Download Proceedings 2011 - Perinatal Priorities

The 30th Conference on Priorities in Perinatal Care in South Africa was held under the
auspices of the Priorities in Perinatal Care Association and sponsored by Abbott Laboratories
SA (Pty) Ltd.
i
Editor’s Note:
The articles included in these Proceedings were, mostly, received electronically and have
been included as submitted by the presenter/author. Faxed articles have been retyped.
Some articles have been shortened.
Abstracts were included where articles were not submitted.
References are available from the authors.
Articles have not been included for presentations, which were withdrawn and not presented
at Priorities.
Late submissions received after the Proceedings had been compiled and passwords allocated
are included at the end of the Proceedings.
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INDEX
COMPARISON OF MOTHERS’ AND COUNSELORS’ PERCEPTIONS OF PREDELIVERY COUNSELING FOR
EXTREMELY PREMATURE INFANTS. BA Seyda
1
PREMATURE LOSS: CAN WE REDUCE EXTREME LOW BIRTH WEIGHT NEONATAL MORTALITY?
Madide A
8
HEAD GROWTH AS AN INDICATOR OF ADEQUATE EARLY NUTRITION IN VERY LOW BIRTH WEIGHT
INFANTS. Kirsten GF
12
SCALING UP KANGAROO MOTHER CARE IN INDONESIA. Anne-Marie Bergh
17
NEONATAL ADMISSIONS AND THEIR OUTCOME AT MANKWENG HOSPITAL (abstract).
MHK Hamese
22
DIAGNOSIS ON ADMISSION, AND CAUSES (PATHOLOGICAL AND SYSTEMIC) OF DEATHS AMONG
NEONATES WHO WERE ADMITTED TO A HIGH CARE NURSERY. S Velaphi
23
THE EFFECT OF HIV EXPOSURE ON NEONATAL NEAR MISSES AND DEATHS (abstract).
Ntlharhi Mathonsi
26
PMTCT GUIDELINES FOR PRETERM INFANTS AND AN INTERIM REPORT OF NEVIRAPINE TROUGH
LEVELS. Max Kroon
27
INTRODUCTION OF NEONATAL EXPERIENTIAL LEARNING SITE AND OUTREACH PROGRAM.
Ruth Davidge
32
NEONATAL OUTREACH IN ZULULAND DISTRICT: WHAT HAS CHANGED? DH Greenfield
42
EXPERIENCES OF STAFF ON QUALITY IMPROVEMENT IN NEWBORN CARE AT VRYHEID
DISTRICT HOSPITAL. BG Malan
46
NEONATAL OUTREACH IN ZULULAND DISTRICT: FACTORS FACILITATNG AND HINDERING
IMPROVEMENT IN THE QUALITY OF NEWBORN CARE. NC Mzolo
49
THE EFFECTIVENESS OF PARTICIPATORY INTERACTIVE CARE IN MPUMALANGA HEALTH SERVICES
(2010/2011). Rendall-Mkosi, K
56
ENSURING SUCCESSFUL IMPLEMENTATION OF STRATEGIES TO REDUCE MORTALITY, A HEALTH
SYSTEM APPROACH. María Belizán
62
TEN, PLUS FIVE, PLUS ONE: REPORT CARD ON HOW SOUTH AFRICA DOING IN IMPLEMENTING THE
16 KEY INTERVENTIONS TO PREVENT STILLBIRTHS, MATERNAL AND NEONATAL DEATHS (abstract).
RC Pattinson
67
TRIPLE RETURN FOR OUR RAND: HOW MANY SOUTH AFRICAN MOTHERS AND BABIES CAN BE
SAVED AND WHAT IS THE COST? Kate Kerber
68
RESEARCH PRIORITIES FOR PREVENTING STILLBIRTHS IN LOW AND MIDDLE-INCOME COUNTRIES:
DELIVERY AND DEVELOPMENT OF INTERVENTIONS. EJ Buchmann
72
UNINTENDED PREGNANCIES IN A NEONATAL UNIT - A PILOT STUDY. S Delport
76
BEING SURE: WOMEN’S DECISION MAKING WITH AN INEVITABLE MISCARRIAGE.
Rana Limbo
78
iii
VIEWS AND ATTITUDES OF PREGNANT WOMEN ON DECISION-MAKING FOR LATE TERMINATION OF
PREGNANCY FOR SEVERE FETAL ABNORMALITIES. C Ndjapa-Ndamkou
83
PROTOCOL FOR PERINATAL BEREAVEMENT MANAGEMENT IN A LOW RESOURCE SETTING.
LL Linley
89
BEST MEDICINE: HUMAN MILK IN THE NICU. Nancy E. Wight
94
THE VALUE OF FOCUS GROUPS: ROLE IN THE INTRODUCTION OF EXCLUSIVE BREAST FEEDING IN
THE NEONATAL UNIT KING EDWARD VIIITH HOSPITAL DURBAN. M Adhikari
101
IS THERE A DIFFERENCE IN NEWBORN FEEDING PRACTICES BETWEEN BABY-FRIENDLY
ACCREDITED AND NON-ACCREDITED FACILITIES? Jordaan M
104
EFFECTS OF FEEDING HUMAN MILK EXCLUSIVELY TO VERY LOW BIRTH WEIGHT INFANTS.
S Delport
108
SUPPORT FOR RELACTATION AMONG MOTHERS OF HIV-INFECTED CHILDREN: A PILOT STUDY IN
SOWETO. Mandisa Nyati
110
HOW LONG DOES FLASH HEATED BREAST MILK REMAIN SAFE FOR A BABY TO DRINK AT ROOM
TEMPERATURE. Maxwell Besser
116
EVALUATION/SURVEY OF THE EFFECTIVENESS OF THE NATIONAL PREVENTION OF MOTHER-TOCHILD TRANSMISSION (PMTCT) PROGRAMME IN SOUTH AFRICA. Debra Jackson
120
THE EFFECT OF HIV STATUS ON PERINATAL OUTCOME AT MOWBRAY MATERNITY HOSPITAL AND
REFERRING MIDWIFE OBSTETRIC UNITS, CAPE TOWN. Sue Fawcus
125
PREVALENCE OF HIV IN WOMEN ENTERING LABOUR WITH UNKNOWN HIV STATUS WHO ACCEPTED
OR DECLINED VOLUNTARY COUNSELING AND TESTING. Gerhard B Theron
129
STEVENS-JOHNSON SYNDROME IN HIV INFECTED WOMEN IN PREGNANCY- A SERIES AT CHRIS
HANI BARAGWANATH HOSPITAL (Abstract). CT Khoza
131
EVALUATION OF REVISED PMTCT PROGRAMME ONE YEAR AFTER INTRODUCTION; A PILOT STUDY
IN INFANTS ADMITTED TO NGWELEZANA HOSPITAL IN NORTHERN KWAZULU-NATAL.
JA van Lobenstein
132
IMPROVING PMTCT IN MSELENI HOSPITAL, MKHANYAKUDE, KZN. Nelson A
138
WHERE ARE THE MEN? UNDERSTANDING MALE INVOLVEMENT IN THE PREVENTION OF MOTHERTO-CHILD HIV TRANSMISSION (abstract). Jennifer D Makin
141
PROJECT KOPANO: A PILOT STUDY USING GROUP SMS TECHNOLOGY TO INCREASE SOCIAL
SUPPORT FOR HIV-POSITIVE PREGNANT WOMEN IN SOUTH AFRICA (abstract). Jennifer Makin 142
10 YEARS OF NATIONAL PPIP DATA. DH Greenfield
143
LATE NEONATAL DEATHS IN SOUTH AFRICA: AN OVERVIEW OF CHILD PIP, PPIP AND VITAL
REGISTRATION DATA. Stephen CR
148
TREND IN PERINATAL, NEONATAL AND MATERNAL INDICES AT MADADENI HOSPITAL: 1990 TO
2009. DR FS Bondi
154
BIRTH ASPHYXIA AND PERINATAL OUTCOME IN A LOW RESOURCED SETTING IN NORTHERN KZN.
Jeremy Blakeney
160
iv
GASTROSCHISIS, OMPHALOCOELE AND IMPERORATED ANUS CHALLENGES IN LIMPOPO PROVINCE
(abstract). MR Mabusela-Montani
163
NEONATAL INFECTION SURVEILLANCE SYSTEM AT EMPANGENI HOSPITAL, SOUTH AFRICA: - A 4
MONTHS REVIEW. NC Kapongo
164
PATTERN AND OUTCOME OF NEONATAL ADMISSIONS AT A REGIONAL HOSPITAL, NORTHERN
KWAZULU- NATAL: JANUARY 2006 TO DECEMBER 2010. NC Kapongo
177
LUNG LAVAGE WITH DILUTED SURFACTANT IN INFANTS WITH MECONIUM ASPIRATION
SYNDROME. Johan Smith
185
EFFECTS OF PROPHYLACTIC PHENOBARBITONE ON NEUROLOGIC OUTCOMES TO HOSPITAL
DISCHARGE IN NEONATES WITH ASPHYXIA. S Velaphi
188
BEST PRACTICE GUIDELINE FOR NEURODEVELOPMENTAL SUPPORTIVE CARE OF THE PRETERM
INFANT. W Lubbe
190
SUSTAINING IMPROVED QUALITY OF ANTENATAL CARE AND ITS ASSOCIATED IMPACT ON
PERINATAL MORTALITY RATES (abstract). Jones K
194
A SURVEY ON THE IMPLEMENTATION OF BANC IN MPUMALANGA. Elsie Etsane
195
TRENDS IN CAESAREAN SECTION BIRTHS AT LOWER UMFOLOZI
USING THE ROBSON’S CRITERIA. Makhanya V
(LUDWMH) HOSPITAL (KZN)
200
IS CONTROLLED CORD TRACTION IN THE THIRD STAGE OF LABOUR NECESSARY? A SYSTEMATIC
REVIEW OF RANDOMIZED TRIALS. GJ Hofmeyr
204
AN ALTERNATIVE BEDSIDE METHOD FOR MANAGING POST-PARTUM HAEMORRHAGE DUE TO
ATONIC UTERUS FOLLOWING VAGINAL DELIVERY. Moran NF
208
MATERNAL NEAR MISS VOICES (abstract). S Nkosi
213
CHANGING PATTERNS OF SEVERE MATERNAL DISEASE: AN AUDIT OF PREGNANT WOMEN WITH
LIFE THREATENING CONDITIONS IN THE PRETORIA ACADEMIC COMPLEX FOR 2008-9 AND
COMPARISON OF PREVIOUS DATA FROM 1997-8 AND 2002-4 (abstract). Priya Soma-Pillay
214
HEALTH CARE WORKER RELATED FACTORS IN MATERNITY RELATED ADVERSE EVENTS.
MG Schoon
215
MIDWIFERY EDUCATORS DISCUSSION PLATFORM BLOEMFONTEIN: FREE STATE PERSPECTIVE ON
PROBLEMS EXPERIENCED IN MIDWIFERY. MG Schoon
219
CONFIDENTIAL ENQUIRIES INTO HYPOXIC ISCHEMIC ENCEPHALOPATHY AS A MARKER FOR
ASSESSING THE QUALITY OF CARE OF WOMEN IN LABOUR (abstract). RC Pattinson
224
COMPLIANCE WITH INFANT FORMULA FEEDING OF HIV POSITIVE WOMEN ONE WEEK FOLLOWING
DELIVERY IN KHAYELITSHA, SOUTH AFRICA. Moleen Zunza
225
USE OF A COMPUTERISED MODEL TO ALLOCATE BEDS AND STAFF RESOURCES TO MATERNAL AND
NEWBORN SERVICES. MG Schoon
230
v
COMPARISON OF MOTHERS’ AND COUNSELORS’ PERCEPTIONS OF PREDELIVERY
COUNSELING FOR EXTREMELY PREMATURE INFANTS
Heather T. Keenan, MDCM, PhD; Mia W. Doron, MD, MTS; and Beth A. Seyda, BS
Introduction
Counseling parents about whether to resuscitate their extremely premature infant at delivery
is fraught with difficulty. The counseling is often done by medical professionals who are
relative strangers to the parents, at a time when the infant’s birth is imminent and parents
are in crisis. In addition, the statistics are not encouraging: infants who are born at <26
weeks of gestation have a reported mortality rate of >50%, with half of surviving children
normal at 30 months of age, 25% with mild to moderate disabilities, and 25% with severe
disabilities. Few factors distinguish these groups in advance, so predicting the outcome of
any specific premature infant is profoundly uncertain. Even these general statistics are a
moving target, as advances in the care of very premature infants change potential outcomes.
How much responsibility parents wish to take in making these extremely grave decisions and
how much authority health care providers wish to relinquish are currently unclear.
In the United States, the past several decades have witnessed a shift in the norms of
medical ethics from physician paternalism to patient autonomy. Accounts of neonates who
were treated aggressively against their parents’ wishes appear frequently in the lay press
and on the Internet, reinforcing the notion that parents resent physician paternalism and
wish to have complete autonomy in making resuscitation decisions.
Empiric research describing delivery room decision-making for premature infants is sparse
but demonstrates physicians’ desire to maintain some decision-making authority for very
premature infants, with most accepting a parental role in decision-making for infants who
are born at the 22- to 24-week range of gestation but not for infants who are born at >26
weeks.
A qualitative study of parents of premature infants in Norway, Brinchmann et a
found that parents wished to be informed, listened to, and consulted, but generally did not
wish to bear the burden of making the final decision about withdrawal of support in the
NICU.
The purpose of this study was to understand mothers’ and counselors’ perceptions of their
roles in decision-making about resuscitation of extremely premature infants at delivery and
1
to assess mothers’ and counselors’ satisfaction with the counseling and decision-making
process.
Methods
This study was conducted over a 2-year period at a North Carolina public teaching hospital
with a level III NICU. The study included women who presented to the hospitals’ obstetric
service and delivered an infant between 22 and 27 completed weeks of gestation and had
received at least 1 session of predelivery counseling.
The person whom each woman
identified as having primarily counseled her about how her infant would be treated at birth
was also included in the study. During the study period, it was policy that infants who were
born at <23 weeks of gestation were considered nonviable and were not resuscitated;
infants who were born at >25 weeks of gestation were considered viable and were
resuscitated; and infants who were born at 23, 24, or 25 weeks of gestation were considered
potentially viable and resuscitated or not on the basis of a decision made after counseling
the parents about the outcomes of extremely premature infants. The study population was
chosen to encompass a spectrum of counseling styles (directive to nondirective) and
outcomes.
Mothers were interviewed 6 weeks after delivery by telephone using a standardized interview
form developed for this study. Charts of eligible mothers and their infants were reviewed for
maternal age, marital status, parity, previous preterm delivery, education, gestational age
and birth weight, treatments received at delivery, and outcome (including survival status and
major diagnoses known by 6 weeks after delivery). All counselors were interviewed by
telephone within 72 hours of delivery using a standardized interview format. This study was
approved by the medical school’s Institutional Review Board.
Mothers’ and counselors’
perceptions of the content, tone, and directiveness of predelivery counseling and their
satisfaction with the decision-making process were obtained. Demographic data were
collected for the mothers, infants, and counselors. Simple descriptive statistics described
demographic characteristics of mothers, counselors, and infants. Pearson’s correlation
coefficient was used to determine agreement within individual mother-counselor pairs about
the content and directiveness of counseling.
Results
Thirty-three counselors and 15 mother-counselor pairs were interviewed.
2
Counselors
Counselors reported that they discussed the infant’s chance of survival (90.9%) more often
than the potential for handicap (69.7%). Fewer than half said that they discussed suffering.
Most of the counselors (81.8%) believed that they knew what the mother wanted for her
infant because the mother told them. Counselors said that 64% of the mothers wanted
“everything” done, and 18% wanted “treatment if the infant looks viable.”
A majority (57.6%) of the counselors believed that they gave the mother a choice about
delivery room resuscitation, and most (69.7%) stated that they had not made a specific
recommendation. Nine (27.3%) of the counselors believed that the physician made the final
decision about resuscitation, 9 (27.3%) believed that the mother made the final decision,
and 13 (39.4%) believed that the decision was made jointly.
Mothers
More than 90% of the mothers who were interviewed were very or somewhat satisfied with
the counseling that they received before delivery and satisfied with the care that their infant
received at birth. Two thirds of the mothers said that the counselor had made a treatment
recommendation, and 60% said that they did not have a choice about how their infant would
be treated. Nonetheless, most mothers agreed with the counselor’s recommendation and
believed that they had had a voice in the decision. Although a majority of the mothers said
that they had no choice about the treatment that their infant would receive at delivery, 73%
were very satisfied with the amount of influence that they had in making the resuscitation
decision. Thirteen (86.7%) of the mothers said that everything that could be done for their
infant was done.
Mother-Counselor Pairs
A comparison of the impressions of the 15 mother-counselor pairs about their counseling
session(s) is presented in Table 1. Counselors were more likely than mothers to report that
they had discussed the potential for handicap and less likely than mothers to report that they
had discussed future suffering. Of note, twice as many mothers reported receiving a
recommendation about delivery room resuscitation than counselors reported making a
recommendation (66.7% vs 33.3%, respectively). When the responses of individual mothercounselor pairs were compared, there was almost no agreement between mothers and their
counselors about either the content or the directiveness of the counseling session(s).
3
Responses to Open-Ended Questions
Mothers were asked open-ended questions about what they considered when deciding how
their infant would be treated to delineate further their responses. Most mothers responded
with personal values, beliefs, or experiences, rather than mentioning the medical information
that was presented during their counseling. Many mothers said that they simply wanted
everything done, for example, “Never a question not to do everything.” Others relied on their
faith, as 1 woman said, “I put my faith in God and hoped He would help the infant and the
doctors.” Only 2 mothers specifically mentioned the infant’s prognosis, whether their infant
would suffer, or the infant’s future quality of life.
When mothers were questioned about why they were satisfied or dissatisfied with their
counseling, the predominant theme that emerged was a desire for information. They
appreciated explanations and knowing what would happen in the delivery room. In general,
mothers who believed that they had no choice in the resuscitation decision stated that they
were satisfied with the amount of influence that they had in the decision-making process for
3 main reasons: (1) they were given information: “Explained step-by-step what they would
do”; (2) they trusted the physicians’ judgment: “The doctors knew what they were doing”; or
(3) they felt included in the process: “Asked my opinion before they did anything.”
When mothers were asked what could be done to help patients like them in the future, all
who responded expressed that they wanted more information with less medical jargon:
“When doctors would explain, the words kept getting bigger and bigger; it would be helpful
to have someone to break it down into more simple explanations.” Some mothers suggested
pamphlets or booklets.
4
TABLE 1
Comparison of Mothers’ and Counselors’ Impressions of Issues
Discussed in Counseling
Chance of survival
Yes
No
Don’t know
Potential handicaps
Yes
No
Don’t know
Suffering
Yes
No
Don’t know
Future suffering
Yes
No
Don’t know
Do you believe that you had/gave a choice?
Yes
No
Don’t know
Did the counselor give a recommendation?
Yes
No
Don’t know
Mothers
n %
Counselors
n %
12 80.0
3 20.0
0
13
1
1
Pearson’s R
92.9
6.7
6.7
- 0.1
53.3
20.0
26.7
0.0
- 0.1
6
6
3
40.0
40.0
20.0
8
4
9
1
26.7
60.0
6.7
4
10
1
26.7
66.7
6.7
9
6
0
60.0
40.0
5
9
1
33.3
60.0
6.7
0.04
6
9
0
40.0
60.0
6
7
2
40.0
46.7
13.3
0.07
10
4
1
66.7
26.7
6.7
5
8
2
4
3
33.3
53.3
13.3
0.0
Discussion
The most striking finding of this study is the lack of concordance between mothers and
counselors about what occurred during their counseling session(s). There was no
concordance on clinical information such as survival and potential for the infant to have a
handicap or about who made decisions and whether the mother had a choice in how her
infant would be treated. The lack of concordance between counselor and mother on issues
of clinical information in this study is similar to that found in a study by Zupancic et al. They
found that increased maternal anxiety decreased the concordance of maternal-physician
responses. Other studies have shown that only a small portion of information is retained
after parents are given traumatic news about their child.
Despite this lack of concordance between counselors and mothers, satisfaction with
counseling was high in our study. As is frequently the case with premature deliveries, in this
study, there was often little time between many mothers’ sole counseling session and their
infant’s birth. It is possible in this situation that the actual medical information was not as
important to mothers as their core values and beliefs. In our study, 73% of the mothers
5
rated their counselors as very caring (8–10 on a 10-point scale), and 60% said that they
were provided with the right amount of information, which may have contributed to the
overall high level of satisfaction in this study.
Comments made by the mothers suggest that most of them viewed their counseling sessions
as inherently interactive and participatory. In this context, mothers may have interpreted
treatment plans put forward by the physicians or nurses as “recommendations” that they
were engaging together. Because the mothers in this study viewed the treatment plans that
were presented to them as recommendations and perceived themselves to be joint decision
makers, they were satisfied even when the counseling was very directive.
An unexpected finding in this study was the high proportion of junior obstetrics residents
identified by mothers as their primary counselor about the resuscitation decision. Most
previous work on delivery room decision-making for extremely premature infants has studied
the viewpoints of attending neonatologists or obstetricians. However, in the teaching hospital
setting, this may not be the person whom the mother identifies as her counselor even
though she has spoken with an attending physician. As 1 of the mothers’ primary desires
was for clear and accurate information, it is important that these residents who do
counseling have knowledge about the outcomes of prematurity and familiarity with the NICU
practices that support premature infants after birth. This finding has implications for
obstetrics residency training and education.
Conclusions
This study suggests that mothers of extremely premature infants perceived the counseling
that they received about resuscitation before their child’s birth as directive. In general,
mothers were satisfied with this type of counseling and considered themselves to be joint
decision makers even when they were given no explicit choice about their infant’s treatment
at birth. This kind of counseling is closer to a model of informed assent than informed
consent. It is possible that a directive form of counseling that gives information and
recommendations but also elicits patient preferences allows mothers to choose their level of
participation in the decision-making process. This may relieve some families of the burden of
a choice that they do not wish to make alone, while allowing other families greater
autonomy.
6
Mothers of extremely premature infants in this study wished to be well informed and wanted
their values and opinions recognized and included in the decision-making process. Physicians
and nurses need to elicit mothers’ preferences for treatment so that these can be
incorporated into the medical plan, as mothers perceived counseling to be directive even
when the counselor had not intended it to be so.
The full online version of this article is located at:
http://www.pediatrics.org/cgi/content/full/116/1/104
7
PREMATURE LOSS: CAN WE REDUCE EXTREME LOW BIRTH WEIGHT NEONATAL
MORTALITY?
Madide A, Kirsten GF
Division of Neonatology, Department of Paediatrics and Child Health, Tygerberg Hospital
Introduction and Objectives
It was estimated six years ago, that 9.6% of all births worldwide, were preterm and that
approximately 85% of these preterm births were concentrated in Africa and Asia (1).This
estimation, however, doesn’t detail the birth weight categories of these preterm births. It is
likely that the figures have increased since the last estimation, particularly in Africa, as
factors associated with preterm delivery, such as maternal HIV infection and malnutrition are
prevalent in this region. In resource – limited settings and areas where prenatal care
attendance by pregnant women is irregular, gestational age is usually unknown and the
infant’s birth weight becomes one of the important markers for survival.
Complete information on the incidence, survival and causes of death of very low birth weight
(VLBW) and extreme low birth weight (ELBW) preterm neonates in South Africa is lacking.
The sixth Saving Babies Report, reporting on approximately 40% of public sector institutions’
deliveries four years ago, reported a figure of 21 084 VLBW deliveries, 39% of whom were
ELBW (2). In the past five years, two public sector hospitals in South Africa, reported
survival rates of 72% and 70.5% respectively for VLBW neonates (3, 4). Such single facility
reports are important and serve to inform on the progress of and guide newborn care in
resource – limited settings that lack a centralized database.
The objectives of this report are to determine survival, causes and timing of death in ELBW
and VLBW neonates in Tygerberg Hospital, a public health sector tertiary hospital in the
Western Cape.
Methods
This is a single facility retrospective cohort analysis of all inborn neonates weighing 1500g
and below during the period 01 January 2009 to 31 December 2010.The total number of
admissions, survival to discharge home or to a low care facility and total deaths were
calculated. Causes and timing of death were calculated in the following four birth weight
subdivisions, in an effort to determine more clearly where the highest mortality was:

≤ 700g
8

701 to 1000g

1001 to 1300g

1301 to 1501g
Early neonatal death (ENND) was defined as death up to and including day 7 of life and late
neonatal death (LNND) from day 8 to 28 days of life.
This particular report is an excerpt from a larger study approved by the Stellenbosch
University Faculty of Health Sciences (SUFHS) committee for human research.
Results
A total of 4 464 inborn babies were admitted to the Neonatal High Care Wards (NHCW) and
Neonatal Intensive Care Unit (NICU) over the selected 24 month period. Twenty eight
percent of the admissions were VLBW. Two hundred and seventy deaths were recorded,
58.8% of these were VLBW. There was a predominance of early neonatal mortality although
the difference in the timing of death was not statistically significant. The survival rates in the
VLBW and ELBW are illustrated in table 1. Table 2 illustrates the timing of mortality.
Results
% Survival
2009
2010
≤ 1500g
83.5
88.5
P =0.01
≤ 1000g
69.5
72.3
P =0.54
1001 to
1500g
90.1
96.9
P =0.0001
Table1. Percentage survival to discharge and timing of death in the VLBW and
ELBW in 2009 and 2010
9
Results
Timing of
Death
≤ 1500g
% Early
≤ 7 days
% Late
7 to 28
days
2009
52.5
47.5
P=0.32
2010
61.5
*P=0.25
38.5
Table 2
The leading cause of death in the ELBW was prematurity –related complications whereas
infection – related mortality was the leading cause in those between 1000g and 1500g as
illustrated in figures 1 and 2 respectively.
Results
Leading causes of death in ELBW 2009 vs 2010
40
p=0.584
35
% mortality
30
25
2009
2010
20
15
10
5
0
Extreme
prematurity
Prematurity-related
complications
Infection-related
Causes of death
Figure 1
Causes of death in the ELBW
10
Results
% mortality
Leading causes of death 1001-1500g 2009 vs
2010
50
45
40
35
30
25
20
15
10
5
0
p=0.447
2009
2010
Prematurity-related
complications
Infection-related
Congenital
anomalies
Causes of death
Figure 2
Causes of death in the 1001g to 1500g birth weight group
Conclusion
There was a significant improvement in the overall survival to discharge of VLBW neonates in
the selected 24 month period. The improvement was more pronounced in babies weighing
more than a 1000g at birth. These survival figures are comparable to those in the developed
countries such as Ireland and neonatal units reporting to the Vermont Oxford Network (5).
This is encouraging as it shows that the goal is achievable even in public health sector
hospitals, with minimal technological intervention.
Infection and complications such as necrotizing enterocolitis remain a challenge as causes of
death and efforts to reduce their occurrence need to be intensified. Attention must be paid
to reducing overcrowding, reinforcing infection control practices, promoting kangaroo mother
care (KMC) as well as breast milk feeding as relatively low-cost measures to reduce these
leading causes of neonatal mortality.
11
HEAD GROWTH AS AN INDICATOR OF ADEQUATE EARLY NUTRITION IN VERY
LOW BIRTH WEIGHT INFANTS
Kirsten GF, Kirsten CL, van Zyl JI. Division of Neonatology, Department of Paediatrics,
Tygerberg Children’s Hospital & the University of Stellenbosch
Introduction
Measuring of head circumference constitutes the simplest method of assessing the
development of the central nervous system and thereby of identifying neonates at risk of
neurodevelopmental disorders. A head circumference <10th centile at discharge is
associated with a risk for poor neurodevelopmental outcome.
Head growth is significantly associated with protein intake. Preterm infants who attained a
protein intake of at least 3g/kg/d within the first 5 days of life were less likely to have a head
circumference measurement <10th centile at discharge.
Very low birth weight (VLBW) infants managed in resource-limited institutions are at an
increased risk of poor growth in the neonatal period as access to parenteral nutrition and
breast milk fortification is limited. During the first week of life protein intake of VLBW infants
on exclusive breast milk feeding in a KMC Unit when fortifiers may not be added is low.
Aim of study
A. To assess head growth:
•
Group 1: VLBW infants managed in the Neonatal High Care Ward (NHCW) of
Tygerberg Children’s Hospital (TCH) in 2001 and who were assessed at 6 weeks
corrected age
•
Group 2: ELBW infants treated in the NHCW of TCH during 2007/8 and who were
assessed at 6 weeks corrected age
•
Group 3: VLBW infants treated from 2006-2010 at Panorama Medi-Clinic Hospital and
who were assessed at discharge from hospital
B. To compare the head circumferences of the infants in Study Group 3 to those reported by
the 2009 Vermont –Oxford Network (VON) Database results.
Patients and Methods:
The infants in Groups 1 and 2 who were treated in the NHCW of TCH received a 10%
glucose/electrolyte solution (Neonatelyte®), EBM and a breast milk fortifier which was only
added once the infants were on full enteral feeding. They were discharged when fully breast
fed, gaining weight and a weight of >1800g was attained. The fortifier was not continued
post-discharge. VLBW infants at Panorama Hospital received parenteral nutrition from day 2,
12
EBM and a breast milk fortifier once full enteral feeding was attained. The infants were
discharged once they were fully breast fed, gaining weight and had a weight of >2000g.
Fortification of breast milk was discontinued at discharge.
Results
Table 1. Anthropometric data of Group 1
(VLBW infants TCH 2001)
Number
Mean BW (g), SD
Mean gestational age (weeks), SD
SGA (%)
Head circumference <10th centile at
birth (%)
83
1233 ± 245
31 ± 2
49
35
Table 2. Anthropometric data of Group 2
(ELBW infants TCH 2008)
Number
Mean BW (g), SD
Mean gestational age (weeks), SD
SGA (%)
Head circumference <10th centile at
birth (%)
71
846 ± 107
29 ± 1.7
60
49
Table 3. Anthropometric data of Group 3
(VLBW infants Panorama Hospital 20062010)
Number
Mean BW (g), SD
Mean gestational age (weeks), SD
SGA (%)
290
1066.4 ± 299
28.8 ± 2.3
17
13
Graph 1. Group 1: head circumference <10th centile at
birth and at 6 weeks corrected age. (VLBW infants TCH
2001)
35
34
33
35%
32
%
31
Head circ. <10th
30
29
30%
28
27
Birth
6 wks corr.
Age
Graph 2. Group 2: head circumference <10th
centile at birth & at 6 weeks corrected age
(ELBW infants TCH 2008)
50
45
49%
40
35
%
30
31%
Head circ. <10th
centile
25
20
15
10
5
0
Birth
6 wks corr.age
Graph 3. Group 3: head circumference
of VLBW infants at Panorama Hospital
at discharge (2006 – 2010)
18
16
17%
14
%
12
10
Head circ at
Panorama at
discharge
8
6
4
2
0
<3rd centile
<10th centile
Head circumference centile at discharge
14
Graph 4. Group 3 Vs VON database: head
circumference of VLBW infants at discharge
30
29%
25
%
20
Head circ at
Panorama at
discharge
Head circ of VON
database at discharge
17%
15
12%
10
5
0
<3rd centile
<10th centile
Head circumference centile at discharge
Summary
Graph 5. Incidence of SGA and the
feeding regimen for the Study
Groups
60
50
40
EBM
fed
%
30
TPN &
EBM fed
SGA
20
10
0
VLBW
2001 TBH
ELBW
2008 TBH
VLBW
Panorama
VLBW
VOND
Graph 6. Head circumference at discharge
or 6 weeks corrected age in the different
Study Groups
35
TPN &
EBM/Formula fed
30
25
%
20
EBM
fed
TPN &
EBM fed
15
10
<3rd centile for head
growth
<10th centile for head
growth
5
0
VLBW
2001 TBH
VLBW
VON
database
15
Conclusions
Despite the addition of a fortifier to the EBM while in hospital, a third of the TCH infants still
had a head circumference <10th centile at 6 weeks corrected age. This could be due to:

