Compliance to maternal care guidelines is high in patients with complications compared to patients without complications. The tip of an iceberg? A retrospective case-control study

BACKGROUND: Rwanda achieved Millennium Development Goal Five (MDG5) and continues to register improvements in maternal health. Maternal death audit revealed that a great number of deaths were due to preventable causes in hospitals. OBJECTIVE: To identify preventable causes of severe maternal outcomes linked to poor guideline utilization in hospitals. METHODS: A retrospective case-control study was conducted. Data were collected for 196 controls (discharged without complications) and 100 cases with severe maternal outcomes (dead or discharged after complications) between 2016 to 2018 at Ruhengeri Referral Hospital in Musanze, Northern Province, Rwanda. Medical case files were reviewed, and outcomes were compared. RESULTS: Guideline utilization in diagnosis during ward rounds was 59% and 54% respectively. Correct guideline utilization [76% vs. 51%, OR: 3.21; 95% CI: 1.69-6.28)], noting of vital signs [65% vs. 22%, OR: 6.50, 95% CI: 3.55-11.96), lab results [76% vs. 48%, OR: 3.59, 95% CI: 2.09-6.21)] and regular ward rounds [76% vs. 39%, OR: 4.81 95% CI: 2.64-8.89)] were statistically different between the two groups. CONCLUSION: Guideline utilization was noted in complicated cases compared to patients without complications, post discharge mortality of 59% could be improved by putting guidelines in place, and attention to the details. There is a need for nationwide medical record review and implementation of a standardized guideline