Download Proceedings 1998 - Perinatal Priorities

The Perinatal Conferences are held under the auspices of the
Department of Obstetrics and Gynaecology, University of Pretoria
and sponsored by Abbott Laboratories SA (Pty) Ltd
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Proceedings : 17th Priorities in Perinatal Care
1998
Editor's Note:
An editorial board was appointed to look at the papers in this year's Proceedings.
Where there were marked errors in the papers these were referred back to the author
for correction. If, however, these were not corrected the paper has been printed in its
original form. The editors thus accept no responsibility for any mistakes found. If
corrections were suggested by the editorial board and these did not in any way affect
the meanings intended in the paper, these changes were made without contacting the
author. We apologise if this causes offence but, in view of the amount of administrative
work involved in contacting the relevant authors, it was felt this was the easiest course
to follow. The abstract has been included where there was no paper submitted.
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Proceedings : 17th Priorities in Perinatal Care
1998
MINUTES OF THE FOURTH AGM OF THE PRIORITIES IN PERINATAL CARE
ASSOCIATION
Date:
Venue:
Wednesday 5th March 1998
Allemanskraal Dam, Free State
Attendance: Approximately 30 delegates to the 17th Conference on Priorities in Perinatal Care
in South Africa
1.
Welcome: Professor Woods welcomed the delegates to the fourth AGM of the
Association.
2.
Apologies: Mrs Dolly Nyasulu and Dr Gerhard Theron.
3.
Minutes of the 3rd AGM: copies of the minutes, which had been distributed to the
delegates earlier, were accepted without amendment or comment.
4.
Chairman's report:
Copies of the report were included with the agenda.
i.
Once again the Priorities in Perinatal Care Conference held at Warmbaths, Northern
Province, in March 1997 was a great success thanks largely to the organisation of
Professor Bob Pattinson and Dr Jenny Makin.
ii.
No meetings of the executive committee were held in the past year.
iii.
A statement on the recording of maternal blood pressure was not distributed as it was felt
that adequate consensus had not been reached. The consensus statement on the
antenatal screening for syphilis was published in the Proceedings of the 1997 Priorities
conference while a document on the newborn health plan was forwarded to the
Department of National Health.
iv.
Following the success of the PAFMACH Conference in South Africa in 1996, the
International Association for Maternal and Neonatal Health (IAMANEH) has invited the
Priorities in Perinatal Care Association to host their triennial meeting in the year 2000.
This offer has been accepted by the executive committee. Mrs Dolly Nyasulu
represented the Association at the last IAMANEH Conference in Brazil in November
1997. The invitation to host this international conference provides the Association with
the opportunity to demonstrate what is being done to improve perinatal care in Southern
Africa. It will also allow local participants to meet colleagues with similar interests from
other countries. It is suggested that the IAMANEH Conference replace the annual
Priorities Conference in 2000. It is hoped that many of the delegates who normally
attend the Priorities meeting will attend the 2000 Conference.
The proposed date will be March 2000 and the proposed title "Priorities in Perinatal Care
in Developing Countries". If possible an out-of-town venue will be used and every effort
will be made to contain costs.
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Proceedings : 17th Priorities in Perinatal Care
1998
5.
Matters arising from the Chairman's report:
The members of the Association present at the AGM supported the decision made by
the committee to host the 2000 IAMANEH Conference in South Africa. They also
supported the idea that the 2000 Conference replace the usual Priorities Conference that
year. It was agreed that Professors Bob Pattinson and Ian Hay co-ordinate the
conference. An organising committee will be formed and The Promotions People will be
hired to assist with the arrangements. The Promotions People had proved to be most
efficient in the organisation of the 1996 PAFMACH Conference. The proposed venue for
the 2000 Conference is Stellenbosch and the probable date being March/April during the
university vacations when residence accommodation will be available. More up-market
accommodation is also available. The venue will be adequate for 350 delegates.
6.
Jeff Ellis bursaries were awarded to 6 applicants. All presented papers or posters at the
Conference.
7.
Sponsorship:
Abbott were thanked for their continued support of the Priorities Conference. It is hoped
that they will continue to give their financial support.
8.
Financial report: No financial statement was issued as the Association currently does not
have an account.
9.
Elections:
The members of the executive committee of the Association (Prof Peter Cooper, Dr
Gerhard Theron, Mrs Dolly Nyasulu, Prof Bob Pattinson and Prof Dave Woods) were reelected for a further year. Prof Dave Woods will continue as the Chairman.
Professor Dave Woods
Chairman
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Proceedings : 17th Priorities in Perinatal Care
1998
TABLE OF CONTENTS
CONTINUING EDUCATION
THE EFFECT OF THE MATERNAL CARE MANUAL FROM THE PERINATAL EDUCATION
PROGRAMME ON THE QUALITY OF ANTE- AND INTRAPARTUM CARE RENDERED
BY MIDWIVES. GB Theron .......................................................................................... 1
PEP UPDATE: THE CURRENT STATE OF THE PERINATAL EDUCATION PROGRAMME. D
Woods ............................................................................................................................ 6
THE LODGER MOTHER UNIT OF GA-RANKUWA HOSPITAL: AN EVALUATION OF THE
MATERNAL EDUCATION AND SUPPORT PROGRAMME. EM Chauke .................. 8
THE WHO REPRODUCTIVE HEALTH LIBRARY. GJ Hofmeyr............................................ 10
NEONATAL INTENSIVE CARE
SURVIVAL OF VERY LOW BIRTHWEIGHT (VLBW) INFANTS IN JOHANNESBURG SINCE
1950. PA Cooper ........................................................................................................ 12
NEONATAL EXCHANGE TRANSFUSIONS - A DISAPPEARING ACT? M Mokhachane ... 15
THE USE OF THE CRIB SCORE IN A DEVELOPING COUNTRY. CH Pieper .................... 16
MATERNAL MORTALITY
OVERVIEW OF INTERIM REPORT ON THE CONFIDENTIAL ENQUIRY INTO MATERNAL
DEATHS IN SOUTH AFRICA. National Committee on Confidential Enquiries into
Maternal Deaths ........................................................................................................... 17
ANTENATAL CARE
HEALTH SEEKING BEHAVIOUR OF PREGNANT WOMEN. T Mabale .............................. 21
PREGNANCY AT AGE 35 AND ABOVE IN AFRICAN WOMEN. EJ Buchmann .................. 24
A SALEABLE SOLUTION: ON-SITE SYPHILIS TESTING IN THE WITBANK DISTRICT. R
Chegwidden ................................................................................................................. 26
THE SCREENING FOR PREGNANCY BACTERIURIA. ET Bvuma ..................................... 28
AUDIT
MATERNAL DEATHS IN THE FREE STATE PROVINCE, SOUTH AFRICA - 1997. MG Schoon
...................................................................................................................................... 31
SEVERE ACUTE MATERNAL MORBIDITY: A PILOT STUDY OF A DEFINITION FOR A "NEAR
MISS". GD Mantel ....................................................................................................... 34
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Proceedings : 17th Priorities in Perinatal Care
1998
FATAL AND NEAR-FATAL MATERNAL INCIDENTS IN THE FREE STATE PROVINCE
REGIONS A AND B DURING 1997. N Basson .......................................................... 37
IS THE LACK OF ANTENATAL CARE AN IMPORTANT AVOIDABLE FACTOR FOR SEVERE
ACUTE MATERNAL MORBIDITY? TE Mdeni ........................................................... 39
THE MIDWIFE OBSTETRIC UNITS, CAPE TOWN. VITAL STATISTICS 1980-1994. HA van
Coeverden de Groot .................................................................................................... 41
INTRAPARTUM CARE
POSITION DURING SECOND STAGE OF LABOUR: A REVIEW OF RANDOMISED
CONTROL TRIALS. C Nikodem ................................................................................. 44
THE MINIMUM PRACTICAL SUCCESS RATE OF VAGINAL BIRTH AFTER CAESAREAN
SECTION: A DECISION ANALYSIS. G Mantel .......................................................... 46
RECTAL MISOPROSTOL IN THE PREVENTION OF POSTPARTUM HAEMORRHAGE: A
PLACEBO CONTROLLED TRIAL. AA Bamigboye .................................................... 49
ORAL MISOPROSTOL FOR LABOUR THIRD STAGE MANAGEMENT: RANDOMISED
ASSESSMENT OF SIDE EFFECTS. GJ Hofmeyr ..................................................... 53
LEVELS OF CARE IN ATTERIDGEVILLE. RC Pattinson ..................................................... 55
INFANT AND POST PARTUM CARE
KANGAROO MOTHER CARE. A Malan ................................................................................ 60
POSTNATAL DEPRESSION IN CONTEXT : A DESCRIPTIVE STUDY. EP Mills .............. 62
VALIDATION OF THE EDINBURGH POSTNATAL DEPRESSION SCALE ON A COHORT OF
SOUTH AFRICAN WOMEN. M de Jager ................................................................... 66
THE EFFECT OF NORETHISTERONE ENANTATE ON POSTNATAL DEPRESSION: A
RANDOMISED PLACEBO-CONTROLLED TRIAL. T Lawrie .................................... 68
THE SMALL BABY
OBSTETRIC CAUSES FOR DELIVERY OF VERY LOW BIRTH WEIGHT (VLBW) BABIES AT
TYGERBERG HOSPITAL. ES Odendaal ................................................................... 70
THE USE OF PLACENTAL HISTOLOGY IN PERINATAL DEATHS. D Greenfield ............. 72
THE INCIDENCE OF NEUTROPENIA AND NOSOCOMIAL INFECTION IN INFANTS OF
WOMEN WITH SEVERE EARLY ONSET PRE-ECLAMPSIA. GF Kirsten ............... 74
PRAZOSIN OR NIFEDIPINE AS A SECOND AGENT TO CONTROL EARLY SEVERE
HYPERTENSION IN PREGNANCY - A RANDOMISED CONTROLLED TRIAL.
DR Hall ..................................................................................................................................... 76
ASSESSMENT OF URINE DIPSTICK TESTING FOR SIGNIFICANT PROTEINURIA IN
PREGNANCY. W Combrink ....................................................................................... 78
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Proceedings : 17th Priorities in Perinatal Care
1998
POSTERS
THE PERSPECTIVES OF RELATIVES REGARDING MATERNAL DEATHS IN THE FREE
STATE. D Motsamai ................................................................................................... 81
IDENTIFICATION OF CAESAREAN SECTIONS WHERE A PAEDIATRICIAN SHOULD BE
PRESENT. E van Deynse ........................................................................................... 83
SCREENING FOR ANAEMIA IN PREGNANCY, UTILISING A COLOUR CHART
COMPARISON METHOD. M Smallwood ................................................................... 85
O'SULLIVAN'S MANOEVRE - SONAR SEQUENCE. HYDROSTATIC REDUCTION OF ACUTE
PUERPERAL UTERINE INVERSION. HRG Ward .................................................... 86
IMPACT OF THE PREGNANCY CONFIRMATION CLINIC ON ANTENATAL CARE.
MV
Tsuari ........................................................................................................................... 88
SYMPHYSIS-FUNDAL MEASUREMENT AS A PREDICTOR OF LOW BIRTHWEIGHT. BS
Jeffrey........................................................................................................................... 91
AMNIOCENTESIS AND THE TAPTEST IN PROTEINURIC HYPERTENSION IN PREGNANCY
"TAPPET": A RANDOMISED CONTROLLED TRIAL. L Freislich ............................. 96
A PROFILE OF PAEDIATRIC DEATHS AT WITBANK HOSPITAL: JUNE TO DECEMBER
1997. E Malek ............................................................................................................. 97
CHANGING PATTERNS IN PRIMARY OBSTETRIC CAUSES OF PERINATAL DEATHS IN
THE WITBANK DISTRICT: THE EFFECT OF THE INTRODUCTION OF THE
PERINATAL PROBLEM IDENTIFICATION PROGRAMME (PPIP). DC Kotze ....... 100
THE IMPORTANCE OF LOCAL AUDIT. M Muller ............................................................... 103
RAPID ASSESSMENT OF MATERNAL AND INFANT CARE IN THE EASTERN HIGHVELD
REGION OF MPUMALANGA. IT Hay ...................................................................... 107
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS : A WHO/UNICEF STRATEGY.
Walter Loening ........................................................................................................... 110
INFANT FEEDING PRACTICES OF MOTHERS OF ONE MONTH OLD INFANTS.
P Dolo......................................................................................................................... 113
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Proceedings : 17th Priorities in Perinatal Care
1998
THE EFFECT OF THE MATERNAL CARE
MANUAL FROM THE PERINATAL
EDUCATION PROGRAMME ON THE
QUALITY OF ANTE- AND INTRAPARTUM
CARE RENDERED BY MIDWIVES
in the study town involved with antenatal
GB Theron
Department of Obstetrics & Gynaecology,
Tygerberg Hospital
hospital files were again identified in the
and intrapartum care.
Subsequent to a
waiting period of three months following the
completion of the manual, samples of
same way as the pre-intervention sample.
Random samples of 60 files each were
Maternal mortality and perinatal mortality
drawn from pre- and post-intervention study
rates in South Africa are unacceptably high.
town samples, likewise 30 files each were
Health care related avoidable factors are
drawn from the control towns. Information
often present. Improving the quality of ante-
on the front and back page of the antenatal
, intra- and postpartum care must be the
card and the partogram were each divided
main component of any effort to reduce
into four subunits to enable a prior and post
these death rates. The aim of this study
intervention comparison (Table I). A check
was to determine changes in the quality of
list was used to measure how complete and
antenatal and intrapartum care rendered by
correct
midwives who completed the Maternal Care
documents. The Maternal Care Manual was
Manual of Perinatal Education Programme
introduced to the 53 midwives in the control
(PEP).
towns, directly following the study.
For this purpose information on
antenatal cards and partograms was used.
information
was
on
these
The
validity of the check list was determined in a
pilot study. The totals of the subunits were
Method
used in the analysis.
A prospective controlled study was done in
three towns in the Eastern Cape Province,
Results
one as the study town and the other two as
The prior visit revealed that the available
control towns, in an area where PEP had
equipment was sufficient to implement
not been used before.
Prior to the
antenatal and intrapartum care as described
implementation of the Maternal Care
in the manual. Access to laboratories for
Manual in April 1994, the area was visited to
routine special investigations were fully
investigate whether it was feasible to do the
functional. Medical cover for the midwives
study in the area. Samples of 200 files from
was available and referral infrastructures
the study and 100 each from the control
from primary levels of care to the hospitals
towns were identified from the labour
existed. The results of the comparison of
registers to serve as the pre-intervention
the pre-intervention and post-intervention
samples. The Maternal Care Manual was
files are shown in Table II to IV. In the study
subsequently introduced to the 40 midwives
town
Proceedings : 17th Priorities in Perinatal Care
1
the
antenatal
card
revealed
1998
significantly
improved
(p=0.001 to 0.014).
levels
of
care
Discussion
The antenatal card
The study area was ideally suitable for the
subunits that improved significantly were:
purpose of the study as it is similar to that
previous obstetric history, determination of
found in most other rural parts of South
gestational
Africa.
age,
routine
special
The study revealed a significant
investigations and notation of symphysis
improvement in the quality of antenatal care
pubis-fundus growth and weight gain
in the study town subsequent to completion
(Tables II and III).
With regards to the
of the Maternal Care Manual. Four of the
partogram only the subunits on uterine
eight subunits that were used to evaluate
contractions
antenatal
(Table
IV),
improved
care
improved
significantly
significantly (p=0.006) in the study town. No
(Tables II and III).
changes occurred in the control towns.
investigations that was evaluated was the
One of the special
serologic test for syphilis. An improvement
from 69% to 94% in this subunit (Table II) is
therefore important.
Three of the four
subunits on antenatal care that did not
improve significantly, were well mastered
(76,8%, 98,7%, 89,7%) prior to the study
(Tables II & III).
In the study town the
information on the partogram only improved
with regards to the subunit on uterine
contractions (Table IV).
Various factors
may have influenced the result.
Table I
The Antenatal Card
Front page
general completeness
previous obstetric history
determination of gestational age
routine special investigations
The Partogram
risk factors and fetal condition
maternal condition
uterine conditions
cervical dilatation and engagement
of the presenting part
-
Back page
general completeness
notation of fundal height and weight gain
presenting part and amount of fetal head palpable above the pelvis
blood pressure and proteinuria
Proceedings : 17th Priorities in Perinatal Care
2
1998
TABLE II
MARKS ALLOCATED FOR THE FOUR SUBUNITS ON THE FRONT PAGE OF
THE ANTENATAL CARD
GENERAL COMPLETENESS
STUDY
TOWN
NO. OF
RECORDS
CONTROL
TOWN
P-VALUES#
(ROWS)
Pre
- mean (SD)
- median
76,8 (21,0)
83,3
56
66,7 (23,0)
66,7
24
0,059
Post
- mean (SD)
- median
82,7 (20,6)
83,3
56
61,5 (24,6)
66,7
48
0,000
p-value #
(columns)
0,13
PREVIOUS OBSTETRIC HISTORY
Pre
- mean (SD)
58,1 (36,7)
- median
100,0
Post
- mean (SD)
- median
p-value
(columns)
78,8 (29,3)
100,0
0,39
36
67,8 (41,6)
64,6
17
0,39
38
49,4 (33,9)
37,5
30
0,000
0,009
0,11
DETERMINATION OF GESTATIONAL AGE
Pre
- mean (SD)
38,3 (22,0)
55
- median
42,9
Post
- mean (SD)
- median
p-value
(columns)
Post
- mean (SD)
- median
p-value*
(columns)
21,4 (21,1)
21,5
24
24,4 (21,0)
28,6
48
0,002#
0,000*
50,3 (28,0)
57,1
56
0,014
0,57
ROUTINE SPECIAL INVESTIGATIONS
Pre
- mean (SD)
68,5 (50,0)
56
- median
100,0
#
NO. OF
RECORDS
93,6 (26,4)
100,0
56
0,001
Student's t-test
Proceedings : 17th Priorities in Perinatal Care
63,3 (50,9)
100,0
24
0,92#
86,4 (35,6)
100,0
48
0,33*
0,007
*
Kruskal-Wallis H
3
1998
TABLE III
MARKS ALLOCATED FOR THE FOUR SUBUNITS ON THE BACK PAGE OF
THE ANTENATAL CARD
GENERAL COMPLETENESS
STUDY
TOWN
NO. OF
RECORDS
CONTROL
TOWN
NO. OF
RECORDS
P-VALUES#
(ROWS)
Pre
- mean (SD)
- median
98,7 (4,9)
100,0
56
97,6 (6,9)
100,0
24
0,42#
Post
- mean (SD)
- median
99,0 (4,6)
100,0
56
97,0 (10,2)
100,0
48
0,32*
p-value #
(columns)
0,78#
0,84*
SYMPHYSIS PUBIS-FUNDUS GROWTH AND WEIGHT GAIN
Pre
- mean (SD)
- median
44,8 (28,8)
45,0
56
29,3 (24,1)
30,0
24
0,023
Post
- mean (SD)
- median
63,9 (27,7)
62,5
55
38,4 (26,7)
35,4
48
0,000
p-value
(columns)
0,001
0,16
PRESENTING PART OF THE FETUS AND AMOUNT OF FETAL HEAD PALPABLE ABOVE THE
PELVIS
Pre
- mean (SD)
- median
30,1 (33,0)
25
50
49,2 (40,5)
50
22
Post
- mean (SD)
- median
38,4 (40,4)
29,2
54
22,2 (32,6)
0,00
40
0,038
0,041
p-value
(columns)
0,26
0,006
BLOOD PRESSURE AND PROTEINURIA
Pre
- mean (SD)
- median
89,7 (21,3)
100,0
56
76,4 (31,1)
100,0
24
0,027
Post
- mean (SD)
- median
85,1 (24,2)
100,0
56
80,9 (26,8)
100,0
48
0,40
p-value*
(columns)
#
0,29
Student's t-test
Proceedings : 17th Priorities in Perinatal Care
0,41
*
Kruskal-Wallis H
4
1998
TABLE IV
MARKS ALLOCATED FOR THE FOUR SUBUNITS ON PARTOGRAM
RISK FACTORS AND MONITORING OF FETAL CONDITION
STUDY
TOWN
NO. OF
RECORDS
CONTROL
TOWN
NO. OF
RECORDS
P-VALUES#
(ROWS)
Pre
- mean (SD)
- median
28,3 (16,3)
27,3
34
27,6 (13,8)
27,3
54
0,85
Post
- mean (SD)
- median
20,2 (15,8)
15,4
34
30,3 (18,3)
30,8
44
0,014
p-value #
(columns)
0,045
0,42
OBSERVATIONS REGARDING MATERNAL CONDITION
Pre
- mean (SD)
- median
46,3 (31,8)
43,7
34
43,1 (31,2)
33,3
54
0,64
Post
- mean (SD)
- median
42,3 (22,5)
36,7
32
37,5 (26,4)
33,3
44
0,41
p-value
(columns)
0,56
0,35
RECORDING UTERINE CONTRACTIONS
Pre
- mean (SD)
- median
68,2 (31,5)
56,3
34
80,7 (33,2)
100,0
54
Post
- mean (SD)
- median
88,7 (27,2)
100,0
32
83,0 (31,9)
100,0
44
p-value
(columns)
0,083
0,42
0,006
0,74
CERVICAL DILATATION AND AMOUNT OF FETAL HEAD PALPABLE ABOVE THE PELVIC BRIM
Pre
- mean (SD)
- median
61,5 (32,5)
63,8
34
46,5 (38,1)
50,0
54
0,061
Post
- mean (SD)
- median
64,9 (30,4)
68,4
32
43,5 (38,0)
45,9
44
0,010
p-value*
(columns)
#
0,66
Student's t-test
0,70
*
Kruskal-Wallis H
PEP UPDATE: THE CURRENT STATE OF
THE
PERINATAL
EDUCATION
PROGRAMME
Proceedings : 17th Priorities in Perinatal Care
DL Woods
Neonatal Medicine Unit, Groote Schuur
5
1998
Hospital, University of Cape Town
manuals were used in state hospitals and
clinics, 2 385 were used in private hospitals,
The Perinatal Education Programme (PEP)
694 in nursing colleges, 4 431 in universities
is a self-help distance learning course which
and 127 in other institutions. Maternal care
enables nurses and doctors to manage their
manuals (9 810) and newborn care manuals
own training in maternal and newborn care.
(6 758) were used in English (10 235) and
It is also being used by medical and nursing
Afrikaans (6 334).
students. PEP aims at improving maternal
The distribution of PEP manuals between
and newborn care in all communities of
the 9 provinces of South Africa was as
South Africa, and consists of a manual on
follows:
Maternal Care and another on Newborn
Gauteng
Western Cape
Eastern Cape
Free State
Kwazulu/Natal
Northern Cape
Mpumalanga
Northern Province
North West Province
Care. The manuals are studied by small
groups of midwives using the principles of
self-help, peer tuition and co-operative
learning.
Controlled
studies
have
documented that PEP significantly improves
the perinatal knowledge, clinical skills,
5 012
4 515
1 680
1 405
1 034
536
523
308
303
attitudes and practice of midwives.
While an increasing number of PEP
Although originally written for nurses in the
manuals were ordered in 1997 from the
Cape Province, PEP is now widely used
Northern (104), North West (99) and
throughout
Mpumalanga (95) provinces, disappointingly
South
Africa
and
many
neighbouring countries.
low numbers of manuals were ordered from
Between 1992 and 1997, 16 569 manuals
the Northern Cape (33) and Free State (31).
were distributed. Most being used in South
During 1997 large numbers of manuals
Africa
(692) and
were still being used in the Western Cape
Botswana (221). Manuals have been sent
(883), Gauteng (848), Eastern Cape (271)
to nurses (10 647), doctors (823), medical
and Kwazulu/ Natal (186). The reason for
students (3 488), nursing students (1 462)
the fewer manuals being used in some
and other health professionals (149) such
provinces needs to be urgently investigated.
as ambumedics.
To date 2744 PEP certificates have been
PEP manuals are used in district and
distributed in South Africa:
regional hospitals as well as clinics in urban
Western Cape
Gauteng
Eastern Cape
Kwazulu/Natal
Northern Cape
Northern Province
North West Province
Mpumalanga
Free State
(15
008), Namibia
and rural areas. Minimal tutoring is needed,
students do not have to leave their place of
employment and most successful students
have
their
expenses
repaid
via
a
retrospective bursary system. While 8 932
Proceedings : 17th Priorities in Perinatal Care
6
871
652
346
222
201
147
119
98
88
1998
Both certificates have been awarded to
1048 participants who have been issued
with PEP badges.
The
Perinatal
Education
Programme
continues to offer the most cost effective
and well documented method of distance
learning for midwives (and doctors) in South
Africa.
If widely implemented, PEP will
improve the standard of maternal and infant
care in all communities.
Proceedings : 17th Priorities in Perinatal Care
7
1998
for their infants at home with confidence.