the high incidence of growth restriction (SGA) in the TCH infants

the fact that they did not receive TPN during the first week of life

fortification of EBM being discontinued at discharge
The head circumferences of the infants at Panorama Hospital at discharge were better than
that reported by the VON database (<10th centile 17% Vs 28%). This difference is difficult
to explain.
The fact that many VLBW infants at TCH had head circumferences <10th centile at 6 weeks
corrected age confirms that the protein and energy content of breast milk for VLBW infants
should be increased by adding a fortifier in order to improve head growth. Assessment of
head growth, from birth to discharge, is critical in order to monitor optimal nutrition.
The impact of post discharge breast milk fortication to breast fed infants should be
determined.
16
SCALING UP KANGAROO MOTHER CARE IN INDONESIA
Anne-Marie Bergh1, Quail Rogers-Bloch2, Hadi Pratomo3, Yeni Rustina,3 Uut Uhudiyah3
Ieda Poernomo Sigit Sidi3, Rulina Suradi3, Reginald Gipson2 for the participating hospitals and
Perinasia
1
MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria; 2 USAID
Health Services Program (HSP) Indonesia; 3 Indonesian Society for Perinatology (Perinasia)
Introduction
Indonesia is one of the few countries that are on target for achieving Millennium Development Goal (MDG) 4 with the reduction of their under-five mortality rate (U5MR). The U5MR
has steadily declined from 86 deaths per 1000 live births in 1990, to 41 in 2008, and is on
target to further reduce to 29 by the year 2015. This in contrast to the situation in South
Africa where the U5MR started off at 56 per 100 live births in 1990 and increased to 67 in
2008, with little prospect of reaching the 19 set as the target for 2010.2
When one compares the distribution of causes of under-five deaths in Indonesia and South
Africa there are striking differences. In Indonesia there were virtually no under-five deaths
due to HIV/AIDS in 2008, whereas in South Africa it accounted for 46% of these deaths. In
contrast, 46% of under-five mortalities in Indonesia occurred in the neonatal period in 2008,
compared to 29% in South Africa. The distribution of the causes of neonatal deaths in
Indonesia and South Africa are however very similar, with 41% of these deaths in both
countries attributed to preterm births. In both countries kangaroo mother care (KMC) is
considered to be one of the solutions to aid in the reduction of neonatal deaths.
KMC was introduced in Indonesia in the 1990s. The Indonesian Society for Perinatology
(Perinasia) has been instrumental in the establishment of KMC, the training of health
professionals and the dissemination of information. As a result of these efforts KMC was
introduced in a number of individual hospitals. Research results showed the acceptance of
KMC practice, even in rural areas. However, the spread of the practice and systematic scaleup of KMC was still slow.
Policy-wise KMC has now been integrated into the Mother- and Baby-friendly Initiative, which
has been part of Safe Motherhood since 2001. In 2009 the National Working Group on KMC
was established by Ministerial decree. Stakeholders in this group include officials from the
Ministry of Health (MoH) and professional organizations, as well as individuals with expertise
in the field of KMC (e.g. university staff). The Working Group is assigned with the further
development of the KMC programme in the Indonesian health care system, amongst others
17
by assisting the MoH in making policies, developing standards and regulations, and providing
guidance in matters related to KMC with a view to contribute to the decrease in the infant
mortality and low birth-weight (LBW) rates.
The Health Services Program (HSP), funded by USAID, embarked on a KMC strengthening
programme in 2008. Key paediatricians and neonatal nurses from three teaching hospitals,
as well as representatives of Perinasia and the government visited South Africa for a twoweek study tour, which also included training in all aspects of KMC practice and
implementation. On their return, these delegates started with implementing KMC or
strengthening current practice. In 2009 to 2010 two of the teaching hospitals were used as
training centres for scaling up KMC to eight more hospitals: two regional hospitals; one
mother and child hospital; one maternity hospital; and four district hospitals. The scale-up
intervention took place in three provinces on Java Island and the final assessment of the
outcomes of the intervention is the focus of this paper.
Method
The scale-up intervention was done over a period of six months between January and June
2010. The period of the intervention was slightly shorter than those reported in other similar
scale-up projects in South Africa and Ghana, where the time period was between eight to 12
months. The project included four stages:
1. Baseline assessment (January to February 2010). This stage attempted to identify the
potential factors that could facilitate or hamper the implementation of KMC in each of the
intervention hospitals. Data was collected on various aspects, including the following: the
health care facility itself; facilities for newborns; status with regard to mother- and babyfriendliness; current status of KMC implementation; feeding and weight monitoring;
documentation and records; follow-up after discharge; issues around staffing; and the
strengths and challenges of each facility. Unfortunately it was not possible to do a preintervention assessment by means of measuring some key indicators in newborn care.
2. Training workshops at two teaching centres (February 2010). Two five-day training
workshops covering both practical and theoretical aspects of KMC were held in Jakarta
and one in Surabaya. Four delegates from each of the target hospitals and a provincial
official from each of the three provinces attended the workshops. Each hospital had to
develop a detailed action plan for implementation.
18
3. Two supervisory visits to each of the eight targeted hospitals (March to May
2010). Members of Perinasia visited each of the hospitals twice to assist with on-the-job
training, to monitor progress and discuss problems. A template was devised for recording
the supervisory visits in a qualitative manner.
4. End-line assessment (June 2010). The first component of this assessment was the
processing of data collected for each KMC patient in the period March to May 2010 in a
standardized KMC monitoring book with key indicators. The second component was linked
to an assessment visit to each hospital, using a standardised progress-monitoring
instrument that measured progress with implementation (not quality of care). Hospitals
were scored out of 100 by means of an adapted version of the six-step, South Africandeveloped progress-monitoring model: awareness making, adopting the concept, taking
ownership, evidence of practice, evidence of routine and integration, and sustainable
practice.
Aspects investigated included the following: history of KMC implementation;
types of KMC practiced; involvement of different role-players; resources; space;
observation of KMC; KMC documentation; health promotion; staff orientation and training
in KMC.
The results below focus on some of the findings of the supervisory visits and some of the
results of the end-line assessment.
Results
During the intervention period 344 infants received mostly intermittent KMC; 208 of these
were treated in the eight targeted hospitals and the rest in the two teaching hospitals.
Although nearly one thousand infants were born in the eight scale-up hospitals during the
study period, only 21% received some form of KMC. It appears as if there may have been
some reluctance to offer KMC to all eligible LBW infants. The reasons for this should be
established. For those infants who did receive KMC, it was practiced for one day or less in
more than a third of the cases. It appears as if KMC was still considered as an add-on
towards the end of the hospital stay instead of being integrated into the neonatal care
programme. Table 1 gives a summary of a few of the indicators on which data was collected
in the intervention period in the eight targeted hospitals.
19
Table 1
Infants receiving KMC in the eight targeted hospitals.
Indicator
n (%)
Total number of LBW infants
979
LBW infants receiving any form of KMC
208
(21.2%)
KMC infants born by caesarean section
70 (33.7%)
Infants receiving KMC for one day or less before discharge
71 (34.1%)
Number of infant deaths in KMC period
3 infants
Average number of days between birth and starting any form of 7.7 days
KMC
Good progress with implementation was observed from the first to the second visit in most
hospitals. Factors facilitating implementation included institutional factors and resources,
management support, staff commitment, and acceptance by families. Common challenges
were record keeping and data collection, budget and infrastructure issues, staff shortages
and rotations, difficulties around discharge and follow-up, and financial difficulties for
families. These factors are similar to those found in the scale-up projects in South Africa and
Ghana and the initial implementation in Malawi.8-10,12
The mean progress score of the ten hospitals was 62 out of 100 points. Nine of the ten
hospitals scored on the level of “evidence of KMC practice” or higher. Only three hospitals
provided continuous KMC services. Figure 1 gives a graphic summary of the progress of the
ten hospitals in relation to each other.
20
Figure 1
Implementation progress in the ten Indonesian hospitals
Conclusion
KMC was successfully implemented in seven of eight hospitals in Indonesia, with the support
of the two teaching hospitals that has been developed as centres of training excellence. The
facilitating factors and challenges to KMC implementation were similar to those found in
other countries. KMC also appears to have been well accepted by most hospitals and
parents.
Introducing KMC is a long-term change process that needs time. It requires dedication,
support and strong commitment of relevant stakeholders, especially from management.
For maximum impact KMC should be integrated into all neonatal services. Furthermore, KMC
standards should be developed for inclusion in hospital accreditation. A complex network of
communication systems is needed for adequate follow-up of KMC infants after discharge.
And lastly, a system of continuous monitoring and evaluation should be established
21
NEONATAL ADMISSIONS AND THEIR OUTCOME AT MANKWENG HOSPITAL
MHK Hamese; M R Mabusela-Montani.
Department of Paediatrics and Child Health,Pietersburg-Mankweng Health Complex
Introduction
Mankweng Hospital neonatal ward is level 1to local community, level 3 to all hospitals in
Limpopo Province. 9 ICU beds and 9 high care beds 6 KMC beds, 24 general beds available
for the whole province. Majority (85%) of patients come from rural communities.
Objective
To determine the reason for neonatal admission and causes of death.
Method
All files of patients admitted in the neonatal unit were retrieved and data analysed. The
following were noted: (1)reason for admission; (2)patient required ventilation; (3) causes of
death; and (4) modifiable factors.
Results
Will be presented in the conference.
22
DIAGNOSIS ON ADMISSION, AND CAUSES (PATHOLOGICAL AND SYSTEMIC) OF
DEATHS AMONG NEONATES WHO WERE ADMITTED TO A HIGH CARE NURSERY
S Velaphi, A Van Kwawegen
Division of Neonatology, Department of Paediatrics, Chris Hani Baragwanath Hospital and the
University of the Witwatersrand
Introduction
Introduction of mechanical ventilation in neonatal intensive care units (NICU) has been
associated with improvement in neonatal outcomes. Developing countries have limited
capacity to provide intensive care. Therefore in developing countries where resources are
limited there is competition in accessing intensive care beds where mechanical ventilation
can be offered, and a number of neonates will die having not been offered intensive care.
The characteristics of infants who die having not been offered intensive care have not been
well documented.
Common causes of neonatal deaths in South Africa have been identified and published in a
number of perinatal care surveys.
These surveys have reported avoidable factors to be
mainly related to obstetric care and few were related to neonatal care. This could be related
to the fact that these reports are based on mortality reviews that are conducted mainly by
obstetricians or healthcare workers involved in obstetric care. The causes of death among
infants who die outside intensive care units and whether there are modifiable factors
associated with these deaths are not well documented.
The aim of the study was to determine characteristics, pathological and systemic causes of
death among neonates who die having not been offered intensive care.
Methods
This was a retrospective review of minutes or records of mortality review meetings held in
the neonatal unit at Chris Hani Baragwanath hospital for neonates who died in the high care
nursery from January 2009 to December 2009. During these meetings demographic and
anthropometric information, pathological causes of death and avoidable factors (systemic
causes) are identified and recorded. For this report, data collected from these meetings were
reviewed.
23
Results
There were 22 849 live births over this time period. There were 3092 admissions to high
care nursery. The common reason for patients being admitted in high care nursery were
respiratory distress {n=1881 (61%)}, asphyxia {n=420 (14%)} and, suspected and definite
necrotizing enterocolitis {n=210 (7%)}. The causes for respiratory distress were hyaline
membrane disease (59%), pneumonia (19%) and meconium aspiration syndrome (9%).
Among the infants who had respiratory distress (n=1881), 500 were put on Continuous
Positive Airway Pressure (CPAP). Among the infants who were put on CPAP, 34% weighed
<1000 grams, 60% weighed between 1000 and 2000 and 6% weighed >2000 grams.
There were 260 deaths that occurred in high care nursery having not been offered intensive
care. Ninety percent of these deaths (235) were reviewed. Seventy four percent were
assessed to be preterm births. More than a half of these deaths (57%) were babies who
weighed <1000 grams at birth and about a quarter (26%) of them weighed more than 2000
grams. Overall the common causes of death were prematurity related (41%), asphyxia
(29%), infections (25%) and congenital abnormalities (5%). Among the term babies the
causes of death were asphyxia (85%) and congenital abnormalities (15%), whereas in
preterm infants the common causes of death were hyaline membrane disease (44%), sepsis
(34%), asphyxia (9%), pulmonary haemorrhage (7%) and intraventricular haemorrhage
(4%).
Among the 235 deaths that were reviewed 150 (64%) were assessed to have avoidable
factors. All the avoidable factors were assessed to be health system related; that is
administrator-related (37%) and healthcare worker-related (27%). Among the administratorrelated avoidable factors the main avoidable factor was unavailability of NICU beds for
mechanical ventilation (91%), and the others being lack of equipment for monitoring of sick
neonate and lack of transport from the clinic to hospital. Among the healthcare workerrelated the main avoidable factor was inadequate infection control (89%) and the others
were inadequate monitoring and inadequate management.
Discussion
Neonates who die in high care having not been offered mechanical ventilation are mainly
those who are extreme low birth weight and asphyxiated term infants. The healthcare
workers who reviewed these deaths felt that if these infants were offered mechanical
ventilation and adequate equipment and transportation were provided 37% of them could
have been avoided. Inadequate infection control measures could have contributed to at least
24
a quarter of these deaths. Though there were no parent-related avoidable factors
documented it is possible that parents could have contributed to not observing infection
control measures, therefore increasing the risk of infection. Overall the common avoidable
factors associated with neonatal deaths outside NICU are lack of resources and poor
infection control. For the country to make an impact on reducing neonatal deaths, care of
preterm infants must be improved including providing adequate equipment, space and
intensive care beds and ensuring that good infection control measures are in place.
25
THE EFFECT OF HIV EXPOSURE ON NEONATAL NEAR MISSES AND DEATHS
Ntlharhi Mathonsi, Robert Pattinson
MRC Maternal and Infant Health Care Strategies Research Unit, Department of Obstetrics
and Gynaecology, University of Pretoria
Aims: To determine the effect of HIV exposure on neonatal near miss and neonatal death
Methods: The standard PPIP format was used to collect data for every neonate that
fulfilled the criteria of a severe neonatal morbidity (neonatal near miss) and mortality at
Kalafong Hospital for the year 2008 and 2009. The criteria of morbidity were based on
neonatal organ dysfunction.
Results: There were 248 neonatal near misses and 75 neonatal deaths (three times as
many neonatal near misses than deaths). Neonatal death rate was twice as common in HIV
exposed than unexposed neonates (OR- 2.3; 95% CI 1.38- 3.84), the neonatal mortality
index and neonates with life threatening conditions were more common in HIV exposed
neonates with a OR- 1.48 95% CI (0.83-2.65) and OR 1.72 95% CI (1.33-22) respectively.
Significantly more HIV exposed neonates had neonatal near misses and deaths due to
intrapartum asphyxia than HIV unexposed neonates. Spontaneous preterm labour was
associated with more neonatal near miss in HIV infected women but death rates were similar
in both groups.
Conclusion: Maternal HIV infection is strongly associated with severe neonatal morbidity
and mortality. Intrapartum asphyxia may be commonly mistaken for possible subclinical
chorioamnionitis or the exposed neonate might respond differently to hypoxia than other
non-exposed neonates.
26
PMTCT GUIDELINES FOR PRETERM INFANTS AND AN INTERIM REPORT OF
NEVIRAPINE TROUGH LEVELS
Max Kroon, Renee De Waal, Alan Horn, Sandi Holgate, Ashraf Coovadia, Mark Cotton, Karen
Cohen, Helen McIlleron
Introduction
Daily NVP prophylaxis (dNVPp) or maternal Antiretroviral Therapy (ART) have been shown to
significantly reduce HIV transmission during breastfeeding and are a vital component of the
2010 WHO Global PMTCT Guidelines and South African National PMTCT Guidelines.
The recommended daily Nevirapine (dNVP) doses are derived from studies of term infants
(>2kg) and are premised on a public health approach to maximise benefit to the majority of
infants. Dosing bands are based on post-natal age and aim to reduce vertical transmission
during breastfeeding by maintaining NVP trough levels >100ng/ml (ten times the in vitro
IC50). NVP levels >3000ng/ml are considered therapeutic in treatment of HIV infection but
the upper limit of the therapeutic range has not been determined.
The 2010 South African National PMTCT Guidelines do not specifically address the issue of
preterm and low birth weight infants and recommend a starting dNVPp dose of 10mg once a
day for babies born weighing less than 2500g and 15mg once a day for those born weighing
2500g or more. Subsequent dose bands are age-based with a recommended dose of 20mg
once a day for infants from six weeks to six months of age. Many preterm infants still weigh
less than 1500g six weeks after birth and weight-based dosing would be more appropriate in
this group. The 2010 WHO Global PMTCT guidelines recommend that infants <2000g start
dNVPp at 2mg/kg with therapeutic drug monitoring (TDM). TDM is only available at the
Department of Pharmacology, University of Cape Town.
NVP elimination is slow immediately after birth but increases over the first weeks and
months of life. NVP is metabolized by the cytochrome P450 enzyme system and is an autoinducer of its own metabolism. This results in the rate of NVP elimination increasing over the
first weeks of chronic therapy. Auto-induction of cytochrome P450 also occurs with fetal
exposure to NVP. Elimination of NVP is more rapid in newborns whose mothers are on NVPbased ART than those who receive their first dose of nevirapine during labour or not at all. A
South African study of single dose NVP (sdNVP) to mothers and their preterm infants
suggests that elimination is slower in preterm than in term infants but at least demonstrated
adequate absorbtion of orally administered NVP. There are no studies of safety, efficacy and
pharmacokinetics of daily NVP in preterm infants.
27
A daily NVP dose of 10mg in these infants may result in high trough levels (>10000ng/ml)
with increased risk of adverse effects and can not be recommended.
Maternal ART has been linked to an increase in low birthweight rates and preterm delivery
itself may increase the risk of vertical transmission. In addition, preterm delivery is often
associated with sub-optimal duration of antenatal maternal ART. Up to 20% of HIV-exposed
newborns may be low birthweight. In South Africa more than 200 000 women living with HIV
become pregnant each year. Therefore as many as 45 000 low birthweight HIV-exposed
infants are born annually. Optimum postnatal prophylaxis in this group is therefore essential.
In South Africa, preterm infants and those weighing less than 1800g are initially managed in
hospital until oral feeding and adequate weight gain are established. Breastfeeding and
breastmilk feeding is a key aspect of their management and strongly associated with better
outcomes. They are usually discharged weighing 1600 – 1800g. Babies with birthweights
1800 - 2000g often remain with their mothers in the postnatal ward and are frequently
discharged within a few days of birth. Both groups are often discharged to resourceconstrained home environments with high background infectious disease-related infant
mortality.
Not breastfeeding is associated with increased mortality and morbidity in children.
Breastfeeding, especially in preterm infants, is a key intervention to reduce infant and young
child mortality, a national public health priority. While breastmilk feeding is strongly linked to
better health outcomes in preterm babies, raw HIV-containing breastmilk fed to preterm
infants with immature gastrointestinal systems may increase postnatal vertical transmission
risk. Heat treatment of breastmilk inactivates HIV while preserving many beneficial
properties and is practised in a number of neonatal units but has had limited uptake in the
community. There is a powerful potential synergy between early heat-treatment of
breastmilk and subsequent breastfeeding on dNVPp that reduces vertical transmission and
promotes safer feeding method selection in preterm infants at discharge.
While there is a paucity of safety, efficacy and pharmacokinetic data to guide dNVPp dosing
in preterm infants it is reasonable to assume that dNVPp will reduce postnatal transmission
risk during breastfeeding in this group as well.
While some evidence suggests that Zidovudine (AZT) is inferior to NVP in reducing postnatal
vertical transmission of HIV in term infants, there is a considerable body of experience in
South Africa with sdNVP and a four weeks course of AZT in preterm infants. The 2010 CDC
guidelines and the 2010 WHO Global PMTCT Guidelines reference adequate pharmacokinetic
and safety data of AZT in preterm infants. Both guidelines support the use of sdNVP and AZT
for six weeks as an effective alternative to dNVPp, provided postnatal exposure to HIV-
28
containing breastmilk is limited. However, this approach adds a layer of complexity that is
confusing and discordant with the current National Guidelines and may compromise PMTCT
delivery and encourage formula feeding when home circumstances militate against this
choice.
The recommendation to use weight-based daily NVP dosing for PMTCT in babies born before
term or weighing less than 2000g is the result of extensive consultation and considerable
deliberation. It provides guidance in the face of limited research in preterm infants and
attempts to balance the risks of uncertain NVP doses and elimination with a need to
harmonise the management of HIV-exposed preterm infants with the 2010 National PMTCT
Guidelines and to optimise HIV-free survival by promoting safe breastfeeding in this
relatively high mortality rate group.
The Guidelines contain recommendations under 8 headings.
1. Infants between 1800g and 1999g are often discharged soon after birth so their NVP
dosing schedule integrates rapidly with the broader national guidelines.
2. Infants weighing less than 1800g usually stay in hospital longer and their regimen
integrates with the broader guidelines later at discharge.
3. We recommended routine therapeutic drug monitoring on days 7, 14, 28 and 42
where possible.
4. Risk-based earlier PCR testing is promoted.
5. Pasteurised own mothers milk or pasteurised donor milk is promoted.
6. It is hoped that recommendation 6 “Feeding and ARV prophylaxis at discharge” will
result in increased breastfeeding rates on appropriate prophylaxis in this especially
vulnerable group.
7. Ongoing management of infants who are PCR negative.
8. Co-trimoxazole (CTX) prophylaxis and infant feeding.
We assumed dNVPp is effective in preterm infants and tried to make the dosing schedule as
simple as possible. We recommended a starting dose of 2mg/kg increasing to 4mg/kg after 2
weeks of postnatal age. These doses are rounded off to 5mg and 10mg in infants with a
birthweight of 1800g and above.
We suggest that exposure to raw maternal milk is limited until maternal viral load is
suppressed. As far as possible the recommendations are in line with the principles of the
29
national and global guidelines. We acknowledged the lack of evidence and undertook to
monitor the program and share experience
The guidelines are condensed into flow diagram 1, below.
The results of routine therapeutic NVP trough concentration monitoring at Mowbray
Maternity Hospital are illustrated in figure 1 below.
Figure 1: Nevirapine Trough Concentrations at Mowbray Maternity Hospital
30
These results are supported by the results of a larger pooled sample (Figure 2) from three
Cape Town Academic Hospitals. No adverse events were reported. The median Nevirapine
trough concentration is significantly lower after 2 weeks of age despite the increased dose
from day 15.
Figure 2
Nevirapine Trough Concentrations at Mowbray Maternity, Tygerberg
Childrens’ and Groote Schuur Hospitals
We conclude that the dosing schedule is safe and the target trough levels are achieved in all
instances. The dosing schedule is robust enough to tolerate operational inconsistencies and
it is reasonable to continue this dosing schedule and discontinue routine therapeutic drug
monitoring. A formal prospective study is still needed.
This care package for HIV-exposed preterm infants addresses a gap in national and global
PMTCT Guidelines.
31
INTRODUCTION OF NEONATAL EXPERIENTIAL LEARNING SITE AND OUTREACH
PROGRAM
Ruth Davidge
Pietermaritzburg Metropolitan Hospitals Complex Area 2 KZN
Objective
To introduce a Neonatal Experiential Learning Site (NELS) with a clinical governance
structure in order to improve the standard of care in Area Two KZN thereby reducing
neonatal morbidity and mortality.
Background:
21 3001 babies die in the first month of life each year in South Africa and about the same
number are still born. In 2000 South Africa committed itself to the Millennium Development
Goals (MDGs). MDG 4 calls for a 2/3rd reduction in child mortality. South Africa is one of only
12 countries world wide whose child mortality is climbing. Some countries with similar gross
national incomes eg Brazil and Egypt have halved their under 5 mortality. South Africa needs
an average reduction of 14% per year in order to achieve MDG 4. Forty one percent (41%)
of child deaths occur in the 1st month of life-the neonatal period. In order to reduce child
deaths neonatal mortality must be reduced.
According to the Every Death Counts and 6th Saving Babies 2006/2007 reports South Africa’s
Neonatal Mortality rate (NMR) is 21/1000 (est.), Stillbirth rate is 23/1000 and Perinatal
Mortality Rate (PNMR) 31.1/1000. Perinatal Mortality in developed countries is <10/1000 and
developing countries<50/1000.
As an emerging economy South Africa’s rates are
unacceptably high in comparison to health expenditure.
Prematurity and birth asphyxia have been identified as leading causes of neonatal deaths
and stillbirths. Health delivery is hampered by inaccessible services, insufficient facilities,
poor physical infrastructure, inadequate equipment and problems with staffing-too few,
inexperienced and unsupported with limited skills. Simple inexpensive interventions eg Basic
antenatal care (BANC), skilled birth attendants, resuscitation, basic care of the newborn and
kangaroo mother care (KMC) amongst others have been identified as effective at reducing
these deaths. The Saving Babies 2006/2007 report made the following recommendationsTrain staff in basic neonatal care including: resuscitation, feeding and fluids, recognition and
management of common conditions (especially sepsis); Produce standardised guidelines;
32
Provide essential equipment and sundries including nasal CPAP; Implement KMC; Improve
neonatal transport.
Context
Kwa-Zulu Natal (KZN) lies on the East Coast of South Africa. It has a population of ten
million people- 3.5 million of which are children under 15 years. There are 3, 300,000 annual
births with a neonatal Mortality 11/1000 (est.) and a life expectancy of 43 years. Of this
population 1.1 million earn <$1/day. Of prime importance though- KZN is the epicentre of
the HIV pandemic with a prevalence of 38.7:1000.58
Area Two is the western most of three areas in KZN. Its population of three million people is
divided into five districts. They are served by nineteen hospitals: one level 3 hospital, four
level 2 hospitals and fourteen level 1 hospitals. There are about 60 000 children to every
one paediatrician. The 53 000 5babies born every year have access to ten Neonatal ICU beds
(ventilated), one neonatologist and one neonatally trained registered nurse. In the Area two
district’s stillbirth rates and one district’s PNMR are above the national average. One district
has the worst still birth rate in the country at 35/10006
Our ability to provide advanced neonatal care is limited due to inadequate facilities. The beds
at the tertiary hospital are permanently filled with a waiting list. It was therefore evident that
it was necessary to increase capacity at lower levels. By improving the standard of care at
these levels it would decrease the number of inappropriate babies requiring tertiary care.
This involved a paradigm shift in focus from in- patient curative care to caring for the
catchment population. Holistic care must be provided including preventative, promotive
curative and rehabilitative care. There must be equitable access to uniform standards and
levels of care. Norms and standards must be set and monitoring and evaluation must be
implemented. This required the introduction of a clinical governance program for neonatal
care in Area Two.
Method
The original plan involved the appointment of a full time coordinator supported by a team of
paediatric and neonatal consultants doing monthly hospital visits. Initially focusing on two or
three hospitals- conducting a preliminary visit, training and support to increase capacity,
weaning and then moving on to the next hospitals. However this plan had to be amended
as the program was rolled out. The ability to build on capacity was hindered due to high staff
33
turnover/rotation and poor support from hospital and district management. It was decided
that support would need to be ongoing with weaning of frequency of visits.
1.
Infrastructure development
Infrastructure includes facilities and equipment. Norms were developed for the design of
maternity units with nurseries and when new stand alone units are planned or units
upgraded we work with the
provincial architect and local staff to design appropriate
facilities. The required number of neonatal beds, spacing, services eg gas and electrical
points, and equipment required for each bed and unit have all been stipulated based on
international norms. Hospital management is encouraged to include gradual achievement of
these norms in their five year plans. Hospitals were also assisted with requesting and
assessing specifications, advised on recommended companies and makes of equipment.
Hospitals were guided in establishing an equipment maintenance system including a daily
equipment checklist and an equipment register tracking purchase details, servicing, repair
and monthly stock taking. Nurses are regularly supported in developing technical skills to
manage the equipment purchased.
2.
Staffing
This is the main focus of the programme. Addressing the staffing crisis was beyond the
purview of the program. The aim was to encourage hospitals to realise neonates’ require
dedicated, trained staff of their own and to assist hospitals with the gradual realisation of
this.
Internationally, stipulating staffing norms has been problematic as hospitals who had more
staff than the stipulated norms proceeded to decrease their numbers. As most of our
hospitals fall short of the minimum we felt it was important to provide norms in order to
assist hospitals in motivating for more staff and allocating staff appropriately. We
recommend the following minimum staffing: General care- 1 professional nurse for every 6-8
patients, Intermediate care -1 professional nurse for every 2-3 patients and Critical care- 1
professional nurse for every 1-2 patients. We are also encouraging a minimum of 2/3rds non
rotational staff in the nursery and that those that have been trained must remain in the unit.
National decentralised post graduate neonatal nurse training is not available in the country
although two universities in Gauteng are offering training. Doctors receive very little neonatal
focus during their basic medical training. The Perinatal Education Program (PEP) was
34
developed to address this need for basic neonatal training but unfortunately has little uptake
in Area 2. The lack of training, knowledge and skills results in nurses and doctors fearing
neonatal care and a reluctance to practice in these units. Advanced midwives in general are
used in labour wards or maternity units. Very few choose to develop their neonatal skills.
Units are frequently staffed with junior inexperienced nurses allocated there regardless of
preference. They receive very little supervision or guidance from seniors. The need for
training and the support of senior staff is evident.
A. In-Reach: NELS Training
This is a two week course held over 2 months offered 4 times per year. The 2 weeks are
split between 2 months to facilitate hospitals releasing staff. It also gives staff time to try
and assimilate knowledge gained in the 1st week. Doctors and nurses are targeted in order
to facilitate communication and the implementation of the changes learnt during the training.
Initially specific hospitals were invited and attendance averaged about 6 per course (on
occasion only 3!).Then we opened it to all hospitals in Area 2 and now attendance averages
10-15
We again had to deal with intention vs. reality-experiential learning vs. theory. The course
was initially based in the NICU with a mainly practical focus however the experience was
dependant on current cases and activity in the unit. Theory was poorly covered with very
little retention of information. It was difficult to structure time constructively. Students were
allocated to partner with unit staff but these staff were generally unable to mentor as they
were junior or extremely busy themselves. Experiential/simulation learning is dependant on
one to one mentorship and is time consuming. 2 weeks was just not sufficient for this.
The course is held at the tertiary hospital due to the availability of venues, programmes and
access to a neonatologist and other consultant support. The participants are exposed to the
unit and staff that their patients are referred to. This improves understanding and
communication between the units. They are also taken to the regional hospital to compare
units and visit the 24hr KMC unit there. Participants are also exposed to systems and other
training programs. They participate in unit and clinical meetings, journal club, PPiP/ CHiP
meetings and X-ray meetings (where possible).
The current curriculum focuses primarily on theory although we do spend 2 hours in the unit
on some days. It is loosely based on the Perinatal Education Programme (PEP). The aim is to
35
touch on the most important aspects of neonatal care. It is not an in depth study but raises
awareness of the subject, encourages further reading and refers the participant to the
relevant guideline.
Basic care of the neonate eg resuscitation, assessment, infection control, fluids and feeds,
KMC and developmental care are covered in the first week. In the second we take a systems
based approach to common conditions and immediate management. Interactive discussions
about practical implementation are prioritised. Problem based, critical thinking methods are
encouraged.
Participants are provided with a resource book with detailed information on the topics
covered. We are hoping this year to encourage participants to purchase the PEP Newborn
manual and write the exam as we have been unsuccessful in getting staff to do this on their
own.
Participants are encouraged to complete a work book and skills checklist. Originally this was
supposed to be completed during follow up visits but commonly the participant wasn’t on
duty for the visit. We now suggest they get the doctor or unit manager to sign off for them.
B. Outreach: Resuscitation training
In an attempt to address the large mortality and morbidity due to birth asphyxia,
resuscitation training has been prioritised. Two 6 hour courses are held per district per year.
They are based on the South African Paediatric Association (SAPA) and American Academy
of Paediatrics (AAP) Neonatal Resuscitation Program (NRP) guidelines. Both theory and
practical experience using manikins is provided with a focus on ventilation and compressions.
We have amended our course a number of times to try and optimise the training but
continue to find the period too short and the participants frequently inappropriate as they
consist predominantly of clinic sisters who see very few deliveries annually. Theoretical
knowledge is tested before and after training.
Outreach - Hospital visits
These are facilitated by the Red Cross Air Mercy service. Paediatric / neonatal consultants
visit monthly mainly focussing on problem management. The NELS coordinator focuses on
hospitals participating in NELS training. Initially a few hospitals were supported intensively
on a weekly basis which was very effective. As the interest and participation has grown more
hospitals are visited and the visits reduced to monthly. This makes change slower and more
difficult to maintain but ensures access for more hospitals. The NELS visits focus on;
36
motivation and support, education and reinforcement, clinical demonstration, assistance and
supervision, case reviews, implementation of guidelines, norms and systems and record
auditing. What is achieved is largely dependant on the circumstances in the unit at the time
and particularly the staff available.
3.
Systems
Amongst the problems of improving standards of care the unavailability of resources is
possibly the most frustrating. It demoralises staff as they are unable to implement the care
they have been taught. They may know the importance of hand washing and how to do it
but if there is no soap or paper towels it’s impossible to do. A lot of time is therefore spent
trying to assist and facilitate the procurement process. Staff were taught the basic
procurement process, a list of essential neonatal sundries was drawn up and information was
given on companies, order codes and approx. costs.
Standardised record keeping facilitates communication, standardisation and continuity. Good
quality records support good quality of care. Following a process of trial and review,
discussion and widespread input a standardised record keeping system has been developed.
We are hoping these records will soon be available through Central Provincial stores (CPS) as
photocopying at institutional level results in very poor quality records.
We also recommend and facilitate the implementation of weekly unit team meetings in order
to improve communication, provide in-service training and incorporate auditing.
4.
Care
We have addressed care from 4 perspectives: Provision of standardised guidelines,
implementation of developmentally supportive Care, provision of kangaroo Mother Care and
provision of breast milk
The development of standardised guidelines and care plans has been a laborious and time
consuming task. The guidelines are two page basic guides to direct care. We have combined
medical and nursing care with the development of clinical and procedural guidelines. We
hope this will facilitate more systematic, logical and cooperative care. Nurses are encouraged
to refer to these to guide their care particularly in the absence of consistent medical care.
37
Through the provision of posters, training and demonstration we have attempted to make
staff more aware of the importance of developmentally supportive care in the reduction of
long term morbidity but many doctors appear to still miss its importance as they focus on the
immediate medical needs of the baby. The use of a SoundEar (Drager Medical) helped
raise awareness of the high noise pollution in many units.
Hospitals have been provided with resources to establish 24hr KMC wards eg TVs, duvets,
KMC holders, camp chairs etc. Intermittent KMC is encouraged from birth in the neonatal
units/maternity wards
.
Breast feeding remains of vital importance in the prevention of infection and is still poorly
enforced in many hospitals. We support hospitals in the establishment of central milk
kitchens, providing pasteurised breast milk ( flash or Pretoria methods), promoting exclusive
breast feeding and are currently involved with establishing a breast milk bank for the area in
order to decrease the incidence of NEC in the premature population.
5.
Monitoring and evaluation
We have developed clinical and record audits and graphs with which to display results.
Hospitals are encouraged to include regular auditing as part of their quality improvement
process. This should occur with the whole team during weekly unit meetings. Action on the
results of the audits is stressed.
PPIP is promoted at all visits. Hospitals are supported in identifying a coordinator (usually the
labour ward unit manager) and progressing from capturing data purely on paper to loading it
on a computer and transmitting it to the district and province. Capturing and presentation of
morbidity data particularly Hypoxic ischaemic encephalopathy (HIE) together with
constructive action based meetings is encouraged.
Results
1.
Infrastructure
One new neonatal unit has been built, two substantially upgraded and one is in the process
of being upgraded. Equipment resources have substantially improved in 5 hospitals (now
close to stipulated norms) Funding provided through Fuchs helped in the provision of vital
equipment to some hospitals in the area. However ongoing problems at HTU are greatly
affecting hospitals ability to maintain their equipment. We are liaising with CPS and the
provincial Health technology unit (HTU) to try and facilitate procurement and maintenance of
38
equipment. There is improved spacing in 5 hospitals. An equipment register has been
developed and is awaiting printing and binding. A computerised version is under
construction.
2.
Staffing
NELS: 4 Hospitals have committed to permanent nursing staff in their neonatal unit including
one hospital which initially had no staff allocated at night. 5 others are working on the 2/3rd
recommendation-generally retaining a few senior staff and rotating junior staff. Two
hospitals have now staffed their 24hr KMC units independently from the unit.
Thirteen (13) NELS courses have been held accessed by fourteen (14) hospitals (1 Tertiary,
3 regional and 10 district) from all five districts. Seventy six (76) nurses (registered or
enrolled) and ten (10) doctors have been trained. Awareness of the course and hospitals
accessing the course has much improved. Retention of these trained staff within the
hospitals remains problematic as doctors and nurses rotate and staff often leave hospitals for
career or personal reasons. Feedback form participants has however been very positive
including the following comments: “It is interesting, we come here with the wrong practice,
but now we are brave and skilled to save babies”; “The course has been very helpful.
Practical approaches were offered to handling situations. I am now inspired to improve
conditions at my hospital”; “I have gained confidence to practice independently and also to
teach my colleagues”; “This course has motivated me to try and improve quality of care in
my institution and making sure that what I have learnt should be practiced and taught to
others”; “It was an eye opener!!
However 2 weeks is still not sufficient and a third purely experiential week has been
requested by many participants.
In addition sets of PEP self study manuals have been distributed to all 18 hospitals
Resuscitation:
Twenty five (25) Resuscitation courses were held. Four hundred and twelve (412) people
received training including twenty four (24) Doctors and 6 paramedics. Average
improvement in theory pre to post test results was 50%. We need to assess the
incorporation of the Helping Babies Breath Programme (HBB) into the course. Hospitals need
to be encouraged to release doctors and nurses particularly from labour ward to attend. Due
to poor retention and implementation there is a need for ongoing reinforcement at the
hospitals through neonatal resus. champions-The Project for Appropriate Technology in
Hospitals (PATH) is working on this project. Purchase by hospitals of inexpensive inflatable
39
resus. dolls (available from Laerdale International) would assist with ongoing skills
acquisition and maintenance.
Outreach Visits:
Eleven (11) hospitals received outreach visits by the coordinator (10 in Area 2 and 1 in Area
1). In total two hundred and fifty five (255) visits have been conducted. In addition Greys
Hospital was visited weekly for 2 hours. These visits are generally well received. The morale
and commitment of staff and reinforcement of systems and practice are supported by these
visits but hospitals do tend to use them to support clinical practice rather than as a support
for training and systems. Better staffing ratios will improve the effectiveness of these visits.
3.
Systems
Fifty five (55) guidelines, nineteen (19) nursing care plans and thirty (30) standardised
records have been developed. These are in regular use in 8 hospitals. Replication and
distribution of guidelines and records are inhibiting more general usage. These require
sponsorship to be printed/bound in a professional user friendly manner. Additional neonatal
resources including posters, perinatal ICD 10 codes, parental handouts, pain assessment
tools and a photographic clinical guide amongst others have been developed but are
awaiting reproduction and distribution. The equipment maintenance system has been fairly
well implemented in the regional and tertiary hospitals with large equipment stocks. It still
requires the proper printing and binding of the equipment register and a link to a
computerised equipment data base. A non stock item (NSI) tracking register is now in use in
most hospitals visitedc to assist with the laborious and lengthy process of procuring surgical
and other sundries. Most of the neonatal sundries required are not routine stock items. This
has been raised with CPS unsuccessfully. Procurement and maintenance of adequate stock
levels remains a challenge.
4.
Care
11 hospitals offer 24hr KMC beds including four new 24 hour KMC units which have been
established. However despite the evidence that abounds on the cost effectiveness and
importance of KMC in decreasing neonatal mortality many hospitals will not prioritise the
establishment and use of 24hr KMC units. Even when a unit is available it is frequently used
for post natal patients or not staffed at all.
One regional hospital has commenced ventilating babies.
40
Developmental care posters have been given to 4 hospitals but it requires ongoing
reinforcement to ensure implementation of most of the principles of developmental care.
Sound levels remain high despite raising awareness with the SoundEar
5.
Monitoring and Evaluation
As teams are small and frequently change regular constructive audit has not yet been
achieved in most hospitals.
PPIP meetings are now occurring in all 5 districts. The areas that are most effective have a
coordinator (usually the labour ward unit manager) driving the process. Computer access is
often a problem and exporting and importing of files can be problematic. Unfortunately the
absence of action plans and accountability at the monthly meetings limits the effectiveness
of PPIP in driving change.
More effective and active coordination at a provincial and national level would assist the
effectiveness of this program.
Conclusions
There is an urgent need to expand the program.
hospitals to mentor would be more effective.
Coordinators with a small group of
Other areas in the province need to be
included and the introduction of a Maternity Experiential Learning Site (MELS) would help
address antenatal and intrapartum problems.
The introduction of a Neonatal Accreditation program is planned for this year. It is believed
this might provide the incentive and motivation for hospitals to comply with the norms and
standards set.
Formal assessment of the impact of the NELS program needs to be undertaken. Findings
thus far are anecdotal and observational.
It is apparent that standards of care have
improved but whether this has impacted on mortality needs to be investigated.
41
NEONATAL OUTREACH IN ZULULAND DISTRICT: WHAT HAS CHANGED?
DH Greenfield, NC Mzolo
Centre for Rural Health, University of KwaZulu-Natal
Introduction
An assessment of perinatal care in Area 3 in the north of KwaZulu-Natal showed that the
outcomes were not as good as they should have been and a programme for intervening was
started in the Centre for Rural Health at the University of KwaZulu-Natal to improve all
aspects of perinatal care. Part of this was an initiative to improve newborn care, starting in
Zululand District. This outreach was supported by the Zululand District Maternal Child and
Women’s Health (MCWH) Management, who have remained very supportive throughout. The
outreach was funded initially by Johnson and Johnson Paediatric Institute and later by the
Discovery Foundation. The outreach was started in 2007
There are 5 District Hospitals in the District, and babies who need a higher level of care are
referred to the Lower Umfolozi War Memorial Hospital (LUWMH) in Empangeni. This entails
an ambulance journey of at least 2 hours.
Methods
A team was established, consisting of an advanced midwife trainer and a neonatal doctor, to
work with the Paediatric consultant at LUWMH and the District MCWH Management.
The outreach programme was to visit all the hospitals regularly to advise on the facilities,
equipment, practices, protocols, patient records, support services and staffing.
The
standards for these had been developed in similar work done in the Limpopo Initiative for
Newborn Care (LINC).
Quality of care was assessed by doing chart reviews using tools
developed for this purpose, and by monitoring the neonatal mortality rates. The Maternity
Unit and Hospital Managements were encouraged to use the Perinatal Problem Identification
Programme (PPIP) for monitoring their perinatal mortality.
All above aspects relating to
newborn care were documented at each visit using a tool developed for this purpose.
Each hospital visit started with a visit to the senior hospital management, and at the end of
the visit a report back was given to them, if possible. Detailed written reports of each visit
were sent to the hospital managements after each visit.
Week-long training programmes in basic newborn care were held for midwives responsible
for the newborn care in the hospitals, and for Enrolled Nurses and Enrolled Nursing
Assistants who were working in, or were to be allocated to, newborn care.
42
In November 2010 an accreditation for quality newborn care was done in all the hospitals.
The findings of this visit form the basis of this report.
Outcomes
1. Physical facilities

One unit has been altered

One unit was in the process of being altered

Only 2 hospitals had a KMC unit initially

One hospital has converted a postnatal ward to KMC unit

One hospital has converted an office into a room for intermittent KMC

One hospital started to use antenatal beds and is now converting a
room into a KMC unit.

Four of the five hospital had insufficient space for the required number
of beds

Three of the five hospitals did not have an adequate number of electric
plugs in the neonatal unit.

Only 1 hospital had sufficient service points in the neonatal unit.

In four of the hospitals it was possible to make recommendations which
will provide more space. In two of these, action was taken to
implement the recommendations.
2. Practice of KMC

Initially KMC was only practised at 2 hospitals

One hospital has restarted using KMC. There was a “unit” but it was not
being used.

One hospital was doing intermittent KMC but is now doing it
continuously.

One hospital has started to do intermirttent KMC where it was not being
done before.

At one hospitral a ward was refurbished and continuous KMC started.

The overall score for the practice of KMC was 77.8%
3. Resucitation areas

Except in I unit, the areas were untidy and disorganised

In 3 hospitals there was no dedicated resuscitation area in the theatre,
with equipment being taken from the labour ward when a caesaean
section was being done.

There are now adequate facilities in all the labour wards, theatres and
newborn care units.

The areas are reasonablly well organised and tidy (score: 83%)
4. Equipment

Resuscitation
Much improved
43
Score now:
95%


Neonatal unit Much improved
Score now:
89%
of
essential equipment available.
All hospitals are in the process of getting equipment for providing
continuous positive airways pressure (CPAP) and, if necessary, the
compressor which is needed. This is being provided by the MCWH
Management in the District.
5. Patient Transport

This remains poor and very slow generally.

Getting an ambulance on site within 3 hours is quick for most of the
hospitals.

It was beyond the capacity of the team to deal with this. It needs
District or Provincial level intervention.
6. Perinatal audit

Monthly audit meetings were being held before the intervention started.
However problems were not necessarily being identified and were
generally not being addressed when they were identified.

PPIP is now being used in all the hospitals as the means for asessing
perinatal mortality and the data used at the perinatal audit meetings.

The process for identifying and intervening when problems are identified
has improved.
7. Patient records

A District patient admission document was being used in all the hospitals

This document was revised in consultation with the unit staff at the
hospitals, and the revised document is now being used in all the
hospitals.

A appropriate newborn observation chart is now being used in all the
hospitals
8. Protocols and guidelines

Most of the units (four out of the five) did not have written protocols or
guidelines for newborn care

All units now have them (those developed in Pietermaritzburg)

In two hospitals they are filed and indexed and available in the neonatal
unit

There is evidence that they are being used
9. Staffing

A few more Professional nurses have been appointed for newborn care

There are too few Enrolled Nurses and Enrolled Nursing Assistants
appointed for newborn care

The newborn units are only staffed at about 25% of the required
number of nurses.
44

There are problems in recruiting, appointing and retaining staff
10. Quality of care

Patient record reviews (scores)
 Documentation on the admission record:
 Patient management
 Overall score
Early Neonatal Mortality Rates





range
mean
range
mean
range
mean 79.2%
69.0 – 91.1%
53.4%
42.2 – 68.5%
65.1%
57.6 – 75.4%
Birth weight > 999g
4.9 – 14.4 / 1000
Birth weight 1000 – 1499g 210.5 – 517.4 / 1000
Birth weight 2500g +
3.4 – 10.6 / 1000
These rates are high and have not really come down during the 3
years of the outreach
Conclusions
1.
The “things” that are needed are generally in place
2.
The quality of care, as measured with the tools, has not improved much, in particular
the early neonatal mortality rates.
3.
There is a very severe staff shortage particularly of nurses. This impinges directly on
the quality of care which can be given.
Recommendations
1.
The appointment and allocation of more nurses for newborn care. This is critical.
2.
The staff who are going to work with the newborns need to be trained in at least
basic newborn care.
3.
Continuing facility visits, ideally on an on-going basis, by the regional paediatricians,
to assess the implementation of what has been taught, and do clinical teaching.
45
EXPERIENCES OF STAFF ON QUALITY IMPROVEMENT IN NEWBORN CARE AT
VRYHEID DISTRICT HOSPITAL
BG Malan
Introduction

Vryheid Hospital is a level 1 district hospital.

The hospital provides for about 400 deliveries per month and receives referrals
from 14 clinics and 1 CHC.

The Special Care Baby Unit has been designed for 8 babies, but has up to 25
babies at a time.

There is an 8 bed KMC Unit.

There is 1 doctor but no paediatrician.

The hospital was part of the centre for rural health (CRH) newborn outreach
programme.

Before we started!

CRH started to visit us in 2007.

With 6 incubators and 6 cribs, most of the essential equipment was in place, but
we still needed a lot of changes.

Staff rotated from Post Natal Ward on daily basis, no permanent staff in SCU.

Equipment:

3 SATS monitors, not working effectively at times.

incubators not maintained properly.

oxygen given randomly.

Very little information and guidelines towards newborn care. We had a problem
with calculating feeds with very limited guidelines.

newborn records scanty.

No statistics were done, very little information appeared on admission book in
order to do proper statistics.

We were still wearing protective clothing. Hand washing done but not
emphasized as the most important way of infection control.

Room temperature was not observed closely or regulated properly - for we do not
have an airconditioner.
Achievements
 Staffing
 We do have permanent allocation of the staff in SCU
 Rotation of staff minimised
 Most of the staff had done the newborn training provided by CRH.
 All staff busy with training on Newborn Care by the Perinatal Education
Programme.
 On-going in service training is now being done.
Protocols and guidelines
 Protocols are readily available and are referred to by doctors and nurses.
 Most of these protocols were provided by CRH
Patient records
 Relevant Records for newborn care have been introduced and implemented.
 These cover admission record, initial assessment, observation and feeding
records, daily weight and newborn care records, weekly growth and
46
circumference chart, HIE charts, phototherapy charts, KMC score sheet,
auditing and statistics.
VRYHEID DISTRICT HOSPITAL
SPECIAL CARE UNIT
STATISTICS OF ADMISSIONS AND CASE FATALITIES
2008
2009
2010
ADMI DIE
CF
ADMI DIE
CF
ADMI DIE
CF
T
D
R
T
D
R
T
D
R
Extr. Low Birth Weight
34
24
71
23
17
73
21
19
90
Very Low Birth Weight
63
17
26
61
18
29
40
14
35
Low Birth Weight
117
5
4
173
8
5
137
5
4
Low Abgar Score
113
3
3
89
3
3
86
2
2
Birth Asphyxia
74
15
20
82
13
16
46
9
20
Respiratory Distress
102
2
2
87
4
5
89
1
1
Meconium Asperation
14
21
1
5
23
2
9
Meconium Exposure
46
190
220
Offensive Liquor
17
11
27
Neonatal Sepsis
20
31
2
7
46
Vacuum Extraction
21
27
11
Neonatal Jaundice
14
28
41
Big Baby
124
122
104
Congenital Abnormality
23
41
25
3
12
Other
27
26
2
8
36
1
3
TOTAL
809
BIRTH WEIGHT
500-999g
1000-1499g
1500-1999g
2000-2499g
2500g +
TOTAL
ADMI
T
34
63
109
107
496
809
66
8
1012
69
7
952
56
6
2008
2009
2010
DIE
CF
ADMI DIE
CF
ADMI DIE
CF
D
R
T
D
R
T
D
R
24
71
23
17
74
21
19
90
20
32
61
18
30
40
14
35
3
3
154
9
6
118
6
5
3
3
118
10
9
98
2
2
16
3
656
15
2
675
15
2
66
8
1012
69
7
952
56
6
KMC





The unit has 8 beds, accessories to support the baby in the KMC position, TV,
Occupational support and reading material.
The CRH team made recommendations for additional items which have
improved the facility ex. a fridge was issued for the mother’s use only.
the mothers accept and practice KMC.
Improved feeding policies have enabled earlier discharge.
Follow up system in place but due to the vested area we serve only a few
return for follow-up.
47
Equipment
 most basic equipment was available. but some not in good working order and
not regularly maintained.
 oxygen therapy has been better regulated since the acquisition of venturis to
use with head box oxygen.
 CPAP equipment is on order and will be used when the all staff have been
trained.
Patient care
 Perinatal review meetings supported by the CRH team have resulted in
improved care, especially in the use of the partogram.
 Patient care has been much improved by using the protocols and guideline
manuals.
 Follow-up on discharged babies ex. LBW, Birth asphyxia and are referred to
the occupational therapists and physiotherapists.
Reasons for our improvement.
 Dedicated staff who is willing to effective change.
 Caring attitude of the staff
 supportive management.
 On-going in service education of staff.
 Availability of resources *material *equipment.
 Frequent health education of mothers.
 recommendations of CRH are readily accepted.
Conclusions
Impact on the community

Earlier discharge of mothers who know more about how to care for their babies.

Decreased neonatal mortality due to avoidable factors.
Impact on clinics

clinics are participating in the perinatal review meetings. as a consequence basic
antenatal care has been strengthened, with better outcomes for the babies.
Challenges

There is insufficient space in the special care unit

there are still insufficient nursing staff to provide adequate care 24 hours per day

The time taken to get lab results is too long, recently 24 hour services provided
but results remain slow to return.
Accreditation

In November the hospital has been assessed for accreditation. Outcome is still
awaited.
48
NEONATAL OUTREACH IN ZULULAND DISTRICT: FACTORS FACILITATNG AND
HINDERING IMPROVEMENT IN THE QUALITY OF NEWBORN CARE
NC Mzolo, DH Greenfield, Centre for Rural Health, University of KwaZulu-Natal Durban
Introduction
The increasing neonatal mortality rates in Zululand district hospitals, and the insights on
neonatal and perinatal mortality rates from the Saving Babies reports motivated the Zululand
District office to establish partnership with the Centre for Rural Health (CRH) to set up an
intervention programme to improve newborn care in all five district hospitals that provide
maternity care. The Zululand Initiative for Newborn Care (ZINC) started in 2007 with funding
from Johnson and Johnson’s Peadiatric Institute (JJPI up to June 2009
As the Zululand district office made Newborn care Initiative a priority, CRH sought funding
and recommenced the intervention with funding from Discovery Foundation in April 2010.
Improvements and achievements have been reported in a paper by Greenfield.
Methods
The intervention started with onsite visits that were conducted by a community Neonatal
Doctor and an Advanced midwife, and subsequently conducted together with the coordinator
for MCWH in the Zululand district (ZINC team).
Meetings were held with hospital management on arrival at each of the facilities and at the
end of the day for a briefing session to review previous action plans and reflect on the
progress noted on the day of the visit
A systematic review of neonatal care using a checklist combined with a clinical round in the
neonatal unit with the maternity staff which was then used for compiling a report from each
visit which was sent to each of the facilities in order to facilitate actions.
Introduction of a revised Newborn Care Admission Record enabled the CRH and district team
to audit neonatal records at every visit with the staff and encouraging the staff to do it
themselves during the interim as the support visits were conducted on alternate months.
A five day training of staff on basic newborn care and providing resources such as
guidelines, protocols and new information from research was fundamental to this
intervention
49
Results and achievements
What has been achieved through this intervention has been discussed in the previous
presentation (Greenfield, Mzolo)
Facilitating factors towards improvement
The roles played by members at each level of care in supporting, supervising and
implementing suggested changes to improve newborn care are fundamental in quality
improvement.
The following areas of responsibilities were noted:
1. Area specialists
2. District management
3. Institutional management
4. Health workers – hands on staff
5. ZINC team
Area Support
Zululand District is one of three districts in Area 3 and gets support from Chief Specialists in
Obstetrics and Gynaecology as well as Paediatric Specialists from Lower Umfolozi District
War Memorial Hospital (LUDWMH) at Empangeni. Partnership with the area team assist in
transferring uniform standards of practice in all three districts thus creating better chances
for sustaining gains from the intervention
District Office Support
1. The Zululand District Office prioritized and supported this initiative by giving it time in
their schedules to participate in the setting up and site visits with the ZINC team.
Assisted institutions with resources where they fell short especially when moratorium on
spending was announced, the district office sought funding to buy essential equipment
for the institutions
2. Representatives from the District Office participated together with the ZINC team in most
of the Perinatal mortality and morbidity meetings to gain insight into the avoidable
factors contributing to increasing perinatal deaths in Zululand hospitals, and plan a way
forward for some of the administrative issues e.g. transport, laboratory results, lack of
equipment where the hospitals were unable to make changes.
50
3. The ZINC and the District held feedback meetings (where possible)on returning from all
the site visits, as this was the best time to meet and give an overview of the impressions
about the visit and bring forward advocacy issues.
Institutional support
1.
The ZINC team worked with hospital management in determining how the
intervention was going to be conducted, what support was a needed, specific actions
to be taken by management and how they would be followed up.
2.
Meetings with management (CEO, Medical and Nursing Managers) on arrival to
review previous action plans and at the end of the day for a reflection session and
make suggestions where needed were valuable
Health care providers in the neonatal unit
Acceptance of their role as change agents , working within a team help them to value each
other’s contribution (different categories ) to improvement in neonatal care
Knowing that the ZINC team will visit the following month kind of pushed them to make
“deliverables” to happen.
ZINC Team
1.
The ZINC team used different strategies to make things happen, such as, persistence
in pushing for change, regular visits for monitoring and providing resource
information supporting the changes e.g. norms, guidelines, protocols, policies e.g.
KMC, bathing of infants, ordering and use of equipment sere
2.
Persistence meant:

Discussing alternative routes to be taken e.g. critical issues of staffing –
letters written by management to District and the Province.

Giving advice on the allocation of other categories of staff (in view of shortage
of midwives) i.e. Enrolled nurses (ENs)and Enrolled Nursing Assistants (ENAs)
in neonatal unit .
51

Saying good bye, but assuring the staff of your coming back and making
comments such as “we are coming back and we know you will do something
about this “

Constant follow up of staff to nag stores’ managers to speed up equipment
orders, and return of repairs. Sometimes the ZINC team had to intervene by
meeting the person concerned face to face and to clarify the urgency of the
resources required and rearrangement of facilities. This role had to be played
by the ZINC team when managers were absent on the day of the visit.
3.
Every visit aimed at uplifting the morale of staff – acknowledge baby steps of
changes and appreciate what does seem to be a minor achievement
4.
Determine, discuss and provide, where possible, the resources required or tools
needed to make the job better – e.g.
Tools for newborn care e.g. guidelines,
checklist for audit , reorganizing the newborn care
admission and
observation
records
5.
Setting standards to be achieved e.g. accreditation process was viewed as making
newborn care important and special
6.
Communication of progress to all staff members in the unit made them all feel
special. This must be done continuously.
7.
The ZINC team encouraged ownership of, and commitment to, interventions by
institutions e.g. strong encouragement of one representative from management to
take rounds with CRH team during the visit and may be agree on time that can be
spent with her / him in recognition of many programmes competing with newborn
care
8.
With regard to support services that do not seem to be giving effective support, the
ZINC team also took time to address them on the significant role they played in
newborn care
9.
Conducted a one week workshop for all Maternity supervisors and / or area managers
from the 5 institutions to discuss the reorganization of the unit, and how to motivate
52
for better facilities and equipment, auditing of records and also management of staff
to motivate and encourage commitment to newborn care.
10.
Conducting the intervention in all 5 institutions encouraged sharing of ideas how
things are done, a bit of a competition and also encouraged bench-marking
Hindering factors
Although these are fewer than the facilitating factors they need to be addressed
1.
Equipment issues : Lack of some essential equipment, lack or limited knowledge of
how to use equipment, Provincial delays in repairs and the certification system of old
and new equipment respectively by the central supply Health Technology Unit
2.
Staff shortages in hospitals resulted in lack of adequate permanent staff allocated for
newborn care especially on night duty (one hospital). This is a critical issue.
3.
In one hospital failure to use approved protocols and guidelines by some sessional
doctors resulted in poor management and ultimately poor doctor- midwife
relationships, where midwives had to insist on using these protocols (lack of
orientation of team in management of patients.
4.
Poor infrastructure - old buildings cannot cater for the number of babies that need
admission that were delivered in some of the institutions. Lack of adequate space /
room for newborn care and failure to establish facilities such as KMC for effective
care of small infants
5.
Provincial financial constraints and the government moratorium, limiting the
possibilities of new structures due to financial constraints and government
moratorium on purchasing and buying.
Lessons Learned

Making people to be fully involved in the change they wish to see : Participation of
the hospital management in all visits and also district managers’ periodic visit with
the ZINC team led to most of the changes, as they participated in most of the clinical
rounds to understand newborn care, constant feedback and seeking advice for
planning

Partnership with MCWH and District programmes manager on what the intervention
will mean e.g. onsite clinical support together with team on the targeted sites
53

The ZINC team and MCWH visiting together as a team with one purpose, one voice ,
one mission .

Establishing and maintain good and trusting relationships

Motivation of staff:
commendations when necessary during sometimes during a
clinical round. Special comments of acknowledging cleanliness, or even one or two
things achieved since the previous visits boost the staff to want more of your support
and to continue improving.

Create awareness of the intervention to all staff members (Multi-disciplinary team
and motivate them to avoid delays in getting desired results

Monitoring : Ongoing support and personal visits are probably the most important
actions to ensure success. Empower staff to monitor their own actions and graph
them
People are busy and sometimes cannot make time. If the facilitator of the intervention does
not allow and enxourage others to be present onsite or during the clinical round, you will end
up doing the work for the people and they will not learn how to do it themselves. It is better
to work with the learners than to work for them! This will empower them.
Conclusion
Change takes time. The ‘things’ – equipment, protocols, practices, etc change first, and this
is a marker of progress. Quality of care follows but takes much longer, and needs a change
in the way people view their work and responsibilities. The strength of this outreach was
that it to a large extent worked with the people responsible for the care, and although
difficult to document, there has been change. There is still work to be done!
Comments from Staff on evaluation of the intervention
Two respondents assisted in acquiring equipment .
“ I would say CRH
has taught us to do business unusual like getting rid of broken
equipment or equipment that we don’t need in the unit, so that we have more space to
perform things like KMC and our unit looks rather like a store room. What I like most after
they visit us on the floor, They go straight to the CEO to give their report so that if we are
doing some motivation or specification for equipment , they speed it up.”
“we have had some slight improvement with equipment , at times we had nothing. It was
through the CRH that we got this equipment. Each time they came they kept asking where is
this and that, and I kept saying it is on order. I then took them to the stores and to my
managers. After that I got some of the equipment through their help “
54
One respondent talking about value of visits.
“ also as the person involved in newborn care , with the first visit of the newborn care team
was brilliant. We worked with their recommendations, and there was a slight improvement,
we are still going towards improvement. They did identify that we had to improve the staff
and also the equipment that is necessary for the unit. Without them really , we were working
, it was normal for us, until someone from outside came in and said –hey, you are supposed
to do this like this e.g. with the arrangement of the drugs for newborn care. And we have
now ordered a thermometer for the nursery; it wasn’t there before they came.”
55
THE EFFECTIVENESS OF PARTICIPATORY INTERACTIVE CARE IN MPUMALANGA
HEALTH SERVICES (2010/2011).
Rendall-Mkosi, K, 3Makin, J., 1Louwagie, G., 1Kamungoma-Dada, I., 2Hugo, J., 3Bergh, A.,
3
Pattinson, R.C.
1
School of Health Systems and Public Health, University of Pretoria.
2
Department of Family Medicine, University of Pretoria.
3
MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria
1
Introduction
Strengthening of antenatal care (ANC) services, and in particular the prevention of mother to
child transmission of HIV (PMTCT), is critical to reducing maternal and child morbidity and
mortality in Mpumalanga province, South Africa. Many of the potential barriers to a patient
benefiting from PMTCT can be overcome if appropriate communication strategies, including
participatory family-centred care, are provided (Chopra et al, 2005, Frizelle et al, 2009).
There is evidence to suggest that if patient consultations are carried out in a respectful way
and with the intention of problem solving and sharing information between the health service
provider and the patient, the patient is more able to take responsibility for their health
(Rowe el al, 2002). This study is a collaboration between the University of Pretoria Faculty
of Health Sciences and the MRC Unit for Maternal and Infant Health Care Strategies, within
the existing Maternal and Child Health Integration (MACH) project in Mpumalanga. Data
collection is incomplete therefore this paper reflects preliminary quantitative results only.
Participatory Interactive Care
Participatory Interactive Care is a generic process of patient interaction, based on joint
knowledge creation, respect, inclusiveness and networking (Eldh et al, 2006; Hugo and
Couper, 2005). New knowledge is created through collaborative interaction. Problem solving
options are discussed in a manner that makes sense to the patient and enables them to
make informed decisions. Respect is a core principle where the patient is respected and
accepted as an individual with unique needs and abilities; where he or she is listened to and
given the opportunity to interact with dignity and autonomy. When information is shared in a
respectful manner it creates the possibility for information to become useful through joint
knowledge creation. The move from power to information sharing in an interaction is a
useful way to consciously change attitude and practice in health care consultations.
Health literacy and patient-held records
Kickbush (2001) reminds us that education and literacy rank as key determinants of health,
among many others, and in particular for women’s health and the health of children.
56
Kickbush states that “information is crucial, but will never be sufficient to address many of
the major challenges faced by disenfranchised and marginalized populations. Components of
health literacy, such as access to information and knowledge, informed consent, and
negotiating skills must constitute part of the overall development effort.” p 294.
Various studies have demonstrated the value of providing patients with their own health
records. The main benefits relate to the higher potential for continuity of care, as well as the
increased sense of responsibility of patients for their own health related behaviours and
compliance with medical treatment (Dickey, 1993; Jerden et al, 2004; WHO, 1994).
It is proposed that by including the ANC patient in her health care process, and by reducing
the gaps in information flow from one service point to another, the process and outcomes of
the PMTCT programme, in particular satisfaction with the service and control of her own
health-related actions, will improve.
Background to the study
During 2009 a process of developing a ‘health handbook’ for use in the Mpumalanga
maternal and child health services was carried out in partnership with some of the health
workers and managers in the province. It is now being called the ‘Family Health File’ (FHF)
and consists of 28 pages of health information in an A4 flip file. Topics focus on reproductive
health, HIV/AIDS, and infant care (WHO, 2001). It has spare pockets for the insertion of the
standard patient health cards such as the antenatal, postnatal and road-to-health cards. In
addition a double-sided page with a summary of the 2010 PMTCT protocol has been inserted
for the use of the health staff. Health staff involved in clinics and maternity wards received
training in participatory interactive care through a series of workshops, and were introduced
to the FHF (Fig 1).
Participatory
interactive
care
workshops
with staff
Family health
file (FHF) to
each patient
in antenatal
care
Respectful
and caring
interaction
with ANC
patients
Exposure to
consistent
health info,
and carrying
records
Interactive
consultation
with FHF as
key tool
Better health –
related knowledge
during pregnancy,
and record
keeping by health
providers
Improved patient
satisfaction and
enablement
Improved
pregnancy
outcomes &
health of
mother and
baby
Fig 1 Framework of participatory interactive care and the effects on pregnancy
outcomes
57
Aim of the study:
To evaluate the effectiveness of participatory interactive care, including the provision of the
family health file, in the public ANC services in Mpumalanga.
Objectives being reported on:

To assess the influence of participatory interactive care on the level of satisfaction and
sense of enablement experienced by the antenatal and postnatal care patients.

