What could improve surgical data system at health facilities with high surgical volume in Ethiopia?

BACKGROUND: The effective management of surgical and anesthesia care relies on quality data and its readily availability for both patient-centered decision-making and facility-level improvement efforts. Recognizing this critical need, the Strengthening Systems for Improved Surgical Outcomes (SSISO) project addressed surgical care data management and information use practices across 23 health facilities from October 2019 to September 2022. This study aimed to evaluate the effectiveness of SSISO interventions in enhancing practices related to surgical data capture, reporting, analysis, and visualization. METHODS: This study employed a mixed method, pre- post intervention evaluation design to assess changes in data management and utilization practices at intervention facilities. The intervention packages included capacity building trainings, monthly mentorship visits facilitated by a hub-and-spoke approach, provision of data capture tools, and reinforcement of performance review teams. Data collection occurred at baseline (February - April 2020) and endline (April - June 2022). The evaluation focused on the availability and appropriate use of data capture tools, as well as changes in performance review practices. Appropriate use of registers was defined as filling all the necessary data onto the registers, and this was verified by completeness of selected key data elements in the registers. RESULTS: The proportion of health facilities with Operation Room (OR) scheduling, referral, and surgical site infection registers significantly increased by 34.8%, 56.5% and 87%, respectively, at project endline compared to baseline. Availability of OR and Anesthesia registers remained high throughout the project, at 91.3% and 95.6%, respectively. Furthermore, the appropriate use of these registers improved, with statistically significant increases observed for OR scheduling registers (34.8% increase). Increases were also noted for OR register (9.5% increase) and anesthesia register (4.5% increase), although not statistically significant. Assessing the prior three months reports, the report submissions to the Ministry of Health/Regional Health Bureau (MOH/RHB) rose from 85 to 100%, reflecting complete reporting at endline period. Additionally, the proportion of surgical teams analyzing and displaying data for informed decision-making significantly increased from 30.4% at baseline to 60.8% at endline period. CONCLUSION: The implemented interventions positively impacted surgical data management and utilization practice at intervention facilities. These positive changes were likely attributable to capacity building trainings and regular mentorship visits via hub-and-spoke approach. Hence, we recommend further investigation into the effectiveness of similar intervention packages in improving surgical data management, data analysis and visualization practices in low- and middle-income country settings.

Improving surgical safety checklist utilisation at 23 public health facilities in Ethiopia: a collaborative quality improvement project.

BACKGROUND: In 2009, the WHO introduced the surgical safety checklist (SSC) as one of the interventions for improving patient safety. The systematic use of structured checklists during surgery has been shown to reduce perioperative morbidity and mortality. However, SSC utilisation has been challenging in low-income and middle-income countries, including Ethiopia. Jhpiego Ethiopia implemented a quality improvement project (QIP) aimed to increase SSC utilisation. METHODOLOGY: A model for improvement was used to design and implement a collaborative QIP to improve SSC utilisation at 23 public health facilities (13 primary health care facilities, 4 general hospitals and 6 tertiary hospitals) in Ethiopia from October 2020 to September 2021. SSC utilisation was defined as when a patient chart had SSC attached and each part of the checklist was completed. Training of surgical staff on safe surgery packages, monthly clinical mentorship and cluster-based learning platforms were implemented during the study period. We analysed bimonthly chart audit reports from each facility to assess the proportion of surgeries where the SSC was used. Shewhart charts were used to conduct a time-series analysis. Additionally, the Z-test for two sample proportions was used to determine if there is a statistically significant change from the baseline measure with a p<0.05. RESULT: In the postintervention period, the overall SSC utilisation improved by 39.9 absolute percentage points to 90.3% (p<0.0001) compared with the baseline value of 50.4% early in 2020. A time-series analysis using Shewhart charts showed a shift in the mean performance and signals of special cause variation. The largest improvement was observed in primary health care facilities in which the SSC utilisation improved from 50.8% to 97.9% (p<0.0001). CONCLUSION: This study demonstrates that onsite clinical capacity building, mentorship and collaborative cluster-based learning platforms can improve SSC utilisation across all levels of facilities performing surgery.

Prevalence of and characteristics associated with operative vaginal birth at Mizan-Tepi University Teaching Hospital.

BACKGROUND: To observe prevalence, characteristics and outcomes associated with operative vaginal birth (OVB). METHODS: We compared spontaneous vaginal birth with OVB. RESULTS: Of 993 women, 759 (76.4%) experienced vaginal birth; 716 were spontaneous (94.3%), 14 (1.8%) underwent forceps-assisted birth and 29 (3.8%) had vacuum assistance. In a multivariable model of OVB (forceps and vacuum), compared with a midwife, general practitioners (OR 5.6, p = 0.04) and integrated emergency surgical officers (OR 42.8, p = 0.001) were more likely to attend. Women experiencing OVB were more likely to receive local anesthesia (OR 3.0, p = 0.009). CONCLUSION: OVB is used sparingly but safely at Mizan-Tepi University Teaching Hospital.

