Practices and Quality of intrapartum care in the main referral hospital of The Gambia

Background: Evidence-based obstetric care is widely advocated for in developing countries. However, the success of its implementation is not well documented. Selected normal childbirth practices in the main referral hospital in The Gambia, were compared to evidence-based practices using the World Health Organization established normal birth standards, as the “Gold Standard”. Direct observation of women admitted with established normal labour and review of medical records of all those observed was carried out for the quantitative paper. Women’s views, expectations and satisfaction on the care received during labour and delivery were explored. Additionally, for maternity unit staff, issues such as daily routines, practices and challenges in carrying out routine procedures were explored. Objective: To assess the practices and quality of delivery care during childbirth in Royal Victoria Teaching Hospital delivery ward in The Gambia. Materials and methods: The study included both retrospective and prospective designs combining also qualitative and quantitative methods. In-depth individual interviews with fifteen postpartum women and an equal number of health care providers were purposively selected. For postpartum women, their views, expectations and satisfaction on the care received during labour and delivery were explored. Additionally, for maternity unit staff, issues such as daily routines, practices and challenges in carrying out routine procedures were explored with the aim to compare these practices with current evidence-based obstetric practices. Of the 136 women selected randomly, non-participant observation from admission through delivery was conducted using a check-list. Descriptive analysis of data was performed and presented in two separate papers; quantitative and qualitative. Results: Harmful or non-beneficial practices were found to be common. Routine parenteral ergometrine prophylactic 92 (67.6%), manual exploration of the uterus 90 (66.1%), intravenous infusion 74 (54.4%) and labour augmentation with oxytocin 62 (45.5%) were common practices. Routine episiotomy without indications was also a norm. Standard beneficial practices such as assessment of vital observations of labouring women, infection control through application of universal precautions, prevention of hypothermia in the newborns and care provider-woman communication were disappointingly infrequent. Evidence-based-care was not often applied as claimed by health care personnel in the study labour ward. Unbeneficial practices such as strict policy on lithotomy position during delivery, routine labour augmentation with oxytocin and episiotomy for all women at first delivery were mentioned by care providers. From the women’s point of view, valued practices like presence of a family member as support during labour and delivery, mobility during the first stage of labour and communication with care providers were restricted. Poor staff attitude was a prominent concern to postpartum women who delivered in the study site. Empathy, patience and politeness care attitudes which women expect from care providers were lacking in the patient-provider interaction. Conclusion: The Quality of intrapartum care in this obstetric referral hospital is below approved standard. Introducing maternity care protocols and guidelines particularly during intrapartum care with supportive supervision may significantly improve quality of maternity care services in this hospital. Key Words: Quality of care, intrapartum care, normal labour, evidence-based obstetrics care and The Gambia