International Journal of Gynecology & Obstetrics
Volume 110, Issue 2 , Pages 181-185, August 2010

Availability and quality of emergency obstetric care in Shanxi Province, China

  • Yu Gao

      Affiliations

    • Corresponding Author InformationCorresponding author. Northern Rivers University Department of Rural Health, Faculty of Medicine, University of Sydney, Lismore, NSW, 2480 Australia. Tel.: +61 2 6620 2112.
    • ,
  • Lesley Barclay

Northern Rivers University Department of Rural Health, Faculty of Medicine, University of Sydney, Lismore, NSW, Australia

published online 07 June 2010.

Article Outline

Abstract 

Objective

To investigate the availability and quality of emergency obstetric care (EmOC) received by women in a rural Chinese province.

Methods

The study was conducted in 7 rural counties and townships in Shanxi Province, China. Data sources included interviews with 7 hospital leaders, 5 maternal and child health workers, and 7 obstetricians; 118 records of complicated delivery were audited, 21 Maternal and Child Health Annual Reports analyzed, and observations conducted of facilities and advanced labor care.

Results

The number of comprehensive EmOC facilities was adequate in all counties. Three counties had fewer basic EmOC facilities than recommended and only 4 counties reached the recommended level. Most of the existing township hospitals did not provide birthing services. All the county hospitals could perform cesarean deliveries with rates from 6.8%–40.8%. The management of complications was not evidence-based. For example, women with pre-eclampsia and eclampsia were given too little magnesium sulfate; women were not closely monitored for hemorrhage after birth and the partograph was used incorrectly with consequences for obstructed labor.

Conclusion

Basic EmOC facilities are not adequate and township hospitals should be upgraded to provide birthing services. The quality of EmOC is poor and needs improvement.

Keywords: China, Emergency obstetric care, Rural health

 

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1. Introduction 

Of the estimated 536000 maternal deaths annually worldwide, 99% occur in low-resource counties, making maternal mortality a major health and development challenge [1]. The majority of maternal deaths are due to just 5 complications: hemorrhage, infection, unsafe abortion, hypertensive disorders in pregnancy, and obstructed labor [2]. Most of the primary causes of maternal deaths are difficult to predict in advance, but are treatable in a functioning health system. UNICEF, WHO, and UNFPA (the UN agencies) recognize that one of the critical pathways to reducing maternal mortality is to improve the accessibility, utilization, and quality of emergency obstetric care (EmOC) during pregnancy and childbirth [3].

Monitoring the level of maternal mortality is difficult and costly in most low-resource countries. The UN agencies have advocated an alternative approach to measure improvement over time and allow governments to track change toward the overall progress in reducing maternal mortality [3]. These UN guidelines for monitoring emergency obstetric services divided health facilities into two groups: basic EmOC (BEmOC) and comprehensive EmOC (CEmOC). Facilities that provide 6 signal functions (parenteral antibiotics, oxytocics, and anticonvulsants; manual removal of placenta; removal of retained products; and assisted vaginal delivery) are defined as BEmOC facilities. CEmOC facilities perform these 6 signal functions as well as cesarean delivery and blood transfusion. The UN guidelines recommend that for every 500000 population there are at least 4 BEmOC facilities and 1 CEmOC facility [3]. The guidelines were updated in 2009 and the recommendation is at least 5 EmOC facilities per 500000 population, at least 1 of which should be CEmOC [4]. Our analysis, however, was based on the first version of the recommendation as the study was conducted between 2005 and 2008.

The UN recommends the case fatality rate as an indicator of the quality of EmOC and the proportion of women with obstetric complications admitted to a facility who died should be less than 1% [3]. However the measurement of quality of care is complex and more indicators are needed as case fatality rates may not necessarily reflect the response and professional performance of the providers [5]. A systematic literature review also showed that data for evaluating the technical quality of EmOC are scarce and varied [6]. In the present study, we used consistency in managing common causes of maternal deaths, comparing this with the best evidence-based practice in recommended management [7] as the indicators for the quality of EmOC.

China's maternal death registration system is good [8]. The maternal mortality ratio (MMR) in 2005 and 2006 was 47.7 and 41.1, respectively. This steadily declined to 34.2 in 2008 [9]. Despite the progress that the Chinese government has made in reducing maternal mortality, critical gaps in the performance between rural and urban areas remain. For example, the MMR in rural areas was double that in urban areas (69.6 and 29.3 in 2000 and 53.8 and 25.0 in 2005) [9]. Reducing mortality in rural areas is a challenge. The facility delivery rate is low, in some villages as low as 28% [10], and there are many barriers, such as financial cost, transport, and traditional customs, for women to access health care [11]. In China, township and county hospitals are the frontline of reducing maternal deaths. In 2003, about 30% of maternal deaths occurred in these two levels of hospitals [12]. However, very few English language publications have reported the availability and quality of EmOC in these hospitals in rural China.

