Download maternal deaths in rural south africa

The 26th 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Articles have not been included for presentations, which were withdrawn and not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.
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INDEX
MATERNAL DEATHS IN RURAL SOUTH AFRICA: UNDERSTANDING THE ROLE OF
COMMUNITY FACTORS. R Weiner
1
CAUSES OF MATERNAL MORTALITY AND SEVERE ACUTE MATERNAL MORBIDITY
(SAMM) IN MAFIKENG HOSPITAL IN SOUTH AFRICA.
P Lomalisa
6
AMBULANCE RESPONSE TIMES IN THE PMNS: ARE WE GETTING THERE?
J Marcus
10
OVERVIEW: SAVING MOTHERS REPORT (2002-2004) (Abstract).
RC Pattinson
13
KEY RECOMMENDATIONS: SAVING MOTHERS REPORT 2002-2004 (Abstract).
M Masasa
14
CHARACTERISTICS OF MATERNAL DEATHS AT ESHOWE HOSPITAL IN 2007
(Abstract). L Che
15
EXPANDING CONTRACEPTIVE HEALTH OPTIONS: THE ECHO STUDY.
JUSTIFICATION AND PROTOCOL (Abstract). M Singata
16
LEVEL OF FETAL HEAD ABOVE BRIM: INTRAPARTUM ESTIMATION USING
PALPATION AND FINGERBREADTHS. E J Buchmann
17
CLINICAL SKILLS TRAINING USING OBSTETRIC MODELS – IS IT WORTH THE
TIME AND EFFORT? E Farrell
20
PREDICTORS OF UTILISATION OF MATERNAL HEALTH SERVICES IN PAARL,
RIETVLEI AND UMLAZI SITES IN SOUTH AFRICA. L Matizirofa
24
EFFECTIVENESS OF THE IMPLEMENTATION OF THE BASIC ANTENATAL CARE
(BANC) PACKAGE IN THE NELSON MANDELA BAY METRO (PORT ELIZABETH).
JS Snyman
28
IMPLEMENTING A BASIC ANTENATAL CARE QUALITY IMPROVEMENT
PROGRAMME USING A TRAINING OF TRAINERS METHODOLOGY IN PRIMARY
HEALTH CARE CLINICS IN SOUTH-WEST TSHWANE (Abstract). E Etsane
39
SIX SUPPLEMENTARY PEP MANUALS (Abstract). DL Woods
40
EVALUATION OF THE RELIABILITY OF THE QUALITY CHECK FORM TO AUDIT
ANTENATAL CARDS (Abstract). JML Malesela
41
COMPARISON OF A PRIVATE MIDWIFE OBSTETRIC UNIT AND A PRIVATE
CONSULTANT OBSTETRIC UNIT. BA Seedat
42
FETAL MOVEMENT COUNTING FOR ASSESSMENT OF FETAL WELLBEING: A
COCHRANE SYSTEMATIC REVIEW (Abstract). L Mangesi
46
iii
HYPERTENSIVE DISORDERS OF PREGNANCY: SAVING MOTHERS REPORT 20022004. J Moodley
47
COMPLICATIONS IN PRE-ECLAMPTIC PATIENTS ADMITTED TO THE OBSTETRIC
UNIT UNIVERSITAS HOSPITAL. JBF Cilliers
53
PERINATAL DEATHS IN HYPERTENSIVE DISEASE IN PREGNANCY - FOUR YEARS
OF EXPERIENCE WITH PERINATAL PROBLEM IDENTIFICATION PROGRAMME AT
TYGERBERG HOSPITAL. DW Steyn
58
DRINKING PATTERNS AMONG THE CAPE COLOURED: RESULTS FROM THE SAFE
PASSAGE STUDY. HJ Odendaal
62
COMMUNITY OBSTETRICS ULTRASOUND SERVICE: EFFECT OF CHANGING FROM
DATING AND DETAIL SCANS TO DETAIL SCANS ONLY. EJ Poggenpoel
67
POST PARTUM HAEMORRHAGE: THE INTRACTABLE PROBLEM.
HA Lombaard
71
SAVING MOTHERS 2002-2004: DEATHS FROM OBSTETRIC HAEMORRHAGE.
S Fawcus
76
DELIVERY AFTER A PREVIOUS CAESAREAN SECTION AT THE CHRIS HANI
BARAGWANATH HOSPITAL. MS Sayed
81
WHO SYSTEMATIC REVIEW OF THE PREVALENCE OF UTERINE RUPTURE
WORLDWIDE, AND DEATHS FROM UTERINE RUPTURE IN SOUTH AFRICA.
GJ Hofmeyr
89
HANDS AND KNEES POSTURE IN LATE PREGNANCY OR LABOUR FOR FETAL
MALPOSITION (LATERAL OR POSTERIOR POSITION) (Abstract). S Hunter
93
MIDWIFERY MODELS? WHAT KIND OF MIDWIFE DOES SOUTH AFRICA NEED?
(Abstract) JM Dippenaar
95
MIDWIFERY IN THE DUAL SOUTH AFRICAN HEALTHCARE SYSTEM (Abstract).
