OBSTETRICAL EMERGENCIES in DISTRICT HOSPITALS

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OBSTETRICAL EMERGENCIESin DISTRICT HOSPITALS

• BOSD, CHICAGO, 2009

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THE DISTRICT HOSPITALin AFRICA

• Serves 100,000 200,000 population
• 50 250 beds
• Staff 25-30 nurses
• 5-10 clinical officers
• 1-2 medical officers (MDs)
• specialists - almost never
• 50-100 major ops /mo. - 2/3 emergencies
• 200 deliveries /mo. - 30-40 with major
  complications

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THE DISTRICT HOSPITALin AFRICA

• Operating Room sometimes 2
• No ICU no Recovery Room
• Basic Lab
• Blood Bank a refrigerator
• 1-2 ambulances inadequate fuel and maintenance
• Referral in 10 from health centers
• Referral out lt 5

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WHO COMES TO A DISTRICT HOSPITAL?

• 3 Months in a 40 bed hospital, Bangladesh
• OB/GYN 178 (33)
• Normal delivery 56
• Complicated delivery 52
• Complicated abortion 27
• Ectopic 2
• OTHER SURGICAL 157 (29)
• Trauma 78
• MEDICAL 142 (26)
• PEDIATRIC 64 (12)

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IS IT EFFECTIVE?

• DALYs
• Life Years Disability Total
• Years
• OB/GYN 1,922 125 2,047 (62)
• SURGICAL 459 236 696 (21)
• PEDIATRIC 372 11
  383 (12)
• MEDICAL 177 7 184 (6)
• TOTAL 1,905 379 3,309
• COST per DALY 10.93

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DO WE MEET THE NEED?Emergency Obstetrical Care
as a measure

• Met Need for EmOC in 4 Countries
• (Assume 15 of deliveries are complicated)
  Met Need Doctors per
• Million
• Kenya 3 140
• Uganda 5 80
• Mozambique 7 30 30
• Tanzania 14 - 35 20
• North eastern region

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NON PHYSICIAN CLINICIANSIN AFRICA

• 25 of47 Sub-Saharan Countries train NPCs to
  diagnose and treat illness.
• Only 5 authorize them to perform major surgery.
• In Mozambique, Malawi, Tanzania they do 85 of
  the surgery outside of major cities

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Assistant Medical Officers in Tanzania

• Since independence (1961)
• Clinical Officers 3 yr. Training for basic
  diagnosis and treatment.
• AMOs selected from COs for 2 yr. training to be
  general practitioners.
• Informal surgical training on the job
• Licensed to practice medicine and surgery

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CLINICAL PERSONNEL IN TANZANIA (2006)

• Medical Specialists 400
• MO, Generalist 600
• AMO. Generalist 1,225
• Clinical Officers 5,430
• Nurses Nurse/Midwives 12,700
• (Population, 38 Million)

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IS IT 2ND CLASS CARE?

• 1. Retrospective review of all 16 hospitals in
  Kigoma/Mwanza, Western Tanzania
• - 39,000 deliveries in 1 year.
• - Met need for emergency OB surgery 30.
• - Case fatality 2.0.
• - 85 of OB surgery by AMOs.
• 2. Prospective review of 1,134 complicated
  deliveries in 14 of the same hospitals.

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CASE FATALITY(UN Guideline 1)

• 
  MWANZA KIGOMA
• University Hosp. 29/14072.1
  -
• Other Govt. Hosp. 73/27642.6
  26/18851.4
• Mission Hosp. 17/18330.9
  2/3690.5
• ALL HOSPITALS 119/60042.0
  28/22541.2
• (Chi square 4.97 plt.026)
• Hospital Maternal Deaths/Hospital Complicated
  Deliveries

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PHASE 2 (Jan., Feb., Mar., Apr., 2006)Methods

• 14 Hospitals (University and 1 small mission
  excluded)
• Review all obstetrical operations eclampsia and
  PPH
• Detailed record kept by Nurse/Midwife with AMO
  of
• - Distance traveled.
• - Time in labor.
• - Condition on admission.
• - Time from admission to operation.
• - Indication for op, type of op, and who did
  it.
• - Outcome Maternal/Infant Death or major
  complication.
• - Blood transfusion given with urgent
  indication.