THE LODGER MOTHER UNIT OF GARANKUWA HOSPITAL: AN EVALUATION
OF THE MATERNAL EDUCATION AND
SUPPORT PROGRAMME
Methods
This was a descriptive study. The sample
comprised 60 lodger mothers of all ages,
EM Chauke
Department of Paediatrics and Child Health,
MEDUNSA
education levels, parity and marital status.
All mothers were interviewed using a
Introduction
structured
Neonatal Intensive Care Units (NICU) are
researcher at the Paediatrics Out-patient
essential for the successful care of very
Department when they came for their four-
immature and sick infants.
week post discharge follow-up visit.
Technology
interview
schedule
by
the
available for neonatal intensive care has
contributed to the reduction of morbidity and
Results
the improvement of outcome. Although the
On their initial visit to the NICU, 62% of the
ideal is to prevent low birth weight, the
mothers were told what was wrong with their
quality of care given to low birth weight
baby. Of these mothers, 92% knew the
infants and the support of their mothers
diagnosis correctly. Ward procedures of nil
must be improved.
per os, oxygen therapy and phototherapy
The Lodger Mother Unit (LMU) of the NICU
were well explained to mothers, but
at Ga-Rankuwa Hospital has been operating
intravenous
since 1991. It is staffed by two trained lay
intravenous therapies were only explained
health care workers, known as directresses.
to 28 and 34 of the mother respectively.
The directresses provide an education
Only 8% of mothers knew all medications
programme covering topics such as breast
being given to their infant, 58% knew some
feeding, hygiene and cord care and also
medications and 36% did not know any of
gives individual support and advice to
the medications given. Although 80% of the
mothers.
mothers thought that the nurses were
infusions
and
oral
and
dedicated, only 8% thought that they were
patient. Doctors were praised by 80% of the
Aim
To
ascertain
whether
the
mothers for their dedication and by 17% for
education
their understanding. Most education
programme given to the lodger mothers in
the Lodger Mother Unit (LMU) and the
Neonatal Intensive Care Unit of GaRankuwa Hospital enables mothers to care
was
given
to
the
mothers
by
the
All mothers said that the information they
directresses and social workers.
Proceedings : 17th Priorities in Perinatal Care
had received in the LMU had helped them to
8
1998
cope well with their baby at home after
discharge.
Conclusion
It appears that most mothers could care for
their infants at home with confidence.
Mothers thought that their stay in the LMU
had been beneficial, but felt that the nursing
staff could be more supportive.
Proceedings : 17th Priorities in Perinatal Care
9
1998
THE WHO REPRODUCTIVE HEALTH
the limitations and realities facing health
LIBRARY
workers in developing countries. The WHO
Reproductive Health Library is an electronic
GJ Hofmeyr
Department of Obstetrics & Gynaecology,
Coronation Hospital and the University of
the Witwatersrand
journal providing health workers and policy
The practice of evidence-based medicine
Reproductive Health.
involves the integration of clinical skills with
include pregnancy and childbirth, infertility,
knowledge of the effectiveness of medical
fertility regulation, sexually transmitted
interventions from the best and most reliable
diseases, and neonatology. In the library,
information available. Each year, more than
Cochrane
2 million medical articles are published.
reproduced with permission from the
Clinicians therefore have to
Cochrane
makers in developing countries with up to
date information and reviews in the field of
rely on
Areas covered
systematic
reviews
Collaboration,
are
and
are
information from reviews from the medical
accompanied by commentaries written by
literature. Unfortunately, traditional reviews
experts with experience of working in
have been shown often to be biased and
developing countries to place the reviews in
misleading.
The systematic review is a
the context of the realities of working in a
scientific method of reviewing the medical
developing country situation. The first issue
literature with the objective of reducing bias.
of the RHL (1997) contains 27 Cochrane
Currently, the best source of systematic
reviews including the following:
reviews available is the Cochrane Library,
1.
2.
Software, Oxford, UK.
3.
the practice of evidence-based medicine is
resources
4.
towards
of
gonorrhoea
and
Antimalarial
prophylaxis
during
Nutritional supplementation during
pregnancy;
interventions which have been shown to be
5.
effective, and away from interventions which
Social support during pregnancy and
labour;
have been shown to be ineffective or
harmful.
Treatment
pregnancy;
particularly important because of the need
scarce
in
chlamydia;
For health workers in developing countries,
direct
treatment
women;
published on disk and CD-ROM by Update
to
Trichomoniases
6.
Unfortunately, the Cochrane
Hypertensive
disorders
during
pregnancy;
Library has limitations in this respect. Firstly
it is expensive and requires a relatively high
7.
Postpartum haemorrhage;
level computer to run it. Secondly, most of
8.
Breastfeeding.
the reviews are written from a first world
The RHL also contained useful information
perspective, and do not take into account
such as sources of funding for research.
Proceedings : 17th Priorities in Perinatal Care
10
1998
Future annual issues will progressively build
on the number of topics covered in the RHL.
The editors of the Reproductive Health
Library have a wide geographic spread,
from Argentina, China, South Africa, USA
and the WHO in Switzerland. Feedback
from users is encouraged so that future
issues can be tailored to meet the needs of
health workers in developing countries.
Proceedings : 17th Priorities in Perinatal Care
11
1998
An analysis of the survival of very low
SURVIVAL OF VERY LOW BIRTHWEIGHT
(VLBW) INFANTS IN JOHANNESBURG
SINCE 1950
birthweight infants was carried out utilising
previously reported data and information
PA Cooper
Department of Paediatrics, University of the
Witwatersrand, Johannesburg
from the computerised database initiated in
1990.
A unit for the care of premature babies was
Results
established at Baragwanath Hospital in
Survival in the early 1950s was reported by
1950. This was a low technology unit where
oxygen
could
be
administered
Kahn et al using pounds (lbs) as the
but
measure
incubators and facilities for intravenous
therapy were not available.
62% reported survival of infants with
birthweight 1360-1810g (3-4lbs) in the early
enormous increase in the numbers of VLBW
1950s.
infants. An intensive care unit with facilities
Survival of VLBW infants has improved
to ventilate infants opened in 1979, which
substantially since 1980, even in those
increased in size during the 1980s to 12
have
seen
weighing
the
recent
innovations
in
<1000g
who
are
seldom
ventilated, as shown in Table 1.
introduction of artificial surfactant and other
more
direct
weighing 1000-1499g was similar to the
and broad spectrum antibiotics as well as an
1990s
making
However, by 1981/82 survival of infants
intravenous fluids, exchange transfusion
The
weight,
comparisons with later figures difficult.
Subsequent
years saw the introduction of incubators,
beds.
of
neonatal
intensive care.
TABLE 1
SURVIVAL OF VLBW INFANTS 1981 - 1996
Weight (g)
< 1000
1000-1499
1500-1999
1981/82
13.9%
1990/91
23.9%
63.6%
91.6%
1995/96
31.6%
70.1%
91.8%
79.1%
93.8%
Since 1990, the biggest improvement in
thus would not have received surfactant,
survival figures has been noted in those
while further analysis of those weighing
infants weighing 800-1300g as shown in
1000-1300g revealed that surfactant use
Table 2, probably related in part to the
could only explain a relatively small
introduction of artificial surfactant. However,
proportion of the increased number of
infants <1000g were seldom ventilated and
survivors in this weight range.
Proceedings : 17th Priorities in Perinatal Care
12
1998
TABLE 2
COMPARISON OF SURVIVAL OF VERY LOW BIRTHWEIGHT INFANTS
BETWEEN 1990-1991 AND 1995-1996 BY 100G BIRTHWEIGHT
CATEGORIES
Birthweight (g)
<700
700-799
800-899
900-999
1000-1099
1100-1199
1200-1299
1300-1399
1400-1499
1990-1991
0%
19.5%
20.3%
32.4%
56.3%
61.0%
63.5%
79.5%
86.3%
1995-1996
6.9%
20.0%
33.0%
41.1%
67.3%
75.9%
78.6%
81.3%
88.1%
To illustrate the dramatic improvement in
reported by Kahn et al and, since the
survival of VLBW infants since the early
original report was in pounds and ounces,
1950s, a comparison with the latest figures
the
available, those for 1995-1996, were
accordingly. The results are shown in the
compared with those originally
table below.
TABLE 3
1995-96
figures
were
analysed
COMPARISON OF THE SURVIVAL OF VLBW INFANTS BORN IN 1951 -52
WITH THOSE BORN IN 1995-96
Birthweight (g)
< 907 (< 2lbs)
907-1355 (2-3lbs)
2%
1951-52
1995-96
25.4%
25%
71.5%
Conclusions
responsible for overall improvements in
When comparing the 1995/96 figures for the
outcome, but it is a combination of many
survival of VLBW infants with those from the
different factors amongst which some may
early 1950s, the enormous progress that
be more important than others. In this case,
has been made in the care of VLBW infants
there is no doubt that factors such as
is apparent. Even in the relatively short
mechanical
period of 15 years since 1981, the
surfactant were very important, but the
improvement in survival is impressive and is
improvements in care of the mother during
still ongoing.
As with most areas of
the antenatal and perinatal periods and the
progress in medical science, it is seldom
general supportive care of VLBW infants at
one particular factor, in this case the
all levels in the neonatal wards are likely to
introduction of mechanical ventilation or the
have been equally important.
ventilation
and
artificial
use of artificial surfactant, that is solely
An increase in survival rates, especially with
from the Baragwanath neonatal unit showed
respect to VLBW infants, always raises the
that only 8.6% of surviving VLBW infants
question of whether there is a concomitant
were handicapped, a relatively low figure in
increase in handicap rates. However, data
comparison with data from other parts of the
Proceedings : 17th Priorities in Perinatal Care
13
1998
world.
Proceedings : 17th Priorities in Perinatal Care
14
1998
NEONATAL EXCHANGE TRANSFUSIONS
these new guidelines. This study evaluated
- A DISAPPEARING ACT?
the impact of instituting these guidelines on
our neonatal exchange transfusion practice.
M Mokhachane, H Saloojee
Neonatal Unit, C.H. Baragwanath Hospital
and the University of the Witwatersrand
Method
Retrospective, descriptive, cohort analysis.
Introduction
All babies who had ETs performed in the
Jaundice remains one of the commonest
neonatal unit at Chris Hani Baragwanath
problems in the neonatal period. Over the
Hospital, over two time periods were
past decade, more liberal criteria for
initiating
phototherapy and
compared. Group 1 - 1990 and Group 2 -
performing
1996 and 1997 combined.
exchange transfusions (ETs) have been
proposed. Our institution has followed
Results
1990
1996/1997
Number of births (Bara & Clinics)
32 372
23 271/~23 000
Number of exchange transfusions (ETs)
194
16/21
% of births requiring ETs
0.6
0.07
% of ETs in term babies
71
46
Mean peak serum bilirubin (SB) at first ET in term babies (mg/dl)
23.4
27.3
Mean peak SB/weight in preterm babies at first ET
12.6
16.6
The study also evaluated the indications for, complication rate and mortality rate owing to the ET
procedure.
a prospective study.
Conclusions
1.
There
has
been
a
dramatic
reduction in the number of exchange
transfusions performed over the
past decade from some 488 in 1984
to less than 20 per annum in 1996.
2.
This
decrease
can
mainly be
attributed to the use of more liberal
criteria for ETs, i.e. a higher serum
bilirubin being tolerated in
both pre-term and term babies.
3.
The impact of this more liberal
practice on neurodevelopmental
outcome has yet to be evaluated in
Proceedings : 17th Priorities in Perinatal Care
15
1998
THE USE OF THE CRIB SCORE IN A
DEVELOPING COUNTRY
0.89-1.34). The logistic regression curve for
CH Pieper, G Kirsten, J Barnes
Dept of Paediatrics and Child Health,
University of Stellenbosch
to that of Great Britain at both ends of the
prediction of death was significantly different
equation (p<0.05).
Tree differentiation
suggests that a BW of 890g should be the
The setting for neonatal intensive care in the
cut-off point.
developing countries is different to that of
Gestational age had no
correlation to outcome. The mortality rates
developed countries. The demand for care
for the 1000-1500g (26 vs 12%) and the
is higher, the available resources are less
>1500g (50 vs 11%) were higher than the
and the disease profile of the babies is often
rates for Great Britain.
more complex.
Conclusions: The babies who have a
Aim
higher CRIB score do better in a developing
To evaluate the Clinical Risk Index for
country, and the babies who have a lower
Babies (CRIB) at Tygerberg (TBH) neonatal
score do worse.
intensive care unit.
A higher nosocomial
infection rate may prove to be a possible
Methods
reason. The admission birth weight should
A prospective cohort study was done on all
be lowered to 890g. GA should be ignored
babies weighing less than or equal to 1500
at admission. It seems to be a relatively
grams and/or having a gestational age of
crude
less than 32 weeks during the period of 1
predictability of either mortality or morbidity
September 1992 to 30 June 1995.
is of such low sensitivity and specificity that
Results: A total number of 458 babies were
it cannot be used to make any decisions on
admitted. There were 116 deaths (26%). of
the ending of treatment in specific cases.
the 328 babies with complete CRIB scores
The validation of an enhanced system in a
80 (24%) died. The late admissions (babies
Third World NICU should be done based on
who were more than 12 hours old but less
sound
than 28 days) were 109 with 29 (26%)
principles.
measuring
clinical
device
and
and
the
epidemiological
deaths. The mean birth weight (BW) was
1191 grams and the gestational age (GA)
was 30 weeks. The highest and lowest FiO2
were 0.82 and 0.42 respectively at 12 hours
of age.
base excess and admission
temperature were -7.8 and 36.1oC and the
mean CRIB score was 6.5. The odds ratio
was similar to TBH and GB (OR=1.09, CI
Proceedings : 17th Priorities in Perinatal Care
16
1998
mainly
OVERVIEW OF INTERIM REPORT ON
THE CONFIDENTIAL ENQUIRY INTO
MATERNAL DEATHS IN SOUTH AFRICA
acquired
immune
deficiency
syndrome - AIDS, obstetrics haemorrhage
(14%), early pregnancy losses (12%) mainly
National Committee on Confidential
Enquiries into Maternal Deaths
septic abortions, and pre-existing maternal
diseases (11%) mainly cardiac disease.
Introduction
This interim report incorporates the data
Women at special risk of maternal death
from the Provinces who had submitted
From the initial findings some pregnant
cases to the NCCEMD by 14/2/98. Several
women are more at risk than others. They
Provinces were involved in piloting the
are:
process of notification.
*
Some started in
Women over 35 years of age. They
August 1997 and gradually more came on
are
board. For this reason, the interim report is
complications
heavily biased by cases from KwaZulu/Natal
obstetric haemorrhage, and heart
(KZN) and Gauteng and there is under-
complications if they have pre-
reporting of deaths from the more rural
existing valvular heart disease.
areas of South Africa. Some conditions,
especially ectopic
abortions,
pregnancies,
thrombo-embolism
*
septic
especially
vulnerable
of
to
hypertension,
Younger women are becoming
victims of AIDS.
and
*
The
women
with
pre-existing
anaesthetic deaths are also probably being
valvular heart disease are at special
under-reported. However, a clear pattern is
risk of heart failure and subsequent
emerging and the NCCEMD felt it necessary
death.
to publicise the initial findings so that action
*
Women who have had a previous
can be initiated to start solving the
caesarean section are at special risk
problems.
of severe haemorrhage as a result
This overview will identify the major issues
of rupture of the uterus.
that have emerged. More detailed reports
*
Women who have had a caesarean
are found in the full interim report which will
section in this pregnancy are at
soon be available at all Health Institutions.
particular risk of developing severe
sepsis after the operation.
FINDINGS
Health seeking behaviour of pregnant
Major causes of death
women
The Big five causes of maternal death are
A feature in the behaviour of some of the
hypertensive conditions in pregnancy (20%),
pregnant women was the delay in seeking
non-pregnancy related infections (18%)
help. This was especially found in relation
Proceedings : 17th Priorities in Perinatal Care
17
1998
to women dying of septic abortions (58%)
-
and in women who died of complications of
recognition
and
management of sepsis.
hypertension (44%). Part of the problem for
women who died of septic abortion was the
Problems at all levels of care
lack of accessibility to termination of
Making good legible notes was a problem
pregnancy services.
detected at all levels of care.
communication
between
clinics
Poor
and
Problems at the primary health care level
hospitals, hospitals and hospitals and health
Detection of women with valvular heart
workers and the clients was also found to be
disease and the appropriate management of
a recurrent problem. This was particularly
women with hypertension in pregnancy were
evident in the transfer of patients from one
the general problems detected at the
health service to another. The clinical notes
antenatal clinics.
of the patient did not accompany the patient
to the new health service.
Problems at the secondary care level
Some clear problems with the emergency
Recommendations
management of critically ill women were
Certain specific problem areas have been
seen at secondary level hospitals. They are
identified which have special reference to
as follows:
medical personnel and administrators. They
*
The diagnosis of women with septic
are:
abortions, and postpartum sepsis;
1.
*
*
Referral
hospitals
for
delay in referring women with
hypertension. It was clear that in
complications
hypertension,
each health region a hospital needs
valvular heart disease, and abruptio
to be identified that is equipped and
placentae to tertiary institutions;
trained to manage the complications
a specific lack of protocols and
of hypertension.
training in the following conditions:
referral criteria and referral patterns
-
needs to be put in place in each
of
complications
of
hypertension;
A clear set of
region.
-
severe haemorrhage;
-
abortions;
presence of pneumonia in a woman
-
anaesthesia for pregnant
under 25 years of age should
women;
immediately alert the medical staff to
management of heart failure
the possibility of the woman being
due
HIV positive and she should be
-
to
valvular
2.
heart
disease;
Proceedings : 17th Priorities in Perinatal Care
Pneumonia
and
AIDS.
The
counselled and tested for HIV.
18
1998
3.
Recognition of obstructed labour.
services.
More
attention needs to be placed on the
the recognition of cephalopelvic
training of doctors to provide safe
disproportion.
anaesthesia for pregnant women.
The use of the
and
the
implicit
9.
Prophylactic antibiotics.
It has
management protocols which follow,
been clearly shown that the use of
must be re-emphasised at all levels
prophylactic
of care.
caesarean sections decreases the
Management of labour in women
post-operative
with previous caesarean sections.
should be standard policy at all
Women with a previous caesarean
places
section must undergo their labours
sections.
10.
in a secondary hospital and a clear
5.
Anaesthetic
Emphasis needs to be placed on
partogram,
4.
8.
antibiotics
prior
morbidity.
performing
to
This
caesarean
Family planning services.
The
protocol must be in place for the
women over 35 years of age are at
management of these women at the
special
secondary level hospitals.
pregnancy.
Availability of blood. A look needs
family planning service needs to be
to be taken at the availability of
focused on this issue and the clients
emergency blood at institutions
counselled accordingly.
risk
of
dying
during
The attention of the
providing delivery services.
6.
Pregnancy
The NCCEMD will start getting the initial
patchy
important messages out to the public and to
implementation of the Choice of
the medical profession and this symposium
Termination of Pregnancy Act of
is such an example. To enhance public
1996 needs to be rectified.
The
awareness of the Confidential Enquiry and
public
that
to ensure better reporting of deaths a
termination of pregnancy is available
pamphlet has been written and distributed.
and specifically at which sites it is
The messages to the health professionals
available.
will be distributed to the Provincial MCWH
Multidisciplinary care. The value
Units where they will organise workshops
of multidisciplinary care needs to be
and symposiums in the Regions and
re-emphasised
in
Districts to get the messages across.
services
at
Termination
of
services.
7.
The
needs
and
institutions.
to
know
the
the
health
training
This is especially
important in relation to women with
pre-existing heart disease.
Proceedings : 17th Priorities in Perinatal Care
19
1998
HEALTH
SEEKING
BEHAVIOUR
OF
PREGNANT WOMEN
T Mabale, M Tsuari, R Pattinson
MRC Research Unit for Maternal and Infant
Health Care Strategies, University of
Pretoria
Introduction
The new policy of free maternal and child
health services has opened doors for
women to access health care during
pregnancy. This provides an opportunity for
health care professionals to offer women
health care in terms of prevention and
intervention in pregnancy related conditions.
In the Atteridgeville community the average
gestational age at first visit is 22 weeks.
This
delay
professionals
restricts
in
health
prevention
of
care
and
intervention in problems such as syphilis,
anaemia, bacterial vaginoses, hypertension,
and many others. Some of these conditions
result in perinatal problems and these affect
neonatal and maternal morbidity and
mortality.
The question then arises as to why women
commence antenatal care in the second half
of their pregnancy? Is it the result of late
diagnosis of pregnancy, or late attendance
at antenatal care facilities? A descriptive
study was undertaken to describe the health
seeking behaviour of pregnant women in the
Atteridgeville community and to understand
what motivated them.
Methods
Women from the Atteridgeville community
were interviewed post-delivery at Kalafong
Proceedings : 17th Priorities in Perinatal Care
20
1998
Hospital, a primary delivery site for the
months.
greater Atteridgeville community.
most
The
A general practitioner (53.2%)
frequently
confirmed
pregnancy.
interview was in the form of a structured
Hospital confirmations accounted for 15.2%
questionnaire and two midwives (TM and
and local clinics the remaining 30.4%.
RK) administered the questions in the
Only 12% of the women started antenatal
women's home language. A database was
created including the patient's age, parity,
gravidity,
behaviour
questions
and
on
on
the
women's
aspects
of
her
understanding about antenatal care. Signed
consent was obtained from each woman
prior to starting the interview.
Results
Ninety-seven women were entered into the
study, and a total of 92 questionnaires were
analysed.
Seven questionnaires were
excluded due to incomplete data.
The average age of the population was 28
years (range 18-42). The median parity was
2 (range 0-5), and the gravidity was 3 (range
1-6).
Amenorrhoae was the most common
symptom which made women suspect that
they were pregnant (74%).
This was
followed by symptoms of nausea and
vomiting (15%), weight gain, breast changes
and feeling unwell (12%).
Thirty-three percent (33%) of the women
confirmed their pregnancy in the first 12
weeks, and 36% confirmed between the
13th and 20th week of gestation.
The
remaining 31% of the women did not
formally confirm their pregnancy, they just
waited to 'show', that is for the pregnancy to
become physically apparent, usually after 5
Proceedings : 17th Priorities in Perinatal Care
21
1998
care during the first 12 weeks of gestation.
not attend antenatal clinic. The distribution
Thirty-two percent started antenatal care
of the time of confirming pregnancy and the
between 13-20 weeks of gestation. Thirty-
time of starting antenatal care (booking) is
four percent of women started antenatal
illustrated in Figure 1.
care from 21-28 weeks of gestation.
Twenty-one percent of the women started
antenatal care clinic after 28 weeks of
gestation. One percent of the women did
Figure 1
The comparison between the time of confirmation of pregnancy and the
time of starting antenatal care
Proceedings : 17th Priorities in Perinatal Care
22
1998
Seventy-nine
understood
percent
antenatal
of
the
care
to
women
be
pregnancy. This belief results in missed
a
opportunities for positive intervention for the
combination of ensuring maternal and foetal
patient by the health care professional in
wellbeing.
early pregnancy.
This comprised a physical
There is a need for a
examination, weighing, blood pressure
programme to explain to the community and
check and listening to the foetal heart on all
some
visits. Twenty-one percent of the women
antenatal care should start at the diagnosis
said it was mainly for screening for disease
of pregnancy.
in blood and urine.
opportunities for positive intervention in
Forty-six percent of the women understood
early pregnancy. The visit to confirm the
booking during pregnancy to be for
pregnancy should be used to initiate
registration purposes that is to book a bed
antenatal care immediately. This implies
for delivery.
that all clinics and hospitals should provide
A small percentage (14%)
understood booking to be the same as care
health
care
professionals
that
This would result in
pregnancy diagnosis.
in pregnancy. The remainder of the women
(40%) did know what the term 'booking'
meant.
In the subgroup of 50 women who
commenced antenatal care after 20 weeks
gestation,
but
had
confirmed
their
pregnancy before 20 weeks gestation. In
this group, reasons for late attendance of
antenatal care were: they waited to 'show'
(55%), they thought antenatal care only
started after 5 months (41.4%), and some
women (3.6%) went to the clinic after
confirming their pregnancy but were told to
come after 5 months gestation.
Discussion
The study showed that most Atteridgeville
women know the symptoms and signs of
pregnancy. They react early to confirm the
pregnancy but delay starting antenatal care.
There is a misconception that antenatal
care
only starts
after 20 weeks of
Proceedings : 17th Priorities in Perinatal Care
23
1998
PREGNANCY AT AGE 35 AND ABOVE IN
AFRICAN WOMEN
Hospital or at any of the eight midwife
EJ Buchmann, RKT Larbi
Obstetrics & Gynaecology, University of the
Witwatersrand and C.H. Baragwanath
Hospital
June to 30 September 1997. Controls, aged
obstetric units (MOUs) in Soweto, from 6
20 to 29, were matched in a 1:1 ratio
following selection using random numbers,
and after adjustment for possible bias in
Introduction
terms of place of delivery. The ratios of
Pregnancy over the age of 35 has been
hospital to MOU delivery in the case and
associated with a number of adverse
control groups were set at 79:21 and 62:38
outcomes. These pregnancies are known
respectively, to reflect the usual pattern that
to carry an increased risk of hypertension,
exists in our health service. Data collection
gestational diabetes, prelabour rupture of
was by record review, using maternal case-
the membranes, perinatal mortality and fetal
files for hospital patients and MOU delivery
chromosomal abnormalities. The study was
registers for clinic deliveries.
undertaken to measure maternal morbidity,
Results
perinatal mortality and morbidity, and the
There were 1047 cases and 1047 controls.
need for obstetric interventions in a
The associated pregnancy risk factors are
population of pregnant African women of
shown in Table 1, and pregnancy problems
age 35 years and above.
in Table 2. Fetal outcome is shown in Table
Methods
3.