JM Dippenaar
96
NON-PREGNANCY RELATED INFECTIONS: SAVING MOTHERS REPORT 2002-2004
(Abstract). RE Mhlanga
97
HAS THE PROVISION OF ANTIRETROVIRALS AT PRIMARY HEALTH CARE LEVEL
INFLUENCED THE MATERNAL MORTALITY RATE IN A RURAL SUBDISTRICT IN
NORTHERN KWAZULU NATAL? JL Nash
98
ESTABLISHING AN ANTIRETROVIRAL CLINIC WITHIN AN ANTENATAL CLINIC
(Abstract). V Black
104
APPROPRIATENESS OF PRENATAL INFANT FEEDING CHOICES BY HIV POSITIVE
WOMEN: IMPLICATIONS FOR INFANT OUTCOMES. D Jackson
105
iv
GROWTH OF INFANTS BORN FROM HIV POSITIVE MOTHERS FED WITH
ACIDIFIED STARTER FORMULA CONTAINING BIFIDOBACTERIUM LACTIS.
PA Cooper
110
ARE WE SAVING BABIES? A CHILD PIP REVIEW OF UNDER-1 DEATHS.
CR Stephen
113
PMTCT INTEGRATION IN SOUTH AFRICA. D Jackson
121
DEVELOPING A PRACTICAL CLINICAL DEFINITION OF SEVERE ACUTE NEONATAL
MORBIDITY TO EVALUATE OBSTETRIC CARE: A PILOT STUDY (Abstract).
MTP Mukwevho
125
ANALYSIS OF THE PATTERN OF MORBIDITY IN A LIMPOPO DISTRICT HOSPITAL
OVER A 3 MONTH PERIOD (SEPTEMBER – NOVEMBER 2006). E Reji
126
PERINATAL MORTALITY IN THE WESTERN CAPE PROVINCE: CHALLENGES AND
ACTION. DH Greenfield
130
STILLBIRTHS AMONG THE CAPE COLOURED: THE SAFE PASSAGE STUDY.
HJ Odendaal
134
PERINATAL CARE SURVEY OF SOUTH AFRICA: 2003-2006 – OVERVIEW.
RC Pattinson
138
PERINATAL STATISTICS FROM THE DISTRICT HEALTH INFORMATION SYSTEM,
2003-2005. L Bamford
152
PERINATAL AND NEONATAL MORTALITY IN MTHATHA IN THE PERIOD 20032005. COMPARATIVE STUDY (Abstract). RF Fernandez
155
IS BABY-FRIENDLY, FRIENDLY TO THE BABY? HM Kunneke
156
IMPLEMENTATION OF DEVELOPMENTAL CARE FOR HIGH-RISK NEONATES: AN
INTERVENTION STUDY. A Hennessy
160
ACCREDITATION PROCESS. AF Malan
165
OUTCOME OF HOSPITAL ACCREDITATION FOR NEWBORN CARE IN LIMPOPO
PROVINCE. PL Mashao
167
MINCC (MPUMALANGA INITIATIVE FOR NEONATAL AND CHILD CARE):
STANDARDISATION OF MORTALITY DATA. E Malek
170
ANTIBIOTIC AND MICROBIOLOGICAL AUDIT – KING EDWARD HOSPITAL
NURSERY - JANUARY – SEPTEMBER 2006 (Abstract). S Singh
174
HOW DID THE ESTABLISHMENT OF A NICU IMPACT ON A FAMILY-CENTRED
PRIVATE MATERNITY UNIT? DV Bowling
175
v
THE PREVALENCE OF GROUP B STREPTOCOCCUS IN THE PREGNANT WOMEN OF
BLOEMFONTEIN (Abstract). M du Toit
181
ARE BACTERIAL INFECTIONS RESPONSIBLE FOR UNEXPLAINED STILLBIRTHS?
(Abstract) NC Mashabane
182
PREVALENCE AND RISKS OF ASYMPTOMATIC BACTERIURIA AMONG HIV
POSITIVE PREGNANT WOMEN. GB Theron
183
THE EFFECT OF MATERNAL HIV INFECTION ON PERINATAL DEATHS IN
SOUTHWEST TSHWANE. L Van Hoorick
186
A LONGTERM REVIEW OF PERINATAL AND NEONATAL INDICES AT MADADENI:
1990 TO 2006 (Abstract). FS Bondi
190
OUTCOME OF PREGNANCY IN HIV INFECTED WOMEN (Abstract). BC Alberts
191
PREVENTING SERIOUS NEONATAL AND MATERNAL PERIPARTUM INFECTIONS IN
DEVELOPING COUNTRY SETTINGS WITH A HIGH PREVALENCE OF HIV
INFECTION: ASSESSMENT OF THE DISEASE BURDEN AND EVALUATION OF AN
AFFORDABLE INTERVENTION IN SOWETO, SOUTH AFRICA. CL Cutland
192
THE SUCCESS OF CPAP AND CUROSURF IN A LEVEL II HOSPITAL. HM Kunneke
198
KMC AND NCPAP: OUTCOME AT 12 MONTHS OF INFANTS <1250G TREATED IN A
STATE HOSPITAL. JI van Zyl
203
THE OUTCOME OF VERY LOW BIRTH WEIGHT INFANTS BORN TO HIV POSITIVE
WOMEN AT TYGERBERG HOSPITAL. GF Kirsten
207
THE BURDEN OF MAJOR CONGENITAL ABNORMALITIES IN NEWBORN INFANTS
MANAGED IN KALAFONG HOSPITAL (Abstract). GJM Wolmarans
210
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MATERNAL DEATHS IN RURAL SOUTH AFRICA: UNDERSTANDING THE
ROLE OF COMMUNITY FACTORS
Weiner R, Penn-Kekana L, Kahn K, Gómez-Olivé FX, Tollman SM
School of Public Health, MRC/Wits Rural Public Health and Health Transitions
Research Unit (Agincourt) and Centre for Health Policy, University of the
Witwatersrand
Introduction
In South Africa, maternal deaths that occur outside of the health system may go
undetected since the Confidential Enquiries into Maternal Deaths data are collected
from forms submitted by the health facility.
