Simpler monitoring systems help doctors in Nigeria treat pregnant people

Researchers tested existing systems used to monitor pregnant mothers to see if they reduce maternal deaths in Nigeria.

Global rates of mothers dying in childbirth are decreasing. But, 94% of these deaths are in developing countries. In 2015, 20% were in Nigeria alone.

Early warning systems (EWSs) can alert doctors when patients need attention. In this study, researchers looked at an EWS based on a chart with a simple numerical score related to vital signs, which helps doctors know when to check on the patient. But, there are few statistical studies about how effective such EWSs actually are for pregnant women in developing countries.

Researchers wanted to see if the EWS works in a developing country like Nigeria. They used statistics to get objective measurements of how well it works. They wanted to determine if the EWS was better for monitoring patients and reducing negative outcomes, like maternal mortality.

The researchers studied 3 specialised hospitals in Northern Nigeria for 8 months. The doctors used the EWS on 1200 mothers and monitored another 1200 using other normal methods. The researchers recorded how doctors used the EWS and the outcomes of the patients. They also interviewed the doctors to see if they felt the EWS was useful.

While the EWS did not seem to reduce maternal mortality or other negative outcomes, the doctors monitored patients more frequently, and caesarean sections decreased. However,  the EWS was only used correctly about half of the time. Despite this, the interviews showed that the EWS indeed helped the doctors in Nigeria. For example, they could evaluate patients more quickly because it was easier to use. They also said that the EWS gave accurate predictions of the attention a patient needed.

This study shows that EWSs designed for one place can also be beneficial to others. The researchers used statistics to confirm that EWSs are effective for developing countries and pregnant women. They also gave essential advice to use EWSs effectively. Unfortunately, the hospitals in this study were under-resourced and understaffed. Thus, the doctors did not have the equipment or time to use the EWS properly. Future studies need to train staff after each rotation and test EWSs on smaller, less specialised hospitals. The researchers say that studies of many more hospitals will more accurately show if EWSs can reduce negative outcomes. The doctors suggested that using a colour-coded EWS would be very helpful.

The UK and Namibian researchers focused on hospitals typical in Africa. Their results show that EWSs could help doctors better use their limited time and resources. These findings can help develop more EWSs and save many African lives.

Abstract

Background: Obstetric Early Warning Systems (EWS) use combined clinical observations to predict increased risk of deterioration and alert health workers to institute actions likely to improve outcomes. The objective of this study was to explore the experience of health workers/managers who implemented a low resource setting-specific statistically derived and validated EWS and to assess its effectiveness in improving health outcomes.

Methods: This mixed-method study included 2400 women admitted to inpatient wards between 1 August 2018 and 31 March 2019 at three tertiary Nigerian hospitals (1 intervention and 2 control) with pregnancy and childbirth-related complications. The quality of patient monitoring and prevalence of outcomes were assessed through retrospective review of case notes before and 4 months after EWS was introduced. Outcomes were maternal death, direct obstetric complications, length of hospital stay, speed of clinical review, caesarean section(CS) and instrumental birth rates. Qualitative interviews and focus group discussions were undertaken to explore the views of healthcare workers on EWS’ acceptability and usability.

Results: EWS was correctly used in 51% (n=307) of cases. Of these, 58.6% (180) were predicted to have increased risk of deterioration, and 38.9% (n=70) were reviewed within 1 hour. There was a significant improvement in the frequency of vital signs recording in the intervention site: observed/expected frequency improved to 0.91 from 0.57, p<0.005, but not in the control sites. CS rate dropped from 39.9% to 31.5% (chi-square p=0.002). No statistically significant effect was observed in the other outcomes.

Health workers reported positive experience using EWS, with the feeling that it helped cope with work demands while making it easier to detect and manage deteriorating patients. Nurses and doctors reported that the EWS was easy to use, evaluate at a glance, and that scores consistently correlated with the clinical picture of patients. Identified challenges to use included rotation of clinical staff, low staffing numbers and monitoring equipment.

Conclusion The implementation of EWS improved the quality of patient monitoring, but a larger study will be required to explore the effect on critical care admission and health outcomes. With modifications to suit the setting, coupled with regular training, the EWS is a feasible and acceptable tool to cope with the unique demands faced in low-resource settings.

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