Objective: The objective of this research was to conduct an epidemiological study for the cases of miscarriages at the Emergency Department of the University Malaya Medical Center, as well as suggest ways to improve the efficiency of providing emergency responses to miscarriage cases presented at the medical institutions’ emergency department.
Study Design: This study analyzed the information on the cases resented at the Emergency Department of the University Malaya Medical Center related to gynae problems, particularly those of the miscarriages cases. The time frame for the gathering of data was 8 months from October 2013 to May 2014.
Results: Over the 8 month period of information gathering, 556 gynae cases were presented at the Emergency Department of the University Malaya Medical Center. The majority of these cases are miscarriage cases totaling 309 or 55.58% of the all the visits. The majority the patients with miscarriage cases belonged to the age group of 18 to 35 years old equivalent to 82.20% and the remaining belonged to the age group of >35 years old equivalent to 27.80%. The discharge rate of the said patients was greater than the admission rate (89.32% vs. 10.68%). The distribution of race was 75.73% Malay and the remaining 24.27 percent was shared by the Chinese, Indian, and Foreigners. The number of patients visiting the Emergency Department having miscarriage cases from 8:00Am to 8:00PM is 56.96% while those who visit from 8:00PM to 8:00AM is 43.04%. All the measured values are statistically different with their counterparts at P < 0.01 except for the data for the time of visits.
Conclusion: There is no definitive trend in the increase or decrease in the number of Emergency Department visits at the University Malay Medical Centre. The centre has an abnormally high number of patients with miscarriage cases compared to the rest of the United States and the world average. There are diverse ways to improve the quality and efficiency of medical service to patients with miscarriage cases. Such ways include the sufficiency of centre personnel designated for emergency response, the acquisition of technologies used to treat and diagnose miscarriage, and increase the knowledge base of each of the personnel. Improvement of the communication between the minority groups and the centre could also be a means of improvement.
Keywords: Miscarriage, Ethnic Group, Emergency Response, Epidemiology, Vagina Bleeding
Epidemiological studies in the field of emergency managements, such as those in Emergency Department (ED) for miscarriage cases, are highly important in improving the quality of services offered by any medical institution whether at the local or national level. The epidemiology of ED visits on diverse medical institutions proves that there are a significant number of miscarriages cases; hence, this particular medical condition is one of the topics dealt with by a significant number of researches.
Miscarriage or vaginal bleeding during the early stage of pregnancy affects approximately 20% of pregnant women in the world. It can pose further adverse implications to the mother’s health if it is not diagnosed and treated efficiently. Accordingly, approximately 50% of mothers who have experienced vaginal bleeding during early stages of pregnancy miscarry, and approximately 20% of them will have recurring miscarriages could occur throughout their lives. It is therefore highly important for medical institutions such the University Malaya Medical Centre to provide timely and efficient emergency services for patients with miscarriages in order to prevent further reproductive health complications in the future. Previous studied on this subject have been performed in primary and obstetric centres. Results from these studies suggest that miscarriages cases are common among women during early years of pregnancy and that there certain risk or conditions could arise from it. These adverse risks and conditions include induced and spontaneous abortion, advanced maternal aging, infertility problems and in capacity to work during pregnancies (Strobio & Pantel-Silverman, 1989; Sipilla, Hartikalnen-Sorri, Oja &Von-Wendt, 1992; Weiss, Malone, Vladaver, J. et al., 2004 and Johns & Jaunlaux, 2006).
The adverse effects of miscarriage to women become more probable when the intervention of treatment that they receive from health care and medical institutions is not sufficient or lacking in good quality (Johns & Jaunlaux, 2006). Hence, there is a need to continuously improve the quality and efficiency of service provided to women with miscarriage cases. Such purpose could be attained if different factors for providing efficient emergency response at the ED department are carefully considered and studied for further improvement. These factors include the age of the patients, their race, proportion of miscarriage cases in relation to other emergency cases, the time of visits to the emergency department, the admission and discharge rates, and the number of emergency response personnel such as the nurses and other members of the medical team.
This study aims to conduct an epidemiological study for the cases of miscarriages at the emergency department of the University Malaya Medical Center. This medical institution was chosen because the University Malaya Medical Centre receives a great number of patients at its green zone every day; a significant number of these emergency cases are those of miscarriages. In line with this aim is the purpose of suggesting ways to improve the efficiency of providing emergency responses to miscarriage cases presented at the medical institutions’ emergency department.