Moreover, community and patient
oriented factors that contribute to maternal deaths may not be fully captured. Using
household level data from Demographic Surveillance Sites (DSS), which collect data
on all births and deaths in a geographically well defined population, maternal deaths
and contributing factors occurring in the community can be assessed. The aim of
the study was to explore factors outside of the health system that may have
contributed to delays in health seeking behaviour and barriers to health care access.
Methods
The study area was the Agincourt sub-district, which is situated in the rural northeast of South Africa. This was a descriptive, exploratory study nested within the
Agincourt DSS which conducts annual censuses to update demographic information
in the area. A verbal autopsy is then conducted on every death to ascertain the likely
cause of death. Where a maternal death occurred between the years 2000 to 2005,
the verbal autopsy was reviewed and followed by a semi-structured interview
conducted with a family member of deceased. Deaths occurring outside of the study
area and deaths that were not related to community factors, e.g. anaesthetic deaths,
were excluded from the interviews. Interviews focused on ability to access transport,
financial barriers and decision-making. Data were analysed using both quantitative
and qualitative methods.
1
Results
1. Socio-demographic profile
The mean age of deceased women was 28 years (range 17-42 years). A large
proportion of the deceased (11/26) were descendants of former Mozambican
refugees.
Nearly a quarter of deaths occurred at home (six of 26 deaths).
2. Burden and causes of maternal mortality
There were twenty-six maternal deaths, 9816 live births giving a maternal mortality
ratio of 265 per 100000. The maternal mortality ratio did not show a clear trend
over the time period and there was no evidence of a reduction in mortality. See table
below:
Table 1
Year
2000
2001
2002
2003
2004
2005
Maternal mortality ratio: 2000-2005
MMR (deaths/100 000 live
births)
344
60
262
387
130
389
The ratio for 2001 is likely to be an underestimate due to underreporting of maternal
deaths. The verbal autopsy technique has previously been found to be a poor source
of cause of death data for maternal deaths.
The table below provides probable
cause of death as assessed by the verbal autopsy review and highlights the large
proportion of deaths where the cause was not known.
Where the cause was
determined, a large proportion were due to indirect causes, particularly HIV/AIDS.
Table 2
Causes of maternal deaths: 2000-2005
Cause
Direct
Number
7
%
26.9
Indirect
11
42.3
Other/unknown
8
30.7
PPH:1; puerperal sepsis 1;
Unspecified: 5
HIV/AIDS:5
Other ID:3
Cancer:1
Heart disease:2
2
Work by Kahn (2006) that measured trends in maternal deaths in the Agincourt subdistrict from 1993, showed a non-significant increase in maternal mortality over the
decade, with the increase largely to HIV/AIDS related deaths.
3. Community-based based barriers to health service access
Key themes that emerged from the interviews were:
i) Different patterns of health service access for direct versus indirect causes of
deaths
ii) Transport and related funding difficulties
iii) Several family members involved in decision-making to seek care
iv) Use of non-medical healers when illness believed not to be related to
pregnancy
v) Weak integration of maternity care and HIV/AIDS services
Transport
Problems that emerged were a lack of access to transport and substantial distances
to walk to reach transport leading to 2nd/3rd delays. For example, one respondent
said:
`The day in which it became critical it did not give us a chance because my husband
came back late in the afternoon and we tried to look for transport only to find that
we couldn’t get any so that we took her to the clinic, only to find that we couldn’t get
transport from the clinic, and by then her condition was critical. We tried to look for a
car only to find that there was no longer time”
There appeared to be a range of transport problems at different times during the
pregnancy. The woman described below was diagnosed with TB during pregnancy,
admitted to hospital during pregnancy, also taken to traditional healer and private
doctor. She had a premature delivery at 6 months at a health facility and was
discharged 2 days post delivery. She was re-admitted two weeks later and died after
three days in hospital.
3
She started ANC at one clinic – then couldn’t afford transport so tried local clinic, but
was told to go back to original clinic. She stopped ANC at one time because “she was
very ill and couldn’t walk” The car owner was not always at home – money for
transport sometimes a problem – sometimes had to delay to next day before going
to get care.