To establish the perceived usefulness and fit of the family health file in promoting
continuity of care in the maternal and child care services.

To establish if there is an improvement in patient health-related knowledge.
Study design
This is a non-randomised intervention study being conducted in the primary health care
clinics of two Mpumalanga Local Municipalities (LM). A complex intervention (one day staff
training workshops and the dissemination of a family health file to every ANC clinic patient)
was carried out in the antenatal care services over a period of 4 months in the intervention
LM in late 2010, and no intervention in the control LM (standard care only).
Population and sample
The population consisted of all women delivering at the 2 hospitals in the 2 LMs and who
had attended ANC in any of clinics in the 2 LMs. Consecutive women were recruited until the
sample size was reached during September and October 2010 (pre-intervention) and during
February and March 2011 (post-intervention).
The sample size for the patient population was calculated such that the study would have
80% power to detect a 5 percent difference in outcomes in the patient provider relationship
scale between the intervention and the control group using mixed linear analysis (Garson,
2008). Since we particularly want to assess the treatment that HIV infected women are
receiving, and since it is estimated that these women form approximately 30% of the
antenatal population, the sample size was increased to 210 per group.
Measurements
A brief structured questionnaire was used to interview the patients at the maternity ward –
pre-intervention and post-intervention. The questionnaire consists of demographic variables
(age, education level, employment status, parity) and scales and questions related to the
58
main outcome measures. The post-intervention questionnaire included questions relating to
the use of the FHF also. The patient’s antenatal card and ward medical records were used to
complete some of the questions. HIV status and birth weight of the baby was obtained from
the birth register in the ward. The antenatal card score was derived from a seven item check
list relating to adequacy of recording on the card. Maximum score could be seven.
The Patient-Healthcare Provider Relationship scale (PPRS) was developed by members of
this research team for use in the south-west Tshwane district. Its primary use was to assess
the quality of the relationship between the patient and the healthcare provider. Subsequent
factor and reliability analyses of the initial 19 item scale resulted in a 14 item scale with a
high reliability (Cronbach alpha=0.91) (unpublished study). A maximum score of 56 would
indicate the poorest experience of satisfaction with the patient/provider relationship.
The Patient Enablement Instrument (PEI) is a validated and standardized instrument that
was developed in the United Kingdom to measure enablement at consultations in primary
care (Howie et al., 1998, 1999). This six item instrument was designed to determine
patients’ feelings of confidence, ability and coping as a result of the consultation (Porter,
1997). A maximum score of 18 would indicate the poorest sense of enablement.
The study received approval from the Mpumalanga Research and Ethics Committee as well
as the Faculty of Health Sciences Research Ethics Committee of the University of Pretoria.
Statistical analysis
Data analysis was done using SPSS for Windows Version 17 (SPSS Inc, Chicago, IL, USA).
The pre-intervention data in each site was compared between the intervention and control
site to assess the level of similarity of the population and outcome measures of interest
using Pearson chi-square test for categorical variables and two-sample t-tests for continuous
variables. The post-intervention data was also compared and tests of significance used to
compare the quantitative measures of interest. Mixed linear analysis (or mixed logistic
regression analysis for binary variables) was performed to take into account random effects
and to control for baseline differences between the two groups and for other factors that
may have an impact on outcome. The proportion of women who reported having received a
FHF was calculated, and frequencies of the feedback responses on their use of the FHF were
calculated.
Results
Baseline data indicates that most demographic characteristics and outcome measures of
interest were similar for the two LMs (Table 1). The only significant difference of interest was
59
found in the proportion of HIV positive patients who had a recorded CD4 count (44.3% in
the intervention site and 28.4% in the control site; p=-0.04), and the completeness of the
ANC card (p=<0.0001).
Table 1
Baseline socio-demographic
respondents
and
clinical
characteristics
Variable
Intervention
site
(N=206)
Control site
(N=218)
*p-value
Age (mean, sd)
25.89(6.51)
26.24(6.25)
NS
Education (n,%)
<=7
8-11
12>
18(8.7)
71(34.5)
117(58.8)
11(5.2)
79(36.6)
126(58.3)
NS
Has a partner (n,%)
89(43.2)
82(37.6)
NS
Mean gestational age at 1st visit
(mean, sd)
24.26(6.00)
24.16(5.81)
NS
Birthweight<=2499 (n,%)
19(10.3)
28(13.5)
NS
Y
6.65(.68872)
4.7(1.605)
<0.0001
Y
Positive HIV status (n,%)
79(38.3)
88(40.4)
NS
CD4 count recorded (n,%)
35(44.3)
25(28.4)
0.04
Baseline CD4 (if done) (mean, sd)
358.51(186.34)
396.48(225.09)
NS
Initiated
(n,%)
64(81.0)
73(82.0)
NS
ANC card score out of 7
sd)
ARVs
before
(mean,
delivery
of
Quality of
care
indicators
Y
Y
*Pearson χ-square test for categorical variables, two sample t-test for continuous variables
Small, but significant, differences were found at baseline between the two LMs in terms of
patient satisfaction and patient enablement scores relating to ANC services and knowledge of
how HIV is transmitted. The PPRS score was poorer in the intervention site (the lower the
score the better), while the enablement (the lower the score the better) and knowledge
score were poorer in the control site. Based on data analysed thus far in the postintervention interviews, there is no difference between the PPRS, enablement and knowledge
scores (Table 2).
60
Table 2
Patient satisfaction, enablement and health related knowledge preand post-intervention
PRE-INTERVENTION
POST-INTERVENTION
Interventio
n sites
(N=206)
Control
sites
(N=218)
Interventio
n sites
(N=53)
Control sites
(N=100)
Mean (SD)
Mean (SD)
p-value
Mean (SD)
Mean (SD)
p-value
Patient
provider
relationship score
26.29(6.72)
24.76(7.00)
0.024
21.33(5.33)
21.45(6.00)
NS
Enablement score
9.37(1.95)
9.92(2.26)
0.008
9.56(2.01)
9.78(2.11)
NS
Knowledge score (HIV)
1.81(.84)
1.41(.64)
<0.0001
1.78(.84)
1.71(0.49)
NS
Variable
A linear regression analysis was done taking into account differences at baseline and
assessing the difference in the post-intervention scores. (Note: not paired analysis since 2
different samples). A significant result was found which suggests that the participatory
interactive care training and family health file provision has led to an improvement in the
patient/provider relationship (Table 3).
Table 3
Linear regression analysis of patient provider relationship score
Variable
Patient
provider
relationship score
β-coefficient
Prepost
-3.924
<0.001
Group
-1.13
0.046
It is a fairly pleasing result that 70% of the patients in the intervention site had received a
FHF. Most of the responses from those who had received one reflected a positive sentiment
and use of the file (92%). The only aspect of concern was that only 35% took it with them
to the maternity ward, and only a few (32%) had experienced an educational session with a
nurse or health promoter using the FHF.
Discussion
Since the study is incomplete, it is of little value to discuss the preliminary results. We are
satisfied that the study is going according to plan and that early indications are that the
intervention is effective and could be introduced across the province.
61
ENSURING SUCCESSFUL IMPLEMENTATION
MORTALITY, A HEALTH SYSTEM APPROACH
OF
STRATEGIES
TO
REDUCE
María Belizán on behalf of the Lancet Stillbirth Series paper 4 group.
MRC Maternal and Infant Health Care Strategies Research Unit
Introduction: A health system is not a machine where the output can be predicted from
the input. The health system is a complex adaptive system with a collection of individual
agents whose actions are interconnected so that one agent’s action changes the context for
other agents. Hence changing the health system so that the quality of care can be improved
is a complex intervention. The aim of this paper is to describe the agents’ interfaces and to
identify existing strategies that are likely to be successful in order to produce effective
change for improving health outcomes.
Methods: Review of the literature and a summary of published literature regarding
successful implementation of health care interventions according to the interfaces.
Results: Improving successful implementation of known life-saving interventions within
health system packages requires consideration of many interfaces that influence whether the
introduction of the packages will be successful or otherwise.
There are seven main interfaces where interaction can bring about change in behavior
(Figure 1). Each interface contributes to the desired effect of reducing unnecessary deaths of
mothers and their babies.
62
Figure 1
Key health system interfaces to affect change
Goal: reduced mortality and morbidity
Coverage
Health care
providers
Patients
7
Quality
Skills
Legend: Interfaces
1.Policy makers–heads of
health
2.Heads of health–health
promotion managers
3.Health promotion
managers–community
4.Health care managers–
community
5.Heads of health–health care
managers
6.Health care managers–
health care providers
Resources
6
Community
Guidelines
4
Messages
Health care
managers
3
Health
promotion
managers
5
2
Heads of
health
7.Health care providers–
patient:
1
Policy makers
The literature review provides experiences of strategies likely to be successful that might be
considered when applying programs (Table 1).
Table 1: Health system interfaces and strategies likely to be successful
Interfaces:
1: Policy makers  heads of health: decide
on and convey policy
2: Heads of health  health promotion
managers: convey policy, decide strategy and
messages for the community
3: Health promotion managers 
community: provide constant messages
4: Health care managers  community:
ensure community has access to health care to
enable policy to be implemented
5: Heads of health  health care
managers: convey policy, and decide allocation
of resources necessary to implement policy
6: Health care managers  health care
providers: convey policy, provide resources and
knowledge and skills necessary to implement
policy
7: Health care providers  patients:
Examples of strategies likely to be
successful
Variable: Conveying magnitude and burden of
disease, cost effectiveness, and availability of
effective solutions, etc.
Diagonal approach (creating demand and
providing resources to fulfil it)
Patient mediated interventions; Mass media;
Participatory interventions
Community mobilization; Financing strategies;
Communication and transport system; Antenatal
risk screening by community health workers;
Maternity waiting homes
Formal integration of services; Improving office
systems; Structural interventions; Provider
incentives
Distribution of educational material; Audit and
feedback; Reminders; Educational meetings; Local
consensus processes; Problem based learning in
continuing medical education; Educational
outreach visits; Local opinion leader; Multifaceted
interventions; Tailored interventions to overcome
identified barriers to change.
Motivational interviews; Patient education
63
provider implements knowledge and skills and
uses of resources to provide care to the patient
within policy guidelines including adequate
information to enable discussion and appropriate
decisions by the patient.
programmes such as Informed patient choice,
shared decision making between patients and
providers, and Patient decision aids
Note: Other interfaces are possible, e.g. direct communication of policy makers with health care providers or
community.
Interface 1: Policy makers  heads of health
The heads of health have to interact with policy maker so that the allocation of resources
falls within the policy. Decisions would be based on information regarding, for example:
Burden of disease, cost effectiveness, availability of effective solutions, political decisions,
actors power, etc.
Shiffman has argued that to propose policies to governments, ideas global health
organizations might be the most important tools in directing policy. Stillbirths are not
prominent on the agenda of policy makers and heads of health despite the high burden and
cost effectiveness of intervention. To put stillbirth and neonatal and maternal death on the
policy agenda, global health advocate need to define the problem, communicate the problem
and solution, and possibly create institutions dedicated to this issue
Interface 2: Heads of health  health promotion managers:
At the interface between heads of health with the health promotion managers decision on
the strategies and messages to the community take place. These consistent messages
should be decided on by head of health in conjunction with policy makers.
Diagonal approach was shown to be effective to improve child survival in Mexico. It is to
create demand of health care interventions by constants messages to community and the
fulfilled the demand by providing resources to health care managers.
Interface 3: Health promotion managers  community
The provision of constant messages should be dictated by health promotion departments of
the various departments of health to the community.
There is some evidence that mass media interventions may have an important role in
influencing the use of health care services for maternal and child health. Patient-mediated
interventions are also used to improve health care with different levels of effectiveness and
feasibility of implementation, such as working with women’s groups in a participatory way
can be an effective mechanism to get messages across or develop local solutions to
problems and improve demand for quality care.
64
Findings of a Cochrane review of 18 Cluster randomized trial showed that community based
packages significantly reduce maternal morbidity by 25%, neonatal mortality by 24% and
stillbirth by 16%, and also increased healthy behaviours such as referrals for pregnancyrelated complications and early breast feeding.
Interface 4: Health care managers  community
Health care managers have direct interaction with the community in terms of improving
accessibility. The effect of interventions to link mothers with skilled care during pregnancy,
labour and birth, were described by Lee and colleagues. They included increasing community
demand for obstetric care through community mobilisation and financing strategies and use
of approaches to bring pregnant women closer to the formal health system such us
community referral systems and transport schemes, antenatal risk screening by health
workers and maternity waiting homes.
Interface 5: Heads of health  health care managers
The health care managers have to interact with the Heads of health so that they get
sufficient resources to be able to allow the health care provider to do their work. The
provision of high-quality services requires staff with appropriate skills and essential
equipment and drugs.
A number of systematic reviews describe the effectiveness of strategies for the selection of
appropriate technology and adequate delegation and use of resources: Formal integration of
services, that is Integration of primary health care services; improving office systems by the
Organisation of office system to increase the use of health service procedures; structural
interventions like Changes in medical records systems, e.g. nursing record systems; or
economic incentives to providers to deliver an specific care.
Interface 6: Health care managers  health care providers
The health care provider must have the knowledge and skills to manage health care users.
For this the health care provider needs to interact with the health care managers to ensure
there are guidelines and resources available to manage the health care user; and the health
care provider must ensure they have the knowledge and skills to implement the guidelines.
Althabe and colleagues described in an overview of systematic reviews the strategies for
improving the quality of health care in maternal and child health in low and middle income
countries. They conclude that the use of manual reminders to promote effective care and the
implementation of clinical guidelines seemed to be the most readily applicable strategies. A
65
multifaceted strategy, integrating interactive workshops, distribution of simple printed
materials and implementation of manual reminders, is also likely to be applicable on largescale basis. This combined strategy could be potentially relevant to training birth attendants
in essential obstetric and neonatal care and neonatal resuscitation and to developing and
implementing clinical guidelines.
In a meta-analysis of before and after studies on the use of perinatal death audit, a 30%
reduction in perinatal mortality was described, but the challenge remains in scaling up audit
and especially in ensuring the action cycle is closed.
Interface 7: Health care providers  patients
The interface that has the most effect is the health care user-health care provider interface.
It is the interactions which will make the user decide to use the medication prescribed or
follow the management plan discussed with her.
During the interaction between health care providers and health care users (patients), an
empathetic relationship improves client satisfaction, but may also be more effective in
improving outcomes. For example, women with diabetes who were given more information
and felt respected achieved better control than those receiving standard treatment.
Some strategies described are: motivational interviews, informed patients choice, share
decision making and patient decision aids. While no randomised trial could be found related
to motivational interviewing or shared decision making in antenatal care, one review found
that antenatal counselling was a key factor in improved uptake of skilled care during
childbirth.
Conclusions: Coverage is improved by provision of basic information and service access to
health care users, and quality of care is improved by ensuring health care providers have
skills, knowledge, and resources to provide care. Specific implementation strategies are
needed to target these aspects of care and meet the needs of the population.
66
TEN, PLUS FIVE, PLUS ONE: REPORT CARD ON HOW SOUTH AFRICA DOING IN
IMPLEMENTING THE 16 KEY INTERVENTIONS TO PREVENT STILLBIRTHS,
MATERNAL AND NEONATAL DEATHS
RC Pattinson
MRC Maternal and Infant Health Care Strategies Research unit, Department of Obstetrics
and Gynaecology, University of Pretoria
Aim: To ascertain how South Africa is faring with the 16 key interventions to prevent
stillbirths, neonatal and maternal deaths.
Method: Compare coverage and quality of care of 16 key strategies in preventing
stillbirths, neonatal and maternal deaths. Data derived from Saving Babies 2008-2009,
Demographic and Health Surveys and provincial reports in NaPeMMCo.
Results:
In the ten key interventions involving mothers, foetuses and neonates are:
1. Periconception folate supplementation or fortification: Good
2. Detection and management of HIV infection: Good
3. Detection and management of hypertension in pregnancy: Mixed
4. Detection and management of gestational diabetes: Poor
5. Detection and management of growth restriction in pregnancy: Poor
6. Detection and management of post-term pregnancies: Poor
7. Detection and management of syphilis: Good
8. Skilled care at birth: Good
9. Basic emergency obstetric care: Mixed
10. Comprehensive emergency obstetric care: Mixed
In the five key neonatal and maternal interventions
11. Tetanus toxiod immunisation: Good
12. Antibiotics for preterm premature rupture of membranes: Unknown
13. Antenatal corticosteroids for preterm labour: Getting better
14. Active management of the third stage of labour: Mixed
15. Neonatal resuscitation: Getting better
In the plus one
16. Contraception: Much room for improvement
Conclusion: South Africa has an estimated SBR of 22.7/1000 births (≥500g) and should
concentrate on detecting and managing syphilis, HIV infection, hypertension in pregnancy,
and improve labour management. To aspire to SBR range ≥5/1000 – <15/1000 (with Brazil
etc.) we must improve labour management.
67
TRIPLE RETURN FOR OUR RAND: HOW MANY SOUTH AFRICAN MOTHERS AND
BABIES CAN BE SAVED AND WHAT IS THE COST?
Kate Kerber for Lancet Stillbirth Series paper 4
Saving Newborn Lives / Save the Children
The recent Lancet Stillbirth series demonstrated that the causes of stillbirths are inseparable
from those that also kill pregnant women and their newborns. ENREF1 Each year there are
350,000 maternal deaths, and 3.6 million neonatal deaths which are recognised in
Millennium Development Goals but there are also 2.68 million stillbirths without global goals
or routine data tracking.
The global burden of stillbirths as well as maternal and newborn deaths is unequally carried
by Africa. According to UN estimates in 2008 in South Africa alone there were 22,000
stillbirths, 21,000 neonatal deaths and 4,500 maternal deaths (Figure 1). In South Africa, as
in many other middle-income countries, interventions for mothers and their babies are best
packaged and provided through linked service delivery modes tailored to suit the existing
health care system. To maximise mortality reduction, high coverage and quality of care is
critical especially in the rural areas and amongst the poorest families. Using methods from
4th paper in The Lancet Stillbirth series, we applied the lives saved and costing analysis to
South Africa. Statistical modelling based on the Lives Saved Tool (LiST) was used to estimate
the potential lives saved and the cost of implementing packaged interventions.
Figure 1: Global distribution of stillbirths, neonatal deaths and maternal deaths
68
Choices about health service implementation and priority interventions are not always based
on systematic decision-making processes and local data.6 Defining the levels of health
system performance by stillbirth rate has been used in this series as a first step in a
transparent and data-driven approach to priority-setting. The top priority should be given to
interventions with the highest mortality impact that are also affordable, feasible, and
improve equity.
Using LiST version 4.2, the current maternal, newborn and stillbirth lives saved were
modelled if packages of interventions were scaled up to universal (i.e. 99%) coverage levels
in different contexts.
The interventions chosen were based on systematic evidence reviews of effect for reducing
stillbirths.2 Maternal- and newborn-specific interventions that can be delivered during the
same contact point as the stillbirth-specific interventions during pregnancy and childbirth
include tetanus toxoid immunisation, antibiotics for preterm premature rupture of
membranes, antenatal corticosteroids for preterm birth, active management of the third
stage of labour, and neonatal resuscitation (Table 1).
Table 1
Interventions modelled in LiST that reduce stillbirths as well as
maternal and neonatal deaths
Interventions to reduce stillbirths
1. Folate supplementation/fortification
2. Detection and management of syphilis
3. Detection and management of HIV*
4. Detection and management of HDP
5. Detection and management of diabetes
6. Detection and management of FGR
7. Induction of labour at 41+ weeks
8. Skilled care at birth
9. Basic EmOC
10. Comprehensive EmOC
Interventions for mothers and newborns
1. Tetanus toxoid immunisation
2. Antibiotics for PPROM
3. Antenatal corticosteroids
4. Active management of the 3rd stage of labour
5. Neonatal resuscitation
*Modelled in a separate but similar analysis for South Africa7
69
LiST is based on The Lancet Child Survival and Neonatal Survival series modelling of lives
saved and is built into the freely available demographic software package (SpectrumTM). LiST
is linked to the modules for estimating the impact of family planning interventions and AIDS
interventions, and is pre-loaded with national-level health status and mortality data for 2008,
as well as intervention coverage. LiST models the impact of changes in coverage of
individual interventions on the reduction of deaths due to specific causes. The effectiveness
estimates for each intervention come from a standardised review process developed by Child
Health Epidemiology Group (CHERG). Inputs and methods have been published elsewhere.
ENREF_13 The cost effectiveness of various interventions was modelled by estimating the
total cost of interventions multiplying average cost per case with the number of women
covered by the different interventions. The methods have been described elsewhere.
If full (99%) coverage of care was reached in 2015, up to 24,000 stillbirths and maternal and
newborn deaths could be prevented each year at an additional cost of just R35 per person
(table 1). This represents an additional 1% of current healthcare spending. The addition of
full coverage of prevention of mother-to-child transmission of HIV/AIDS has been estimated
to save 37,000 newborn and child lives in 2015.7
Table 1
Cost per stillbirth, maternal and neonatal death averted
Total
cost
additional Cost
per
averted
Cost per maternal and
stillbirth newborn death and
stillbirth averted
Basic ANC
R 109,345,000
R 70,0000
R 49,000
Advanced ANC
R 504,125,000
R 260,000
R 260,000
Childbirth care
R 930,057,000
R 198,000
R 103,000
R 1,519,186,000 R 185,000
R 113,000
Subtotal
of
interventions
stillbirth
R
Total package (M+N) 1,730,211,000 R 211,000
R 94,000
As in most low- and middle-income countries, improving coverage and quality of emergency
obstetric care in South Africa will have the greatest impact on maternal and neonatal deaths,
as well as stillbirths (Figure 2). Syphilis identification and treatment is of moderate impact
but lower cost and highly feasible. Advanced antenatal care including induction for postterm pregnancies, detection and management of hypertensive disease in pregnancy, fetal
growth restriction, gestational diabetes, will further reduce mortality, but at higher cost.
70
Figure 2
Potential lives saved at full coverage, by package
A focus on implementing effective care during pregnancy and birth results in a triple return
on every Rand invested since maternal and neonatal deaths as well as stillbirths are
prevented. Stillbirths count for families and need to count in health systems too.
71
RESEARCH PRIORITIES FOR PREVENTING STILLBIRTHS IN LOW AND MIDDLEINCOME COUNTRIES: DELIVERY AND DEVELOPMENT OF INTERVENTIONS
EJ Buchmann
University of the Witwatersrand, for the Lancet Stillbirth Series
Introduction
In low and middle-income countries, stillbirths remain a significant problem, especially
related to potentially preventable stillbirths resulting from intrapartum hypoxia. To achieve
reductions in stillbirth rates in these environments, research needs to be done to identify not
only the causes of stillbirths, but also what interventions may prevent stillbirths. Among all
the possible research avenues, priority areas must be identified so that research funding and
efforts can be appropriately directed.
The Child Health and Nutrition Research Initiative (CHNRI) method for identifying research
priorities in health care uses a systematic expert scoring system for prioritization of
competing research questions. The method first requires the compilation of a list of contextspecific research questions based on published evidence, workshops and individual expert
opinion, and then considers the collective wisdom of a number of experts who work
independently on scoring these research questions to identify the priority research avenues.
The scoring is systematic, relying on the assessment of each suggested research question in
terms of five domains: answerability, effectiveness, deliverability, reduction of disease
burden, and equity. For a robust and stable priority listing, about 20 experts are needed to
provide this ‘collective wisdom’.
The objective of this exercise was to determine research priorities for prevention of stillbirth
in the context of low and middle-income countries.
Methods
The CHNRI method was used, as described above. A list of research questions, separately
for low and middle-income contexts, was compiled from several sources where research
gaps had been clearly identified – the BMC stillbirth series, an International Journal of
Gynecology and Obstetrics paper, proceedings from a GAPPS workshop, the Cochrane
database, and the opinions of members of the Lancet stillbirth series group. Questions were
divided into delivery and development categories, for the outcome of preventing stillbirth.
Delivery refers to health system and policy for delivering proven health care interventions to
points of health care. Development refers to context-specific adjustments, applications or
improvements in proven health care interventions. Fifty-two questions were compiled for
low-income settings (27 on delivery, and 25 on development). Forty-five questions were
72
compiled for middle-income settings (15 on delivery, and 30 on development). Scorers were
chosen by the Lancet stillbirth series group, separately for low and middle-income country
contexts, from networks of recognized experts and researchers who were expected to have
valuable opinions on research to prevent stillbirths in these contexts. Efforts were made to
achieve diversity in location, gender and language. All chosen scorers were contacted by
email and sent scoring sheets, and reminded if they did not respond. Eventually, 22
responded for low-income countries, and 19 responded for middle-income countries. The
questions were analysed using descriptive methods according the standard CHNRI scoring
system.
Results
The top five questions for delivery, and the top four questions for development are shown in
panels 1-4, exactly as they were worded.
Panel 1. Top five questions on delivery of interventions in low-income countries
1. Does training and retraining of professional midwives in antenatal and intrapartum
care reduce stillbirth rates?
2. What is the most cost-effective antenatal care package, with clearly defined
component interventions, for the prevention of stillbirths?
3. Does training of community health workers in pregnancy health promotion reduce
stillbirth rates?
4. Can community mobilisation strategies improve care seeking patterns and reduce
stillbirth rates?
5. Do training drills for simulating management of obstetric emergencies reduce stillbirth
rates?
73
Panel 2. Top four questions on development of interventions in low-income
countries
1. How effective is a simplified partograph with an easily applied management protocol
for identifying problems during labour and preventing intrapartum related stillbirth?
2. What is the optimal management, including drugs, follow-up, admission and timing of
delivery, for pregnancy-induced hypertension and chronic hypertension?
3. What are the safest, most acceptable and most cost-effective methods for detecting
intrapartum fetal distress in resource-poor settings?
4. What is the optimal management for prelabour rupture of the membranes, and for
suspected amniotic fluid infection?
Panel 3. Top five questions on delivery of interventions in middle-income
countries
1. What is the most effective strategy for implementing on-site syphilis screening and
treatment at antenatal clinics?
2. What is the most cost-effective antenatal care package, with clearly defined
component interventions, for the prevention of stillbirths?
3. Does training and retraining of midwives and physicians in neonatal resuscitation
reduce stillbirth and neonatal death rates?
4. How can perinatal audit and facility quality improvement be most effectively
undertaken to reduce stillbirth rates?
5. Do training drills for simulating management of obstetric emergencies reduce stillbirth
rates?
74
Panel 4. Top four questions on development of interventions in middle-income
countries
1. How effective is a simplified partograph with an easily applied management protocol
for identifying problems during labour and preventing intrapartum related stillbirth?
2. Using dosing and dose-range studies, what are the safety profiles of oral and vaginal
misoprostol for induction of labour?
3. What is the optimal management for prelabour rupture of the membranes, and for
suspected amniotic fluid infection?
4. Does the use of insecticide-treated nets reduce the stillbirth rate in areas with low
malaria transmission rates or areas where Plasmodium vivax is the most dominant
pathogenic parasite?
Discussion
The CHNRI method for identifying research priorities has now been applied to prevention of
stillbirths. Research priority areas for delivery in both low and middle-income contexts are in
training and audit and, in low-income countries, making antenatal and intrapartum care
more accessible to communities. For development, the research priorities are in intrapartum
care, such as partograph, rupture of membranes, induction of labour and fetal monitoring, as
well as in management of hypertension in pregnancy.
75
UNINTENDED PREGNANCIES IN A NEONATAL UNIT - A PILOT STUDY
S Delport
Dept of Paediatrics, Kalafong Hospital, University of Pretoria
MRC Unit for Maternal and Infant Health Care Strategies
Introduction
Worldwide more than 50% of pregnancies are unintended. Against a background of poverty
an unintended pregnancy can be a death sentence for the infant.
The consequences for the mother are that she seeks a termination of pregnancy which may
lead to complications such as a postpartum haemorrhage in a future pregnancy or if she
proceeds with the unintended pregnancy, inadequate antenatal care.
Unintended
pregnancies may also recur. The consequences for the infant are prematurity, desertion,
child abuse, infanticide, malnutrition and death.
Unintended pregnancies occur because of inadequate contraception. Promiscuity amongst
the youth is on the rise, leading to teenage pregnancies (around 5000 during 2009/2010).
Inadequate contraception may be the result of an inadequate service because of vacant
posts in the public service.
Women are also faced with limited contraceptive choices, are
often uninformed and unguided and this scenario leaves them unempowered.
In South Africa poverty, overcrowding, scarcity of water, suboptimal health care and
inadequate sanitary facilities have a detrimental effect on the survival of infants. In addition,
5.8 million South Africans are living with HIV/AIDS. A large number of unwanted infants are
found dead on dumping sites and are not reflected in the infant mortality rate and a number
of unwanted newborn infants are found alive in refuse bags.
Six thousand newborn infants
die annually in state hospitals and a further 60 000 deaths occur in children ≤5 years. The
infant mortality rate (IMR) has been rising and is currently 73/1000.
Objective
To determine the number of unintended pregnancies in the neonatal service at Kalafong
Hospital.
Patients and Methods
As per standard of care a reproductive history is obtained from mothers of newborn infants
which includes information about previous pregnancies, ages and genders of children and
whether the current pregnancy was intended. If it was unintended because of inadequate
contraception, advice is given and appropriate contraception initiated. If the pregnancy was
76
intended, enquiry is made into satisfaction with the current method of contraception and
optimal child spacing discussed.
Results
Over a 1-month period (1/9/1010 – 30/9/2010) 90 women were counseled. Their median
age was 25 years (range 15 - 41 years), 38/90 (42%) were primigravida and 22/75 (29%)
were HIV-infected. Of 49 women questioned 35/49 (71%) had an unintended pregnancy.
Sixty-four women were in the age group 20 – 34 years and 34/64 were questioned of whom
21/34 (62%) had unintended pregnancies.
Conclusion
The majority of pregnancies are unintended which may lead to life-threatening
consequences for the mother and infant.
Discussion
A disregard for responsible conception seems to prevail in South Africa which is fuelled by
concurrent sexual relationships and promiscuous sexual behaviour. Family planning averts
30% of maternal deaths and 10% of infant deaths. In the light of the high IMR, effective
long term reversible methods of contraception (such as intrauterine contraceptive devices)
need to be encouraged and implemented to effect responsible, planned conception and
optimal child spacing.
77
BEING SURE: WOMEN’S DECISION MAKING WITH AN INEVITABLE MISCARRIAGE
Rana Limbo, Jo Glasser, Maria Sundaram, Breanna Ries
Research supported by Gundersen Lutheran Medical Foundation, Inc.
Background: Early pregnancy loss, defined as the unintended ending of a pregnancy before
20 weeks completed gestation, is a worldwide health problem. Approximately one in five
known pregnancies ends in miscarriage. Of those, about 80% occur in the first trimester
(DeCherney, Nathan, Goodwin, & Laufer, 2007). Quantitative and qualitative researchers
report a wide range of emotional, social, and cultural aspects of the miscarriage experience.
Neugebauer and colleagues (1997) demonstrated higher levels of depression in women six
months after a miscarriage, compared with community controls. A relationship with a nurse
significantly accelerated resolution of depression following miscarriage for both men and
women (Swanson, Chen, Graham, Wojnar, & Petras, 2009). Côté-Arsenault and Dombeck
(2001) studied the degree of fetal personhood identified by women in a subsequent
pregnancy after loss. Of these 74 women, 82% had miscarriages in the first trimester and
75% of all women believed this was the death of a baby or child. Anxiety and minimal social
support have also been reported (Côté-Arsenault & Dombeck, 2001; Stratton & Lloyd, 2008).
When faced with inevitable miscarriage, women have three treatment options: Wait for
miscarriage to occur spontaneously, undergo a surgical procedure (suction curettage), or
use medication (misoprostol) to hasten the miscarriage (Schauberger, Mathiason, &
Rooney, 2003). The decision is a difficult one for many women and may have persistent
and pervasive psychological consequences (Neugebauer et al., 1992; Wieringa-de Waard
et al., 2002). Generally, diagnosis of inevitable miscarriage is a sudden occurrence,
leading to the need to make multiple decisions about what to do next. Table 1
summarizes the treatment outcomes for the women in this study.
Table 1
Treatment choice
Watch and Wait
Office D&C
OR D&C
9
8
6
Medical
(misoprostol)
1
Women’s decision making before and during a miscarriage is relatively unexplored. The
purpose of this qualitative, descriptive study was to explore with women their experience of
making treatment and other decisions after receiving the diagnosis of inevitable miscarriage.
Methods: Twenty four English-speaking women, all of whom were >18 years of age, had
experienced an early miscarriage (<12 weeks gestation) in the past two weeks to four
months, and had talked with a health care provider prior to the miscarriage about how to
proceed, gave consent to participate in the study. The study had prior Institutional Review
Board approval. Participants were interviewed by telephone for 30 – 75 minutes, using a
semi-structured interview guide. The interviews were digitally audio recorded and files
downloaded to a password-protected research site on a Gundersen Lutheran Health System
server. The interviews were transcribed verbatim by one of three research assistants. The
interview began with the invitation, “Tell me about how you learned that you were going to
have a miscarriage?” with this follow-up question: “Think back to when you learned that you
were going to have a miscarriage. What went into knowing what you were going to do
next?” Directed content analysis was used to code the interviews. The interviewers made
written notes during the interviews that documented participant responses and provided
beginning content analysis (e.g., notations about “certainty” and types of decisions). Written
transcripts were coded using underlining, margin notes, and summary phrases or sentences
by the research team individually or in groups. The researchers identified types of decision
making and conditions for decision making and coded and tabled decision types and
conditions. We ended recruitment when we had diversity in the sample to reflect 1. the three
different types of treatment decisions: surgery, medical, and watch and wait; 2. variation in
the meaning of the pregnancy and loss (i.e., “living matter,” “it,” and “baby”); 3. a range of
educational levels and income levels; 4. variation in number of children (0 to 4); and 5. some
with history of prior loss.
Results: Women identified numerous types of decisions associated with the miscarriage,
among them what type of treatment to choose, who to tell and when, who to contact with
questions and when, and keeping or changing social and family obligations.
Analysis of the data showed that “being sure” that the pregnancy was no longer viable was
the key condition in making a treatment decision. As this woman reports:
Um, basically I knew because I started spotting as I did last time. And then um, it got
heavier and I requested to see someone for an ultrasound, so for that point that was
the final for sure, knowing that I was going to have another miscarriage. Having that
ultrasound again.
Women wanted to be sure to avoid moral and religious conflicts they associated with elective
abortion and to fulfill their role as protector of their unborn child. Being sure that the
pregnancy was not viable (i.e., certainty/uncertainty) emerged as a central theme and
created the context for treatment decision making for most women. A confirming ultrasound
79
(sometimes done for a second and even third time) and the onset of bleeding or bleeding
becoming heavier generally led to women being sure.
That’s when he started with it…that if I wasn’t comfortable, if I didn’t think that the
baby was…if I thought the baby was alive we could do more ultrasounds.
So I’m sitting here looking at these pills and I put them in the applicator and it was
very difficult because in my mind what was going through is, hmmm ‘I’m killing my
baby here.’ But then I kept having to remind myself ‘I don’t have a baby, you know,
there is no baby there that I’m killing’ um and that, you know, was final.
Other factors associated with being sure included having an intuitive sense something was
wrong, body changes that were different from a previous pregnancy or different from one
time period to another within this pregnancy, comparing one’s own pregnancy to written
information about normal pregnancy, and trust in the health care provider. Women
frequently noted that a trusting relationship with their health care provider influenced their
decision and provided comfort. “…he said that you might just wanna give it a week and think
about it and so that’s where I made my, I just counted on his years of experience.”
Women who had their miscarriage at home needed better explanations of what to expect
and supplies for managing the process.
I think… it seemed like it happened quickly because, um, it went from very, very mild
spotting to all of a sudden just coming very fast. That’s the part that kind of took me
by surprise. Um, I was prepared for it in the sense that I stayed at home and I didn’t
go anywhere, because I didn’t know what was going to happen. And so… um… but
yet I was grateful that I was able to be prepared, because I can’t imagine something
like that would start happening to someone, and they had no idea what was going
on. I mean, at least for me, I would have been completely incapacitated had I been
in public or at work or something.
Participants spoke of the need to make multiple decisions following the inevitable
miscarriage diagnosis. Many of these decisions involved, or could have involved, a nurse.
While most providers focused on the treatment choice, participants reported making a
variety of decisions throughout the experience, such as when to call the nurse advisor or
clinician, whom to bring with them to the ultrasound or surgical appointment, and how to tell
others about the loss.
How I was going to get back there [to her husband’s company picnic] and get the
kids and not make a big show of it and I didn’t want to tell him there in front of all
80
his co-workers and everything and how I was going to get through the afternoon and
just uh, what I was going to tell him or how I was going to tell him.
Participants related that the need to make so many decisions evoked a variety of questions
and emotions.
Discussion: We investigated women’s experiences making the decisions that must be made
following an inevitable miscarriage diagnosis. Like other researchers, we found that trust in a
physician or midwife strongly influenced treatment choice (Gurmankin, Baron, Hershey, &
Ubel, 2002). Also consistent with previous research (Limbo & Wheeler, 1986), most
participants viewed their miscarriage as the loss of a baby. As noted in Côté-Arsenault and
Dombeck (2001), a woman undergoing inevitable miscarriage may view the pregnancy as a
person with whom she has a relationship, or the persistent potential for life, despite clinical
evidence of inevitable demise. Our data on the need to be sure of nonviability before
consenting to a treatment that would end the pregnancy, support the characterization of the
decision as a moral dilemma. Only one participant explicitly used the term “abortion,” but
nearly all discussed potential for continuing life as a factor in their decision making. The only
participant who did not use the term “baby” stated, “ …there was clarity now … there’s
pregnancy matter there, but there’s no life amongst that pregnancy matter so we need to do
a D & C.”
Given past studies showing dissatisfaction with medical care during miscarriage (Rowlands &
Lee, 2010), these data are surprising because of the paucity of negative comments about
health care providers. One explanation for the finding is that the Resolve Through Sharing
program was founded at Gundersen Lutheran Health System in 1981. Since that time,
physicians, nurses, ultrasonographers, managers, laboratory technologists, and others have
had education and training to help create a culture of support around women with
threatened or inevitable miscarriage. It is also possible that women who were dissatisfied
with care chose not to participate in the research.
Limitations: The participants reflected the demographics common to the area surrounding
their health care facility. Most childbearing women are Euro-American and married. Teens
are not represented in our sample. Only one woman was not Euro-American. Women with
other demographics may view their miscarriages differently and make different decisions or
make the same decisions for different reasons.
81
Conclusion: Overall, women in this study needed to be sure their pregnancy was not viable
before deciding on aggressive treatment. Study results provide nurses, physicians, social
workers, ultrasonographers, and other professional caregivers insight into what might be
going on for a woman who has just learned that her pregnancy will end. Providing time to
select a treatment option, carefully assessing or reassessing viability, and helping her
anticipate other types of decisions enhance the care the woman and her family receive.
82
VIEWS AND ATTITUDES OF PREGNANT WOMEN ON DECISION-MAKING FOR LATE
TERMINATION OF PREGNANCY FOR SEVERE FETAL ABNORMALITIES
C Ndjapa-Ndamkou, L Govender
Department of Obstetrics and Gynecology, Nelson R Mandela School of Medicine, University
of KwaZulu-Natal; Inkosi Albert Luthuli Central Hospital, Durban
Introduction
In South Africa, termination of pregnancy is performed at any gestation if it is agreed that
the continuation of pregnancy would result in a severely handicapped child. Detection of
severe congenital fetal abnormalities after viability poses a major challenge to the women
with the regards to continuing or terminating the pregnancy. The South African literature is
scant on the views and attitudes of pregnant women with severe fetal abnormalities towards
late termination of pregnancy (LTOP). This study describes the experiences of the “choices”
that parents face in days and weeks following the prenatal diagnosis of a severe fetal
abnormality and the decision whether to terminate the pregnancy or not.
Aim
To ascertain the views and attitudes of pregnant women towards late termination of
pregnancy (LTOP) after the prenatal diagnosis of a severe fetal anomaly.
Method
A semi-structured questionnaire based prospective descriptive study was conducted from
August 2010 to October 2010 at the Fetal Medicine Unit at Inkosi Albert Luthuli Hospital, in
KwaZulu-Natal. Pregnant women with severe or complex fetal abnormalities detected after
24 weeks gestation were recruited. A Fetal Medicine Specialist saw all women and the
decision for a severe fetal abnormality necessitating the option for TOP was based on a
consensus opinion by a multidisciplinary team. The fetal anomalies included both lethal and
non-lethal types. All women had prior counseling about the types and lethality of fetal
anomaly including the management options; by two or more of the following healthcare
workers: Fetal Medicine Specialist, Clinical Geneticist, Obstetrician, Midwife Nurse Genetic
Counselor, Clinical Psychologist and / or Social Worker. An informed consent was obtained
from all participants and study received ethical approval from the University of KwaZuluNatal. The researcher administered the questionnaire. The participants were divided in two
groups: those that accepted TOP and those that declined TOP or continued pregnancy.
Women were interviewed on a follow-up visit before the termination procedure or delivery (if
pregnancy continued) and again shortly after delivery, but before discharge from hospital.
The interview was conducted using the patients’ preferred language and in the privacy of a
counseling room or side ward. A nurse interpreter assisted when required. The responses
were analyzed using a statistical package with descriptive statistics calculated. A p value
<0.05 was used for statistical significance.
Results
Fifteen pregnant women with severe fetal abnormalities were studied over the three-month
period. The women were analysed according to the groups mentioned. Five women accepted
TOP and 10 declined. Demographic and social characteristics are shown in Table 1. There
was no significant difference in terms of race, parity, religion; marital status, gestational age
at diagnosis and type and lethality of the fetal anomalies. Women who chose to continue
their pregnancies were significantly younger than those who opted to terminate (p< 0.05).
No women indicated that they were told by the health worker(s) to either continue or
terminate the pregnancy. All women stated that they were given sufficient time by the
hospital staff to make their own decision about their unborn baby after the options were
explained.
Diagnosis of fetal abnormalities
The women who decided to continue (declined TOP) with pregnancy had fetal abnormalities
as follows: spinal abnormalities (n=3), severe microcephaly (n=1), achondrogenesis (n=1),
acrania (n=1), hydrops/cardiac abnormality/hydrocephalus (n=1) and hydrocephalus alone
(n=3). Five women who accepted TOP had fetal abnormalities as follows: Achondrogenesis
(n=1), hydrocephalus (n=2), holoprosencephaly (n=2),
Table 1
Comparison of demographic and social characteristics.
Characteristics
Age (yrs) (mean +
range)
Race
Black
White
Parity mean (range)
Marital status
Single
Married
Religion affiliation
Christian
Other
Gestational age at
diagnosis
Continue
pregnancy
(n=10)
25 (20-32)
Terminate
pregnancy
(n=5)
31 (22-35)
9
1
1 (0-3)
4
1
2 (1-3)
7
3
4
1
9
1
31 (25-36)
4
1
31 (25-36)
84
P - value
< 0.05
NS
NS
NS
NS
NS
Pre-delivery interviews
Women who decided to continue pregnancy
All ten women stated that they were adequately informed about the nature and lethality of
the fetal anomaly and options for management. The mean gestational age (range) at
suspicion of fetal abnormality was 28 (23-34) weeks and at confirmation of diagnosis in our
unit was 31 (25-36) weeks. The mean (range) number of counselling sessions by a health
worker prior to their decision was 2 (2-4). . During this period, seven of the 9 patients had
further discussions with husbands/partners while 2 patients did not discuss the problem with
any family members. Four of the 7 patients who had discussions with husband/partner had
further discussions with family as follows; parents (n=1), aunt (n=1), sister (n=1) and
mother-in-law (n=1). One patient had further discussion with a spiritual leader. For nine
patients it was a joint family decision to continue with their pregnancy and gave one or more
of the following reasons: hoping that the baby will be born okay and surgery will correct the
problem (n=2); husband, refused TOP (n=2); difficult decision- fear of killing the unborn
baby and let nature take its course (n=3), baby is a gift from God and want to see baby
alive (n=4); there should be no interference and let see what happens after the baby is
born, (n=4).
Women who agreed to terminate pregnancy
All women indicated that they were adequately informed about the fetal anomaly and
options for management. The mean gestational age (range) at suspicion of fetal abnormality
was 29 (22-35) and at confirmation of diagnosis in our unit was 32 (27-35) weeks. The
mean (range) number of counselling sessions by a health worker prior to their decision was
2 (2-4).
During this period, all had further discussions with their husbands/partners. In
addition, all women had further discussions with one or more other family members as
follows; mother (n=3), father–in-law (n=1), and mother-in-law (n=1).
None of these
women consulted with a spiritualist to assist in their decision-making. Reasons cited for the
TOP included one or more of the following: baby will be born abnormal and will suffer during
life (n=2), costly to care for handicapped child (n=4); unable to cope with an abnormal or
brain damaged child (n=3), and child will suffer till it dies (n=2). All five women said that
they made the correct decision to terminate the pregnancy.
Post delivery interviews
85
Table 2 illustrates the comparison in answers to the same questions between the groups. All
women had seen their babies after delivery. Two women regretted their decision to continue
with the pregnancy to term after seeing their abnormal babies, one of which died shortly
after delivery and the other alive at the time of the interview. These women were also not
visited by their family members who had previously assisted in the decision-making to
continue with the pregnancy. Eighty percent of the women admitted that they had no
intention of planning a pregnancy in the next year. Seven of the ten women who continued
with the pregnancy demonstrated poor recall about the nature of the fetal anomaly and the
chances of recurrence in future pregnancies. Four of the 10 women who decided to continue
with the pregnancy felt they needed further counselling by the Social Worker before
discharge from hospital. Majority of the women said that they were treated in a caring and
compassionate manner by the healthcare workers.
Table 2
Comparison of post delivery interviews outcomes.
Continue
pregnancy
(n=10)
Terminate
Pregnancy
(n=5)
Questions
Yes
No
Yes
No
Have you seen the baby?
Do you feel you made the correct choice for your baby?
Have any member of your family visited you since you
delivered the baby?
10
8
7
0
2
3
5
5
4
0
0
1
6
2
3
4
8
7
4
1
4
1
4
1
7
3
4
1
Would you like to speak to a Social Worker before you go
home?
Will you be planning for another pregnancy within the next one
year?
Has anyone (doctor/nurse) explained what might happen in
your next pregnancy?
Were you treated in a professional manner with a caring
attitude by the hospital staff?
Discussion
Our study showed that majority of the women that opted to continue with their pregnancy
was significantly younger that those who decided to terminate. There was no difference in
terms of parity, race, marital status, religion, type / lethality of fetal anomaly and gestational
age at diagnosis between the groups. Against expectations, religion played no role in the
women’s choices. Majority of the patients indicated that their decisions were influenced by
family members. No women stated that were told by the health worker to either terminate
or continue with the pregnancy. Patients who had termination of a pregnancy following the
diagnosis of severe fetal abnormalities expressed their difficulty in making painful decisions
86
while others were overwhelmed by the reality of the situation and indicated that they were
unable to take in certain information provided during the counseling session by the
multidisciplinary team.
What was striking from their accounts was their sense of
unpreparedness for immediate decision - making.
All our patients did see the baby after delivery in both the groups. The love for the baby and
that the baby was God’s gift was the main reasons given for wanting to see the baby. In the
group that decided to terminate, the last sight of their baby was reason enough for wanting
to see the baby. In an earlier study, Hunt et al., (2009) reported that most of their patients
diagnosed with fetal abnormalities wanted to see their baby after delivery. The reasons given
for wanting to see the baby included hoping for visual reassurance that something “really”
was wrong.
An example being, one woman said: I wanted to see the lesion on his spine
because I wanted to be sure that there had been no mistake; while some parents reported
pleasure in their baby’s appearance.
In earlier studies, Breeze et al (2007) reported 12 (60%) of twenty patients decided to
terminate their pregnancy following ultrasound detected fetal abnormalities (Breeze et al.,
2007). Gammeltoft and co-workers reported that 17 (57%) of the 30 patients with fetal
anomalies decided to terminate their pregnancy (Gammeltoft et al., 2008). The percentage
of women requesting to terminate pregnancy in our study was low compared to studies done
elsewhere. The large number of patients deciding to continue with pregnancy in our study
raises dilemmas for health care professionals about how best to prepare them for physical
experiences and the decisions that they will confront in the immediate repercussions of their
decision.
One third of women in our study (4 who continued and 1 who terminated) requested to see
the Social Worker before discharge from hospital. These women needed further counseling
and reassurance about their decision- making after being faced with the reality of the
situation. Contrary to other findings, women in our study referred to the feelings of rightness
of their decision to terminate their pregnancy, even in the midst of all suffering, following
confirmation that the fetus was severely malformed or will suffer severe morbidity should the
baby survive. (Dallaire et al., 1995; David, 1978; White-Van Mourik et al., 1992).
Conclusion
The immediate and long term repercussions pregnant women face when they opt for a TOP
is disappointing, more so because they were not anticipated. In addition, these women are
cautious about future pregnancies. It was distressing to note that three patients in our series
87
lacked family support in time of need.
Despite the small numbers, this study illustrates that
woman’s views and attitudes towards late TOP are variable. Partners and family members
played an important role in decision–making for their unborn baby. However, follow up
studies assessing the long-term views and attitudes of women towards late TOP will be
important for comparison with initial decision-making process. There is a need for larger
studies comparing views and experiences of women having a spontaneous perinatal death vs
iatrogenic intrauterine fetal death by intracardiac potassium chloride for a severe or complex
fetal anomaly. Furthermore, follow up studies of the views and attitude of women towards
caring for severely handicapped children is required.
88
PROTOCOL FOR PERINATAL BEREAVEMENT MANAGEMENT IN A LOW RESOURCE
SETTING
LL Linley*#, C Sturrock #, Z Bassardien*, M Johnstone*, C M Nelson*#,S Mullins*#
* Mowbray Maternity Hospital, #University of Cape Town
A Mother’s Story
No fetal heartbeat. These three words began the surreal journey of several attempts to
induce labour and finally my daughter’s stillbirth at dawn on Friday 3rd January 2003. I
named her Iman (Faith) Bongiwe (Gratitude) and she was buried at noon on that same day
according to Islamic rites. In the weeks that followed I waded through each day trying to
keep my head above an ocean of sorrow. I mostly hibernated. I slowed down to a routine of
getting my other two sons off to school and then returning to bed where I spent most of the
day. Family and friends showered me with all levels of support and comfort, but still around
three months later I did not want to go on. I just wanted to stop breathing, to stop time
moving me forward. Being a writer, I had begun journaling on the very same day that we
were told our baby was no longer alive. I wrote for my own relief and sanity and to try to
capture as much of her and her impact, for remembrance as time passed by. It helped
immensely to have a place to ventilate without censorship of my thoughts and feelings. Six
years later a book had emerged entitled Invisible Earthquake: a woman’s Journal through
stillbirth published by new South African women’s press Modjaji Books in 2009. It is not only
a poetic memoir but includes a medical perspective and support resource information. Above
all, it is a tribute to my daughter, made with immeasurable love. I have known from the start
that she did not come to bring me sorrow. She is my greatest teacher and her dying has
intensified my living, deepening my gratitude for all that I have and strengthening my
compassion for others. Iman Bongiwe is fully present in our family memories and in the lives
of those who carried my family and I through the initial shock. She lives through us and
through all those whom her story, our story has made an impact on. Through this book and
opportunities like this to speak out, that circle widens and the overwhelming silence and
invisibility around her life and death and many others like hers, is penetrated.
Permission: Malika Ndlovu : Article for Lancet Stillbirth Series 2011
Introduction
Mowbray Maternity Hospital (MMH) is a level 2 obstetric hospital in the Metro West region of
the Western Cape. It has approximately 10,000 deliveries per year. The patients delivering at
MMH come both from the area surrounding the hospital, and are referred in (majority) from
3 Midwife Obstetric Units (MOUs) in the drainage area.
Bereavement support has been perceived as a necessity at the hospital, and in the MOUs of
the Metro West region for the past 17 years. A loose protocol was written for the MOUs in
the mid 1990s. This is currently being re-examined both for the MOUs and for Mowbray
Maternity Hospital. The importance of perinatal bereavement support in all settings
examined thus far is evident. A recent UCT psychology honours thesis on neonatal death
narratives has highlighted the importance of the narrative both for the mother’s processing
of her grief, and for the information it can provide to the health worker.
Supportive bereavement management needs to be planned and structured, it is not costly
and it is essential to the resolution of the mother’s grief.
Statistics 2009