This was a cohort study. The cases were
The need for obstetric and neonatal
interventions is shown in Table 4.
women of age 35 and above who delivered
at Chris Hani Baragwanath
Table 1
Associated pregnancy risk factors
Age > 35
Age 20-29
Significance
Mean ages
37.7
24.4
Mean parity
3.9
1.0
p<0.0001
First booking (weeks)
26.2
24.9
p<0.0001
Unbooked at delivery
6.9%
4.8%
OR 1.5 (1.0-2.2)
Previous caesarean
13.4%
7.2%
OR 2.0 (1.5-2.7)
Haemoglobin <10g/dl
10.5%
7.5%
OR 1.4 (0.9-2.1)
Weight (kg)
77.6
68.5
p<0.0001
OR = odds ratio with 95% confidence interval
Proceedings : 17th Priorities in Perinatal Care
24
1998
Table 2
Associated pregnancy problems
Age > 35
Age 20-29
Significance
Hypertension:
Proteinuric
Nonproteinuric
All
5.7%
17.2%
22.8%
3.2%
6.0%
9.3%
OR 1.8 (1.2-2.8)
OR 3.2 (2.3-4.5)
OR 2.9 (2.2-3.8)
Gestational diabetes
0.9%
0.0%
p<0.003
PROM
6.9%
2.6%
RR 2.7 (1.7-4.1)
Age > 35
Age 20-29
Significance
Mean birthweight (g)
2914
2991
p<0.01
Birthweight <2500g
21.0%
13.4%
RR 1.6 (1.3-1.9)
Perinatal mortality
42/1000
33/1000
RR 1.3 (0.8-2.0)
Age > 35
Age 20-29
Significance
Admission before labour
23.5%
12.0%
RR 2.0 (1.6-2.4)
Labour induction
14.5%
7.4%
RR 2.0 (1.5-2.5)
Caesarean section
22.7%
13.1%
RR 1.7 (1.4-2.1)
Neonatal admission
12.7%
8.3%
RR 1.5 (1.2-2.0)
PROM=Prelabour rupture of the membranes
RR=relative risk with 95% confidence interval
Table 3
Fetal outcome
Table 4
Interventions required
Discussion: Study limitations included the
antenatal care after 20 weeks.
absence of women who delivered outside
Although there were comparable perinatal
the health service, especially in private
mortality rates between the older and
clinics. Early pregnancy problems, such as
younger mothers, this was achieved in the
abortion, ectopic pregnancy and termination
older group at the cost of a significantly
of pregnancy were excluded as these do not
increased rate of interventions.
present at our maternity hospital.
therefore expensive and difficult to treat
The
It is
sample was too small to include rare but
these women.
important outcomes such as maternal death
ages of 35 and over can be characterised
or
abnormalities.
as being at increased risk of hypertension,
be
prelabour rupture of membranes and
fetal
chromosomal
Hypertension
could
not
classified
caesarean section.
because most mothers only booked for
Proceedings : 17th Priorities in Perinatal Care
Pregnancies at maternal
25
1998
sent back to the clinic from the laboratory
A SALEABLE SOLUTION:
ON-SITE
SYPHILIS TESTING IN THE WITBANK
DISTRICT.
*
and hopefully found their way into the
patient’s file. If she returned and was found
*
R Chegwidden , DC Kotze ,
RC Pattinson**
*Witbank Hospital, Witbank
** Director MRC Maternal and Infant Health
Care Strategies Research Unit, Department
of Obstetrics and Gynaecology, University of
Pretoria
to have positive syphilis serology, she was
treated. The minimum time for the process
was 3 days, but in fact the patients with
positive serology were usually treated four
weeks later at the next antenatal visit, if at
all.
In January 1996, the Perinatal Problem
It was decided to introduce the on-site RPR
Identification Programme1 was introduced
testing in the District, and this eventuated in
into Witbank Hospital. In the first seven
January 1997. In the first seven months of
months it was noted that the perinatal
1997, 6 deaths due to syphilis were
mortality rate (PNMR) was 46,6/1000
recorded. It was thought that this reduction,
deliveries. In 14 cases the death was due
from 14 deaths to 6 deaths, was due to the
to syphilis (10,4% of the total deaths). The
introduction of the on-site testing. To test
documentation of the perinatal deaths due
this hypothesis, the antenatal cards of
to syphilis is probably an underestimation as
women delivering at the Polyclinic (a
in only 39% of all the perinatal deaths, was
Midwife Obstetric Unit in Witbank) and at
the serological status of the patients
Witbank Hospital were collected for July,
regarding syphilis known.
1996 and July, 1997.
The screening system used in the Witbank
Each card was
assessed to see if syphilis screening was
District at that time was of taking blood at
performed and if so, was the result in the file
the antenatal clinics and sending it to the
and what was the result.
SAIMR laboratory. The results then were
The results are shown in Table 1.
Antenatal cards available
Syphilis testing performed
Syphilis test results available
No results available
Positive cases
Prevalence
July 1996
N
%
109
100
62
58
55
50
7
9
13%
July 1997
N
%
108
100
96
89
85
79
11
11
13%
P
<0,00
<0,00
All women who had positive syphilis
screening in 1997. Problems still remain as
serology were treated.
evidenced by the lack of total coverage.
Resistance to performing the test at the
It is clear from the table that there has been
Polyclinic has been overcome by the use of
a major improvement in antenatal syphilis
nursing assistants at the Polyclinic who
Proceedings : 17th Priorities in Perinatal Care
26
1998
have been specially trained in performing
the RPR on-site.
The current cost at the SAIMR for a
negative test is R6.56, and for a positive test
R18.04 (confirmation and determining the
titre). Added to this is the cost of transport
of the specimens which is R0.72 per
kilometer. Some of the clinics are 40km
away and this adds substantially to the cost.
The cost of the initial equipment was
R4900.00 (rotator and centrifuge), and
thereafter R0.90 per test. Delport and van
den Berg2 state that no special equipment
other than the actual test kit is required.
Gravity can be used to separate out the
plasma and the patients can rotate the test
cards.
This system has the added
advantage in that nothing can break.
On-site RPR testing has solved the
problems related to antenatal syphilis
screening in the Witbank District.
We
suggest it should become the norm in
similar districts.
Acknowledgements
We would like to thank the Health Systems
Trust and the Medical Research Council for
supporting the introduction of the Perinatal
Problem Identification Programme into the
Witbank district
LR Pistorius, ET Bvuma, RC Pattinson
Dept of Obstetrics & Gynaecology,
University of Pretoria and Kalafong
THE SCREENING FOR PREGNANCY
BACTERIURIA
Proceedings : 17th Priorities in Perinatal Care
27
1998
Academic Hospital
and treatment remain controversial. It is
accepted standard of obstetric care to
Introduction
screen all patients at the first antenatal visit.
Asymptomatic bacteriuria in pregnancy is
Studies
associated with acute pyelonephritis and
reagent
strip
testing
for
leukocyte esterase, nitrites and protein have
preterm labour. These complications can
given conflicting reports. Local studies for
be reduced by treating patients with
bacteriuria in pregnancy have given poor
bacteriuria. A programme of screening and
sensitivities and specificities. We undertook
treatment is likely to be cost-effective, but
a prospective cohort study, firstly, to test the
depends on the local prevalence of
bacteriuria and pyelonephritis.
on
efficacy of reagent strip testing as a
Optical
screening test for asymptomatic bacteriuria.
screening methods
Secondly, we considered the feasibility of
inoculating a urine sample onto growth
medium at a primary care level by the
nursing staff.
Literature report on urine dipstick testing
Sensi (%)
Speci (%)
PPV (%)
NPV (%)
N+
41
99
84
96
N-
(36-45)
(99-100)
(79-88)
(95-96)
L+
58
90
30
97
L-
(52-64)
(89-91)
(26-34)
(96-97)
L+ or N+
72
90
35
98
L- or N-
(67-77)
(89-91)
(31-38)
(97-98)
Patients and Methods
central laboratory on the remaining urine
The study was conducted in four primary
samples within 6 hours of collection. The
care clinics surrounding Kalafong Hospital
early urine culture was used as the gold
over 4 months. A total of 299 patients were
standard for analysis. A culture of 100 000
enrolled at their first antenatal visit. Oral
organisms/ml or more of a single organism
consent was obtained.
The clean catch
was considered as a positive result.
urine specimens were tested using Multistix
Patients with a positive nitrite were treated
9 (Ames Multistix, Bayer Diagnostics)
with Nitrofurantoin. Those patients with a
reagent strips and 0,001 mls inoculated
positive leukocyte esterase test had to
directly onto MacConkey and blood agar
confirm the results of the urine culture the
plates. The procedure was repeated at the
following
Proceedings : 17th Priorities in Perinatal Care
28
day
and
were
managed
1998
accordingly. The sensitivity, specificity and
Info 6(WHO 1994) and the correlation
predictive values for each reagent strip test,
coefficient was derived using Statistix 4.0
individually
(1992 Analytical Software).
and
in
combination
were
calculated using the Chi squared test, Epi
Results
The prevalence of asymptomatic bacteriuria
was 11% (33/299). If 2 or more organisms
were considered as contaminated, then the
contamination rate was 1% (3/299). If the
Staphylococcus
epidermis
and
saprophyticus were excluded, then the
contamination rate was 16% (49/299).
Results of the urine cultures are shown in
Table 1 below.
Table 1
Isolates from significant bacteriuria
Isolates
No. of patients (%)
Escherichia coli
16 (48,5%)
Staphylococcus epidermis
4 (12,1%)
Klebsiella species
3 (9,1%)
Proteus species
1 (3%)
Streptococcus faecalis
4 (21,1%)
Pseudomonas species
2 (6,1%)
Bacilus
1 (3%)
Proceedings : 17th Priorities in Perinatal Care
29
1998
Another 84 (28%) patients had equivocal
nitrite and protein reagent strip testing and
results (10-100 000 organisms/ml).
bacteriuria
The
(p<0.05).
The sensitivity,
overall correlation coefficient (Pearson's p)
specificity and predictive values of the
between early and delayed cultures were
reagent strip test results, either separately
0,70. There was a significant association
or in combination are reflected in Table 2
between the results of leukocyte esterase,
and
Table 2
Table
3.
Fresh urine dipstick testing for pregnancy bacteriuria
Sens (%)
Spec (%)
PPV (%)
NPV (%)
N+
18
97
46
91
L+
42
67
14
90
P+
30
90
27
91
L+ or N+
52
66
16
92
P+ or N+
46
87
31
93
L+, P+ or N+
61
60
16
92
Table 3
Delayed urine dipstick testing for pregnancy bacteriuria
Sens (%)
Spec (%)
PPV (%)
NPV (%)
N+
30
93
33
91
L+
55
58
14
91
P+
6
97
20
89
L+ or N+
64
55
15
92
P+ or N+
33
90
29
92
L+, P+ or N+
67
53
15
93
Conclusions
recommend the use of reagent strip testing
Reagent strip testing is an attractive and
for
cost-effective
for
bacteriuria in pregnancy. The search for an
Urine culture,
optimal screening method should continue.
way
of
asymptomatic bacteriuria.
screening
the
screening
of
asymptomatic
particularly in the developing world is
expensive and not feasible. The reason for
the poor sensitivity and specificity with
dipsticks testing locally is not clear.
Equivocal results could represent an early
phase in bacteriuria and its value has not
been clarified. The clinic staff with minimal
coaching were able to inoculate the urine
onto the agar plates. This can be exploited
in further studies. At present we do not
Proceedings : 17th Priorities in Perinatal Care
30
1998
complete a notification form and submit a
MATERNAL DEATHS IN THE FREE
STATE PROVINCE, SOUTH AFRICA 1997
copy of the case records to be reviewed by
the research team. All cases were reviewed
MG Schoon, RH Bam, N Basson, D
Motsemai, L Beyers, HS Cronje
by the research team and data processed
on a computerised database. As the true
Introduction
number of deliveries in the province for the
Maternal mortality is an important health
period are unknown, the official population
parameter in developing countries. In South
estimates for the province were used. The
Africa the published mortality ratios varied
number of babies under 1 year corrected
between 48/100 000 and 550/100 000
with an estimate of perinatal mortality
deliveries. The only data available for the
(35/100 000) was used as denominator for
Free State Province are deaths that
an estimate of the mortality rate.
occurred at the tertiary care institutions.
The research team also graded care offered
The published mortality rate was 287/ 100
to the patient. In cases with sub-optimal
000 deliveries for the period 1980-1985 and
care the team tried to estimate if the care
171/100 000 deliveries for the period 1986-
would have made any difference in the
1992. The objective of this study was to
outcome (grade 1), if other management
determine the mortality rate, causes and
could possibly have changed the outcome
quality of care as accurately as possible in
(grade 2) or if other management would
the Free State Province.
definitely have changed the outcome (grade
3). This grading was done for each level of
Patients and Methods
care. In the final analysis the worst case
A research assistant was employed to build
scenario was taken as the grade for quality
an information network with all clinics,
of care.
institutions and community leaders in the
province to enable the researchers to obtain
Results
information of all maternal deaths.
A
During the period 1 January 1997 - 31
maternal death was defined as any death
December 1997 a total of 86 maternal
during any gestation or within 42 days after
deaths were recorded in the province.
the end of the pregnancy.
As far as
Insufficient data for interpretation due to
possible, relatives of the deceased were
records incomplete or lacking were found in
interviewed with the aid of a structured
11 (13%) of the cases. Final analysis was
questionnaire
based on the 75 cases with sufficient data.
to
obtain
additional
information.
The
Health care workers were instructed to
demographic data were: age (27, 16-45),
Proceedings : 17th Priorities in Perinatal Care
31
statistical
mode
and
range
for
1998
Gravidity
(1,1-8),
Parity
(0,0-6)
and
All known deaths in pregnancy were
gestational age at time of death (40, 5-41).
documented irrespective of relationship to
In 17 (23%) cases the woman died with the
the pregnancy. The high rate of missing
foetus undelivered and 16 (21%) were
data (12%) makes it impossible to comment
delivered by caesarean section. The mean
on
admission-death interval was 4.6 days (0-
Diseases' definition of maternal death. Only
39).
a few deaths were related to violence. Of
The leading primary causes of death were
concern is the high death rate at primary
infective 17 (23%), obstetric haemorrhage
care institutions in the province.
16 (21%), hypertensive disease 15 (20%)
reflects an inability of the health care
and medical disease in pregnancy 9 (12%).
workers to identify risk appropriately and to
The primary causes of death are stratified
refer the cases to a specialist care centre.
in Table 1 and the final causes of death in
The high rate of sub-optimal care in the
Table 2.
province,
HIV results were known in 29
the
International
both
at
Classification
primary
and
secondary level
In only 17 (24%) of the cases with sufficient
interpreted as either inadequately trained
data to assess quality of care as related to
staff or lack of specialist supervision and
the circumstances leading to the death,
internal audit.
management was regarded as optimal.
Infective causes remain an important cause
Serious health care worker involvement was
of death. Escalation of the HIV epidemic
present in 35 (73%) of the 48 cases
now becomes evident in maternal mortality.
assessed as sub-optimal. In these cases
There were 8 confirmed AIDS related
delay in taking action (54%) was the most
maternal deaths in the 13 cases known to
important factor, followed by delay in
be HIV positive. In the other 5 cases, 3
diagnosis,
were assumed terminal of AIDS and other
and
iatrogenic
factors.
could
This
cases and 12 (44%) were positive.
misconduct
institutions
care
of
be
preventable conditions missed or ignored.
Puerperal sepsis is common and the
Discussion
diagnosis often
delayed. Obstetrical haemorrhage remains
patients received prior to death.
a problem in the province. Death due to
probably reflects a typical tip of an iceberg
hypovolaemic
shock
as it could be extrapolated that this
common
may reflect
and
is
unacceptably
This
insufficient
represents the general quality of care in the
resuscitation skills of the professionals
province. Actions to correct the quality of
dealing with these patients.
care need to be taken.
The provincial authorities should take note
In conclusion the provincial authorities need
of the high rate of sub-optimal care that
to take immediate action to address the
Proceedings : 17th Priorities in Perinatal Care
32
1998
mortality rate. We believe that an active
peripheral hospitals should be motivated to
program of in-service training including
refer patients to referral hospitals earlier and
resuscitation skills, sepsis awareness and
closer relations with the tertiary institution
hypertension management needs to be
should be encouraged.
introduced.
Table 1
Health care workers in the
Primary causes of death
Abortion
Acute collapse
Anaesthetic related
Ectopic pregnancy
Embolism
Haemorrhage
Hypertension
Infective
Medical disease
Non Obstetric
No primary cause
Data not available
Table 2
n
% of all deaths
% of available deaths
1
2
4
2
3
16
15
17
9
3
3
11
0.16
2.33
4.65
2.33
3.49
18.60
17.44
19.77
10.47
3.49
3.49
12.79
1.33
2.67
5.33
2.67
4.00
21.33
20.00
22.67
12.00
4.00
4.00
n
% of all deaths
% of available deaths
15
11
13
1
12
1
8
7
1
6
11
17.44
12.79
15.12
1.16
13.95
1.16
9.30
8.14
1.16
6.98
12.79
20.00
14.67
17.33
1.33
16.00
1.33
10.67
9.33
1.33
8.00
Final Causes of Death
Cardiac
Cerebral
Hypovolaemic shock
Liver failure
Multi-organ failure
Renal failure
Respiratory failure
Septic shock
Other
Unknown
Data not available
Proceedings : 17th Priorities in Perinatal Care
33
1998
SEVERE
ACUTE
MATERNAL
MORBIDITY: A PILOT STUDY OF A
DEFINITION FOR A "NEAR MISS"
Outcome measure
The primary obstetric factors and the organ
systems that failed.
GD Mantel*, E Buchmann**, H Rees***, RC
Pattinson*
MRC Unit for Maternal & Infant Health Care
Strategies*, Department of Obstetrics &
Gynaecology, Kalafong Academic Hospital*,
Reproductive Health Research Unit*** and
Chris Hani Baragwanath Hospital**
Identification of
episodes of sub-standard care and missed
opportunities.
Results
147 near misses and 30 maternal deaths
were identified. The commonest reasons
Objective
for a near miss were an emergency
The purpose of this paper is to report a pilot
hysterectomy in 42 cases (29%), severe
study testing a definiton of severe acute
hypotension in 40 cases (27%) and
maternal morbidity i.e. a maternal near miss.
pulmonary oedema in 24 cases (16%). The
A national multi-centre study using this
most common initiating obstetric conditions
definition has been embarked upon to
were hypertension in 38 cases (26%),
assess the relationship between a maternal
haemorrhage in 37 cases (25%) and
near miss as defined in this paper and
abortion or puerperal sepsis in 29 cases
maternal mortality.
(20%).
amongst
Design
The primary obstetric factors
maternal
deaths
were
hypertension (33%), sepsis (27%) and
A 1-year prospective descriptive multi-centre
maternal medical diseases (17%) in 10, 8
study.
and 5 cases respectively.
Sub-standard care was identified in 82
Setting
cases.
Kalafong and Pretoria Academic Hospitals,
Breakdown in the health care
administration was identified in 33 cases
catering for the delivery of indigent women
and patient-orientated missed opportunities
in the Pretoria Health Region.
on 34 occasions.
Methods
Conclusions
A near miss describes a patient with an
The definition of severe acute maternal
acute organ system dysfunction, which if not
morbidity identified nearly 5 times as many
treated appropriately, could result in death
cases than maternal death. This definition
(see Table 1). The case notes of women
allows for an effective audit
fitting this definition and all maternal deaths
system of maternal care, because it is
were analysed and compared.
clinically based, the definition is robust and
the cases identified reflect the pattern of
Proceedings : 17th Priorities in Perinatal Care
34
1998
maternal death.
Proceedings : 17th Priorities in Perinatal Care
35
1998
Table 1
Proposed clinical criteria for a maternal near miss
MARKERS
A
ORGAN SYSTEM
BASED
1.
Cardiac dysfunction
2.
Vascular dysfunction
i)
Hypovolaemia requiring 5 or more units whole blood
or packed cells for resuscitation
3.
Immunological
dysfunction
i)
ii)
Intensive care admission for sepsis
Emergency hysterectomy for sepsis
4.
Respiratory dysfunction
i)
Intubation and ventilation for more than 60 minutes for
any reason other than for a general anaesthetic.
Oxygen saturation on pulse oximetry less than 90%
lasting more than 60 minutes.
The ratio of the partial pressure of oxygen in arterial
blood to the percentage oxygen in inspired air is 3 or
less, i.e. paO2/FiO2 is 3 or less.
i)
ii)
ii)
iii)
5.
Renal dysfunction
i)
ii)
Pulmonary oedema: A clinical diagnosis necessitating
intravenous furosemide or intubation.
Cardiac arrest
Oliguria, defined as less than 400ml per 24 hours,
which does not respond to either careful adequate
intravascular rehydration or attempts at inducing a
diuresis with furosemide or dopamine.
Acute deterioration of Urea to above 15mmol/l or of
Creatinine to above 400mmol/l.
6.
Liver dysfunction
i)
Jaundice in the presence of pre-eclampsia. Preeclampsia defined here as a blood pressure of 140/90
or greater together with 1 plus or more of proteinuria.
7.
Metabolic dysfunction
i)
ii)
Diabetic keto-acidosis
Thyroid crisis
8.
Coagulation dysfunction
i)
Acute thrombocytopenia requiring a platelet
transfusion.
9.
Cerebral dysfunction
i)
ii)
Coma in a patient lasting more than 12 hours.
Subarachnoid or intracerebral haemorrhage.
B
MANAGEMENT BASED
1.
Intensive care admission
i)
For any reason
2.
Emergency hysterectomy
i)
For any reason
3.
Anaesthetic accidents
i)
Severe hypotension associated with a spinal or
epidural anaesthetic. Hypotension defined as a
systolic pressure less than 90mmHg lasting more than
60 minutes.
Failed trachial intubation requiring anaesthetic
reversal.
ii)
Proceedings : 17th Priorities in Perinatal Care
36
1998
vs 27,6 years.
FATAL AND NEAR-FATAL MATERNAL
INCIDENTS IN THE FREE STATE
PROVINCE REGIONS A AND B DURING
1997
The majority of
patients (95,1%) were Black. The
mean parity and gravidity were 1,3
and 2,3 respectively.
MG Schoon, N Basson, RH Bam, L Beyer, I
Niemand, MKD Motsamai
Dept of Obstetrics and Gynaecology,
University of the Orange Free State
The HIV
positive rate was much higher in the
near-miss leading to death group
(21,2 vs 11,9%) - however in a very
Introduction
high
The Maternal death/Near-miss project is a
information
combined venture between the Universities
Surprisingly 23,9% of our patients
of Witwatersrand, Pretoria and the Orange
did not attend any form of antenatal
Free State with aim of investigating serious
care.
2.
maternal morbidity and mortality. A near-
percentage
(45,4%)
was
this
unknown.
Delivery Data
miss is defined as a failure of an organ
Nearly 48% of all pregnancies
system in the mother that can lead to death.
yielded liveborn babies.
What is not known is whether studying
percentage of pregnancies (5,6%)
near-misses will reflect pathological causes
were multifetal. The mean gestation
of maternal death and missed opportunities
when delivery took place was similar
in the medical service and in the community.
at 32 weeks for both groups.
3.
The exact extent of maternal morbidity and
A high
Near-miss incidents
mortality in pregnancy in the Free State is
The main category by far was
unknown other than the cases managed at
cardiac
the Academic Institutions in Bloemfontein.
especially pulmonary oedema -
The aim of the study is therefore to examine
followed by respiratory dysfunction
abovementioned unknown factors.
We
(12,7%)
hereby present the analysis of the first years
(11,3%).
dysfunction
and
renal
(47,2%)
-
dysfunction
data (1997) of patients handled in health
regions A & B of the Free State.
Results
During 1997 a total of 142 cases were
reported. Of these 109 (76,8%) were nearmisses alone and 33 (23,2%) were nearmisses leading to death.
1.
Demographic Data
The mean age of the patients in
both groups was very similar - 26,5
Proceedings : 17th Priorities in Perinatal Care
37
1998
4.
Primary Obstetric Problem
Hypertensive disorders (36%) form
the bulk of this category.
Evaluation
The panel of investigators found suboptimal
care to have been given in 31,6% of the
Near-miss group and to 28,8% of the Near
miss leading to death group. The majority
of this suboptimal care occurred in levels 2
& 3 care settings. Inadequate medical care
is the main component of avoidable factors
identified in cases where suboptimal care
was given to the patients.
