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Indian Pediatr 2020;57: 1006-1009 |
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Documentation and Reporting of Perinatal
Deaths in Two Districts of Karnataka, India: A Situational
Analysis
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HN Harsha Kumar,1
Shantaram Baliga,2
Pralhad Kushtagi,3
Nutan Kamath2
and
Sucheta S Rao2
From Departments of 1Community Medicine,
2Pediatrics, and 3Obstetrics and Gynecology,
Kasturba Medical College, Mangalore, Manipal Academy of
Higher Education (MAHE), Karnataka, India.
Correspondence to: Dr HN Harsha Kumar, Former Associate
Professor, Department of Community Medicine, Kasturba
Medical College, Mangalore, Manipal Academy of Higher
Education (MAHE), 575 001, Karnataka, India.
Email:
drhnhk@rediffmail.com
Submitted: February 18, 2019;
Initial review: June 07, 2019;
Accepted: January 01, 2020.
Published online: June 12, 2020;
PII: S097475591600194
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Objectives: In Karnataka state, perinatal
mortality rate is almost equal to infant mortality rate.
This preliminary study was conducted in two districts of
Karnataka to study potential problems to start of perinatal
death audit. Methods: Hospitals providing
maternal and child health care services, which met study
inclusion criteria, in Dakshina Kannada and Koppal Districts
were included. Following variables were studied: (i)
Documentation and reporting systems in these hospitals; (ii)
Role of health care personnel in documentation and reporting
(iii) Existing system of audit, if any. Results:
Totally 94 hospitals met our criteria with Dakshina
Kannda District having 63 (67.02%) and the rest in Koppal
District. Documentation and reporting was poor in Koppal
District and inadequate in Dakshina Kannada district. Health
care personnel were apprehensive about perinatal death
audit. Conclusion: Problems identified need to
be addressed before starting perinatal death audit.
Keywords: Death audit, Infant mortality, Perinatal
mortality.
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Karnataka has shown a reduction of
infant mortality rate (IMR) from 71 in the year 1980 to 35
in the year 2011 [1]. The perinatal mortality rate (PMR) has
also decreased from 40.2 in the year 1980 to 33.4 in the
year 2011 [1]. But the contribution of PMR to IMR in
Karnataka has varied from 60 to 70% during this period of
time. For reasons that are not clear, the contribution of
PMR to IMR in Karnataka has increased from 95 to almost 99%
from the year 2011 to 2013 [1]. An audit of perinatal deaths
could help in understanding and rectifying the causes for
perinatal deaths. However, there is no perinatal death audit
system in India. To start a perinatal death audit system, it
is essential to carry out a preliminary study exploring the
issues and problems that exist to start perinatal death
audit. Thus, a preliminary study would help understand the
problems that need to be addressed to start a perinatal
death audit system.
The maternal and child health care
facilities are not uniformly developed in Karnataka; the
northern districts lag behind the southern districts [1].
The issues and challenges to starting a perinatal death
audit in a relatively backward northern district of
Karnataka may not be the same as compared with a better
developed southern district. We conducted this study to
enlist the problems, if any, in starting a perinatal death
audit in two different districts of Karnataka.
Methods
This descriptive study was a part of a
three-year interventional project conducted in two districts
of Karnataka in the year 2015. The initial
pre-interventional survey was carried out over one year.
Dakshina Kannada district located in southern Karnataka is
well developed with much better facilities as compared with
Koppal district from the northern part, which is considered
as one of the five backward districts of Karnataka [2,3].The
entire system involved in documentation and reporting
perinatal care in both the districts of Karnataka were
explored and documented. All government hospitals and those
private hospitals which provided maternal and child health
services with any one or more facilities for conducting: (i)
normal delivery (ii) high-risk delivery, and (iii)
normal and high-risk neonatal care were included for the
study.
The components of perinatal care
documentation system included for the study were
documentation and reporting systems (like documentation of
the case related information, and reporting system); and the
role of healthcare personnel involved in perinatal care in
documenting and reporting of perinatal deaths. Details of
the documentation and reporting systems considered for the
study were as follows: Presence of registries for
documenting deaths, death certificates, person filling the
death certificates, case sheets, person preparing the case
sheets, registries for documenting data from field area
covered by that government hospital, routine reporting (like
weekly reports, monthly reports, nil reports), and
maintenance of records in the hospitals.
Apart from the information available
about the components mentioned above, some non-governmental
organizations (NGOs) in both the districts were also
contacted. These NGOs have a system of tracking infant
deaths by gathering information from house-to-house visits.
