Process of care delivery
Among all women giving birth at Taiz Houbane MCH Hospital in the study
months (n=1014 in August and n=428 in November), the rate of caesarean
sections differed significantly with 10.7% (108/1014) and 19.2%
(82/428), respectively (RR 0.55, 95% CI 0.42-0.71). No differences in
distribution of indications for the caesarean sections were found
between the two study months. The three most common indications were
prolonged labour (28%, 53/190), two or more previous caesarean sections
(19%, 36/190), and foetal distress (13%, 25/190). Among caesarean
sections due to prolonged labour in the high- and low-volume month, in
63% (19/30) and 83% (19/23) the action line was either not crossed or
the partograph unused when deciding on the surgery, and in 53% (16/30)
and 30% (7/23) oxytocin augmentation had not been tried. Among
caesarean sections due to foetal distress, half (6/12 and 6/13) were
performed with the foetal heart rate documented in the normal range
(110-160 beats per minute). Among the included women with vaginal
births, 0.8% (2/250) and 2% (4/250) were delivered by vacuum
extraction (Table 2).
Among all included women for in-depth audit, significantly more women
were induced in the low-volume month (50/358 (14%) and 74/332 (22%);
RR 0.62, 95% CI 0.45-0.87). Among the included women delivering
vaginally (n=250 in each study month), there were no differences between
the two months in achieving the additional audit criteria. Among women
admitted before or during first stage of active labour, 80% (152/190)
and 85% (161/190) had at least one correct plot of labour progress on
the partograph’s alert line (RR 1.31, 95% CI 0.84-2.03), and if first
stage of labour exceeded four hours, 85% (58/68) and 94% (48/51) had
the cervical dilatation re-plotted (RR 2.50, 95% CI 0.72-8.62). When
excluding labour inductions, oxytocin augmentation was applied in 23%
(51/220) and 26% (51/193) (RR 0.88, 95% CI 0.63-1.23), of which
oxytocin was initiated prior to crossing the partograph’s action line in
12% (26/220) and 10% (19/193) (RR 1.22, 95% CI 0.70-2.13) (Table 2).