Sub-optimal care in stillbirths - a retrospective audit : Evaluation of the prenatal care and possibilities for quality improvements with special focus on non-western immigrants

Background: Improved perinatal care has decreased stillbirth rates radically. Audits may identify main current quality of care issues in stillbirth to identify areas for further improvements. The aims of this study were to identify sub-optimal factors likely to have contributed to stillbirths and to test if sub-optimal factors were more frequent among non-western than western women. Material and method: Perinatal deaths in Oslo and Akershus have systematically been audited by perinatal committees and attributed to optimal or sub-optimal care when compared to guidelines; categorised as maternal self-care, care from health care providers and communication. This is a summary of audit results of all the 356 stillbirths after 24 weeks of gestation in Oslo and Akershus during 1998-2003 (4.2 per 1000 deliveries). The study population consisted of 31% non-western women. Results: Sub-optimal factors were identified in 37% of the deaths. When compared to western women, non-western women had increased risk of sub-optimal care (OR=2.4, 95% CI 1.5-3.9), they had increased risk of stillbirth (OR=2.2, 95% CI 1.3-8.7), and more often they received sub-optimal obstetric care (OR=3.8, 95% CI 1.6-3.9), as e.g. misinterpretation/lack of intervention at signs of fetal distress, or incorrect assessment of labour progression. A common failure in antenatal care was unidentified or inadequate management of intrauterine growth restriction. Erroneous management of absent fetal movements was documented both within health care and with pregnant women. Non-western women were less prone to follow recommendations given by health professionals, e.g. not attending the program for antenatal care or not taking consequences of recommendations given by health care providers. Inadequate verbal communication was documented in 47% of the deaths among non-western mothers; interpreter was used in 29% of these. Conclusions: Sub-optimal care factors were more common among non-western immigrants. Possibilities for improvements were reduction of language- and cultural barriers, better identification and management of growth restriction and absent fetal movements, and adequate intervention in complicated vaginal births; with increased vigilance towards non-western women. NORSK SAMMENDRAG: Dødfødte i Oslo og Akershus i 1998-2003 Evaluering av perinatalomsorgen og muligheter for kvalitetsforbedring – med spesielt fokus på ikke-vestlige innvandrere Formål: Forbedret perinatalomsorg har redusert dødfødselsratene radikalt. Audit kan bidra til å identifisere områder for hvor ytterligere kvalitetsforbedring kan være mulig. Målet med denne oppgaven var å identifisere suboptimale faktorer ved svangerskap og fødsel ved dødfødsler, og om suboptimale forhold forekom hyppigere blant ikke-vestlige enn vestlige kvinner. Materiale og metode: Alle dødfødsler har kontinuerlig blitt vurdert av perinatalkomiteene gjennom audit. Omsorgen har blitt klassifisert som optimal eller suboptimal relatert til retningslinjer, og kategorisert som mors egenomsorg, omsorg fra helsepersonell og kommunikasjon. Dette er en oppsummering av auditresultatene av alle dødfødte i Oslo og Akershus fra svangerskapsuke 24 i perioden 1998-2003 (356 dødfødsler, 4.2 per 1000 fødte). Studiepopulasjonen bestod av 30.9 % ikke-vestlige kvinner. Resultater: Suboptimale faktorer var identifisert i 37 % av dødsfallene. Sammenlignet med vestlige kvinner, hadde ikke-vestlige kvinner økt risiko for suboptimal omsorg (OR=2.4, 95 % CI 1.5-3.9), økt risiko for dødfødsel (OR=2.2, 95 % CI 1.3-3.8) og hadde oftere fått suboptimal fødselsomsorg (p