Between 2004 and 2007 we conducted a project funded by the Australian Research Council (ARC) looking at the impact of policy on delivery of regional maternity care in two Chinese provinces. We conducted a baseline assessment of the current level of maternity service women received in two provinces. In Sichuan province we mostly collected data in county/urban and minority settings and in Shanxi Province the focus was more rural. The study we report here was based on the results in Shanxi Province. As a component of the larger study, the goal of the study reported here was to determine the current availability and quality of rural EmOC in Shanxi Province of China.

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2. Materials and methods 

The settings and methods of the larger ARC study are described elsewhere [8], [11]. The present study used mixed methods to document the availability and quality of EmOC services in 7 rural counties (labeled DX, FX, NW, PD, XY, ZZ, HG), across 3 districts. Districts were selected with a high, medium, and low MMR compared across the Province. In each county we purposively sampled one major hospital according to the number of live births in 2005. We randomly sampled between 20% and 100% of all medical records of deliveries complicated by hypertensive disorders in pregnancy, postpartum hemorrhage (PPH), and obstructed labor. Data sources also included interviews with 7 hospital directors, 5 maternal and child health workers, and 7 doctors and midwives; and analysis of 21 Maternal and Child Health Annual Reports (2003–2005) from our areas of study, and observations of all the facilities and 7 advanced labors with patients’ verbal consent. Research instruments for records audits, observations, and most of the interviews were adapted from the WHO Safe Motherhood Assessment Tools [13]. The field work, including interviews, medical record audits, and observations, was conducted by the first author, a Chinese obstetrician. Qualitative data were recorded in a field diary in Chinese and translated into English. The numerical data were entered into SPSS version 15.0 (SPSS, Chicago, IL, USA) for descriptive analysis.

The study received ethical approval from the Human Research Ethics Committee at Charles Darwin University and gained agreement from relevant local health bureaus.

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3. Results 

3.1. Availability of EmOC services 

The number of CEmOC facilities for the population was adequate in all 7 counties, and above the recommended minimum of 1 per 500000 population in 6 counties. Three counties were below the minimum number of BEmOC facilities recommended (4 per 500000 population) and the other 4 counties had more than 4 BEmOC facilities. The details of the availability of EmOC services by county are presented in Table 1.

Table 1. Availability of emergency obstetric care (EmOC) services in 7 counties in Shanxi Province in 2005.
CountyDXFSNWPDHGXYZZTotal
Population200 0002500001580003200002830002480003500001809000
Live births161918151732248034491812234915256
Facility delivery rate (%)59.952.053.299.681.894.992.678.8
No. of facilities providing CEmOC133334320
CEmOC per 5000002.56.09.54.75.38.14.35.5
No. of township hospitals1113141223111094
Township hospitals providing BEmOC (%)0.030.850.08.313.027.320.021.3
BEmOC per 5000000.08.022.23.11.86.04.35.5

Source: MCH Annual Reports of 7 counties and interviews with MCH health workers during March to November 2006.

Although there were a number of township hospitals in each county, most provided no birthing services, let alone BEmOC. As Table 1 shows, in DX and HG counties, almost no township hospitals could provide BEmOC. In NW, only half were able to provide the services. This means that many village women with obstetric emergencies must travel long distances to reach an EmOC facility. Furthermore, not only did some counties lack BEmOC facilities, but the facilities that did exist were not functioning as they should.

3.2. Quality of EmOC Services 

All but one of the 7 hospitals had adequate oxytocin, magnesium sulfate (MgSO4), antibiotics, and syringes readily available in the labor room. In one hospital they were kept elsewhere because the head nurse expressed concerns that “the doctors were stealing medicines to provide birth service outside [of their hospital].” All the hospitals could perform cesarean delivery; however cesarean rates varied across the hospitals. Six hospitals had relatively low rates of cesarean (6.8%–21.7%) and one hospital (PD) had a higher rate (41%). All the hospitals conducted vacuum extraction, but none performed forceps deliveries although the equipment was available. Interviews with the staff found that forceps delivery was not accepted by patients, and the staff had lost their skills through lack of use.

