ttests, Mann Whitney U test, Kruskal Wallis Test and Chi-square tests. Descriptive statistics included means and standard deviation as applicable. Relevant frequencies were represented in tables and graphs. Chi-square test of independence were used on cross-tabulations to see the significant relationships in resources at the various health facilities. The Kruskal Wallis test was used to compare specific variables across the different types of health facilities. The qualitative data was analysed using thematic content analysis. Finally, a Delphi Technique using ESMOE experts was employed to validate a practice framework to implement relevant ESMOE modules into midwifery training to enhance competencies of midwives and implementation of the guidelines. Results The findings of this study indicated that many barriers and challenges exist that prevent successful implementation of ESMOE interventions which would further reduce maternal mortality rates in SA. Of the 11 facilities chosen 45.5% (n= 5) were community health centres, whilst 54.5% (n=6) were hospitals. In phase two the results revealed that the CHCs and DH did not meet the criteria of being fully BEmONC compliant, which resulted in increased referrals to regional and tertiary hospitals. This was evident by the significant difference in normal vaginal deliveries at combination hospitals as compared to CHC (p=.037). An average of 2505 deliveries were conducted at combination/regional hospitals over a four- month period with averages of 1247 at a DH and 957 at a RH as compared to only 224 deliveries at a CHC. A general shortage of essential equipment was found across facilities. The CHCs had significant shortages of CTG machines and intravenous regulators. Staff with ESMOE training were insufficient to staff all the maternity units across the facilities. District A, the bigger of the two districts with eight facilities had a significantly lower number of ESMOE trained advanced midwives (n=11) as compared to District B with three facilities (n=12). The number of maternal deaths that occurred over January 2016 to April 2016 at three combination hospital were 82% (n=14) as compared to 12% (n=2) at the regional hospitals and only 6% (n=1) that occurred at a District hospital and no deaths at a CHC. Deaths due directly to hypertension were 41% (n=7), HIV was 6% (n=1), whilst 53% (n=9) were from other causes not directly relevant to this study. A significant number of relevant maternal deaths 54.5% (n=6) were due to delays in seeking treatment and sub-standard care. Transport delays to the health facility contributed to 18.2% (n= 2) deaths, whilst non-compliance to treatment and poor record keeping were found in 27.3% (n=3) of the relevant maternal deaths. The interviews with the midwives in phase three yielded results that were suggestive of inadequate ESMOE training, lack of updates, lack of regular skills and drills exercises that contributed to lack of knowledge and skills in providing effective EmOC. Other challenges in effectively implementing emergency obstetric care included poor morale due to staff shortages, heavy burdens of workload, lack of motivation and support that contributes to sub-standard care. In the final phase the researcher took these findings and built on this by developing an algorithm that shows the need to improve midwifery clinical competencies. This algorithm was taken further to develop a practice framework that proposes to implement ESMOE interventions into the basic midwifery training to improve relevant knowledge and skills in managing obstetric emergencies effectively within a collaborative team approach. Conclusion This study has shown that gaps in the implementation of ESMOE guideline interventions in the selected facilities in KZN could have contributed to sustained high MMR in the province. The midwives expressed the need for regular training and updates to continuously improve and maintain their knowledge, skills and competencies in providing effective obstetric care. The data allowed the development of an algorithm for improved emergency obstetric patient care and a practice framework for training of midwives to ensure optimal implementation of the guidelines.