Implementation of maternal guidelines to reduce preventable intra-partum death at a selected public hospital in Gauteng

Abstract

INTRODUCTION Maternal death during pregnancy, childbirth, and the postpartum period is a tragedy with a catastrophic impact on families and serves as an important indicator of a health care system. More than one-third of maternal deaths occur during the intrapartum period and the majority of these deaths are largely preventable. Women continue to die from largely preventable causes despite global and national maternal care guidelines in place to reduce preventable maternal deaths. A preventable intrapartum death is a possible and probable potentially avoidable maternal death due to substandard care and missed opportunity. Reducing preventable intrapartum maternal deaths requires effective implementation of essential intrapartum guidelines such as monitoring of labour and childbirth, early identification of abnormalities, timely intervention, and treatment of complications.

AIM The study aimed to determine the causes of preventable intrapartum maternal deaths, implement selected intrapartum maternal care guidelines, and evaluate the outcomes of the implemented guidelines at a selected public hospital in Gauteng province.

RESEARCH DESIGN AND METHODOLOGY The researcher selected a sequential mixed methods research design and conducted the study in three phases. Using multiple approaches allowed the researcher to generate quality data and to gain an insight into the phenomenon under investigation. Phase 1 involved the collection of quantitative data with the use of a PPIP tool to retrospectively audit the preventable intrapartum maternal deaths between January 2018 and December 2021 in the labour unit at the selected public hospital. In Phase 2, the researcher in collaboration with the midwives implemented specific intrapartum guidelines based on the findings from Phase 1. Implementation research is a scientific investigation into the processes and factors that influence the implementation of evidence-based programmes and policies in real-world situations. Implementation research prompts researchers to describe both the implementation strategy techniques used to promote implementation of the evidence-based intervention and the effectiveness of the intervention that was being implemented. The objective of implementation research is to improve the quality of care and health outcomes of patients by implementing guidelines or health care programmes. In Phase 3, a focus group interview was used to evaluate the outcomes of the implemented intrapartum guidelines to reduce preventable intrapartum maternal deaths. Qualitative content analysis of transcripts, interviews and reflective dairies was used during data analysis.

FINDINGS Phase 1 found that a total of forty-eight intrapartum maternal deaths were potentially preventable. Obstetric haemorrhage (37.5% n=18) and hypertensive disorders (31.2% n=15) in pregnancy were shown to be the most common causes of preventable intrapartum maternal deaths. Using a bottom-up approach in Phase 2, the researcher and the midwives selected specific intrapartum maternal guidelines at a consensus workshop. The three specific maternal guidelines to be implemented throughout the intrapartum period were: use of the partogram, management of hypertensive diseases, and management of obstetric haemorrhage from retained placenta. The implementation phase lasted from February 2023 until June 2023. Phase 3 had three sections for evaluation of the outcomes of the implemented maternal guidelines, the individual narrative interviews and the focus group interviews. Using the PIPP audit tool, four (4) intrapartum maternal deaths that had happened during the implementation phase were audited. Two (2) intrapartum maternal deaths were preventable. A content data analysis was conducted on the 20 individual narrative interviews. The interviews yielded four interrelated themes: (1) Adherence to selected intrapartum maternal care guidelines; (2) Improved decision-making, (3) Effective intrapartum maternal care guidelines, and (4) Barriers to effective implementation of the intrapartum maternal care guidelines. Using content data analysis, eleven themes emerged from the focus group interviews, namely (1) Available and accessible intrapartum maternal guidelines, (2) Value the multidisciplinary approach. (3) Support clinical evidence-based practice, (4) Relevant intrapartum maternal care guidelines, (5) Awareness of the use of evidence-based midwifery practice, (6) Dissemination of results from implemented intrapartum maternal care guidelines, (7) Engaging relevant stakeholders, (8) Adequate infrastructure, (9) Adequate staffing, (10) Availability of medical equipment and consumables, and (11) Clinical audits.

CONCLUSION This study was conducted at a selected public hospital in Gauteng Province in South Africa. To improve clinical practice and intrapartum maternal care to achieve the best intrapartum patient outcomes, the researcher believes and hopes that this study will provide policymakers, clinical governance, midwives, nursing service managers, clinicians and other health care providers an insight into the significance of incorporating research into clinical practice.

Keywords: Implementation, guidelines, intrapartum, preventable maternal death, midwife, labour unit