Conclusions
*
This study will undoubtedly give us a
better idea of severe maternal
morbidity and mortality in regions A
& B of the Free State.
*
12 new cases are identified monthly
in our regions.
*
Although antenatal care is free of
charge and readily available, still
23,9% of patients did not attend any.
*
Hypertensive disorders are by far
the primary obstetric problem in both
groups.
*
In 1997, 33 patients died (23,2%) of these 24,7% received suboptimal
care and could possibly or probably
have been avoided.
IS THE LACK OF ANTENATAL CARE AN
IMPORTANT AVOIDABLE FACTOR FOR
SEVERE
ACUTE
MATERNAL
MORBIDITY?
Proceedings : 17th Priorities in Perinatal Care
TE Mdeni*, GD Mantel*, H Rees**, RC
Pattinson*
MRC Unit for Maternal and Infant Health
38
1998
Care Strategies*, Department of Obstetrics
& Gynaecology, Kalafong Academic
Hospital* and
Reproductive Health
Research Unit, Chris Hani Baragwanath
Hospital**
death. An in depth interview on the socioeconomic background of each "near miss"
patient, and where possible, the relatives of
a maternal death were undertaken.
Outcome measure
Introduction
The number of antenatal visits or her
Maternal mortality has been a notifiable
reasons for the lack of antenatal care were
condition since 1 December 1997. Methods
recorded.
of audit of maternal morbidity are being
Results
developed, one example being the "Near
There were a total of 160 near misses and
Miss" study in Soweto, Pretoria and
29 maternal deaths identified over one year.
Bloemfontein. In this study, every maternal
145 near misses and the families of 18 of
death or pregnant woman experiencing
the maternal deaths were interviewed. Of
severe acute morbidity is assessed for
the patients that survived 49 women (34%)
examples of missed opportunities with
respect
to
the
client
herself,
never attended a clinic, hospital or private
her
practitioner for antenatal care. Of these
management by her health care workers
non-attenders,
and the health system itself.
24
had
to
have
an
emergency hysterectomy, 15 had severe
hypotension, 5 developed acute renal
Objective
failure, 4 went into pulmonary oedema and 1
To assess whether failure to attend
intensive care admission. However 24 of
antenatal care by a pregnant client is a
these women (49%) did not know that they
major avoidable factor in cases of severe
were pregnant in the first place, 11 having
acute maternal morbidity (maternal "near
an ectopic pregnancy and 13 being
miss") and mortality.
abortions
Design
i.e.
all
early
pregnancy
complications. Of the other non-attenders,
A multi-centre descriptive study over one
7 had had an unwanted pregnancy, 4 had
year.
concealed their pregnancies, 4 women
could give no reason for not attending for
Setting
not attending for antenatal care, 5 were
The data from one unit i.e. Kalafong and the
postponing their antenatal care until later, 3
Pretoria Academic Hospitals is reviewed.
had transport and financial problems and 2
Intervention
women could not take time off from work.
A "near miss" describes a patient with a
Of the 96 women who had booked, 52
acute organ system dysfunction, which if not
(54%) had attended the health care services
treated appropriately, could result in her
3 or more times, but another 22 were
Proceedings : 17th Priorities in Perinatal Care
39
1998
unsure of the exact number of visits. The
any antenatal care. However, nearly half of
families of 18 of the 29 deaths have been
these women claimed they were actually
interviewed. Seven patients' antenatal care
unaware that they were pregnant because
was unknown to their families and 2 had
of a complication at an early gestational
never attended.
age. Traditional antenatal care starting late
Nine had attended
antenatal care.
in pregnancy, is not effective in preventing
Discussion
this morbidity.
Thirty four percent of women experiencing
available early pregnancy diagnosis service
severe acute maternal morbidity did not
could help in decreasing severe maternal
attend antenatal care. Half of these women
morbidity.
Possibly a more freely
said they were unaware they were pregnant
in the first place. These women all had an
early pregnancy complication i.e. either an
ectopic pregnancy or an abortion. Another
14% had an unwanted pregnancy.
The
question is, could this morbidity have been
avoided?
These women may have
suspected a possible pregnancy or had
worrying symptoms (e.g. amenorrhoea,
abnormal
vaginal
abdominal pain).
bleeding,
or
lower
Possibly lack of easy
accessibility to the public health care service
prevented
these
women
seeking
an
explanation, such as pregnancy, for their
symptoms. A suggested solution, therefore,
is that easier, more convenient access to a
pregnancy confirmation service, may identify
pregnancies earlier, and with resultant
timeous appropriate referral (e.g. to an
emergency
gynaecology
department/casualty or to a termination of
pregnancy service) the acute morbidity may
have been averted.
Conclusions
One third of women who had had severe
maternal morbidity had not been seen for
Proceedings : 17th Priorities in Perinatal Care
40
1998
THE MIDWIFE OBSTETRIC UNITS, CAPE
TOWN. VITAL STATISTICS 1980-1994
study period, the percentage decreased
HA van Coeverden de Groot, AA van
Coeverden de Groot, DH Greenfield
University of Cape Town and Provincial
Administration of the Western Cape
indications accounting for 82% of referrals,
from 30,8 to 19,6.
The 6 commonest
were: hypertension; abnormal obstetric
history; malpresentations; "fetal distress";
prolonged
Primary perinatal care in the Peninsula
pregnancy;
and
medical
complications.
Maternal and Neonatal Service (PMNS) in
Cape Town is provided by Midwife Obstetric
Labour Ward admissions
Units (MOUs). Community acceptance of
such
an
almost
entirely
These totalled approximately 211 000,
midwife-run
divided into:
programme is largely dependent on the
*
latter's safety record for patients and their
Deliveries - increasing over the 15
years from some 600 to 1 100 per
newborn infants. This paper presents the
month, totalling some 145 000.
vital statistics produced by the MOUs
*
between 1980 and 1994.
Infants "born before arrival" (BBAs) a total of some 13 000, or 6% of all
admissions, with little variation.
Booking and antenatal visits
There
were
approximately
*
239
000
approximately 53 000 patients, or a
bookings and 1 201 000 antenatal visits. In
fairly
an effort to halt the continuously escalating
transfers,
patients was introduced in the PMNS in
all
The 6 commonest
were:
hypertension,
prelabour rupture of membranes,
visits per booking (an approximation of the
preterm labour and antepartum
number of visits per patient) decreased from
haemorrhage.
7,7 to 4,6. This was achieved without any
mortality
of
prolonged labour, "fetal distress",
1984. As a result, the number of antenatal
perinatal
25%
indications, accounting for 83% of
antenatal visits for low risk (i.e. MOU)
in
constant
admissions.
number of visits, a curtailed schedule of
deterioration
Intrapartum referrals to hospital -
Postnatal maternal referrals to hospital
or
Only three percent of patients were
morbidity, either in the MOUs or in the
transferred postnatally for maternal reasons.
PMNS as a whole.
The
four
commonest
indications,
accounting for 90% of referrals, were:
Antenatal referrals to hospital
postpartum
Antenatally, 24% of patients booked at the
retained
placenta; hypertension;; and extensive
MOUs were referred to hospital. Over the
Proceedings : 17th Priorities in Perinatal Care
haemorrhage;
perineal lacerations.
41
1998
approximately 50% and 20% of the rate for
the PMNS as a whole.
Main maternal problem in the MOUs
The hypertensive disorders of pregnancy
constitute the most important maternal
Perinatal deaths
problems in the MOUs, accounting for 18%
Among the 211 815 infants born during the
of all the referrals.
study period, there were 2 846 stillbirths and
1 129 neonatal deaths, a total of 3 975
Neonatal transfers to hospital
perinatal deaths, giving an uncorrected
Only four percent of the infants, born in the
perinatal mortality rate (PNMR) of 19 per 1
MOUs plus BBAs, required transfer to
000 total births.
hospital.
approximately 60% and 40% of the figure
The 6 commonest indications,
These figures were
accounting for 91% of referrals, were:
for the PMNS as a whole, respectively.
birthweight <2 500g; respiratory distress;
The MMRS and PNMRs for the MOUs are
asphyxia neonatorum; neonatal jaundice;
satisfactory, but have risen markedly during
congenital anomalies and infections. The
the latter years of the study period.
small number of referrals for neonatal
jaundice testifies to the efficiency with which
Community and ethnic differences in
the MOU midwives administer phototherapy.
vital statistics.
The above mentioned vital statistics entirely
Unbooked patients
fail to highlight the marked differences
On average, these accounted for only five
between ethnic groups and between settled
percent of labour ward admissions.
and squatter communities, for several
important parameters. Thus, in 1994, the
Patients managed in the MOUs
following differences were noted inter alia:
This number is made up of booked plus
*
Antenatal referrals - a more than
fourfold difference between the
unbooked patients, a total of some 249 000.
"lowest referral" and the "highest
referral" MOU.
Maternal deaths
*
There were 32 maternal deaths among the
Intrapartum
referrals
-
a
60%
labour ward admissions during 1980-1993
difference between the "lowest
(1994 data incomplete), 10 in the MOUs and
referral" and the "highest referral"
22 in hospital. The uncorrected maternal
MOU.
*
mortality rates (MMR) for labour ward
BBAs - a more than threefold
admissions, and for the MOU deliveries plus
difference between the "best" and
BBAs were 17 and 7 per 100 000
the "worst" MOU.
respectively.
These
figures
Proceedings : 17th Priorities in Perinatal Care
*
were
42
PNMR - a more than threefold
1998
difference between the "best" and
the "worst" MOU.
Conclusion
These data show what can be achieved by
a primary perinatal care system, staffed by
dedicated and competent midwives, such as
the MOUs in the PMNS Region.
The
statistics presented provide a yardstick for
other Third World perinatal programmes.
Proceedings : 17th Priorities in Perinatal Care
43
1998
pelvis outlet.
POSITION DURING SECOND STAGE OF
LABOUR: A REVIEW OF RANDOMISED
CONTROL TRIALS
Theoretically, squatting
provides all the advantages of the erect
position,
together
with
the
possible
C Nikodem, J Gupta*, J Hofmeyr
University of the Witwatersrand and
Coronation Maternal and Child Hospital
* St James University Hospital, Leeds, U.K.
advantages of increasing both the inlet and
Introduction
be that women do not have the appropriate
The position women would naturally adopt
muscular fitness and stamina to remain
during birth has been described as early as
squatting for some time and that it may
1882 by Engelmann.
He observed that
increase perineal trauma. Lately, the advent
primitive women not influenced by the
of a supported squat during delivery, either
Western societies, would try to avoid the
using a birthing cushion or stool seems
dorsal position.
attractive.
outlet pelvis dimensions.
The major
disadvantages of the squatting position may
Today the majority of
women in Western societies deliver in a
dorsal, semirecumbent or lithotomy position.
Aims
It is claimed that the dorsal position enable
Our aims with this review is to evaluate the
the midwife/obstetrician to monitor the fetus
available
better and to ensure a safer birthing
information about the benefits and possible
environment.
contemporary
disadvantages for the use of alternative
investigators agree that an upright position
positions during the second stage of labour.
Not
all
scientific
evidence
to
gain
is most advantageous for labour. Deliveries
in a birthing chair have been studied, but
Methods
there is conflicting data on the possible
We included any randomised controlled trial
advantages and disadvantages of using a
that
birthing chair for delivery.
requirements comparing different birthing
The squatting position for birth is often the
positions. Nineteen studies were included.
most natural position, and is often used by
Few studies were excluded, mainly as
women if left alone to choose a position,
results were presented in other trials that
lateral position, birth cushion, Comparison
were included or abstracts had not enough
between any two of the following positions
information. The overall quality of included
may be included. birth Supine or lithotomy
studies was poor and therefore the
position, any upright stool, birth chair,
conclusion must be regarded as tentative.
met
our
preset
methodological
squatting, kneeling, Taylor hang/squat
position. comfortable position for birth.
Results
Radiological studies have shown that
In the studies reviewed, the use of an
squatting increases the diameter of the
upright position during second stage of
Proceedings : 17th Priorities in Perinatal Care
44
1998
labour significantly reduced, the duration of
second stage and the need for c/s or for
assisted deliveries [OR 0.28(0.69-0.97)].
Although the upright posture has shown a
significant increase in the incidence of
second degree tear's [OR 1.28(1.08-1.51)],
the
incidence
of
episiotomies
was
significantly reduced [OR 0.67(0.58-0.77)].
There was no difference between the
comparisons regarding manual removal of
placenta, need for blood transfusions,
admission to neonatal intensive care unit or
prenatal death. Post partum haemorrhage
showed a significant increase in the women
that used an upright posture, especially
those who used a birthing chair [OR
1.76(1.34-2.32)]. Not one of the 25 studies
describes a scientific method of blood loss
collection. The difference in the blood loss
may be due to the absorption of blood by
the bed linen, while the blood collection for
those delivering in a birth chair is usually in
a specific container and linen is not soaked.
Conclusion
Based on current evidence women who
prefer to deliver in an upright posture should
be encouraged to do so. However, in view
of the poor quality of trials further research
is needed, using well designed protocols
and controlled methods of blood collection
and information on the need for blood
transfusions.
THE MINIMUM PRACTICAL SUCCESS
RATE OF VAGINAL BIRTH AFTER
CAESAREAN SECTION: A DECISION
ANALYSIS
Proceedings : 17th Priorities in Perinatal Care
G Mantel
MRC Unit for Maternal and Infant Health
Care Strategies
45
1998
who has had a previous Caesarean section.
Introduction
A large proportion of Caesarean sections
Method
are performed on women who have had a
A retrospective review of the Kalafong
previous Caesarean section. In order to
obstetric database from mid-1993 to early-
reduce the high repeat Caesarean section
1997 was performed (40 months). Perinatal
rate, it is recommended that a trial of labour
and maternal outcome measures of women
in these women can effectively achieve
who had had previous Caesarean section
more vaginal deliveries.
These studies
were extracted. Outcome measures sought
report a seventy five to eighty three percent
were the mode of delivery, perinatal death,
vaginal delivery rate amongst those opting
maternal death, major maternal morbidity,
for a trial of labour. Overall, the length of
such as uterine rupture, hysterectomy or
hospital stay, the incidence of postpartum
operative injury, minor maternal morbidity,
transfusion, and of postpartum fever is
such as puerperal sepsis, blood transfusion,
significantly less in those undergoing a trial
or wound infection. From this information,
of labour, as opposed to those delivering by
an attempt was made to construct a
elective Caesarean section. However these
decision analysis tree.
trials
patient utility factor for each possible
do
report that uterine rupture,
emergency hysterectomy,
and
After applying a
rupture
outcome, a mathematically derived 'more
related perinatal and maternal deaths are
preferable' mode of delivery can be chosen,
associated with a trial of labour in women
for the individual patient.
with a previous Caesarean section.
sensitivity analysis on each key probability
It was noted locally, however, that on the
and utility was performed to test the
yearly statistics for 1995/1996 only 65
robustness of the conclusion.
women out of a total of 234 women
Results
attempting a vaginal birth after a previous
1237 women with a previous caesarean
caesarean section at Kalafong Hospital
section delivered at Kalafong Hospital from
were successful (27.8%). This compared
mid-1993 to mid-1996.
unfavourably with other reported local and
women had an elective caesarean section
international experience, making it difficult to
and a further 12% had a caesarean section
council our future patients presenting to
in early labour. The remaining 73% had a
antenatal clinic with a history of a previous
variable attempt at a vaginal delivery, with
caesarean section.
just over half of them requiring an
The aim of this paper is to use the process
emergency
of 'decision analysis' to reach an objective
planned elective caesarean section group
decision on the mode of delivery in a women
had a perinatal mortality rate of 32.9 per
Proceedings : 17th Priorities in Perinatal Care
46
caesarean
Finally, a
15% of these
section.
The
1998
1000 births above 500g as opposed to 40.5
outcomes is shown in Figure 1.
for the attempted vaginal delivery group
probability of each outcome derived from
(ns). There were 2 maternal deaths and 8
the above results is shown in Table 1. As
ruptured uteri (9 per 1000 for the trial labour
some of the outcomes were not recorded in
group). It was not possible to extract the
the Kalafong database, figures were used
rate of minor morbidity from the database.
from
other
papers
describing
The
similar
patients.
Decision analysis
For the purpose of this exercise the utility for
A decision analysis tree with the possible
a possible outcome was taken as zero for
death, 0.5 for major morbidity, 0.8 for minor
morbidity and 1 for intact survival. Readers
are referred to standard articles on how
utilities and expected utilities are derived
from a particular patient.
From the decision analysis tree we found
that the decision to attempt a vaginal
delivery was sensitive to the success rate of
a trial of labour. Below a 35% success rate
it would be more useful for the prospective
parturient to opt for an elective caesarean
section, while a success rate above 35%,
the preferred option would be a trial of
labour.
Fig 1
Decision Analysis Tree
Proceedings : 17th Priorities in Perinatal Care
47
1998
Table 1
The probability of each outcome derived from the Kalafong obstetric
database or from the literature as indicated *
Planned vaginal birth
Planned elective c/section
Probability
Rupture
Vaginal
delivery
Emergency
c/section
Elective
c/section
Emergency
c/section
Mode of delivery
Death
Major morbidity
Minor morbidity
Intact survival
0.009
0.25
0.125
0.625
0
0.43
0.00012*
0.002*
0.043*
0.95488
0.561
0.00068*
0.038*
0.093*
0.86832
0.55
0.00047*
0.008*
0.076*
0.91553
0.45
0.00068*
0.038*
0.093*
0.86832
Conclusions
In women who have had a previous
caesarean section, we now have the
probabilities of various outcomes from our
own service with which to counsel our
antenatal patients. The minimum of a 35%
success
rate
for
vaginal
birth
after
caesarean section is a useful and realistic
yardstick to use in the audit of obstetric
practice.
Proceedings : 17th Priorities in Perinatal Care
48
1998
effective in the prevention of postpartum
RECTAL
MISOPROSTOL
IN
THE
PREVENTION
OF
POSTPARTUM
HAEMORRHAGE:
A
PLACEBO
CONTROLLED TRIAL
haemorrhage; the uterotonic effect on the
postpartum
uterus
has
also
been
documented.
AA Bamigboye, JG Hofmeyr, DA Merrell
Depts of Obstetrics & Gynaecology.
Coronation and Natalspruit Hospitals and
the University of the Witwatersrand
Misoprostol, a prostaglandin E1 analogue
marketed for use in the prevention and/or
treatment of peptic ulcer disease caused by
Introduction
Excessive
non steroidal anti inflammatory agents, has
maternal
after
been shown to be safe in humans. It is a
childbirth is a major cause of morbidity and
myometrial stimulant of the pregnant uterus
mortality, not only in developing countries
by
but also in developed countries. In rural
prostanoid receptors and is clinically proven
communities, lack of access to skilled birth
to be a uterotonic agent when administered
attendants who are able to administer
orally and vaginally for induction of labour.
parenteral oxytocics, the high incidence of
Side effects of oral misoprostol are
anaemia in pregnancy, non-availability of
essentially gastro-intestinal and are dose
safe blood transfusion services and lack of
dependent.
refrigeration to store oxytocics worsens the
hypotensive effects of a high oral dose of
outcome of post partum haemorrhage.
misoprostol have been documented, a
Active management of the third stage of
property which can be an advantage over
labour which includes use of oxytocic
the ergot containing oxytocics which are
therapy, early cord clamping and placental
hypertensive.
delivery
easily stored at room temperature and
by
cord
blood
traction
loss
has
been
selectively
binding
to
Clinically
EP-2/Ep-3
insignificant
Misoprostol is affordable,
demonstrated to be an effective prophylactic
possesses a shelf life of several years.
measure against postpartum haemorrhage.
The objective of this study therefore is to
Side effects of conventional oxytocics
investigate the use of rectal misoprostol
range
compared with placebo in preventing
from
nausea,
vomiting
and
hypertension to postpartum eclampsia,
intracerebral
infarction,
haemorrhage,
cardiac
arrest,
postpartum haemorrhage.
myocardial
pulmonary
Patients and methods
oedema and inadvertent administration of
The study was approved by the Committee
the parenteral oxytocic to the neonate
for Research on Human subjects of the
causing neonatal convulsion.
University of Witwatersrand.
In a prospective observational study, oral
women in labour at Natalspruit Hospital,
misoprostol has been suggested to be
Johannesburg, were asked to participate in
Proceedings : 17th Priorities in Perinatal Care
49
Low risk
1998
the trial and informed consent was obtained.
code for analysis.
Baseline data were recorded. Allocation
was by means of sealed, opaque containers
Results
containing 400g of misoprostol or placebo
Records of 4 of the 550 allocations could
tablets in a computer-generated random
not be traced (all from the placebo group).
sequence. A limitation of the study was that
Data for the remaining 546 women were
identical placebo tablets could not be
analysed.
obtained.
variables are shown in Table 1. Age and
The allocated tablets were inserted rectally
parity were well matched, as was the
within one minute of delivery of the baby,
occurrence of perineal trauma.
immediately after clamping the cord. Linen
The mean duration of the third stage was
soiled with blood and liquor was changed
similar; 6.6 minutes (SD 14.8) in the
and a new absorbent, plastic-backed linen-
misoprostol group and 6.4 minutes (SD 8.4)
saver and low-profile plastic bedpan placed
in the placebo group. In the misoprostol
beneath the patients' buttocks to facilitate
group 13 women (4.8%) had blood loss of
subsequent
1000ml or more, compared to 19 women
blood
collection.
Blood
The baseline and labour
collection in the plastic bedpan continued
(7%) in the placebo group.
until one hour after delivery of the baby.
infusion was required in 5 women (1.8%) as
Perineal trauma (episiotomy, 1st or 2nd
against 13 (4.4%) respectively.
degree tear) was noted and if present
Discussion
sutured, taking care not to discard the
Visual estimation of blood loss after delivery
swabs used during this procedure for later
has been shown to underestimate true
weighing. Patients were carefully observed
blood loss.
for features of excessive blood loss and if
therefore taken to be 1000mls or more
present, active intervention commenced by
measured blood loss in this study.
giving 1 ampoule of syntometrine and if
The potential for this trial to demonstrate a
bleeding persisted, syntocinon 20 units
difference in the rate of excessive blood loss
infusion in 1 litre of ringers' lactate.
between the misoprostol and the placebo
Exactly 1 hour after delivery, all blood on the
group was clearly limited by the need to
linen-saver was scooped into the bedpan
administer conventional oxytocics as soon
with the blood already collected in the
as blood loss appeared to be more than
bedpan and this was carefully measured.
usual. The sample size was calculated to
All linen-saver(s) and the vaginal pad(s)
give an 80% chance of detecting a reduction
used were weighed.
in blood loss > 1000mls to 5% from 12.5%
All data were entered onto a database (Epi
(based
on
data
Info 6) before breaking of the randomisation
randomised
trials
Proceedings : 17th Priorities in Perinatal Care
50
Syntocinon
Significant blood loss was
from
two
showing
previous
estimated
1998
postpartum haemorrhage of 4.1% with
Of particular interest was the fact that
active management of the third stage
shivering was noted in only 7.1% of the last
compared with 13.5% with physiological
70 women, with no obvious increase in the
management.
The actual difference of
misoprostol group. In an uncontrolled series
4.8% vs 7% did not reach statistical
of women receiving postpartum misoprostol
significance. This 31% reduction is similar
600g orally, shivering was noted in 62%. If
to that from a recent Swedish trial in which
rectal misoprostol is confirmed in larger
the incidence of measured blood loss
studies
>1000ml was 6.2% following oxytocin 10u
postpartum blood loss, the reduction in side-
vs 8.8% following placebo (29% reduction).
effects may be an important advantage of
to
be
effective
in
reducing
this route of administration.
Conclusions
In this study there was a trend towards
reduced postpartum haemorrhage using
misoprostol 400g rectally, but with the
numbers studied this was consistent at the
95% certainty level with anything between a
large reduction and a small increase in
occurrence. Of importance is the apparent
lack of side-effects compared with the oral
route of administration.
