title: Clinical audit to enhance safe practice of skilled birth attendants for the fetus with nuchal cord: evidence from a refugee and migrant cohort.
abstract: BACKGROUND
  Current evidence for optimal management of fetal nuchal cord detected after the head has birthed supports techniques that avoid ligation of the umbilical cord circulation. Routine audit found frequent unsafe management of nuchal cord by skilled birth attendants (SBAs) in migrant and refugee birth centres on the Thai-Burmese border.
  
  
  METHODS
  The audit cycle was used to enhance safe practice by SBA for the fetus with nuchal cord. In the three birth centres the action phase of the audit cycle was initially carried out by the doctor responsible for the site. Six months later a registered midwife, present six days per week for three months in one birth facility, encouraged SBAs to facilitate birth with an intact umbilical circulation for nuchal cord. Rates of cord ligation before birth were recorded over a 24 month period (1-July-2011 to 30-June-2013) and in-depth interviews and a knowledge survey of the SBAs took place three months after the registered midwife departure.
  
  
  RESULTS
  The proportion of births with nuchal cord ligation declined significantly over the four six monthly quarters from 15.9% (178/1123) before the action phase of the audit cycle; to 11.1% (107/966) during the action phase of the audit cycle with the doctors; to 2.4% (28/1182) with the registered midwife; to 0.9% (9/999) from three to nine months after the departure of the registered midwife, (p < 0.001, linear trend). Significant improvements in safe practice were observed at all three SMRU birth facilities. Knowledge of fetal nuchal cord amongst SBAs was sub-optimal and associated with fear and worry despite improved practice. The support of a registered midwife increased confidence of SBAs.
  
  
  CONCLUSIONS
  The audit cycle and registered midwife interprofessional learning for SBAs led to a significant improvement in safe practice for the fetus with nuchal cord. The authors would encourage this type of learning in organizations with birth facilities on the Thai-Burmese border and in other similar resource limited settings with SBAs.
authors.forename: Megan
authors.initials: M
authors.lastname: Parr
authors.forename: Colley Paw
authors.initials: CP
authors.lastname: Dabu
authors.forename: Nan San
authors.initials: NS
authors.lastname: Wai
authors.forename: Paw Si
authors.initials: PS
authors.lastname: Say
authors.forename: Ma
authors.initials: M
authors.lastname: Ner
authors.forename: Nay Win
authors.initials: NW
authors.lastname: Tun
authors.forename: Aye
authors.initials: A
authors.lastname: Min
authors.forename: Mary Ellen
authors.initials: ME
authors.lastname: Gilder
authors.forename: François H
authors.initials: FH
authors.lastname: Nosten
authors.affiliation: Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, PO Box 46, Mae Sot, Tak 63110, Thailand. rose@shoklo-unit.com.
authors.forename: Rose
authors.initials: R
authors.lastname: McGready
mesh_terms: D000293:Adolescent; D000328:Adult; D000488:Allied Health Personnel; D054869:Clinical Audit / Q000379:methods*; D036861:Delivery, Obstetric / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D005858:Germany; D006801:Humans; D008427:Maternal Health Services / Q000592:standards*; D008875:Middle Aged; D008880:Midwifery / Q000592:standards; D053589:Nuchal Cord / Q000517:prevention & control*; D011181:Postnatal Care / Q000592:standards; D011247:Pregnancy; D011787:Quality of Health Care; D012036:Refugees; D012189:Retrospective Studies; D012424:Rural Population; D014171:Transients and Migrants; D055815:Young Adult