Pregnancy outcomes at Mizan-Tepi University Teaching Hospital: A Comparison to the Ethiopian Demographic and Health Surveys.

BACKGROUND: To compare outcomes at Mizan-Tepi University Teaching Hospital to national and regional data and to plan quality improvement and research studies based on the results. METHODS: This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1, 000 women who delivered at Mizan-Tepi University Teaching Hospital. RESULTS: Our convenience sample was young (median age 24 years) with a primarily school level or less of education (68.6%). Only about 5% of women had a history of prior cesarean birth, 2.1% reported they were human immunodeficiency virus seropositive, and the median number of prenatal visits was four. Women were commonly admitted in spontaneous labor (84.5%), transferred from another facility (49.2%; 96.8% of which were referred from a health center), and had their fetal heart rate auscultated on admission (94.7%). Only 5.2% of women did not deliver within twenty-four hours and the cesarean birth prevalence was 23.4%. Many women were delivered by midwives (73.2%; all unassisted vaginal births), 89.2% were term deliveries, and 92.5% of neonatal birthweights were 2500 grams or heavier. Less than five percent of women delivered stillbirths (4.3%) and 5.7% of livebirths experienced neonatal death by the day of discharge. There were no maternal deaths in the cohort. CONCLUSION: The prevalence of stillbirth and neonatal death were the most notable findings, while there was no maternal death in the cohort.

Characteristics and Outcomes Associated with Cesarean Birth as Compared to Vaginal Birth at Mizan-Tepi University Teaching Hospital, Ethiopia.

INTRODUCTION: The objective of this study was to observe characteristics and outcomes associated with cesarean birth as compared to vaginal birth. METHODS: This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1, 000 women. Data was collected on admission, delivery, and discharge by trained physician data collectors on paper forms through chart review and patient interview. RESULTS: Data on mode of delivery was available for 993/1000 women (0.7% missing data), 23.4% of whom underwent cesarean. These women were less likely to have labored (84.5% versus 87.4%), more likely to have been transferred (62.0% versus 45.2%), more likely to have been admitted in early labor (53.0% versus 48.6%), more likely to be in labor for longer than 24 hours (10.7% versus 3.3%) and were less likely to have multiple gestation (7.7% versus 3.9%), p < 0.05. In a Poisson model, history of cesarean (aRR 2.0, p < 0.001), transfer during labor (RR 1.5, p = 0.003), labor longer than 24 hours and larger birthweight (RR 2.7, p 0.001) were associated with an increased risk of cesarean. CONCLUSION: Our analysis suggests cesarean birth is being used among women with a history of prior cesarean and in cases of labor complications (prolonged labor or transfer), but fresh stillbirth is still common in this setting.

Mode of Delivery Among Women with a History of Prior Cesarean Birth at Mizan-Tepi University Teaching Hospital.

OBJECTIVES: The objective of this study was to observe mode of delivery among women with a history of prior cesarean birth. METHODS: After collecting data on a convenience sample of 1,000 women giving birth at 28 weeks gestation or greater at Mizan-Tepi University Teaching Hospital, we reduced the sample to only include women with a history of prior cesarean birth. We wanted to observe mode of delivery among this cohort and determine if any characteristics were associated with elective repeat cesarean birth, as compared to vaginal birth after cesarean. RESULTS: Of 1,000 women in our convenience sample, data on history of prior cesarean birth was missing on 2 women (0.2%). Of the remaining women, 49 (4.9%) reported a history of prior cesarean; 44 (89.8%) reported one prior cesarean and 5 (10.2%) women had two prior cesarean births. Repeat cesarean birth occurred in 65.1% (n = 29/44) of women with one prior cesarean and in 80.0% (n = 4/5) of women with two prior surgeries. Among the total cohort of women with a history of prior cesarean birth, of those who experienced repeat cesarean birth (n = 33), 27.3% (n = 9) occurred pre-labor, 69.7% (n = 23) occurred intrapartum after the onset of spontaneous labor, and 3.0% (n = 1) occurred intrapartum during the course of an induced or augmented labor. Labor onset and cervical exam on admission were statistically significantly different in bivariate comparisons of women who successfully achieved vaginal birth after cesarean as compared to those who gave birth by repeat cesarean birth, and postpartum maternal antibiotics were more common after repeat cesarean birth, p < 0.05. In a multivariable model of factors associated with successful vaginal birth after cesarean, the likelihood of successful vaginal birth was increased 15% for each increasing centimeter of dilation on a woman's admission cervical exam (RR 1.15, p= 0.004). CONCLUSION: Almost one-third of women in our observational cohort attempted trial of labor after cesarean; those that were successful were more likely to have been more cervically dilated on their admission exam. No sociodemographic or obstetrical characteristics were more likely among women who underwent pre-labor repeat cesarean birth as compared to intrapartum cesarean birth.