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RISK INDICATORSSurgeon AMO or MO

• AMO MO
• of ops. For AMI 32.1
  33.6
• 
  p0.72
• of patients adm.
• with major acute prob.
  6.5 9.8
• 
  p0.14
• of patients adm.
• with major chronic prob.
  17.7 15.4
• 
  p0.50
• 
  Chi Square

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BAD OUTCOMES

• All maternal deaths.
• Perinatal deaths with fetal heart on admission.
• Major complications
• - Ruptured uterus after admission.
• - Wound infection with more than 2 weeks
  hospitalization.
• - Uterine hemorrhage after Cesarean.
• - Burst abdomen.
• - Operative vesico-vaginal fistula.
• - Ureteral injury.

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OUTCOMES(Operated Cases. AMO MO)

• AMO MO p
• 
  n929 n143
• Maternal Death 1.6 3.5
  0.12
• Perinatal Death
• (Fetal Heart ) 6.4 1.6 0.21
• Major Complication 2.9 7.7
  0.004
• ALL BAD OUTCOMES 8.7
  7.7 0.62
• 
  Chi square.

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OUTCOMES(Mission Hospital Govt. Hospital, all
cases)

• MISSION
  GOVT. p
• n313 n820
• Maternal Deaths 2.2 2.3
  0.94
• Perinatal death
• with fetal heart 1.5 7.9
  0.0002
• Major complication 3.2 1.7
  0.12
• ALL BAD OUTCOMES 7.0 9.8
  0.62

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PERINATAL DEATH(Operated cases - Fetal Heart
on admission)

• MISSION HOSPITALS
• Alive Dead
• AMO 190 3 1.6
• MO 69 1 1.4
• GOVERNMENT HOSPITALS
• Alive Dead
• AMO 545
  47 7.9
• MO 43
  3 6.5

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QUALITY INDICATORSSURGEON AMO - MO

• AMO MO
• 1) Ops. NOT Clear Fetal Ind. or AMI 41.6
  47.6
• 
  p0.18
• 2) Over 3 hr. to urgent op.
  43.7 42.4
• 
  p0.89
• 3) Blood need urgent/ no blood 53.0
  45.8
• 
  p0.51
• 
  
  Chi Square

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CONCLUSIONS

• Between AMOs and MOs there were no differences in
  outcomes, risk indicators, or quality of care
  indicators.
• Between Mission and Government Hospitals there
  were important differences mission hospitals
  had better outcomes for mother and infant, better
  access to blood transfusion, and fewer patients
  with severe chronic risk on arrival.
• All hospitals had important problems in service
  delivery.
• Despite the problems, 2 case fatality should
  reduce maternal mortality by 75.
• BUT BECAUSE MET NEED WAS ONLY 30, ONLY A 25
  REDUCTION CAN BE EXPECTED

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HOW TO MEET THE NEED?

• More Facilities
• 1 per 500,000 is not enough in Africa.
• - More hospitals or better health
  centers?
• More Staff MOs, AMOs, Nurses
• - Specialists or Generalists?
• More Money a little will do a lot
• - hospitalS already have 50 of District
  Budget.
• - 1 more per capita will buy the
  essentials.
• Cost of Transport its not just the car.

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TRAUMA OBSTETRICS

• The Same Basic Needs
• A transport system.
• Blood.
• Trained Personnel Nurse/Midwives
• AMOs
• Medical Grads
• - Facility not so important

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MOZAMBIQUE 2007

• 61 Tecnicos de Cirurgia 7,000 cesareans
• 28,000 major operations
• The right people.
• A system.

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WHICH OPERATIONS?

• OPERATION DALYs per OPERATION
• Cesarean for Absolute
• Maternal Indication 50
• Ectopic Pregnancy 36
• Appendectomy 5
• Other Acute Abdomen 16
• Chest Tube 25
• ALL OB/GYN 21
• ALL GENERAL SURGERY 11
• ALL TRAUMA 8