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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 Articles have not been included for presentations, which were withdrawn and not presented at Priorities.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. ii 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: 102 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. 103 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. 105 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