Proceedings : 17th Priorities in Perinatal Care
51
1998
Table 1
Comparison of baseline variables between women randomly allocated to
receive misoprostol 400g rectally or placebo in the prevention of
postpartum haemorrhage, expressed as mean values (standard deviation)
or numbers (%). Missing data indicated by n values, the number of patients
included in each analysis
Enrolled
Age (years)
Parity
Episiotomy
Table II
Placebo
n
275
(5.8)
271
27.3
(1.3)
259
2.6
(60%) 266
159
(6.0)
(1.4)
(60%)
Comparison of outcome variables between women randomly allocated to
receive misoprostol 400g rectally or placebo in the prevention of
postpartum haemorrhage, expressed as numbers (%). Missing data
indicated by n values, the number of patients included in each analysis
Misoprostol
n
271
Enrolled
Primary outcomes:
Blood loss > 1000ml
270 13 (4.8%)
Need for additional
271 9 (3.3%)
oxytocic
Need for syntocinon
271 5(1.8%)
infusion
Secondary outcomes:
Placenta delivered
271 76(28%)
spontaneously
3rd stage > 30 268 1(0.37%)
minutes*
"Side-effects"*
- Shivering
34 1(2.9%)
- Abdominal pain
271 1 (0.37%)
- Vomiting
271 1 (0.37%)
*
Misoprostol
n
271
269
26.3
251
2.4
263
158
Placebo
n
275
Relative risk
p=
(95% CI)
272 19(7%)
0.69(0.35-1.37) 0.37
275 13(4.7%) 0.70(0.31-1.62) 0.54
275 12(4.4%)
0.42(0.15-1.18) 0.15
275 71(26%)
1.09(0.82-1.43) 0.62
272 2(0.73%)
36 4 (11%)
275 0 (0%)
275 1 (0.36%)
numbers too small for meaningful analysis
Proceedings : 17th Priorities in Perinatal Care
52
1998
orally and has few side-effects. However,
ORAL MISOPROSTOL FOR LABOUR
THIRD
STAGE
MANAGEMENT:
RANDOMISED ASSESSMENT OF SIDE
EFFECTS
preliminary studies have suggested that
misoprostol in the puerperium causes
shivering in some women. The purpose of
JG Hofmeyr, C Nikodem, M de Jager,
A Drakeley, B Gilbart
Dept of Obstetrics & Gynaecology,
Coronation Hospital and University of the
Witwatersrand
this study was to detemine the magnitude of
this side-effect and whether it is doserelated.
Background
Setting
Postpartum haemorrhage is an important
An academic hospital in Johannesburg,
cause of maternal mortality and morbidity.
South Africa with 7000 deliveries per
In sub-Saharan Africa the maternal mortality
annum.
rate is established to be 655 per 100 000
live births. As many as 25% of maternal
Method
deaths in rural areas are due to postpartum
Women in labour were randomly allocated
haemorrhage.
In Britain, where most
to receive misoprostol 600g or placebo
women have access to medical care
orally (part 1), or misoprostol 400g or
including the use of ocytocic drugs, the risk
600g or placebo orally (part 2) after the
of maternal death from haemorrhage is
birth of the baby. Conventional oxytocics
about 1 in 100 000 births. The routine use
were given immediately if blood loss was
of oxytocics such as Syntometrine (oxytocin
thought to be more than usual. Postpartum
5IU and ergometrine 0.5mg) or oxytocin
blood loss in the first hour was measured by
alone is associated with a significant
collection in a special flat plastic bedpan.
reduction in the occurrence of postpartum
Side-effects up to one hour after delivery
haemorrhage.
were recorded.
Misoprostol (Cytotec, Searle) is a methyl
ester of prostaglandin E1 additionally
methylated at C-16 and is marked for use in
the prevention and/or treatment of peptic
ulcer disease caused by prostaglandin
synthetase inhibitors. It has been shown in
several studies to be an effective myometrial
stimulant of the pregnant uterus. Its use in
the third stage of labour has recently been
suggested. It is inexpensive, easily stored
at room termperature, rapidly absorbed
Proceedings : 17th Priorities in Perinatal Care
53
1998
Results
a. 600g
c. Placebo
b. 400g
Shivering
Part 1
Part 2
Combined
p
values
p
values
p
values
a vs c
b vs c
a vs b
133/300 (44%)
81/199 (41%)
214/499 (43%)
65/199 (37%)
33/300 (11%)
30/199 (15%)
63/499 (13%)
.0000
.0000
.0000
.0001
.12
86/2999 (29%)
53/200 (27%)
139/499 (28%)
28/200 (14%)
13/299 (4%)
5/200 (2.5%)
18/499 (3.6%)
.0000
.0000
.0000
.003
.003
Pyrexia
> 38
Part 1
Part 2
Combined
Conclusions
Misoprostol
400-600g
orally
in
the
puerperium causes shivering and pyrexia
which is dose-related for pyrexia and
possibly for shivering, but no serious side
effects. These studies were not designed to
have
sufficient
power
to
assess
its
effectiveness in preventing postpartum
haemorrhage (no significant reduction was
found). Because of the potential benefits for
childbearing women, particulary those in
developing countries, further research to
determine its effects with greater certainty
should be expedited.
Proceedings : 17th Priorities in Perinatal Care
54
1998
a growing informal settlement on the
LEVELS OF CARE IN ATTERIDGEVILLE
western outskirts of Atteridgeville.
RC Pattinson, LR Pistorius, GD Mantel,
MRC Unit for Maternal and Infant Health
Care Strategies and Department of
Obstetrics and Gynaecology, University of
Pretoria and Kalafong Hospital
This study was undertaken to ascertain the
applicability of the 80% primary, 15%
secondary and 5% tertiary levels of care
assumption to a black urban population.
Introduction
It has been widely accepted that for a
Methods
community pregnant women, about 80% will
With computer randomisation, one month in
require primary care only, 15% secondary
1996 was randomly selected. Two authors
level care and 5% tertiary level care. These
(LRP and GDM) reviewed the patient files of
figures have been used extensively to plan
all Atteridgeville residents who delivered at
obstetric health services.
Kalafong Hospital during this month. From
Kalafong Hospital is situated on the eastern
the patient files, basic demographic data
border of Atteridgeville in Pretoria, and
was extracted, as well as data on
serves as a primary and secondary hospital
complications during the patients’ antenatal,
for the pregnant patients resident in
Atteridgeville.
intrapartum and postpartum progress that
Except for patients with
would warrant referral to secondary or
cardiac lesions who are referred to Pretoria
tertiary levels of care. The level of care for
Academic Hospital for obstetrical care, all
different complications was agreed prior to
tertiary care is managed in Kalafong
data collection, with the basic principle that
Hospital as well. On average, 2350 patients
patients would be managed on the lowest
from Atteridgeville deliver at Kalafong
appropriate level of care. The levels of care
Hospital annually. It is uncertain how many
indicated
patients make use of private medical
Education
lower urinary tract infection could be
two percent of Atteridgeville residents
managed at primary care level with
deliver in other state hospitals in Pretoria.
appropriate management guidelines.
Community based statistics can therefore
As
another example, a patient with a previous
gleaned from Kalafong Hospital’s
caesarean section could be managed in a
obstetrical data base.
primary level antenatal clinic, but should
Atteridgeville is an urban, historically
deliver in a secondary level obstetric unit.
disadvantaged community with 88 333
Results
People predominantly
May 1996 was selected as the month for
reside in permanent structures, but there is
Proceedings : 17th Priorities in Perinatal Care
Perinatal
example, a patient with an uncomplicated
unpublished) demonstrated that less than
female residents.
the
Programme was used as a guideline. For
facilities, but a recent survey (Pattinson,
be
by
investigation.
55
From the computerised
1998
database, 157 Atteridgeville residents were
eighty seven patients (57%) could be
identified who delivered during this month.
managed in a primary care antenatal clinic.
Of the 157, 148 files could be retrieved from
Fifty two patients (34%) should be referred
the medical record archives. In four other
for secondary care, and 13 patients (9%)
patients, enough data could be extracted
should be referred for tertiary care. The
from the labour ward register to enable a
reasons for referral to the different levels of
grading of the appropriate level of care. No
care are reflected in Table 1.
record could be found of five patients (either
Sixty nine patients (45%) could deliver in a
in the medical record archives or in the
primary care labour unit. Seventy patients
labour ward register), and these patients
(46%) should be referred for secondary
were excluded from analysis.
level intrapartum care, and thirteen patients
All but 13 patients (9%) attended antenantal
(9%)
care in the health service clinics.
One
intrapartum care. The reasons for referral to
hundred and eight patients (71%) started
the different levels of care are reflected in
their antenatal care in the community clinics
table 2.
in Atteridgeville and 9 patients at Kalafong
During the puerperium, seventy six patients
Hospital (6%). The other patients attended
(50%) could be managed on a primary care
a variety of clinics or private medical
level. Sixty-five patients (43%) should be
practitioners for their antenatal care. The
referred for secondary care, and 13 patients
median age at delivery was 25 years. Nine
(7%) should be managed on a tertiary care
patients (6%) were younger than 18 years at
level. The reasons for the different levels of
delivery, and 14 patients (9%) were older
care are reflected in Table 3.
than 35 years at delivery. There were 44
All in all, 47 patients (33%) could be
nulliparous patients (29%), and 11 patients
managed antenatally, intrapartum, and
(7%) with a parity of five or higher at
postpartum at a primary care level.
delivery. The low birth weight rate was 18%.
patients (56%) needed secondary care at
There were two stillbirths, and no neonatal
some stage, and 16 patients (11%) needed
deaths. (Perinatal mortality rate 13/1000 for
tertiary care at some stage during their
birth weight of 500g and higher).
pregnancy or puerperium.
The
should
be
referred
for
tertiary
81
caesarean section rate was 18%. The main
indications for caesarean section were fetal
Discussion
distress,
The assumption of 80% primary, 15%
breech
cephalo-pelvic
presentation,
disproportion,
and
previous
secondary and 5% tertiary levels of care for
caesarean section.
were not applicable to a black urban
In assessing the appropriate levels of care,
population. A more realistic assumption for
it was judged that the antenatal care of
this population would be 30% primary, 60%
Proceedings : 17th Priorities in Perinatal Care
56
1998
secondary and 10% tertiary levels. These
densely populated areas of South Africa.
figures are based on the assumption that all
Alternatives would be to have a Medical
patients will be referred appropriately. They
Officer Obstetric Unit (MOOU) or Mega-
also assume that the primary level of care is
Obstetric Units (M-OUs). An example of a
equivalent to that provided by a Midwife
MOOU is the obstetric service run by the
Obstetric Unit (MOU).
Accepting these
Mamelodi Day Hospital in Pretoria. In this
assumptions the results are very similar to
unit there are medical officers available 24
the actual utilisation figures reported from
hours a day. They are based at casualty but
Cape Town and Soweto.
do regular ward rounds in the labour ward
The central assumption for this article is
and see problem cases. Cases requiring
making the level of care given by the
caesarean sections are referred out to other
midwife equivalent to primary care and any
delivery sites. Using this system for 1996
care given by a doctor as secondary or
and 1997 the referral rate has been only
more.
This is a realistic assumption as
22,5% and the perinatal mortality rate for the
there is a currently a drive for the creation of
whole community, including referrals, has
many MOUs in South Africa. In an MOU,
been constant at about 20/1000 deliveries
the midwives are responsible for all the care
(PPIP data – Pretoria Region). This system
of the pregnant woman, with perhaps
is probably closer to that envisaged by the
visiting doctors on occasion.
To be
World Health Organisation when the 80%
effective, a MOU must remain open for 24
primary, 15% secondary and 5% tertiary
hours a day, and for this there must be a
levels of care were proposed. The Mega-
bare minimum of 8 midwives and 3 assistant
Obstetric
nurses. To try and make the MOU cost-
dedicated obstetric staff available 24 hours
effective, a minimum number of deliveries
a day. To justify the expense of having
must occur. If one assumes the deliveries
doctors on call 24 hours a day doing just
required need to be 5 per day (or about
obstetrics, the number of deliveries must be
1800 deliveries per year), and using 70% of
large.
the population requiring secondary or
caesarean sections must be performed at
tertiary care (from the levels of care
these sites.
established above), the community served
These models do not address the situation
would need to have a pregnant population
in rural areas, only those in urban areas.
of 6000 per year. At 20 deliveries per 1000
The situation in rural areas is more complex
population, a community of 300 000 people
because of the lower density of population
would be needed to justify a MOU. This
and the more scarce resources.
simple calculation brings into question the
It is hoped that these community-based
viability of MOUs for anything but the most
statistics, based on what should be a
Proceedings : 17th Priorities in Perinatal Care
57
Units
are
large
units
with
Operative obstetrics for example
1998
representative urban community, can assist
decisions on the future of obstetrical care in
medical managers to make evidence-based
their Provinces.
Table 1.
Antenatal complications
Only the most commonly occuring complications in each category are noted. Numbers do not always tally,
as one patient can have more than one complication.
Primary care (87 patients = 57%)
Urinary tract infection
Previous caesarean section
Antepartum haemorrhage
Secondary care (52 patients = 34%)
Poor obstetric history
Anaemia
Hypertension
Underlying medical condition
(epilepsy 1; asthma 3)
Rhesus negative
Tertiary care (13 patient = 9%)
Poor obstetric history
Hypertension remote from term 4
Complicated urinary tract infection
Insulin dependent diabetes mellitus
Proceedings : 17th Priorities in Perinatal Care
11
7
1
13
12
9
4
4
6
3
2
58
1998
Table 2.
Intrapartum complications
Only the most commonly occuring complications in each category are noted. Numbers do not always tally,
as one patient can have more than one complication.
Primary care (69 patients = 45%)
Mild anaemia
Poor obstetric history
Born before arrival
6
5
1
Secondary care (70 patients = 46%)
Previous caesarean section
Hypertension
Breech presentation / multiple pregnancy
Underlying medical condition
Prelabour ruptured membranes
Moderate or thick meconium
Low birth weight infant
20
Caesarean section
Tertiary care (13 patients = 9%)
Complicated hypertension
Underlying medical conditions
Very low birth weight infant
Table 3.
10
8
7
8
7
4
23
4
3
8
Postpartum complications
Only the most commonly occuring complications in each category are noted. Numbers do not always tally,
as one patient can have more than one complication.
Primary care (76 patients = 50%)
Secondary care (65 patients = 43%)
Postoperative (Caesarean section)
Stillbirth / late abortion
3
Postpartum surgery
(sterilisation 6; third degree tear 1)
Tertiary care (11 patients= 7%)
Complicated hypertension
Underlying medical conditions
Very low birth weight infant
Table 4
22
7
4
3
8
Highest level of care needed
Primary care:
Secondary care:
Tertiary care:
57 patients (33%)
81 patients (56%)
16 patients (11%)
Proceedings : 17th Priorities in Perinatal Care
59
1998
expressed
KANGAROO MOTHER CARE
breastmilk.
Mothers
are
encouraged to breastfeed their babies
A Malan
frequently using whatever feeding position is
Kangaroo Mother Care (KMC) was started
most comfortable. Tucking the infant under
in Bogota, Colombia in 1979. Drs Rey and
the arm (football position) often works best
Martinez commenced this management of
for small babies as it allows good control of
preterm infants in response to overcrowding
the head of the infant and suckling can be
of their neonatal unit. Since then it has
monitored by the thumb and fingers. In
been put into practice in many countries with
immature infants latching-on must be
beneficial effects.
By tradition KMC is
actively done for the baby as well as
divided into kangaroo position, kangaroo
compression of the areola. A satisfactory
nutrition and kangaroo discharge.
daily weight gain should be present. The
stimulation of the infant at the breast greatly
aids lactation.
Kangaroo position refers to the skin-toskin placement of the preterm infant
between the breasts of the mother. Apart
Kangaroo discharge irrespective of weight
from a nappy (and perhaps a cap and
is possible once the infant is feeding
booties) the infant is naked. The mother
satisfactorily and weight gain is maintained.
does not wear a bra and secures the baby
Very small infants can go home to continue
by her tucked-in clothes or a wrap-around
KMC. Of importance is the training of the
cloth. The mother is to maintain an upright
mother prior to discharge and a system of
or semi-reclined posture including being
follow-up, on a daily basis if required. The
propped
are
father or another person can provide KMC
encouraged to walk about and perform
when the mother has a shower or bath. The
ordinary tasks with the infant in the
mother should provide 24 hour KMC for the
kangaroo
be
benefit of the baby. Towards term the infant
commenced as soon as the infant's
usually provides cues that he/ she is ready
condition is stable. In practice, it is often
for discontinuance of the kangaroo position.
up
in
bed.
position.
Mothers
KMC
can
done at each and every visit by the mother
to the neonatal unit. Some units commence
Clinical applications
KMC while infants are still on IV fluids, and
These are usually reported according to the
respirators.
available level of neonatal facilities and
Kangaroo nutrition aims at establishing
care. Most of the physiological studies have
exclusive breastfeeding as is the case with
been done in tertiary care units.
kangaroos.
studies are quoted to indicate the uses of
need
tube
Immature infants will initially
and/or
cup
feeding
Proceedings : 17th Priorities in Perinatal Care
A few
KMC in different settings.
with
60
1998
Anderson described the benefits of KMC in
practices. It is easy to do in any situation.
a tertiary care unit in the United States.
They found that temperature regulation was
In affluence, it is a precious gift.
as good as in an incubator and that TcPO 2
In financial constraints, it is a useful addition
did not decrease.
to infant care.
There were fewer
apnoeic episodes, no additional risk of
In poverty, it may be the only means of
infection, and improved regulation of the
survival.
infants' behavioural state. Breastfeeding
rates
were
higher
and
breastfeeding
continued for longer periods.
In
Zimbabwe,
Bergman
showed
an
increased survival from 10% to 50% for
infants below 1500g. Charpak reported on
a very large randomised control trial in
Bogota. Survival and growth to one year
were not compromised with KMC. Hospital
stay was shortened and the incidence of
both overall and severe infections was
reduced. The incidence and duration of
breastfeeding were favourably affected.
A small pilot study at Groote Schuur
Hospital found similar benefits from only 12
hours of KMC per week. Daily weight gain,
hospital stay and breastfeeding were
significantly improved. The mother lodger
ward has now been converted into a 10 bed
KMC ward. Mothers are given their infants
for 24 hour KMC under the supervision of a
nurse
or
nursing
assistant.
The
arrangement allows for maximum interaction
between staff and mothers, and provides a
much
better
assessment
of
planned
discharge earlier than practised previously.
The
above
and
other
studies
have
demonstrated that KMC holds real benefits
for infants, mothers and hospital (or clinic)
Proceedings : 17th Priorities in Perinatal Care
61
1998
POSTNATAL DEPRESSION IN CONTEXT
: A DESCRIPTIVE STUDY
baby=6.6 months). Fifty five percent were
EP Mills
i.e. many of those who were employed
dissatisfied with their employment status,
outside the home, wished to remain home
Method: Prior to attending Postnatal
with their infants, and vice versa.
Depression (PND) Support and therapy
babies were planned (90%), although only
Groups, 210 mothers were interviewed in a
75% of the mothers actually wanted a baby
structured 2-hour Assessment Interview,
at the time of falling pregnant; 25% became
designed to give an understanding of PND
pregnant in order to please other members
in the context of the woman's life. Referrals:
of the family. Fertility treatment had been
self-referred (41%); Clinic Sisters and
used in 10% of the pregnancies.
Midwives (19%); GP (12%); Psychologist
raises the issue of pregnancies that are
(10%); Ob-Gyn (10%); Psychiatrist (8%).
either unwanted, or wanted "too much", i.e.
Average scores on Edinburgh Postnatal
under- or over-investment in the baby.
The
This
Depression Scale (EPDS)=14.4.
Psychopathology:
The
psychological
Subjects: Women, married (90%) on
history shows that, although few of them
average 4.8 years, average age 32; with
had been treated, 41% of the women had
tertiary education (60%).
had
She describes
depressive
episodes
since
their
herself as "a high-achiever", "perfectionist";
childhood.
"organised and in control", and usually
depression prior to the birth of the baby.
"happy and gregarious", the oldest child in
Previous PND occurred in 56% although
her biological family (41%), or the oldest
only 40% had received treatment. Eating
daughter (70%). Her role in her original
disorders had affected 24% of the women,
family
although not all of them had been clinically
is
described
as
"caretaker",
"peacemaker", or "little mother".
All of them had experienced
Her
diagnosed. (It would be interesting to study
relationship with her own mother is "difficult"
the relationship between eating disorders in
to "poor" (71%), and with her father "not
the mother, and difficulties with breast-
good" (89%).
feeding, feeding problems in the baby, and
colicky babies.) A quarter of the women had
The context: All of the primigravida (55%)
been sexually abused in childhood.
had been working prior to the birth of the
Family psychopathology: Depression in a
baby, and 71% had not returned to
first-degree relative was reported by 78% of
employment outside the home at the time of
the women.
the Assessment Interview (average age of
occurred in 36% of the women's mothers,
Proceedings : 17th Priorities in Perinatal Care
62
PND was known to have
1998
and 30% said "Don't know". Most families
had also become depressed since the
considered
was
baby's birth, and the spouses were later
shameful. Substance abuse in first-degree
found to score 14.4 average on the EPDS.
that
"mental
illness"
relatives was reported by 46% of the
women.
The birth: In spite of attending antenatal
classes, only 25% of the women reported a
Recent or current life stresses: Typical
positive birth experience. Fifty two percent
stressors, apart from the baby, were:
delivered by Caesarean section, of which
relationship problems or illness within the
20.9%
family (20%); financial worries (18%);
complications were reported by 32.8%.
housing- or work-related stress (16%);
None of the women was invited to write a
bereavement (12%).
Birth Report, or given the opportunity to
were
elective.
Perinatal
describe how she experienced the birth of
The pregnancy: During the pregnancy,
her baby. Many of the women, felt that
58% of the women were in good physical
social attitudes take little cognisance of the
health, but only 25% reported their mood as
enormity of the experience of giving birth.
being "good" during pregnancy. High levels
Preparation for after the birth: The women
of anxiety were reported by 41.4% of the
usually worked up to the last minute. They
women;
feeling
made physical preparation for the baby,
None of them told their
whom they expected to fit into their lives.
obstetricians; none of them was counselled
The focus of the antenatal classes was on
or treated for depression or anxiety during
the birth. None of the women felt that she
pregnancy. During her pregnancy, nobody
was adequately prepared for "life after birth".
and
depressed.
31.4%
reported
took her low mood or anxiety seriously.
After the birth, she was ashamed, and felt
Social Support: 50% of the women
guilty about her unhappiness, and people
described their partners as being of "no
around her trivialised her feelings.
help" when they came home from the
hospital. By the time the baby was a few
The marital relationship: The marital
months old, 54.2% of them were "giving
relationship during the pregnancy was
good parenting support". At the same time,
described as "not good" (42.8%), and was
many of the husbands or fathers of the
perceived to have deteriorated further since
babies were not allowed by their wives to do
the birth of the baby (47%). Only 32% of the
as much as they would have liked. Even
women considered that the relationship was
when the baby's father was giving "good"
still "good" after the birth of the baby. Many
parenting support, 64.8% of the women felt
women (49%) considered that their partners
that
Proceedings : 17th Priorities in Perinatal Care
63
their
partners
were
"emotionally
1998
unsupportive".
possible.
Grandmothers were willing or able to be
avoided being alone with the baby. "Good"
involved in the care of 38% of the babies.
bonding was reported by 57% of the
However, 75% of the women perceived their
women, and "slow" by 28%.
own
Mothers' perception of their babies:
mothers
as
being
"emotionally
unsupportive" or "unavailable".
Some of the women actively
Many of
Although the women were depressed, 62%
them felt unable to discuss their depression
of them described their babies as "good",
with their mothers. The birth of the baby
while 29% said the babies were "demanding
improved
and fussy".
the
grandmother-mother
Nonetheless, 70% of the
relationship in 37%; remained unchanged in
mothers admitted to "losing control" with
41%, and worsened in 9% of cases. The
their babies, - shouting, throwing them
extended family of 23% provided the woman
roughly on the bed, shaking, or hitting them.
with "good" support. Friends were helpful
Many more confessed to wanting "to throw
for 14.8%.
the baby against the wall", or "smother it
with a pillow when it won't stop crying".
Breast-feeding: Many of the women, who
Although 38% of the babies suffered from
breast-fed successfully (70%), had felt
colic, or slept less than expected (8%), only
confused and inadequate in the beginning.
14.7% had been ill.
They complained that lactation advisors had
treated them insensitively. Although 31.4%
Conclusions: The impact of Postnatal
actively disliked breast-feeding, they did so
Depression on the woman, her infant and
"for the good of the baby". There was no
her
significant correlation between time of
deleterious. The study indicates that better
weaning and onset of PND, but difficulty
preparation for parenthood would have
with establishment of breast-feeding was
made the impact of the baby easier to
associated with some of the symptoms of
accommodate, confirming previous findings
PND.
by the author.
relationship
with
her
partner
is
There is concern about
undiagnosed depression during pregnancy,
Bonding: Although the average age of the
especially as interventions at that time have
baby at the time of the Assessment
been shown to be successful. Clearly it is
Interview was 6.6 months, 15% of the
important that health professionals are
women considered that they had not
sensitised to the prevalence and insidious
bonded.
nature of PND.
They attended to the physical
Early diagnosis and
needs of the infants, if no alternative
interventions will minimise the long-term
caretaker was available; but preferred to
effects.
leave the baby to its own devices when
Proceedings : 17th Priorities in Perinatal Care
64
1998
Proceedings : 17th Priorities in Perinatal Care
65
1998
depression, this is supported by others.