The entire data gathering procedure was conducted in eight straight months from October 2013 to May 2014. The data was gathered from the data repository of the University Malaya Medical Centre, Emergency Department. The number of patients presented in the ED from the said time period was gathered with focus on the following information: diagnosis (type of gynae case), ethnicity, disposition of the attending emergency personnel (admission or discharge), time of presentation or registration to the emergency department, and age. This information was tabulated and was analyzed using the functions in the Microsoft Excel application. From the data gathered the following comparisons were made: comparison between admission and discharge rates, comparison between age groups (18 to 35 and more than 35 years of age), comparison among races, and comparison of time of visits to the emergency department (8:00 AM to 8:00 PM and 8:00 PM to 8:00 AM). The data gathered were all quantitative information and where analyzed quantitatively. Accordingly, the degree of difference between the compared variables was determined for their statistical significance using the Chi-square Test, expressed in P value. The P value which served as the standard was randomly selected to be 0.01, which is relatively lower; hence, stricter than the commonly used value of 0.05. This means that any actual P value computed from the gathered data that is less than 0.01 means that the differences between the two measured variables is statistically significant and vice versa. All the formulas associated with these measures are included the Microsoft Excel application which was used for the computations. The results of the analysis are shown in figures for easier interpretations.
Results and Discussion
Results indicate that 556 patients were reported at the Emergency Department of the University Malaya Medical Centre, having gynae cases from the October 2013 to May 2014. The month of December showed the highest number of patients while the month of February showed the least number of patients. The behavior of the curves for all gynae cases and miscarriage cases is the same. There is no statistical difference between the two measurements at (P > 0.01). The curves are not linear curves. This means that the number of patients per month could be in random increase or decrease (See Figure 1). This also means that it cannot be predicted whether there will be an increase or decrease in the number of miscarriages presented at the emergency department of the University Malaya Medical Centre in the coming months or years.
These statistical measures are significantly higher than those recorded in past studies in the United States and some parts of the world. For example, in a study conducted by Everett (1997) it was shown that only approximately 25% of pregnant women presented in emergency departments at different medical institutions in the United States have miscarriages.
Similar percentage (approximately 25%) was shown in the study by Wilcox, Baird, and Weinberg (1999) for women with miscarriage presented at the emergency departments of various hospitals in the US. This percentage further decreased through time. In a study conducted by Wittels, Pelletier, Brown, and Camargo (2008), it was shown that the number of miscarriage among women presented at the emergency departments have decreased to only 1.6%. Still a much lower percentage was recorded by Indig, Warner and Saxton (2011) in this study. Accordingly, only 1.2% of the 12, 061 patients presented in the emergency rooms had cases of miscarriage. The higher number of miscarriages in Malaysia compared to the United States and the average percentage in the world only proves that there must be an extensive improvement in the emergency response process and facilities of the medical institutions such as the University Malaya Medical Centre in order to make sure that all patients who presented will be given the appropriate services that they need at a high quality. This observation is supported by figure 2.
Figure 1: Distribution of patients presented at the Emergency Department from October 2013 to May 2014
A comparison of the number (in terms of percentages) of the number of patients having different types of gynae cases showed that the most prevalent gynae case is miscarriage at 55.58%. It is followed by menstrual disorder at 18.88%, then by other gynae cases at 10.43%. The rest of the five gynae cases have an even distribution of percentages from 0.30% to 5.50%. The difference among the gynae cases is statistically significance with P < 0.01 (See figure 2). It should be noted that this huge discrepancy in the percentage of miscarriage cases compared to other gynae problems means that the equipment, facilities, and personnel should be in a significantly higher number or proportion compared to those used for other gynae cases. The University Malay Medical Centre, should therefore make sure that it has enough personnel designated at handling the huge number of patients with miscarriage cases. A specialized ward for patients with mis carriage cases could also be an alternative to increase the quality of service rendered by the University Malay Medical Centre. In a study conducted by Assefa, Mosse and Hailemichael (2011), they have investigated the level of patient satisfaction before and after specialized wards were created at University Specialized Hospital. Results of their study showed that specialization of wards result to better patient care in terms of the length of time for medical and emergency response team members to respond to cases presented, and in terms of the quality of the medical expert – client relationship. The patients feel that sufficient time is provided to them by the medical experts on specialized wards over those wards were there are diverse cases of sickness and illnesses being handled.