Availability of safe blood for transfusion is essential for quality EmOC. In our study, 5 of 7 hospitals kept blood in their own facilities and the other 2 hospitals (HG, NW) asked nearby hospitals for blood when needed. In general, it took 1–3hours to get blood from other hospitals. Interviews with hospital directors revealed that the blood bank in the city delivered blood once a week and it was difficult to predict how many units of blood they would need. The hospitals must still pay the cost for expired and surplus blood.

Five hospitals had sufficient newborn resuscitation equipment and 2 hospitals (DX, NW) did not. There were no stillbirths recorded in 2 hospitals (PD, XY), 3 each in the DX, FS, and NW hospitals, and 9 and 11 in ZZ and HG hospitals, respectively. It was difficult to interpret the relationship between frequency of stillbirths and the availability of resuscitation equipment because of small numbers. However, many staff reported that they did not know how to use the equipment.

The medical records for 118 women were audited across the 7 hospitals to assess the quality of care received during their complicated deliveries. No maternal death was identified. The findings of the medical record audits are presented in Table 2.

Table 2. Summary of the medical complication audits in 7 hospitals in Shanxi Province in 2005.
HospitalHGZZXYPDNWFSDXTotal
Hypertensive disorders in pregnancy
No. of women1086396648
Vaginal births (%)4 (40)1 (12.5)0 (0)0 (0)6 (66.7)3 (50)5 (83.3)19 (39.6)
MgSO4 (%)6 (60)5 (62.5)1 (16.7)1 (33.3)3 (33.3)1 (16.7)0 (0)17 (35.4)
Anti-hypertensive (%)6 (60)4 (50)3 (50)2 (66.7)6 (66.7)4 (66.7)0 (0)25 (52.1)
Postpartum hemorrhage
No. of women811215422
Vaginal births (%)2 (25)1 (100)1 (100)1 (50)1 (100)4 (80)2 (50)12 (54.5)
Cesarean (%)6 (75)0 (0)0 (0)1 (50)0 (0)1 (20)2 (50)10 (45.5)
AMTSL (%)8 (100)1 (100)1 (100)2 (100)1 (100)0 (0)4 (100)17 (77.3)
Blood transfusion (%)6 (75)1 (100)1 (100)2 (100)1 (100)5 (100)3 (75)19 (86.4)
Obstructed labor
No. of women10128881148
Vaginal births (%)3 (30)1 (8.3)0 (0)0 (0)0 (0)0 (0)0 (0)4 (8.3)
Cesarean (%)7 (70)11 (91.7)8 (100)8 (100)8 (100)1 (100)1 (100)44 (91.7)
Partograph use (%)7 (70)11 (91.7)0 (0)5 (62.5)1 (12.5)0 (0)0 (0)39 (59.1)

Abbreviation: AMTSL, active management of the third stage of labor.

3.2.1. Hypertensive disorders in pregnancy 

The age of the mothers affected by hypertensive disorders in pregnancy ranged from 19–44years, with parity between 0 and 4. Six women had eclamptic seizures, 5 occurred before labor, and 1 after labor.

The WHO recommends a standard treatment for eclampsia and severe pre- eclampsia: a loading dose: 4g of MgSO4 intravenously, followed by 10g by intramuscularly; maintenance dose: 5g of MgSO4 intramuscularly every 4hours [7]. Anticonvulsive therapy should be maintained for 24hours after delivery or the last convulsion, whichever occurs last. The WHO recommends that antihypertensives are needed if diastolic blood pressure remains above 110mm Hg. The record auditing, however, showed MgSO4 was not used correctly. All the hospitals gave women smaller than recommended doses for eclampsia and severe pre-eclampsia and did not maintain treatment for 24hours after birth. As shown in Table 2, no hospital correctly managed all their cases: the adherence to recommended management was zero in 1 hospital, about 17% in 2 hospitals, about 30% in 2 hospitals, and over 60% in the remaining 2 hospitals. Interviews with the doctors revealed that they thought a smaller dose was safer. They had heard that MgSO4 is dangerous, but they did not know why and thought it would be safer to give a lower dose.

We found that most women were administered antihypertensives such as nifedipine and hydralazine when their diastolic blood pressure was less than 110mm Hg. Table 2 shows that adherence to the recommended administration of antihypertensive medicine was zero in 1 hospital, 50% in 2 hospitals, and over 66% in the other hospitals. Staff interviewed thought that antihypertensives were safer and quicker than MgSO4 to reduce blood pressure. One doctor said: “magnesium sulfate needs to be monitored carefully and be maintained for a very long time. We don't have enough nurses to monitor for its dangerous side effects. So we decided to reduce its dose but add antihypertensive medicines to reduce the blood pressure quicker.”

