Changing patterns of emergency obstetric care at a Nigerian University hospital

OBJECTIVE: To analyze the changing patterns of critical obstetric care over two consecutive 3-year periods and identify the factors responsible for the trend through combined audits of near miss and maternal mortality at a Nigerian University hospital. METHODS: Retrospective audit and comparison of "near misses" and maternal deaths recorded in 1999-2001 and 2002-2004 at a tertiary care center in southwest Nigeria. The definition of near miss morbidity was based on validated disease-specific criteria. For each near miss and maternal death, the local audit committee compared the actual management with local treatment protocols and explored avoidable factors. Case fatality rate was calculated for "critically ill obstetric patients" (CIOP-CFR) for both periods. The cause-specific case fatality rate (CFR) was used to assess the trend in standards of care for life-threatening obstetric conditions. Data were compared using the chi(2) or Fisher's exact test. P<0.05 was considered statistically significant. RESULTS: There were 175 near misses and 27 maternal deaths in 1999-2001 and 211 near misses and 44 maternal deaths in 2002-2004. The CIOP-CFRs for the two periods showed a declining (but non-significant) trend in the standard of emergency obstetric care for life-threatening conditions (13.4% to 17.3%, P=0.250). The CIOP-CFR for postpartum hemorrhage significantly increased from 3.1% to 21.1% in the 2nd period (P=0.033), reflecting a decline in the standard of care. Lack of blood for transfusion became a more significant administrative problem in the 2nd period occurring in 17.8% of all critically ill patients managed in 2002-2004. There was a notable though statistically insignificant increase in the non-adherence to treatment protocol among cases of maternal death in 2002-2004 compared with 1999-2001. CONCLUSIONS: The standard of critical obstetric care in this center is suboptimal with no evident improvement over the 6-year period. This audit supports the feasibility of including near miss reviews in maternal death audits to provide insights into the trend in the quality of emergency services for severe maternal complications while highlighting factors associated with deficiency or improvement in care for specific maternal conditions.