VALIDATION OF THE EDINBURGH
POSTNATAL DEPRESSION SCALE ON A
COHORT OF SOUTH AFRICAN WOMEN
However some researchers have used a
threshold score of 9-10 or 11-12. Since its
TA Lawrie, GJ Hofmeyr, M de Jager,
M Berk
Dept of Obstetrics & Gynaecology,
Coronation Hospital & Dept of Psychiatry,
Johannesburg General Hospital, University
of the Witwatersrand
inception, it has been used in a number of
Introduction
Method
Postnatal depression (PND) is considered
The study was conducted over a period of 3
by
common
months. 108 consecutive women attending
complication of the puerperium. In a country
the postnatal clinic were asked to participate
like South Africa, where the majority of the
in the study. All the women were six weeks
population has been denied accessible
postpartum. Two French-speaking women
health care in the past, it is not surprising
and one Gugurati-speaking woman were
that screening for PND amongst women has
excluded. Only two women declined to take
not been a priority. Generally, very little
part in the study.
systematic study of PND has occurred in
obtained from all participants. The EPDS
non-Western cultures. Despite this, there is
was read to the women by the research
reason to believe that PND is at least as
midwife in a private consulting room, and
common in our urban communities as the
translated, if necessary, by one of two
prevalence rates of 10-15% in Western
multilingual nursing sisters experienced in
countries, taking into consideration the
translation. A doctor unaware of the EPDS
psychosocial stressors associated with
scores conducted structured psychiatric
increased risk of depression, are common in
interviews using DSM-IV criteria and the
South Africa, with high unemployment rates,
MADRS.
high crime rates, poverty, divorce and many
understanding preliminary questions with
single parent families.
The 10-item
regard to her family, employment, health
Edinburgh Postnatal Depression Scale
and recent pregnancy, a translator was
(EPDS) was developed as a screening tool
used.
for clinical and research purposes and
"gold standard" and cases of depressive
initially validated on British women. The
illness (major and minor) were defined
initial validation of the EPDS against the
according to the DSM-IV criteria.
many
to
be
the
most
countries outside of Great Britain, including
the United States, Australia, New Zealand,
Iceland, Sweden and The Netherlands.
Verbal consent was
If the participant had difficulty
The DSM-IV was considered the
Research Diagnostic Criteria by Cox et al
(1987) suggested a threshold score of 12-
Results
13 out of 30 to identify women with major
Proceedings : 17th Priorities in Perinatal Care
Afrikaans was the most common language
66
1998
spoken, followed by Zulu and Tswana.
honestly.
Thirty-two women were not sufficiently
The primary motivation for this study was to
proficient
a
validate the use of the EPDS for research
Eight women fulfilled DSM-Iv
purposes on this particular Johannesburg
criteria for major depression disorder and
community, and according to the results can
seventeen women for a minor depressive
be used for this community.
in
translator.
disorder.
English
The
and
needed
recommended
EPDS
threshold of 12-13 identified 7 cases of
major depression, resulting in a sensitivity of
87.5% and specificity of 72.3%. At their
threshold, twelve of the seventeen cases
(70.6%) of minor depression were identified,
resulting in a combined sensitivity of 76%,
specificity of 81.8% and PPV of 57.6%.
Lowering the threshold to 11-12 improved
the combined sensitivity (80%) and the
sensitivity for major depression alone
(100%) but the number of cases of minor
depression remained the same.
Conclusion
Limitations
to
this
study
should
be
emphasised. The sample size is small. The
cultural background composition of the
sample and its urban character do not make
these results readily applicable to all South
African women, particularly rural women.
The use of a translator, although carefully
instructed in EPDS and the psychiatric
interview,
inevitably
imposes
certain
limitations on the reliability of the data.
Furthermore, a "climate of openness" has
been distinctly lacking in South Africa for
decades and even the health services have
been viewed with suspicion. This may have
influenced some women not to answer
Proceedings : 17th Priorities in Perinatal Care
67
1998
women aged 18 years or more, who were
THE EFFECT OF NORETHISTERONE
ENANTATE
ON
POSTNATAL
DEPRESSION:
A
RANDOMISED
PLACEBO CONTROLLED TRIAL
agreeable to using an alternative nonhormonal method of contraception for the
duration of the trial, were asked to
TA Lawrie, GJ Hofmeyr, M de Jager,
M Berk
Department of Obstetrics & Gynaecology,
Coronation Hospital and the Department of
Psychiatry, Johannesburg Hospital and the
University of the Witwatersrand
participate within 48 hours of delivery.
Written informed consent was obtained from
all participants.
Although current antidepressant medication
and/or
Introduction
study were randomly allocated to receive a
depression and progesterone is used in
single dose of norethisterone enantate or a
some countries for the prevention and
postnatal
1ml normal saline placebo by intramuscular
depression.
injection. Randomisation was double blind.
Progestogens in contraceptive agents and
Consenting women were interviewed at
hormone replacement therapy have been
enrolment, one week, six weeks and three
implicated in causing depressive symptoms.
The
psychological
impact
of
months post partum.
using
Montgomery-Asberg Depression Rating
postnatal period is unknown. The objective
Scale (MADRS) were administered at each
of this trial was to assess the effect of
visit, the former being administered verbally.
postnatal administration of a long-acting
contraceptive
norethisterone
enantate,
on
The Edinburgh
Postnatal Depression Scale (EPDS) and the
progestogen contraceptive agents in the
progestogen
exclusion
excluded on this basis. Participants in the
possible etiological factor in postnatal
of
were
criteria for the trial, there were no women
Progesterone deficiency is considered a
treatment
psychotherapy
The presence of headaches, backache,
agent,
exhaustion, pain or other symptoms, in
postnatal
addition to the mode of infant feeding, was
depressive symptomatology. In addition, we
noted at each visit. Participants were asked
sought to determine its effect on serum sex
to keep a daily diary regarding their bleeding
hormone concentrations at six weeks
after delivery and this was returned to the
postpartum and their association with
interviewer after completion of the last
depression.
interview. At the last interview, the women
were asked when, if at all, their interest in
Methods
This
was
a
double-blind
sex had returned, and this was recorded as
randomised
weeks postpartum. Blood specimens were
placebo-controlled trial that was conducted
taken at the six-week visit, centrifuged and
at Coronation Hospital, Johannesburg.
the serum stored at -700C. Serum analysis
Between December 1995 and March 1997,
Proceedings : 17th Priorities in Perinatal Care
68
1998
was undertaken only once data collection
the progestogen group compared to the
was complete.
placebo group. Hormone parameters failed
The primary outcome measures were
to correlate with depression scores. There
depression at six weeks and three months
were no significant differences in secondary
postpartum, as continuous and categorical
outcomes except for vaginal bleeding which
(MADRS>9; EPDS>11) variables; and
more women in the progestogen group
serum
considered troubling.
concentrations
of
oestradiol,
progesterone and testosterone at six weeks
Conclusions
postpartum.
outcomes
Depot norethisterone enantate given within
measures were mode of infant feeding,
48 hours of delivery is associated with an
libido and vaginal bleeding. Ethics approval
increased risk of developing postnatal
for the trial was obtained from the University
depression.
of
should be used with caution in the
the
Secondary
Witwatersrand
Committee
for
Progestogen contraceptives
Research on Human Subjects.
immediate postnatal period and in women
Results
with a history of depression. Randomised
Ninety women were enrolled to each group.
controlled trials are needed to evaluate the
Three month follow-up was 93.3%. Overall,
role of progesterone therapy for postnatal
characteristics
depression.
comparable
of
the
except
groups
for
a
were
chance
discrepancy in mode of delivery. Twentyfour women in the progestogen group and
10 women in the placebo group underwent
Caesarean section for delivery of their baby.
Consequently, the appropriate statistical
methods were employed to analyse primary
and secondary outcomes to correct for this
discrepancy.
With regard to the main
outcome measures, those women receiving
the progestogen injection were at a
significantly greater risk of developing
depressive symptomatology by six weeks
postpartum according to mean depression
scores
on
objective
and
subjective
measures than women receiving placebo.
Mean serum oestradiol and progesterone
concentrations were significantly lower in
Proceedings : 17th Priorities in Perinatal Care
69
1998
membranes,
OBSTETRIC CAUSES FOR DELIVERY OF
VERY LOW BIRTH WEIGHT (VLBW)
BABIES AT TYGERBERG HOSPITAL
hypertensive
disease,
antepartum haemorrhage, intrauterine death
and congenital abnormalities.
ES Odendaal, DW Steyn, HJ Odendaal
Dept of Obstetrics & Gynaecology, MRC
Perinatal Mortality Research Unit
Hypertensive diseases included chronic
hypertension,
pregnancy
induced
hypertension and pre-eclampsia.
It also
Background
included all the complications due to
The Total Perinatally Related Wastage at
hypertensive disease, e.g. fetal distress,
Tygerberg Hospital is 31.5/1000 deliveries.
abruptio placentae and intra-uterine death.
Up to 60% of these deaths were babies with
Antepartum haemorrhage excluded patients
a very low birth weight. The incidence of
with underlying hypertension.
VLBW babies in first world countries is 1-
Other causes were maternal illness and
2.5%. However, the incidence at Tygerberg
intra-uterine growth retardation unrelated to
Hospital is 8.8%.
a hypertensive disease.
Objective
Results
To determine the primary reasons for the
A total of 227 patients were admitted to the
delivery of very low birth weight (VLBW)
study. One patient was excluded from the
babies.
study as the data in her file was inadequate.
Of the remaining 226 patients, 210 were
Design: Cross-sectional descriptive study.
singleton
pregnancies
pregnancies.
Setting: Tygerberg Academic Hospital.
and
16
twin
Six babies from the twin
pregnancies were excluded from the
analysis due to a birthweight exceeding
Study Period: 01 March 1997 - 31 August
1499g.
1997.
The mean age of our patients was 26.5
years. The range of the gravidity was 1 to 8
Methods
and of the parity 0-5. 82% of our patients
Data was collected from all mothers who
were booked with a median clinic visit of 4.
delivered babies weighing 500-1499 grams.
20 Patients were VDRL positive. A Doppler
The following primary causes were selected
resistance index was performed in 79
and clearly defined: Spontaneous preterm
patients. 30 of these babies had absent
labour,
end diastolic flow.
Primary
preterm
causes
hypertensive
prelabour
for
disease
rupture
delivery
101
Proceedings : 17th Priorities in Perinatal Care
of
were
spontaneous preterm labour 65 (28.8%);
(44.7%);
preterm prelabour rupture of membranes 21
70
1998
(9.3%); intra-uterine death 17 (7.5%);
antepartum
haemorrhage
10
(4.4%);
congenital abnormalities 3 (1.3%) and
others 9 (4%). Of the hypertensive cases
43 were delivered for fetal distress, 16 for
fetal distress due to abruptio placentae, 20
for maternal reasons, 19 for intra-uterine
death and 3 for both fetal and maternal
reasons.
Preterm labour occurred in 65 patients and
preterm prelabour rupture of membranes in
21 patients. The median time from onset of
symptoms to admission was 7 hours. The
mean cervical dilatation was 5.7 + 3cm.
Thirty one patients had a cervical dilatation
of
more
than
6cm
on
admission.
Suppression was attempted in only 23
patients. The median time that the delivery
was postponed was 32.2 hours. Infection
was demonstrated in almost 50% of our
patients with preterm labour or preterm
prelabour rupture of membranes.
Conclusion
Hypertension, preterm labour and preterm
prelabour rupture of membranes are the
main causes for delivery of the VLBW baby.
Keeping in mind the high morbidity and
mortality as well as the socio-economic
implications, one should give priority to
research in this problem area. Perhaps we
should look at more aggressive treatment of
early onset hypertension in order to reduce
complications. One should also look for
better screening methods for the earlier
detection of preterm labour.
Proceedings : 17th Priorities in Perinatal Care
71
1998
THE USE OF PLACENTAL HISTOLOGY IN
PERINATAL DEATHS
patients.
Placental examination was
DH Greenfield, DL Woods, H Wainwright, G
Petro
Department of Paediatrics, Pathology &
Obstetrics, UCT
patients where the clinical cause was not
unhelpful in 56 patients, 40 of them in-
obvious or there was idiopathic preterm
labour.
Aims
1.
Conclusions
Does placental histology:
*
Change
the
Placental histology was useful in:
clinical
Macerated stillbirths. The primary obstetric
diagnosis?
*
Confirm
the
cause could be identified in 86% of cases -
clinical
mainly "placental insufficiency".
diagnosis?
*
Preterm related deaths. In 64% of cases a
Make no difference, or is
cause was found, mainly chorioamnionitis.
unhelpful?
2.
In only 38% of patients with a fresh stillbirth
In what circumstances is it useful/
at or near term was the placental histology
not useful to do placental histology.
useful.
Placental histology was therefore helpful
Methods
where there was a macerated stillbirth or
A retrospective review was done of
unexpected preterm labour.
placental histology on Midwife Obstetric Unit
(MOU)
related
perinatal
deaths
from
1/1/1996 - 31/12/1997.
The babies were divided into 3 categories:
*
Macerated stillbirths.
*
Preterm labour with no obvious
cause.
*
Fresh stillbirth/neonatal death at or
close to term, where the primary
obstetric cause of death was not
obvious.
Results
There were 705 perinatal deaths during this
period. 196 (28%) of those had placental
histology.
The clinical diagnosis was confirmed in 18
Proceedings : 17th Priorities in Perinatal Care
72
1998
Effect of placental histology on cause of death
Diagnosis changed
Macerated SB
Preterm related
Fresh SB at term
n
71
%
37
10
118
21
57
196
Diagnosis confirmed
Not helpful
60
11
29
100
Changes made in the diagnosis
*
Macerated SB
New diagnosis
Preterm labour with
chorioamnionitis
Syphilis
Chorioamnionitis at term
Placental insufficiency
Other
*
5
other
6
0
3
38
7
62
0
0
3
9
Preterm related
New diagnosis
Preterm labour with
chorioamnionitis
Placental insufficiency
Other
*
Clinical diagnosis
unknown
9
Clinical diagnosis
Idiopathic preterm labour
19
Other
0
9
7
35
0
2
2
Fresh SB at term
New diagnosis
Syphilis
Chorioamnionitis at term
Placental insufficiency
Other
Proceedings : 17th Priorities in Perinatal Care
Clinical diagnosis
Unknown
2
2
3
0
7
73
Other
0
0
0
3
3
1998
or perinatally acquired infection were
THE INCIDENCE OF NEUTROPENIA AND
NOSOCOMIAL INFECTION IN INFANTS
OF WOMEN WITH SEVERE EARLY
ONSET PRE-ECLAMPSIA
excluded. Neutropaenia was defined as a
neutrophil count below the 5th centile for
postnatal age on the reference curves of
GF Kirsten, CL Kirsten, E Mansveld
Departments
of
Paediatrics
and
Haematology, Tygerberg Hospital and the
University of Stellenbosch
Mouzinho et al.
Nosocomially acquired
infection was defined as the number of (a)
proven
infections
(clinical
signs
and
Very low birth weight (VLBW) infants born to
symptoms of infection and isolation of
women with pre-eclampsia have a higher
bacteria from the blood); or (b) probable
incidence of neutropaenia (50%) at birth
infections (clinical signs and symptoms and
which is associated with an increased risk of
a C-reactive protein level > 10ug/ml.)
nosocomial infection.
Neutropaenia in
Umbilical artery Doppler flow velocities
previous studies was defined according to
recorded during the last 7 days before
reference values for normal term infants.
delivery were used for analysis.
Objective: To determine: a) the incidences
Results: 192 mother/infant pairs were
of neutropaenia (as defined according to
studied. The infants' mean birth weight was
reference values specific for VLBW infants)
1238g, SD 231 and mean gestation age
and nosocomial infections and, b) whether
30.4 weeks, SD 1.9. Thirty three (17.2%)
there is an association between the severity
infants were neutropaenic of whom 8 (24%)
of pre-eclampsia (umbilical artery Doppler
developed a definite and 7 (21%) a probable
flow velocities) and the incidence of
infection.
neutropaenia in infants born to women with
infants, 22 (13.5%) developed a definite and
severe pre-eclampsia remote from term.
24
Of the 159 non-neutropaenic
(15.5%)
a
probable
infection.
Neutropaenia was significantly associated
Patients and Methods: All infants born
with nosocomial infection during the first 21
before 34 weeks gestation and their
days of life (p=0.0029). Thirteen (6.8%)
mothers with pre-eclampsia admitted to
infants died; six from pulmonary related
Tygerberg Hospital over a 21 month period
complications while five died from infection
were studied. Mothers with infection were
and two from necrotising enterocolitis.
excluded from the study.
A complete
None of the maternal white blood cell
automated blood count was done within the
indices were related to either neutropaenia
first 72 hours of life. Differential cell counts
or nosocomially acquired infection in her
were done manually and the total white cell
baby.
count corrected for the presence of
The mean neutrophil count (3.1x109/l versus
nucleated red blood cells. Infants with ante-
4.1x109/1) (p=0.0001) and platelet count
Proceedings : 17th Priorities in Perinatal Care
74
1998
(136x109/l versus 188x109/l)(p=0.000) of the
infants with absent end diastolic Doppler
flow velocities were significantly lower
(p=0.0001) than those of the infants with
normal Doppler flow velocities.
Summary
*
17%
of
the
infants
were
neutropaenic;
*
a significant association was noted
between
neutropaenia
nosocomial
umbilical
infection,
artery
and
absent
Doppler
flow
velocities and neutropaenia and
thrombocytopaenia.
Conclusions
Infants born to women with pre-eclampsia
remote from term should be screened for
neutropaenia during the first 72 hours of life.
Screening for neutropaenia is even more
important in those infants with absent
umbilical artery Doppler flow velocities.
Those
with
neutropaenia
should
be
monitored closely for the presence of
infection so that antibacterial therapy may
be administered early.
Proceedings : 17th Priorities in Perinatal Care
75
1998
PRAZOSIN OR NIFEDIPINE AS A
SECOND AGENT TO CONTROL EARLY
SEVERE
HYPERTENSION
IN
PREGNANCY
A
RANDOMISED
CONTROLLED TRIAL
Results
Age, gravidity and parity of mothers in both
groups were comparable. Days gained on
the second anti-hypertensive agent did not
DR Hall, HJ Odendaal, DW Steyn, M Smith,
E Carstens
differ significantly (14,8 vs 16,1 p=0,69),
while 4,8 more days were gained using
Objective
nifedipine as the cross-over "third agent"
To determine whether prazosin or nifedipine
is
more
appropriate
second
(p=0,01).
line
Indications for, and type of
delivery did not differ significantly. All the
antihypertensive agent in pregnancy.
mothers with low platelets (not HELLP
syndrome) were in the nifedipine group. In
Design
the prazocin group there were more non-
Randomised controlled trial.
viable, mid-trimester (5 vs 1) and more third
trimester (2 vs 0) intra-uterine deaths.
Setting
Tygerberg Hospital, a tertiary referral centre.
Conclusions
Prazocin and nifedipine as second line anti-
Subjects and Methods
Patients
(n=150)
with
early
hypertensive agents allowed comparable
severe
amounts of time to be gained, although this
hypertension in pregnancy, or severe pre-
changed when used as cross-over third line
eclampsia, whose blood pressure could not
agents. The greater number of intra-uterine
be adequately controlled by methyldopa
deaths in the prazocin group needs to be
2g/day, and who were otherwise stable,
controlled carefully.
were randomised to receive either prazocin
or nifedipine. Both drugs were increased as
necessary in a stepwise fashion. When the
maximum dose was reached, the other drug
was added in a cross-over pattern. Failure
to control blood pressure, or the onset of
maternal
or
fetal
complications
were
indications for delivery. Patients reaching a
minimum gestational age of 34 weeks
without
complications
were
delivered
electively.
Proceedings : 17th Priorities in Perinatal Care
76
1998
Table 1a
Days gained with the second and third anti-hypertensive agents
(mean and standard deviation)
Nifedipine
Prazocin
Difference
P value
Second agent
15 (28)
12.4 (20)
2.6
0.9
Third agent
11.1 (6)
6.3 (6)
4.8
0.01
Second and third agent (column as 2nd
agent)
16.1 (28)
14.8 (22)
1.3
0.69
Table 1b
Days gained with the second and third anti-hypertensive agents
(median and range)
Nifedipine
Prazocin
Difference
P value
Second agent
6 (1-193)
7 (1-149)
1
0.9
Third agent
8 (5-29)
5 (1-25)
3
0.01
Second and third agent (column as 2nd
agent)
7 (1-193)
9 (1-157)
2
0.69
Table 2
Intra-uterine deaths (IUD)
Nifedipine
Prazocin
P value
All cases of IUD
1
7
0.03
Mid-trimester/ pre-viable IUD
1
5
0.11
Third trimester IUD
0
2
0.24
Proceedings : 17th Priorities in Perinatal Care
77
1998
of pre-eclampsia is intermittent and wished
ASSESSMENT OF URINE DIPSTICK
TESTING
FOR
SIGNIFICANT
PROTEINURIA IN PREGNANCY
to test the efficiency/efficacy of a single
dipstick reading in detecting significant
GR Howarth, W Combrink, LR Pistorius
Dept of Obstetrics & Gynaecology, Kalafong
Hospital and University of Pretoria
proteinuria.
So as to overcome the
intermittent protein secretion problem we
also utilised the dipsticks to assess a 24
Introduction
hour urine specimen.
Maternal hypertension alone is associated
with a perinatal mortality either similar to or
Patients and Methods
lower than that of normotensive women.
Should
proteinuria
accompany
Three hundred and thirty two antenatal
the
patients that were found to be hypertensive
hypertension then the perinatal mortality
were admitted for quantification of a 24 hour
increases substantially and the most
urine specimen.
important perinatal prognostic factor in
admission by means of dipstick by the
hypertension in pregnancy is the presence
nursing staff. Urine was then collected for
or absence of proteinuria.
Our
management
of
Urine was tested on
patients
24 hours and at the end of the collection the
with
bottle was shaken and a dipstick analysis
hypertension in pregnancy is home based
was performed, by a single observer (WC)
once significant proteinuria has been
on an aliquot removed from the 24 hour
excluded. As the onset of proteinuria in pre-
specimen.
eclampsia is sudden, we remain concerned
positive and negative predictive values as
that these patients may develop proteinuria
once discharged from hospital.
The sensitivity, specificity,
well as the 95% confidence intervals were
For this
calculated utilising Epistat, where the
reason we dispense dipsticks (usually in the
admission dipstick result and the dipstick
form of multisticks, that we cut off below the
performed on the 24 hour specimen were
protein indicator to facilitate interpretation)
compared to a laboratory analysis of the
and instruct patients to test for proteinuria at
total protein excreted in the 24 hour
least once daily. Patients are instructed to
specimen.
report to hospital for admission and formal
24 quantification of proteinuria if they detect
Results and discussion for dipstick on a
any colour change on the proteinuria
single voided specimen :
indicator. We are aware that the proteinuria
Seventy four of the patients had significant
Admission
proteinuria (>300mg/24 hours).
laboratory value of 24 hour urine
dipstick
compared
to
collection
Proceedings : 17th Priorities in Perinatal Care
78
1998
Dipstick results
Negative
Trace
1+
2+
3+
<300mg protein/24 hours
95
33
80
25
25
>300mg protein/24 hours
4
20
6
21
23
Total
99
53
86
46
48
A patient will only be able to interpret
indices for when there is a colour change
whether there is a colour change of the
(i.e. a trace or more).
dipstix or not and we calculated the
Dipstick colour change (i.e. trace or more) on a single voided specimen
>T
Sensitivity
Specificity
+ve PV
-ve PV
95 (86-98)
37 (31-43)
30 (24-36)
94 (89-98)
While the dipstick on a single voided
predictive value of dipstick on a single
specimen appears to be relatively sensitive,
voided specimen means that the diagnosis
it has the disadvantage that in two thirds of
of proteinuria should be made with caution
cases (233/332) the test will be positive.
when utilising this method.
Due to the low positive predictive value of
the test the patient would have to be
Results and discussion for dipstick test
admitted for laboratory quantification of the
on 24 hour urine collection:
urinary protein. For the same reason more
Seventy four of the patients had significant
than two thirds of patients admitted would
proteinuria (>300mg/24 hours).
not have significant proteinuria. The low
positive
Dipstick on 24 hour urine collection compared to laboratory value on same urine
Dipstick results
Negative
Trace
1+
2+
3+
<300mg protein/24 hours
130
58
62
7
1
>300mg protein/24 hours
0
4
22
34
14
130
62
84
41
15
Total
Proceedings : 17th Priorities in Perinatal Care
79
1998
Dipstick colour change (i.e. trace or more) on 24 hour urine collection
>T
Sensitivity
Specificity
+ve PV
-ve PV
100 (94-100)
50 (44-57)
36 (30-43)
100 (97-100)
All given as percentages, 95% confidence intervals in brackets
quantification of proteinuria and at least 24
As
the
95%
confidence intervals of
hours will have been saved.
sensitivity for detecting proteinuria overlap
for both methods neither is more sensitive.
The test on the 24 hour urine collection will
have significantly more negative results than
the test on the single voided specimen (130
versus 99, p<0,001). Although the positive
predictive value is no better than that of the
dipstick on a single voided specimen (36%
versus 30% and their 95% confidence
intervals overlap), there is an advantage that
the patient may bring the 24 hour urine
specimen into the hospital with her. Semiquantative protein analysis may now be
performed by the medical personnel as the
dipstick finding performed by them may be
compared to the box.
The positive
predictive value of either 3+ or 4+ both
exceed 80%.
