Criteria-based audit on management of eclampsia patients at a tertiary hospital in Dar es Salaam, Tanzania

It is estimated that every year eclampsia is associated with about 50 000 maternal deaths worldwide, most of which occur in developing countries[1, 2]. The incidence of eclampsia is higher in developing countries (1 in 100–1700 deliveries) than in developed countries (1 in 2000 deliveries). This is probably due in particular to pregnant women's lack of easy access to appropriate antenatal care in those settings. Even in countries with low maternal mortality, a substantial proportion of the maternal deaths will be attributed to pre-eclampsia/eclampsia. In the United Kingdom, pre-eclampsia and eclampsia account for 15% of the direct maternal deaths and two-thirds are related to pre-eclampsia [3].

Although eclampsia remains a cause of maternal and foetal morbidity and mortality in developed countries, the incidence has fallen considerably in developed countries due to high quality antenatal care [4, 5]. However, this decline is not yet observed in developing countries [6, 7].

Criteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in developing countries. CBA compares current practices against written and agreed upon criteria. The selected criteria are based on evidence-based care and they are measurable activities that are appropriate for the setting in which they are used. A recent criteria-based audit conducted in Uganda demonstrated that improvements in the quality of obstetric care can be achieved with little expense [8]. Obstetric care of high quality is a prerequisite for low maternal morbidity and mortality which require commitments of care providers and the hospital managements [8, 9]. There are three types of medical audits namely case reviews/case-note presentations, national level confidential enquiries and CBA.

At Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania, up to 30% of maternal deaths are attributed to eclampsia, and eclampsia is associated with a fivefold increase in perinatal mortality [10]. Therefore, the aim of this study was to introduce of criteria-based audit to assess the quality of care among eclampsia patients admitted at a tertiary referral hospital in an African setting, and discuss possible interventions as a basis to improve the quality of care.

This paper describes the first, second and third steps of the audit cycle, i.e. identification of criteria of best practice and applying the set standards against the current practice to identify areas that are in need of improvement. The next step will be intervention to facilitate evidence-based obstetrical practice at MNH and to evaluate improvements made on the management of patients.

Ethical clearance for this work has been granted by the ethical committee of Muhimbili University of health and allied sciences, Dar es Salaam Tanzania.

There were 389 cases of eclampsia among 7667 deliveries during the study period. The typical case of eclampsia was a young primiparous woman (Table 1). Out of 389 cases of eclampsia, 184 (47%), 159 (41%) and 46 (12%) had antepartum, intrapartum and postpartum eclampsia, respectively. Most cases of antepartum eclampsia were preterm (73%) whereas intrapartum (61%) and postpartum (71%) eclampsia more often developed at term. A median of two seizures had occurred before admission (Range: 1–12). The hospital-based incidence of eclampsia was 504 per 10,000 women or 5.1% of all mothers admitted.

This study evaluated the hospital care of patients with eclampsia in a low-income country and revealed several suboptimal factors that must be corrected in order to improve maternal and foetal outcomes. Most of these improvements can probably be performed without extra monetary input. This was the first attempt to identify areas of weakness in the management of eclampsia patients in this urban tertiary centre. In this stage of the audit cycle our main task was to evaluate the current practice against set standard, the next level of the audit will assess the practice after intervention.

The importance of audit and the collection of process indicators were highlighted at the Safe Motherhood Technical Consultation in Colombo in 1997 and criteria-based audit is a proven method to improve the quality of maternity care [15, 16]. An audit may play a dual role, not only to monitor change in support of clinically effective practice but also as an educational tool. It is part of a process for improvement and can empower health workers to conduct their own quality assessments and seek their own solutions that are locally appropriate and internally driven [16].