“Yes we could go there and talk to the owner that we don’t have
money, condition is bad, and finds that they refuse saying they don’t have petrol. In
that way we end up sleeping and not going. Or we will try to borrow from relatives
and when they give us it is then they will transport us”
Decision making
The need to involve several family members in decision-making to seek care may
have led to delays (first delay) in several cases as demonstrated by quotes from
separate respondents:
“we were still thinking that my sister could come so that we could decide together on
what to do, or maybe we could take her to the hospital, only to find that when my
sister arrives, by then she was critical to such an extent that she was unable to talk”
“it was I together with her parents because one cannot take someone’s child to a
doctor without her parents consent”
Use of non-medical healers
Use of non-medical healers appeared to be more common when illness was believed
not to be related to pregnancy and this may have led to a delay.
“After being supplemented with drips her parents came and took her along back
home. They told the hospital staff that her illness needed to be treated in a
traditional way as they thought it was not any other illness but it was Tindzhaka”.
Discussion
Health and demographic sites offer an additional source of data on maternal deaths
that complements national facility-based data by offering a population-based
perspective.
These sites can generate information that both measures maternal
deaths and that contributes to a better understanding of community factors that may
have contributed to the deaths. Maternal mortality has not decreased in Agincourt
4
population during the period 2000-2005 and a large proportion of deaths are from
indirect causes, specifically HIV/AIDS.
Nonetheless, direct causes still remain
important.
Strategies to address maternal mortality need to be broadened to include
community-based experiences.
To overcome delays in reaching services in rural
areas, interventions that consider reliable transport and related finance need to be
developed.
Safe pregnancy messages and/or birth preparedness plans that target families and
communities may assist in swift decision making when problems arise.
Here
women’s groups may have an important role. The often quoted `four delays’ model
may not always be applicable for indirect deaths
Information/data needs
The ongoing surveillance of community factors to inform and monitor interventions
needs to be considered in conjunction with efforts to monitor and decrease maternal
deaths at provincial and national levels.
Interventions
Partnerships involving local communities and health services are essential to develop
and implement effective interventions. Transport and related funding require context
appropriate decisions about if these would be best managed by the health services,
community and/or contracted/private sector.
Pregnancy planning including birth
preparedness plans at ANC that consider where the woman will deliver, what
transport she will use including in emergencies, warrants consideration. It appears
that increased integration of HIV/AIDS and maternity care will promote the
management of AIDS in pregnancy.
5
CAUSES OF MATERNAL MORTALITY AND SEVERE ACUTE MATERNAL
MORBIDITY (SAMM) IN MAFIKENG HOSPITAL IN SOUTH AFRICA
Patrick Lomalisa (Mafikeng Regional Hospital)
Debra Jackson (School of Public Health, University of the Western Cape)
Introduction
Despite all measures taken by the South African government since 1994 to address
inequalities inherited from the apartheid regime, there is a continuous increase of
maternal mortality ratio (MMR) in the country and the Northwest province is amongst
the highest. In addition, with the high prevalence of HIV/AIDS infection, nonpregnancy related infections have become the commonest cause of maternal deaths
in South Africa.
The combination of the review of maternal deaths and severe acute maternal
morbidity (SAMM) cases allows the identification of trends in quality of maternal care
and the changes of causes of diseases in earlier stage. Most studies to date in South
Africa combining the two audits have been conducted primarily in urban areas and
academics hospitals.
The objective of this study is to identify the primary obstetric causes, avoidable
factors and missed opportunities of maternal mortality and SAMM in a rural regional
hospital in South Africa
Methods
Mafikeng regional hospital is the referral institution for the central district of the
Northwest province in South Africa. The district has an estimated population of
800,000 inhabitants with 7 district hospitals, 14 community health centers, 70 clinics
and 21 mobile clinics(6). This was a retrospective analysis of all maternal deaths and
obstetric patients admitted to the intensive care unit (ICU) in the Mafikeng regional
hospital between 01/01/2005 and 30/04/2006. All patients during pregnancy or
within 42 days of its termination irrespective of HIV status and obstetric cause who
required continuous intensive monitoring or mechanical ventilation and survived in
ICU were included as cases of SAMM. Statistical analysis was performed by Statistical
Package for Social Sciences (SPSS) programme using Chi-square and Fisher exact
6
tests for categorical data whilst student t and signal tests for continuous data. A pvalue (two-tailed test) of <0.05 was considered significant.
Results and discussion
There were 4293 births, 16 maternal deaths and 141 obstetric admissions (3.2%
total deliveries) to the ICU during the review period. 8 of the 16 maternal deaths
reported in this study died in ICU.
There was no statistical difference regarding the demographic profile between the
maternal deaths and SAMM cases (table 1).The mean age for the maternal deaths
was 26.4+7.4 years with a range of 15 to 37 years. 93.7% and 12.5% respectively
attended antenatal care and were HIV positive in the death group.
There were predominance of direct obstetric causes among the maternal deaths of
which 31.3% and 18.8% were respectively due to complications of hypertension and
pregnancy related sepsis. Indirect causes were less common and only 18.8% were
due to non-pregnancy related infections. Cases due to complications of hypertension,
early pregnancy losses (abortion, ectopic pregnancy), pre-existing maternal diseases
and anesthetic complications revealed a low mortality index whilst sepsis cases both
related and non-related with pregnancy and obstetric hemorrhage showed high
mortality indices (table 2).