Metro West Region Deliveries: 40,000

Perinatal Mortality Rate >500g: 32/1000 live births

Practically this means that at MMH and in the 7 Midwife Obstetric Units, the perinatal
bereavement support load in 2009 was

MMH: ENND: 81; SB: 191:

7 MOUs: ENND 76; SB: 170
Role of Autopsy in Counselling

Accurate diagnosis essential for counselling of families who have experienced a
perinatal loss: diagnosis relates not only to the cause of death, but also to recurrence
risks in subsequent pregnancies.

Relevance of recurrence risks not limited to heritable diseases. Extends to disorders that
might be managed differently in subsequent pregnancies, or that are unlikely to recur.¹
Reports have reconfirmed the known inaccuracy of clinical diagnoses compared with
necropsy findings in determining causes of perinatal death. Ona Faye-Peterson and
colleagues² reviewed 416 stillbirths and deaths within 48hrs of birth that occurred over
a 29- month period from January 1992. 139 (33%) of these cases underwent necropsy.
Among the 48 infants with anatomical anomalies, the diagnosis was changed or clarified
in 16 (33%), additional information was obtained in two (4%), and unsuspected
disorders were diagnosed in four (8%). In some of these infants the additional
information would have increased estimates of the risk of recurrence in subsequent
pregnancies.
90
Application of autopsy/placental histology: Important considerations
1.
Is facility easily available? What is the likely time delay of funeral?
2.
Is diagnosis of cause of death uncertain?
3.
Is histology likely to help with the diagnosis?
4.
What is the minimum likely to be helpful: placenta only? Biopsy? Organ histology?
Full postmortem?
5.
Do parents fully understand what will be done? Are parents willing?
6.
Do parents have a follow-up appointment for results?
Naming the Baby
Four of the women gave names to their babies which held significant meaning for them.
Zanele called her baby “Lihle” (beautiful), Nontombi called her baby Bayilitha (light), and
Bongeka called her baby Onakho (God can).
Zodwa named her baby Sibongile, which
means “we are grateful”.** Colleen Sturrock Psychology Honours thesis UCT 2010
Mementoes/ Holding the Baby/ Naming the Baby: Parents’ choice

Generally well received, sometimes controversial, because based on Euro-American
theories of grief and loss (adaptation through creation of memories) Death Studies 22 :
61-78 !998 Mary Pat Herbert

Important: Sensitivity and respect to different cultural practices

Footprints/name band/lock of hair/ photograph: easy to use cell phone. Either parents’
or own and send to computer to print
Reasons for Bereavement Support: Parents view?

Parents identified the caregivers’ behavior and handling of the stillbirth as important.
Findings showed that caregivers should support parents in moments of chaos and at
other difficult times. The parents needed assistance in both facing and separating from
the baby. BIRTH 31:2 June 2004**

The six “qualities” that summarized the findings were: “support in chaos,” “support in
the meeting with and separation from the baby,” “support in bereavement,”
“explanation of the stillbirth,” “organization of the care,” and “understanding the nature
of grief.” Findings indicated that the hospital is under an obligation to organize the care
and make it possible for parents to see the same caregivers again, and to offer extra
ultrasound investigations and checkups without unnecessary bureaucracy. BIRTH 31:2
June 2004**
91

An important factor in helping parents grieve is empathic support, from both their
friendship circle and medical staff. Conversely, the responses of medical staff can
exacerbate their distress, and affect both short and long term grieving. Reponses which
diminish the loss, withhold information, or imply that the parents are in some way to
blame engender a painful sense of powerlessness. Parents who feel they have been
listened to, given as much information as possible, and been allowed to make their own
choices, experience interaction with medical staff as supportive and helpful in dealing
with their loss (Corbet-Owen & Kruger, 2001; Covington & Theut, 1999; Klier, Geller &
Ritsher, 2002). **
** Colleen Sturrock: Meaning-making after Neonatal Death : Psychology Honours thesis
UCT 2010
Components of Bereavement Support

Initial Counselling: Emotional support, Diagnosis where possible

Mementoes: Footprints, photographs

Autopsy consideration

Death certificate

Discuss funeral/burial

Follow-up counselling at 6 weeks
Role players in Perinatal Bereavement Support

Healthcare staff: midwives, clinicians

Social workers

Community Support network: NPO eg church / mosque /community health workers: all
may need training

Family/friends: maybe limited
Training

Undergraduate and Postgraduate students: medical and nursing

Health personnel: clinicians, midwives

Social workers

Community organisations

Guidelines for Counselling parents bereaved in the perinatal period

Importance of listening, good communication
92
Protocol Checklist for Bereavement Management in a Low-resource Setting
1. Initial Counselling: midwife/clinician (same day) (guidelines)
2. A staff member to just “be” with mom, facilitate contacting family member
3. Offer to show/ facilitate holding/Naming baby:*cultural consideration
4. Mementoes*: foot/handprints/lock of hair/photograph
5. Consider placental histology/ partial or full autopsy
6. Explain histology/postmortem request fully, obtain consent
7. Discuss funeral arrangements
8. Physical care: breastmilk suppression, pain relief
9. Consider need for folate/aspirin
10. Consider
letter
for
future
pregnancies:
eg
Severe
hypoxia/Group
B
Strep
infection/prematurity related to recurring cause
11. Consider special clinic referral for mother: reproductive failure/psychologist (rare)
12. Follow-up appointment at 6 weeks
13. Bereavement leaflet
Acknowledgements

All parents who have lost a child before birth or in the neonatal period: our teachers

Colleen Sturrock

Malika Ndlovu

Gladys Mjijwa

Invaluable nursing, social work and medical colleagues at MMH and MOUs

Anne Friedlander: Thesis on perinatal loss in SA context
93
BEST MEDICINE: HUMAN MILK IN THE NICU
Nancy E. Wight MD, IBCLC, FABM, FAAP
Neonatologist, San Diego Neonatology, Inc.
Medical Director, Sharp HealthCare Lactation Services
Sharp Mary Birch Hospital for Women & Newborns
San Diego, California, USA
March 9, 2011
The benefits of human milk for term infants are well recognized. Human milk is
species-specific and has been adapted through evolution to meet the needs of the
human infant, supporting growth, development, and survival. It has only been in the
very recent past that significantly preterm infants have survived and that attention
has been paid to the crucial role of nutrition in the long-term outcomes for these
infants.
Current research confirms that human milk especially benefits the preterm infant in
several areas: host defense, gastrointestinal development, special nutrition,
neurodevelopmental outcome, indirectly through a physically and psychologically
more healthy mother, and ultimately, economic and environmental benefits. Human
milk has been rediscovered as one of the key factors in improving overall infant
outcomes and is now the standard of care in the neonatal intensive care unit (NICU).
Human milk is more than nutrition; it is medicine for both the infant and his mother:
the milk for the infant, and the provision of it for his mother. The benefits of human
milk extend well beyond the neonatal period.
The science of human milk is
expanding at a rapid rate, but there is still, and will probably always be, some art
involved in establishing and maintaining a mother’s milk supply and transitioning an
infant to full exclusive breastfeeding.
As healthcare providers we would like to
recognize the mother’s unique contribution to her infant’s wellbeing, and empower
her to nurture her infant.
Barriers/Challenges to Breastfeeding in the NICU
Physical Environment. It is fairly easy to see that the physical environment of the
NICU may be a significant impediment to successful breastfeeding.
It is noisy,
brightly lit and intimidating without much privacy, and with a perceived high stress
level.
Often the infant cannot be handled or held for some time because of
physiologic instability and a multitude of tubes and wires. In addition, many times
the infant has been transported from a distant delivery hospital or the mother is too
ill herself to visit the NICU.
Infant Factors. The small size and perceived fragility of the infant, the infant’s
physical appearance and medical complications are also barriers to breastfeeding.
The small size of the infant’s mouth when compared to the mother’s nipple,
combined with poor oro-motor skills and suck-swallow-breathing dyscoordination are
often frightening to the mother.
Maternal Factors.
Family members and health care professionals sometimes
discourage these mothers from initiating lactation as they think that providing milk
will be an added stress.
Mothers may be advised, usually in error, that their
medications preclude the use of their milk. Similarly, mothers may be inappropriately
advised that their high-risk conditions may interfere with adequate volumes or
composition of milk.
In South Africa, maternal HIV positive status is a major
obstacle.
Mothers of VLBW infants often feel a loss of control of their lives and a loss of role as
a mother. The infant is in the hands of strangers and she is the outsider. Several
studies indicate that providing milk for their infants helps mothers cope with the
emotional stresses surrounding the NICU experience and gives them a tangible claim
on their infants.
Mothers who deliver preterm are at increased risk for delayed lactogenesis and
stress- mediated lactation problems that can affect milk volume adversely.
The
prevention, diagnosis and treatment of low milk volume needs to be given a high
priority with evidence-based strategies and appropriate investment of NICU
resources.
95
Social Environment. The infant’s father, grandparents and other family members
or friends may also have significant influence over the mother, providing either
enormous support or significant barriers to establishing breastfeeding.
Financial Factors. Financial barriers also contribute: availability and cost of breast
pump rental or purchase, availability and cost of storing pumped milk, and the cost
of other supplies to support breast pumping or feeding. Some mothers may also
need to cover the cost of travel to and from the hospital, and the housing cost of
remaining close to the infant for an extended period of time, if free facilities are not
available at the hospital or close by.
Healthcare System.
Unfortunately, one of the biggest barriers to successful
breastfeeding is the healthcare system and well-meaning health care providers.
Inconsistent advice, lack of knowledge or misinformation, personal experience, poor
attitude, lack of support by health care professionals, lack of time, and hospital
policies have all been noted to create barriers to successful breastfeeding for
mothers of NICU infants.
Many healthcare providers have not had the education and training to support
breastfeeding families.
Education alone will not change professional behaviour.
Existing studies also suggest that nursing knowledge or attitudes can influence
mothers’ breastfeeding decisions in the NICU. Significant increases in knowledge are
possible with nursing education, but attitudes are more difficult to change.
Obstetricians,
pediatricians,
family
practitioners
and
hospital
staffs
may
unintentionally undermine breastfeeding by providing formula company access to
patients via commercial literature and formula marketing strategies such as baby
clubs, gift bags and free formula.
Patient education materials and “gifts” are
attractive and perceived as “free”. In reality, formula prices include the costs of
those materials and ”gifts”. Medical staff wearing lanyards and badge-holders, or
using pens, pads and coffee mugs with formula company logos implies (hopefully
unintended) endorsement. Because marketing clearly influences physician choices,
96
professional societies have developed ethical guidelines that recognize and advise
how to mitigate the influence of pharmaceutical company marketing messages and
gifts. A full review of this issue is available at www.nofreelunch.org.
Perinatal Support for Breastfeeding
The decision to breastfeed is usually made early in the pregnancy if not before
45-47.
Provider encouragement significantly increases breastfeeding initiation among
women of all social and ethnic backgrounds. Obstetric and family practice physicians,
nurses and other staff are especially well placed to begin education, risk screening
and anticipatory guidance regarding lactation. Counseling allows patients to become
familiar with the fact that breastfeeding is best from a medical perspective. Prenatal
intention to breastfeed is one of the strongest predictors of initiation and duration of
breastfeeding.
Antepartum hospital stays are opportunities for dispelling myths (e.g. “I can’t
breastfeed because I have a premature infant.”) and for providing anticipatory
guidance regarding procedures to ensure a full milk supply and safe storage and use
of pumped milk.
A mother’s perceptions of her prenatal physician’s and hospital
staff’s attitudes on infant feeding has been found to be a strong predictor variable of
later breastfeeding.
Although all healthcare professionals who care for mothers and infants should have a
general knowledge of lactation physiology and breastfeeding management,
supporting the mother of a NICU infant often requires special knowledge, skill and
experience. Several models of support have been developed. International Board
Certified Lactation Consultants (IBCLC) are one method to assist in increasing
breastfeeding rates in the NICU through staff and mother education, clinical
consultation and support. In some units, well-trained NICU RNs and peer counselors
may have the knowledge and experience to counsel and manage complicated NICU
breastfeeding issues.
97
Physician advocacy for breastfeeding can have tremendous impact.
Physicians
should find opportunities to praise mother’s efforts to provide this “liquid gold” for
their NICU infant. Care should be taken to separate the decision to provide a few
days or weeks of pumped breastmilk from the commitment to long-term, exclusive
breastfeeding.
Policies & Procedures
In addition to a basic breastfeeding policy for birthing hospitals, the NICU should
have its own NICU breastmilk/breastfeeding policy or policies to cover, at a
minimum: basic principles; collection, storage and handling of a mother’s own milk
for her infant, and misadministration of one mother’s milk to another mother’s infant.
NICUs using fresh and/or heat-treated donor human milk, should also have policies
and procedures covering this area.
Ancillary policies could also include trophic feeding and other uses for small amounts
of colostrum (eg mouth care), kangaroo care, alternative feeding methods, cobedding twins, continuous visitation and pre-discharge rooming-in, outpatient followup and vendors/gifts.
As noted above, a simple formula-logo lanyard can have
unintended consequences when worn by a health care employee. All policies should
clearly specify who is responsible for each component of lactation support.
Costs & Benefits of Lactation Support in the NICU
Providing lactation support in the NICU is not without cost. Lactation consultants,
staff education, pump kits and other supplies, non-commercial patient education
materials, breastmilk storage bottles and caps, and dedicated space and equipment
for pumping are expenses to the NICU.
However, when both the general cost
savings from breastfeeding and the specific cost savings to the NICU through
reduced NEC, late-onset sepsis, shorter hospital stays and less use of hospital
resources such as total parenteral nutrition (TPN) are considered, the investment
gives dramatic returns.
98
Of course the most important benefit of lactation support in the NICU is the
decreased morbidity and mortality and improved long-term outcomes associated with
the provision of human milk for preterm and ill newborns. In addition, animal data
and a few recent human studies suggest that the neuroendocrinology of the lactation
mother may down-regulate the magnitude of the maternal postpartum stress
response.
Breastfeeding Continuous Quality Improvement (CQI)
Recent studies have demonstrated the effectiveness of quality improvement
measures directed towards the nutrition of NICU infants. Consistent and
comprehensive monitoring of growth, nutritional status, and nutritional outcome
measures were part of the approach that led to markedly improved and more costeffective nutrition outcomes for VLBW infants.
Having a coordinated, multi-faceted
breastfeeding support program has been demonstrated to improve breastfeeding
initiation and continuation rates, even in populations least likely to breastfeed.
The “measure to improve” paradigm has proved as effective in breastfeeding CQI
efforts as in other areas of medical quality improvement. The California Perinatal
Quality Care Collaborative (CPQCC) has established methodologies which include a
databse, toolkits, workshops, webcasts and full collaboratives, with close attention to
human milk and breastfeeding as a method of improving nutrition for VLBW infants.
An initial step towards assessing and improving the nutrition of premature infants is
determining who is going to be held responsible for evaluating and tracking
breastfeeding and overall nutritional outcomes.
Potential participants include
nutritionists, physicians/nurse practitioners, nursing staff, discharge planners,
pharmacy staff, developmental specialists and occupational therapists (who may
have expertise in oral feeding practices). There are data documenting the benefit of
including a nutritionist and having a team approach to this clinical challenge.
99
Conclusions:
Despite considerable evidence to the contrary, breastfeeding is still perceived by
some as a lifestyle choice, not a healthcare issue. Health care providers are afraid
to “push” breastfeeding for fear of making mothers feel “guilty” if they do not
breastfeed. As breastfeeding is even more important for preterm/NICU patients than
for term infants, physicians and other healthcare providers have a responsibility to
provide accurate evidence-based information of the consequences of a mother’s
decision, just as we do with other recommendations and parental decisions in the
NICU. “With-holding such information would be considered unethical if it involved
respiratory care or a surgical procedure. Providing parents with research-based
options for infant feeding should be handled in a manner consistent with NICU
policies for other decisions about infant management”.
THE VALUE OF FOCUS GROUPS : ROLE IN THE INTRODUCTION OF EXCLUSIVE
BREAST FEEDING IN THE NEONATAL UNIT KING EDWARD VIIITH HOSPITAL
DURBAN
M Adhikari, Anna Coutsoudis, Nadia Nair, Radhika Singh. Department of Paedaitrics, Nelson
R Mandela School of Medicine, University of KwaZulu Natal
Background
The value of focus group discussions has been recognized in the social sciences.
Focus
group research involves organised discussion with a selected group of individuals to gain
information about their views and experiences of a topic. The focus group is suitable for
revealing perspectives on a topic, and insights into individuals understanding of the topic.
One definition of a focus group is a group of individuals selected and assembled by
researchers to discuss and comment on, from personal experience, the topic that is the
subject of the research (Powell 1996).
The important characteristic of the focus group is to gain insight on the data produced by
the interaction between the moderator and the participants. Participants must have a specific
experience of the topic under discussion and predetermined questions attempt to address
these issues (Merton and Kendall 1946). Why Focus Groups and not another method? –
focus group research examines respondents’ attitudes, feelings and beliefs. These aspects
are not easily tested in any other method of research (Morgan and Kreuger 1993)
It is usually recommended that the number of participants per group six to ten (MacIntosh
1993), but some researchers have used up to fifteen people (Goss & Leinbach 1996) or as
few as four (Kitzinger 1995). The sessions can be repeated and following an intervention
the sessions can be conducted again.
When nursing staff raised concerns about the number of LBWI receiving formula feeds, it
was decided that discussions would be held with them to determine the circumstances
around this specific issue. Flash heating the milk of HIV positive mothers (Israel-Ballard, et
al 2007) was being introduced to make breast feeding safer for HIV exposed babies and we
were aware that reservations were expressed by nursing staff that this might stigmatize the
HIV infected mothers.
heating.
We therefore also discussed issues around acceptability of flash
Aim
Focus groups were undertaken around maternal feeding choices, especially to assess
perceptions and attitudes to breast feeding in a time of HIV AIDS and the acceptance of
flash heating. weighed.
Methods
We used focus group discussions with nurses, counselors and mothers and firstly we
discussed nursing staff perceptions with respect to what counselors informed mothers. The
obstetric nursing staff were then consulted. Mothers were interviewed and finally counselors
were involved in a group session. Issues around acceptability of flash heating were discussed
in all groups.
All staff were offered training on the benefits of breast milk and exclusive breast feeding
(when? Was it before or after the focus group discussions).
Results
Group discussions with nursing staff revealed that they were aware that counselors tended
to guide mother to formula as a choice of feed.
Nursing staff were not clear whether they could re-counsel the mothers on their choice of
feeding.
Some nurses were confused about the fact that breast feeding still provided a benefit if the
HI virus was transmitted to the baby through breast milk.
The overall benefits of breast feeding were discussed with the staff.
The role of flash heating was introduced and despite their reservations as
expressed above, they were prepared to try the procedure.
Mothers explained that they were unsure why they chose to use breastfeeding or formula
feeding
Discussions
with
counselors
revealed
young
women,
some
had
not
achieved
matriculation,they feared HI Virus. If HIV virus was in breast milk , this was bad!
Therefore, they tended to suggest replacement feeding.
In addition, they often did not fully understand confidentiality, they did not understand the
mother’s feeling when she was HIV positive following a rapid test. For the CD4 counts,
mothers needed time to accept the situation.
Implications of the results of the focus group discussions:
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The occurrence of NEC in small sick babies born to HIV positive mums who chose formula
feeding, swayed the decisions to breastfeeding.
Mothers who met AFFAS criteria were requesting flash heating while baby in NNU. Mothers
were trained in the preparation of replacement feeds. (LBWI formula not in the PMTCT
programme)
The explanation of flash heating with a physical demonstration was undertaken.
Risks and benefits were presented, feeding choices were re-assessed and the feasibility
explored.It was suggested to mothers with small and sick babies to offer breast feeding first
then mum could make a further decision for replacement feeds, closer to discharge, provided
she met the criteria.
Flash heating was a ‘battle’ for some months, but then became successful so much so that
we are using it as a pasteurization system for pasteurizing donor milk from HIV negative
women.
Conclusions
As a result of first listening to what mothers and staff were saying we were able to
implement changes in our neonatal unit resulting in higher numbers of women exclusively
breastfeeding even among HIV positive mothers. Additionally flash heating became a
successful method for mothers who were HIV positive and chose to breast feed, some
mothers even continued flash heating at home. Besides the HIV counselor, the unit now has
a mother counseling mothers and a dedicated counselors have been appointed to the Unit.
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IS THERE A DIFFERENCE IN NEWBORN FEEDING PRACTICES BETWEEN BABYFRIENDLY ACCREDITED AND NON-ACCREDITED FACILITIES?
Jordaan M; Saloojee H
Introduction:
Breastfeeding practices in South African health institutions can generally be categorised as
being poor, with South Africa having one of the lowest exclusive breastfeeding rates in the
world.
Although most infants are breastfed at birth, only 10% of infants by age three
months, and 7% at six months are still exclusively breastfed. The commonest practice is
mixed breastfeeding with 88% of infants older than 10 weeks being offered this.
The Baby-Friendly Hospital Initiative (BFHI) is a global initiative of UNICEF and the WHO that
aims to create a health care environment that is promotive, protective, and supportive of
breastfeeding, through implementing the Ten Steps to Successful Breastfeeding. By August
2008, 221 hospitals in South Africa (41%) had BFHI accreditation. Accredited Baby-Friendly
facilities are reassessed every 2 or 3 years to see whether they still comply with the 10
steps. In 2008, 17 facilities in South Africa lost their BFHI status (personal communication,
Ms. Ann Behr). Little evidence about newborn feeding practice in South African health care
facilities exists. This study aimed to document practices around breastfeeding support and
compliance with the BFHI’s 10 steps to successful breastfeeding.
Methods:
Study design: This was a cross-sectional study, conducted in nine facilities in Gauteng. A
questionnaire was verbally administered on-site to 165 mothers of well infants, and 65
nursing staff. Healthcare facilities reflecting all levels of health care provision were included,
including tertiary (Chris Hani Baragwanath), secondary (Coronation and Leratong) and
district (Germiston and South Rand) hospitals, and four midwife obstetric units (MOUs).
Baby-friendly certified facilities were matched with non baby-friendly facilities using the
following criteria: same level of designation (e.g. regional hospital or MOU), and facility of
comparable size as determined by the number of deliveries per year.
Subject selection criteria: Nurses and mothers were selected on the basis of
convenience. Criteria used for including mothers in the study were: well mothers (able to
take care of their infants) with well infants (not requiring oxygen or antibiotics, or no acute
condition requiring referral) that were rooming-in. Infants needed to have a birth weight
>1.8kg. Number of mothers interviewed varied between sixty for the tertiary hospital, to six
104
for the MOUs. Number of staff interviewed varied between twenty for the tertiary facility to
six for some MOUs.
Study tool: The tool used in this study was an adaptation of the WHO BFHI Monitoring tool
from the Guide for monitoring and reassessing Baby-friendly Hospitals. The study was
conducted from January to April 2008. Any facility needed at least 80% for each step in
order to “pass” that step. They are required to “pass” all ten steps in order to be declared
and accredited as a Baby-Friendly facility.
Ethics: Permission to perform the study was obtained from the Committee for Research in
Humans Subjects (Medical) at the University of the Witwatersrand, as well as from the
relevant provincial and regional departments of health.
Results:
All baby-friendly accredited facilities performed better than non-accredited facilities. MOUs
generally performed best, then district, secondary, and lastly tertiary facilities. Suboptimal
practices existed in both baby-friendly accredited and non-accredited facilities, but more so
in the latter.
Breastfed within one hour of birth (step 4): At Coronation and Chris Hani Baragwanath
Hospitals, less than 10% of babies were breastfed within one hour of birth. At other facilities
the score ranged from 30% to 100%. Newborn babies at Chris Hani Baragwanath Hospital
were taken to the labour ward nursery directly after birth where they were fed a formula
feed and waited till a bed was found for their mother. Practices were influenced both by
standard facility practices, as well as beliefs of the nursing staff.
Exclusive breastfeeding (step 6): 93% of babies of HIV negative mothers who chose to
breastfeed got formula feeds at least once at Chris Hani Baragwanath Hospital. Half of the
babies at Coronation Hospital, and one third of babies at Germiston Hospital got formula
supplementation, while at the rest of the facilities there was 100% exclusive breastfeeding.
Staff believing that babies should be breastfed on demand: Only about one third of
staff at Chris Hani Baragwanath and Coronation Hospitals believed a baby should be
breastfed on demand. The score ranged from 67% to 80% for the other non baby-friendly
accredited, and 80% or above for the baby-friendly accredited facilities.
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Advice and support from nursing staff: Baby-friendly accredited facilities performed
poorly in all steps requiring advice and support from nursing staff, in other words all steps
that necessitated time spent with the mother. Only one third of mothers were helped with
breastfeeding (step 5), while almost half the mothers were first-time mothers. Only half of
the mothers received advice to breastfeed on demand (step 8). Very few support groups
were still functioning, and few mothers were counselled on what to do if problems with
breastfeeding were encountered after discharge from the facility (step 10). Many mothers
bought formula, bottles and teats even before delivery just in case they have difficulty
breastfeeding.
Knowledge, beliefs and practices of nursing staff: Unfortunately, even in facilities
where 100% of the staff had been trained, there was still poor knowledge (step 2) and
beliefs amongst the staff. Established staff were more reluctant to change, making it difficult
for newer staff to implement new practices. Staff were often confused about infant feeding
in the context of HIV. For example several staff members believed HIV was only transmitted
to a breastfed baby through the blood of the mother once the baby had teeth and bit the
mother. Policy changes were not effectively communicated to staff members, so some staff
thought formula was supplied free of charge for 4 months, others thought it was for 6
months, others did not know.
Counselling and education of the mothers (step 3) was poorly done in most facilities.
Inadequate, and at times inaccurate, information was offered. Even in baby-friendly
accredited facilities, only some aspects of breastfeeding were covered in antenatal sessions.
Knowledge of mothers was not as good as expected; e.g., on the question of how frequently
a baby should be fed, only half of mothers in the tertiary facility knew that babies should be
breastfed on demand.
Baby-friendly accredited facilities performed very well and scored 100% in step 4
(breastfeed within one hour), step 6 (only breast milk), and step 7 (rooming-in). These steps
seem to bring about facility practices that are sustainable over time, and seem to be
“protected” by a change in facility practices. In most facilities the baby remained with the
mother once brought to the mother. All the facilities scored 100% for step 9 (no artificial
teats or pacifiers). Baby-friendly certified institutions were significantly better than nonaccredited facilities for step 2 (training) (p=0.05), step 4 (initiating breastfeeding within one
hour) (p=0.05), and step 7 (rooming-in) (p=0.02)
106
Conclusion
Baby-friendly facilities generally performed better than non-accredited facilities. However,
their performance did not justify maintenance of their accredited status. None of the facilities
passed all of the 10 BFHI steps. Before a facility is evaluated for reaccreditation of their BFHI
status, the facility is notified in advance. Most facilities work very hard then to get everything
in order again, and most retain their accreditation status. This resulted in only some positive
practices sustained over time. It is possible to change feeding practices in a facility if there is
adequate commitment from the staff, including middle and senior management of the
facility.
107
EFFECTS OF FEEDING HUMAN MILK EXCLUSIVELY TO VERY LOW BIRTH WEIGHT
INFANTS
S Delport
Dept of Paediatrics, Kalafong Hospital, University of Pretoria
MRC Unit for Maternal and Infant Health Care Strategies
Introduction
The most important beneficial effect of human milk is the prevention of hospital-acquired
infections (HAIs) including necrotizing enterocolitis (NEC) in vulnerable very low birth weight
(VLBW) infants. HAIs lead to a prolonged hospital stay, overcrowding and death. Human
milk should be used exclusively and this practice is only possible with the availability of donor
milk.
Donor milk became available to the neonatal service at Kalafong Hospital during September
2006 supplied by the South African Breast Milk Reserve. From this time all infants ≤2000 g
received human milk after birth for a minimum period of 14 days. Thereafter only infants
whose mothers were not available received formula (preconstituted).
Before September 2006 formula was administered to adoptees, HIV-exposed infants and in
the event of inadequate maternal lactation.
Objective
To determine the effects of feeding human milk exclusively to VLBW (≤1500 g) infants.
Patients and Methods
VLBW infants admitted for 3.5 years before the exclusive use of human milk (Epoch 1) and
for 3.5 years thereafter (Epoch 2) were studied by retrospective audit.
The outcome
measures were survival until discharge from hospital, mortality due to HAIs and length of
hospital stay. Place of birth, member of a multiple pregnancy, admission to the neonatal
intensive care unit (NICU), HIV-exposure and etiology of death were also studied.
Results
During Epoch 1 (1/1/2003 – 30/6/2006) 839 VLBW infants [median birth weight 1200 g
(range 500 – 1500 g)] were admitted vs 734 VLBW infants [median birth weight 1185 g
(range 460 -1500)] during Epoch 2 (1/1/2007 – 30/6/2010). Their clinical characteristics are
outlined in Table 1. During Epoch 1 more infants were admitted to the NICU [433/938(52%)
vs 463/734(64%)(p<0.01)] and more infants were HIV-exposed [200/726(28%) vs 242/687
(35%)(p<0.010].
108
Table 1
Clinical characteristics of ifants admitted during Epoch 1 vs Epoch 2.
Birth Weight
(median, range)
Inborn*
Born before arrival*
Multiples*
NICU*
HIV-exposed*
Epoch 1
(n = 839)
1200 g
(500 – 1500 g)
719/837
(86%)
66/837
(8%)
156/838
(19%)
433/839
(52%)
200/726
(28%)
Epoch 2
(n = 734)
1185 g
(460 – 1500 g)
623/722
(86%)
59/722
(8%)
152/732
(21%)
463/734
(64%)
242/687
(35%)
p - value
NS
NS
NS
NS
<0.01
<0.01
*Number of infants
NS: Not significant
The survival of all infants ≤1500 g was 78% vs 80% and for infants >1000 g, 90% and
92% during Epoch 1 and Epoch 2 respectively. The survival of extremely low birth weight
(ELBW) infants (<1000 g) was 53% during Epoch 2 vs 39% during Epoch 1 (p < 0.01). The
mortality due to HAIs was 15% during Epoch 1 vs 8% during Epoch 2 (p =1.0).
The median length of stay (LOS) was 31 days (range 3 – 130 days) during Epoch 1 vs a
median LOS of 37days (range 8 – 122 days) during Epoch 2.
The Kaplan-Meier survival curve showed that the risk of death at any given point in time
during hospitalisation within the first 80 days of life is 1.54 fold that of Epoch 2 when in
Epoch 1 (HR = 1.54, p = 0.05).
Conclusions
The exclusive administration of human milk decreases the risk of death during hospitalisation
of VLBW infants and also decreases the mortality of ELBW infants.
A lodger facility for mothers and an on-site human milk bank are essential prerequisites to
facilitate the exclusive administration of human milk to vulnerable infants.
109
SUPPORT FOR RELACTATION AMONG MOTHERS OF HIV-INFECTED CHILDREN: A
PILOT STUDY IN SOWETO
Mandisa Nyati1, Hae-Young Kim2, Ameena Goga3, Avy Violari1, Glenda Gray1, Louise Kuhn2
1. Perinatal HIV Research Unit (PHRU), Chris Hani Baragwanath Hospital, Soweto, Gauteng
2. Mailman School of Public Health, Columbia University, New York, NY, USA
3. Medical Research Council, Pretoria, Gauteng
Background and Rationale
It is now well established that breastfeeding is the healthiest practice for babies who are
HIV-infected.
Both South African guidelines and WHO guidelines strongly support
breastfeeding for HIV-infected babies. Prior to the recent changes in infant feeding policy in
South Africa, many HIV-infected women chose to avoid all breastfeeding in an attempt to
avoid the risks of HIV transmission. Infant feeding counseling begins in the antenatal period
when women generally make decisions about how they will feed their infants. The time
soon after delivery is also important in establishing breastfeeding. Thus for HIV-infected
women decisions about how to feed their infants are made before the child’s HIV status is
known.
Several studies have observed that HIV-infected children who are breastfed have
significantly reduced morbidity and mortality than HIV-infected children who are not
breastfed.
For example, the Zambia Exclusive Breastfeeding Study demonstrated that
stopping breastfeeding early is particularly harmful for children who are already HIV infected.
Among 157 HIV-infected children who had positive PCR results before 4 months of age,
those who were assigned to the continue breastfeeding group had a significantly better
prognosis that those assigned to the early weaning group. So mortality was significantly
greater in infected children who stopped breastfeeding than those who continued for longer.
Young HIV-infected children have a poor prognosis with high rates of mortality within the
first year of life in the absence of therapy. Even in the presence of therapy, mortality rates
of children, particularly those under a year of age, are typically considerably higher than
adults starting therapy.
Furthermore, standard criteria based on CD4 count and clinical
criteria perform poorly to predict which children require antiretroviral therapy.
diagnosis programs have now been established in the Gauteng region.
Infant
These programs
allow mothers to learn their babies’ HIV status at a young age. Early identification of HIV
infection in babies provides an opportunity to support healthier infant feeding. Augmenting
breasting at this stage may impact positively on infant outcome.
110
We hypothesized that HIV-infected women who have not initiated breastfeeding or who have
not fully established breastfeeding can establish and maintain breastfeeding after learning
their infant’s HIV status before 14 weeks of age if they are give adequate support and
counseling.
The objective of this pilot study was to evaluate the feasibility and acceptability of support
for breastfeeding among HIV-infected women at the time their infant was diagnosed with
HIV infection. For some of these women who had either not initiated any breastfeeding or
who had stopped breastfeeding, this support would include support for relactation.
Relactation is defined as the initiation of lactation at a time unrelated to postpartum milk
production. This practice has been described in a variety of other circumstances such as restarting breastfeeding after weaning, and disruptions to breast feeding initiation caused by
prematurity or neonatal illness.
Examples of other family members taking over the
breastfeeding of orphaned infants have been reported as well as examples in adoption.
Relactation has not to our knowledge formally been tried as a method to provide optimal
nutrition and immunological support to an HIV-infected child whose mother is not
breastfeeding at the time of the child’s HIV diagnosis. Thus our study aimed to investigate
the utility of this practice in a context where initiation of breastfeeding is uncommon among
HIV-infected women.
Methods
We conducted a pilot study in Soweto to examine the feasibility of relactation among HIVinfected children. Mothers of HIV-infected infants identified at the Perinatal HIV Research
Unit at Chris Hani Baragwanath Hospital in Soweto were contacted to participate in the
study. If infants were 8-12 weeks of age and mothers were willing to be in the study,
mother-infant pairs were enrolled between Sept 2008 and May 2010. After enrollment into
the study, mother-infant pairs were excluded if mothers were unwilling or too weak to
attempt to breastfeed, had body mass index < 18.5 or a CD4 count <50, or the child had
birth weight < 1.4 kg. At our site prior to the changes in guidelines, most HIV-infected
women tended to chose to formula feed their infants and formula was available as part of
the PMTCT program.
Mothers eligible for the intervention were offered counseling to
support breastfeeding, including support around breastfeeding initiation for those who had
not attempted to establish any breastfeeding or who had stopped prior to enrollment.
111
At enrollment, socioeconomic parameters and breastfeeding history were examined. Motherinfant pairs were then followed for 24 weeks with regular counseling, evaluation of feeding
practices and attitudes, and assessments of maternal and infant morbidity and growth. At
each visit, mothers and infants were weighed and infant’s length was recorded. Blood
samples were drawn from infants at enrollment, 3 months and 6 months post-enrollment
and from mothers at enrollment and 6 months to measure CD4 count and plasma viral load.
Also, breast milk was pumped for exactly 5 minutes and the amount of milk produced was
measured at each visit. All infants were started on antiretroviral therapy as were women who
met clinical criteria. Mothers were considered to have successfully established relactation if
infants were given 100% of total milk intake by breastfeeding at 24 weeks.
To prepare for the study training of the study doctor, nurses and counselors was conducted.
This included the 2 week breastfeeding support training curriculum of the WHO as well as
inservice training.
A specific workshop was developed by lactation specialists on the
physiology and support necessary for relactation that was attended by staff in the HIV
clinics. We also conducted focus groups with health care workers and clinic attenders to
investigate their interest in relactation.
Results
Cohort description: Of 116 women approached, 16 did not meet eligibility criteria, 70
declined and 30 (25.9%) were enrolled into this study. Among the 30 women enrolled, one
woman had CD4 count too low (<50) and was excluded, one infant died, four women
withdrew from the study, and five women were lost to follow up. Thus, follow-up to 24
weeks could be completed for 19/30 mother-infant pairs. Of these 11 (58%) mothers were
fully breastfeeding their infant at 24 weeks.
The other 8 women were able to produce
breast milk during the initial weeks of the study but had difficulty overcoming infant latching
problems and did not sustain full breastfeeding to 24 weeks.
We examined the reasons for the large number of women who declined to participate in the
study when first approached. The need to return to work was the most commonly stated
reason, followed by not wanting to breastfeed or being afraid of re-infecting their infants.
Others were planning relocate. Psychological distress around the time of infant diagnosis
made enrollment around this time difficult. A high burden of visits required for initiation of
antiretroviral therapy was also a barrier.
112
Uptake of relactation: 11 of 19 women were completely breastfeeding their infants at 24
weeks giving us a success rate at 24 weeks of 58%. 100% of the milk feeds given at 24
weeks in these women were breast milk. 8 women attempted to establish full lactation but
were not able to continue breastfeeding through to 24 weeks. All were able to initiate some
breastfeeding but this declined to 17% at week 12 and 0% at week 24.
All women were able to produce milk at enrollment and during the first weeks of the study.
None of the mothers who did not reestablish breastfeeding through 24 weeks was producing
breast milk by the end of 24 weeks. Women who established relactation produced about 20
ml of breast milk on average with 5 minutes of pumping throughout the study duration – a
higher volume than those who did not establish lactation.
There were no significant difference in clinical and sociodemographic factors between
women who established relactation and those who did not. It is important to note that
children were on average 60 days of age when enrolled into the study and this did not differ
between those who were able to establish breastfeeding vs. those who did not.
On careful questioning at enrollment, 8/11 women who were able to establish lactation
reported “ever” exposing the infant to breast milk vs. 4/8 women who did not establish
lactation. Also, among those who established relactation, 7/11 women were predominantly
breastfeeding at enrollment vs. 1/8 women who did not establish lactation (p=0.06). 8/11
women who were able to establish lactation established a period of breastfeeding prior
enrollment vs. 3/8 who did not establish lactation. Among the 11 women who established
relactation, 6 women were giving 100% of total milk intake by breastfeeding at enrollment
and 2 women were mix-feeding, and the other 3 women had never breastfed and were
formula-feeding. Relactation was fully supported by the 1st week visit for the women who
were mix-feeding and 2/3 mother-infant pairs who had never breastfed while the other
woman (1/3) was able to relactate by the 3rd week study visit.
Mothers whose infants had latching problems expressed breast milk much more frequently
either to feed the infants or to stimulate breast milk production. When each mother was
evaluated for positioning of the baby and the baby’s attachment to the breast/nipple with
detailed description, only 29.7% of women who had infant latching problems seemed to
breastfeed in a correct and effective way vs. 97.9% of those who established relactation (p
< .0001). Also, while 91.8% of women who established relactation put the baby to the
113
breast even s/he did not need to feed, 34.4% of women who were not able to relactate did
so (p <.0001). The average sucking time was significantly different among the two groups
(8.2 min for relactation failed group vs. 13.8 min for relactation established group).
Clinical outcomes: The CD4 percentage and plasma viral load at enrollment, 3 month and
6month were not significantly different among infants who were relactated and those who
were not at 24 weeks. There were small differences in growth with slight benefits favoring
those who were breastfed.
The number of sick visits was fewer in infants who relactated compared to those who did not
establish breastfeeding but the difference did not reach statistical significance. The reasons
for sick visits of infants included body rash, cough, diarrhea, gastroenteritis, LRTI, URTI and
nasal congestion. There was no evidence of harm to mothers by establishing breastfeeding.
Attitudes: At the time of enrollment, attitudes towards breastfeeding were universally
positive and mothers reported being confident and willing to breastfeed. During the study,
mothers who successfully established relactation became more positive about relactation and
reported being satisfied with relactation because 1) of feelings of bonding with the infant 2)
infant grows well and stays healthy 3) breast milk is easily accessible; no need to prepare
milk 4) mother saves money. For similar reasons, most of the time family members fully
supported breastfeeding except when mothers were sick or babies were not latching at all.
Attitudes became much more negative in those who were not able to establish breastfeeding
(p<.0001). They were discouraged in that even though they tried and were willing to
breastfeed infants, infants refused to suckle or there was not enough milk produced to feed
the infants.
What we have learned
Counseling to support relactation uncovered and was able to correct a number of
misconceptions about breastfeeding and HIV. Women were relieved to learn that
breastfeeding was not unequivocally “bad” if you are HIV-positive. However, support for
relactation was difficult and required considerable motivation from mothers and clinic staff.
Introduction of this issue at the time of infant diagnosis was not ideal. Other issues
predominate at this time, including the need to initiate antiretroviral therapy and maternal
distress and anxiety is usually high. Nevertheless, infant feeding counseling around this time
is critical for ensuring good outcomes. Correct information about the physiology of
114
breastfeeding, as well as relactation, should be incorporated into antenatal infant feeding
counseling, so that later counseling can be more effective.
There are several limitations in the study. First, since this was a pilot study with only 30
subjects, it was difficult to observe statistically significant associations. There remain several
laboratory studies for us to complete. Our study was done largely before the new changes
to the South African infant feeding guidelines that now provide more support for
breastfeeding for HIV infected women.
Despite these limitations our data suggest that relactation is achievable for HIV-infected
women if there is extensive counseling to support as well as strong motivation of mothers
and clinic staff. Many women who refused to participate were afraid of re-infecting their
infants and did not want to breastfeed, indicating that misconceptions about breastfeeding
and HIV are prevalent in this population. Antenatal infant feeding counseling for HIV-infected
women needs to be improved.
115
HOW LONG DOES FLASH HEATED BREAST MILK REMAIN SAFE FOR A BABY TO
DRINK AT ROOM TEMPERATURE
Maxwell Besser, Herzlia High School
Mitchell Besser, mothers2mothers
Debra Jackson, University Western Cape
Louise Goosen, Mowbray Milk Matters breast milk bank
Background Information
HIV can be transmitted from mother to child at different times and in different ways. One
time period is during the pregnancy. Another time it can be transmitted is during child birth.
The time period this study is focusing on is during breast feeding. This picture below shows
when the baby receives the HIV and the percentage of babies who receive it during that
time (figure 1). For all mother-to-child-transmission of HIV, 2/3 takes place during pregnancy
and 1/3 takes place after pregnancy during breast feeding. During pregnancy, 1/3 of
transmissions occur when the baby is in the uterus and 2/3 occurs during child birth.
Figure 1
Mother to child transmission of HIV
Pregnancy 2/3
Inside uterus 1/3
Breast feeding 1/3
Delivery 2/3
The best food for babies is breast milk. Babies who are breast fed grow better, their immune
system is stronger and they get fewer infection. Babies who are formula fed are at greater
risk of diarrhoea and respiratory illnesses. But, a baby born HIV negative can receive the HIV
116
infection through the breast milk if the mother is HIV positive. The challenge is to find out
how best to feed HIV negative babies born to HIV positive mothers.
The HIV in breast milk can be killed through flash heating. Through flash heating breast milk
placed in a glass jar is placed in a pot of room temperature water that is brought rolling boil.
This way the nutritional value of the breast milk is retained while the HIV virus is killed. In an
environment where there is no refrigeration milk can become contaminated with bacteria
that would make the baby sick. Food is generally safe to eat but if left unrefrigerated
bacteria can grow in it which would make it unsafe for people especially babies to eat or
drink. These bacteria can give the baby diarrhea or other symptoms that could be potentially
life threatening. Staphylococcus aureus and Escherichia coli are the two main bacteria that
can cause these symptoms and it is important to know when food is no longer safe to eat or
drink because of the growth of bacteria.
The basis for this study was to see how long after milk had been flash heated, to kill the
HIV, would it no longer be safe for a child to drink. This study had been done before looking
at an 8 hours interval after flash heating and found the breast milk to be safe for that period
but that is not long enough for a mother to go to work and come back without having to
worry about producing another bottle of breast milk. Another study looked at a 12 hour
interval after the milk went through Pretoria Pasteurisation, a process similar to flash
heating,
but
this
method
is
no
longer
recommended
for
use
by
mothers.
Aim
My aim in this project is to see how long after a mother heats breast milk that is infected
with HIV/AIDS to kill the virus will the milk, kept at room temperature, no longer be able to
be fed to her child.
Hypothesis
My hypothesis is that after 12 hours of the milk sitting without refrigeration it will no longer
be safe for the child to drink and the mother will have to make a new jar of milk.
Method:

Breast milk was obtained from the Mowbray Milk Matters breast milk bank.

