title: Early warning systems to improve maternal health in Nigeria: design, validation, and evaluation of a modified obstetric early warning chart for use in low-resource settings
Creators: name: Umar, Aminu
Publisher: name: University of Liverpool Repository
Year: 2020

description: Background: One basic way to prevent maternal deaths in healthcare facilities is through early detection of changes in physiological parameters that are suggestive of clinical deterioration before such changes become irreversible and fatal. This is the aim of the Early Warning Systems (EWS). The objectives of this PhD were to introduce and evaluate the use of obstetric EWS in Nigerian tertiary hospitals. Methods: A preliminary investigation of the evidence supporting the usefulness of EWS in obstetric practice was achieved via a systematic literature review. The baseline formative research employed mainly qualitative methods to assess the feasibility of implementing EWS in three Nigerian tertiary hospitals. Then a robust dataset, consisting of 4360 women with severe maternal outcome (SMO: maternal death or near miss) and 1000 obstetric admissions without SMO diagnosis, collected across 42 Nigerian tertiary hospitals, was used to develop a statistically derived obstetric EWS model and score-based chart for use in low-resource settings using a case-control multivariate logistic regression analysis. The resulting EWS chart was implemented across all obstetric units of a university teaching hospital in Nigeria. Two other teaching hospitals were recruited as control facilities. Following implementation, we employed mixed research methods to assess the effectiveness of EWS in improving health outcomes and explore the experience of health workers/managers implementing the EWS. Results: The systematic review showed that EWS are effective in predicting severe obstetric morbidity and mortality, can potentially contribute to improved quality of care/health outcomes, and may be feasible to implement in low-resource settings. The feasibility study confirmed the absence of EWS, a checklist or any guidelines on how to trigger response to obstetric emergencies across the three hospitals. Vital signs were routinely monitored despite shortages of monitoring equipment and human resources. However, understanding of their potential utility as early pointers to maternal deterioration was deficient among healthcare workers. The resulting EWS from our SMO model consisted of seven clinical parameters (respiratory rate, temperature, systolic blood pressure, pulse rate, consciousness level, urine output and delivery mode for postpartum patients). The model had excellent screening characteristics for SMO (86% (95% CI 81–90) sensitive and 92% (95% CI 89–94) specific and maintained good discriminatory power across all our internal validation data sets (area under ROC curves consistently above 90%). Following implementation, nurses and doctors found EWS easy to use, easy to evaluate at a glance, and accurate, but, usage rate was considerably low (&lt;50%). Significant improvement in quality of vital signs monitoring was experienced in the intervention, but not in any of the control sites. Rotation of clinical staff, shortages of monitoring equipment and human resources for health were identified challenges. Conclusion: To the best of our knowledge, this research reports for the first time an internally validated statistically developed diagnostic predictive model for obstetric morbidity and mortality among all women admitted to obstetric wards in a low-resource setting. Our findings showed that it is feasible to implement the obstetric EWS in low-resource settings and this can improve the quality of patient care through better monitoring frequency and medical review based on abnormally high EWS scores. The EWS we developed could be used to evaluate quality of patient care through assessing whether trigger events result in clinical action, and timeliness of clinical action. Surveillance of patients who trigger action could allow for further evaluation and discussion of quality of care, for example at maternal morbidity and mortality meetings. Overall, with staff education on usefulness of EWS, coupled with continuous training and retraining, it is feasible to implement obstetric EWS as a potentially acceptable patient monitoring tool to cope with the unique demands faced by obstetric practice in low-resource tertiary healthcare settings.