Figure 2: Percentages of gynae cases and miscarriages at the University Malaya Medical Centre (UD = uterine disorder, TP = trauma pregnancy, M = miscarriage, MD = menstrual disorder, LTI = lower track infection, HG – hyperemesis gravidarum, and EP = ectopic pregnancy)
In terms of emergency response attendant disposition, the majority of the miscarriages cases presented were discharged within the 8 month period, while the rest remained admitted. The rate of discharge is 89.32% while the rate of retained admission was at 10.70%. The difference between the two measures is statistically significant with P < 0.01 (See Figure 3).
This statistical measure is not accordance with the findings of related studies such as the research conducted by Wittels et al. (2008) which shows that more than 50% of patients with cases of miscarriage in the United States would only normally last in the hospital for four (4) hours. This implies that the discharge rate is relatively fast in the US compared to University Malay Medical Centre. In this research, however, the minimum stay of patients with miscarriage cases is one week. Wittels et al. (2008) further showed that this length of stay (weeks to months) is normal for American women with ectopic pregnancy not with miscarriages.
This huge discrepancy in the length of stay of patients between the two countries would suggests that the United States is more efficient in responding to the miscarriage cases presented at their hospitals’ emergency departments. In a study conducted by Wendt, Crilly, May, Bates and Saxena (2013), it was explained that the delivery of service for patients with pregnancy complication cases such as miscarriage vary in terms of outcomes, setting and approach. This variation is due to the diversity in the delivery models that are available for use. They have therefore studied two of these models and how efficient they are in providing the required medical services needed by patients with pregnancy complications. The two models studied were the Early Pregnancy Assessment Service (EPAS) and the Early Pregnancy Assessment Protocol (EPAP). Note that these two models are also extensively used in Europe and the United States. In the said study, they have monitored different parameters of emergency response service which include: time to see clinician, admission rate, increase in ultrasound use, and increase in pain score. They have monitored these parameters for six months each before and after the implementation of ach model. Results from their study have shown that the time to see the clinician has decreased from 35 minutes to 29 minutes; admission rate was decreased from 14.5% to 8.5%; increased ultrasound sue from 63% to 74%, and increase in pain score documentation from 10% to 36%. Results from study strongly suggest that difference in approach in providing emergency response service for patients greatly influence the efficiency and quality of the service provided. Hence, one of the possible improvements that the University Malay Medical Centre could do in improving its service at the emergency department is by adapting a model such as the EPAS and EPAP.
Figure 2: Proportion in percentages of patients with cases of miscarriage who were discharged or remained admitted at the time period of the study, which is eight straight months
Comparing the number of patients with miscarriages cases in terms of age group shows that the majority of them belong to the age group of 18 to 35 years old (82.20%) and the rest belong to the age group of more than 35 years old (17.80%). The difference between these two measures is statistically significant at P < 0.01 (See figure 4). Note also that the average age of patient with miscarriages cases is 30.08 years old. This result is in accordance with the results conducted in the United States. Accordingly, in the US the majority of the patients with miscarriages cases are below 35 years old and their average age is 29 years old (Wittels et al., 2008). Indig, Warner and Saxton (2011) also show similar results in their study with the average age of women having miscarriage cases to be 29.03 years old, and the percentage of women with ages from 18 to 35 years at approximately 75%.
The fact that the majority of the patients presented in the Emergency Department at the University Malay Medical Centre have important repercussion to the general expectation of patients to the medical service provided there. In a study conducted by Rahmqvist (2001), it was shown that younger patients tend to have higher expectations in the quality of medical service provided by any of the wards or departments in a medical institution. The said study asked 3, 400 patients (with ages from 1 to 94 years of age) from admitted from the different hospital departments and admitted at different wards using a questionnaire comprising of 33 questions. Twenty one (21) of the said questions elicit information as to the perception of the patients about the quality of the health care provided by the respective departments where they were admitted and some of the questions elicit information as to their sense of satisfaction in obtaining the services provided by the hospitals. The main outcome measure used by the study was the Patient Satisfaction Index Scor (PSI). One of the major findings of the said study was that age is the major determining factor of PSI. The study also noted that the trend is that there is a direct relationship between patients’ age and PSI. This means that as the age of the person increased the more like he or she will provide higher PSI – higher patient satisfaction rating. This results also suggests that the ED of University Malay Medical Centre should have a high standard for its quality of service because the majority of its patients presented at the ED with miscarriages cases belong to the younger age group of 18 to 35 years old.
Figure 4: Percentage of patients with cases of miscarriage according to age groups
With regards to the distribution of patients with miscarriage cases in terms of race, the majority of them are Malay (75.73%), the rest – Chinese, Indian, and Foreigners – share the remaining 24. 27%. The difference between the four measures is statistically significance at P < 0.01. Note that if the two other races - the Chinese and the Indians are counted as Malaysian race then the percentage of Malaysian patients rises to approximately 89%, and the Foreigners to 11%. The difference between these two measures is also statistically significant at P < 0.01 (See figure 5).