60ml of milk was placed into each of the eight containers and then placed into a pot
of water at room temperature.

The pot of water was brought to a rolling boil which is called “Flash heating”.
117

The containers were taken out and kept at room temperature.

The temperature of the room was measured and then one of the containers was
placed in a freezer every four hours starting at negative zero (no flash heating) then
0 hours then 4 hours and so forth for twenty four hours.

The temperature of the freezer was -22ºC

The containers were taken on ice to the South African Bureau of Standards (SABS)
laboratory.

At SABS each container was tested for Staph (Staphylococcus aureus) and E. coli
(Escherichia coli).
Results
A specimen of milk was set aside, not flash heated and labeled -0 hours. Breast milk was
flash heated and specimens were set aside and frozen every 4 hours for 24 hours. The
specimens were cultured and tested for Staphylococcus aureus and Escherichia coli. For each
time period there was no harmful growth of either bacterium. The date and time along with
the room temperature was noted before placing each specimen in the freezer.
Specimen
Time/Date
Temperature
- 0 hours
0 hours
4 hours
8 hours
12 hours
16 hours
20 hours
118
E. coli
Staph
24 hours
ND = Not Detected
Conclusion

E.coli (Escherichia coli) and Staph (Staphylococcus aureus) are the main bacterial
infections that cause breast milk to be unsafe for babies to drink.

After we tested each of the milk samples for both bacteria we see that for up to 24
hours no Staph or E. coli colonies grew in the milk.

Because of this we can understand that HIV positive mothers living without
refrigeration can know that their milk will remain safe for their child to drink for 24
hours.

This means that the mother can go to work and come back or sleep through the
night without having to sterilise a new batch of milk.
Applications
This study could be used in everyday life because it will let HIV positive mother know long
the milk will remain safe for their child to drink if they don’t have refrigeration and how long
they are able to stay away from their child before the need to produce and flash heat more
breast milk.
Further research
It is always good to repeat the study to confirm our findings and it could be done for a
longer period of time and looked at for another bacteria. It could be done for a longer period
of time, Test for other bacteria besides E. coli and StaphIt would be good to do it with a two
controls on that is positive for Staph and one that is positive for E. coli.
Acknowledgments
Millicent Julius
South African Bureau of Standards (SABS)
Catherina Kruger
119
EVALUATION/SURVEY OF THE EFFECTIVENESS OF THE NATIONAL PREVENTION
OF MOTHER-TO-CHILD TRANSMISSION (PMTCT) PROGRAMME IN SOUTH AFRICA
Debra Jackson, RNC MPH DSc, UWC, MRC/HSRU, South Africa
Ameena Goga, MD., MS., MRC/HSRU, South Africa
Thu-Ha Dinh, MD., MS., US CDC/GAP
PMTCT guidelines in South Africa
2002-2007
Single dose Nevirapine for mother at labor and newborn within 72 hours
2008-2010
1. Maternal:
1. If CD4>=200  AZT at 28 weeks + sd NVP at labor
2. If CD4<200  HAART
2. Newborn: Sd NVP at birth + 7 day AZT
3.
DNA PCR at 4-6 weeks of age, the 1st immunization visit
2010+
New WHO Guidelines including Tx from 14 weeks Dual-Tx or HAART (<350 CD4) + Infant
NVP throughout breastfeeding
Background
•
National PMTCT program started in 2002
•
Existing databases - surveillance systems for monitoring PMTCT programme
–
DHIS – aggregated data (positivity – reports of 1st PCR/EID)
–
NHLS DNA PCR data/EID – HIV prevalence among infants who tested
<
3months
–
•
HSRC household surveys (0-2yrs): HIV prevalence in 0-2
Existing operations research for evaluating PMTCT programme
–
Good Start I – 3 selected sites in South Africa
–
Coetzee – programme in Cape Town
–
Coovadia – programme in Africa Centre
–
Rollins – evaluation in KZN districts -this study is based on the Rollins model
of testing all children at 6 week immunization visit
Survey/Evaluation Questions
Primary questions (Effectiveness)
•
Mother to child transmission (MTCT) rates at 6 weeks of age
120
•
Infant Prevalence at 6 weeks of age
Secondary questions (Operationalization)
•
HIV acquisition during pregnancy
•
PMTCT missed opportunities – PMTCT cascade
•
Risk Factors for MTCT at 6 weeks
Methods: Sampling
1st stage: selection of facilities:
•
Multi stage, PPS and systematic sampling methods
•
Facilities were stratified by : size (immunisation load) & HIV prevalence.
•
Very small (<130 DPT1 coverage p/a ) facilities are excluded
•
580 facilities across all nine provinces are selected.
•
Spent 2-4 weeks in each facility
2nd stage: sampling of mother & infant pairs
•
12, 200 DBS from consecutive/systematic enrolment of all infants (4-8 wks)
attending for 1st DPT dose, and whose caregivers consent to participate and being
tested for HIV
Identify HIV Exposed Infants (Biomedical marker) using ELISA test to identify
maternal antibodies in infant blood
ELISA
Test
121
Data Collection via cell phones – real time upload of data as collected in the field
SMS System: return for test results/follow-up visits – used to remind subjects to
return for infant results
Laborator
y
“Please return to the clinic for your baby’s
check-up and 10 week immunization”
122
PMTCTE Data Collection (Jun-Dec 2010)
PMTCTE Study Profile (as of 6 Dec 2010)
Eligible Infants = 10282
Consented for survey = 10172 (99%)
Questionnaire without DBS = 61
Obtained Questionnaire and DBS = 10111 (99%)
ELISA Results = 9646 (95%)
PCR Results on ELISA positive (exposed) = 2739
Pending lab results = 465
Demographic characteristics
Mother = 97%
Education - Grade completed 8-12 = 77%
Marital Status – Single = 73%
Brick/Cement Block House = 75%
Water piped in house/yard = 77%
Flush Toilet = 54%
Cooking Fuel – Electricity/Gas/Paraffin = 92%
Ran out of food in last 12 months = 16%
Preliminary Findings on ELISA and PCR positivity
•
Presumed Maternal HIV prevalence is similar to that expected based on the ANC HIV
Surveillance - 30.1% (95% CI 29.1-31.0).
123
•
Crude Infant HIV prevalence at immunization clinics is approximately 1.2%.
•
The PCR results of DBS performed on infants aged 4-8 weeks (antenatal and
intrapartum transmission) suggest a Perinatal Transmission rate of 4.0% (95% CI
3.3-4.8%) overall.
Conclusions
•
This report presents preliminary crude results from the SAPMTCT Evaluation.
•
Use of real-time data collection for national surveillance is feasible and allows timely
access to results
•
While 4% MTCT is encouraging, expected postnatal transmission may suggest 18
month MTCT will exceed 5% national target.
•
Repeat surveys are planned in 2011 & 2012 to
track progress towards national
objectives with the addition of a postnatal follow-up component of HIV-exposed
infants to measure 18 month HIV-Free Survival
Acknowledgements
We would like to thank our funders for their support!
•
South African National Department of Health
•
Centers for Disease Control and Prevention/PEPFAR, South Africa
•
UNICEF
We would also like to thank the health staff at the 580 study sites, the study staff and the
mothers/caregivers and infants who participated in the SAPMTCTE.
124
THE EFFECT OF HIV STATUS ON PERINATAL OUTCOME AT MOWBRAY MATERNITY
HOSPITAL AND REFERRING MIDWIFE OBSTETRIC UNITS, CAPE TOWN
Deon Kennedy, Sue Fawcus (Department of Obstetrics and Gynaecology, University of Cape
Town)
Max Kroon (Department of Neonatology, University of Cape Town.
Introduction
33,4 Million people were living with the Human Immune Deficiency virus by the end of 2009
with sub-Saharan Africa the most affected region. Maternal HIV infection is the leading
underlying cause of maternal and child morbidity and mortality in South Africa. In the Metro
West (former PMNS) of Cape Town, maternal mortality is known to have contributed to an
increase in maternal mortality rates. A meta-analysis of world literature suggests a clear
association between HIV infection and perinatal mortality. In Tshwane, South Africa, an
audit in 2006 showed that both stillbirth and neonatal mortality rates were significantly
higher for HIV positive mothers compared to HIV negative, with intrapartum asphyxia,
preterm labour and infections contributing to the difference.
Aims and Objectives
To study the impact of maternal HIV status on perinatal outcome at Mowbray Maternity
Hospital (MMH),a secondary level hospital in Cape Town, South Africa; and its catchment
MOUs.
Specific Objectives:
1) To compare the perinatal mortality rate in the group of HIV exposed with the HIV
negative group and the untested group.
2) To determine where possible, the primary obstetric cause of adverse outcome and
compare this in HIV exposed to the HIV negative and the untested group.
3) To compare the incidence of Neonatal Encephalopathy in the group of HIV exposed
with the HIV negative group and the untested group.
Methods
The study was a retrospective descriptive and comparative audit. MMH is level two obstetric
hospital serving a low to middle income urban population. Three
community Midwife
Obstetric Units refer to MMH; Khayelitsha, Guguletu and Mitchells Plain. All deliveries at MMH
and its referral midwife obstetric units from January 2008 to December 2008 were audited
with respect to HIV status and other demographic data. All deliveries with perinatal mortality
125
and or neonatal encephalopathy were identified and analyzed in detail. Data on HIV status of
all mothers delivering at MMH and catchment MOUs was obtained from PMTCT registers.
Results
There was a total of 18 870 deliveries at the units being studied. The number of deliveries to
HIV positive mothers were 3259 (17,2 %): see Table One.
Table 1
Number of deliveries by HIV status at Mowbray Maternity Hospital
and referral MOUs.
INSTITUTION
Mowbray
maternity
hospital
Mitchells Plain
MOU
Khayelitsha MOU
Guguletu MOU
TOTAL
Total HIV +ve
deliveries
1747 (18,7%)
Total HIV –ve
deliveries
7044 (75,4%)
Total untested
deliveries
547 (5,8%)
Total number of
deliveries
9338
368 (8,7%)
3235 (77,1%)
589 (14%)
4192
659 (25,8%)
485 (17,4%)
3259
(17,2%)
1678 (65,7%)
2011 (72,1%)
13 968
(74%)
216 (8,4%)
291 (10,4%)
1643(8,7%)
2553
2787
18 870
The stillbirth rate in the HIV positive population for the units being studied was 17,1 per
1000 deliveries. In the HIV negative population this rate was 8,3 per 1000 deliveries. The
odds ratio was 2,07 [CI, 1.5-2.8] with a p-value of <0,0001. The neonatal death rate in
the HIV positive population was 4,6 per 1000 deliveries, this as opposed to a rate of 3,1 per
1000 in the HIV negative population. The odds ratio was calculated as 1,46 [ CI, 0.8-2.6]
with a p-value of 0,26. The perinatal mortality rate in the HIV population was 21,7 per 1000
deliveries. In the HIV negative population this rate was 11,7 per 1000 deliveries. The odds
ratio was 1,91 [CI, 1.4-2.5] with a p-value of <0,0001; see Table 2.
Table 2
Stillbirth rate
Neonatal
Death rate
Perinatal
Mortality
rate
Comparison of perinatal mortality rate by HIV status for the
combined study population.
HIV positive
17,1 per
1000
4,6 per 1000
HIV negative
8,3 per 1000
Untested
77,2 per 1000
3,1 per 1000
10,3 per 1000
21,7 per
1000
11,5 per
1000
87,6 per
1000
*Comparing HIV positive to HIV negative group.
126
Odds Ratio*
2,07 (1,52,8)
1,4 (0,812,6)
1,91 (1,42,5)
p-value
<0.0001
0.26
<0.0001
A comparison of the pattern of primary obstetric cause for perinatal mortality showed that
infection, intra uterine growth restriction and ante partum haemorrhage were significantly
more common as a cause for perinatal death in the HIV positive population; see Table 3.
Table 3
Comparison of Perinatal mortality rate per primary obstetric cause.
Primary obstetric
cause
HIV
positive
HIV
negative
Untested
Odds ratio*
p-value
Preterm
labour
Infection
4,2 per
1000
5,2 per
1000
3,3 per
1000
3,0 per
1000
1,2 per
1000
1,8 per
1000
34 per 1000
1,3 (0.76-2.5)
0.35
5,4 per
1000
4,8 per 1000
4,3 (2,19-8,4)
<0.0001
1,8 (0.89-3.6)
0.14
3,0 per
1000
3,6 per
1000
0,6 per
1000
1,2 per
1000
2,4 per
1000
12,1 per
1000
4,7 (1.93-11.7)
0.0005
2,8 (1.37-5.93)
0.006
2,7 per
1000
0,3 per
1000
0,6 per
1000
0,0
1,8 per
1000
0,5 per
1000
0,5 per
1000
0,4 per
1000
13,9 per 1000
1,48 (0.69-3.17)
0.41
4,8 per 1000
0,5 (0.06-4.2)
0.86
3,6 per 1000
1,2 (0.2-5.9)
0.86
Asphyxia
IUGR
APH
Unexplained
Hypertension
Congenital
Abnormality
Other
4,2 per 1000
*Comparing HIV positive to HIV negative group.
The risk of neonatal encephalopathy (predominantly Hypoxic Ischaemic encephalopathy) in
the HIV exposed population was 4,9 per 1000 deliveries as opposed to 2,07 per 1000
deliveries in the HIV negative group. Comparing the two groups found an odds ratio of 2,36
[CI, 1.28-4.35] with the p-value 0,008.
The untested group of patients is shown in this study to be at particularly high risk of
adverse perinatal outcome. This group includes both mothers who declined HIV testing and
also those who had no antenatal care in the index pregnancy.
There was no significant difference in age and parity between the HIV positive and negative
groups.
Discussion
The study findings that stillbirth rate and Perinatal Mortality rate were significantly higher in
HIV positive mothers compared to HIV negative corresponds with other studies including the
127
Tshwane study. There was no significant difference in neonatal death rates; this could
possibly be explained by the high quality of neonatal care at MMH. Our study showed that
Infection, IUGR, and antepartum haemorrhage were significantly more common as a cause
of perinatal death in HIV positive mothers. This differs from the Tshwane study where
preterm labour and asphyxia were more common. However the neonatal encephalopathy
rate was significantly higher in the HIV exposed group and thus it is possible that
intrapartum hypoxia resulted in morbidity rather than mortality. Further research is needed
(a) to establish whether there a direct effect of Maternal HIV infection on perinatal outcome
or whether there could be confounding factors such as socio economic status;
and (b)
analysis of perinatal outcome by maternal CD4 level and by treatment status.
Conclusion.
Perinatal mortality and neonatal encephalopathy rates at MMH and referring MOUs were
significantly higher in an HIV exposed group compared to negative counterparts. More
comprehensive testing must occur so that the number of HIV untested mothers is reduced.
128
PREVALENCE OF HIV IN WOMEN ENTERING LABOUR WITH UNKNOWN HIV
STATUS WHO ACCEPTED OR DECLINED VOLUNTARY COUNSELING AND TESTING
Gerhard B Therona, David E Shapirob, Russell B Van Dykec, Mae P Cababasayb, Jeanne
Louwd, D. Heather Wattse, Marc Bulterysf, Linda M Styerg, Robert Maupinh
a
Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Stellenbosch
University and Tygerberg Hospital, South Africa. b Center for Biostatistics in AIDS Research,
Harvard School of Public Health, United States. c Department of Pediatrics, Tulane University
Health Sciences Center, New Orleans, LA, United States. d KidCru, Department of Pediatrics
and Child Health, Faculty of Health Sciences, Stellenbosch University and Tygerberg Hospital,
South Africa. e Pediatric, Adolescent and Maternal AIDS Branch, Centre for Research for
Mothers and Children, Eunice Kennedy Shriver National Institute of Child Health & Human
Development, National Institutes of Health, 6100 Executive Blvd., Room 4B11, Bethesda,
MD, United States. f Director, CDC Global AIDS Program - China U.S. Centers for Disease
Control and Prevention (CDC) CDC-GAP China Office Suite 403-Dongwai Diplomatic Office,
g
23 Dongzhimenwai Dajie, Beijing 100600, China.
Bloodborne Viruses Laboratory,
Wadsworth Center, New York State Department of Health, Albany, New York United States.
h
Health Science Centre, Louisiana State University, Pediatric ACTU, 1542 Tulane Avenue,
New Orleans, LA, United States.
Introduction
A cluster-randomized trial was conducted to compare the feasibility and acceptance of
intrapartum versus postpartum counseling and rapid HIV testing in a midwife obstetric unit
and labor ward in a district hospital. The HIV prevalence of women who met the inclusion
criteria but chose not to partake in the study was of critical importance. There is a paucity
of knowledge about the prevalence of HIV infection among women declining testing.
Methods
A prospective, cluster-randomized trial was done to determine (1) the feasibility and
acceptance of IP versus PP HIV counseling and rapid testing and (2) the acceptance of and
ability to administer antiretroviral prophylaxis to HIV infected women and their infants.1 The
study was conducted in the Macassar Midwife Obstetric Unit and Helderberg Hospital. Fetal
cord blood specimens were collected in an anonymous, unlinked fashion from all women
approached for study participation, regardless of whether or not women consented to study
participation.
This anonymous sampling was conducted in similar fashion to the South
African national annual antenatal HIV seroprevalence survey, which is accomplished by
obtaining an additional blood specimen, without consent, at the time blood is obtained for
syphilis serology and blood grouping from women who book for antenatal care. Cord blood
were collected as dried blood spots (DBS) and stored at 4° C. No patient identifiers were
included on the cord blood specimens; only the site name, date and time of collection, and
129
the study arm were documented. DBS were analyzed for HIV antibody by EIA and WB. 95%
confidence intervals (CI) were calculated using exact binomial methods.
Results
Of 7238 women screened for study participation from 1 October 2004 to 30 September
2006, 1041 (14%) had undocumented HIV status, of whom 542 (7.5%) were eligible for the
study. Of the 542 eligible women, 343 (63.3%) accepted VCT and were enrolled to the
study. The most common reason why women declined VCT was that they knew their HIV
status but it was not documented in their patient record (36.7% of cases). Based on 513
anonymous cord blood DBS samples with complete study site and randomization arm
information, the overall seroprevalence among eligible women was 13.3% (95% CI 10.4,
16.5%), similar to the 13.1% seroprevalence (95% CI 9.7, 17.2%) among the 343 enrolled
women, with no significant differences noted comparing the randomization groups.
A
comparison by randomization group and by site did not reveal any significant differences in
seroprevalence.
Conclusion
The general perception is that women knowing they are HIV positive may choose not to
consent for voluntary counselling and testing (VCT).
In South Africa with a higher HIV
prevalence, 50 women who initially declined antenatal HIV screening had a seroprevalence
rate of 44% compared to a background rate of 29.4%.
Overall, the acceptance rate
(63.3%) of participating in the study and HIV rapid testing did not differ significantly
between the IP and PP groups. The overall seroprevalence of 513 anonymous samples was
13.3% similar to the 13.1% of the 343 enrolled women. The background seroprevalence
among eligible women was similar to that among enrolled women, which suggests that study
participation did not select for a group with substantially different seroprevalence from those
who declined.
The study was supported by the International Maternal Pediatric Adolescent AIDS Clinical
Trials Group (IMPAACT).
130
STEVENS-JOHNSON SYNDROME IN HIV INFECTED WOMEN IN PREGNANCY- A
SERIES AT CHRIS HANI BARAGWANATH HOSPITAL
CT Khoza, A Lukhaimane, K Kgwefane, J Hull, Y Adam
Introduction:
HIV infected patients have been shown to be 15 times more likely to present with
inflammatory conditions and have a1000- fold increase in developing SJS or TEN. In a survey
of a severe adverse skin reactions to drugs in Malawi, HIV infected persons were 5 times as
likely to be affected and pregnant women were also more likely to develop a severe reaction
as compared to non-pregnant women. The case fatality rate has been quoted as 30% in well
resourced area. South Africa has a high prevalence of HIV and approximately 40% are on
ARV’s in the Johannesburg Metropolitan area, many however will be started on ARV
regimens containing Nevirapine. Nevirapine has been associated with Steven’s Johnson
Syndrome. Apart from the high case fatality rate and the morbidity associated with the
condition, there may also be an effect on the foetus. We intend to use the information to
make recommendations regarding protocols for management and for the use of Nevirapine.
Aim:
Aim is to review the clinical factors, pharmacologic factors, management and outcome of
women and babies who present to CHBH with SJS.
Methods:
A retrospective, cross-sectional study studying the demographic factors, pharmacologic
factors, pregnancy related factors, and outcome of the pregnancy will be studied. A
prospective cohort to continue data collection will also be commenced in February 2011.
Results:
There were 4 women admitted to Chris Hani Baragwanath Hospital from April 2010 to
December 2010. Their ages ranged between 18-36, the parity was between 0 and 2. All had
presented to antenatal clinic in the second trimester. None of the women had been using
ART prior to the pregnancy. The length of time that women were taking ART was 3, 7, 8 and
11 weeks before they developed skin lesions. In 3 women the initiating agent was thought to
be Neviripine and 1 woman was on Efavirenz and the initiating agent was thought to be
Bactrim. The range of CD4 counts were between 179 and 329 at commencement of ART.
Three of the 4 women needed to be cared for in a High care setting. Three out of 4 women
presented in the 3rd trimester, and went into labour. One woman went into labour before a
second regimen could be started. Women not in the first trimester of pregnancy should
perhaps be started on an alternate drug to Nevirapine and another agent used for
prophylaxis against PCP used. Further study on these toxicities is required.
131
EVALUATION OF REVISED
PMTCT PROGRAMME
ONE YEAR
AFTER
INTRODUCTION; A PILOT STUDY IN INFANTS ADMITTED TO NGWELEZANA
HOSPITAL IN NORTHERN KWAZULU-NATAL
JA van Lobenstein, D Reijlink, AMM Oonk
Department of Paediatrics, Ngwelezana Hospital, Empangeni
Background:
South Africa is ranked 52 in the UNICEF under-5-mortality raking list of November 2009 with
a mortality rate of 67 per 1000 life births. Since the United Nation Development Goals were
adopted in 1990 the infant mortality rate of South Africa has been increasing till 2005 and
has been unchanged since. It is therefore unlikely that South Africa will meet the United
Nations Millennium Development Goal no 4 by 2015 despite excellent National Guidelines on
HIV/AIDS, PMTCT and the incorporation of Pneumococcal Conjugated Vaccine and Rotavirus
Vaccine in the National Vaccination Schedule in 2009.
Children in South Africa die primarily because of neonatal problems (30%), HIV/AIDS (35%)
and common infections like gastro-enteritis, pneumonia, sepsis and meningitis. The Child PIP
mortality audit data showed that malnutrition plays a role in 65% of these children and that
HIV/AIDS contributes to 4 out of 5 under five deaths.
Prevention of Mother to Child
Transmission (PMTCT) in HIV-infected mothers is therefore the key interventions in
addressing the high under-5 mortality rate in South Africa. The National Strategic Plan 20072011 HIV & AIDS and STI has therefore set a goal of 95% coverage of all pregnancies.
MTCT ranges from 15-45% and occurs during three major time points during pregnancy and
the postpartum period: in utero (5-10%), intrapartum (10-20%) and during breastfeeding
(10-20%). Strategies to reduce MTCT focus in these periods of exposure include amongst
others maternal and infant use of ART. The role of ART in PMTCT is to reduce the viral
replication and viral load in pregnant women, to act as a pre-exposure prophylaxis for
babies, by passing the placenta and to act as a post-exposure prophylaxis for babies, after
delivery and during breastfeeding. Where combined interventions are taking place, the risk
of MTCT is as low as 1-2%.
In line with new scientific evidence and the political will to fight HIV/AIDS the South African
PMTCT guidelines were revised in 2009.
132
Figure 1
PMTCT algorithm
The major improvements are: all pregnant women will be eligible to start ART at a higher
CD4 count of less than 350/mm3, patients with clinical WHO stage 3 including Pulmonary
Tuberculosis and stage 4 can start ART, AZT prophylactic treatment is will now being
prescribed as early as from 14 weeks of gestation age, a single dose Tenofovir and
Emtracitabine will be given to the mother after delivery to prevent development of
Nevirapine resistance and finally extended prophylactic treatment for the newborn with
Nevirapine for 6 weeks or till cessation of breastfeeding.
Figure 2: Infants who are exclusively breastfed whose mothers are
not on lifelong ART4
Our study aims to evaluate the revised PMTCT guidelines a year after implementation.
133
Methods:
For the duration of a 6 week period extending from October to November 2010, all mothers
of newly admitted infants to the Paediatric ward at Ngwelezana Hospital were asked to
complete a questionnaire. The questionnaire, which was conducted by two medical interns
with the assistance of student nurse translators, explored all aspects of the revised PMTCT
2010 programme. Only children born younger than one year of age were included to ensure
participation in the updated PMTCT 2010 programme.
Results:
General:
There were 42 mothers enrolled in the study of which 61% (n=26) were infected with HIV.
The mean age of the HIV infected mothers was 26,8 year.
Antenatal clinic visit:
-
The first antenatal visit to the clinic was at an average gestational age of 12,1 weeks
(SD±6,9) and 83% of all mothers were tested for HIV during this visit.
-
Of the mothers that tested negative, 81% was tested again at 32 weeks of gestational
age.
-
Safe feeding counselling was received by 83% of the mothers; only 3 mothers changed
their feeding choice: 2 from breast- to formula feeding.
-
20% of the HIV positive mothers did not know their CD4 count at the time of admission
of the child, 50% had a CD4 of less than 350/mm3.
ART during pregnancy:
-
Of the HIV infected mothers, 23% received HAART; 60% of the mothers with a low CD4
count were started during pregnancy.
-
12% of the HIV infected mothers was never started on ART.
ART during delivery:
-
72% of the pregnant mothers received appropriate ART; 23% claimed to have only
received Nevirapine. The mothers struggled to answer the questions regarding
medication used during delivery as many could not recall the name and period of the
drugs taken.
-
16% of the HIV infected mothers did not receive any ART during delivery.
134
Nevirapine treatment for infant post delivery:
-
88% of the HIV exposed neonates received appropriate Nevirapine treatment for 6
weeks; 8% only received for 4 weeks.
EPI: 6 weeks immunisation visit:
-
5 of the 26 exposed children were younger than 6 weeks at the time of admission so
never attended the EPI clinic.
-
All other children attended their local EPI clinics at 6 weeks of age.
-
67% of the exposed children received Co-trimoxazole.
-
In 81% of these children an HIV-PCR test was performed.
-
Only 30% of the children that were still being breastfed and whose mother was not on
HAART, received continuation of Nevirapine beyond 6 weeks.
PCR result known to mothers:
-
Only 10% of the mothers got to know the PCR result at the next 10 weeks EPI clinic visit
-
46% had a positive PCR test result but only 41% of this group was referred for HAART.
Of the HIV exposed children 54% turned out to be HIV infected and in 27% the PMTCT
programme prevented transmission.
Discussion:
Antenatal:
The positive findings of this observational study was that 83% of the mothers was tested at
the first ANC visit and that 81% of the HIV negative mothers was tested again in later in
pregnancy. A total of 88% (65% PMTCT and 23% HAART) received ART during the
pregnancy and 83% of the mothers recalled to have received safe feeding counselling. 80%
of HIV positive mothers knew their CD4 count at the time of admission of their children but
only 60% of the mothers with a low CD4 count received HAART.
Delay in workup for HAART and logistical problems in getting the blood results could be
reasons at clinic level for the low number of mothers on HAART. Mothers might not have
returned timely to the clinic due to anxiety about the blood test results and related starting
of lifelong HAART.
135
Perinatal:
The main positive finding here is that 88% of the exposed neonates received NVP and most
of them for a period of 6 wks. Only 72% received ART but recall of the mothers of the
different medications taken during delivery was poor. Many of them had multiple others
drugs and supplements as well and being in labour doesn’t assist in memorising given drugs.
It is unfortunate that paediatricians don’t have access to the ANC card. The new RTHbooklet will definitely improve this lack of information and needs urgent implementation.
Postpartum:
The first 6 weeks clinic visit was attended by all mothers expressing confidence in the
national vaccination schedule. At the clinic 81% of the exposed children got an HIV-PCR-test
and 86% of the HIV infected mothers received safe feeding counselling. It is unfortunate
that still only 67% of the exposed children received co-trimoxazol prophylaxis. Failure to
disclose at the clinic doesn’t account fully for this low figure as the PCR output is much
better. Poor adherence at home might play a role. While half of the infected children die
before the age of 2 years, only 41% of the PCR positive children were promptly referred for
HAART treatment. The fact that only 10% of the mothers knew the PCR test result 1 month
after the test was taken, supports this poor output. Fear for a positive result and logistical
problems initially in retrieving the PCR results at the clinics probably both play a role. The
extended Nevirapine prophylaxis during breastfeeding was added in the latest PMTCT update
and has no good coverage yet as only 30% of breastfed infants received correct NVP. The
different diagrams for the different feeding choices and for mothers on HAART may have led
to confusion. Lack of integration of services beyond the 6 weeks EPI clinic visit may lead to
missing of exposed children in need for extended Nevirapine prophylaxis.
Despite the fact of our small study population, our non validated questionnaire, our lack of
professional translators, lack of recall by mothers and documentation by health professionals
regarding ART received as part of PMTCT and the selection bias of sick hospitalised infants,
we learned from this study that the rollout of the revised PMTCT programme still proves to
be difficult. The correct implementation of each step measured at a maximum of around
85% and was often lower. The antenatal part has improved significantly over the years. The
postpartum part of the PMTCT programme, including Bactrim prophylaxis, extended
breastfeeding related Nevirapine usage and prompt referral for HAART after PCR testing
needs urgent improvement.
136
To assist the quality of implementation of the revised PMTCT programme 2010 we
recommend regular audits per clinic. The new RTH-booklet with the PMTCT flow sheet/tick
box needs urgent implementation and will prevent mistakes from clinic staff and will create
more awareness in Primary Health Clinics and Delivery Rooms amongst patients about what
PMTCT medication to expect and when.
137
IMPROVING PMTCT IN MSELENI HOSPITAL, MKHANYAKUDE, KZN
Nelson A, Fredlund V
Background
Mother to child transmission of HIV continues to be a major cause of infant mortality and
morbidity. More than 29% of pregnant women receiving antenatal care tested HIV positive in
South Africa in 2008. Major changes were made to the Prevention of Mother to Child
Transmission (PMTCT) program in 2010. PMTCT national targets in antenatal care in 2010
include:
“• Ensure HIV-positive women enter the PMTCT program
• Prevent mother-to-child transmission
• Provide AZT from 14 weeks of pregnancy or lifelong ART as soon as possible, depending
on a mother’s clinical indications“. As well, they include new ART intervention during labour
to minimize the risk of mother to child HIV transmission and to minimize the risk of
developing resistance.
Implementing these new changes has been a challenge in rural settings.
Mseleni Hospital is a district hospital situated in the North of KZN with a PHC clinic based
ARV programme. It serves a population of 85,000 and has 190 beds. It comprises 8 outlying
satellite clinics, 1 gateway PHC clinic and 2 mobile clinics, covering a total area of 100 x
30km.
Some of these clinics serve remote locations with an underdeveloped transport
system, making it difficult for patients to attend clinic regularly, and even more difficult for
them to access the hospital. Another major problem has been staffing levels in the clinic and
poor telecommunication (phone lines broken down, etc). With such logistical hindrances, it
seemed difficult to implement the new PMTCT guidelines quickly and efficiently.
We looked at how we have managed to increase our uptake of HIV positive women on the
PMTCT program as well as to implement new ART intervention during labour.
Methods
We completed an observational study using as a study population the pregnant women from
Mkhanyakude district delivering in Mseleni Hospital in the month of August 2010 and
December 2010. As a primary outcome, we looked at our CD4 count coverage.
As
secondary outcomes, we looked at the implementation of new ART intervention during
labour and at the proportion of breast-feeding to formula feeding practices.
138
We used the maternity statistics of Mseleni Hospital for the month of August 2010 and
December 2010, correlating the maternity admission book and PMTCT register.
We interviewed the main contributors to implementing these changes, i.e. M. Nqandeka
(Primary Care Coordinator), Dr L. Hobe, Dr A. Webb, Dr L. Dowds.
Results
August 2010
Women who delivered
148
RVD positive
46
Known CD4
18
On ART
11
On dual therapy
27
Truvada
27
NVP to babies
40
BF babies
35
Table 1
PMTCT coverage in labour
Mseleni Hospital
%
December
2010
%
100.0
170
100.0
31.1
64
37.6
39.1
61
95.3
23.9
21
32.8
58.7
43
67.2
58.7
43
67.2
87.0
64
100.0
87.5
59
92.2
ward in August 2010 and December 2010,
As seen in Table 1, there were a similar percentage of RVD positive pregnant women who
delivered in August and December 2010 (31 and 37 % respectively). In August 2010, only
39% of RVD positive patients had a known CD4 count at delivery with 23% of them being on
ARV and 58% on dual therapy. On the other hand, in December 2010, 95% of pregnant RVD
positive women had a known CD4 count at birth with 32% on ARV and 67% on dual
therapy.
All women on dual therapy were given Truvada during labour in August and December 2010.
We also noticed that Nevirapine coverage in newborns improved between August and
December 2010. The rate of breast-feeding to formula feeding was similar and adequate.
Discussion
There was an important improvement in CD4 coverage of RVD positive women between
August and December 2010. A few keys steps were implemented in the clinics to improve
PMTCT.
Pregnant women are tested for HIV at their booking visit. If the test is positive, a CD4 count
is sent. In the past, there have been major issues with tracing the CD4 count result, lost
results, etc. The first major step was the introduction in every clinic of a SMS printer in
139
September 2010 (provincial initiative). This machine allows receiving CD4 count results (as
well as AFB and PCR) directly from NHLS in 5 days.
The second step was to find out how to implement changes. We invited all the key workers
from clinics (nurses, data capturers and counselors) to a workshop to talk about the key
areas for change and discuss the detail of how to ensure that the changes went ahead.
The third step was to implement these changes by doing intense in-house training of clinic
sisters. Every month, all clinic sisters come to Mseleni Hospital for training (after the
Maternity mortality meeting) for a full day. The new PMTCT program was taught and
implemented that way.
Looking at our statistics, we can also notice that the percentage of RVD positive pregnant
women on ART has gone from 23% to 32%. This finding is consistent with starting ART with
CD4<350 rather than <200 as it was the case in the 2008 PMTCT program.
From looking at the statistics, it is difficult to see if the rest of the PMTCT measures have
been implemented. From case observations, it seems that most women book after 14 weeks
and are therefore started on the PMTCT program much later than that. More in depth study
would be needed to find out why pregnant women are not booking early.
Acknowledgments
We would like to thank the maternity department as well as M. Nqandeka, Dr L. Hobe, Dr A.
Webb, Dr L. Dowd for their contribution to this poster.
140
WHERE ARE THE MEN? UNDERSTANDING MALE INVOLVEMENT
PREVENTION OF MOTHER-TO-CHILD HIV TRANSMISSION
IN
THE
Kevin Koo, Jennifer D. Makin, and Brian W. C. Forsyth
Background: Involvement of male partners may increase adherence to and improve
outcomes of programs to prevent mother-to-child HIV transmission (PMTCT). Greater
understanding of factors impeding male-partner testing is needed.
Methods: A cross-sectional, mixed-methods study was conducted at a community health
center in Tshwane, South Africa. Semi-structured interviews were completed with 124 men
whose partners had been recently pregnant. Six “invitation cards” encouraging partner
communication and clinic attendance were subsequently evaluated by 158 fathers and 409
mothers.
Results: 100 (80.6%) participants knew their partners had tested during pregnancy. 74
(59.7%) men had been tested, with 34 (45.9%) testing positive; 39 (52.7%) tested during
pregnancy. A man's likelihood of testing was associated with increased HIV/AIDS knowledge,
believing that male testing is important, and partner disclosure of HIV status (all p<0.05).
Men who discussed testing with partners were more likely to be married (p=0.004), to be in
exclusive relationships (p=0.05), and ultimately to seek testing (p=0.05). Men whose
partners tested positive were more likely to have tested than those with HIV-negative
partners (92.0% versus 46.1%, p=0.003) and to have tested during the pregnancy than
after (69.2% versus 28.1%, p=0.03), and the results were more often positive (91.3%
versus 28.1%, p<0.001). Of six invitation cards evaluated, one card about fatherhood and
responsibility was preferred by 40.5% of fathers and 30.8% of mothers.
Conclusions: Of men whose partners recently completed PMTCT, 60% have been HIVtested; over half were tested during the pregnancy. An invitation card could facilitate
improved quality of relationships and partner communication, which are important factors
underlying male-partner testing in PMTCT.
141
PROJECT KOPANO: A PILOT STUDY USING GROUP SMS TECHNOLOGY TO
INCREASE SOCIAL SUPPORT FOR HIV-POSITIVE PREGNANT WOMEN IN SOUTH
AFRICA
Andrea Lach Dean, Anna Kydd, Jennifer Makin, Brian Forsyth
Background
Many of South Africa’s HIV-infected women receive their HIV diagnosis during pregnancy.
Though Prevention of Mother-to-Child HIV Transmission (PMTCT) is universally available, the
psychological impact of diagnosis can impact adherence to treatment. Project Kopano seeks
to evaluate the feasibility and acceptability of using text messaging to support HIV+
pregnant women in South Africa and provide early evidence of its ability to (1) decrease
social isolation, (2) overcome typical barriers to providing support such as stigma, and (3)
adequately address topics relevant to PMTCT adherence.
Methods
Seven HIV+ women (gestational ages 16 to 32 weeks) from two urban antenatal clinics
received mobile phones and were invited to use SMS to discuss HIV, health and pregnancy
over the 12-week intervention. All participants were simultaneously connected via group SMS
software as well as a “Clinician” to guide the group and answer questions.
Results
A total of 1022 individual SMSes were sent regarding medical and psychosocial topics related
to HV and PMTCT. Closure interviews centered on themes of HIV knowledge and the
experience of community and revealed that participants would have declined enrollment in
an onsite support group due to stigma suggesting that Project Kopano’s anonymity and
uniquely non-rigid nature allow it to reach socially isolated women.
142
10 YEARS OF NATIONAL PPIP DATA
DH Greenfield
Neonatal Medicine, UCT
Introduction
Good information is essential for the assessment of problems and outcomes of progammes
which are intended to bring about improvement, and for identifying problems for which
interventions are needed. The Perinatal Problem Identification Programme (PPIP) was
developed in order to document perinatal mortality – rates, causes of death and avoidable
factors. When used the programme is able to calculate mortality rates, document causes of
death by frequency, and similarly document the avoidable factors which have been
identified.
When the problems have been identified, it should be possible to take action to reduce or
prevent many of these from recurring, and so reduce perinatal mortality. The expectation
was that by using the programme widely, there should be a reduction in perinatal mortality
in South Africa. The main usefulness of the programme is at facility level where the local
problems can be identified.
The programme has been used voluntarily in South Africa at sentinel sites since 2000, and in
some places even before this, as the original programme was developed in the early – mid
1990s. There has therefore been 10 years of data entry into the programme at facilities
around South Africa. This data has been sent to the MRC Unit for Maternal and Infant
Health Care Strategies, at the University of Pretoria. Five “Saving Babies Reports” have been
produced based on the data in the National PPIP data-base.
These contained
recommendations about how to improve the outcomes. The question is, ”What, if anything,
has changed over the last 10 years as the result of the information being available?”
Methods
The National PPIP database was analysed by level of care and birth weight categories. The
levels of care were divided into: Community Health Centres (CHC), District Hospitals (DH),
Regional Hospitals (RH), Provincial Tertiary Hospitals (PT) and National Cebtral Hospitals
(NC).
The birth weight categories were divided into 500g categories, from 500g to 2500g or more.
The perinatal and neonatal mortality rates, causes of death and avoidable factors were
assessed.
143
The data was analysed in 3 year periods:
2000 – 2002, 2003 – 2005, 2006 – 2008. 2009
data was for the single year.
The data presented is for infants with a birth weight of 1000g or more.
Results
1.
There is data for about 3 000
00 deliveries documented in
the programme
2.
The proportion of the data
has changed from mainly
Regional hospitals to mainly
District hospitals.
This is
probably due to some
Provinces
requiring
all
facilities
to
use
the
programme.
Perinatal mortality rates
450.0
400.0
350.0
300.0
250.0
2000 - 2002
2003 - 2005
200.0
2006 - 2008
2009
150.0
100.0
50.0
0.0
1000g +
3.
Perinatal Mortality rates
These are highest in the
smallest babies
1000 - 1499g
1500 - 1999g
2000 - 2499g
2500g +
100
80
The overall rate for infants with a birth weight of > 999g is 28.6 / 1000 births
60
4.
Early Neonatal Mortality rates
The overall rate for infants
with a birth weight > 999g is
8.7 / 1000 live births
The rates are noticably high
in the District hospitals
East
West
40
North
ENNMR by level of care
20
14.0
0
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
12.0
10.0
2000 - 2002
8.0
2003 - 2005
2006 - 2008
6.0
2009
2000 - 2009
4.0
2.0
0.0
CHC
144
Dist Hosp
Reg Hosp
Prov Tert
Nat Cent
Total Tert
Total SA
5.
Early Neonatal Mortality rate
in infants weighing 1000 –
1499g at birth
ENNMR: 1000 – 1499g
300.0
The rates are about 230 –
250 / 1000 live births in the
District hospitals.
This
means
that
in
these
hospitals, one out of every
four babies in this weight
category will die
250.0
200.0
2000 - 2002
2003 - 2005
150.0
2006 - 2008
2009
2000 - 2009
100.0
50.0
0.0
CHC
6.
Dist Hosp
Reg Hosp
Prov Tert
Nat Cent
Total Tert
Total SA
Primary Obsteric Cause of death
The main causes are:
 Unexplained intrauterine
death
 Antepartum haemorrhage
(mainly
abruptio
placentae)
 Intrapartum hypoxia
 Spontaneous
preterm
labour
 Hypertensive disease
Primary Obstetric Cause of death (%)
30.0
25.0
20.0
2000 - 2002
15.0
2003 - 2005
2006 - 2008
2009
10.0
5.0
0.0
IUD
APH
SpPL
IPA
Hpt
Fet Abn
Inf
IUGR
If the patients where there is abruptio placentae with hypertension are included in
“hypertension” then hypertension becomes the third higest cause of death.
7.
Final Neonatal,Cause of death
Immaturity and hypoxia are by
far the major causes of death
Final Neonatal Cause of Death (%)
45.0
40.0
35.0
30.0
25.0
Immaturity
Hypoxia
20.0
Infection
Congen abn
15.0
10.0
5.0
0.0
2000 - 2002
145
2003 - 2005
2006 - 2008
2009
8.
Probable Avoidable factors
Patient and medical staff avoidable factors
predominate
The patient related factors may be related to
transport problems
Probable Avoidable factors: (% of total
deaths)
Patient Associated Factors
Medical Personnel Factors
Administrative Factors
Delays in
attending
antenatal
care
9.4
AN Care
problems
5.0
Facilities
inadequate
3.0
ANC
Attendance
8.5
Labour care
problems
4.9
Personnel
related
2.1
Delays in
attending or
transferring
2.3
Transport
problems
1.5
Neonatal
care
1.3
Medical staff related factors can certainly be
addressed
9.
Hypoxia in relation to the deaths of big babies
Hypoxia, mostly related to labour, is the main cause of death in infants with a
birth weight of 2500g or more
Fresh still births and Early Neonatal deaths:
Primary obstetric cause of death
Intrapartum hyoxia
Unexplained Intrauterine Death
Trauma
Total
%
48.9
6.2
4.8
59.9
Birth weight: 2500g +
Final Neonatal cause of death
%
Hypoxia
65.2
65.2
Conclusions
1. The main primary obstetric causes of death are:
 Unexplained intrauterine death
 Spontaneous preterm labour
 Intrapartum hypoxia
 Hypertension
2. The main final neonatal causes of death are:
 Immaturity related
 Hypoxia
3. There are interventions which can reduce the deaths in all these categories
4. Many of these deaths are occurring in the District and to some extent in the
Regional hospitals
5. We have a very good tool for identifying the problems but
6. There has been no change in the mortality rates over the 10 years !!!
146
What is needed to improve the quality of care?