Avoidable factors were found in 93.7% of maternal deaths of which 25% were
patients related, 50% due to administrative factor and 75% related to health care
providers (table 3).Although no statistical difference was reported between the 2
groups regarding the patients related factors and the delay due to transport
problems, we observed more avoidable factors among the deaths regarding the
health care providers factors and the administrative related factors (p=0.008 and
p<0.001 respectively)
There is no unanimity in criteria used to identify SAMM case. We used admission to
ICU as proxy for severity because most of complicated obstetric cases were admitted
7
in ICU due to lack of high dependency unit in the maternity ward and because of
retrospective study it was easy to identify cases. We observed that direct obstetric
causes (complications of hypertension, obstetric hemorrhage and pregnancy related
sepsis) were the most common causes of life-threatening illnesses in the reviewed
period. These findings were similar to studies in other developing countries and in
South Africa before the epidemic of HIV/AIDS infection.
Although, non-pregnancy related infections were the common causes of maternal
deaths in South Africa in the last 2 reports by the confidential enquiry into maternal
deaths, it did not contribute as the common cause in this research. There was no
difference of HIV status between the two groups in this audit and further research is
needed to observe the changes of diseases patterns observed since the
implementation of the anti-retroviral treatment service in public sector hospitals in
South Africa.
There is persistence of shortage of skilled attendants in public sector hospitals in the
country and as reported in many developing countries, the shortage of skilled
attendant is more pronounced in rural area.
Conclusion
Complications of hypertension in pregnancy and obstetric hemorrhage were the
commonest causes of maternal mortality and morbidity. The lack of skilled attendant
was the most avoidable factor reported resulting in high proportion of substandard
management.
Table 1
Comparison of demographic profile between maternal deaths
and SAMM cases
Age(years)
Mean+SD
Range
Parity
Median
Range
Attended
antenatal care
HIV Positive
Deaths(n=16)
SAMM(n=133)
p-value
26.4+7.4
15-37
26.5+7.4
15-44
NS
1.0
0-8
15(93.7)
0.0
0-7
110(82.7)
NS
2(12.5)
3(2.3)
NS
8
NS
Table 2
Comparison of primary obstetric causes between maternal
deaths and SAMM cases
Cause
Deaths(n=16)
SAMM(n=133)
p-value
Hypertension
Obstetric
hemorrhage
Pregnancy
related sepsis
Early pregnancy
losses
Anesthesia
complications
Non-pregnancy
infections
Pre-existing
maternal
disease
5(31.3)
5(31.3)
93(69.6)
21(15.8)
0.003
NS
Mortality
index (%)
5.2
19.2
3(18.8)
4(3.0)
0.002
42.8
0(0.0)
8(5.8)
NS
0.0
0(0.0)
2(1.5)
NS
0.0
3(18.8)
2(1.5)
0.009
60
0(0.0)
2(1.5)
NS
0.0
Table 3
Comparison of avoidable factors between maternal deaths and
SAMM cases
Avoidable factor
Avoidable
factor
present
Patient related
Abortion
Deaths(n=16)
15(93.7)
SAMM(n=133)
70(52.6)
p-value
0.001
4(25.0)
0(0.0)
30(22.5)
1(0.8)
NS
Delay help
3(18.8)
10(7.5)
Administrative
related
Delay
transport
Lack
trained
staff
Health
care
related
Substandard
management
in
regional hospital
8(50.0)
13(9.8)
1(6.3)
7(5.3)
7(43.7)
4(3.0)
12(75.0)
50(37.6)
8(50.0)
50(37.6)
9
<0.001
0.008
AMBULANCE RESPONSE TIMES IN THE PMNS: ARE WE GETTING THERE?
Jason Marcus, Sheila Clow
Division of Nursing and Midwifery
Faculty of Health Sciences
University of Cape Town
Introduction
Response times of ambulances to calls from Midwife Obstetric Units (MOUs) in the
Cape Peninsula, although varied, are perceived by midwives in peripheral units as
slow. The PMNS is a well functioning service based on established referral protocols
and routes as well as secondary and tertiary level support. Delays in transporting
women experiencing complications during or after their pregnancies to higher levels
of care may have negative consequences such as fetal, neonatal or maternal
morbidity or death.
Method
An exploratory descriptive study was undertaken to investigate the response times of
ambulances of the Western Cape Emergency Medical Services (EMS) to calls from 5
MOUs in the Peninsula Maternal and Neonatal Service (PMNS) in Cape Town.
Response times were calculated from data collected in specific MOUs using a
specifically developed instrument. Recorded data included time of call placed
requesting transfer, diagnosis or reason for transfer, priority of call and the time of
arrival of ambulance to the requesting facility. Mean, median and range of response
times, in minutes, to various MOUs and priorities of calls were calculated. These were
then compared using the Kruskal-Wallis test to detect any statistically significant
differences. A comparison was then made between the recorded and analysed
response times to national norms and recommendations for ambulance response
times and maternal transfer response times respectively.
Results
A wide range of response times was noted across the whole sample see Table 1.
Median response times across all priorities of calls and to all MOUs in the sample fell
short of EMS national norms and the 2002 recommendations made by the NCCEMD.
10
No statistical differences were noted in the response times between various priorities
of calls and MOUs.
