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Background: There are problems of quality in maternity services at primary health care level in South Africa. Many of these problems can be traced to non-adherence to the maternity care guidelines and lack of tools to support clinic staff and managers in their roles. Objective: The aim of this research was to investigate the utility of e-health (computerized) decision support systems at addressing the problem of compliance of health workers to the maternity care guidelines at primary health care in South Africa. At present there are no documented studies on e-health clinical decision support systems for primary health care in South Africa, though clinical decision support systems for primary health care are listed as part of the e-health strategy of the National Department of Health. Methods: An e-health decision support system named the Bacis (Basic Antenatal Care Information System) Program was developed, then implemented and evaluated at a primary health care clinic. The duration of the study was two years: this includes development, implementation and evaluation. Results and Conclusion: There was an overall improvement in compliance from 85.1 % to 89.3%. This result was not statistically significant. However when results were stratified into specific categories, the Bacis Program showed statistically significant improvement in compliance over the checklist system in three out of nine important categories. These are compliance at booking, patients younger than 18 years and patients booking after week 20. Further, insights and experience were also gained on development and implementation of clinical information systems at resource strained environments such as primary health care in South Africa. These results, insights and experience are invaluable for the implementation of the proposed e-health strategy in South Africa. © Schattauer 2013.
The study methodology was divided into two phases. Phase one was on the development of the Bacis Program, and documenting this development experience. Phase two involved the field testing of the Bacis Program with the aim of measuring the extent to which it could be used for improving compliance of nurses at primary health care to the maternal health protocols. The Bacis Program is an e-Health clinical information system. It was developed at the South African Medical Research Council by the researcher (V. Horner), with the assistance of medical experts. It was conceptualised by the researcher (V. Horner, abbreviated as VH) and the study obstetrician (TJ. Mashamba, abbreviated as TJM) as a tool that could be used at primary health care clinics to improve compliance to maternal health protocols and the BANC checklist. The researcher (VH) played the role of the knowledge engineer and software developer, and the study obstetrician (TJM) acted as the domain expert. A project implementation team was formed which consisted of the researcher (VH); the study obstetrician (TJM) who is the chief consultant on obstetrics and gynaecology at the tertiary hospital in the district; the manager for maternal and child health in the district; the sub-district manager on maternal and child health; and the chief director of the Department of Health in Tshwane Health District. The implementation team was composed so as to involve the main stakeholders in order that permissions for implementing the Bacis Program at the clinics and permissions for data collection would be expedited. It was possible to bring these people together because improving dissemination and compliance with the maternity care guidelines is one of the major goals of the Department of Health in South Africa. The project utilised a budget of 160000 USD, which was sourced from the National Research Foundation (NRF) of South Africa. The main items in the budget were the purchase of six computers and scanners for use at the antenatal care sections of three clinics that had initially been selected as study sites; software licenses for Microsoft Office and Microsoft Access which are needed for the Bacis Program; the salary for the researcher (VH) and an assistant; and finally project operational costs such as travel expenses and project stationery. The Bacis Program was initially deployed at three clinics in Tshwane Health District though data from one clinic only is reported in the study due to administrative problems that occurred at the other two clinics during the course of the study. The problems experienced by the two clinics are elaborated on further in Section 2.2.4 under study sample and participants. The Bacis Program uses patient specific information entered during an antenatal visit in order to perform: risk classification, identification of patients for referral and scheduling of maternity care interventions. To perform these tasks the Bacis Program uses its rule base and knowledge base that have been developed in collaboration with medical experts. However, the final decision is taken by the nursing sister. The Bacis Program is only intended as an aid in the decision making process i.e. it is a decision-support system. ►Figure 1 and ►Figure 2 are screenshots of the user interface of the Bacis Program, which show some of its risk assessment items. The extended list of features of the Bacis Program is the following: Screenshot of patient history menu Screenshot of pregnancy plan and reminders menu As noted in the last point of the features, the Bacis Program also acts as an electronic antenatal record in addition to its clinical decision-support system function. Therefore the Bacis Program is much more comprehensive as a maternity system, having many more features than the District Health Information System, and it satisfies many of the points in the e-health strategy of the National Department of Health for clinical decision support at primary health care [9]. The aim of the field evaluation of the Bacis Program was to measure improvements in nurse compliance with the maternity care guidelines as well as a usability review and acceptability of the Bacis Program as a decision aid for nurses at primary health care. A before and after design consisting of two cohorts at the study clinic was employed in order to compare and measure improvements in compliance. The retrospective cohort (before wing) consisted of patients who were treated before introduction of the Bacis Program. The prospective cohort (after wing) consisted of patients who were treated after introduction of the Bacis Program. The method of assessing compliance was a record review. The review measured compliance to the guidelines for eighteen (18) antenatal protocol items corresponding to the main tasks that nurses are expected to carry out at the clinics [4, 5]. These are: Previous pregnancy history; Current pregnancy history; General medical history; General examination; SFH (symphysis fundal height); Fetal heart rate; Fetal lie and presentations; Severe symptoms (these are: severe headache, abdominal pain or discomfort, reduced fetal movement, abdominal bleeding and liquor drainage); Pregnancy infections; Blood pressure; Proteinuria; Maternal weight and height; Rh (rhesus blood group) screening; Syphilis screening (this is also called RPR screening – Rapid Plasma Reagin test); Haemoglobin screening; HIV screening and implementation of Prevention of Mother To Child Transmission of HIV – which is abbreviated as PMTCT; Glycosuria; and Prophylaxis (these are