Adequate numbers of staff
Adequately trained staff
Adequate facilities
Adequate equipment
Protocols and guidelines for clinical care
Suitable patient records
Good patient transport sytem
But the knowledge and skills must be put into practice - implementation
 Constant clinical supervision and teaching at facility level
147
LATE NEONATAL DEATHS IN SOUTH AFRICA: AN OVERVIEW OF CHILD PIP, PPIP
AND VITAL REGISTRATION DATA
Stephen CR, Grey’s Hospital, Pietermaritzburg and Child PIP Project
Bamford LJ, Child and Youth Health Directorate, National Department of Health
Patrick ME, Grey’s Hospital, Pietermaritzburg and Child PIP Project
Deaths during the neonatal period contribute significantly to under-five mortality rates, thus
reductions in the number of deaths during this period are a key component of overall efforts
to improve survival of young children. Furthermore, because global neonatal mortality rates
have fallen more slowly than overall under-five mortality rates, the proportion of deaths
which occur during the newborn period has increased over time.
In South Africa, whilst data regarding the early newborn period have been widely analysed
and disseminated, data regarding both the number and cause of deaths during the late
neonatal period (7–27 days) have been lacking. Some data on late neonatal deaths are now
becoming available – both as a result of improvements in routine registration of births and
deaths through the vital registration system, and through wider implementation of the Child
Healthcare Problem Identification Programme (Child PIP) audit process which collects
information on deaths which occur in paediatric wards. Although these data are not always
complete, they provide valuable insights into the number, causes and quality of care
associated with late neonatal deaths in South Africa.
The presentation aimed to provide an overview of available data on late neonatal deaths
from a number of data sources. These include data collected through:

Vital registration

The Perinatal Problem Identification Programme (PPIP)

The Child Healthcare Problem Identification Programme (Child PIP)
Vital registration data
Vital registration data are compiled by Statistics South Africa, based on birth and death
notifications which are collected by the Department of Home Affairs. Advantages of the
system are that all deaths should be registered, and all deaths which occur in facilities will be
registered.
However some deaths, especially those which occur at home, may not be
registered.
148
Year
Births
Early Neonatal Death Rate
Late Neonatal Death Rate
2003
1 118 771
Registered
7.0
Adjusted
10.4
Registered
2.7
Adjusted
4.1
2004
1 111 539
7.1
9.4
3.0
3.9
2005
1 103 623
8.7
10.2
3.0
3.6
2006
1 095 651
8.9
10.2
3.5
4.0
2007
1 087 930
8.7
9.9
3.6
4.1
Table 1
Neonatal Mortality Rates based on StatsSA data and adjusted for
under-reporting
Early Neonatal Death Rates (ENDR) and Late Neonatal Death Rates (LNDR) based on vital
registration data for each year from 2003 to 2007 are presented in Table 1. The registered
death rates are based on the registered births and deaths. The adjusted rates have been
adjusted for under-reporting, although it must be stressed the accuracy of the estimates use
to determine the adjustment factor are difficult to verify. The data suggest that South Africa
had an LNMR of around 4.1 per 1 000, and an ENMR of just less than 10 per 1 000. These
are lower than UN estimates which report a mortality rate of 21 per 1 000 for South Africa.
The leading causes of death reported include infection, asphyxia and prematurity.
StatsSA data suggest that late neonatal deaths in South Africa account for just under 30% of
all neonatal deaths which is a slightly higher percentage than that seen internationally. This
may reflect fewer early deaths due to good perinatal care, as well as a disproportionately
higher number of late newborn deaths due to HIV-related disease, which becomes more
evident towards the end of the newborn period. However uncertainties regarding the
accuracy of the data mean that data should be interpreted with care.
Vital registration also provides information regarding the place of death. As expected a high
percentage of early newborn deaths occur in hospital, while less than 60% of late newborn
deaths take place there. Just under 30% of late neonatal deaths occur at home, and
although this is relatively high, it is lower than proportion of post-neonatal deaths which
occur at home which is estimated at 44%.
Perinatal Problem Identification Programme (PPIP) data
PPIP is designed to monitor perinatal care and outcomes, and it provides good quality data
on antenatal care, birth history, cause of death as well as the quality of care received by
newborns who die in maternity facilities. PPIP therefore provides some data on late newborn
149
deaths, but the data are not representative of late neonatal deaths in the general population.
PPIP mostly includes newborns who have never been discharged from hospital and as a
result premature, low birth weight infants, as well as infants with other delivery related
conditions are somewhat over-represented.
Early Neonatal mortality
rate
Late Neonatal mortality
rate
13.8
11.9
1.9
All > 1000g
10.2
8.7
1.5
500 – 999g
500.8
460.1
40.7
1000 – 1499g
188.4
158.7
29.7
1500 – 1999g
52.1
44.4
7.7
2000 – 2499g
13.7
11.8
1.9
2500g +
5.1
4.3
0.8
Weight category
All
Table 2
Neonatal
rate
mortality
Neonatal mortality rates by weight category (PPIP data 2005 –
2009)
Eighty-two percent of newborns who died in the late neonatal period were low birth weight
infants with a high proportion (59%) having very low birth weight or extremely low birth
weight. Immaturity and infection were the leading causes of death in these newborns. For
late newborn deaths in infants with normal birth weight, infection remained the leading
cause of death, although hypoxia and congenital abnormalities also contributed significantly.
The maternal HIV status for newborns who died in the late neonatal period was unknown in
one third of cases. Approximately 40% of mothers, whose test result was known, were
infected.
Child Healthcare Problem Identification Programme (Child PIP)
Child PIP collects data on all children admitted to children’s wards in hospitals in South
Africa. Child PIP collects good quality data on every death, including information on the
child’s social, nutritional and HIV context, as well as cause of death and quality of care data.
Disadvantages include the fact that only hospitals deaths are included, and that only about
30% of hospitals in South Africa currently collect and submit Child PIP data.
150
Year
2005
2006
2007
2008
2009
Total
NN admissions
1 355
2 769
4 354
7 867
6 253
22 778
NN deaths
76
150
192
440
426
1 284
5.6
5.4
4.2
5.6
6.8
5.6
Neonatal IHMR
Early NNDs
8
35
84
122
182
431
Late NNDs
23
87
124
204
191
629
All neonatal deaths
31
122
208
326
373
1 060
Neonatal MFs
52
206
386
804
1 183
2 631
MF rate (per death)
1.7
1.7
1.9
2.5
3.2
2.5
Table 3
Newborn deaths and modifiable factors, Child PIP data (2005 –
2009)
Child PIP data on newborn deaths is shown in Table 3. A total of 22 778 newborns were
admitted to participating hospitals during this period and the in-hospital mortality rate was
5.6%. Late newborn deaths accounted for approximately 60% of the audited neonatal
deaths. On average of 2.5 modifiable factors were identified for each audited death. The
majority of deaths were due to infections, and of these, septicaemia was the most common
cause, followed by pneumonia, acute diarrhoeal disease, PCP pneumonia and meningitis.
The HIV status for almost half of newborns dying in children’s wards was unknown which
represents an enormous gap in care. Over 40% of late neonates babies dying in hospital
were either exposed or already diagnosed as infected, and only 10% tested negative.
It is significant that 45% of all late neonates dying in children’s wards died within 24 hours
of admission. This is a much higher proportion than that recorded for all child deaths (29%).
This may reflect a combination of factors including the rapid progression of illness in
newborns, late presentation and a failure to provide adequate emergency care for sick
newborns.
PPIP and Child PIPP include information on avoidable or modifiable factors. For late
neonates, about half of all modifiable factors were attributed to clinical personnel, about one
fifth to administrators, and the remainder to caregivers. The leading modifiable factors in
late newborn deaths are shown in Table 4.
151
PPIP data
Child PIP data
Clinical
•
•
•
Admin
•
•
•
Patient
•
•
•
Clinical
•
•
•
Admin
•
•
•
Family
•
•
•
personnel
Delay in referring
Inadequate NN management plan
Nosocomial infection
Inadequate nursery facilities
Lack of ICU beds/facilities
Insufficient nurses
Never initiated ANC
Delay in seeking care – mother and baby
Booked late
personnel
Clinic: inadequate use of IMCI
A&E: poor case assessment
Ward: inadequate monitoring
Lack of ICU beds/facilities
Lack of staff (nurses & doctors)
Resuscitation equipment inadequate
Delay seeking care
Severity of illness
Home treatment with negative effect
Summary

Current data suggest that the late neonatal mortality rate is approximately 4 per
1000 live births with almost one third of neonatal deaths occurring during this period.

Infections are the leading cause of death during the late newborn period.

A high proportion of infants who die during this period are HIV infected or exposed.

Many gaps in the quality of care provided to newborns can be identified. These
include:
a.
Basic, simple clinical care processes are not followed in hospitals or clinics, where
IMCI approaches are often not used. Provision of adequate emergency care for
neonates was another significant gap in care that was identified.
b.
Many ill newborns are admitted to paediatric wards which are often not designed
or equipped to care for sick newborn infants.
c.
Postnatal care (for mothers and babies) has been identified as a particular gap,
although the data do not provide guidance as to the extent to which deaths
could have been avoided with better post-natal care.
Recommendations
a.
Quantity and quality of data needs to be improved through strengthening of birth and
death registration, as well as the further expansion of PPIP and Child PIP, ideally to
all facilities in South Africa
b.
Newborns must receive the care they require, both at home and when they become
ill and are admitted to hospital. Specific recommendations include:
–
Newborns admitted to hospital must receive appropriate care in wards which
have facilities specifically designed for small babies. In small to medium-sized
hospitals this invariably means the nursery or newborn unit. Resources need to
152
be specifically allocated to this group of children to ensure that equipment,
guidelines and staff are in place.
–
Better definition and implementation of a post-partum care package which must
include community-based services is required
c.
Ongoing strengthening of PMTCT and other HIV prevention strategies.
153
TREND IN PERINATAL, NEONATAL AND MATERNAL INDICES AT MADADENI
HOSPITAL: 1990 TO 2009
DR FS BONDI, MADADENI HOSPITAL, KZN
INTRODUCTION:
Access to health care has significantly improved since 1995 for the majority of the lowincome population of Amajuba District (pop= 0.5m). In particular, obstetric and neonatal
services are free and there are ongoing knowledge and skills development strategies to
enhance the performance of health care workers. The core interventions are the Perinatal
Education Programme (PEP), Basic Antenatal Care (BANC) and the Better Birth Initiative
(BBI). These programmes aim to improve the percentage of women initiating antenatal care
before 20 weeks as well as improve evidence-based intrapartum .
The other strategies are the Kangaroo Mother Care (KMC) and the Baby Friendly Initiative
(BFI). In 2000, primary health care (PHC) become the bedrock of health care delivery
system in South Africa (SA), and thus, in Amajuba district, maternity services were largely
transferred to nine- midwifery- 24hour run clinics.
The prevention of mother- to- child transmission (PMTCT) of HIV commenced in 2003 and in
2007 the programme was scaled up as enshrined in the national HIV/AIDS/STI Strategy for
2007 to 2011.
Madadeni Hospital and its adjoining clinics use the Guidelines for maternity care in South
Africa and since 2002, these facilities have provided data for the perinatal problem
identification programme (PPIP) .Also in 2002, Amajuba health facilities accomplished the
BFI and COSASA accreditation and to maintain these standards they received regular
monitoring and support from the district office.
As a result of these developments and changing healthcare in SA, we reasoned that there
has been an overall improvement in neonatal and obstetric care in our district. The present
audit seeks to assess the quality of care by using a wide range of perinatal and neonatal
indicators.
METHODS
This is a retrospective descriptive audit for all deliveries 500g or more that occurred in
Madadeni Hospital and its annexed nine clinics between 1990- 2009. The study population of
145,034 comprising 141,133 life births and 3901 (2.7%) still births.
This investigation was conducted in two parts; the first part is an observational study to
determine the trend in maternal and neonatal indices from 1990 to 2009. For the second
part, the 145,034 infants were divided into four five- year interval study groups based on
154
prioi grounds: 1990 to 1994, 1995 to 1999, 2000 to 2004 and 2005 to 2009. These intervals
represent limited accessibility and segregation of maternity services which were also fee
paying (1990- 1994); free obstetric and neonatal services and desegregation of healthcare
(1995- 1999); training and skills development of maternity staff as well as commencement
of targeted intervention programmes such as , PMTCT for HIV (2000- 2004) and finally
scaling up of these health strategies due to prior suboptinmal performance (2005- 2009).
The latter period also coincided with a more comprehensive HIV/AIDS/STI programme and
monthly outreach visits by a consultant pediatrician to our facility.
For most part of the study period (1990- 2006), maternity and neonatal bed space remained
unchanged and Madadeni Hospital provided level II care. Care service also did not change
much from 1990 to 2009 apart from, increased use of prenatal steroids, magnesium sulphate
and the establishment of a four- bedded high care unit for neonates in 1996. In 2007,
Newcastle Hospital (15km away) was upgraded to provide level III services for Amajuba
district, including the opening of NICU. Thus, an increasing number of high- risk mothers
were expected to have had their babies in Newcastle there after.
RESULTS
GENERAL OBSERVATIONS:
Between 1990 and 2009 there were 145,034 births in Madadeni and its annexed clinics. The
overall mean +/- SD values for SBR, PNMR NMR and MMR were 28(8.9), 45(12.4), 19(15.8)
and 109(150.9) respectively. The SBR was 26 at the beginning of the study (1990- 1994),
rose to 32 between 2000 and 2004 and it dropped to 25 during the latter period (2004 to
2009).This pattern was also exhibited by PNMR, NMR and MMR (figs. 1&2 ).
TOTAL BIRTHS:
Of the 145,034 babies, 85.7% were born in Madadeni Hospital, 12.8% in the clinics and the
remaining 1.5% were delivered at home. When the study groups were examined, there has
been a decline in babies born in Madadeni and its adjoining clinics. However, following the
establishment of a regional centre in Newcastle in 2007, the deliveries paradoxically actually
increased in Madadeni when the study periods 2004 to 2005 and 2005 to 2009 were
compared. These findings are displayed in (Fig.3).
CLINIC UTILIZATION:
The clinic delivering rate, percentage of overall
births that occurred in the clinics, has
declined steadily since 1990 and so also are the number of laboring women presenting in the
155
clinics to have their babies. By contrast, referrals from the clinics to Madadeni Hospital have
increased steadily. These findings are exhibited Fig 4.
ADMISSIONS TO SCBU:
The initial trend was an increase in proportion of babies admitted to SCBU. This has dropped
significantly since 2008 (Fig.5).
INFECTIONS:
This was major achievement for peripartum Sepsis and Syphilis exhibited a sharp downward
decline (Fig.6).
DISCUSSIONS:
A major milestone in the South African health care delivery system occurred after 1994,
when obstetric and neonatal services were made free in public hospitals, PHC became the
bedrock of care and a number of health strategies were implemented so as to improve
quality of care. Unfortunately, recent reports indicate that these efforts have not translated
to good health outcomes and SA is amongst the few countries in the world that is unlikely to
meet the targets for MDGs 4 and 5. Overall, the findings in this study lend support to these
reports. However, it is pleasing to note that in this series, there have been improvements in
perinatal indices after 2007.
156
(Fig.1)
(Fig.2)
157
(Fig.3)
(Fig.4)
158
(Fig.5)
(Fig.6)
159
BIRTH ASPHYXIA AND PERINATAL OUTCOME IN A LOW RESOURCED SETTING IN
NORTHERN KZN
Jeremy Blakeney. Medical Officer. Lower Umfolozi District War Memorial Hospital.
Introduction:
Birth asphyxia remains a frequent cause of chronic handicapping conditions: cerebral palsy,
mental retardation, learning disability and epilepsy. It makes a significant contribution to
perinatal deaths in South Africa. Birth asphyxia is defined as a condition of impaired gas
exchange leading, if it persists, to progressive hypoxemia and hypercapnia with a significant
metabolic acidosis by the World Federation of Neurology Group. The clinical criteria to define
birth asphyxia have not been standardised and vary between institutions. Clinical parameters
are not able to determine the duration of asphyxia or the nature of the insult.
In South Africa, 16% of perinatal deaths are attributed to birth asphyxia. There is an
asphyxia mortality rate of 7.21/1000 births at district hospitals and 5.65/1000 births at
referral hospitals. This makes it the 3rd leading cause of perinatal deaths behind spontaneous
preterm births and unexplained preterm labour. Many of these deaths were thought to be
avoidable. The avoidable factors that cause mortality can also cause morbidity.
The aim of this audit was to identify avoidable factors for birth asphyxia during the antenatal
and intrapartum care at Lower Umfolozi District War Memorial Hospital.
Method:
All asphyxiated babies born at Lower Umfolozi District War Memorial Hospital (LUDWMH)
from November 2010 to January 2011 were analysed. LUDWMH is a level 2/3 rural maternity
and neonatology hospital in northern KwaZulu-Natal. Institutional permission was obtained.
Clinical criteria were set for birth asphyxiated babies to ensure that the insult had taken
place intrapartum. Inclusive criteria were; depression at birth (defined by a 5 minute APGAR
of less than 8) and a metabolic acidosis (defined by a pH of less than 7.25 and a base excess
of less than -12).
Babies with congenital anomalies, congenital infections and extreme prematurity were
excluded. So were babies that had been delivered before the onset of labour.
All asphyxiated babies had their antenatal and intrapartum care analysed at a daily morbidity
and mortality meeting by team of doctors and midwives. Substandard care and avoidable
factors that could contribute to birth asphyxia were identified. These were divided into
160
patient related, healthcare worker related and administrative associated; and recorded with a
coding system similar to that of the Perinatal Problem Identification Programme (PPIP). The
severity of asphyxia was documented according to the Sarnat classification of Hypoxic
Ischaemic Encephalopathy (HIE). The rate of neonatal survival until discharge from hospital
was recorded.
Results:
From November 2010 to January 2011, 19 intrapartum asphyxiated babies were born. 15
were vaginal deliveries and 4 were caesarean sections.
There were 2 deaths from intrapartum asphyxia. The severity of HIE varied but 5 neonates
were classified as HIE 2 or worse.
161
Analysing the antenatal period; 20% of patients had patient related avoidable factors and
20% had healthcare worker related factors. Analysing the intrapartum period; 35% of
patients had administrative related avoidable factors, 30% had healthcare worker related
factors and 25% had patient related factors.
The most common patient related factor was a delay in seeking help during labour present in
25% of patients. The most common health care worker related factors were fetal distress
not detected intrapartum (30%) and a prolonged 2nd stage of labour with no intervention
(15%). The most common administrative related avoidable factor was a delay in transport
from clinic to hospital (15%). Analysis of the babies born by caesarean section showed that
75% had a decision to delivery interval of over 1 hour.
Discussion:
This audit identifies deficiencies. Too many women are not appropriately monitored or are
being monitored but fetal distress is not picked up. Healthcare workers must have regular inservice training and education on fetal monitoring, interpretation and timeous action when
an abnormal CTG occurs. The perinatal committee at LUDWMH have been tasked with
ensuring regular training takes place. Midwives have been encouraged to call doctors early
for assistance with the second stage of labour to avoid unnecessary prolongation.
The small number of caesarean births in this audit suggests delays in caesarean sections are
contributing to intrapartum asphyxia. A further audit is to be done specifically focusing on
caesarean sections to see if there is a problem. The hospital management must be involved
in delays in caesarean sections due to staff shortages and alternate arrangements made to
ensure optimal service delivery at all times.
The ambulance service is unable to meet the needs of the maternity service. Not only are
there not enough ambulances to collect patients from outside, there are also insufficient
ambulances to transfer patients requiring hospital care from clinics. To address the transfers
between clinic and hospitals planning is being done with EMRS to have a greater number of
maternity ambulances available and measures in place to prioritise women in labour.
There still exist in our community a number of women who don’t access healthcare to an
appropriate level during pregnancy. Health education for the general public and pregnant
women in this area should be emphasised. Patients are being educated about the lack of
ambulances at antenatal visits and encouraged to make alternative transport arrangements.
Emphasis is put on the warning signs of labour and presenting to hospital in time.
A further audit is to be done in a year’s time to see if these interventions have had any effect
on reducing intrapartum asphyxia.
162
GASTROSCHISIS, OMPHALOCOELE AND IMPERORATED ANUS CHALLENGES IN
LIMPOPO PROVINCE
M R Mabusela-Montani, MHK Hamese.
Department of Paediatrics and Child Health. University of Limpopo (Polokwane campus)
Introduction
Mankweng Hospital neonatal unit is the only level 3 hospital in Limpopo Province. All patients
with surgical conditions in Limpopo province our referred to our unit. There is no paediatric
surgeon in the province. Patients are therefore referred to DR George Mukhari Hospital.
Aim of Study
To indicate the need of paediatric surgeon in Limpopo and paediatric anaesthetist.
Method
All patients files of patients admitted in the unit with gastroschisis ,omphalocoele and
imperforated anus were retrieved and reviewed January to December 2010.
Results
Will be presented at the conference
Conclusion
Mankweng Hospital needs a paediatric surgeon and to reduce costs by sending patients to
Gauteng province.
163
NEONATAL INFECTION SURVEILLANCE SYSTEM AT EMPANGENI HOSPITAL,
SOUTH AFRICA: - A 4 MONTHS REVIEW.
Ndaye C Kapongo, Edith Bal-Mayel, Ingrid Gasarasi, Adelola Olaosebikan, Samantha Singh,
Menitha Samjowan, Thandeka Khanyile, Nonhle Ngcobo, Mujinga Kalala, Nomonde Bengu
Paediatric Department, Neonatal Unit, Lower Umfolozi District War Memorial Hospital,
Empangeni
Introduction
During the past years remarkable advances have been made in the medical care of sick
newborn infants. Regional intensive-care units have been established throughout the world
and accumulating evidence suggests that the strategy of regionalization of neonatal care has
reduced morbidity and mortality in this high-risk population. But improved survival rates,
longer length of stay in neonatal intensive care units (NICU) and more invasive procedures
have led to an increasing incidence of neonatal nosocomial infections which may not only
prolong hospital stay but also contribute to mortality.
Neonatal infections are estimated to cause 1.6 million annual deaths or 40% of neonatal
deaths in developing countries.
In a comprehensive review of community and facilities-
based data, neonatal infection as a proportion of all causes of death in the neonatal period
ranged from 4% to 56% in 17 hospital-based studies, and 8-84% in 24 community-based
studies. These figures were 3-20 times higher than those reported for hospital-born babies
in industrialized countries. Klebsiella pneumonia, other gram-negative rods (Escherichia coli
(E. coli), Pseudomonas spp, and Acinetobacter spp) and staphylococcus aureus were the
major pathogens among blood stream isolates reported. It is no longer possible to overlook
the important contribution of neonatal infections to neonatal mortality and overall infant
survival.
To reduce neonatal mortality caused by infections will need a strong case for investment in
expanded surveillance activities and further research on diagnosis, etiology, and optimal
management of neonatal sepsis at all levels of the health system, particularly at the
community and hospital level. A key component of infection control is surveillance: The
collection, management and organization, analysis (interpretation) and reporting of relevant
data regarding infections. Active surveillance is essential to identify alterable risk factors and
detect systems problems. Although there have been in South Africa several reports
concerning epidemics with specific bacterial agents in newborn intensive-care units, little has
been reported concerning the result of prospective surveillance of the total neonatal infection
in a regional
neonatal unit. In October 2010, a locally adapted Neonatal infection
surveillance system was put in place with electronic data set linked to our routine Epi-Info.
Admission data set. The aim was to determine the epidemiological profile of all neonatal
164
infection in the unit evaluating etiological agents, microbial sensitivity, and affected sites. We
aimed to observe the endemic levels of infection, early detection of outbreaks and define risk
factors according to the patients profile and procedures used. In this report, we present
neonatal infection data collected during a 4 months period from October 2010 to January
2011.
Materials and Methods
Clinical facilities
Empangeni Neonatal unit is part of a child and Maternal Hospital, Lower Umfolozi District
War Memorial Hospital (LUDWMH) in North-East of Kwazulu-Natal, South Africa. This is the
only maternity and neonatal regional referral centre for an area with a population estimated
at 2 Millions. According to census 2001, poverty rate and unemployment rates stand at
63.5% and 53.7% respectively. The proportion of households with access to safe water
(32%) and sanitation (24%) are far below the national figures (79% and 62%, respectively).
Fifty thousand (50 000) live births occur in the entire area annually including 10 000 at
LUDWMH .The neonatal service was introduced at the hospital in 1998 with a 15 unit beds
without intensive care facilities. Between 1999 and 2008 the unit was expanded to 92 bed
neonatal units: 16 NICU beds, 40 high care, 16 special care beds and a Kangaroo mother
care (KMC) unit (20 beds). Because of the burden in neonatal admissions needing
mechanical ventilation, our NICU unit is set up to allow only 2.8 meters square around every
infant bed which is below the provincial norms of 5 meters squares.
Surveillance procedures
Neonatal infection surveillance system activities have been integrated to routine medical and
nursing daily duties. As part of the unit infection control policy, a patient infection control
sheet was designed. Every antibiotic prescribed is documented on the patient infection
control sheet. (Responsibility: Prescribing doctor). The infection control sheet includes :
Patients demographics, admission details, antibiotic information ( date, type ,check list of at
least 16 reasons for prescribing antibiotics , check list of selected risk factors, septic work up
details ( Cell count ;Platelet count, C-reactive protein: CRP; Blood culture and antibiotic
sensitivity information), final diagnoses, patient outcome, infection conclusion information).
Daily Medical officer (MO) ward allocation includes an MO allocated for antibiotics round. The
routine duty is to complete the missing information of infection control sheets, identify
patients on antibiotic therapy without completed infection control sheet, to update
information regarding current line of antibiotic and laboratory results, to prepare consultant
165
round to review problematic cases, chest and abdominal x-rays. We also use the weekly
neonatal unit mortality review meeting to identify missed patients. The final level of tracking
possible missed patients is during the monthly review of discharge summaries while
preparing routine admission computerized data for monthly analysis. Bacterial cultures of
tracheal aspirates of intubated neonates were performed on admission, day 3 of admission
and when clinically indicated. Antibiotic policy in the unit consisted of intravenous soluble
Penicillin and Gentamycin as the initial regimen. Piperacillin & tazobactan combination plus
Amikacin constitute the second line of antibiotics. Meropenem and Teicoplanin combination is
used as third line therapy and where necessary a fungal cover may apply.
Definition of Infection
Infection was considered to be present if a diagnosis of infection was made by the physician
responsible of the care of the patient in line with the unit guidelines on antibiotic use and
infection criteria. Appropriate cultures were obtained and therapy instituted. The modified
CDC criteria (for sepsis, pneumonia, meningitis, urinary tract infection) to suit age-specific
findings in neonates or premature infant ≤ 28days are used in the unit. These criteria are
described in details elsewhere (7). Additional modifications were done to suit local
implementation and local laboratory test normal ranges.
Criteria for the diagnosis of
radiographic pneumonia included infiltrate, consolidation, and effusion. “Clinical pneumonia”
two of the following: apnea/ bradycardia, new onset of tachypnea, new onset of dyspnea `
(retraction, nasal flaring, grunting). For “clinical sepsis” no organism is detected in the blood
culture but one of the following is present: fever/hypothermia, apnea/bradycardia,
tachypnea,
unexplained
metabolic
acidosis,
and
unexplained
hypoglycaemia/
hyperglycaemia. And physician instituted antimicrobial therapy in line with the unit
guidelines. For confirmed laboratory sepsis: recognized pathogen is isolated from the blood
culture
or
coagulase
negative
staphylococcus
(CONS)
is
isolated
form
blood
culture/intravascular access device and the neonate has any of the signs described for
clinical sepsis and at least one of the following laboratory signs: CRP>6 mg/dl , leucopenia <
5000/µl, thrombocytopenia <100 000/µl , leucocytosis ≥30 000/µl. Incidence, incidence
density and site-specific incidence densities were calculated as described by Marrisa MussiPinhata et al.
Definition of Nosocomial Infection
An infection developing in an infant in the unit could be acquired from three sources:
Perinatally acquired- infection acquired in utero or during labor and delivery that became
166
manifest soon after birth. Community acquired- Those present on admission and clearly not
perinatally acquired (acquired in another hospital or at home). Nosocomial or unit acquiredThose not present or incubating on admissions that were incidental to care in the unit.
Infections that occur up to 48 hours of life are considered perinatally acquired and those that
occur after 48 hours of life or up to 72 hours after discharge are considered Nosocomial
infections. Since the incubation periods of infections occurring in the neonates are not well
defined, it is sometimes difficult to separate clearly the two types of infections. During
hospitalization any justifiable change of line of antibiotics was counted as episode of
infection.
Statistics
The Chi-square test was used to assess differences in relative frequencies. For Capturing and
all calculations, we used the computer programme Epi-Info 3_5_1. Differences were
regarded significant if the P-value was <0.05.
Results
Patients Population
Information related to the patient population is summarised in Figure 1. During the period
reviewed 760 infants were admitted to the unit. Six hundred and ten infants had hospital
stay duration more than 48 hours. This constituted our study population. Among them 214
were treated with first line antibiotic only for perinatally acquired infections and 133 infants
developed in total 206 episodes of Nosocomial infections observed during the review period.
Perinatally acquired Infections
Infection information according to Birth-weight category and body site regarding this group
of infants is shown in table 1.
Two hundred and fourteen (28.1%) were treated for
perinatally acquired infections. One hundred and fifty two (71%) had low birth-weight. The
sites of infection in order of frequency were: Pneumonia (59%), sepsis (35%), surface
infections (3.7%) and meningitis (1.4%). Twenty three (30.6%) organisms were isolated
from 75 infants diagnosed with sepsis. The frequency of pathogenic organisms recovered
from the blood is shown in table 2. The most commonly isolated agents were E. coli (4),
Enterococcus Faecalis (3), Pasteurella Canis (2), Group B streptococcus(2), Listeria
monocytogenes(2) and CONS(2). The isolates are still susceptible to the unit initial antibiotic
regimen (Table 2 & Table 3).
167
Total Nosocomial infections
During the 4 months of surveillance, a total of 206 episodes of Nosocomial infections (from
133 infants) were detected among the study population of 610 infants, a cumulative
incidence of 33.7 per 100 admissions (Table 3). The sites of infection in order of frequency
were sepsis (67%), pneumonia (26.6%), necrotizing enterocolitis (4.8%) and meningitis
(0.9%).
Bacteriology of Nosocomial Infections
Thirty nine isolates were recovered from the blood and Tracheal aspirates. The frequency of
pathogenic organisms recovered from the various infection sites is shown in Table5. The
most commonly isolated agents were Klebsiella spp (41%), Acinetobacter B. (15%) and
CONS (12.8%). The majority (12) of Klebsiella spp were isolated from the tracheal aspirates
in neonates with clinical pneumonia criteria. Fourteen out of sixteen (87.7%) isolates of
Klebsiella spp were susceptible to Amikacin and only one (6%) showed sensitivity to
Piperacillin & Tazobactan. Vancomycin was effective against all the 5 CONS isolates.
Birth-weight with and Nosocomial Infection
The 62.1 per cent total Nosocomial infection rate in the smaller babies with a birth weight
less than 1500g was significantly higher than the 37.8 per cent in the larger infants over
1500 g at birth ( p < 0.0000050). The smaller babies did not experienced a greater risk of
multiple infections (1.6 infections per patient) than the larger infants (1.41 infections per
patient) .When examined according to body site of infection a significant association was
found between lower birth weight (< 1500 g) and a higher rate of pneumonia and sepsis.
Duration of hospitalization and Nosocomial Infections
The average duration of hospitalization for the total 760 infants admitted to the unit during
the period in review was 6.5 days. Among the 610 infants hospitalised for a minimum of 48
hours, the 133 in whom a Nosocomial infection developed stayed an average of 26.8 days.
The 214 infants treated for perinatally acquired infections stayed an average of 13.0 days
whereas the 263 without an infection remained an average of 6.8days. We were unable to
determine the precise role of Nosocomial infection in prolonging the duration of
hospitalization because of the presence of multiple factors in the infants with long hospital
stays (e.g. lower birth weight and more severe underlying disease, chronic lung disease).
168
Association of Nosocomial infection with Mortality
Infant with Nosocomial infections had significant increased mortality (Table 7). There was
8.7% mortality rate among the 477 infants without Nosocomial infections and 14.2% rate in
the 133 babies who experienced 206 episodes of Nosocomial infection (OR=1.95 CI 95%
1.05-3.60 P –value <0.0226062).
Risk Factors for Nosocomial Infections
Some host characteristics and patient-care practices appeared to be associated with
significant higher risk in the Univariate analysis (Table 6); specifically very low birth weight
(OR 2.8, CI 1.75-4.49) umbilical venous catheter(OR 3.99 CI 2.43-6.56) tracheal tube(2.52
CI 1.53-4.14) and CPAP (OR 2.35 CI 1.27-2.10). The timing & type of the first feed, maternal
HIV status, maternal CD4 count, Teenage mother status, maternal hypertensive diseases,
and parity were not significantly associated with Nosocomial infection in the Univariate
analysis.
DISCUSSION
Neonatal mortality is increasingly recognized as an important global health challenge that
must be addressed if we are to reduce health disparities between rich and poor countries.
Neonatal infections, asphyxia and consequences of premature birth are responsible for the
majority of neonatal mortality. A key component of infection control is surveillance. Most
reports used a positive culture, whether blood, spinal fluid, or urine, to determine rate of
neonatal infections. In poor resources areas facing important laboratory challenges, this
approach is not appropriate to describe the full extent of neonatal infections. Our routine
surveillance system includes infants with clinical symptoms of infections who had negative
cultures, especially suspected blood stream infections with a systemic impact. Clinical signs
of infection include temperature instability, respiratory distress, feeding intolerance,
metabolic acidosis, and blood sugar instability. These symptoms are non-specific and may
indicate a problem other than infection and consequently lead to over-estimation of the
infection rate. Provide that consistent use of diagnosis criteria is at acceptable level; such
approach might provide at the local level realistic assessment of the extent of the problem,
identify major modifiable factors, inspire the design of specific infection control measures
and evaluate the impact of their implementation. Neonatal surveillance programs must be
time-and cost-effective and focus on the most important data. It is a responsibility of every
staff member to contribute to this process. The concept of incorporating the infection control
activities in daily medical and nursing routine activities should be encouraged. Overall
169
nosocomial infection rates are not useful, as they are influenced by hospital type and patient
mix, as well as by surveillance methods. Thus comparison of crude data from different units
is impossible. P. Gastmeier et al. had validated an approach using modified CDC criteria to
suit age-specific finding in neonates or premature infants’ ≤ 28 days. They suggested that by
stratification of birth-weights and standardizing device days, data generated from
surveillance systems using modified CDC criteria are appropriate for inter-hospital
comparison and quality assurance. The 33.7 per cent nosocomial infection rate observed in
LUDWMH neonatal unit is markedly higher than the 6.3 per cent rate recorded in the same
unit previous years using the culture positive approach. Currently there is no reliable entire
LUDWMH rate to compare the neonatal infection rate to. The observed high rate may be in
part due to the difficulty of the surveillance system to discriminate a genuine episode of
Nosocomial infection from a genuine aggravation of the perinatally-acquired infection. It is a
policy in the unit to repeat the FCB and CRP on day 3 for all patients on first regimen
antibiotic therapy for perinatally-acquired infection. Our surveillance system is set up to
count any justifiable change in line of antibiotic as episode of new infection. However there
are set of clinical and laboratory signs as guideline to any antibiotic line change. Analysing
the timing of antibiotic line change, there is clear evidence that 59% of antibiotic change to
2nd line regimen occurred between day 3 and day 5 of admissions. The most comprehensive
studies on epidemiology of hospital infections at NICUs were carried out by the CDC, by
means of the National Nosocomial Infection System (NNISS).
The overall rates of
Nosocomial infections per patient (total number of infections per 100 patients) at US
Neonatal units range from 1.8 to 15.3 per cent. There are no comprehensive studies similar
to the NNISS in Africa or South African literature. A study done at a Berlin neonatal unit
using modified CDC criteria reported a neonatal infection rate of 24.6 per cent among 904
infants hospitalized for over 48 hours. Nosocomial infection rates were significantly higher in
with birth-weight less than 1500 g. (p< 0.0000050). This is in line with findings in previous
reported surveillance results. Prematurity by itself is a risk factor for Nosocomial infections
because preterm neonates are immune compromised and have increased susceptibility to
infection due to an immature system, inefficient neutrophil function and lack of antigen typespecific antibodies to pathogens in their environment. In addition to the inability to mount a
mature immune response, preterm infants are exposed to a multitude of therapies during
their NICU stay that places them at risk for acquiring an infection. Neonatal care procedures
that provide a portal of entry for pathogens include intubation and ventilation, central
venous
catheters
and
parenteral
nutrition,
multiple
peripheral
intravenous
lines,
venipuncture, urinary catheters. Of the therapeutic interventions used in NICU, the use of
170
central venous catheter and endotracheal intubation are most associated with Nosocomial
infection. In this review their relative risk ratio were 2.37 (CI 1.74-3.24) and 1.66 (CI 1.302.21), respectively.
The infants with nosocomial infections, as a group, were hospitalised an average 4 times
longer than non-infected neonates. This is in line with some reports using similar approach.
We were unable to clearly determine whether the occurrence of nosocomial infections itself
contributed to a longer period of hospitalization, or whether the lower-birth weight, sicker
infants requiring a more prolonged hospital stay were more prone to nosocomial infections.
Bacteriology isolates are still a small number for us to make reliable observation during the
period reviewed. Klebsiella spp (41%), Acinetobacter baumannii (15%) and CONS (12.8%)
were the common organisms recovered for Nosocomial infections. E.coli (4/12),
Enterococcus Faecalis (3/12), Group B streptococcus (2/12) and Listeria monocytogenes
(2/12) were among the isolates in perinatally-acquired infections. The emergence in the unit
of resistant Klebsiella spp to Meropenem is of great concern.
The diagnosis of pneumonia and the determination of its cause is particularly challenging in
neonates. We recognize that the operational definition of pneumonia used (new infiltrate on
x-ray study, clinical diagnosis as per modified CDC criteria and treatment with a course of
anti-microbial agents) may have resulted in the exclusion of some cases and inclusion of
cases that were not truly bacterial in origin.
It appears that the high rate of neonatal Nosocomial infection in the unit is related to a
number of host and environmental factors. Very low- birth-weight (VLBW), central venous
catheterization and the presence of tracheal tube are strongly associated with the occurrence
of Nosocomial infections. Preterm infants with birth-weight less than 1500g are more likely
to receive the 2 invasive procedures. Our surveillance results, although preliminary,
emphasize the clinical importance of Nosocomial infections in this vulnerable group of
neonates. Surveillance for neonatal Nosocomial infections as a means of quality assessment
should focus on VLBW infants. In addition to the well established strategies of hand-washing
and other routine general infection control measures in place, Quality assurance programmes
should aim at:
1. Improve and maintain a team commitment to early extubation as it decreases the number
of days an endotracheal tube is in place as a portal for infection.
2. Improve a team commitment to an early feeding protocol (preferably breast milk). It
increases the number of infants who are successfully fed early. Early feedings minimize
changes in the intestinal mucosa that increase the risk of NEC and the translocation of
intestinal microbes that lead to sepsis in infants who are kept nil per os.
171
3. Designating a limited number of specially trained nurses and doctors as member of a
central line team for both placement and maintenance with the aim to improve competency
of insertion skill and standardization of maintenance techniques.
4. Improve the team commitment to limiting exposure to antibiotics as exposure to broadspectrum antibiotics changes the pathogens in the community, hospital, and the NICU.
5. Improve the team commitment to decreasing the number of skin punctures
6. Utilizing a multidisciplinary skin care committee to identify new and more effective skinprotective products adds dimension to the development of a strategy that maintains skin
integrity.
A neonatal infection surveillance system based on simple clinical and laboratory criteria can
help in poor resources areas to evaluate the extent of neonatal infection, the risk associated
with Nosocomial infection in a neonatal unit with intensive care activities. Adopting a
structured strategy that changes unit practices to address those risks and evaluating the
impact of the newly adopted strategies by tracking infection sites and organisms, the
incidence of Nosocomial infections in the neonatal population can be reduced.
Figure 1. STUDY POPULATION
1st line
Antibiotics
2nd line
or 3d line
Antibiotics
113 (yes)
327(yes)
214 (no)
760
Study population
n= 610
Perinatally
Acquired
Infection: n=214
263 (no)
Nosocomial
infection n=133
20 (yes)
No Infection
433 (no)
n=263
150
172
Table 1. Perinatally acquired Neonatal infection According to
Birth-Weight Category and Body Site
n (%)
Perinatal
Acquired
Infection
n (%)
<1000g
38 (5)
15 (7)
1000-1499g
101(13.3)
1500-1999g
BWT CAT
Tot.
Admiss.
Blood
Cultur
Done
n
Respirat.
Pneum.
Sepsis
Bact.
Mening.
Surf.
Infection
n
n
n
n(+)
15
0
15 (1)
0
0
57 (26.6)
53
43
13 (2)
1
0
171(22.5)
57 (26.6)
52
40
15(7)
0
2
2000-2499g
110(14.4)
23 (10.7)
18
13
8(3)
1
1
>=2500 g
340(44.7)
62 (29)
57
32
24(10)
1
5
195
(91)
128
75(23)
3
8
760
Total
214
(28.1)
Table 2. Frequency and Antibiotic Sensitivity of Gram Negative
Organisms in Perinatally Acquired Infections.
Gram Negative Organisms
N = 12
Genta
Amikacin
Sensitive
Sensitive
Deaths
n =1
E. Coli
4
4/4
4/4
-
Pasteurella Canis
2
2/2
2/2
-
Bacillus Cereus
1
1/1
1/1
-
Citrobacter Species
1
1/1
1/1
-
Klebsiella Species
1
1/1
1/1
1
Pseudomonas Aeroginosa
1
1/1
1/1
-
Salmonella Species
1
1/1
1/1
-
Serratia Marcesns
1
1/1
1/1
-
173
Table 3. Frequency and Sensitivity of Gram Positive Organisms in
Perinatally Acquired Infections.
Gram Positive Organisms
N= 11
Peni G/ Ampi.
Tazo/Piper.
Deaths
Sensitive
Sensitive
n =2
Enterococcus Faecalis
3
3/3
3/3
1
Group B Streptococcus (GBS)
2
2/2
0/2
1
Listeria monocytogenes
2
2/2
0/2
-
Staphylococcus Epidermidis
2
0/2
0/2
-
Staphylococcus Aureus
1
0/1
0/1
-
Staphylococcus Capitis
1
0/1
0/1
-
Table 4. Nosocomial Infections in the Empangeni Neonatal Unit
According to Birth-Weight Category and Body Site
Study
Population
Nosocomi
Infection
(Patients)
Infection
Episodes
Pneum.
Sepsis
Menin.
NEC
<1000g
31
16
29
6
21(2)
0
2
1000-1499g
81
62
99
26
66(10)
1
6
1500-1999g
137
23
42
10
31(2)
0
1
2000-2499g
88
7
8
3
4(2)
0
1
2500g or
More
273
25
28
10
17(6)
1
0
Total
610
133
206
55
139(22)
2
10
Infection Rate
-
-
33.7
9.0
22.7
0.3
1.6
n (+)
174
Table 5. Frequency and Antibiotic Sensitivity of Pathogenic
Organisms in Nosocomial Infection According to Site.
Sites
n
Amik.
Tazo.
Mero
Vanco
Acinetobacter B.
6
2/6
0/6
0/6
-
Klebsiella Species
12
12/12
1/12
8/12
-
Proteus Species
1
1/1
1/1
1/1
-
Pseudomonas A.
1
1/1
1/1
1/1
-
E. Coli
4
2/4
4/4
4/4
-
Klebsiella Species
4
2/4
0/4
4/4
-
Enerobacter Species
1
1/1
1/1
1/1
-
Acinetobacter
1
1/1
0/1
0/1
Blood Culture
Staph. Epidermidis
5
-
-
-
5/5
(Gram Pos.)
Staph. Aureus
1
-
-
-
1/1
Staph. Cohnii
1
-
-
-
1/1
Strep. Group D
1
1/1
1/1
1/1
-
Candida Alb.
1
-
-
-
-
Trach. Aspirate
Blood Culture
( Gram Neg)
Blood Culture
0rganisms
Table 6.Selected Risk Factors for Neonatal Nosocomial Infection
at Empangeni Neonatal Unit . Univariate analysis (n=347)
RISK Factors
No of
Newborns
OR
CI 95%
P-value
139
2.8
1.75-4.49
< 0.0000050
Umbilical Venous
catheter > 2 days
174
3.99
2.43-6.56
< 0.00000001
Tracheal Tube > 2 days
103
2.52
1.53-4.14
< 0.000947
CPAP
90
2,35
1.27-2.10
0.0003821
1st Baby feed
( Formula vs breast milk)
347
( 104 vs 224)
0.84
0.45-1.27
0.26541
HIV Exposed
113
0.92
0.57-1.51
0.73535
Maternal CD4
350 or less
24
-
-
0,35768
Teenage Mother
50
0.92
0.5-1.52
0.7044906
Birth weight (g)
1500-2500
< 1500
175
Table 7. Nosocomial Infection and Mortality Rates at Empangeni
Neonatal Unit According to Birth-Weight Category
Episodes of
infections
No of Infants
Deaths
Infants with no Infection
-
477 *
40
(8.7%) *
Total Infections
206
133 *
19
(14.2%) *
< 1000 g
29
15
5
(33.3%)
1000-1499 g
99
63
7
(11.1%)
1500-1999 g
42
27
3
(11.1%)
2000-2499 g
8
8
0
2500 g or more
28
25
4
* Odd Ratio =1.95
( CI 95% : 1.05-3.60)
(16%)
P < 0.0226062
Table 8. Average Duration of Hospitalization and Nosocomial
Infection According to Birth-Weight Category
Population
Study
n= 610
Infants with
no Infections
n=263
Perinatally
Acquired
infection ( n=214)
Nosocomial
infections
n= 133
Overall Mean
Hospital stay
(days)
7.29
6.87
13.03
26.84
< 1000 g
8.7
3.2
9.09
33.9
1000-1499 g
23.65
19.06
22.56
34.4
1500-1999 g
10.8
10.2
12.64
20.8
2000-2499 g
3.93
4.5
7.6
11.8
2500 g or more
3.05
3.83
7.46
13.8
176
PATTERN AND OUTCOME OF NEONATAL ADMISSIONS AT A REGIONAL HOSPITAL,
NORTHERN KWAZULU- NATAL: JANUARY 2006 TO DECEMBER 2010.
NC. Kapongo, J. van Lobeinstein, N. Bengu, A. Olaosebikan, S. Singh, M. Samjowan, I.
Gasarasi, M. Kalala, T. Khanyile, N. Ngcobo, E. Bal-Mayel, Z. Duze
Paediatric Department, Neonatal Unit, Lower Umfolozi District War Memorial Hospital
(LUDWMH)
Introduction
Despite global declines in under-five and infant rates in recent decades, neonatal mortality
rates have remained relatively unchanged. Neonatal deaths account for two-third of deaths
in children less than 1 year of age, and nearly 40% of all deaths in all children less than 5
years. Over 98% of these deaths occur in developing nations with the highest rate in Africa.
Infections (32%), asphyxia (29%) and consequences of prematurity & congenital anomalies
(34%) have been reported to be the major causes of neonatal deaths. Low birth-weight
(LBW), is an overriding factors in the majority of the deaths. Many more newborn who
survive have brain insult, resulting in severe disabilities such as convulsive disorders,
cerebral palsy and cognitive impairments, thus adding further burden to healthcare, social
systems and the home environment. Thus, interventions that prevent morbidity during the
neonatal period have the potential to be highly cost-effective and impact health far beyond
the neonatal period. Many of the newborns who receive formal medical care are treated in
rural District hospitals and other peripheral health centres. Little data demonstrating trends
in neonatal admissions and outcome in rural health facilities in resource poor regions have
been published. More data are needed. Such information is critical in planning public health
interventions. In this report we therefore aimed at describing the pattern of neonatal
admissions at a regional neonatal unit with strong ties to rural District hospitals in Northern
KwaZulu-Natal province, South Africa.
Material and Methods
Clinical Facilities
Empangeni Neonatal unit is part of a child and Maternal Hospital, Lower Umfolozi District
War Memorial Hospital (LUDWMH) in North-East of Kwazulu-Natal, South Africa. This is the
only maternity and neonatal regional referral centre for an area with a population estimated
at 2 Millions. According to census 2001, poverty rate and unemployment rates stand at
63.5% and 53.7% respectively. The proportion of households with access to safe water
(32%) and sanitation (24%) are far below the national figures (79% and 62%, respectively).
Fifty thousand (50 000) live births occur in the entire area annually including 10 000 at
177
LUDWMH .The neonatal service was introduced at the hospital in 1998 with a 15 unit beds
without intensive care facilities. Between 1999 and 2008 the unit was expanded to 92 bed
neonatal units: 16 NICU beds, 40 high care, 16 special care beds and a Kangaroo mother
care (KMC) unit (20 beds). Because of the burden in neonatal admissions needing
mechanical ventilation, our NICU unit is set up to allow only 2.8 meters square around every
infant bed which is below the provincial norms of 5 meters squares.
Data collections
Neonatal data
A prospective, Electronic surveillance system of all neonatal admissions has been in place at
LUDWMH Neonatal Unit since 2000. Based on this system, monthly admission profile report
is generated for routine hospital statistics, unit quality assurance projects and other various
unit oral presentations. On admission and at discharge or death, standardized clinical and
laboratory data are collected in a monthly edited admission book template compatible with
CDC Epi-Info. 3_5_1 locally designed data set. Data extracted include Date of admission,
patient’s details, maternal details, demographics, presenting signs, admissions diagnosis,
final and secondary diagnosis, treatment and procedures & complications, outcomes and
date of outcome. Basic laboratory tests. Infants admitted to neonatal intensive care unit
(NICU) have additional page for standardized NICU details. Formulation of clinical diagnoses
follow recognized guidelines for management of common illness with limited resources (5).
A secretary support team helps to update daily the information (final diagnosis, secondary
diagnosis, outcome and date of outcome). A monthly data clean up is done before to run the
monthly program which generates result for the monthly report.
Maternity delivery data.
Maternity data were retrieved from hospital PPIP data and from the Excel data summary
compiled monthly using maternity clerk data forms.
Statistical Analysis
Capturing and analysis were carried out using CDC Epi-Info-3_5_1 programme. This include
simple frequency analysis, Stratified analysis to determine stratum specific odds ratio, Chisquare associations to determine odds ratios and confidence intervals, Summary odds ratio
and parametric& non parametric one way analysis of variance test for comparing means,
Analysis for linear Trend in proportions using the extended Mantel-Maenszel Chi-square. A
5% level of significance was used.
178
Results
A total of 52 139 live birth deliveries were recorded at LUDWMH from 2006 to 2010 and a
total of 10 137 infants were admitted to neonatal unit during the same period giving a
neonatal morbidity rate of 19.4% meaning one in 5 live births will be admitted to the
nursery.(Figure 1). Details regarding birth weight category, sex, mode of delivery and total
deaths are summarized in table 1. Infants with birth-weight less than 1500g constituted
21.3% of total admissions and accounted for 62.9% of total deaths. The overall survival rate
of extreme premature and very low birth weight infants were 33.4% and 82.3%,
respectively. There was an increase in the burden of neonatal admissions both in crude
number and as a proportion of total live births with the total annual number of neonatal
admissions increasing by 27% from 1809 cases in 2006 to 2306 cases in 2010. (Trend =
190, p value <0.00000). Except for the extreme low birth-weight babies, the other 4 birth
weight categories described in table 2 accounted for the increase in neonatal admissions.
Hyaline membrane disease, neonate for weight gain and TTN were the diagnoses
significantly associated with positive trend in neonatal admissions (Trend 107, p <0.00000;
Trend 12.085, p<0.00051; Trend 20.57, p< 0.00001; respectively) (table4). Asphyxia
(16.4%), HMD (13.8%), pneumonia (13.4%), neonate for weight gain (10.6%), TTN
(10.8%), sepsis (5%), were the major admission diagnoses. The overall case fatality rate
was 10.1% and the neonatal mortality rate (infant’s ≥1000g) was 11 per 1000 live births.
HMD (29.8%), extreme prematurity (25.7%), asphyxia (12.8%), sepsis (5%). Pneumonia
(7.8%), Meconium aspiration syndrome (2.8%) were the major causes of neonatal deaths.
There was also an increase in NICU admissions both in crude number and as a proportion to
total nursery admissions (table 6). The neonatal intensive care admissions increased from
205(11.3%) in 2006 to 544(23.5%) in 2010 in contrast to reducing NICU case fatality which
declined from 28.8% to 18.8% (Trend 10.092, p<0.00149). Of the total nursery admissions,
3243(32%) infants were HIV exposed, 5125(50.6%) were HIV-non exposed and
1769(17.4%) infants had unknown status. The majority, 8420 (83.1%) of infants were born
at LUDWMH. The rest 1717 (16.9%) were referred. Home deliveries, 591 infants (36%)
constituted the single largest referral entity. The rest 503(30.6%), 330(20.1%), 102(6.2%),
114(6.4%) were from Uthungulu, Umkhanyakude, Zululand Districts and Area 1,
respectively.
Discussion
District health facilities play a pivotal role in the health care delivery system in resource-poor
countries, acting both as primary referral centres and also coordinating care at the peripheral
179
health facilities. The nature and composition of the in-patient burden at this level may reflect
the community burden, more so than that at larger referral hospitals. Unfortunately data
from district hospitals in developing countries are limited in both quality and quantity.
Regional hospital with strong ties to rural districts can help to bridge this gap. Our data
shows that neonatal admissions both in absolute number and as a proportion of total live
births have substantially increased over the past 5 years. Further studies are needed to
determine the underlying factors that could account for the increase. Possible factors could
be a combination of nursery capacity expansion, increased district hospital referrals as
outreach programmes improve regional and district hospitals coordination, the sustained
high fertility rate (estimated to be above 6.0 in 2001 census) coupled to prematurity
complications. Our review failed to assess the trend of in-utero transfer to the hospital. A
Caesarean section and vacuum delivery seem to be associated with high morbidity
(admission to nursery). Twenty per cent of C/S and 51.1 % of V/E deliveries were admitted
in contrast with only 16.6% of non assisted vaginal deliveries. This increased mortality did
not translate into increased mortality. Underlying pathologies could well be the confounding
factor for the increase morbidity than the mode of delivery itself. HMD and asphyxia
constituted the 2 major causes of death with significant relevance in term of quality
assurance programme. The survival rate of VLBW infants has improved over the 5 years
period from 78% to 87% in 2010. Improved NCU facilities, the introduction of surfactant in
2004, the use of Neopuff, the strategy of using CPAP as first line of respiratory support are
some of which have contributed to this improved survival rate. Despite this tremendous
progress in saving infants with birth-weight 1000-1499g, they remained a significant
proportion of neonatal death in the unit.
Recent Nursery infection surveillance system
review revealed that VLBW infants were significantly associated with Nosocomial infection.
There is a realization that further progress in survival in this neonatal population group will
be difficult unless Nosocomial infection is prevented the difficulties identified at hospital level,
is a small proportion of the problem viewed at community level. It is particularly poignant
that many neonatal deaths occur in the community, without the newborn ever having
contact with the appropriate health services. Many obstetric and neonatal management
strategies have been developed during the past decades in efforts to improve the outcome
of preterm births. These strategies to name but a few , have included regionalized maternalneonatal transport system, development of neonatal intensive care units, and interventions
such as attempting to delay delivery using tocolytic drugs or enhancing fetal lung maturation
by administration of corticosteroids to the mother. Coordinated hospital and communitybased studies are needed to bridge fundamentals gaps: How many home deliveries do we
180
miss for each birth at health institution? For each born before arrival how many did not have
the opportunity to reach heath facilities and why?
The goal of improving hospital-based care of new-born babies and reducing the impact of
the 3 major indentified factors (prematurity, infections and asphyxia) on neonatal deaths and
consequently on child survival and optimum child development can only be achieved by the
collaborative efforts of clinicians, nurses ,administrators, public health professionals, health
policy makers, and users, who must be brought together on a common platform. This
coordinated process should be fed by quality data in touch with the dynamic of health
problem in the community.
Total live births and Neonatal admissions Empangeni Hospital
Jan 2006 to Dec 2010
12000
10000
8000
6000
Live Birt hs
Nursery Adm.
4000
2000
0
2006
2007
2008
2009
Live Birt hs
11015
10756
9923
10536
9691
Nursery Adm.
1809
1857
2005
2160
2306
181
2010
Table 1. Sex , Birth-weight category, Mode of delivery and Deaths (2006 to 2010)
N0
SEX
Bwt-Cat.
Total
NICU
Admission
n (%)
Deaths
Mortality %
admission
% of
%
survival per
Bwt Category
Males
5596
55.3
-
439
-
Females
4519
44.5
-
588
-
missing
22
0.2
-
2
< 1000g
550
5.5
166 (10.8)
366
35.5
33.4
1000-1499 g
1597
15.8
566(36.7)
282
27.4
82.3
1500-1999g
1912
18.9
319(20.7)
131
12.7
93.1
2000-2499g
1316
13
156(10.1)
68
6.6
94.8
≥2500g
4758
47.0
336(21.8)
182
17.6
96.1
missing
4
0.03
-
0
0
-
-
10 137
1543
1029
10.1%
-
Mode Delivery
NO
% / Tot
%/ per
Mod deliv.
NVD
4595
45.4
16.6
625
60.7
-
C/S
5351
52.8
22.8
395
38.3
-
V/E
134
1.3
51.1
9
0.87
Table 2. OVERALL TREND IN NEONATAL ADMISSION PER WT
CATEGORY
JAN 2006 TO DEC 2010
500-999 g
1000-1499
g
1500-1999
g
2000-2499
g
2500 g
2006
95
264
369
209
872
2007
106
324
376
224
827
2008
109
327
359
268
942
2009
133
321
390
284
1032
2010
107
361
418
331
1085
Trend
5.368
22.636
10.925
51.928
83.647
P value
P=0.02051
P=0.00000
P=0.00095
P=0.0000
P=0.00000
182
Table 3. Admission Diagnosis
Diagnostic Category (Top 9)
• Prematurity: 2834 (27.5%)
• Asphyxia : 1944(19.2%)
• Infection 1936(19.1%)
• RD : 1154 (11.4%)
• Social 507 (5%)
• For observation 456(4,5%)
• Cong anom: 308 (3%)
• Jaundice : 284(2.8%)
• Metabolic/Endo.:257 (2.5%)
Diagnosis (Top 10)
• Asphyxia (16.4%.)
• RDS(13.8%)
• Cong pneum(13.4%)
• For WT gain (10.6%)
• TTN (10.8%)
• Sepsis (5%)
• Lodger(4.7%)
• For Observation (4.4%)
• Extreme prem (4%)
• Jaundice (2.4%)
Table 4. OVERALL TREND IN BURDEN OF INDIVIDUAL TOP 5
CLINICAL DIAGNOSIS 2006-20010
RDS
For wt gain
Cong
Pneum.
TTN
Asphyxia
2006
218
232
257
169
333
2007
196
285
264
191
356
2008
263
188
322
169
368
2009
330
199
258
262
327
2010
390
170
255
304
266
Trend
107.880
12.085
1.067
20.578
2.303
P= 0.00000
P=0.00051
P=0.30154
P=0.00001
P=0.12911
P VAUE
183
Table 5. Causes of deaths