3.2.2. Postpartum hemorrhage 

Vaginal bleeding greater than 500mL after delivery is defined as PPH [7]. The causes of PPH are uterine atony, a retained placenta, inverted or ruptured uterus, and cervical, vaginal, or perineal lacerations [14]. Uterine atony is the most common reason for PPH and it accounts for 75%–90% of primary PPH [15]. According to Prendiville et al. [16], active management of the third stage of labor can effectively reduce hemorrhage due to atony.

Of the 22 women who developed PPH, 2 were transferred to hospital with heavy bleeding after birthing at home and the rest gave birth in hospital. The recorded reasons for PPH were uterine atony (n=15, 68%), retained placenta (n=4, 18%), uterine rupture (n=1, 4.5%), laceration (n=1, 4.5%), and unknown cause (n=1, 4.5%).

According to the medical records, all but 1 hospital had actively managed the third stage of labor (Table 2). However, labor observations showed that this was practiced poorly and postpartum women were improperly monitored. Labor observation showed that in PD and XY hospitals, no blood pressure measurements were taken and no uterine massage was performed during the first 30 minutes after delivery of the placenta while women were still under close observation in the labor room. After women were discharged from the labor room it was not possible to continue taking observations. Casual conversations with some women revealed that many of them were asked by staff to massage their own uterus. Most family members did not know how to do this properly.

Despite two hospitals not storing blood, most women with PPH were transfused. Blood was even transfused to women whose hemoglobin was higher than 7g/dL, which is contrary to WHO recommendations [7].

3.2.3. Obstructed labor 

Of the 48 women diagnosed with obstructed labor, 38 (79.2%) were multiparous and 10 (20.1%) were primiparous. Six women were referred from home or other lower-level hospitals when obstructed labor was identified; the other 42 obstructed labors occurred in the hospitals where birth was planned.

To end an obstructed labor, the WHO recommends that if the fetus is alive, the cervix is fully dilated, and the fetal head is at 0 station or below, the fetus should be delivered by vacuum extraction; if the fetal head is at –2 station, the fetus should be delivered by vacuum extraction and symphysiotomy or by cesarean; if the cervix is not fully dilated or if the fetal head is too high for vacuum extraction, delivery should be by cesarean [7]. As shown in Table 2, 44 (92%) obstructed labors ended with cesarean delivery. Of the 44 cesarean deliveries, 11 (25%) were conducted while the cervix was fully dilated. Three births could have employed vacuum extraction as the fetal head was at +2 station.

The WHO recommends using partographs because this can help birth attendants make better decisions in the diagnosis and management of prolonged and obstructed labor [7]. In our study, however, we found that a partograph was recorded in few obstructed labors: 3 hospitals did not use it at all, 3 hospitals used it occasionally, and 1 hospital used it for almost every case. For those cases that did have a partograph, it was incomplete and the way it was used varied among hospitals. For example, the partographs used had no alert line or action line, and obstetricians and midwives did not know the meaning of these terms. None said that they had heard these terms before. The reason for this appears to be that neither term was written in the Chinese language textbook on which staff rely. Interviews with the staff found that no standardized partographs were provided to these county hospitals, nor had training been provided in their use. We also found that the staff interviewed did not value the partograph. One midwife said: “we are busy every day, and don't have time to draw it. Who will look through the partograph? We always take action positively, even before the partograph tells us.”

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4. Discussion 

The paper describes the availability and quality of EmOC services in 7 rural counties in Shanxi Province, China. We found that although the rural counties had an adequate number of CEmOC facilities, functional BEmOC facilities were non-existent or inadequate. This is consistent with findings from a national needs assessment in 24 countries, which included both low- and high-resource countries [17].

Most of the existing township hospitals in the rural counties studied were not able to provide BEmOC services. Women in these areas travelled a long distance to give birth in the county hospitals, which were the CEmOC facilities. This greatly increased the workload of staff in the county hospital. Furthermore, village clinics and township hospitals experienced increasing difficulty generating income and keeping their qualified staff.