Conclusion
The only advantage of the dipstick testing of
the 24 hour urine collection is that should
the patient notice a colour change, she
presents at the hospital with a completed 24
hour urine sample. Staff testing this and
finding > 3+ proteinuria
may decide there is proteinuria with a
80% certainty. Alternatively the urine can be
sent
directly
to
the
laboratory
Proceedings : 17th Priorities in Perinatal Care
for
80
1998
distances to be travelled and the problems
THE PERSPECTIVES OF RELATIVES
REGARDING MATERNAL DEATHS IN
THE FREE STATE
with the notification of some of the deaths
this tends to be problematic. In the analysis
D Motsamai, MG Schoon, RH Bam, N
Basson, L Beyer
Dept Obstetrics & Gynaecology, UOFS
we tried to determine from the information
given to the field worker regarding the
previous illnesses, pregnancy complications
Introduction
and circumstances at the maternal death to
An integral part of the ongoing multi-centre
what extent the interviewee knew what led
study into maternal mortality and morbidity
to the maternal death.
in South Africa is the structured interview of
the relatives (in case of a maternal death) by
Results
a field worker (nursing sister). The rationale
So far information of 85 deaths have been
is to enable the researchers to make as
received. The mean age of the deceased
accurate a diagnosis of the circumstances
was 28 years (range 15-45), 13% were Para
leading to and the cause of death as
0 and 72% Para 1-3, the mean pregnancy
possible.
duration at death was 33 weeks, 32% had
had no antenatal care and the mean
Methods
scholastic level was Grade 7.
The field worker conducts an interview at
To date 77 interviews have been conducted
home with a relative of the deceased. The
with the following relatives: parents 26
field worker must try to interview the
(34%; mothers 21 (27%)), siblings 23 (30%;
member of the deceased's family who has
sisters 19 (25%)), husbands 12 (17%) and
the
other
most
information
regarding
the
relatives
and
in-laws
(19%).
circumstances leading to the death. She
According
then conducts the interview without prior
circumstances leading to the death were
knowledge of the medical diagnosis of the
negligence (13; 17%), no transport (4; 5%),
case and by not asking leading questions.
lack of trust in or fear of health personnel (3;
The questionnaire consists of demographic
4%), witchcraft (2; 3%); lack of health
and socio-economic data as well as an in-
facilities (2; 3%) and secrecy about the
depth examination of any illnesses the
pregnancy (2; 3%).
patient had during her last pregnancy. Part
An attempt was made to determine whether
of this is an attempt to determine whether
the relatives knew of the primary and final
the relatives knew the cause of the death.
causes of the maternal deaths. For the 85
The interviews are done as soon as
cases documented to date the following
possible after the patient died, but given the
diagnoses were made for the primary cause
Proceedings : 17th Priorities in Perinatal Care
81
to
them
aggravating
1998
of the maternal death: undeterminable in 19
disease 8 (9%) and other in 12 cases
cases
(19%),
(14%). The diagnoses of the final cause of
haemorrhage 15 (18%), hypertension 15
death was undeterminable in 21 cases
(18%), maternal
(25%), organ failure 31 (36%), cerebral
(22%),
infection
16
complications 11 (13%), hypovolaemic
shock 10 (12%), septic shock 8 (9%) and
other in 4 cases (5%). In Table 1 the level
of the knowledge of the relatives is given.
Table 1
Knowledge of the Maternal Death (n=77)
Knowledge of the cause
Primary cause
Final cause
Yes
18 (23%)
14 (18%)
No
29 (38%)
33 (43%)
4 (5%)
4 (5%)
26 (34%)
26 (34%)
Possibly
Undeterminable if sufficient
knowledge
In only 7 (9%) of the cases did the family
have sufficient knowledge of both the
primary and final cause of the death and in
26 (34%) of the cases they definitely did not
know what was the cause of the maternal
death.
Conclusions
Steps will have to be taken where possible,
to inform the relatives of the deceased
about the circumstances leading to the
death.
Proceedings : 17th Priorities in Perinatal Care
82
1998
and thus the decision to audit the indication
IDENTIFICATION
OF
CAESAREAN
SECTIONS WHERE A PAEDIATRICIAN
SHOULD BE PRESENT
and paediatric outcome of all caesarean
sections over a six month period.
GR Howarth, E van Deynse, LR Pistorius, E
Honey
Dept of Obstetrics & Gynaecology, Kalafong
Hospital and University of Pretoria. MRC
Research Unit for Maternal and Infant
Health Care Strategies
Patients and Methods
All 331 caesarean sections over a three
month period (this is an interim analysis of
the first three months of the study:
Introduction
November - January) performed at Kalafong
It may be ideal to have a paediatrician
present
at every caesarean
Hospital were audited. The indication for
delivery.
caesarean
However due to ever increasing numbers of
caesarean
sections
and
was
collected.
Immediate neonatal outcome was evaluated
increasing
by means of the Apgar score, resuscitation
paediatric workload in the absence of
performed and need for neonatal special or
increased staffing, this ideal is becoming
more difficult to fulfill.
section
intensive care. It was felt that it would be
The American
preferable for a paediatrician at delivery is
Academy of Paediatrics and the American
Apgar <7, neonatal resuscitation score >3 or
College of Obstetricians and Gynaecologists
nursing category A or B.
have published guidelines stating that each
institution should develop a list of fetal and
Results
maternal complications that require the
During the three month period there were
presence of an individual qualified at
1332 deliveries of which 331 (40%) were
neonatal resuscitation at caesarean section.
caesarean sections.
No such formal list exists at Kalafong
Hospital
Paediatrician required
Fetal distress
67
CPD
11
Previous caesarean section
7
Breech presentation
6
Failed induction
3
Pre-eclampsia
4
Other
6
104
Proceedings : 17th Priorities in Perinatal Care
No paediatrician required
58
58
67
18
10
4
12
227
83
1998
Discussion
From the data available at present we can
only conclude that it is probably not
necessary to have a paediatrician for
caesarean section when performing a
caesar for previous caesarean section.
Once the trial is completed we will study the
need for a paediatrician not only according
to indication, but also other criteria such as
meconium in the amniotic fluid and other
factors.
Proceedings : 17th Priorities in Perinatal Care
84
1998
requires no batteries or maintenance, is
SCREENING
FOR
ANAEMIA
IN
PREGNANCY, UTILISING A COLOUR
CHART COMPARISON METHOD
virtually
indestructible
and
allows
haemoglobin estimation to occur at the clinic
M Smallwood, GR Howarth, LR Pistorius,
RC Pattinson
Dept Obstetrics & Gynaecology, Kalafong
Hospital and University of Pretoria. MRC
Research Unit for Maternal and Infant
Health Care Strategies.
and is an ideal device for measuring
haemoglobin at rural clinic level. The device
has been tested in general clinics, but not
on an exclusive population of pregnant
patients.
Introduction
Due to the high prevalence of, ease of
Patients and Methods
treatment for, and potential complications
The
associated with anaemia in pregnancy, all
haemoglobin in 2g/dl increments from 4g/dl-
pregnant patients should be screened for
14g/dl. The card was utilised by a single lay
the condition. A recent study has shown
observer (MS) to estimate the haemoglobin
that at present, <15% of antenatal patients
of 213 antenatal patients, these findings
at rural clinics have their haemoglobin
were
tested during pregnancy.
haemoglobin value on the same patients.
The reasons
card
allows
compared
for
to
estimation
the
of
laboratory
being lack of, or broken equipment,
transport problems or laboratory costs. The
Results
WHO has devised a colour scale card for
Of the 213 patients, 61 had a laboratory
the estimation of haemoglobin levels which
haemoglobin of less than 10g/dl.
is cheap,
Lab Hgb <10g/dl
Lab Hgb >10g/dl
32
7
39
29
145
174
61
152
213
Sensitivity 52%, specificity 96%, positive predictive value 82%, negative predictive value 82%.
Card Hgb <10g/dl
Card Hgb >10g/dl
Discussion
While the card is not expensive and easy to
use, the sensitivity of the card for antenatally
identifying patients with a haemoglobin less
than 10g/dl is too low for it to be used as a
screening tool in antenatal clinics.
Proceedings : 17th Priorities in Perinatal Care
85
1998
replacement. Four grades of inversion have
O'SULLIVAN'S MANOEUVRE - SONAR
SEQUENCE.
HYDROSTATIC
REDUCTION OF ACUTE PUERPERAL
UTERINE INVERSION
been described by Barr. Causes can be
grouped as iatrogenic, uterine pathology
and uterine atony. Most commonly, it is
HRG Ward
Department of Obstetrics & Gynaecology,
Tygerberg Hospital
caused by premature traction on the cord
before placental separation. Other features
include adherent placentae, uterine tumors,
Introduction
tocolysis and multiple births.
Acute puerperal uterine inversion (APUI) is
an
obstetric
emergency
and
APUI
prompt
can
be
avoided
by
awaiting
spontaneous placental separation followed
reduction can be achieved using vaginal
by careful controlled cord traction. it should
hydrosufflation. Sonar images in sequence
be
record the procedure for the first time.
anticipated
in
high
risk
patients.
Resuscitation should be commenced prior
to any attempt at reduction once the
Case report
diagnosis is confirmed. Assistance should
A 34 year old G1P1 was referred after
be obtained. Wide bore intravenous access
resuscitation from a secondary hospital with
with two lines, tocolysis using Hevaprenaline
APUI. She had delivered a 3285gm baby
10g ivi or MgS04 4g over 5 mins and
uneventfully at a primary facility but
appropriate blood replacement should be
developed acute third stage haemorrhage.
arranged. An indwelling urinary catheter is
APUI was immediately obvious on arrival.
advisable.
Vaginal replacement of the uterus followed
hydrostatic, digital and surgical, with the
with spontaneous placental separation.
latter two requiring general anaesthesia.
Vaginal hydrosufflation was commenced -
Hydrostatic reduction requires the patient in
watertight occlusion was facilitated by
the supine position, and the uterus,
straightening and adducting the patient's
preferably with the placenta still attached,
legs effectively clamping the vulva around
replaced into the vagina.
the attendant's arm. Three litres of 0.9%
procedure
sequential
sonar
was
recorded
images
successful reduction.
A 20g Foleys
urinary catheter is fed over the attendant's
saline was infused under pressure. The 9
minute
Reduction options include:
gloved fist in the vagina. The patient's legs
by
are straightened and adducted to facilitate a
confirming
water tight fit. Three litres of saline are
Recovery was
rapidly infused into the vagina until the
uneventful.
uterus is reverted.
Discussion
Placental removal
should follow. Complications include failure
Hydrostatic reduction requires that the
with the need to proceed surgically, water
uterus is returned into the vagina for final
intoxication and infection. Once the uterus
Proceedings : 17th Priorities in Perinatal Care
86
1998
is in position then uterine massage,
oxytocin,
ergometrone
and
even
prostaglandin administration may be needed
for adequate contraction.
Conclusion
Acute puerperal uterine inversion can be
safely
reversed
without
general
anaesthesia, using vaginal hydrosufflation
according to O'Sullivan. This is facilitated
by the straightening and adduction of the
patient's legs. The sonar sequence of a
successful reduction is presented for the
first time.
Proceedings : 17th Priorities in Perinatal Care
87
1998
For women who wish to continue with their
THE IMPACT OF A PREGNANCY
CONFIRMATION CLINIC ON ANTENATAL
CARE
pregnancy, a screening history will be taken,
followed by a physical examination, nitrituria,
LR Pistorius, RC Pattinson, B Jeffrey,
MV Tsuari
blood and glucose. Blood testing for Rh
incompatibility and syphilis serology will also
Introduction
be done on site. A motherhood card will be
In the Atteridgeville community a large
given and the patient will attend at her local
proportion of pregnant women commence
clinic (see flow diagram).
antenatal care in the latter half of pregnancy
despite the introduction of free antenatal
Results
care.
The study is presently on-going. At the end
of the study, data on the following
Aim
parameters will be evaluated:
To introduce a pregnancy confirmation clinic
*
Gestational age at confirmation of
as part of antenatal care to determine firstly,
pregnancy and hence first antenatal
whether this would decrease the gestational
visit.
*
age at which patients commence antenatal
Factors related to early pregnancy
care and secondly, whether this would alter
complications
other ourcome measures such as perinatal
pregnancy and abortions.
*
mortality, low birth weight rate, stillbirth:
Visits
to
other
neonatal death ratio and perinatal care
professionals
index.
pregnancy.
*
e.g.
in
ectopic
health
the
current
Referrals from clinics to secondary
Patients and Methods
and
A descriptive study will be undertaken
indications for the referrals.
*
tertiary care
Factors
related
are pregnant. This service will be offered at
outcome
e.g.
three clinics: Saulsville and Vembe Clinics
results,
at Atteridgeville and Folang Clinic which
incompatibility, etc.
involving all women who suspect that they
care
centers
to
pregnancy
syphilis
anaemia,
serve the Pretoria Central Business District.
*
Pregnancy outcome; and
A urine test for pregnancy will be done,
*
The
patient's
and
serology
rhesus
satisfaction
with
antenatal care.
followed by an abdominal ultrasound
regardless of the patient's future plans for
the pregnancy.
The data will be collected from the labour
Women who request
termination will be referred to the TOP clinic
ward
for counselling and further management.
Kalafong Hospital, a secondary and tertiary
Proceedings : 17th Priorities in Perinatal Care
88
and
gynaecological services
at
1998
centre
for
the
greater
Atteridgeville
community. Patients who deliver elsewhere,
will be requested to complete a pre-paid
postcard with information of the pregnancy
outcome.
Proceedings : 17th Priorities in Perinatal Care
89
1998
Flow Diagram
Pregnancy Confirmation Clinic
URINE
POSITIVE
NEGATIVE
ABDOMINAL
ULTRASOUND
REFERRAL
CONTINUE
TOP
FPC
INTRAUTERINE
PREGNANCY
EMPTY
UTERUS
TOP CLINIC
URINE DIPSTICK
LNMP >
7W
LNMP < 7W
BLOOD
PRESSURE
GOPD
SAME
DAY
REPEAT U/S AFTER 2W
COUNSEL ABOUT SX & SIGNS
OF ECTOPIC PREGNANCY
GOPD
INFERTILITY
BLOOD SAMPLE
RH, RPR, HB
ANTENATAL
CLINIC/ REFERRAL
COLLECT
DELIVERY DATA
Proceedings : 17th Priorities in Perinatal Care
90
1998
available at most small hospitals and clinics.
SYMPHYSIS-FUNDAL MEASUREMENT
AS
A
PREDICTOR
OF
LOW
BIRTHWEIGHT
Symphysis-fundal measurement requires
no sophisticated equipment, is inexpensive
BS Jeffrey, RC Pattinson, J Makin
Department of Obstetrics & Gynaecology,
Kalafong Hospital and University of Pretoria.
MRC Unit for Maternal and Infant Health
Care Strategies
and easy to perform.
Symphysis-fundal measurement has been
found to be useful in identifying fetuses with
intrauterine growth restriction. Quaranta et
Introduction
al identified 73% of infants with a birth
Low birth weight is the greatest contributor
weight below the tenth percentile by the use
to perinatal morbidity and mortality in South
of symphysis-fundal measurements. The
Africa. Infants with a birth weight of more
diagnosis of intrauterine growth restriction
than 2000g seldom require admission to
can only be made if gestational age is
specialised
known
neonatal
units,
whereas
or
with
serial
measurements.
authors
have
examined
neonates with a mass of less than 2000g
Several
frequently require
Most
usefulness of a single symphysis-fundal
peripheral hospitals and Midwife Obstetric
measurement in predicting birth mass. Dare
Units
et
do
not
such
have
care.
the
facilities
or
al
found
that
the
symphysis-fundal
appropriately trained staff to care for low
measurement in labour had a correlation
birth weight infants and it is expensive and
with birth mass of 0.742.
difficult to transfer the low birth weight infant
Soderberg
after delivery. Transfer after delivery also
measurement and abdominal girth and
results in critical delays in instituting
found a correlation of 0.63 with birth mass
treatment. It is much better to transfer the
but symphysis-fundal measurement alone
pregnant woman with the fetus still in utero.
had a correlation of only 0.57, however this
In order to identify those women with
study was within a general population with
fetuses requiring transfer but not to swamp
birth masses ranging from 1500g to more
secondary and tertiary hospitals with
than 5000g.
unnecessary referrals, it is important to
Bergstrom and Liljestand used a single
devise some means by which fetuses likely
symphysis-fundal measurement in labour
to have a birth mass of less than 2000g can
and found that a measurement of 30cm
be identified with a high degree of sensitivity
predicted with 90% probability a birth mass
and specificity.
greater than 1950g if the fetal head was not
Clinical estimation of fetal size is inaccurate,
engaged in the pelvis and greater than
especially for small fetuses.
There is a
2250g if the fetal head was engaged. In a
tendency to overestimate the mass of the
study performed at Kalafong Hospital,
small baby. Ultrasound facilities are not
findings were similar with a significant
Proceedings : 17th Priorities in Perinatal Care
91
used
Pschera and
symphysis-fundal
1998
correlation between symphysis-fundal height
and
and birth mass (r=0.72). It was determined
Measurements were not taken during a
that
uterine contraction.
the
critical
symphysis-fundal
intra-observer
measurements.
measurement for predicting a birth mass
The two symphysis-fundal measurements
less than 2000g was 29cm, with a positive
were recorded on a data sheet together with
predictive value of 78%. It was found that
the patients gravidity, parity, the state of
abdominal girth measurement did not
engagement of the fetal head, the state of
improve the predictive value.
the membranes (ruptured or intact), the fetal
This study was performed in order to
presentation and a subjective assessment
prospectively test the value of a symphysis-
of the patient's body habitus. After delivery
fundal measurement in labour of less than
the infant was weighed with a Salter Model
29cm as a predictor of birth mass below
40A scale.
2000g.
The information on the data sheets was
captured
onto
a
database
(Microsoft
Patients and Methods
Access) according to the patient's hospital
A cohort was selected from the patients
number.
admitted to the labour ward at Kalafong
complete, information regarding number of
Hospital in labour. Inclusion criteria were:
deliveries, birth masses and symphysis-
*
Singleton pregnancy
fundal measurements was extracted. The
*
In latent or active labour
information was then analysed using single
*
Consent of the patient that her
descriptive statistics.
Once
data
collection
was
information be used for the study.
Symphysis-fundal
measurement
was
Results
performed according to the method of
A total of 1216 women were included in the
Westin by the registrar on call on two
study. 121 neonates had a birth mass of
occasions at least ten minutes apart. The
less than 2000g (10%). For predicting a
measurements were taken with a measuring
birth
tape with the markings facing the patient's
measurement of less than or equal to 29cm
abdomen. The tape was turned around to
had a sensitivity of 69% and a specificity of
see the markings only when the position of
98% with a positive predictive value of 81%
the symphysis-fundal measurement on the
and a negative predictive value of 97%.
tape had been determined. It was found in
The predictive values for this and other
the previous study at Kalafong Hospital that
symphysis fundal measurements are shown
there is a good correlation between inter
on Table 1.
Table 1
mass
of
less
than
2000g,
a
Results of symphysis-fundal measurement as a predictor of birth mass less
than 2000g
Proceedings : 17th Priorities in Perinatal Care
92
1998
SF cut-off measurement
29cm
30cm
31cm
32cm
Sensitivity
69%
77%
83%
84%
Specificity
98%
97%
96%
92%
Postive predictive value
81%
74%
68%
55%
Negative predictive value
97%
97%
98%
98%
The analysis was repeated under several
would change the sensitivity or specificity.
different
Results are shown in Table 2.
conditions,
to
see
whether
exclusion of patients with certain criteria
Table 2
Analysis of results under varying conditions
SF cut-off measurement
SF=29cm
SF=29cm Fetal
head not
engaged
SF=29cm
Obese patients
excluded
SF=29cm
Membrane
intact
Sensitivity
69%
68%
68%
67%
Specificity
98%
98%
98%
99%
Positive predictive value
81%
84%
83%
87%
Negative predictive
value
97%
95%
96%
96%
There was a good correlation between
A receiver operator curve was drawn for
symphysis-fundal measurement and birth
various
mass with a correlation coefficient of 0.736
measurements and is shown in Figure 1.
cutoff
symphysis
fundal
(p<0,05).
Figure 1
Proceedings : 17th Priorities in Perinatal Care
93
1998
Proceedings : 17th Priorities in Perinatal Care
94
1998
Using
a
symphysis-fundal
cutoff measurement of 30cm, there were 27
measurement of less than or equal to 29cm,
false negatives of which 15 had a birth mass
38 fetuses with a birth mass of less than
of greater than 1800g.
2000g were missed (i.e. false negatives).
fetuses missed by the 30cm cutoff and with
Of these fetuses, 19 had birth masses
a birth mass of less than 1800g are shown
greater than 1800g. With a
on Table 3.
Table 3
cutoff
Outcomes for
Outcomes of fetuses less than 1800g missed by 30cm cutoff
Stillborn
2
Pre-viable
1 (700g)
Admission to neonatal high care
4
Admission to neonatal intensive care
3 (2 died)
No follow-up record available
2
Total
12
Discussion
so many false positives. If a cutoff of 30cm
This study has shown that a symphysis-
is used, the false positives will be reduced
fundal measurement of less than or equal to
to 26%, while still providing a sensitivity of
29cm is a good predictor of birth mass less
77% for fetuses greater than 2000g and
than 2000g. It is also encouraging that of
86% for fetuses greater than 1800g.
those fetuses missed by this cutoff, fifty
figure of 30cm is also an easy value to
percent had a birth mass of greater than
teach and remember. For these practical
1800g and therefore would be unlikely to
reasons,
need admission to a high care neonatal unit.
measurement of less than or equal to 30cm
If symphysis-fundal measurement is to be
as a referral criteria for probable birth mass
used as a referral criterion to hospitals with
of
neonatal units, the practical implications
measurement chosen by each unit will
must be considered.
On the receiver
depend on the capacity of the unit to cope
operator curve, the measurement with the
with large numbers of referrals and the
most favourable sensitivity to specificity is
prevalence of low birth weight in the
31cm. Using this measurement, however,
population served by that unit.
less
our
than
unit
would
2000g.
choose
The
A
a
cutoff
will result in 32% of referrals being false
positives, i.e. fetuses with a birth mass of
greater
than
2000g
and
therefore
unnecessary referrals. The unit where the
study was performed would not be able to
cope with a large number of referrals due to
Proceedings : 17th Priorities in Perinatal Care
95
1998
cost.
AMNIOCENTESIS AND THE TAPTEST IN
PROTEINURIC
HYPERTENSION
IN
PREGNANCY
"TAPPET":
A
RANDOMISED CONTROLLED TRIAL
A pilot study commenced December 1996;
with
an
randomised.
LR Pistorius, GR Howarth, L Freislich, RC
Pattinson, G Mantel, E Honey, SD Delport,
JD Makin
Dept of Obstetrics and Gynaecology,
Kalafong Academic Hospital and University
of Pretoria
MRC Unit for Maternal and Infant Health
Care Strategies
anticipated
100
patients
In the period between
December 1996 and 1997, only 30 patients
were recruited to the trial.
An
independent
audit
was
therefore
undertaken to establish whether the study
should be stopped, continued until 100
patients are recruited, or if it should be
Introduction
expanded to a multicentre study.
At present, there is uncertainty whether
amniocentesis for lung maturity has a role in
the treatment of patients with proteinuric
hypertension in pregnancy and uncertain
gestational age.
Study Design
The study is a prospective, randomised
controlled trial.
Patients with proteinuric
hypertension in pregnancy qualify for
inclusion if doubt exists about gestational
age, the fetal weight is estimated by
ultrasound between 800 and 2000g and the
patient qualifies for expectant management.
The
patient
is
amniocentesis/no
then
randomised
amniocentesis.
to
If
amniocentesis is performed, the taptest is
used to ascertain lung maturity.
if the
taptest indicates lung maturity, the fetus is
delivered. If the taptest is immature, the
patient is managed expectantly.
The endpoints of the study are perineonatal
mortality/morbidity,
maternal
mortality/morbidity and hospital stay and
Proceedings : 17th Priorities in Perinatal Care
96
1998
death, duration of hospital stay and
A PROFILE OF PAEDIATRIC DEATHS AT
WITBANK
HOSPITAL:
JUNE
TO
DECEMBER 1997
avoidable factors.
E Malek, S Onyari, P Naidu
Dept of Paediatrics, Witbank Hospital and
University of Pretoria
Method
A descriptive study of all paediatric deaths
from 1 June 1997 to 31 December 1997 at
Objective
Witbank Hospital wards and ICU.
