title: Confidential enquiries into quality of care of women in labour using Hypoxic Ischemic Encephalopathy as a marker.
abstract: OBJECTIVE
  To identify avoidable factors contributing to neonatal morbidity and mortality due to "birth asphyxia" and to ascertain if hypoxic ischemic encephalopathy (HIE) alone could act as a good marker for avoidable factors associated with "birth asphyxia".
  
  
  METHODS
  Kalafong Hospital, South Africa, a regional hospital unit that caters for mainly indigent urban population but also receives referrals from the Mpumalanga Province.
  
  
  METHODS
  All neonates and intrapartum stillbirths fulfilling the criteria of birth asphyxia born at the Kalafong Hospital during 2008 and 2009 were included. Neonates born at less than 34 weeks gestation, born with infection, major congenital malformations or inborn errors of metabolism and intrapartum deaths due to abruption placentae were excluded. Neonates referred from Level 1 clinics postnatally, who qualified with these criteria, were also included in the study. The files were retrieved, and avoidable factors were identified. Avoidable factors were classified into 3 groups: patient associated, administrative and medical personnel associated problems.
  
  
  RESULTS
  In 2008 and 2009, 10117 babies were born at Kalafong Hospital. 224 babies with intrapartum related asphyxia were identified (22.1/1000 births). This group consisted of 14 intrapartum stillbirths, 85 neonates with mild asphyxia, 125 babies with severe asphyxia of which 41 had a neonatal near miss markers without HIE and 84 with HIE. Fifteen of the babies with HIE subsequently died. The number of avoidable factors identified per case file reviewed increased with the severity of the hypoxic event, mild asphyxia 0.74, neonatal near miss without HIE 0.85, HIE survivor 0.91, and stillbirth or neonatal death 1.29. Major avoidable factors for birth asphyxia were refusal of medical treatment, inadequate facilities, no detection of or reaction to fetal distress, and incorrect management of second stage. The avoidable factors detected in neonates with HIE were the same as those detected in the whole group.
  
  
  CONCLUSIONS
  The avoidable factors described in a confidential enquiry concentrating on the labour management of women delivering neonates with all grades of "birth asphyxia" were similar to those found in women delivering neonates with HIE. HIE in neonates is a clearly defined condition, making it a good marker to use to review the quality of intrapartum care received by the women who delivered neonates with HIE.
authors.affiliation: Registrar, Department of Obstetrics and Gynaecology, KULeuven, Belgium.
authors.forename: A
authors.initials: A
authors.lastname: De Knijf
authors.affiliation: MRC Maternal and Infant Health Care Strategies Research Unit, Department of Obstetrics and Gynaecology, University of Pretoria, Kalafong Hospital, Pretoria, South Africa.
authors.forename: R C
authors.initials: RC
authors.lastname: Pattinson
keywords: Audit; Birth Asphyxia; Hypoxic Ischaemic Encephalopathy; Intrapartum Care; Quality of Care