The cesarean delivery rate in rural areas was much lower than in large cities (12.8% vs 39.5%) according to the 2003 Chinese National Health Service Survey [18], [19]. In our study hospitals, the majority had a low cesarean rate, consistent with the national survey findings. Reasons for a low rate in these areas appear to include that women prefer to have a natural birth, the cost of cesarean delivery, and the staff's geographic and academic isolation from modern practice. The hospital director also seems to influence the incidence of cesarean delivery. For example, the head of PD hospital, which had the highest rate, was an obstetrician with 5years of formal medical university training who had accepted contemporary Chinese obstetric standards. It is ironic that the directors of those hospitals with rates closer to contemporary western recommendations were not obstetricians and two of them were not doctors.

Evidence-based training on management of life-threatening complications is urgently needed in rural hospitals. We found that women received poor and dangerous care. For example, although MgSO4 is recommended as the first line for severe pre-eclampsia and eclampsia and its schedule for use is well established [20], women in the study hospitals were administered lower doses than recommended. Postpartum hemorrhage is the most common cause of maternal death although the provincial government has often provided training on its management [21]. The atonic uterus was the major cause recorded in audits for PPH in our study, consistent with findings from other studies [22]. Research shows that persistent uterine massage effectively reduces the amount of blood loss [23]; however, women in our study were poorly monitored after birth. This suggests that the training programs are ineffective or need improvement and these programs should be evaluated carefully. We found the partograph was not used or was used incorrectly in the hospitals evaluated. Research has shown that by using a partograph the birth attendant can successfully identify the failure of labor to progress and take action to avert prolonged labor [24].

Research has shown that training of healthcare providers had a significant impact on improving their skills and the quality of care they provided [25]. Our study in Sichuan and Shanxi Provinces found that most doctors and midwives had had no in-service training for many years [11], [26]. In-service training is an effective way for local staff to keep their knowledge and skills up to date. However, we found that continuing medical education and in-service training was not encouraged by the hospital leaders [27]. We were told that hospitals were reluctant to bear the cost of training and that doctors would not come back after training because they would want to practice in urban areas on higher salaries.

Many factors have restricted use of evidence-based medicine in daily practice. First, it is evident that Chinese doctors have great difficulty accessing the international (mostly English language) evidence because of the language barrier. As Xiong and Fang [28] pointed out, currently few papers on evidence-based obstetric practice have been published in Chinese, and there is no regular updated Chinese language website on this topic. Second, interviews with local staff showed that many Chinese physicians doubt the validity of evidence from the Cochrane reviews [28] as they believe they need evidence from studies conducted in China. Third, there are no Chinese guidelines or textbooks that reflect current evidence and this prevents the evidence from being applied in hospital routines. Finally, as Qian et al. [29] stated, hospital directors have strong influence in evidence application. It appears that the staff would rather follow a directive of the hospital director than the international recommendations. This is possibly because the hospital directors have the power to change the current hospital policy or make a new policy in their hospital. In addition, in China there is a social need to obey; the creation of harmonious relationships in the work environment is essential as that is where people spend most of their time.

The main limitation of the present study is the poor quality of the medical records in these hospitals. Many records were incomplete and treatments were not recorded or our observation data reported elsewhere suggests that some events were recorded when they did not happen [27]. The poor quality of medical records confirms the poor quality of medical practice in these hospitals, but it also reflects that the doctors placed little value on good records. Another problem with the records was the apparent underreporting of stillbirths and, possibly, maternal deaths. This may reflect that there were no cases, however this seems highly unlikely; for example, no stillbirths were identified among 4000 births in PD and XY hospitals. This is unlikely, but we could identify no other data to verify this.

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5. Recommendations 

It is strongly recommended that, rather than building new hospitals supplied with sophisticated equipment, poorly functioning township hospitals be upgraded to provide basic, accessible, and affordable BEmOC services. By doing so, the workload in county hospitals could be relieved and the clinicians there could have more time to update their knowledge and provide a better quality of CEmOC.

Evidence-based training on management of eclampsia, PPH, and obstructed labor is urgently needed in rural hospitals. We found women received poor, harmful, and dangerous EmOC services. Effective training on how to use the partograph should be included in formal medical and midwifery education and be provided to all current obstetric clinicians.

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Acknowledgments 

This work was supported by the project “Improving Birth Outcomes in China: Consequences and potentials of policy, state and professional interactions” (LP0454943) jointly funded by the Australian Research Council, the Second Hospital of Shanxi Medical University, and the Western China Second Hospital Sichuan University.

Conflict of interest

The authors have no conflicts of interest to disclose.

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PII: S0020-7292(10)00226-2

doi:10.1016/j.ijgo.2010.05.001

International Journal of Gynecology & Obstetrics
Volume 110, Issue 2 , Pages 181-185, August 2010

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