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October 2003 Obstetrics in Cairo: Actual Practices Versus Evidence-based Protocols In 1995, more than half a million women worldwide died in childbirth, nearly all in the developing world. (By contrast, fewer than 500 of the deaths occurred in all of North America.) In 1994, the Egyptian Ministry of Health estimated Egypt’s maternal mortality ratio (MMR) at 174 deaths per 100,000 live births. (In 1995, Canada had an MMR of 6, the United States, 12.) Since then Egypt has lowered its MMR to 84, an improved but still substantial rate. Government programs focused on obstetric emergencies have contributed to this reduction; however, little is known regarding the experience of women with normal deliveries. To address this gap, researchers documented normal-birth practices at El-Galaa Teaching Hospital, a large obstetrics facility in Cairo, where 20,000 women give birth and about 225 doctors are trained annually. To investigate actual practices in normal deliveries at the hospital, Council researchers designed a study that minimized subjective judgments and instead used as the gold standard evidence-based protocols that are globally recognized. They trained 12 female, non-staff obstetricians to record more than 200 variables while observing women throughout labor and delivery. All medical interventions and most verbal interactions were recorded. In all, 176 women were followed from admission through discharge, a total of 28 days and nights of uninterrupted observation. The pattern of using the drug oxytocin to shorten labor was among the practices observed. Oxytocin shortens labor by stimulating uterine contractions (“augmentation”). It is safe when used correctly—protocols restrict its use to poor progress in labor—but inappropriate usage or inadequate supervision can result in complications that include uterine rupture and fetal distress. In the United States, where approximately 15 percent of normal labors are augmented, roughly 25 percent of medical-legal settlements are oxytocin-related. The pattern of oxytocin usage in Egyptian facilities previously was undocumented. The study found that 91 percent of deliveries were augmented. Of the augmentations, 93 percent were inappropriate, including giving oxytocin at the first exam, before progress of labor could be observed (41 percent) and/or administering the drug in spite of good progress (24 percent). Two contraindications were simultaneously present for almost half the cases (45 percent). Other findings include important discoveries regarding the pattern of administration of anti-hemorrhage drugs, inconsistencies in recording progress of labor on medical charts, and the relationships between physicians and patients. Barbara L. Ibrahim, Council regional director for West Asia and North Africa, reports that the administration and staff of El-Galaa Hospital had an immediate, positive response to the study findings. "We succeeded in our goal to actively engage management and staff in thinking about clinical practice, and they are eager to institute needed improvements the study brought to light." Karima Khalil, one of the study's authors, adds, "The study has generated considerable interest in Egypt and abroad. The findings have important implications for the training of new physicians, particularly in developing countries. We are now disseminating our methodologies, data collection tools, and other findings throughout Egypt and the region to advance the quality of obstetric care for women anticipating normal labor." The research team consisted of Mohamed Cherine of El-Galaa Hospital, Nevine Hassanein of John Snow International, Amr Elnoury and Lamia Mohsen of Cairo University, Hania Sholkamy of the American University in Cairo, Nabil Younis of Al-Azhar University Faculty of Medicine, and Miral Breebaart and Zeinab Farahat of the Population Council, and was coordinated by Karima Khalil of the Population Council. The study was funded by the Ford Foundation, the American University in Cairo's Social Research Center, and the Population Council. |
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