Table 1
Response times for entire sample in minutes
n=48
106.67
82.5
77.28
10;330
Mean
Median
SD
Range (min;max)
There was no statistically significant difference in the response times to the various
MOUs, indicating that none is more advantaged or disadvantaged than the others as
indicated in Table 2.
Table 2
Response times comparison between units in minutes
Mean
MOU 1
MOU 2
MOU 3
MOU 4
MOU 5
n=10
n=9
n=10
n=9
n=10
Median
93.5
100
123
110
106.5
SD
64
65
120
85
85
Range
73.85
93
75.58
81.55
89.29
15;220
35;275
20;240
10;240
10;330
P=0.8940
In comparing the response times of the various categories of calls (Table 3), there
was no significant statistical difference in response times, indicating that call
prioritisation made no difference to the response times.
Table 3
Comparison of the various categories of calls
Mean
Median
SD
Range (min;max)
P=0.1893
O/A
n=17
U/A
n=12
F/S
n=6
Neo
n=5
95.65
85
73.91
10;330
115.67
65
91.44
20;275
87.93
75
61.93
10;220
175
185
70,98
75;240
O/A = Ordinary ambulance
U/A = Urgent ambulance
F/S = Flying squad
Neo= Neonatal transfer
11
The second “Saving Mothers” report in 2002, recommended that “50% of
ambulances should arrive within 60 minutes” of being called. The following Table 4
suggests demonstrates that the response times in this sample falls short of this
target.
Table 4
Comparing all call categories with 2002 "Saving Mothers"
report recommendations
Category of call
Ordinary ambulance
Urgent ambulance
Flying squad
Neonatal
All calls
% < 60 min
% > 60 min
No. < 60 min
41%
42%
43%
0%
35.5%
59%
58%
57%
100%
64.50%
7 out of 17 calls
5 out of 12 calls
6 out of 14 calls
0 out of 5 calls
18 out of 48 calls
Conclusion
The perception of delayed response times of ambulances to MOUs in the PMNS was
confirmed in this small, but significant study. In view of the most recent revision of
the target set by the NCCEMD in 2006 for ambulance response times, where
ambulances should arrive within 60 minutes 70% of the time, considerable room for
improvement exists for ambulance response times in the PMNS.
12
OVERVIEW: SAVING MOTHERS REPORT 2002-2004
R C Pattinson, J Moodley
National Committee on Confidential Enquiries into Maternal Deaths, National Department of
Health, South Africa.
In this triennium (2002-2004) there have been a 29.8% increase in the number of
deaths reported compared with the previous triennium (1999-2001). The “big five”
causes of death have remained the same, namely non-pregnancy related infections
(37.8%), complications of hypertension (19.1%), obstetric haemorrhage (antepartum
and postpartum haemorrhage; 13.4%), pregnancy-related sepsis (8.3%) and preexisting maternal disease (5.6%). There has been a dramatic increase in the rate of
maternal deaths/100000 live births in non-pregnancy related infections (75.6%), less so
but still large in the major categories of hypertension (34.1%), obstetric haemorrhage
(40.7%), and pregnancy related sepsis in viable pregnancies (48.9%). Significantly
there was no increase in deaths due to abortion. Women less than 20 years were at
greater risk of dying due to complications of hypertension and pregnancy related sepsis
whereas women 35 years and older were at greater risk of dying of obstetric
haemorrhage and pre-existing medical disease. The peak age of women dying due to
non-pregnancy related infections was 25-34 years and the peak age of women dying due
to abortion was 30-34 years. The proportion of the various causes of maternal deaths
varied between the levels of care, however non-pregnancy related infections was the
most common cause at all levels of care. Postpartum haemorrhage and anaesthetic
related deaths occurred most commonly at level 1 hospitals whereas complications due
to hypertension and pregnancy related sepsis occurred at the same frequency at level 2
and 3 hospitals. Non-attendance and delayed attendance at the health institutions were
the most common patient orientated problems. Poor transport facilities, lack of health
care facilities and lack of appropriately trained staff were the major administrative
problems. The most frequent avoidable factors were failure to follow standard protocols,
poor problem recognition and initial assessment. Delay in referral and managing women
without referral were common problems in level 1 institutions.
Assessors thought
36.7% of the deaths were clearly avoidable within the health care system (patient
orientated factors were excluded). Over 80% of maternal deaths due to anaesthetic
complications and postpartum haemorrhage were thought to be avoidable.
Hypertension, obstetric haemorrhage, pregnancy related sepsis and anaesthetic
complications were responsible for three-quarters of avoidable deaths. Progress on the
implementation of the ten key recommendations made in the 1999-2001 report has been
poor over the triennium.
A strategy including a systematic outreach programme and the incorporation of the
recommendations into the key performance areas of the respective levels of management is
suggested to improve the implementation of the recommendations.
Full report available at: www.health.gov.za
13
KEY RECOMMENDATIONS: SAVING MOTHERS REPORT 2002-2004
M Masasa
National Committee on Confidential Enquiries into Maternal Deaths, National Department of
Health, South Africa.
