How to improve the quality of care for women with postpartum haemorrhage at Onandjokwe Hospital, Namibia: quality improvement study

BACKGROUND: Postpartum haemorrhage (PPH) is the leading direct cause of maternal morbidity and mortality worldwide. The sustainable development goals aim to reduce the maternal mortality ratio to 70 per 100,000 live births. In Namibia, the ratio was reported as 265 per 100,000 live births in 2015 and yet little is published on emergency obstetric care. The majority of deliveries in Namibia are facility-based. The aim of this study was to assess and improve the quality of care for women with PPH at Onandjokwe Hospital, Namibia. METHODS: A criterion-based audit cycle in all 82 women with PPH from 2015 using target standards for structure, process and outcomes of care. The audit team then planned and implemented interventions to improve the quality of care over a 10-month period. The audit team repeated the audit on all 70 women with PPH from the same 10-month period. The researchers compared audit results in terms of the number of target standards achieved and any significant change in the proportion of patients’ care meeting the predetermined criteria. RESULTS: In the baseline audit 12/19 structural, 0/9 process and 0/3 outcome target standards were achieved. On follow up 19/19 structural, 6/9 process and 2/3 outcome target standards were met. There was one maternal death in the baseline group and none in the follow up group. Overall 6/9 process and 2/3 outcome criteria significantly improved (p < 0.05) from baseline to follow up. Key interventions included training of nursing and medical staff in obstetric emergencies, ensuring that guidelines and standard operating protocols were easily available, reorganising care to ensure adequate monitoring of women postpartum and ensuring that essential equipment was available and functioning. CONCLUSION: The study demonstrates that the quality of care for emergency obstetrics can be improved by audit cycles that focus on the structure and process of care. Other hospitals in Namibia and the region could adopt the process of continuous quality improvement and similar strategies.