This helped to cross-verify the information about perinatal
deaths from the government and private hospitals.
Semi-structured checklists were developed
to record all the components of the documentation and
reporting systems mentioned above. These semi-structured
check-lists were pre-tested in neighboring district of Udupi
to know the feasibility and appropriateness for use. Some
open-ended items were introduced so that any other relevant
observation could be documented.
Permission was obtained from the
Government of Karnataka to conduct the study. The district
commissioners of the two districts were directed by the
state government to provide the necessary administrative
support for the study. Four qualified medical social workers
who were trained to fill the checklists collected the data
by visiting the health care facilities. They filled the
semi-structured checklists by a combination of observation
and interaction with the doctors and support staff present
in the hospitals. The filled checklists were scrutinized by
the investigators. In case of any queries, the healthcare
facilities were approached more than once to collect the
data.
The filled forms were studied, and
discussions conducted by the investigators to arrive at
solutions for improving the documentation and reporting of
perinatal deaths. The qualitative data is presented in
numbers and percentages.
Results
The details of the institutions that met
the study criteria are presented in Table I.
Most hospitals in Koppal (29, 93.5%) did not maintain case
sheets. Most hospitals in Dakshina Kannada maintained case
sheets (60, 95.2%), but in majority the records did not have
clinical information necessary to carry out the audit. When
present, the details in case sheets were not legible.
Table I Details of the Government and Private Hospitals that Met the Study Criteria in
Two Districts of Karnataka
| Type of health- |
Koppal |
Dakshina |
Total |
| care facility |
district |
Kannada district |
|
|
(n=63) |
(n=31) |
|
| Government hospitals |
|
|
|
| PHCs |
4 |
7 |
11 |
| CHCs |
1 |
3 |
4 |
| District hospital |
1 |
1 |
2 |
| Private hospitals |
25 |
52 |
77 |
| *PHCs: Primary
health centres; CHCs: Community health centres. |
In Koppal district, the documentation was
almost non-existent in private hospitals; most (21, 67.7%)
did not document any perinatal deaths. Based on the
information collected from the NGOs of that area, when the
hospitals were asked about such deaths, they verbally
confirmed it. But there were no written/documented details.
As the hospitals did not document these, they did not report
to the authorities. Government hospitals also did not have
adequate information. They did not report all the neonatal
deaths. Register for documenting first information report
(FIR) of neonatal deaths in Koppal district hospital was not
available. In Dakshina Kannada district, documentation was
much better and the district hospital maintained death
registry for documenting FIR of perinatal deaths.
Most of the doctors in both the districts
were not aware of the existence of a separate death
certificate for documenting perinatal deaths. Medical
officers in charge of government hospitals did not pay
attention to weekly or monthly reporting of neonatal deaths,
still births and perinatal deaths. Some of them had
delegated the responsibility of filling the registries to
the nursing staff.
At the time of start of this study, there
was no perinatal death audit system in both the districts.
However, neonatal deaths were audited as part of infant
death review as per National Health Mission (NHM)
guide-lines. Verbal autopsies were done to some extent.
There was no auditing of fetal deaths in antenatal period.
However, the facility-based death review (FBDR) began much
later after our study project was underway. FBDR was
introduced by the government as a part of child death
reporting. According to it following activities had to be
undertaken: (i) the deaths are expected to be
discussed at all the facilities, (ii) report sent to
the district health office, and (iii) district health
office collects verbal autopsy reports and sends the summary
for line-listing of neonatal deaths to the state health
department. These activities were not being done fully. The
functioning of existing neonatal death audit system in both
the districts is shown in Table II.
Table II Functioning of Existing Neonatal Death Audit System in Both the Districts
|
Indicator of functioning of existing audit
system |
Dakshina Kannada
district |
Koppal
district |
| Statistics
and line listing of deaths at district level |
Maintained |
Maintained |
| Proceedings
of death audit meetings, (if any) |
Not available |
Not available |
| Feedback
sent after the audit, (if any) |
Not available |
Not available |
|
Number of FBDR carried out in the hospitals |
No data available |
No data available |
|
Reports received from private and public
institutions and copies of the FBDR |
No data available |
No data available |
| Registries
maintained in district health officer (DHO) office |
Yes |
No |
| Guidelines
for FBDR received from Government of Karnataka
maintained in the DHO office |
Yes |
No |
| FBDR: Facility
based death reviews. |
Discussion
The documentation and reporting of
perinatal deaths in Dakshina Kannada and Koppal districts
was found to be sub-optimal in this study. A review of
studies on under-reporting indicates that, while both live
births and neonatal deaths may be underreported, fetal
deaths are much more likely to go unreported [4,5]. Reports
from developed countries show that incomplete reporting of
vital events varied from 10-30% [6-8].
