ABSTRACT

Objectives: The aims of the present study were to estimate the perinatal mortality rate in Omdurman region at Khartoum, Sudan, and to describe and categorize the perinatal deaths at the central Omdurman Maternity Hospital in order to select groups for assessment by qualitative audit. Furthermore, to assess the three most commonly used perinatal death classification systems, (1) the Nordic-Baltic, (2) the Aberdeen, and (3) the Wigglesworth, regarding applicability and justification for practical use in quality assurance and audit activities in a developing country. Finally, to assess two large groups of perinatal deaths, intrapartum deaths of non-malformed infants and neonatal death of mature infants above 34 weeks, by an interdisciplinary qualitative audit.

Material and methods: The area-based crude perinatal mortality rate (PMR) in one year, 1998-1999, was estimated from project data from Omdurman Maternity Hospital, one general hospital, and a primary health care unit, and from data collected for civil registration.

In a three and a half month period of 1999, 192 deaths at Omdurman Maternity Hospital were categorized by the Nordic/Baltic perinatal death classification, and compared with those in a European country with a high level of perinatal care, Denmark 1996, and those in another European but less well developed country with health care in transition, Donetsk region, Ukraine 1997-98.

In a three-month period of 2000, 166 perinatal deaths at Omdurman Maternity Hospital (OMH), Khartoum Sudan, were prospectively described. Time-related events during pregnancy, delivery and the neonatal period were prepared in narratives of 166 perinatal deaths for the purpose of audit. A panel of two Danish and one Sudanese obstetrician categorized the cases according to (1) the Nordic-Baltic, (2) the Aberdeen, and (3) the Wigglesworth classification. A total of 43 non-malformed intrapartum deaths and neonatal deaths above 34 weeks were selected for evaluation by interdisciplinary qualitative internal and external audit.

Results: The area-based PMR in the Omdurman area was estimated to be 5.4%. Two categories, intrapartum deaths of non-malformed infants and neonatal deaths of infants above 34 weeks, which include a large proportion of potentially avoidable cases, were excessively larger at OMH than in the two other regions.

By classification of the perinatal deaths using all three classification systems, Nordic-Baltic, Aberdeen, and Wigglesworth, a similar fraction of cases (about 85%) were allocated to one category only, and in 15% of cases the assessors were in doubt into which of two categories the cases should be allocated. The optimal perinatal death classification should rely on simple, routinely recorded variables for allocation into mutually exclusive groups, which should be associated with specific areas for health care interventions.

The audit activity was preceded by a two days workshop at the hospital. Individual assessments based on 43 detailed narratives were followed by regular consensus meetings. This structure seemed useful for interdisciplinary discussions, and the audit process resulted in several specific suggestions for quality improvement in data collection, interdisciplinary collaboration, and obstetric and neonatal care.

Conclusion: The area-based perinatal mortality rate in Omdurman is about 10 times higher than in affluent societies, and two categories of perinatal deaths, intrapartum deaths of non-malformed infants and neonatal death of mature infants above 34 weeks, were excessively larger at Omdurman Maternity Hospital than in Denmark and Ukraine.

Classification of perinatal deaths by common classification systems in developing countries is associated with significant problems regarding application, validity and usefulness. The Nordic-Baltic classification seems to be most suitable for appropriate stratification using simple routinely recorded variables and providing categories associated with specific levels of care.

The audit process resulted in several specific suggestions for quality improvement in data collection, interdisciplinary collaboration, and obstetric and neonatal care. The interdisciplinary adverse outcome audit is a good starting point for quality assurance in a developing country. However, since adverse outcome audit is only focusing on selected cases and may encourage interventions without considering the full impact on the population, it should be combined with other quantitative and qualitative quality assessment activities for improvement of perinatal care.