The National Committee for the Confidential Enquiries into Maternal Deaths (NCCEMD)
reviewed the recommendations as outlined in the Saving Mothers 1999-2001 report,
assessing whether the recommendations are still relevant. New targets and indicators are
identified for those recommendations that are still crucial for this report. For the first time in
the Saving Mothers report, the NCCEMD, with inputs from the Provincial Assessors and the
Provincial and National Coordinators for Maternal Health Services in the country, identified
the key strategies to accelerate implementation of the recommendations. The team identified
the Golden Threads to the implementation strategies as:
 Introduction of recommendations into managers Key Performance Areas
 Outreach on-site, face to face teaching and training that is documented
Areas for implementation of the recommendations are classified into policy and
management, administration and monitoring and clinical practice where applicable. Targets
to be achieved have been specified and should be fully in place by December 2007. The
Maternal, Child, Women’s Health and Nutrition Cluster of the National Department of Health
will supply detail on the action plan for the implementation and monitoring of the
recommendations.
14
CHARACTERISTICS OF MATERNAL DEATHS AT ESHOWE HOSPITAL IN 2007
L Che
Obstetrics and Gynaecology, Eshowe Hospital
Introduction
There were 3090 women that delivered in Eshowe Hospital in 2006.
delivered vaginally and 924 women had caesarean sections done.
From these, 2158
We had 7 maternal deaths in 2006, due to the following:
 6 deaths were due to HIV/AIDS opportunistic infections;
 And 1 was due to acute respiratory failure, was not well diagnosed because no ANC
and only in hospital for 72 hours.
There is still the problem of patients not being tested for HIV in the early stages of
pregnancy. No other complications such as antepartum haemorrhage, sepsis, postpartum
haemorrhage or post abortion and, eclamptic pregnancy were the causes of our maternal
death.
The challenge in the reduction in maternal mortality is still an interesting aspect at Eshowe
Hospital.
15
EXPANDING CONTRACEPTIVE
JUSTIFICATION AND PROTOCOL
HEALTH
OPTIONS:
THE
ECHO
STUDY.
Mandisa Singata, GJ Hofmeyr, Sandy Ferreira, Lindeka Mangesi
Effective Care Research Unit. East London Hospital Complex, Univ of Fort hare, University of
Witwatersrand
Background
The only two areas in which maternal mortality in South Africa could be dramatically reduced
are treatment of HIV and reduction of unwanted pregnancies. During the first 6 months of
2006, over 2000 pregnancies were terminated at the East London Hospital complex alone.
This represents only a proportion of the unwanted pregnancies.
Depot progestogen contraception accounts for the majority of modern non-barrier
contraception used by adolescents in South Africa (80%). In a systematic review, the rate of
discontinuing depot progestogen contraception within 12 months was 49%.
The utilization of contraceptive services is directly related to the range of contraceptive
choices offered. In the Eastern Cape, the use of the IUCD has virtually disappeared.
Modern intrauterine contraceptive devices (IUCDs) are safe, effective, and quickly reversible
long-term contraceptives that require little attention after insertion. Declining use of the
IUCD in Ghana has been attributed to rumours about adverse effects, and worries about
bleeding and weight loss.
Objective:
To compare the risks and benefits of the copper IUCD and injectable progestogen
contraception with respect to: discontinuation, unplanned pregnancy, side-effects, infections,
and depression
Methods:
Women attending family planning clinics in the East London/Mdantsane area who meet the
screening eligibility criteria for the trial will be counselled and offered participation in the
trial.
Baseline details will be taken, including demographic data, medical history, weight, and a
brief questionnaire. The participating women will be allocated to the contraceptive method
(depot progestogen or IUCD) by drawing the next in a series of consecutively numbered,
sealed opaque envelopes containing allocation cards in computer-generated random
sequence.
To show a reduction in unplanned pregnancy from 3% to 2% will require 4023 women in
each group (alpha = 0.05, beta = 80%).
Outcome:
A clinical benefit of the trial will be the re-training of family planning services in the use of
the IUCD. The results of the trial will be used for future counselling of women requesting
contraception. Improved contraception options have the potential to reduce unwanted
pregnancies and maternal mortality.
16
LEVEL OF FETAL HEAD ABOVE BRIM: INTRAPARTUM ESTIMATION USING
PALPATION AND FINGERBREADTHS
E J Buchmann
Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Hospital and
University of the Witwatersrand, Johannesburg, South Africa
Estimating the level of the fetal head is essential in clinical assessment during labor.
Failure of the head to descend in the presence of adequate uterine contractions is an
important sign of cephalopelvic disproportion (CPD). Descent may be determined on
abdominal examination by estimating fifths of head palpable above the pelvic brim.
Probably the most frequently used and standard method is the one described by
Crichton2 based on the amount of sinciput and occiput felt. An alternative is the
method suggested by Notelowitz, which uses horizontal fingerbreadths above the
symphysis pubis as a measuring tool. Each fingerbreadth corresponds to one fifth of
head. According to both Crichton and Notelowitz, a head that is two-fifths or less
palpable above the brim is engaged in the pelvis. Both the Crichton and Notelowitz
methods were presented in the literature without any supporting data to prove their
clinical value. They have also not been compared. The objectives of this study were
to compare the Notelowitz method with the Crichton method of estimating the level
of the head.
Methods
This prospective cross-sectional comparative study was performed at Chris Hani
Baragwanath Maternity Hospital, Johannesburg. The researcher performed supine
abdominal examinations between contractions on nulliparous women at term in the
active phase of labor. All fetuses were alive with vertex presentations. Level of the
head was estimated first by Crichton’s method, followed by the Notelowitz method.