To determine the profile of paediatric deaths
Analysis of avoidable factors was done
at Witbank Hospital between 1 June 1997
using a framework of identification codes.
and 31 December 1997 with specific
reference to: age, cause of
Proceedings : 17th Priorities in Perinatal Care
97
1998
Admissions and Deaths - June-December 1998
Month
JUN
JUL
AUG
SEPT
OCT
NOV
DEC
Admissions
102
81
85
76
81
84
82
Deaths
2
4
8
2
3
10
8
Percentage
s
1.96
4.93
9.41
2.63
3.70
11.90
9.76
Total Number of Deaths: 37
Average Number of Deaths per month: 5
Average Number of Admissions per month: 84
Duration of Stay
< 24 hours
19%
24-48 hours
24%
< 5 days
27%
> 5 days
30%
Age Distribution
Age
< 1 month
1-6 months
6-12 months
12-24 months
> 24 months
Number
3
18
4
7
5
%
8.1
48.6
10.8
18.9
13.5
Proceedings : 17th Priorities in Perinatal Care
98
1998
Avoidable Factors
Late presentation
20
Medical personnel underestimate child's condition
11
Inappropriate management
10
Malnutrition
9
Discussion
(a) Liaising with clinics; identification
There was a total of 37 deaths within the
of high risk patients for early referral
seven months. The average admission per
to 1st, 2nd or 3rd degree levels.
month was 84 with an average of 5 deaths
(b) Enforcing use of Road to Health
per month.
Charts
The majority of children or
of
all
levels
for early
infants who died were less than 12 months -
identification of malnutrition and
and were mainly caused by: prematurity and
other
HIV related illness.
management.
Approximately 20%
problems
and
their
have HIV as a diagnosis. The majority of
(c) Aggressive management of HIV
deaths
infected patients using available
occurred
within
48
hours
of
admission (43%); with 19% dying within 24
protocols.
hours.
(d) Health educating parents/ child
Deaths in those greater than 12
months were associated with malnutrition as
providers/traditional
healers
on
an underlying problem plus an infection or
dangers of use of herbal remedies in
metabolic problem due to herbs or medicine
children.
given prior to admission.
Solutions
1.
Intervention planned and initiated to
improve patient care at all levels:
Proceedings : 17th Priorities in Perinatal Care
99
1998
CHANGING PATTERNS IN PRIMARY
OBSTETRIC CAUSES OF PERINATAL
DEATHS IN THE WITBANK DISTRICT:
THE EFFECT OF THE INTRODUCTION OF
THE
PERINATAL
PROBLEM
IDENTIFICATION PROGRAMME (PPIP)
clinic. Ogies is about 40 Km from Witbank
DC Kotze, Chief Professional Nurse,
Witbank Hospital
RC Pattinson, Department of Obstetrics and
Gynaecology, University of Pretoria and
Kalafong Hospital
about 120 Km away.
and Witbank Hospital serves as the primary
delivery site for it.
Witbank Hospital’s
tertiary referrals are sent to Kalafong and
Pretoria Academic Hospital in Pretoria –
Monthly feedback meetings were held with
staff from the whole district and detailed
discussions of the perinatal deaths were
held with representatives from each area in
Introduction
The
Perinatal
Problem
the Witbank District.
Identification
Where specific
Program (PPIP) was introduced into the
problems were identified they were dealt
Witbank District in January 1996.
with, using continuing medical education
PPIP
helps identify problems associated with
and applying it to the district.
Perinatal care in an area. This study was
PPIP enables users to predefine areas or
undertaken to describe any changes in the
functional units for data collection. These
use of the health system.
can be combined in various ways to
determine perinatal problems in a specific
Method
population or delivery site.
The first seven months of 1996 were
various combinations the perinatal problems
compared with the same period in 1997.
for the District, the Kwaguqa Community,
There are two delivery sites in the Witbank
Witbank Hospital, the Polyclinic and Ogies
District. An MOU at the Polyclinic, which
were determined.
serves the Kwaguqa Community, and the
During the two study periods the number of
Witbank Hospital, which served as a referral
referrals from Polyclinic to Witbank Hospital
hospital for the district and primary delivery
in labour, the number of antenatal referrals
site for those living around the hospital and
(from all antenatal clinic sites) to the high
for Ogies.
risk clinic and number of tertiary referrals to
There
are
four
antenatal
Thus using
Pretoria were recorded.
clinics,
Hlalanikahle and Polyclinic in Kwaguqa,
Ogies and Witbank Hospital.
Results
Witbank
Tables 1, 2 and 3 compare the primary
Hospital also has a high-risk antenatal
causes of death, the referrals and various
perinatal indices for different areas in the
Witbank District respectively.
As can be seen there was a significant drop
Proceedings : 17th Priorities in Perinatal Care
100
1998
in the perinatal mortality rate and this was
This was associated with significantly
due mainly to a drop in deaths due to
increased referrals to the hospital and high
syphilis, spontaneous preterm delivery,
risk clinic.
antepartum hemorrhage and hypertensive
The Perinatal Care Index (PCI) rose in all
conditions in pregnancy.
sites
Table 1
except
that
of
Ogies.
Comparison of the Witbank District’s primary obstetric causes of death
from January to July 1996 and January to July 1997
CAUSE
Unexplained Intrauterine Death
Due to lack of information
Truly unexplained
Intrapartum asphyxia
Trauma (Breech del/ruptured uteri)
Syphilis
Spontaneous Preterm Delivery
Antepartum hemorrhage
Hypertensive Conditions
Fetal abnormalities
Primary Intrauterine Growth Impairment
Maternal Diseases
TOTAL
TOTAL DELIVERIES
Proceedings : 17th Priorities in Perinatal Care
JANUARY – JULY
1996
29
20
9
9
4
JANUARY – JULY
1997
19
13
6
12
5
14
18
15
10
6
1
0
135
2513
6
5
4
3
3
4
2
82
2318
101
P
NS
NS
NS
=0.08
<0.01
<0.05
=0.06
NS
NS
<0.005
1998
Table 2
Referrals from antenatal clinics to the hospital and from Witbank Hospital
to tertiary centres
JANUARY - JULY
1996
275
JANUARY – JULY
1997
335
Antenatal clinics to high risk clinic
46
113
Witbank Hospital to Kalafong and Pretoria
Academic Hospital
9
12
Polyclinic to Witbank Hospital
Table 3
21,81%
Increase in
referrals
112%
Increase in
referrals
N.S.
Changes in perinatal care indices for the different sites in the Witbank
district
PERIOD:01 JANUARY – 31 JULY 1996
POLYCLINIC
Total Deliveries
WITBANK HOSPITAL
Total Deliveries
KWAGUQA COMMUNITY
Total Deliveries
PERIOD:01 JANUARY – 31 JULY 1997
637
PNM 11.0
LBW 5.31
PCI 0.48
Total Deliveries
559
PNM 8.9
LBW 6.8
PCI 0.76
1876
PNM 52.8
LBW 15.3
PCI 0.24
Total Deliveries
1759
PNM 32.3
LBW 20.1
PCI 0.47
1460
PNM 41.4
LBW 11.8
PCI 0.24
Total Deliveries
1452
PNM 22.2
LBW 15.7
PCI 0.53
OGIES
Total Deliveries
258 Total Deliveries
224
PNM 59.3
PNM 50.0
LBW 20.2
LBW 17.4
PCI 0.27
PCI 0.28
(PNM – Perinatal Mortality Rate; LBW – Low Birth Weight percent; Perinatal Care Index – PCI)
Conclusion
workers. This probably resulted in observed
There are many possible explanations for
increase of referrals of problem cases to the
the improvement in perinatal care in the
relevant clinic or hospital, giving those
Witbank District.
However, the most
patients an improved chance of survival.
plausible explanation is the result of the
Improved care probably occurred in those
audit.
areas as well.
PPIP identified the problems and
resultant concentrated teaching in these
specific areas probably led to an increased
awareness of the problems by the health
Proceedings : 17th Priorities in Perinatal Care
102
1998
THE IMPORTANCE OF LOCAL AUDIT
Methods
M Muller
Middelburg Hospital
The
Perinatal
Problem
Identification
Programme (PPIP) was introduced in the
district through:
Objective
*
To compare the perinatal problems in two
Monthly
causes
well defined health districts - Middelburg
meetings,
and
to
analyse
allocate
avoidable
factors.
and Lydenburg - over a period of 24
*
months.
Bimonthly feedback and continuing
medical education for Middelburg
and Lydenburg districts.
Results
The basic perinatal indices
Middelburg District
1996
1997
Total deliveries
2336
2611
Perinatal mortality rate #
33,8
40,4
Low birth weight rate (%)
12,8
10,6
Stillbirth/neonatal death rate #
1,5:1
1,5:1
Perinatal care index
0,26
0,23
Lydenburg District
1996
1997
Total deliveries
1896
1804
Perinatal mortality rate #
49,5
35,2
Low birth weight rate (%)
12,3
13,2
Stillbirth/neonatal death rate #
1,36:1
3,9:1
Perinatal care index
0,20
0,32
Hospitals: Lydenburg District 1996-1997
Lydenburg
Belfast
Waterval Boven
Total deliveries
2214
751
435
Perinatal mortality rate #
36,8
61,4
34,7
Low birth weight rate (%)
13,4
11,9
11,7
Stillbirth/neonatal death rate #
1,36:1
2,5:1
3,5:1
Perinatal care index
0,32
0,14
0,28
* Babies of 1000g or more
*
# rates per 1000 deliveries
Pattern of Disease
PNM defined babies >1000g
Proceedings : 17th Priorities in Perinatal Care
103
1998
Primary obstetrical causes of death
Middelburg District
Lydenburg District
1996
1996
1997
no
%
1997
no
%
no
%
no
%
Intrapartum asphyxia
7
8,1
12
11,8
17
21,5
11
17,5
Spontaneous preterm labour
18
20,9
20
19,6
14
17,7
9
14,3
Infections
10
11,6
19
18,6
7
8,9
5
7,9
Antepartum haemorrhage
5
5,8
4
3,9
7
8,9
3
4,8
Hypertensive disorders
11
12,8
10
9,8
6
7,6
7
11,1
Others
35
40,8
34
36,3
28
35,4
28
44,4
TOTAL
84
100
99
100
79
100
63
100
Final causes of deaths
Middleburg District
Lydenburg District
1996
1996
1997
no
%
no
1997
%
no
%
no
%
Intrapartum asphyxia
7
21,9
7
21,2
13
41,9
4
36,4
Prematurity related
14
43,8
13
39,4
8
25,8
4
36,4
Infections
5
15,6
8
24,2
4
12,9
2
18,2
Other
6
18,7
5
15,2
7
19,4
1
9,0
TOTAL
53
100
33
100
32
100
11
100
The most common neonatal causes of
neonatal cause of death was prematurity
death in Middelburg District was intrapartum
related.
asphyxia and prematurity related. There
The apparent increase in deaths caused by
was no difference in intrapartum asphyxia
infection increased in both districts is
between 1996 - 1997, while a slight
because RPR was done on every patient
decrease in deaths caused by prematurity
since 1997 and syphilis was diagnosed
related.
more often than before.
In Lydenburg district the most common
Maternal Syphilis serology of perinatal deaths
Middelburg District
Lydenburg District
Maternal syphilis serology
1996
1997
1996
1997
RPR positive
16,4
15,7
6,1
10,8
RPR negative
31,0
68,7
2,0
47,3
RPR not done
52,6
14,8
89,7
37,8
Results not available
0,0
0,9
2,0
4,1
Proceedings : 17th Priorities in Perinatal Care
104
1998
Avoidable factors:
Middelburg District
Lydenburg District
1996
1997
1996
1997
Patient
30
25
22
6
Administrative problems
8
6
13
8
ANC
7
6
4
3
Intrapartum
21
15
31
12
Neonatal care
4
8
11
0
Referrals
9
9
19
9
Insufficient notes
33
26
21
19
Medical personnel
Discussion
personnel calling for expert assistance.
Conditions worsen in Middelburg District
Transport in Belfast is a major problem as
and improved dramatically in Lydenburg
well.
District, but Belfast Hospital is still a problem
To address the problems more personnel
in the district.
started with the PEP programme.
Problems in Middelburg District:
perinatal mortality committee was selected
*
in Middelburg to discuss each perinatal and
*

Neonatal
care:
inadequate
monitoring, inadequate resuscitation
neonatal
Intrapartum care: Fetal distress not
occurred to determine the cause and solve
detected
it.
because
signs
were
death
immediately
A
when
it
Workshops were given to antenatal
interpreted incorrectly, fetus was not
clinics to introduce one antenatal card for
monitored.
the
Delay in medical personnel calling
Continuous lectures and training on the
for expert assistance.
correct usage and interpretation of the
district
and
give
training
on
it.
In Lydenburg District birth asphyxia was in
partogram are given to improve intrapartum
1996 a major problem but improved with the
care.
intervention
of
the
partogram
and
Conclusion
appointment of the Cuban doctors.
It is important to note the causes of death
In Lydenburg District - Belfast Hospital was
are different in each district as are the
a major problem with delay in referring
problems. Thus each district needs such an
patients for secondary/tertiary treatment,
audit if it wishes to identify and solve its
medical
personnel
maternal and infant health care problems.
underestimated/overestimated fetal size,
Therefore, define the problem before
fetus distress not detected because fetus
proclaiming the solution.
was not monitored, delay in medical
Proceedings : 17th Priorities in Perinatal Care
105
1998
Proceedings : 17th Priorities in Perinatal Care
106
1998
RAPID ASSESSMENT OF MATERNAL
AND NEONATAL SERVICES IN THE
EASTERN HIGHVELD REGION OF
MPUMALANGA
cost-effective interventions.
Method
IT Hay, RC Pattinson
MRC Research Unit for Maternal and Infant
Health Care Strategies
All hospitals were visited in one week.
A “walk-through” visit was made to the
maternity and neonatal sections.
Introduction
A copy of the Birth register for March 1997
The population of the Eastern Highveld
Region
of
Mpumalanga
is
(randomly chosen) and the neonatal ward
seriously
register for March and April 1997 was
underserved in terms of health professionals
obtained for analysis.
trained in Obstetrics and Neonatal Care.
gravidity and parity was analysed.
Maternal and Perinatal mortality statistics
The
Caesarean section rate, Low Birth Weight
are either not available or are insufficiently
Rate (LBWR), Perinatal Mortality Rate
exposed to medical audit.
(PNMR) and Perinatal Care Index (PCI) was
A Rapid Assessment Technique was
calculated (Table I).
utilised to identify services in need of
Table I
Maternal age,
Results : Hospital Birth- and Neonatal Register Analysis
HOSPITALS
BIRTHS
CAESAR RATE %
LOW BIRTH WEIGHT
RATE
PERINATAL
MORTALITY RATE
/1000 (> 1000gm)
PERINATAL CARE
INDEX
MATERNAL AGE
(in years)
median
< 15
16 – 18
35 – 39
> 40
GRAVIDITY ( as a %)
PRIMIPARA
MULTIPARA
GRAND MULTIPARA
(balance not recorded)
1
86
13
12
2
42
?
)
3
47
2
18
4
128
13
18
5
136
13
9
6
157
11
10
7
149
8
16
8
112
9
14
9
79
24
8
29
85
55
22
31
36
72
75
0.4
) birth
) weight
) not
) recorded
0.21
0.33
0.4
0.32
0.43
0.19
0.1
25
1
11
11
2
25
0
19
12
5
24
0
8
6
0
21
2
30
5
3
23
4
17
7
1
27
3
6
8
3
22
4
19
6
4
22
3
9
10
4
24
3
18
9
4
42
36
10
(2)
45
38
17
28
53
13
(6)
52
33
15
36
53
9
(2)
31
61
8
46
42
10
(2)
36
59
3
(2)
42
48
9
(1)
Proceedings : 17th Priorities in Perinatal Care
107
1998
The PCI is the ratio between LBWR (as a
of the population tested.
percentage) and the PNMR (> 1000 grams).
Ten questions were posed to attending staff
The higher the value, the better the
and the findings were summarised in Table
perinatal care is. The LBWR acts as an
II.
indicator of the socioeconomic status
Table II
Results : Ten Questions
QUESTIONS
1.
Is the Patient Carried Antenatal Card
utilised?
2.
Is the Partogram (with action line)
utilised?
3.
Is equipment adequate for vacuum
extraction?
4.
Is a 24 hour emergency Caesarean Section
Service available?
5.
Is equipment adequate for neonatal
resuscitation?
6.
Is there a referral capacity to neonatal
secondary and tertiary care services?
7.
Are key personnel trained in PEP and/or 7.
DEPAM?
8.
Is the PNM Rate calculated on a District 8.
basis?
9.
Is the PNM Rate exposed to regular audit?
10.
Does the hospital have to rely on nonresident part-time doctors?
SUMMARISED FINDING
1.
In very few, format inadequate.
2.
Not in any hospitals.
3.
In few hospitals.
4.
In most hospitals but not in all.
5.
In few hospitals.
6.
Almost none.
Almost none.
No
9.
10.
No
In some hospitals
Discussion
secondary (and later tertiary) levels of care
The patient carried Antenatal Card and
needs to be developed within the Region.
Partogram are not utilised and should be
implemented.
Limitations
Equipment for vacuum extractions and
PNM Rates and PCI could be calculated for
neonatal resuscitation requires upgrading.
the Region (by month of survey) but the
Key personnel require training in PEP or
individual hospital sample sizes were too
DEPAM.
small for confident conclusions at a hospital
Hospitals largely served by non-resident
level.
doctors on sessions appointments showed
The population size, birth rate and number of
the lowest PCI (3, 8 & 9).
home deliveries is unknown. The service
The PNM Rate should be exposed to regular
coverage could therefore not be determined.
audit.
The capacity to manage neonates requiring
Conclusions
Technique requires validation. This will be
Data acquired by the RAPID ASSESSMENT
done by employing the technique in hospitals
Proceedings : 17th Priorities in Perinatal Care
108
1998
in the Highveld Region (where the Perinatal
Problem Identification Programme is in
operation) for comparative purposes.
Major and immediately remediable health
problems were exposed.
Proceedings : 17th Priorities in Perinatal Care
109
1998
of particular relevance to those concerned
INTEGRATED
MANAGEMENT
OF
CHILDHOOD ILLNESS : A WHO/UNICEF
STRATEGY
with priorities in perinatal care.
Walter Loening
What are the main elements of IMCI?
There are three main components:
The Integrated Management of Childhood
Improved case management at primary level
Illness (IMCI) is a strategy developed by the
and related training
Division of Child Health and Development of
Case management is based on simple but
WHO, with the full support of UNICEF, to
well structured protocols, which in turn are
redress the continuing and unacceptably
underpinned by extensive and ongoing
high under five mortality in developing
countries.
research. There is ample material for the
Whereas there is nothing
training course of primary care workers,
strikingly new about this approach it does
which is designed to extend over a two week
improve the overall child health care by
period. The material requires adaptation to
'bringing it all together'.
the needs of this country and subsequently
to the conditions prevailing in the various
Rationale for an Integrated Strategy
provinces. As climatic, social and economic
Projections based on the global burden of
determinants of the disease profile vary from
disease (1996) indicate that a relatively small
country to country and region to region
number of diseases, viz. acute respiratory
careful
infections, diarrhoea, malnutrition, malaria
essential.
and measles, will continue to contribute up to
problem(s), to classify the severity and to
on
embark on the treatment. Although IMCI in
disease specific interventions, such as ARI
Diarrhoeal
most instances does not cover the early
Disease.
neonate there is a section devoted to the
Nevertheless the strategy is based on
young infant aged 1 week to 2 months. It is
lessons learned from the latter two. IMCI is
in this period that the neonate who was
not another programme displacing earlier
subjected to birth asphyxia or some other
ones or adding to their number, but it is a
strategy
which
complements,
(It is pleasing to note that
the nurse in most instances - to identify the
This in itself speaks for integrating the
of
is
Booklet, which assists the practitioner - i.e.
diseases that leads to the child's demise.
Control
material
The mainstay of this material is the Chart
it is not a single but rather a combination of
and
the
provided generous assistance in this task.)
least the next two decades. Not infrequently
focusing
of
paediatricians around the country have
70% of the world's under five mortality for at
management rather than
adaptation
setback presents as a problem with which
amongst
the mother cannot cope.
others, EPI, Nutrition programmes and Safe
Motherhood. It is the last mentioned that is
Proceedings : 17th Priorities in Perinatal Care
110
1998
Efficient health system support structures
facilities
There is little is any chance for IMCI to make
*
substantial inroads on the disease burden
Family and community behaviours
related to IMCI
unless certain elements of the health care
*
Prevention interventions
system are functioning efficiently:
*
Impact of the IMCI strategy.
i)
drug supply management has to
Several institutions in this country are
ensure a steady supply of the limited
collaborating with WHO in this regard. There
range of prescribed drugs;
is obviously ample room for research
patient referral must run smoothly
projects in other areas, particularly those
with appropriate feedback to the
related to perinatal issues.
ii)
referring facility;
iii)
the health information system must
The Status of IMCI in South Africa and
be in position to capture the data that
Globally
are essential for monitoring and
The concept of IMCI has had the support of
evaluating the process.
the Department of Health for more than a
This should not be beyond the capacity even
year. At the Provincial Health Restructuring
of some ailing health administrations, as
Committee the administrative heads of
implementation of IMCI is initially confined to
health
a few pilot sites in each province.
enthusiastically. The stage has now been
of
the
provinces
accepted
it
reached where eight of the nine provinces
Improved family and community child care
are actively engaged in the early phases of
practices
implementation.
A great deal of emphasis is placed on
Thirty nine countries are at various stages of
counselling the 'mother', thereby ensuring
incorporating this strategy into their health
compliance, improved health care seeking
structures.
behaviour and eventually a child-safe
America are particularly enthusiastic about
environment in the community. Community
the benefits which IMCI offers.
Countries in Africa and Latin
health workers and health promotion officers
could be called upon to assist in this activity.
The Benefits of IMCI
In summary the benefits of this strategy can
Research
be listed as follows:
The Child Health and Development Division
It addresses priority child health problems.
of WHO has identified five priority areas:
Classification of the severity of the problem
*
Case management of childhood
provides a system of triage.
illness
It encourages efficient use of resources,
IMCI implementation at first-level
especially of drugs.
*
Proceedings : 17th Priorities in Perinatal Care
111
1998
There is an emphasis on the role of the
mother.
IMCI is adapted to local circumstances.
It improves interprofessional relationships.
The morale of the primary care worker is
boosted.
Proceedings : 17th Priorities in Perinatal Care
112
1998
feeding practices of mothers of infants in the
INFANT FEEDING PRACTICES OF
MOTHERS OF ONE MONTH OLD INFANTS
first month of life in this community.
UE MacIntyre, P Dolo
Department of Paediatrics & Child Health,
MEDUNSA
Aim
To document the infant feeding practices of
Introduction
mothers of infants between three and eight
The recommended age for the introduction
weeks of age with a view to planning
of foods other than breast milk into an
appropriate intervention strategies.
infant's diet is between four and six months.
However, the introduction of supplementary
Methods
feeds as early as the first month of life is
Mother were interviewed in their own
common in South Africa. Although signs of
language by trained interviewers using a
undernutrition, associated with the too early
semi-structured
use of supplementary feeds, are frequently
Questions were asked regarding: types of
seen in the medical paediatric wards of Ga-
feeds given including breast milk, formula,
Rankuwa Hospital, little is known of the
water and solids; preparation of feeds;
interview
schedule.
frequency of feeds; reasons for giving
formula and/or water.
Results and Discussion
Table 1
Sample description of infants
Number
Mean age (days)
Sd
Males
36
43
9,7
Females
26
33
16,0
Total
62
39
13,5
Of the 62 mothers interviewed, 58 (93,5%)
incidence of early supplementary feeding in
were feeding formula, water or solids in
our study is higher than that reported in other
addition to breast milk, 3 (5%) were
studies and is cause for concern. In a study
exclusively breast feeding and one was
of infants in Soweto, Richter showed that at
giving only formula feeds. The main reason
four months old, 94% of infants are still
mothers gave for giving formula was that
breast fed, but 39% were giving gruel, 22%
their breast milk was insufficient (59%).
commercial porridges and 27% mashed
Mothers gave water because the child was
vegetables and fruit. The reasons given for
thirsty (19%), to prevent constipation (51%)
introducing such food is infant crying,
and with gripe water for cramps (9%). The
interpreted as hunger. In Venda, 36% of
Proceedings : 17th Priorities in Perinatal Care
113
1998
children younger than three months were
and continually monitored in hospitals.
given gruels or commercial cereals daily,
although almost all of them were still breast
fed.
Conclusion
The introduction of complementary feeds
within the first three to eight weeks of life is
an extremely common practice among
mothers attending the postnatal clinic at GaRankuwa Hospital.
The most frequently
given reason for giving formula was that the
mother believed her breast milk was
inadequate to meet her infant's needs.
Mothers gave water to relieve thirst or to
prevent constipation.
Limitations
The sample was limited to a small number of
mothers attending the postnatal clinic at GaRankuwa Hospital. Thus, the results may
not be generalisable to the whole community
served by Ga-Rankuwa Hospital. A future
study is planned to investigate infant feeding
practices and the sources of infant feeding
information in the community.
Recommendations
The results of the study have highlighted the
need for further research to identify and
address the reasons for incorrect infant
feeding
practices
and
to
implement
programmes to train health care workers to
provide correct breast feeding advice to
mothers both ante and postnatally. Also, the
'Baby friendly initiative' must be implemented
Proceedings : 17th Priorities in Perinatal Care
114
1998