The main areas of care which were suboptimal in terms of the set standards were mainly inadequate medical history, lack of review of management plans by specialists, not delivered within 24 hours, and poor monitoring during labour. In this centre the medical history is recorded by junior doctors (interns, junior residents) but the management plan is the responsibility of a more senior doctor (senior residents and specialists), Although a quarter of the patients were reviewed by specialist it did not make any difference since the specialist were most often called for very sick patients, however, this study did not evaluate the condition of the patient at the referring hospital prior to referral. Eclampsia is such a potentially dangerous condition that need comprehensive care in order to prevent both maternal and foetal morbidity and mortality [17], hence, a specialist assessment of all patients is mandatory irrespective of their condition on admission. The majority of the specialist doctors live far from the hospital and do not spend nights in hospital even when they are on duty. Therefore, to improve the standards of care in this urban tertiary centre as a long term solution the hospital management should create an environment to enable the specialist to spend nights at the hospital when on call. However, for an interim solution junior medical personnel (doctors/nurses) should be trained (continued medical education) to be able to effectively manage these patients under close supervision by senior obstetrician.

Despite access to a well-equipped laboratory the majority of the patients were not properly investigated, hence, early diagnosis of serious morbidity and mortality such as the HELLP syndrome [17, 18] was impossible. In contrast to studies from developed countries renal failure and coagulation problems were relatively rare in the current study, only severe cases were detected. This might be due to inadequate use of laboratory to detect impaired renal function as indicated by fewer patients having test for serum urea and creatinine.

Pregnant women in Tanzania have free medical care, therefore, there was no cost for laboratory test. Lack of conducting these tests may reflect the inadequacy of current protocols or lack of knowledge among health care providers on the pathophysiology of eclampsia.

This audit shows the positive effect of magnesium sulphate as indicated by few recurrent seizures after initiation of the treatment, however, lack of deep tendon reflex test was a serious omission. This is an important test, since the evidence shows that magnesium toxicity is monitored by appropriate clinical monitoring [19] not necessarily magnesium serum levels. Some of the women with recurrent seizures might have needed an increased dose while others might have needed a reduced dose in order to avoid toxicity. Magnesium toxicity may result in coma, cardiac or respiratory arrest [19, 20]. This finding might have been due to lack of coordination between doctors and nurses or lack of documentation. This assessment should normally be done by either a nurse or a doctor.

The most common reasons for maternal deaths were cerebral haemorrhage and pulmonary oedema. Both these complications should be possible to prevent through more adequate control of the blood pressure and fluid balance. Intermittent positive pressure can also be used to treat pulmonary oedema until the pathology resolves, however, this service was not available in the study area. There is a need to have adequately equipped intensive care units in tertiary centres for treatment of severe preeclampsia and eclampsia in order to reduce maternal and foetal morbidity and mortality.

Preterm delivery and low birth weight are well known major causes of perinatal mortality [21]. Few preterm mothers received corticosteroids in this study, maybe because most of them were referred and had spent considerable time at the referring hospital, and therefore were delivered as soon as they were admitted to MNH. The high prevalence of low birth weight (51%) found in this study is coherent with other reports [22, 23].

A major limitation of this study is that it was performed at a tertiary hospital that receives patients from other hospitals where standards of care are not known. Furthermore, the standard of care during pregnancy as well as the role of antenatal care has not been assessed. However, a previous study by Urassa et al in the same hospital indicated poor ability of antenatal care to perform even basic investigations such as proteinuria and to initiate appropriate monitoring of risk cases. As primary prevention of eclampsia cannot be expected there is a great need of effective life saving obstetric emergency care in all levels. The three municipal hospitals in Dar es Salaam accounted for 75% of all admissions and 70% of the maternal deaths in the unit. Therefore, it is not possible to achieve a major change in outcome of eclampsia unless the primary care providers play their role of early detection of the problem, provide first aid, and prompt referral to higher centres for definite management. It is necessary to streamline the referral system and have common management protocol in all referring hospitals.

Potential areas for further improvement in quality of emergency care for eclampsia relate to standardizing management guidelines, greater involvement of specialists in the management of eclampsia and continued medical education on current management of eclampsia for junior staff.