calcium, iron and folic acid). A professional nurse from the study clinic was enlisted as the study nurse. She used the Bacis Program to conduct antenatal patient visits. A qualitative component was also introduced in order to document the reasons for non-compliance with the maternity care guidelines at the study clinics. However, the results of the qualitative interviews on reasons for non-compliance are reported elsewhere [3]. Compliance was measured as a combination of completion and response. Completion the first part of compliance checked whether the protocol item (i.e. antenatal care task) was carried out when due. Response checked whether the medical response to risk factors or abnormal values was adequate. This is sometimes called interpretation and decision making [5, 12]. For example a check was done whether a value for haemoglobin was entered at the first visit (at booking). If yes, then a tick for completion, otherwise it was marked as not completed. There is however the possibility that an item may have been done, but not recorded in the patient card. But based on review of the cards there was no way of ascertaining this. Hence missing information was scored as not completed. For response: if for example the value recorded in the card for haemoglobin was 6 g/dL, then the nurse was expected to refer this patient, otherwise the response was marked as inadequate by the reviewer. Information for the response was also taken from the cards, and missing information was also judged as response not adequate. For compliance to be satisfied the item had be completed (recorded in the patient card), and the response to any abnormal values had to be adequate. The response adequacy is computed as the number of times that the response was adequate divided by the number of risk factors identified in the review. Similarly the percentage for completion is the number of times the item was actually carried out, divided by the number of times it was due. The Bacis Program was also subjected to a usability evaluation in order to examine how the nurses interacted with it and whether they found it to be an acceptable aid. The method for evaluating usability was to measure data input accuracy of the study nurses and to carry out qualitative interviews with them in order to understand whether they considered the Bacis Program an acceptable aid. The themes covered by the usability interviews are the following: Relevance of the clinical content of the Bacis Program. This theme required the nurses to compare the content and process of the Bacis Program with actual practice; The usability and cognitive aspects of the Bacis Program, such as, the time needed to learn the Bacis Program as well as the time taken to complete the tasks of the Bacis Program; The last theme was usefulness of the reminders and alerts of the Bacis Program as well as the method used for issuing them. Finally, as part of the field evaluation, the antenatal record feature of the Bacis Program was used to report on patient outcomes. These patient outcomes are however also reported elsewhere [3]. The study clinic is located in a semi-rural township about 45 kilometers from the Pretoria central business district. The population of the township is estimated at about 80000. The township consists of formal dwellings as well as shacks, with many backroom dwellings. It has high unemployment (40%) and HIV prevalence (22%) [13]. Its profile fits that of a typical underserved area in South Africa, with a high burden of health issues. The characteristics of the study clinic are shown in ►Table 1. The Bacis Program was created with the goal of helping to improve health care services in under-serviced areas such as Winterveldt. Characteristics of the study clinic. *Taken from: Profile of the North West Province: demographics, poverty, income, inequality and unemployment [13] Although three clinics were enrolled initially in the study, only the data from Kgabo Community Health Centre in Winterveldt was included in the results. The data from the other two clinics, Temba Community Health Centre and Soshanguve III Community Health Centre was not included. This is because their data was not complete due to administrative problems that occurred during the study. Firstly, at one clinic, two nurses were found initially who used the Bacis Program faithfully. These two nurses managed to enroll 300 patients and captured all their first visits (booking) faithfully. However, they were not able to remain in the study for nine months due to staffing constraints at their clinic and as a result only completed about four months of the total nine months of data collection. The patients enrolled at this clinic were thus not included in the results because they were not tracked for the full duration of their pregnancies. At the second clinic, also due to staffing constraints, a nurse could not be found who could use the Bacis Program. As an alternative, a data capturing clerk was enlisted. The Bacis Program, however, is intended for use by professional nurses. Hence, the results from the second clinic were also not included in the compliance review. Compliance is reported for 100 patients of the 319 patients in the prospective cohort. ►Table 2 shows the place of delivery of the prospective cohort including the 100 patients reviewed for compliance. The 100 patients in the compliance review are those whose antenatal cards could be found and who delivered at the clinic between January 2011 and June 2011. As the women delivered their babies, the researcher, assisted by the study nurses, made copies of study patient files. Of the 144 patients who delivered at the clinic, cards could only be found for 100 of them. The 25 patients in the before wing (retrospective cohort) were chosen for logistic reasons of doing a thorough review. For example the time taken to review a card by the researcher was about three hours, this includes creating an entry in the data collections system and entering the review data for the patient. The effort expanded in the review was similar to doing a case study. The researcher often had to do multiple rounds of review of the cards when discrepancies in the criteria were picked up and needed correction. Hence fine tuning of review criteria also consumed much time. The review effort also applied to the 100 patients of the prospective cohort. As described in the results section statistical calculations were however possible with these sample sizes. Delivery information of the prospective cohort (n = 319 patients) * Odi Hospital ** Dr. George Mkhari Hospital The duration of the field evaluation was nine months: patient enrolment was four months, and the remaining five months were used to track follow up antenatal visits and patient deliveries. All patients reporting their pregnancies during the study were enrolled in the prospective cohort. The retrospective cohort was selected from 115 cards that were available of women who delivered between November and December of 2010 before the Bacis Program was introduced at the study clinic. The clinics only keep patient cards for six weeks post delivery, hence there are never more than 160 cards of patients post delivery at the clinics. From an unordered collection of files for November and December 2012, and after shuffling them, the researcher selected the first twenty five files. For data analysis basic descriptive statistics were used.
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