HMD (29.8%)
Extreme-Prem. (
25.7%)
Asphyxia (12.8%)
Septicemia 5.0%
Cong Pneumonia
7.8%
M.A.S (2.8%)






Total deaths : 1029
10.1 % of nursery
admissions
Total Neonatal
Deaths : 977 (all wt)
Total Neonatal
Deaths >1000 g) :611
NMR:11/1000
In patients vs
Referred OR=2.55
(p< 0.00000)
Table 6 Neonatal intensive care admissions and deaths (20062010)
Year
Nursery
admissions
NICU
N (%)
NICU deaths
Case fatality
%
2006
1809
205 (11.3)
52
28.5
2007
1857
289(15.5)
38
24.9
2008
2005
318(15.8)
44
21.2
2009
2160
466(21.5)
109
23.4
2010
2306
544(23.5)
100
18.4
Mortality ( Trend =10.009 , p value <0.00149
184
LUNG LAVAGE WITH DILUTED SURFACTANT IN INFANTS WITH MECONIUM
ASPIRATION SYNDROME
Johan Smith, Bjorn Baadjes, Stefan W Maritz
The Division of Neonatology, Tygerberg Children’s hospital, Tygerberg 7505
Meconium aspiration syndrome (MAS) is a very common problem, most frequently
encountered in term or post-term newborn infants born in developing countries. The burden
posed by MAS in South Africa is highlighted by its incidence - affecting some 4-11/1000 live
born infants in the public health sector of South Africa, compared to 0.5/1000 in the USA.
The condition often results in severe hypoxemic respiratory failure that carries a mortality
rate in both developed and developing countries of approximately 30%. The hypoxemic
respiratory failure is due to multi-facetted meconium-induced lung injury (MILI). The
approach to respiratory support is therefore multi-pronged and is aimed at relieving
hypoxemia, ameliorating airways and alveolar inflammation, surfactant dysfunction and
persistent pulmonary hypertension. No specific therapeutic ‘silver bullet is available.
Bolus surfactant replacement therapy has been proven beneficial in the treatment of MAS by
improving systemic oxygenation, reducing the need for extracorporeal membrane
oxygenation (ECMO) and length of hospital stay, but without affecting mortality rates. Lung
lavage (washout) with dilute surfactant has recently emerged as an alternative to bolus
therapy in MAS, which has the advantage of removing surfactant inhibitors from the alveolar
space in addition to augmenting surfactant phospholipid concentration. Combined animal
and human data suggest that lung lavage is safe, practicable and alters the course of MAS.
We analyzed data from our past experience with ventilated infants diagnosed with MAS and
found that there was no difference in systemic oxygenation over the first 48 hours of
ventilation in infants treated with high frequency oscillation (HFO)-only, infants treated with
conventional mechanical ventilation (CMV) and a group of infants treated with CMV and
surfactant bolus administration. We therefore changed our approach to the management of
infants with severe MAS by incorporating lung washout (lavage) with a suspension of dilute
bovine surfactant. The aim was to assess its effect on oxygenation and course of the
condition in comparison to the historical data. The first 9 consecutive ventilated human
infants diagnosed with MAS were recruited between November 2009 and June 2010.
Broncho-alveolar lavage (BAL) was performed with 20 ml/kg dilute surfactant (Survanta,
Abbott Laboratories, South Africa) (1:5; Survanta: 0.9% Sodium Chloride). The surfactant
was diluted to a concentration of 5mg/ml and was instilled in two aliquots of 10ml/kg (total
185
20ml/kg). The changes in oxygenation (a/A ratio) over the first 48 hours were compared to
the pooled data of the historical controls referred to above. Figure 1 shows the comparative
graph in which it was clear that the mean straight line regressions fitted to the individual
group data of the BAL group was significantly better than that of the mean regression line of
the a/A ratio of the pooled data of the historical controls. The 3 groups did not differ in
regard to their Y vs time relationship but that of Group 4 (BAL-group) differered significantly
from the rest. Subsequently, a total of 21 infants have been treated with BAL. Their
significantly improved changes in systemic oxygenation (AaDO2) (mean ± SD) following
lavage are shown in figure 2. Fifteen of the infants (79%) were extubated within the first
week of life (time to extubation: 5.33 ± 6.5 days). The overall survival rate was 90%, in
keeping with the findings of the recently published randomized controlled trial on lung lavage
(Dargaville PA, et al. 2010). The results of our changed protocol in managing infants with
severe MAS are promising. Survivors, however, require long term neurodevelopmental
outcome.
Figure 1:
The changes in the square root of the a/A ratio following treatment.
Mean straight line regressions fitted to the individual group data of
the BAL group was significantly better than that of the mean
regression line of the a/A ratio of the pooled data of the historical
controls.
186
Figure 2
Changes in alveolar-arterial oxygen tension difference (AaDO2) of
intubated infants over the first 96 hours of life. Post-treatment
values were significantly different compared to pre-lavage values
(P<0.05).
187
EFFECTS OF PROPHYLACTIC PHENOBARBITONE ON NEUROLOGIC OUTCOMES TO
HOSPITAL DISCHARGE IN NEONATES WITH ASPHYXIA.
S Velaphi, M Mokhachane, R Mphahlele, E Beckh-Arnold
Division of Neonatology, Department of Paediatrics, Chris Hani Baragwanath Hospital and the
University of the Witwatersrand
Introduction
Neuroprotection has been shown to be important in preventing morbidity and mortality
secondary to brain injury related to perinatal asphyxia. Mechanisms involved in brain injury
secondary to asphyxia include formation of oxygen radicals. One of the manifestations of
brain injury secondary to asphyxia is hypoxic ischaemic encephalopathy which may present
with convulsions. Reducing brain damage related to oxygen radical formation may reduce
brain injury therefore reducing incidence of encephalopathy and seizures.
Phenobarbital is one of the drugs that may play a role in neuroprotection as it reduces
cerebral metabolism and decreases lipid peroxidation. These effects may be beneficial in
reducing brain injury associated with reperfusion. In addition its anticonvulsant effects might
reduce seizures which may result in further brain injury if they are not controlled. The aim
of the study was to determine effects of prophylactic phenobarbital on incidence of seizures,
hypoxic ischaemic encephalopathy (HIE) and mortality to hospital discharge.
Methods
Neonates who were born at gestation of >34 weeks and/ or weighed >2000 grams and
required resuscitation at birth and met the following criteria: base deficit of >16 mmol/l
within an hour post-delivery with one of the following, Apgar score <7 at 5 minutes, or
required resuscitation for >5 minutes were enrolled into the study. Patients were randomized
using sealed envelops to either normal saline (placebo) or Phenobarbital 40 mg/kg
(intervention) infusion over an hour. During infusion the following vital signs were monitored
for; heart rate, blood pressure, respiratory rate and oxygen saturation. Infants were
monitored for development of seizures during their stay in hospital and had daily
neurological examination and were assessed for encephalopathy using Sarnat staging.
Results
Ninety four patients were enrolled in the study, 44 patients in the placebo group and 50 in
the phenobarbital group. Maternal and infant characteristics were similar between the two
groups. The extent of need for resuscitation, Apgar scores, base deficit, pH and severity of
188
encephalopathy were not different at enrolment between the two groups. Twenty one
patients of the 44 patients in the placebo group (47%) compared to 15 of the 50 patients in
the Phenobarbital group (30%) developed clinical seizures (p = 0.054). There were no
differences in incidence of HIE at 7 days of life (p=0.375) and mortality at discharge
between the two treatment groups (p=0.975). There were also no differences between the
two groups in duration of hospital stay (p=0.491).
Discussion
Prophylactic Phenobarbital administered at a dose of 40 mg/kg in near-term/ term infants as
an infusion over an hour is safe. Though the incidence of clinical seizures was reduced
among the patients who received Phenobarbital, this was not statistical significant.
Prophylactic use of phenobarbital in infants with asphyxia did not result in improvement in
short term-outcomes namely encephalopathy with or without seizures and mortality to
hospital discharge.
Limitation of the study is that number of patients enrolled was small. There was no
monitoring for electrographic seizures. The criteria used for selection of patients were liberal
or included infants with mild asphyxia therefore make it difficult to compare it with other
strategies that have been studied for neuroprotection. There was no monitoring for longterm outcomes.
Further studies with a large number of patients using Phenobarbital with or without other
interventions like hypothermia on long term neurological outcome need to be conducted.
189
BEST PRACTICE GUIDELINE FOR NEURODEVELOPMENTAL SUPPORTIVE CARE OF
THE PRETERM INFANT
Dr Welma Lubbe, North-West University, HC Klopper, SJC van der Walt
Introduction
In South Africa an average of 14.6% of infants are born of low-birth-weight and are at risk
for developmental delays. Components of neurodevelopmetal supportive care (NDSC) are
implemented in South African hospitals, however, no best practice guidelines (BPGs) could
be found for the implementation of NDSC as a care approach in South Africa or
internationally. This study was done to identify the concepts to be included in NDSC as well
as to develop BPGs for the South African context, since research stated that ‘Developmental
care will make the biggest difference and be most successful in the most challenged settings
with little resources’Als et al. (2003:405) and Goldberg-Hamblin et al. (2007:167).
Problem
Survival improved over the last few decades (Perlman, 2007:1339; Aita & Snider, 2003:223;
Goldberg-Hamblin, Singer, Singer & Denney, 2007:163; Lotas & Walden, 1996:681), but long
term developmental outcomes not (Als, 2001:4; Als, 1999:18; NANN, 2000:1; European
Science Foundation, 2002-2004; WHO, 1996 [Online]; UCSF Children’s Hospital, 2004:67,68;
NIH, 2006 [Online]; Perlman, 2007:1339; Goldberg-Hamblin et al., 2007:163; Lotas &
Walden, 1996:681).
This resulted in a range of morbidity & disease, physical and
developmental challenges (Symington & Pinelli, 2006 [Online]) and a socio-economic burden
of the preterm infant and his / her family on society (Lubbe, 2009).
NDSC has been
identified and well research as care approach to address the challenges mentioned and Als et
al. (2003:405) and Goldberg-Hamblin et al. (2007:167) stated that ‘Developmental care will
make the biggest difference and be most successful in the most challenged settings with
little resources’.
However, the implementation of NDSC in South African hospitals seems to be fragmented
rather than being implemented as a comprehensive care model or approach and furthermore
no Best Practice Guidelines (BPG’s) for the NDSC of the preterm infant were available
nationally or internationally (at the time of the study), and therefore the aim of this study
was to develop such BPG’s.
190
The research question that arised is ‘What should best practice guidelines (BPGs) for NDSC
in public sector hospitals in South Africa entail?’ leading to the aim of the study namely to:
develop BPGs for NDSC in the public sector in SA.
Data collection for this study was performed in three phases namely: Phase 1: Systematic
review to identify the components of NDSC from literature. Phase 2: Checklist design and
situational analysis using the checklist and key-informant interviews to determine the
operationalisation of NDSC in South African public sector NICU’s (12 selected newborn units),
and phase 3: The development of best practice guidelines for NDSC of the preterm infant.
Results:
An integrative literature review was performed to collect all documents that describe
components of NDSC. By means of a multi-level sampling process 179 documents were
selected and critically analysed during phase 1.
After critical analysis a total of 117
documents were found to be of good quality and included in the synthesis. From these
documents 42 concepts of NDSC were identified from the ILR. They were grouped together
according to similar themes with their supporting evidence.
From this evidence 25
conclusion statements were formulated.
Figure 1
Results from integrative literature review process
191
During phase 2 of the study a checklist was designed from the results of phase 1 and this
checklist was piloted and used to perform a situational analysis of 12 selected newborn units
to determine the operationalisation of NDSC in South African public sector NICU’s. These
observations were followed by key-informant interviews with unit managers, shift leaders or
a delegated healthcare professional working in the neonatal unit. 54 conclusion statements
were derived from phase 2 of the study divided as follow:
observations - conclusion
statements 26-56, interviews - conclusion statements 57- 64 (support to operationalisation)
and conclusion statements interviews: 65 - 79 (barriers to operationalisation).
The total of 79 conclusion statements from phase 1 and 2 were grouped into themes and
synthesised to formulate BPGs in stage 3.
Table 1
Example of conclusions statements reached and grouped as themes
CONCLUSION STATEMENTS
THEMES (components)
Create an environmental design similar to the intra-uterine
environment
Provide a supportive environment for sleep
Environment
Create a micro environment conducive to preterm infant
development
These BPGs were graded to determine the sufficiency of evidence and strength of
recommendations for implementation and recommendations for implementation were
formulated. These guidelines are:
Table 2
17 guidelines as identified from phases 1 and 2 of the study
1. Environment
7. Family-centered care
13. Communication
2. Positioning
8. Family education
14. Protocols
3. Handling
9. Parent profile
15. Management support
4. Individualised care
10. Staff education
16. Resources
5. Self-regulation
11. Multi-disciplinary team
17. Implementation time
6. Feeding
12. Staff attitude
192
The next figure provides an example of one of the actual guidelines including the supporting
evidence for the guideline as well as implementation recommendations.
EXAMPLE
BEST PRACTICE GUIDELINE 8 - FAMILY EDUCATION
Parent education is provided to support parent-infant interaction
–
Sufficiency of evidence: A
Evidence from stage 1 and 2 supports this BPG.
Stage 1: Conclusion statements 24
Stage 2 (a): Conclusion statements 30, 52
Strength of recommendation for implementation: 1
Educating parents regarding their preterm infant improves parent-infant interaction.
Implementation recommendations
Focus parental attention on the preterm infant and not the condition.
Teach parents to recognise early stress signs in their preterm infant.
Teach parents appropriate touch to ‘tune in’ to the preterm infant and provide or assist with
care.
Start a structured parenting support program, such as Little Steps® Premmie Parenting
Workshops.
Figure 2: Example of BPG on family education
Further research in progress includes the international validation of these guidelines,
development of recommendations, grounded in literature, on the implementation of BPG’s
for neonatal intensive care and other newborn units throughout, within the South African
context.
193
SUSTAINING IMPROVED QUALITY OF ANTENATAL CARE AND ITS ASSOCIATED
IMPACT ON PERINATAL MORTALITY RATES
Pattinson RC, Etsane E, Jones K, Sutton V, Ferreria T, Bergh A-M, Makin JD
MRC Maternal and Infant Health Care Strategies research unit, Department of Obstetrics and
Gynaecology, University of Pretoria
Objective: To evaluate the sustainability and effect of the basic antenatal care quality
improvement programme introduced in the fourteen primary health care clinics of SouthWest Tshwane, from 2005-2010.
Methods: A quality of antenatal care improvement programme was designed using the
WHO Integrated Management of Pregnancy and Childbirth manual and introduced using a
training of trainer’s methodology. The training programme also gave instruction regarding
changing the way antenatal care was organised and in the development of clinic based
protocols and referral routes. The quality of antenatal care was assessed prior to the
introduction of the programme, four months, one year and five years after its introduction
using a score sheet by collecting the antenatal cards at the referral hospital. A control group
of antenatal cards was also collected at the same time from clinics referring to the hospital
but not involved in the programme to act as a control group. After completion of the
training, quarterly BANC meeting were held in the sub-district to ensure communication of
new developments and to clear-up any problems in referring between clinics and the
hospital.
Results: There was an improvement in the average score of the implementation group,
from 68.0% to 71.0% (p=0.00) at four months, 74.0% (p=0.00) at one year and 76.0%
(p=0.00) at five years. The Perinatal mortality rate (≥1000g) for the 5 years before the
introduction of BANC was 20.5/1000 birth and after 13.8/1000 births (p<0.000)
Conclusion: The skills and procedures learnt with the introduction of BANC have been
sustained since its introduction, and this has been associated with a 33% reduction in
perinatal mortality.
194
A SURVEY ON THE IMPLEMENTATION OF BANC IN MPUMALANGA
Elsie Etsane,1 Anne-Marie Bergh,1 Bob Pattinson,1 Jenny Makin,1 MACH1 integration teams2
1
MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria
2
Mpumalanga Department of Health
Introduction
The Basic Antenatal Care (BANC) programme was introduced in Mpumalanga in 2008 as part
of the integration of maternal and child health services in the province (MACH I). This
initiative is based on the assumption that the improvement of the integration of maternal,
newborn and child health services, using antenatal care and PMTCT as points of departure,
would lead to better quality of care. The partners are the Mpumalanga Department of
Health, the sub-districts serving as academic service learning sites for University of Pretoria
(UP) students, the UP departments of Family Medicine, Paediatrics, and Obstetrics &
Gynaecology, the MRC Unit for Maternal and Infant Health Care Strategies, and UNICEF,
which is the main funder.
A four-pronged survey was done in 2010 and at the beginning of 2011 in seven sub-districts
where UP has service learning sites, namely Emakhazeni; Emalahleni; Mbombela North;
Mbombela South; Nkomasi East; Mkhondo; Umjindi. The purpose of the survey was to get a
sense of the progress with implementation of BANC.
Methods
1.
442 antenatal cards were scored for 2010
2. 506 new mothers completed anonymous questionnaires prior to discharge from hospital
in 2010
3. Qualitative interviews were held with staff in 12 clinics in 2010
4. A checklist was used in 2011 to score six clinics on the progress they have made in the
implementation of BANC
Results
1. Antenatal card scores:
The antenatal cards scores are summarised in Table 1. The card score improvement from
less than 55% in 2008 to more than 70% in 2009 was sustained in 2010. The target is
however to have an average score of at least 80%. Continued support is therefore needed to
keep the momentum.
195
Table 1. Summary of antenatal card scores.
Baseline 2008
2009
2010
Number of cards scored
339
210
442
Mean score (out of 25)
13.57
18.60
17.57
Standard deviation
2.25
3.00
3.56
Average percentage
54.3%
74.4%
70.3%
Compared with baseline (p value)
-
<0.0001
<0.0001
Areas that scored the poorest with regard to card completion were:
Foetal presentation
14%
LNMP, EDD
60%
1st & 32wk visits countersigned
35%
Plotting of gestation @ 1st visit
60%
Presence of IUGR detected
45%
Hb, Rh
62%
Correct plotting of SFH
55%
Action plan & interventions
62%
Identification/recording of risks
57%
Transport arrangements
64%
2. Self-report of mothers:
The questionnaire completed anonymously by mothers on discharge included closed items
derived from the antenatal card, with the provision for open-ended responses at various
points:
•
Personal information (age, education, other children)
•
Clinic visits (which clinic[s], date of first visit, VCT, number of clinic visits,
appointments for visits)
•
History (age, 1st child, LMP, EDD)
•
Examination (BP, urine, heart, movement, bloods taken)
•
Interpretation and decisions (risks/problems, where to give birth, transport,
contraception)
The demographic details of respondents were as follows
Total respondents
Mean age
Under 20 years
506
24.96 years
125 (25%)
Primigravida
Mean gestation at first clinic visit
Mean number of antenatal visits
249 (49%)
4.31 months
4.14 visits
Average schooling
10.8 years
Range of visits
1-10 visits
Table 2 gives a summary of the aspects that mothers reported were done well in antenatal
care and the points for which little explanation was given.
196
Table 2
Mothers’ self-report on antenatal care.
Things done well
n
%
VCT offered at first visit
Next appointment always given
BP taken every time
Foetal heart checked at last visit
Asked about baby’s movements
Urine tested at every visit
Blood taken at any visit
Where to go for birth
462
481
465
458
461
461
476
437
91
95
92
91
91
91
92
86
NO
explanation
or
information given
How to check movements
Why urine test is important
Risks in pregnancy
Why BP is important to take
Expected date of delivery
Arrange transport
Why blood was taken
Contraceptives
n
%
324
261
246
249
185
156
113
88
64
52
49
47
37
31
22
18
3. Staff reports:
Clinic staff were mostly positive about the BANC training and the training materials, which
were reported to be used in subsequent in-service training. They also reported
improvements in skills and knowledge (e.g. the use of the checklist and the gestational
wheel and measuring SF). The BANC checklist was found to be useful because it
systematically ensures that all examinations and treatments are done with each visit, which
in turn leads to the early detection of problems. However, the checklist was used “on and
off” in some clinics, especially the side of the sheet devised for follow-up visits. This was
mainly due to lists being out of stock or lack of photocopying facilities. Although there was a
general feeling that the workload had decreased with the new visit schedule, the time spent
per patient was more and the administrative tasks, the paper work related to BANC, were
resented - “There is a lot of work to be done and a lot of papers to fill in”.
Challenges that were reported included: staff shortages, which made it difficult to implement
BANC; shortage of materials; inadequate auditing; and lack of support for BANC
implementation. The students who did the interviews also observed that not all the clinic
sisters were conversant in BANC and that the feedback from BANC training to the rest of the
staff did not amount to in-service training but was a mere report-back session. They also
reported on BANC-trained staff who were not assigned to antenatal duties. The students
furthermore noticed that not all clinics had and or used protocols. Poor communication
between different referral levels was also mentioned.
4. Checklist for implementation progress:
In the beginning of 2011 a BANC implementation checklist was piloted in six clinics in five of
the sub-districts. The checklist is constructed according to the different components of the
BANC programmes and information should be provided by the facility manager and the
197
midwife in charge of antenatal care. The person doing the survey should also do a walkthrough and observe the availability of equipment, tests, documents, etc. The questionnaire
has a few sections to elicit general information on BANC training (when, where, number of
people trained and general impressions on strengths and weaknesses of implementation).
The sections on service delivery have questions on the facilities and how they are used and
on the provision and schedules for antenatal care. There is also a section on the availability
of equipment used in antenatal care and the availability of rapid tests. The section on
records probes about the use of antenatal card, the checklist, integrated flow charts, the
handbook, the file with protocols, referral routes, referral letters, the medicine list and
equipment list.
There is a separate section on the use of the checklist, whether a checklist is completed for
all antenatal patients, whether both sides of the sheet (checklists for 1st visit and follow-up
visits respectively) are used, what is done with the checklists and whether there are regular
audits of checklists. The section on protocols makes provision for the ticking of protocols that
have been developed, signed and reviewed. Questions in the section on the auditing of
antenatal cards pertain to who normally does the audit, the number of times audits have
taken place, and what is done with the audit results. In the way-forward section the
supervisor will review with the staff what is still lacking and discuss a plan of action on what
would be improved before the next supervisory visit.
Some of the findings from this pilot correspond with aspects identified in other legs of the
project. The students’ previous observations on the absence or non-use of protocols were
confirmed in this study. Rh tests were not available in any of the clinics, whereas only two
clinics did their own Hb tests, with one not having the necessary digital sticks or slides in
stock at the time of the survey. Half of the clinics also reported dipstix to be out of stock
from time to time. Materials like checklists are not always available due to lack of stationary
or the non-availability of photocopying facilities.
Skills identified for further improvement were requests for training in some of the clinical
skills (e.g. cardiac examination), skills to plot the graph on the antenatal card correctly and
the use and interpretation of rapid tests. Health promotion also came out as a strong need,
as well as on-site support for BANC implementation. It also appeared that there is a need for
a better understanding of the general principles of quality improvement.
198
Conclusion
• The gains in the antenatal card scores remained significantly higher after the introduction
of BANC. The specific areas with lower scores need further attention during refresher
courses.
• Health education remains a big gap in antenatal care and women do not know why certain
procedures are done. The newly developed family health file may assist in providing in this
communication need.
• The progress of implementing the BANC programme in the clinics should be monitored
regularly and be part of supervision and outreach activities. Better strategies for
monitoring progress with BANC implementation should be devised.
• The BANC implementation checklist needs to be simplified and refined to become a
supervisory tool.
199
TRENDS IN CAESAREAN SECTION BIRTHS AT LOWER UMFOLOZI
HOSPITAL (KZN) USING THE ROBSON’S CRITERIA
(LUDWMH)
Makhanya V, Govender L, Kambaran SR
Department of Obstetrics and Gynaecology, Lower Umfolozi District War Memorial Hospital,
Empangeni, KwaZulu natal
Introduction
Robson’s criteria

The system was proposed by British Obstetrician Michael Robson. It is based on ten
well-defined and mutually exclusive categories.

It was thought that these categories could be used to provide insight into the
makeup of caesarean section rate.

This ten-category classification system is based on the following obstetric concepts:
A. Category of the pregnancy
B. Previous obstetric record
C. Course of labor and delivery
D. Gestation
The main strengths of this classification

The ten mutually exclusive categories in this system reflect the group of women who
are relevant in clinical practice.

The systems takes into consideration the difference in obstetric or patient population.

This classification system detects where the major differences in caesarean section
rates exist.

It permits further subcategory analysis within each category.

It allows comparison of caesarean rates for facilities that serve similar types of
obstetric populations.
200
Robson’s classification:
1
Nullipara, gest >/= 37 weeks,cephalic presentation,spont. onset of
labour
2
Nullipara, gest >/= 37 weeks,cephalic presentation,induced or elective c/s.
3
Multipara, gest >/= 37 weeks,cephalic presentation,spont.onset of labour
4
Multipara, gest >/= 37 weeks,cephalic presentation,induced or elective c/s.
5
Multipara, gest >/= 37 weeks,cephalic presentation, previous c/s.
6
Nullipara,breech presentation.
7
Multipara,breech presentation.
8
Multiple pregnancy.
9
Transverse/oblique lie
10
Preterm,gestation < 37 weeks
Data source: Robson MS (2001) Classification of caesarean section . Fetal and
Maternal Medicine review, 12, 23-39
Study
Aim
Identify categories with high caesarean section rate and contribution to overall caesarean
section rate.
Objectives
-To target problem categories to reduce overall caesarean section rate at LUWMH
Method
-
Retrospective chart review of all women who delivered at LUDWMH, KZN between 1
May- 31 July 2010
-
Institutional permission given.
201
Total Deliveries: May- July (2553)
Primps-1079
Multips-1474
C/S
NVD
(n =1090)
42.7
57.3%
We had 2553 total deliveries of which 1090 (42,7%) of women had c/s
Overall c/s rate
35
30
P
e
r
c
e
n
t
a
g
e
25
20
may
15
june
july
10
5
0
1
2
3
4
5
6
7
8
9
10
Robsons
Discussion
-
Categories 1, 10, 3, and 5 contributed more to the c/s rate in our institution, with cat.
9 being the lowest;
-
On reviewing the literature we note that our findings are similar to a study done
elsewhere.
An Australian study, with a CS rate of 28.3%, showed a similar result
ANZJOG, 2007)
202
(Riggs
et
al;
CONCLUSION

Robson’s criteria demonstrates the need to focus on the women in groups 1,3,5 and
10

Robson’s alone is insufficient for identifying areas for targeted interventions to reduce
CS rate at LUWMH

We need to subcategorize into: antenatal care, extremities of age, preexisting
medical conditions, conditions acquired during pregnancy, intrapartum care and
indications.

Further research is required to put interventional structures in place to reduce CS rate
in categories that contribute most.
203
IS CONTROLLED CORD TRACTION IN THE THIRD STAGE OF LABOUR NECESSARY?
A SYSTEMATIC REVIEW OF RANDOMIZED TRIALS
G Justus Hofmeyr1, Nolundi T Mshweshwe1 A Metin Gülmezoglu2
Effective Care Research Unit, University of the Witwatersrand, University of Fort Hare,
Eastern
Cape
Department
of
Health,
East
London,
South
Africa
3
UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and
Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
1
Introduction
Postpartum haemorrhage (PPH) is a major cause of maternal mortality in both developed
and developing countries. Globally it is estimated that PPH occurs in about 11% of women
who give birth. The incidence is thought to be much higher in developing countries, where
many women do not have access to a skilled attendant at birth and where active
management of third stage of labour may not be routine (Mousa 2007).
Active management consists of a group of interventions including administration of a
prophylactic uterotonic at or after delivery of the baby, early cord clamping and cutting,
controlled cord traction to deliver the placenta, and uterine massage. Recently, due to
emerging data on beneficial effects of delayed cord clamping on term (McDonald 2008) and
preterm (Rabe 2004) newborn haematological indices, international recommendations on the
timing of cord clamping have changed. It is recommended to delay cord clamping until the
caregiver is ready to initiate controlled cord traction (thought to be around two to three
minutes) (Mathai 2007). Uterotonics used as part of the active management of third stage
of labour include synthetic oxytocin, ergometrine, and various prostaglandins. Oxytocin has
the advantage of minimal side effects when given intramuscularly or by slow intravenous
infusion. The limitations are that it is not very heat stable, and requires parenteral
administration. Uterine massage (trans-abdominal rubbing of the uterus to stimulate
contractions by release of endogenous prostaglandins) is usually recommended after delivery
of the placenta.
On the other hand, expectant management means waiting for the signs of separation of the
placenta and its spontaneous delivery, and late cord clamping, which is clamping the
umbilical cord when cord pulsation has ceased (hands-off approach) (Begley 2008).
204
There is good evidence that the package of active management of the third stage of labour
(AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60%
to 70% (Begley 2008).
Controlled cord traction is one of the components of AMTSL that requires training in manual
skill for it to be performed appropriately. Cord traction was introduced into obstetric practice
by Brandt in 1933 and Andrews in 1940 (Brandt 1933). The procedure, which became known
as the Brandt-Andrews manoeuvre, consists of elevating the uterus suprapubically while
maintaining steady traction on the cord, once there is clinical evidence of placental
separation and the uterus is contracted. In 1962 the term controlled cord traction was
introduced by Spencer as a modification which aims to facilitate the separation of the
placenta once the uterus contracts, and thus shorten the second stage of labour (Spencer
1962). This is achieved by applying traction on the cord, accompanied by counter-traction to
the
body
of
the
uterus
towards
the
umbilicus
(Stearn
1963).
Current
clinical
recommendations and most recent studies describe this or a similar method (ICM 2003).
Controlled cord traction may result in complications such as uterine inversion, particularly if
traction is applied before the uterus has contracted sufficiently, and without applying
effective counter-pressure to the uterine fundus. It is therefore a manual skill which requires
considerable practical training in order to be applied safely. Its use is limited to settings with
access to birth attendants with reasonably high levels of skill and training. If it is possible to
omit controlled cord traction from the active management package without losing efficacy,
this would have major implications for effective management of the third stage of labour in
settings with limited human resources.
Expectant management of the third stage of labour is preferred by some women and
practitioners. It is seen as a more physiological and less interventionist approach, avoids
uncomfortable procedures shortly after birth when the mother wishes to concentrate on the
baby, and reduces the risk of uterine inversion. Sometimes nipple stimulation is used to
enhance uterine contractions by stimulating the release of endogenous oxytocin.
Cord traction may hasten the process of separation and delivery of the placenta, thus
reducing blood loss and the incidence of retained placenta. It is thought that administration
of a uterotonic drug may cause uterine contraction and retention of the placenta if not
combined with controlled cord traction.
205
Objectives
To evaluate the effectiveness of controlled cord traction during the third stage of labour,
either with or without conventional active management.
Methods
We considered randomised trials evaluating the effects of controlled cord traction for women
who have given birth vaginally at 24 weeks' gestation or more. We excluded quasi-random
allocation trials .
Primary outcomes
1.
Blood loss of 1000 ml or more after birth
2.
Manual removal of the placenta
Search methods for identification of studies
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register by contacting
the Trials Search Co-ordinator (4 February 2011).
Data collection and analysis
Two review authors independently assessed for inclusion all the potential studies we
identifed as a result of the search strategy.
For eligible studies, two review authors
extracted the data using a data form. Two review authors independently assessed risk of
bias for each study. For dichotomous data, we presented results as summary risk ratio with
95% confidence intervals. We carried out statistical analysis using the Review Manager
software.
Results
The search of the Cochrane Pregnancy and Childbirth Group's Trials Register found five trial
reports. One study was included (Althabe 2009). Four studies were excluded. Two were
excluded because of inadequate allocation concealment (quasi-randomized trials) (Bonham
206
1963; Kemp 1971). Two trials were excluded because they compared controlled cord tract
with routine uterotonics with passive third stage without early uterotonics (oxytocin infusion
only after delivery of the placenta) (Khan 1997), or draing versus non-draing of the placenta
(Sharma 2004).
The trial of Althabe 2009 had adequate allocation concealment. Blinding was not possible.
Only 5/204 women were not included in the final analysis.
There were no statistically
significant differences between the groups for any of the reported outcomes: 1 trial, 199
women: Blood loss >1000ml: Risk ratio (RR) 0.58, 95% confidence interval (CI) 0.14 to
2.37; Blood loss >500ml: 0.75; 0.42 to 1.32; prolonged 3rd stage of labour: 0.56, 0.25 to
1.26. We repeated the analysis to assess the effect of inclusion of the quasi-randomized
trials (Bonham 1963, Kemp 1971) on the results. The differences remained statistically nonsignificant: Blood loss >500ml: 3 studies, 2095 women: 0.66; 0.42 to 1.02. In the study of
Kemp 1971, Moderate or severe pain was experience more frequently in the controlled cord
traction group: 1 trial, 713 women: 0.32; 0.24 to 0.47.
Discussion
Only one relatively small study met the inclusion criteria (Althabe 2009). There were no
statistically significant differences between the groups. It is important to keep in mind the
possibility of type 2 error (inadequate sample size to detect a true difference).
Conclusions
There is inadequate evidence from this review to change practice. In most well-resourced
settings, the current standard is full active management of the third stage of labour,
including routine use of a uterotonic drug, delayed cord clamping and controlled cord
traction. Further research is needed to justify the considerable expenditure on training of
health personnel for performing controlled cord traction safely. A large WHO trial which
enrolled >24 000 women is currently being analysed, and is likely to provide more precise
evidence to guide practice.
Acknowledgements
The Cochrane Pregnancy and Childbirth Team for administrative and editorial support.
207
AN ALTERNATIVE BEDSIDE METHOD FOR MANAGING POST-PARTUM
HAEMORRHAGE DUE TO ATONIC UTERUS FOLLOWING VAGINAL DELIVERY
Moran NF, Naidoo B.N.
Introduction
Post-partum haemorrhage (PPH) is the third most common category of maternal death in
South Africa. One of the common scenarios for maternal death from PPH is bleeding from an
atonic uterus following vaginal delivery. Initial management in such a case should include
fluid resuscitation, removal of clots from the vagina and uterus and the administration of
drugs (oxytocic agents) to encourage the uterus to contract. If the PPH persists despite
these initial measures, a surgical or mechanical method will be required. Before taking the
patient to the operating theatre there are bedside methods which can be performed. These
may be temporising methods, employed with the aim of reducing the bleeding while awaiting
theatre or transfer to a higher level institution. Alternatively, the bedside surgical or
mechanical method may in itself be successful in treating the PPH so that no subsequent
intervention is necessary. Commonly recommended bedside methods include bimanual
compression of the uterus or balloon tamponade of the uterus. For balloon tamponade, there
are purpose-designed balloons such as the Bakri balloon. Where these are not available, a
balloon can be made from a condom or a latex glove attached to a giving set, and
hydrostatic pressure used to create the tamponade within the uterus. The efficacy of these
bedside methods has not been well evaluated in clinical trials, and there may be practical
difficulties in performing these methods. We describe an alternative method which has some
theoretical and practical advantages. The method was devised by Dr B.N.Naidoo.
The Naidoo Method
It is assumed that appropriate available pharmacological treatment of the atonic uterus has
been administered, and that resuscitation efforts are ongoing. If there is persistent bleeding,
the following steps are then performed without delay:

The patient lies in the supine position

Insert a foley’s catheter per urethra, and keep it in place to ensure continuous
bladder drainage.

Pack the vagina (not the uterus) tightly with ribbon gauze or any other available
packing material (e.g. sanitary pads). This step controls any bleeding from vaginal or
cervical tears, and also raises the uterus into the abdominal cavity where it will be
fully accessible for the next step. In order to pack the vagina tightly enough, more
208
than one roll of gauze may often be required. Use sponge-holding forceps or
equivalent to pack the upper vagina first, and work downwards to ensure the whole
vagina is tightly packed. Care should be taken to pack gently so as not to traumatise
the vagina mucosa.

Grasp the fundus of the uterus through the abdominal wall and, using one or both
hands, continuously massage and compress the uterus, in order to prevent bleeding
and encourage uterine contraction.

