Lars T Johansen1, Pål Øian. 1. The Norwegian Board of Health Supervision, Norway. ltj@helsetilsynet.no
Abstract
BACKGROUND: It is rare for babies to die or be injured during birth in Norway. We aimed to investigate whether maternity care was inadequate in cases reported to the Norwegian Board of Health Supervision and to single out areas in maternity care where there is potential for improvement. MATERIAL AND METHOD: The material consists of cases reported to the Norwegian Board of Health Supervision in the three-year period 2006-2008 in which babies died or were severely injured during delivery. We recorded data on: maternity unit, fetal monitoring, delivery method, personnel involved and type of inadequate maternity care. RESULTS: The material consists of 81 cases. Babies died during or after deliver in 58 cases and were severely injured in 23 cases. The health trusts reported 42 of these events to the Board of Health Supervision; the remainder were reported by the patient ombudsman or the parents. There was inadequate fetal monitoring in 68 % of the births and delayed delivery in 67 %. A gynaecological specialist was not called for 44 % of the births. The number of cases of injuries in relation to the number of deliveries reported to the Board of Health Supervision was significantly higher for small maternity units (< 1000 births per year) than for larger units. INTERPRETATION: Doctors and midwives need a better knowledge of fetal monitoring. Maternity units must develop sound procedures for singling out high-risk births, use of fetal monitoring, calling for a doctor and reporting to the Board of Health Supervision. Exercises in dealing with acute situations should be held. Small maternity units appear to be most vulnerable to adverse events.
BACKGROUND: It is rare for babies to die or be injured during birth in Norway. We aimed to investigate whether maternity care was inadequate in cases reported to the Norwegian Board of Health Supervision and to single out areas in maternity care where there is potential for improvement. MATERIAL AND METHOD: The material consists of cases reported to the Norwegian Board of Health Supervision in the three-year period 2006-2008 in which babies died or were severely injured during delivery. We recorded data on: maternity unit, fetal monitoring, delivery method, personnel involved and type of inadequate maternity care. RESULTS: The material consists of 81 cases. Babies died during or after deliver in 58 cases and were severely injured in 23 cases. The health trusts reported 42 of these events to the Board of Health Supervision; the remainder were reported by the patient ombudsman or the parents. There was inadequate fetal monitoring in 68 % of the births and delayed delivery in 67 %. A gynaecological specialist was not called for 44 % of the births. The number of cases of injuries in relation to the number of deliveries reported to the Board of Health Supervision was significantly higher for small maternity units (< 1000 births per year) than for larger units. INTERPRETATION: Doctors and midwives need a better knowledge of fetal monitoring. Maternity units must develop sound procedures for singling out high-risk births, use of fetal monitoring, calling for a doctor and reporting to the Board of Health Supervision. Exercises in dealing with acute situations should be held. Small maternity units appear to be most vulnerable to adverse events.