Obstetric anaesthesiology in level I and II hospitals in the Free State : a study and audit of remedial interventions
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Reports from the maternal death notification system showed a high number of maternal deaths from anaesthesia in the Free State. I initiated this study in order to investigate and rectify factors identified as being associated with this problem. The study method used was an audit cycle. I selected from the literature on maternal deaths the five main factors most likely to be relevant ie manpower, use of regional anaesthesia, anaesthetic drugs and equipment, resuscitation protocols and the referral system. In the first part of the study (Phase 1), every level one and two hospital in the Free State in which Caesarean sections (CS’s) were being performed was inspected to determine whether the required standards for these factors were being met. The intention was to then implement remedial interventions to correct any problems identified in Phase 1 and then in Phase 2 to repeat the hospitals visits to assess the effect of the interventions. Phase 1 showed deficiencies in essential anaesthetic drugs and equipment in most hospitals. Hospital staff and managers were clearly informed regarding these problems but there was only a slight overall improvement in standards when the audit was repeated in Phase 2 and even a decline in certain aspects. Anaesthetic manpower was studied using self-completed questionnaires. Only a third of these questionnaires were returned and they showed that doctors were largely inadequately trained and supervised whilst administering obstetric anaesthesia. These results were presented to Free State Department of Health Top Management. Concern over possible bias regarding the doctors who returned the forms was raised and it was requested this study should be repeated using a different method to improve the response rate. This was done in Phase 2, a 69% response rate was achieved and the results confirmed the Phase 1 findings. Management was presented with these findings and interventions to resolve these problems was suggested to them. Use of regional anaesthesia was studied via inspection of theatre record books. In Phase 1 it was found that 71% of CS’s were performed using regional anaesthesia (RA), close to the proposed goal of 75%. However, in some hospitals no or few CS’s were performed using RA. There followed remedial interventions in which RA was promoted and in Phase 2 it was found that 84% of CS’s had been performed using RA. Unfortunately there is now concern that RA is being over utilised and general anaesthesia is not being administered when appropriate. In Phase 1, there were virtually no hospitals in which up-to-date resuscitation protocols were displayed. Protocols were distributed to all and in Phase 2 more, but not all, hospitals had the required protocols on display. The referral system was studied in Phase 1 using data collection sheets which were to be completed by the doctors when a patient had a CS. There was such poor compliance with this part of the study that it was decided that to resolve this would require a completely separate study utilizing greater research resources. Further investigation was therefore abandoned. Performing this audit had the desired result of improving the awareness of problems relating to obstetric anaesthesia in the Free State, at a Provincial and National level amongst both health care professionals and management. Although the remedial interventions did not “cure” some of the problems identified, progress was made and where progress was not made there is now greater knowledge as to where the problems lie. It remains for those who have the resources to tackle these issues, which are largely concerned with manpower, to take cognisance of the results of this study and implement the suggested corrective measures.