Performance of Integrated Emergency Surgical Officers at Mizan-Tepi University Teaching Hospital, Mizan-Aman, Ethiopia: A Retrospective Cohort Study.

INTRODUCTION: Surgical physician extenders are used in Ethiopia and sub-Saharan Africa where there is a lack of surgical providers. METHODS: We tested characteristics associated with and outcomes of births attended by an integrated emergency surgical officers (IESOs) as compared to midwives and physician providers. RESULTS: Of 1,000 women in our convenience sample, data on birth attendant was missing on 5 women (0.5%). Of the remaining women, almost three-fourths (73.6%, n = 732) of women were attended by a midwife, almost a quarter were attended by an IESO (24.4%, n = 243), 10 women were attended by a physician with a General Practitioner level of training (1.0%), 5 women were delivered by an Ob/Gyn resident (0.5%), and 5 women were attended by an Ob/Gyn (0.5%). Women had a higher likelihood of being attended by an IESO than a midwife if they underwent forceps-assisted (RR 88.4, p < 0.05), vacuum-assisted (RR 45.2, p < 0.05), or cesarean birth (RR 161.8, p < 0.05) as compared to an unassisted vaginal birth. IESOs are performing more operative vaginal and cesarean births than other delivery providers. Outcomes of their deliveries are worse than those of midwives, but this is likely due to the acuity level of the patients and not the provider type.

Use of Cesarean Birth at Mizan Tepi University Teaching Hospital, Mizan Aman, Ethiopia.

OBJECTIVES: The objective of this analysis was to review indication and utilization of cesarean birth among Robson Classification of Cesarean Birth subgroups. METHODS: This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1,000 women who delivered Mizan Tepi University Teaching Hospital in the summer and fall of 2019. RESULTS: Data on mode of delivery was available for 993 women, 23.4% of which underwent cesarean birth. The leading indication for cesarean birth was a fetal indication (46.2%), followed by a maternal indication (35.9%); elective cesarean birth was the indication for one cesarean birth. Robson Groups 1 and 3 (primary cesarean among nulliparous and multiparous women) accounted for the largest proportion of the overall population of women (30.2% and 36.8%), and cesarean birth rates within these groups were 19.4% and 16.1%, respectively. In all remaining groups, cesarean birth rates were at least 17.1%, ranging to as high as 100.0%. Pre-labor cesarean was highest in Robson Group 5 (multiparous women with a history of cesarean birth). CONCLUSION: Further analysis of risk factors associated with cesarean birth in women whose labor was induced or augmented, or those undergoing preterm birth, might offer additional target risk factors to modify.

Use of Cesarean Birth among Robson Groups 2 and 4 at Mizan-Tepi University Hospital, Ethiopia.

BACKGROUND: Primary cesarean birth rates were high among women who were either nulliparous (Group 2) or multiparous (Group 4) with a single, cephalic, term fetus who were induced, augmented, or underwent cesarean birth before labor in our study cohort. OBJECTIVES: The objective of this analysis was to determine what risk factors were associated with cesarean birth among Robson Groups 2 and 4. METHODS: This study was a prospective hospital-based cross-sectional analysis of a convenience sample of 1,000 women who delivered at Mizan-Tepi University Teaching Hospital in the summer and fall of 2019. RESULTS: Women in Robson Groups 2 and 4 comprised 11.4% (n = 113) of the total population (n = 993). The cesarean birth rate in Robson Group 2 (n = 56) was 37.5% and in Robson Group 4 (n = 57) was 24.6%. In Robson Group 2, of all prelabor cesareans (n = 5), one birth was elective cesarean by maternal request; the intrapartum cesarean births (n = 16) mostly had a maternal or fetal indication (93.8%), with one birth (6.2%) indicated by "failed induction or augmentation," which was a combined indication. In Robson Group 4, all 4 women delivered by prelabor cesarean had a maternal indication (one was missing data), and 3 of the intrapartum cesareans were indicated by "failed induction or augmentation." In multivariable modeling of Robson Group 2, having a labor duration of "not applicable" increased the risk of cesarean delivery (RR 2.9, CI (1.5, 5.4)). The odds of requiring maternal antibiotics was the only notable outcome with increased risk (RR 11.1, CI (1.9, 64.9)). In multivariable modeling of Robson Group 4, having a labor longer than 24 hours trended towards a significant association with cesarean (RR 3.6, CI (0.9, 14.3)), and women had a more dilated cervix on admission trended toward having a lower odds of cesarean (RR 0.8, CI (0.6, 1.0)). CONCLUSION: Though rates of primary cesarean birth among women who have a term, single, cephalic fetus and are induced, augmented, or undergone prelabor cesarean birth are high, those that occur intrapartum seem to be associated with appropriate risk factors and indications, though we cannot say this definitely as we did not perform an audit. More research is needed on the prelabor subgroup as a separate entity.