Once the uterus is felt to be contracted and the patient is well resuscitated, the
uterine compression can be stopped and the vaginal pack removed.
For the Naidoo method to be successful, it is essential that at least one person remains by
the patient’s bedside throughout, continuously massaging (rubbing up) the uterus. The
method trusts that, given this encouragement, the uterus will eventually respond and do
what it is designed to do post-delivery, namely to contract. It is not uncommon that there is
bleeding both from the atonic uterus and from vaginal or cervical tears. The Naidoo method
addresses bleeding from both sources simultaneously.
Comparison to other bedside methods
Bimanual compression of the uterus. The Naidoo method is similar to bimanual compression
(one hand in the vagina, the other on the abdomen). The vaginal pack in the Naidoo method
plays a similar role to the fist in the vagina in bimanual compression, in that they both lift the
uterus out of the pelvis. However, the Naidoo method is more dignified and comfortable for
both the patient and the care-giver, and is therefore more likely to be sustained in the
emergency situation. It is the more practical method, especially if it has to be sustained for a
prolonged time, for example while awaiting transfer from a clinic to a hospital. It will also be
more effective in controlling any bleeding from vaginal or cervical tears.
Balloon tamponade of the uterus. The purpose-designed balloons (e.g.Bakri) are currently
very expensive, and are therefore unlikely to be made available to all sites where deliveries
occur. The Naidoo method could be used at all such sites. Compared to the condom or glove
balloon tamponade techniques, the Naidoo method may be quicker and easier to set up.
Overall then, the Naidoo method is more practical to implement. It has the added advantage
of controlling bleeding from vaginal and cervical tears. Theoretically at least, the Naidoo
method is a superior method for treating atonic uterus as it encourages contraction of the
uterus, therefore addressing the cause of the PPH. In contrast, balloon tamponade is likely
to discourage contraction of the uterus, as a foreign body is inserted into the uterus.
209
There are potential disadvantages of the Naidoo method depending on the circumstances of
the case. Firstly, for the method to work, it is essential that at least one care-giver remain
with the patient at all times to continuously massage the uterus. Although this is what should
happen anyway, there may be circumstances (for example due to staff shortage), where it is
impossible for a care-giver to remain with the patient throughout. In such a case, the balloon
tamponade method may be more effective, as tamponade could still be maintained, even
when the patient is left alone. Secondly, if the patient is very obese, it may be difficult to
grasp the uterus through the abdominal wall in order to massage it. If this is the case, again,
a balloon tamponade method might be preferable.
Experience with the method
Between them, the two authors have used the Naidoo method in a total of eight cases of
severe PPH due to atonic uterus. In all eight cases the method was successful in achieving a
good outcome for the mother without the need for a laparotomy. One of these cases is
described below.
Case Report
A 28 year-old gravida 3, para 2 booked late for antenatal care at her local clinic. She was
unsure of her dates, and her symphysis-to-fundal height was 33cm. Her booking Hb was
8,6g/dl. In her first pregnancy, she had had a caesarean section for a breech presentation.
In her second pregnancy, she had eclampsia, and had a normal vaginal delivery of a fresh
stillbirth.
Two weeks after her booking visit, she presented to the clinic, in labour. Her BP was 120/69,
her pulse 80bpm. She was found to be fully dilated with a breech presentation. She promptly
delivered a set of twins, undiagnosed until that point. The twins were 500g and 600g
respectively and both died shortly after delivery.
The placenta of the second twin was retained and there was heavy bleeding. Resuscitation
was started with intravenous crystalloid fluid, and an oxytocin infusion and intramuscular
syntometrine were administered. The patient was transferred to hospital.
On arrival at hospital, BP was 96/60, pulse 106bpm. It was confirmed that the placenta was
retained, but there was no active bleeding. Resuscitation was continued with colloid fluid.
Her Hb was 5.6 g/dl, and her platelet count was 138x103/µl. She was given two units of
packed red cells, after which her BP was 144/77, and her pulse 80bpm.
A manual removal of the retained placenta was attempted in the labour ward, but failed. The
patient was then taken to theatre for manual removal under anaesthetic. The surgeon had
210
difficulty reaching the placenta manually, and proceeded to remove the placenta in pieces
with ovum forceps. A uterine curettage was then done and the patient given 600µg
misoprostol rectally and kept on an oxytocin infusion. She was transferred to the recovery
room.
The surgeon was called back to the recovery room because the patient was bleeding
profusely per vagina. Her BP was 99/61, her pulse 120bpm. Her Hb fell to 5.5 g/dl and her
platelets to 81x103/µl. The surgeon took the patient back to theatre, and, under anaesthetic,
packed the uterus with gauze in an attempt to stop the bleeding. Three further units of
packed red cells were ordered, as well as a pool of platelets, and an infusion of freeze dried
plasma (FDP) was started.
A consultant was called in to theatre. The patient was examined in the lithotomy position. It
was clear that the patient was bleeding past the uterine pack. The pack was removed. The
consultant identified a large loose piece of placenta still within the uterus and removed it
with forceps. The uterus was examined and was found now to be empty. There was no
evidence of rupture of the uterus. However, the uterus remained completely atonic and was
bleeding heavily. Furthermore, there was diffuse bleeding from multiple sites in the vagina
and on the cervix. It was presumed that this was due to a combination of a coagulopathy
and minor trauma sustained during the attempts at removal of the placenta.
A decision was immediately made to manage the situation with Naidoo’s method. A foley’s
catheter was already in place, draining the bladder. The vagina was packed tightly with
ribbon gauze, and two assistants stood over the patient and took turns to continuously
massage the uterus through the abdominal wall. The vagina was continuously observed to
check whether there was bleeding through the vaginal pack.
This process was maintained for an hour, during which time the anaesthetist continued to
resuscitate the patient intensively. Three units of FDP were given, and three units of packed
red cells were transfused as well as a pool of platelets. By the end of this hour, the BP was
114/74 and pulse 74bpm. The uterus was now contracted, and there had been no bleeding
past the vaginal pack. As the patient was still under anaesthetic, it was decided to remove
the vaginal pack at this stage (had the procedure been done at the bedside, the pack could
have been left in and removed the following day, when the patient was fully resuscitated and
stable). The bleeding from the vagina and cervix had much reduced and four sutures were
placed to achieve complete haemostasis. Blood tests were taken at this stage with the
following results: Hb 7.1g/dl, platelets 61x103/µl, and INR 1.14. She was transferred out of
theatre and made an uneventful recovery.
This case illustrates some of the benefits of the Naidoo method in a real-life situation:
211

quick to set up

easy to perform

addresses vaginal and cervical bleeding, as well as the atonic uterus

allows effective resuscitation to be given

encourages the uterus to contract

avoids laparotomy
Conclusion
An alternative bedside method of managing PPH due to atonic uterus has been described.
The authors feel it has life-saving potential as it is easy to learn and could be quickly
performed by both doctors and midwives in most delivery settings. It deserves further
evaluation.
212
MATERNAL NEAR MISS VOICES
Spencer Nkosi, Mopetle Langa, Bob Pattinson
MRC Maternal and Infant Health Care Strategies Research Unit, Department of Obstetrics
and Gynaecology. University of Pretoria
Department of psychology, University ofWitwatersrand
Aim: To describe the mental, psychological and physical experience of maternal near miss
event had on the women.
Setting: Steve Biko Academic Hospital and Kalafong Hospitals
Method: Qualitative study was undertaken on women who agreed to be interviewed was
performed. The women were interviewed after the near miss event and again around a
month of discharge. A semi structured interview was held and recorded by SN. The data was
transcribed and analyzed.
Results: 38 women agreed to be interviewed. 16 had complications of hypertension 12 had
post partum haemorrhage, 2 cardiac patients, 1 medical condition (osteogenesis imperfect),
3 ectopic pregnancy cases, 2 severe septic cases (puerperal sepsis 1 case ending with
hysterectomy)1 high spinal case , 1 bladder rupture post delivery. 28 of the babies were
born alive in our unit. The remaining babies were shared between fresh stillborn and 2
macerated stillbirth. 32 patients experienced intense, disagreeable emotional and
psychological symptoms that produce feeling of death, 12 of the patients experienced
depression and of those 1 patient had severe depression. 14 patients had experienced
psychotic events, either visual or auditory hallucinations. These patients also had fixed false
belief of being persecuted. 9 had to adjust with inability of reduced global assessment
function. 10 had experienced sexual dysfunction. Interestingly sleep deprivation, high care
and ICU routine seemed not to be factor with patients. They accepted the environment and
routine of the units.
23 of the 38 still had severe emotional problems at one month follow up. 1 patient needing a
referral to psychologist. The patients who went for emergency hysterectomy expressed not
knowing or understanding that they had the procedure. 5 of those who had lost their babies
were still in grieving process
Conclusion: Saving a life is not enough; we need to pay attention to their emotional and
mental well-being as well. Women surviving severe pregnancy complications are at high risk
for postpartum depression. A postpartum follow up clinic where these women who
experienced a maternal near miss can be re-evaluated and counselled is necessary.
213
CHANGING PATTERNS OF SEVERE MATERNAL DISEASE: AN AUDIT OF PREGNANT
WOMEN WITH LIFE THREATENING CONDITIONS IN THE PRETORIA ACADEMIC
COMPLEX FOR 2008-9 AND COMPARISON OF PREVIOUS DATA FROM 1997-8 AND
2002-4
Petro Mulder, Priya Soma-Pillay, Hennie Lombaard, Peter Macdonald, Robert Pattinson
Department of Obstetrics and Gynaecology, University of Pretoria, and MRC Maternal and
Infant health Care Strategies Research Unit
Aim




To audit life threatening conditions for 2008-9 in the Pretoria Academic Complex
To compare the patterns of life threatening conditions of 2008-9 with two previous
audits, 1997-8 and 2002-4, and to identify any new trends
To assess the impact the HIV epidemic had on our disease profile
To assess the impact of a revised protocol on postpartum haemorrhage
Setting: The Pretoria Academic Complex comprises one central hospital (Steve Biko
Academic Hospital - SBAH), one regional hospital (Kalafong Hospital) two district hospitals
(Mamelodi and Tshwane District Hospitals) and three community health centres (Pretoria
West, Laudium and Stanza Bopape) that conduct births. It serves a population of mainly
indigent, urban South Africans
Methodology : Maternal near miss auditing has been performed in the Pretoria Academic
Complex since 1997. The same definitions and methodology has been used. Data is
collected at the regional and central hospitals at the daily morning meetings and is entered
on a Maternal Morbidity and Mortality Audit System database modified to accommodate
maternal near misses.
Results: There has been a 35% increase in births in the Pretoria Academic Complex over
12 years. The pattern of women with life threatening conditions has changed in 2008-9 with
more cases occurring with pre-existing medical and surgical conditions and complications of
hypertension, but fewer cases occurring with life threatening conditions with miscarriage.
However, the mortality index has significantly increased for miscarriage in 2008-9 compared
with 2002-4 and there was also a non significant increase in cases with pregnancy related
sepsis. There was a drop in the mortality index of obstetric haemorrhage but this did not
reach significance. Women who were HIV infected had more non-pregnancy related
infections and pregnancy related sepsis. HIV infected women with a life threatening
condition had a significantly increased mortality index.
Conclusion: In 2008-9 there has been deterioration in the outcome of women with severe
sepsis. HIV infection played a role in pregnancy related sepsis and possibly miscarriages.
The change in protocol in managing obstetric haemorrhage to include a balloon catheter to
stop the bleeding prior to going to theatre before doing a hysterectomy seems to have
reduced the mortality index.
214
HEALTH CARE WORKER RELATED FACTORS IN MATERNITY RELATED ADVERSE
EVENTS
MG Schoon1, S Kabane2, S Wiitacker3
1- Specialist -Maternal & Child health task team, Free State University; 2- Head:Health-Free
State Department of health; S Whitacker, CHOSASA
Introduction
Maternal death assessments is well established and the Saving mothers reports indicate
administrative and health worker related factors as important in avoidable deaths.
Substandard care and transport related issues is a problem elsewhere in Africa.
The Free State department of health embarked on an adverse events reporting system to
assist the department of health to determine areas of concern. Adverse health outcomes are
a worldwide phenomena affecting 4-17% of patients admitted to health care facilities. Many
adverse outcomes are precipitated by systemic influences in the health system. Identifying
these areas could assist the department in more appropriately channelling the available
funding to reduce risk, and could assist the department to lobby for additional financial
resources to improve outcomes.
The maternal and under-1 year outcomes in the province is challenging and follows the
South African trend with respect to the millennium goals (no improvement or reversal). A
critical assessment of events reported could assist the corporate management in overhauling
the health system to improve outcomes.
The Counsel for Health Service Accreditation of Southern Africa (COHSASA) is assisting the
Free State provincial Department of Health with an adverse incident management system.
The question arose if such a system would reflect similar factors than the maternal death
assessment process.
For the purpose of this study, the maternity related adverse events were subjected to a
similar assessment process than described in the Saving mothers report.
Patients and Methods
A system of reporting adverse events in the province have been introduced in 2007. This
system allows any health care worker to report an adverse event or outcome utilising a
telephonic call centre where an official records the events on a computerised database and
attempt to classify the event in terms of a severity rating. This information is provided to the
management of the institution involved, who should interrogate the information and do a
root cause analysis to determine the causal aspects relating to the incident.
215
The operator allowed the health worker calling into the system an opportunity to describe
the event, and then prompted some questions to improve the quality of the information
provided.
In this study all the database records with reference to maternal services have been selected
for analysis. These files were subjected to a reassessment by the principle author based on
similar criteria used to assess health care worker related factors as was published in the
Saving mothers 2007-2009 report. The cases were assessed to determine if there was health
care worker related avoidable factors present or not. The original database information with
respect to behaviour, level of care, incident severity rating and diagnosis were used in this
analysis.
Analysis of the data was done using the Epiinfo Database and statistics software for public
health professionals (version 3.3).
Biases and concerns
The information recorded was a voluntary process by health care workers and therefore
reflect a selection bias as reported by the health care workers. Some events did not relate to
patients as the system was also used by health care workers using the system to voice
frustrations with the health care system. There were also an information selection bias as
health care workers provided selective information to the call centre operator that could
have influenced the assessment of the available data. The operator entered data for all
adverse events and the questions was not specifically designed for maternal services.
Results
All events with reference to maternal services in the AIMS database during the period
September 2007 to July 2010 were extracted. During this period 187 records were recorded
with identifiers relating to maternal services. There were 4 entries reported by more than 1
reporter
Table 4 Primary
diagnosis
Frequency Percent
95% Conf
Limits
leading
to
duplication
and
were
excluded
from
the
Hypertension
16
10.5%
6.1%
16.4%
Infection
16
10.5%
6.1%
16.4%
Intrapartum
75
49.0%
40.9%
57.2%
reported incidents did
Medical disease
3
2.0%
0.4%
5.6%
not relate to a specific
Obstetric hemorrhage
14
9.2%
5.1%
14.9%
Other
15
9.8%
5.6%
15.7%
patient,
although
Thrombo-embolism
3
2.0%
0.4%
5.6%
valuable
information
11
7.2%
3.6%
12.5%
was
153
100.0%
Unknown
Total
216
analysis. A further 30
provided
on
systems defects in those cases.
The primary diagnosis was adjusted to be similar in nature than that used in the saving
mothers report. As these cases did not all result in death, a category “intrapartum” was used
to describe labour related events that did not complicate in categories that would result in
death. Table 1 describe the underlying primary diagnosis of the adverse events reported.
Of
the
153
patient
adverse events, 114
events
were
related
(74.5%)
classified
as
serious (SAC 1 or 2). Almost
half of all reported patient
related adverse events listed in
table 2, 75(49.0%) were due to
intrapartum
complications
excluding the 14 (9%) of cases
that
were
associated
with
adverse events. Hypertension
and infection accounted for 16
cases each (10.5%). In 11 events (7.2%) the primary cause was unknown.
The main staff categories associated with the patient related adverse events are listed in
table 3 and the administrative category in table 4. Lack of skill and protocol violations were
identified in 50 % of events reported. In only 19 (20%) the health system was thought to be
the main factor. Staff behaviour contributed largely to the events. There were 106 cases
(69%) with direct health care worker related factors affecting the outcome and in 89 (58%)
NS
NS
NS
NS
NS
NS
<0.05
NS
<0.05
NS
HEALTH WORKER RELATED FACTORS
Delay_in_referring (Yes/No)
Incorrect_management (Yes/No)
Infrequent_No_monitoring (Yes/No)
Initial_Assessment (Yes/No)
manage_inappropriate_level (Yes/No)
Problem_recognition (Yes/No)
Prolong_Abnormal_monitor (Yes/No)
Substandard_Care (Yes/No)
Health_worker_related_factor (Yes/No)
Asphyxia
NS
NS
NS
NS
NS
NS
NS
<0.01
NS
NS
Death
Asphyxia
ADMIN FACTORS
Accessibility (Yes/No)
Barrier (Yes/No)
BLOOD (Yes/No)
Communication (Yes/No)
facility (Yes/No)
ICU (Yes/No)
PERSONNEL (Yes/No)
STAFF_SHORTAGE (Yes/No)
Transport (Yes/No)
ADMIN_Avoidable_Factor (Yes/No)
Death
there were administrative factors.
NS
NS
<0.01
NS
NS
<0.05
NS
NS
NS
NS
NS
NS
NS
NS
<0.05
NS
<0.05
NS
Appropriately trained staff and transport issues were prominent administrative features.
Transport related issues were in particular interfacility transport problems, highlighting
217
substantial organisational problems with providing adequate interfacility transport for referral
between levels of care. The correlation in patients who died with staff shortage was a
negative correlation- staff shortages was less likely to be a factor in the cases that resulted
in death. In 15 of the 16 cases where there were inadequate monitoring, the cases resulted
in a death. Deaths also were reported in 75% of cases where problem recognition was
identified as a factor. Although the linear regression analysis did not indicate prolonged
abnormal monitor, managing patients at an inappropriate level and delay in referral as a
significant factor, the risk ratios of these factors were significant. Twenty-three of the 31
cases where a delay in referral was identified was reported as a death (p 0.001) as was 22
of the 29 cases thought to be managed at an inappropriate level (P 0.0014).
Delay in performing a caesarean section had a profound effect on the occurrence of birth
asphyxia, although there were no significant impact relating to maternal deaths.
In the non-patient related events reported, the bulk was used by staff as a mechanism to
complain about operational or administrative difficulties experienced at ward level.
Conclusions
Adverse outcome in maternal services are under-reported. Analysis of those reported,
however, did identify gaps that the health authorities need to address. These include interfacility transport, health professional skills issues such as ability to recognise problems and
the influence of infrequent or no observations on patients. Reporting and investigation of
adverse outcomes may assist health authorities to implement relevant quality assurance
programs in maternal and neonatal services.
The reporting of adverse outcomes should be encouraged by all health workers to improve
the ability of the health authorities to identify priority areas that requires attention.
It is of concern that there is a great proportion of events associated with reckless behaviour.
A more thorough assessment of staff behaviour is necessary. This could provide key
information in assisting to identify and rectifying a suggested crisis in professionalisms and
stewardship.
218
MIDWIFERY EDUCATORS DISCUSSION PLATFORM BLOEMFONTEIN: FREE STATE
PERSPECTIVE ON PROBLEMS EXPERIENCED IN MIDWIFERY
MG Schoon1, E Bekker2, B Kunene3
1 Department of Obstetrics & Gynecology, Free State University, Bloemfontein; 2 School of
Nursing, Free State University,3 Manager Midwife Aids Alliance Current at Mothers to
Mothers to be.
Introduction
The millennium goals are slipping out of reach for South Africa in spite of priority expressed
by the African Union and the South African government. This is regarded as a catastrophe
for health in South Africa. At the centre of this catastrophe is the staff rendering services in
maternal care. The recent massive strike action have also accentuated the vulnerability of
this service and it’s staff.
Initial assessments in the province highlighted a concern with the levels of knowledge and
skills of health professionals working in maternal settings. This concern is supported with
assessments made in the Saving Mothers report published by the National Committee for
Confidential Enquiries into maternal deaths, as well as the magnitude of adverse events
reported through the provincial adverse event reporting system in the province (unpublished
data).
In view of these concerns, a discussion platform was organised between various training
platforms of health care workers with respect to maternal services, as well as provincial
facilitators and some managers in maternal and neonatal settings in the province. The
purpose was to review the current situation and come up with simple solutions that talk to
the various categories while considering the availability of resource in the province. This
event took place on 19 & 20 August 2010 and the event was sponsored by the Midwives Aids
Alliance and was attended by 43 health professionals including nursing/midwife professionals
and some medical professionals representing all the academic institutions providing training
in midwifery or obstetrics in the province and institutions where professional trainees are
accommodated.
Methods: The discussion platform was opened by an overviews of maternal outcome in the
province, followed by an overview of midwifery training with comments on issues discussed
at the midwifery educators forum held earlier in the year and an overview of key issues
identified at the national midwives summit in May. An overview of the problems associated
with the IMCI program was also presented by Prof. Dave Woods.
219
After the introductory key issues were debated through structured small group discussions
and debates. This was followed by a constructive session determining the way forward and
the top 5 key priorities was determined through an election process.
Key issues affecting maternal services
1. Workforce image: Lack of self-respect of practitioners working in maternal services
was mentioned on various occasions. This was thought to be problematic due to a
general lack of appropriate role models and leadership promoting quality of care in
maternal services. The negative image of midwives is thought to be as a consequence of
the current situation that all nurses are regarded as midwives rendering a situation
where midwifery is not practiced by choice. Some even commented that problematic
staff is sent to labour wards as a form of punishment. Urgent action is needed to restore
the image of midwives within the maternal sections. It was suggested that a process of
value clarification need to be undertaken to allow midwives to reclaim their profession
and to clarify the core values needed to render quality maternity care with dedication.
Direct entry midwifery programs and focused specialisation could open pathways to attract
staff with the right attitude and dedication.
2. Maternity education: All groups identified gaps in training of midwives. There is a lack
of standardisation of training by the different schools in the province. There is clearly a
skills gap as the health department have to develop training programs to fill the gaps.
Educators felt that the end product of their training is good, but not appropriately utilised by
the service delivery platforms. In contrast, the service delivery units highlighted that the link
between educators and the service delivery work-force is sub-optimal. The fact that
educators are not actively involved in service delivery and the lack of clinical facilitators
assisting midwifery students and staff in the work environment adds to the problems in the
training of midwives. If the link between the service delivery platform and the educators can
be improved, inappropriate training could be removed from the curriculum.
Some educators felt that the current service delivery platform does not provide the
environment and role models required for quality health professional training. Alternative
thoughts were that the health professional educators should provide training within the
service and funding envelope.
220
From the discussions it was clear that there should be a more unified approach to training
with much more consultation and coordination between the various training schools. A
uniform output in terms of delivery competencies should be seeked irrespective of the
profession or the school providing the training. The national guidelines and strategies should
form part of the standardised approach.
3. Clinical competencies
There was a reasonable consensus at the discussion platform that skills and competencies
are lacking. Currently there is no mechanism to enforce activities to retain competencies.
Continuous educational development (CPD) for nurses working in maternal services have to
be fast tracked, and even be implemented at provincial level as part of a process to ensure
quality assurance.
Some of the problems affecting quality in maternity units is the generalist approach in the
nursing fraternity. This approach does not take in consideration the patient turn-over
required to maintain skills in health professionals. Inadequate exposure leads to a higher
incidence of adverse events. The lack of focused specialisation have resulted in a general
failure in the family planning program. Skill associated problems is seen particularly in the
delivery process, where dicey
decisions have a profound effect on adverse outcome.
Restoring dedicated skilled staff with a desire to work in the maternal services is required to
improve practical skills.
In medicine, subspecialisation have diminished the focus on general obstetrics and the
combined effect of less focus on basic obstetric care and rotation of skills out of a highly
specialised area with high morbidity and mortality impact is dangerous resulting in the
outcomes observed in the province.
4. Management and leadership
Lack of good management and leadership is contributing to the poor quality services. There
are not enough strong managers who do not turn a blind eye to discipline and corruption.
Managers need to ensure an enabling environment for the delivery of quality care, but this is
often lacking. Sub-optimal care that is allowed to continue without consequences adds to a
general lack of discipline in the delivery platform. The rotation of skilled staff out of the
maternal services as well as rotation within different maternal subsections was highlighted as
a general problem resulting in staff rendering service without the appropriate competencies.
The selection of staff sent for workshops is not optimal which results in failure to bring back
the skills to the staff that remained behind.
221
The inability of managers to ensure that services are rendered through a team effort,
including not only nursing/ midwifery professionals, but also the medical professionals, add
to poor quality service. Many institutions do not have perinatal review meetings and the
multi-disciplinary ward rounds have been discontinued.
5. Management and leadership
Roles of various players in midwifery are poorly defined. Experienced midwives are often
subjected to decisions by junior and inexperienced medical practitioners overruling decisions.
Some staff sent for advanced training courses come back and provide the same service as
prior to the additional training. Scope of practice for advanced midwives in is not in place
and there is disagreement country wide as what their role and function should be. The
needs for subcategories and focused areas of specialisation to create cheaper and more
effective health professionals were highlighted. A huge outcry was present to reintroduce the
old “green epaulette” midwife as in the past. It was emphazised that this training should be
at an appropriate level to allow further training and career improvement in line with
professional requirements. An interesting concept was a modular approach to training of
skilled birth attendants based on competencies required irrespective of the professional
group. This highlighted the multi-professional dynamics in midwifery skills and the need for
active multi-professional involvement in delivery of maternal services.
6. General
Lack of good management and leadership is contributing to the poor quality services. There
are not enough strong managers who do not turn a blind eye to discipline and corruption.
Managers need to ensure an enabling environment for the delivery of quality care, but this is
often lacking. Sub-optimal care that is allowed to continue without consequences adds to a
general lack of discipline in the delivery platform. The rotation of skilled staff out of the
maternal services as well as rotation within different maternal subsections was highlighted as
a general problem resulting in staff rendering service without the appropriate competencies.
The selection of staff sent for workshops is not optimal which results in failure to bring back
the skills to the staff that remained behind.
The inability of managers to ensure that services are rendered through a team effort,
including not only nursing/ midwifery professionals, but also the medical professionals, add
to poor quality service. Many institutions do not have perinatal review meetings and the
multi-disciplinary ward rounds have been discontinued.
222
Conclusions
Academics and operational staff attending the discussion platform have frankly highlighted
issues that were frequently said informally. Some very constructive views were expressed
during the proceedings that could assist in improving maternal and child health outcomes.
It is encouraging to see that midwives are coming forward to suggest ways to improve
midwifery services. This indicates that we are probably ready for active involvement of a
special breed to assist us in moving forward.
Suggestions to do introspection of the current workforce and to establish a provincial register
of competent midwives show some dedication to improve the image of the midwife.
Ultimately it is important that we need to recognise that caring for the pregnant women and
their babies is a multi-professional, multi dimensional team effort of various role players
including midwives, medical practitioners and health management.
Unfortunately
educational processes, nursing policies and subspecialisation in medicine had an impact on
the quality of services. Roles and responsibilities of various role players are not clearly
defined. Well experienced senior midwife professionals allow poor decisions by junior and
inexperienced medical staff to adversely affect patients.
Discussion platforms as these are important, not only to highlight issues in the discipline but
to also draft a way forward. In the Bloemfontein discussion platform the following 5 were
identified as top priority:
1. Introduce mechanisms to strengthen competencies.
2. Value clarification of the midwifery profession
3. Introduce a provincial register of competent midwives
4. Establish clinical facilitators in all institutions
5. Strengthen preventative programs such as family planning services and sexually
transmitted disease.
Both the training institutions and the department of health should play a defining role in
implementing these actions. However, leadership of midwives in South Africa should combine
forces to drive initiatives such as these as country wide efforts. United they would strengthen
initiatives and in the process reduce the burden on our mothers and children.
223
CONFIDENTIAL ENQUIRIES INTO HYPOXIC ISCHEMIC ENCEPHALOPATHY AS A
MARKER FOR ASSESSING THE QUALITY OF CARE OF WOMEN IN LABOUR
A. De Knijf*,SD Delport, RC Pattinson
MRC Maternal and Infant Health Care Strategies Research Unit, Department of Obstetrics
and Gynaecology, University of Pretoria, Kalafong Hospital, Pretoria, South Africa.
*
- Registrar, Department of Obstetrics and Gynaecology, Leuven Catholic University
Objective: To identify avoidable factors contributing to neonatal morbidity and mortality
due to “birth asphyxia” and to ascertain if hypoxic ischemic encephalopathy (HIE) alone
could act as a good surrogate for avoidable factors associated with “birth asphyxia”.
Setting: Kalafong Hospital, South Africa, a regional hospital unit that caters for mainly
indigent urban population but also receives referrals from the Mpumalanga Province.
Methods: All neonates and intrapartum stillbirths fulfilling the criteria of birth asphyxia born
at the Kalafong Hospital were included. Neonates born at less than 34 weeks gestation, born
with infection, major congenital infection or inborn errors of metabolism and intrapartum
deaths due to abruption placentae were excluded. Neonates referred from Level 1 clinics
postnatally, who qualified with these criteria, were also included in the study. The files were
retrieved, and avoidable factors were identified. Avoidable factors were classified into 3
groups: patient associated, administrative and medical personnel associated problems.
Results: In 2008 and 2009, 10117 babies were born in at Kalafong Hospital. 224 babies
with intrapartum related asphyxia were identified (22.1/1000 births). This group consisted of
14 intrapartum stillbirths, 85 neonates with mild asphyxia,125 babies with severe asphyxia of
which 41 had a neonatal near miss markers without HIE and 84 with HIE. Fifteen of the
babies with HIE subsequently died. The number of avoidable factors identified per case file
reviewed increased with the severity of the hypoxic event, mild asphyxia 0.74, neonatal near
miss without HIE 0.85, HIE survivor 0.91, and stillbirth or neonatal death 1.29. Major
avoidable factors for birth asphyxia were refusal of medical treatment, inadequate facilities,
no detection of or reaction to fetal distress, and incorrect management of second stage. The
avoidable factors detected in neonates with HIE were the same as those detected in the
whole group.
Conclusion: The avoidable factors described in a confidential enquiry concentrating on the
labour management of women delivering neonates with all grades of “birth asphyxia” were
similar to those found in women delivering neonates with HIE. HIE in neonates is a clearly
defined condition, making it a good marker to use to review the quality of intrapartum care
received by the women who delivered them.
224
COMPLIANCE WITH INFANT FORMULA FEEDING OF HIV POSITIVE WOMEN ONE
WEEK FOLLOWING DELIVERY IN KHAYELITSHA, SOUTH AFRICA
Moleen Zunzaa, Gerhard B Theron b, Justin Harvey c
a
Department of Interdisciplinary Science, Stellenbosch University, South Africa,
b
Department of Obstetrics and Gynaecology, Stellenbosch University, South Africa, cCentre
for Statistical Consultation, Stellenbosch University, South Africa
Introduction
Mother-to-child transmission (MTCT) of HIV is responsible for over 300 000 HIV infections
annually in children in Sub–Saharan Africa. Exclusive formula feeding eliminates postnatal
MTCT of HIV, however this feeding practice is not the norm in most African communities.
Earlier observations suggest highest risk of postnatal transmission of HIV through breast milk
to be during the first months of life especially soon after delivery.
Breast engorgement that occurs a few days after delivery is associated with an increase in
breast milk viral load. When mixed feeding occurs a few days following delivery the risk of
HIV transmission is likely high. The study aim was to assess infant feeding practices, one
week following delivery of HIV positive mothers who intended to formula feed their infants.
Methods
A consecutive sample of 95 HIV positive-mother infant pairs was recruited soon after
delivery from 11 May to 25 August 2010, from one Midwife Obstetric Unit in Khayelitsha.
Socio-demographic information and intended infant feeding option were recorded on
recruitment. Mothers received one kilogram of infant commercial formula for the first week
and were to obtain subsequent formula supplies from their local clinics as part of routine
services.
HIV-positive mothers at least 14 years of age, who intended to exclusively formula feed their
infants, were to receive infant formula from the PMTCT programme and had consented to
participate, were eligible to participate in the study.
Infant-feeding practices were defined as:

Breastfeeding: The child had received breast milk direct from the breast with a
sucking episode that lasts two minutes or longer or receiving expressed breast
milk.
225

Exclusive formula feeding meant that the infant was receiving only infant
commercial formula and not breastfeeding at all, however, other fluids and foods
were not restricted.

Exclusive breastfeeding was defined as the infant receiving only breast-milk and
no other liquids including water, with the exception of medicines, vitamin drops or
syrups and mineral supplements.

Mixed feeding was defined as formula feeding while giving breast milk or food
based fluid or solid food at the same time.
Face-to-face interviews were conducted one week following delivery at the clinic to ascertain
infant feeding practices. The study relied on information provided by the mothers to assess
infant feeding practices.
A total sample size of 62 HIV positive mothers-infant pairs was required to estimate the
proportion of mothers who exclusively formula feed one week following delivery. The sample
size was determined to achieve a precision of  5.5% (95% confidence interval).
Statistica version 9.0. (StatSoft Inc, 2009) was used for descriptive analysis. Baseline
characteristics were compared between mother-infant pairs who had responded to the
follow-up interview and non responders using t-tests for continuous variables that were
normally distributed or Mann-Witney U test for skewed variables. Comparisons between
categorical variables were investigated with contingency tables and likelihood ratio chisquared tests.
The study was approved by Human Research Ethics committee of Stellenbosch University.
Results
Two hundred and eighty three mother-infant pairs were examined for eligibility in the study,
95 were confirmed eligible and were enrolled. Figure 1 shows flow of participants in the
study. Main reasons for non-eligibility were: mother’s HIV negative status who were
exclusively breastfeeding their infants (n =184), HIV positive mother who was exclusively
breastfeeding (n = 1). Reasons for declining to participate were: lack of interest about the
study (n = 2), mother stayed too far from the research site to return for the follow-up
interview (n = 1).
226
283 mother-infant pairs were examined
for eligibility
3 declined to
participant
185 were non eligible
95 eligible participants were
enrolled
64 completed study
Figure 1
31 non responders to follow- up
interview
Flow of participants in the study
Table 1 below describes the baseline characteristics of mother-infant pairs enrolled in the
study. All birth outcomes were singletons, with 86 (91%) being normal deliveries and 9 (9%)
were complete birth before arrival at the clinic.
Table 1
Baseline characteristics of HIV positive mother – infant pairs
enrolled in the study
Characteristics
value a
Responders (%)
Non responders (%)
(n = 64)
Mean maternal age. [years (SD)]b
0.79
Mean Birth weight.[grams(SD)]b
0.25
Median CD4 count [Median(n)]c
0.21
Highest Level of education d
Primary
Grade 8-10/Std 6-8
0.42
Grade 11-12/Std 9-10
Tertiary
Parity d
<3
0.19
3
Marital status d
Not married
Married
0.56
Unmarried partners
P –
(n = 31)
27(5.3)
27(5)
3003(507)
3123(392)
333(54)
373(27)
1(1.6)
37(57.8)
2(3.1)
2(6.5)
24(37.5)
16(51.6)
0(0.00)
40(62.5)
24(37.5)
37(57.8)
6( 9.4)
15(48.4)
16(51.6)
18(58.1)
21(32.8)
5(16.1)
227
13(41.9)
8(25.8)
Water supply d
Shared tap
Own tap
0.87
Employment status d
Unemployed
House wife by choice
0.37
Wage earner
Type of fuel used for cooking d
Paraffin
Gas
0.71
Electricity
36(56.3)
49(76.6)
11(17.2)
18(58.1)
28(43.8)
13(41.9)
21(67.7)
4(6.3)
1(3.2)
9(29.0)
10(15.6)
4(12.9)
5( 7.8)
49(76)
23(74.2)
4(12.9)
Statistical significance was set at p < 0.05. Actual p-value is reported as the overall value
for the complete variable.
b
t-test was used for comparisons of mean estimates.
c
Mann- Witney U test was used to compare median estimates.
d
Likelihood ratio chi-squared test was used to compare categorical variables.
a
Sixty-four HIV positive mother-infant pairs completed the study. The response rate was
67%. Median interview day was day 8. Sixty-two mothers (97%) [95% CI: 95% to 99%],
exclusively formula fed their infants. Fifty (78%) [95% CI: 73% to 83%] mothers gave their
infants formula milk only. Two mothers breast fed their babies. Twelve (19%) gave their
babies other fluids or food. Eleven gave water, glucose water or gripe water and 1 gave
cereal or porridge. Breast engorgement occurred in 51 (80%) mothers. Only 5 (8%) mothers
had received advice about what to do when breast engorgement occurs from the facility
health providers.
Discussion
The majority of HIV positive mothers in Cape Town, Metropolitan area exclusively formula
feed their infants. Hilderbrand et al reported similar findings in Khayelitsha, South Africa.
However, sub-optimal feeding practices have been reported in other studies.
The finding that almost none of the mothers had received advice regarding what to do when
breast engorgement occurs is important. This has important clinical implications especially in
communities where exclusive formula feeding is not the norm.
The study has some limitations. The response rate was 67%, this may have weakened
validity of estimates and conclusions drawn from this study. Given that baseline
228
characteristics were comparable between responders and non responders, we may conclude
that the non responders most likely resemble the responders in their feeding practices.
However, the 33% loss to follow-up is a concern, that this may have biased estimates and
conclusions drawn from the study.
Conclusion
We are confident that compliance with formula feeding of HIV positive mothers one week
following delivery is at an acceptable level. Levels of breast engorgement and lack of
counselling on breast engorgement were high. Mothers must be informed about; the
dangers of mixed feeding when breast engorgement occurs and on non-pharmacological
methods of managing breast engorgement.
229
USE OF A COMPUTERISED MODEL TO ALLOCATE BEDS AND STAFF RESOURCES TO
MATERNAL AND NEWBORN SERVICES
Marthinus G Schoon
Community obstetrician. Department of Obstetrics & Gynaecology, Free State University,
Bloemfontein
Head of clinical department (medical)-Maternal and Child health unit, Free State Department
of Health.
Introduction
There are no acceptable or agreed on beds and staff norms for maternal and neonatal
services. Provincial service transformation plans do not specifically address maternal bed and
staff needs although some provinces have made some attempt to determine some neonatal
norms. These transformation plans have not been accepted and was drafted prior to a
reengineering approach have been suggested for primary health care and is generally a
hospicentric approach.
The National committee for confidential enquiries into maternal deaths (NCCEMD) have
recommended for years that staff norms be developed without any visible results. As the
millennium development goals end date draw closer, the South African Government have
identified failure of the existing health system to achieve these goals. Maternal and child
health have been prioritised as a national health priority and recently was included in one of
the 4 cabinet approved health outcome priorities for the country. Lack of beds and staffing
norms does not assist focus the national priority down to grass root level.
In an attempt to develop norms, a formula driven calculation based on activity standards
have been developed based on the number of deliveries within institutions. As the beds are
calculated on activity, the staff levels would link to the beds. This could be used to determine
the beds and staffing needs at institutional levels.
Methodology
Formulas were developed based on logic assumptions of bed needs and staffing linked to
assumed acuity within the defined wards.
The formulas were included in a Microsoft Excell spread sheet in such a fashion that it
included variables from a standards spreadsheet so the calculations could be changed
without changing the formulas within the spread sheet. All the calculations are based on the
number of deliveries within an institution as this is an easy measurable variable captured on
the district health information system. The assumptions were circulated to different role
players and then compared to existing facilities and staffing in a sample of institutions within
the province.
230
The calculations was the applied to 6 selected caesarean facilities in the province to compare
the bed requirement and staffing needs calculated with the current situation. The actual
beds and staff utilization was then compared for the selected institutions with the bed and
staff allocations computed with the model
BEDS NEEDS AND NORMS
Both maternal and neonatal bed numbers have been calculated based on the number of
deliveries within the institution. Each area have been subdivided into different sub-category
beds as there are potentially different needs with respect to workload or acuity requiring
different staffing compositions.
The variables in the standards table refer to standards describing either facility utilisation or
workload:
The level of care value was used to make provisioning for increased acuity and/or length of
hospitalisation at the higher end facilities.
Generic formula:
Bed requirements = [Deliveries
PA]*[Delivery Admission rate]* [Length of stay]
/365/BUR]&[level of care variable]
The level of care variable was individualised for specialised areas to make
provisioning for the specific subsection needs:
ANTANATAL WARD
POSTNATAL
MATERNAL HIGH CARE
BABYROOM
NHCU
NICU
KMC
Maternity OT (max cases)
Maternity admissions
Delivery rooms
=
=
=
=
=
=
=
=
=
=
Deliveries PA
Deliveries PA
Deliveries PA
Deliveries PA
Deliveries PA
Deliveries PA
Deliveries PA
Deliveries PA
Deliveries PA
Deliveries PA
*
*
*
*
*
*
*
*
*
/
Admission per delivery ratio
Admission per delivery ratio
Admission per delivery ratio
Admission per delivery ratio
Admission per delivery ratio
Admission per delivery ratio
Admission per delivery ratio
Admission per delivery ratio
(Admission per delivery ratio
365
*
*
*
*
*
*
*
*
+
*
(LOS
(LOS
(LOS
LOS
LOS
LOS
LOS
(LOS
*
+
+
*
*
*
LOS
/
+
LCV)/365/BUR
LCV) /365/BUR
LCV) /365/BUR
(1+LCV/4) /365/BUR
(LCV*LCV)/2/365/BUR
LCV*(LCV-1) /365/BUR
/365/BUR
LCV) /365/BUR
LCV) /365/BUR
24/BUR
LCV = level of care value where 0= delivery site, 1= caesarean section site and 2= specialist centre
Acuity: Acuity refer to the professional time required per bed (patient) during a 24 hour
period. An acuity of 4 therefore reflects an average of 4 hours activity per patient. (e.g. if a
patient requires 4 hourly observations taking 15 min nursing time per set of observations –
observations would account for 1.5 hours acuity per 24 hours. Moring and evening take-over
rounds would add another 30 minutes. If food was dished by nursing staff 3 time per day
231
TABLE OF STANDARDS
ANTANATAL WARD
POSTNATAL
MATERNAL HIGH CARE
BABYROOM
NHCU
NICU
KMC
Labour ward NVD
Labour ward CS
Maternity OT
Maternity admissions
Inter-facility referral rate**
Acuity
6
4
12
4
12
20
1
8
6
2
8
14%
Daily ambulance trips
6
Staff normal work week
Standard overtime
commuted overtime
Absence factor
40
0
16
service
days per
week
Service hours
per day (8/24)
admissions
per delivery
LOS (day)
BUR
BUR inv
7
7
7
7
7
7
7
7
7
7
7
24
24
24
24
24
24
24
24
24
24
24
0.7
1.04
0.1
0.7
0.3
0.04
0.08
0.8
0.2
0.22
1.4
2
1.5
3.8
1
6
10
8
8*
8
0.2
2*
0.8
0.7
0.7
0.8
0.7
0.7
0.7
0.7
0.7
0.65
0.8
1.25
1.43
1.43
1.25
1.43
1.43
1.43
1.43
1.43
1.54
** referrals between L1 and
L2 facility
Dr
Acuity
0.2
0.20
0.40
0.05
0.30
1.00
0.00
1.00
1.00
8.00
0.3
Proportion
of patients
seen by
doctor
1
1.00
1.00
0.10
1.00
1.00
0.05
1.00
1.00
1.00
1
* refer to value as hours
(number of trips an ambulance can manage per day - this will depend on distance)
% (deliveries at that level)
25%
CS rate GP level
45%
CS rate specialist level
1.3
could add another 15 minutes to the acuity. Dispensing medicines 4 hourly could add
another1.5 hours to the acuity. This would include all categories of staff and the staff
numbers required to provide this work, will then have to be sub-divided into the required
skills-mix. Doctors acuity also reflect the hours doctors input required and the proportion of
cases seen by a doctor would reflect situations where only selected cases are managed by a
medical practitioner.
Calculations were made for the bed numbers outlined in the above formulae.
The staff were calculated according the following formula based on acuity and normal
workweek.
Staff required for workload = (([Number of beds]*[acuity]*[service days per
week]* [service hours per day]/24)/[weekly work hours])*[Absence factor]
A factor of 30% was calculated for staff absence from the workplace. This includes vacation
leave, sick leave and training. The calculations were made at higher than normal due to the
large female population to make provision for maternity leave.
For medical personnel the staff required per workload is multiplied by the level of care value
to make provisioning for greater staff requirements at the higher level and to zero the
medical staff at the CHC level.
Results
Beds were calculated for all the various sub sections of the services and was totalled to come
with a total bed requirement of maternal and neonatal services. Staff were calculated for the
various subsections and were totalled for maternal and neonatal services. The actual number
of staff were calculated according the work load. Due to the fact that maternal services is a
designated 24-hour service, the minimum number of staff were assigned where the actual
232
required staff were less than the minimum requirement. To provide a professional nurse,
staff nurse and assistant nurse per shift, the minimum required number of nurses working a
40 hour work week is 16.2 and the minimum number of medical practitioners is 5.5. In the
final totals the fractions were rounded up to the next integer.
The beds and staff requirements are tabled in the following table for the various levels of
care.
The calculated needs were used on a sample of institutions within the Free State province
based on the current DHIS delivery data (2010) and the PERSAL report of December 2010.
As the staff was not stratified for maternity services, the staff required as calculated as a
proportion of the total staff in the institution.
Institution
level
of
care
Hospital
Total
numbers
of beds
Beds
utilised
Hospital
Patients
admitted
2009
Maternity
section
Patients
admitted
2009
Maternity
admissions
as % of
hospital
admissions
Maternity
section
Total
deliveries
Deliveries
as %
hospital
admissions
Maternity
section
Caesarean
deliveries
CS
Rate
PB
1
85
60.3
6445
2813
43.6%
3385
52.5%
1272
37.6%
TO
1
126
44.5
6191
3312
53.5%
2540
41.0%
511
20.1%
BB
1
135
88.5
7482
2376
31.8%
1366
18.3%
450
32.9%
DB
2
135
86.9
7295
1121
15.4%
900
12.3%
601
66.8%
BK
2
340
235.4
13990
2682
19.2%
2303
16.5%
774
33.6%
BW
2
450
297.4
16120
3325
20.6%
3437
21.3%
1425
41.5%
Maternity
section
Number of
beds in use
Propotion
of hospital
bed for
maternal
services
Maternal
beds
Calculated
on current
activity
PB
20
23.5%
TO
30
23.8%
BB
41
30.4%
DB
19
14.1%
BK
35
10.3%
Institution
BW
68
15.1%
Actual and calculated nursing staff
Institution
PN
Total staff
Deviation
Baby beds
in use
baby Beds
as % total
hospital
beds
baby beds
Calculated
current
activity
41
29
21
9
10.6%
0
0.0%
27
20
18
-1
17
22
-24
15
11.1%
12
8.9%
12
20
-3
3
45
66
10
17
5.0%
20
-2
16
3.6%
37
52
Assigned
staff
(Maternal &
neonatal)
Calculated
staff
Assigned
as % of
total
Calculated
as % total
PB
41
76
UK
74
?
97.4%
TO
31
68
UK
68
?
100.0%
BB
62
128
30
57
23.4%
44.5%
DB
91
184
15
36
8.2%
19.6%
BK
131
266
42
143
15.8%
53.8%
BW
212
416
74
194
17.8%
46.6%
233
Deviation
20
8
36
Completed questionnaires were received from 6 of the 9 facilities in the province designated
for cesarean section service and were subjected to the computer modeling. Three facilities
were classified as level 1 and 3 facilities as level 2 service. The total bed for level 1
institutions varied between 85 and 135 beds while the level 2 institutions varied between 135
and 450. Level1 hospitals had 23-30% of hospital beds allocated to maternity service and 011% to newborn babies. Level 2 institutions had 10-15 % beds and 3.6-9% beds allocated
to maternal and neonatal services respectively. Variation of actual beds against calculated
bed needs varied between a 50% under supply and 140% over supply of maternal beds and
60% under and 25% over supply of newborn beds. In 2 facilities the calculated beds were
within 3% of the actual beds in use for maternal services. None of the newborn beds were
within 40 % of the actual beds. There were huge variations between the institutions with
respect to nursing staff and the proportion of maternal staff to the total staff establishment.
Discussion
Evaluating the existing service delivery against a computerised staff model allowed to
identify inconsistencies between institutions in allocating resources to maternal care.
Emphasis on new born babies was less profound than expected. This could be because of
variables in the model over-estimating needs, but beds varied between adequate and more
than double the numbers under allocated indicating a probable neglect for neonatal services.
There are also huge inconsistencies in allocation of staff to maternity and neonatal services.
The maternal nursing staff varied between 8 and 24% of the total hospital staff and the
calculated staff numbers vary between 20% and100 % of the total hospital nurses. This
clearly demonstrates the inconsistencies of resource allocations and highlight the existing
staff shortage at institutions.
Conclusions
An activity based formula driven model can be used for calculating the resource
requirements of any institution. Use of a formula driven model could be easily adapted to
computer programs such as Excel and could be used by authorities to calculate their beds
and staff needs.
Such a model could also assist clinical managers to ensure that ministerial priority is affected
at institutional level
This model could be refined to serve as a provincial or national
standard or norm to allocate beds resources as well as staff at institutional level.
234