This distribution of patients with cases of miscarriages based from race clearly shows that the Malay race is the dominant race, and the other races; which include Indian, Chinese and Foreigners are minorities. Past studies emphasize that the ethnic minorities are usually disadvantage in receiving the best quality of health care due to the reason that the system of medical or health care created in the majority of medical institutions are not standardized to provide equal privileges for all people of different races or ethnicity.
In a study conducted by Cooper, Hill and Powe (2002), it was emphasized that there are other diverse factors that influence the quality of medical service provided to foreign patients and patients belonging to minority groups such as ethnic minorities. According to the authors, the model called the Institute of Medicine’s (IOM) model would help in identifying the particular factors that causes disparities in the quality of medical service provided between the majority and the minority groups. The authors further explained that the said factors, in general, are the following: financial, personal (language or communication barriers and culture), structural barriers, mediators, or care, and health service utilization. They also explained that there are still some factors that are highly relevant to the said issue hence there is a need to modified the IOM. Hence, they have made modification to it. The modification resulted to the identification of other factors which include: health care policies, and other health care mediators. According to the said research a successful initiative to improve providing medical care to patients should include the following: provide multifaceted interventions; intense approaches; linguistically and culturally appropriate methods of providing medical service; tailoring, improved access to services; partnership with stakeholders, which includes the patients on all ethnic groups; and involvement of the community. Lastly, results of the said study recommends that medical institutions such as the University Malay Medical Center must prioritize the creation of an efficient communication medium to facilitate the dissemination of information among the ethnic groups of race – both minority and majority groups.
Figure 5: Race distribution of patients with miscarriage cases at the University Malaya Medical Centre
Results for the “time of emergency visits for patients with cases of miscarriage” show that 56.96% of the patients presented themselves in the Emergency Department between 8:00AM to 8:00PM; while 43.04% presented themselves between 8:00PM to 8:00AM. The Chi-square test yielded a P value of 0.164, which is relatively larger than he standard value of 0.01. This means that there is no statistical difference between the two measures; that is, there is an equal number of patients presented at the Emergency Department at any time of day or at any of the two time periods (See figure 6).
The distribution of the patients in terms of time of presentation in the Emergency Department suggests that there are an almost equal number of people presented at any given time of the day. In accordance with this distribution, it will be necessary for the University Malay Medical Centre to make sure that its emergency response personnel are evenly distributed throughout the day. Just like any other emergency response, personnel at the emergency department of the University Malay Medical Centre must not only be sufficient in numbers, they must also have the proper knowledge to respond to the miscarriage cases presented every day. Such initiative will involve the human resources department and the leaders of the said medical organization. Accordingly, the human resources depart must make sure that the people are well-trained to respond to emergency scenarios. This may require the medical institution to provide trainings and allow its personnel to have to pursue further education to cope up with the improvements in emergency response procedures and the equipment used. It must also make sure that there are enough people to take over existing personnel in case the latter are unable to perform their duties (World Health Organization, 2011).
Figure 6: Percentage of patient visits to the emergency department for time frames 8:00AM – 8:00PM and 8:00PM – 8:00AM.
The number of Emergency Department visits with miscarriage cases in the University Malay Medical Center is relatively higher compared that of the United States and the world. This may be perceived as a problem at first, but it can also perceive as an opportunity to test the different strategies to improve the quality and efficiency of health care or emergency response service. The said medical institution may face challenges that may be unique to itself due to the abnormal number of miscarriage cases that are presented in its emergency department in a monthly basis. These possible challenges include: sufficiency in the number of facilities and equipment such as ultrasound devises to accommodate the huge influx of patients with miscarriage cases; the sufficiency of the number and knowledge base of its personnel; challenges in providing equal medical service to minority groups (which include the Chinese, Indian, and other foreign races); and challenges in meeting the high expectation of the young patients. Fortunately, there are diverse ways to address these challenges. Accordingly, the University Malay Medical Center could adapt diverse tested models of for efficient medical service in order to help standardize and make the entire medical care procedure efficient. It could also conduct initiatives to create an efficient communication process between itself and minority patient groups so as to make sure the important information are disseminated efficiently. The said medical institution could also engage its leaders and its human resources department more extensively to make sure that its personnel are sufficient in number, knowledge, and skills; and that there is enough personnel reserve for contingency measures.
