Abstract
ObjectiveTo test whether introduction of a midwife‐performed triage checklist and focused ultrasound improves diagnosis and referral for obstetric conditions, including multiple gestation, placenta previa, oligohydramnios, preterm birth, malpresentation, and abnormal fetal heart rate.MethodsWe implemented an intake log (Phase 1), a checklist (Phase 2), and a checklist plus ultrasound scan (Phase 3) at three primary health centers in Eastern Uganda for women presenting in labor. Intake diagnoses, referral status, and delivery outcomes were assessed, as well as sensitivity and positive predictive value (PPV).ResultsBetween February 2018 and July 2019, 1155, 961, and 603 women were enrolled across the three phases (n=2719); 2339 had outcome data. Incidence of any outcome‐confirmed condition was 8.8%, 7.9%, and 7.1% (P=0.526) for each phase, respectively. The proportion of referred women with a condition did not change between Phases 1 and 2 (7.8% versus 8.6%, P=0.855), but increased in Phase 3 (48.4%, P<0.001). Sensitivity improved with each intervention; PPV decreased with ultrasound.ConclusionUse of ultrasound plus checklist increased referrals and sensitivity for high‐risk conditions, with decreased PPV. The checklist alone improved correct diagnosis, but not referral. Further evaluation of these triage interventions to maximize diagnostic accuracy, referral decisions, and outcomes are warranted.
Highlights
Three-quarters of the estimated 295 000 annual maternal deaths are due to direct obstetric complications and half of 2.6 million third-trimester stillbirths occur during labor and delivery.[1,2] Improved quality of care, during the intrapartum period, can reduce preventable maternal and perinatal mortality
This study aimed to evaluate if triage interventions—a checklist, focused ultrasound scan and referral transportation support—improved the ability of primary health centers (PHCs) midwives to correctly diagnose high-risk conditions and appropriately initiate referral to the district hospital (DH)
Outcome data were obtained on 2339 deliveries, including women who were admitted to the PHC upon presentation (n=2271), or women referred to the DH or re-admitted as the result of failed referral (n=68)
Summary
Three-quarters of the estimated 295 000 annual maternal deaths are due to direct obstetric complications and half of 2.6 million third-trimester stillbirths occur during labor and delivery.[1,2] Improved quality of care, during the intrapartum period, can reduce preventable maternal and perinatal mortality. In many low- and middle-income countries, failure to receive adequate care when a facility is reached, the third delay,[3] is exacerbated by lack of supplies, personnel shortages, long waiting times, and weak referral protocols.[4]. Care is a critical component of quality maternity care.[5] Inter-facility referral relies on a confluence of factors, such as timely arrival of a woman in labor, appropriate identification of high-risk conditions by providers, emergency transportation, and communication between the referring and receiving facilities.[6] inconsistent understanding of clinical criteria for referral, guideline non-compliance, inadequate clinical skills, lack of confidence in decision-making, and absence of transportation remain critical gaps at PHCs.[7,8,9] These barriers are exacerbated by weak communication across the health system, and further delays when a referral hospital is reached
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
