A clinical audit of the completeness of antenatal card recording in Chris Hani Baragwanath academic hospital

A research report submitted in partial fulfillment of the requirements for the degree of Master of medicine (MMED) in obstetrics and gynaecology the faculty of health sciences University of Witwatersrand September 2017BACKGROUND AND OBJECTIVES The antenatal card is a record keeping tool that can be used to audit the quality of antenatal care given. The recommendations from the national guidelines for maternity care in South Africa are that this card should be fully documented to aid with continuity and improve on the quality of care given in pregnancy. The main aim of the study was to assess documentation of all the variables on the green antenatal card at Chris Hani Baragwanath Academic Hospital. METHODS This was a retrospective, cross-sectional study in which 300 antenatal cards were audited for the month of September 2015 at Chris Hani Baragwanath Academic Hospital. The cards were collected from three postnatal wards following discharge of the patients. Information on the card was then transferred to a data sheet and the participant given a code to maintain confidentiality. The information audited included documentation of the demographic details, the past obstetric history, the past medical and surgical history, past social and family history, education given during the pregnancy, ultrasounds done, blood results and a focused clinical examination. RESULTS Three hundred antenatal cards were audited. The median age of the patients was 28 years, with a median parity of 1.0 and mean gestational age at booking of 18.9 weeks. None of the cards had complete documentation of all the variables put together. More than half of the patients [n = 204, (68%)] had 4 or more visits in the current pregnancy. The section of the card that had the most incomplete documentation was the part of contraception that classifies the pregnancy as planned or unplanned with only 1 card (0.3%) being documented. The past medical and family history had 299 (99.7%) and 296 (98.7%) cards documented respectively. Variables under the past obstetric history had documentation ranging between 75.8% (n = 163) and 100 % (n = 215), with five out of the six variables above 90%. Social habits were documented in 192 cards (64.0%) with 22 women (11.5%) being alcohol drinkers and 10 (5.2%) being smokers. Half of the patients [n = 157, (52.3%)] had an ultrasound performed in pregnancy with most of them done in the second [n = 77, (49.0%)] and third trimesters [n = 66, (42.1%)]. Most of the blood results had more than 90% recording with the HIV test result being the most frequently documented [n = 289 (96.3%)]. The various aspects of education in pregnancy were incompletely documented with lifestyle modification being the lowest recorded [n = 73 (24.33%)]. Recording of the focused clinical examination was more than 95% for each of the variables audited. CONCLUSION We audited the antenatal card in terms of its completeness in this study. It was commendable that the documentation of most of the variables was close to the 100% documentation recommended by the national guidelines. These included the past medical and family history, the past obstetric history, previous contraception used and choice of future contraception, Rhesus and HIV blood tests and the focused clinical examination. This study showed that there is still much improvement needed in the documentation of some aspects of the antenatal card. These included recording of whether the pregnancy was planned or not, social habits and education given in pregnancy. We need to adhere to the national guidelines of maternal care to have better pregnancy outcomes.MT201