Based on the problems identified by this
study, we identified four categories of solutions for
starting perinatal death audit (Box 1).
Starting a perinatal death audit would help in knowing
causes, identifying problems that need to be solved and help
arrive at solutions. Such a system would help identify
‘preventable’ perinatal deaths. Targeting and reducing
preventable perinatal deaths should be a priority. Though
neonatal mortality declined from 31 in 2011 to 24 in 2017,
it has reduced just one point per year [9], and we do not
know what proportion of these were preventable perinatal
deaths. A survey of maternal and neonatal care facilities in
these two districts has revealed deficiencies in managing
high risk cases [10]. Even though efforts are being made to
improve health care infrastructure under National Health
Mission (NHM), poor healthcare infra-structure and
inefficiency in the healthcare delivery in rural areas has
been reported [11]. Considering the fact that deficiencies
exist for managing high-risk cases, it is certain that some
perinatal deaths are preventable [10]. The prerequisites
i.e., documentation, record keeping, and reporting would
help to start perinatal death audit and identify preventable
perinatal deaths, apart from providing inputs for planning
intervention strategies.
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Box 1 Suggested Solutions for
Starting Perinatal Death Audit
Improving documentation at the
hospitals
• It should be made mandatory for
the doctors to fill all the case sheets pertaining
to maternal and neonatal care provided in the
hospitals.
• Maintenance of separate file
for keeping copies of all the case sheets pertaining
to perinatal deaths
• To maintain a registry with
contact details of the parents would help in
cross-verification and clarification if needed.
• Prompt weekly / monthly
reporting of all the perinatal deaths in hospitals
to the District health officer (DHO) would be
required.
Improving the role of health care
personnel
• Doctors should be trained to
fill the separate perinatal death certificates.
• Doctors should fill all the
details in the case sheets.
• In private hospitals, nurses
should be made in charge of maintaining registries
and sending routine reports.
• In government hospitals clerks
should be in charge of maintaining registries and
routine reporting to the District health officer.
• About perinatal deaths
occurring in the community, nurses in government
hospitals who are in charge of covering the
population in the field area (designated for that
hospital) should prepare and provide a First
information report (FIR) to the hospital of all the
perinatal deaths that occurred in their field area.
• Information about perinatal
deaths occurring in the community (outlined above)
could be used to update the registries in the
government hospitals.
Improving the reporting system in
the district
• District health officer (DHO)
(alternatively known as Civil surgeon) should make
it mandatory for all the hospitals to report at
least once in a fortnight including nil reporting.
• DHO should designate a Taluka
medical officer (alternatively called Block Medical
Officer) to scrutinize all the death certificates
and case sheets. This should preferably be done by
Medical officer in charge of implementing
Reproductive child health programme in the district.
• This officer should also seek
and obtain information from all the NGOs tracking
infant deaths in the district. · A clerical staff
member should be designated to update the registries
and prepare monthly reports of all the reported
perinatal deaths in the district.
• Proceedings of all the
facility-based death reviews carried out every month
should be documented and kept in a separate file.
Copy of feedback, if any, sent to the hospitals
(Government or private) should be kept in the DHO
office.
Enhancing compliance with
reporting system at the district level
• Training programme covering
perinatal death auditing, writing death summaries,
filling perinatal death certificates and reporting
formats doctors.
• At the time of training,
apprehensions about implications of auditing among
health care personnel should be addressed. This will
help remove fear and improve compliance.
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This study was limited to only two
districts of Karnataka. As most of the hospitals in Koppal
district did not document and report, further details like
errors in filling up of case sheets and death records could
not be identified. However, inclusion of one district from
well- developed southern part and one from backward northern
part of Karnataka shows that the problems identified are
similar.
Our findings suggest that the healthcare
personnel have to be trained for documentation and
reporting, before introducing perinatal death audits.
Contributors: HK, PK, SB, NK, SR:
took part in drafting the protocol; HK, SB, PK: organising
the data collection and supervising field work; SB, PK, NK,
SR: cross-checking of the filled forms; HK: statistical
analysis; HK, SB, PK: writing the paper.
Funding: Department of Health
Research, Ministry of Health Family Welfare, Government of
India (DHR/GIA/35/2014).
Competing interest: None stated.
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What This Study
Adds?
Improvements in documentation and reporting
systems are required to initiate the perinatal death
audit system in the Districts covered in this
survey.
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