Limitations of the study
The findings and the suggestions made in this study are limited in practical application, only, to the University Malay Medical Centre. Unlike the aforementioned previous studies, the samples used in them came from diverse medical institutions, and the data were gathered from thousands if not millions of hospital records. This study, on the other hand, relied only on very few data taken from the records repository of the University Malay Medical Centre. Also, it was aforementioned that the said medical institution is in a unique standing against other medical institutions mentioned on the previous study, mainly due to the relative size of the population that was presented in its Emergency Department with miscarriage cases. Note also that the duration of the information gathering was also relatively short compared to the majority of studies conducted with similar topics. The said studies would usually take years of observation and information gathering. The shortest time used among the discussed related study was one year, while this study only used eight months. There are missing essential information, therefore; such as those of the remaining unaccounted months. Note that such information could have changed the behavior of the curve presented in figure 1. There could have been trend in the increase or decrease of miscarriage presented at the Emergency Department. This insufficient time for ample gathering adds up to the uncertainty of the findings herein presented. Moreover, it should be noted that the suggestions presented are more general than specific, this is due to fact that there are no data to show that there are problems encountered at the Emergency department of the University Malay Medical Centre. Such information could have included patient feedback on the quality of the emergency service provided by the medical institution, or the things that are lacking in it. This information would have been valuable to make specific action items that the said medical institution could do.
Assefa, F.; Mosse, A. and hailemichael, Y. (2011). Assessment of Clients' Satisfaction with health Service Deliveries at Jimma University Specialized Hospital. Ethiopian Journal of Health Science, 21(2), pp. 101–109.
Cooper, L.A.; Hill, M.N. and Powe, N.R. (2002). Designing and Evaluating Interventions to Eliminate Racial and Ethnic Disparities in Health Care. Journal of General Internal Medicine, 17(6): 477 – 486.
Everett, C. (2001). Incidence and outcome of bleeding before the 20th week of pregnancy: prospective study from general practice. British Medical Journal, 315(1), pp. 32 – 34.
Indig, D.; Warner, A. and Saxton, A. (2011). Emergency department presentations for problems in early pregnancy. Australian and New Zealand Journal of Obstetrics and Gynecology, 51(1), pp. 257 – 261.
Johns, J. and Jaunlaux, E. (2006). Threatened Miscariage as a Predictor of Obstetric Outcome. American Journal for Obstetrics and Gynecologists, 107(1), pp. 845 – 850.
Rahmqvist, M. (2001). Patient satisfaction in relation to age, health status and other background factors: a model for comparison of care units. International Journal for Quality in health Care, 13(5), pp. 35 – 390.
Sipilla, P.; Hartikalnen-Sorri, A.L.; Oja, H. and Von-Wendt, L. (1992). Perinatal Outcome of Pregnancies Complicated by Vaginal Bleeding. BJOG, 99(1), pp. 959 – 963.
Strobio, B. and Pantel-Silverman, J. (1989). Gestational Vaginal Bleeding and Pregnancy Outcome. American Journal of Epidemiology, 129(1), pp. 806 – 815.
Wendt, K.; Crilly, J.; May, C.; Bates, K. and Saxena, R. (2013). An outcomes evaluation of an emergency department early pregnancy assessment service and early pregnancy assessment protocol. Emergency Medicine Journal. doi:10.1136/emermed-2013-202887. Retrieved from: <http://emj.bmj.com/content/early/2013/10/17/emermed-2013-202887.full>.
Weiss, J.L.; Malone, F.D.; Vladaver, J. et al. (2004). Threatened Abortion: A Risk factor for Poor Pregnancy Outcome, a Population-Based Screening Study. American Journal for Obstetrics and Gynecologists, 190(1), pp. 745 – 750.
Wilcox AJ, Baird DD, Weinberg CR. Time of implantation of the concepts and loss of pregnancy. New English Journal of Medicine, 340(23), pp. 1796 – 1799.
Wittels KA, Pelletier AJ, Brown DF, Camargo CA. United States emergency department visits for vaginal bleeding during early pregnancy, 1993–2003. American Journal of Obstetrics and Gynecology, 198 (5), pp. 523.e1 – 532.e6.
World Health Organization (2011). Hospital emergency response checklist An all-hazards tool for hospital administrators and emergency managers. Retrieved from: <http://www.euro.who.int/__data/assets/pdf_file/0020/148214/e95978.pdf>.
Raw and Computed Data
Table 2: Proportion of visits to the Emergency Department with Gynae Cases and Miscarriage Cases