The researcher was blinded to the findings of previous examinations and was not
involved in obstetric management of these women. His findings were not revealed to
the attending clinical staff. After delivery, the length of labour and mode of delivery
were noted, with caesarean section for poor progress accepted as evidence of CPD.
Descriptive statistics were used in comparisons of the Notelowitz and tape measure
methods with the Crichton method of estimating head above brim. The three
17
methods were compared with respect to sensitivity, specificity, positive predictive
value and negative predictive value for CPD.
Results
The researcher examined 320 nulliparous women. The mean birth weight of infants
born was 3138 (±415) g, with a range of 1880 to 4800 g. In comparison with the
Crichton method, the Notelowitz method showed a tendency to higher estimation of
fetal head level above the brim, especially at two-fifths (Notelowitz mean 2.47 fifths)
and one-fifth of head (1.65 fifths) (Table 1). Two-hundred and twenty-six women
(70.7%) delivered spontaneously vaginally. These women were considered not to
have had CPD. Eighty (25.0%) had caesarean sections for poor progress and
therefore had CPD by definition. The remaining 15 women (4.7%) had caesarean
sections for fetal distress and were excluded from further analysis because they
could not be classified as having or not having CPD. The predictive value of these
methods for CPD was assessed, using three-fifths versus two-fifths as cut-offs for the
Crichton and Notelowitz methods. Three-fifths by Crichton proved to be less sensitive
for CPD than by Notelowitz (79% vs. 88%), but was more specific (44% vs. 34%)
(Table 2).
Discussion
These methods of estimating head descent have not been compared previously.
Fifths palpable assessed by the Notelowitz method differed from the Crichton method
at low levels of head. It is of concern that out of 70 heads palpated as two-fifths
above (just engaged) using the Crichton method, 33 (47%) were three-fifths (not yet
engaged) using the Notelowitz method. Either the Crichton method overestimates
the degree of descent, or the Notelowitz method underestimates it.
When the
methods were evaluated for prediction of CPD, the greater sensitivity of the
Notelowitz method suggests greater clinical value than the Crichton method as an
estimate of engagement.
18
Table 1
Mean fifths of head palpated above the pelvic brim with the
finger-breadth method of Notelowitz, according to fifths of
head palpated using the Crichton method as a standard
(n=320).
Fifths by
Crichton
Number
palpated
Mean fifths by Notelowitz
(95% confidence interval)
Standard
deviation
Range
fifths
5
4
3
2
1
0
8
78
115
70
23
26
4.75
4.06
3.09
2.47
1.65
0.00
0.46
0.34
0.34
0.50
0.49
-
4-5
3-5
2-4
2-3
1-2
-
Table 2
(4.43-5.07)
(3.99-4.13)
(3.03-3.15)
(2.35-2.59)
(1.45-1.85)
in
Sensitivity, specificity, positive predictive value and negative
predictive value for cephalopelvic disproportion (CPD) of
unengaged fetal heads found in the active phase of labour,
using Crichton and Notelowitz methods (n=305)
Unengaged head:
≥three-fifths (Crichton)
≥three-fifths (Notelowitz)
Sensitivity for CPD*
63/80 (79%)
70/80 (88%)
Specificity for CPD†
100/225 (44%)
77/225 (34%)
Positive predictive value‡
63/188 (34%)
70/218 (32%)
Negative predictive value§
100/117 (85%)
77/87 (89%)
*Sensitivity = proportion of women who had caesarean section, with head unengaged
†Specificity = proportion of women who delivered vaginally, with head engaged
‡Positive predictive value = rate of caesarean section if head unengaged
§Negative predictive value = rate of vaginal delivery if head engaged
19
CLINICAL SKILLS TRAINING USING OBSTETRIC MODELS – IS IT WORTH
THE TIME AND EFFORT?
E Farrell
MRC Unit for Maternal and Infant Health Care Strategies
Dept of Obstetrics and Gynaecology, Kalafong Hospital and University of Pretoria
Introduction
The number one cause of death in the perinatal period for South African babies over
1000g, is intrapartum asphyxia. It has become clear through research done in the
last few years that the clinical skills of so-called “skilled attendants” looking after
women in labour in the public sector, are of a very poor standard. There is no doubt
that this leads to mismanagement of patients and eventually death of babies, as
indicated by the avoidable factors identified in audits of perinatal deaths.
The clinical skills of midwives and doctors attending to patients in labour needs to be
improved drastically and urgently. Correct examination skills and documenting of
findings need to be taught, but currently there is no evidence available to indicate
that using models as a training tool is an effective way of improving clinical skills in
the evaluation of obstetric patients.
Aims
The aim of this study was to determine the effect of clinical skills training, using
obstetric models, on medical students’ clinical skills when examining live patients in
labour.
Method
Final year medical students were divided into 2 major groups. The study group
received obstetric skills training using models available in the skills lab of the
University of Pretoria before they had their final clinical evaluation on live patients.
The other (the control group) did not receive any model training. Both groups of
students also received the standard, in-block training on patients that they
encountered in the antenatal clinic and in the labour ward, while they were doing
duties there.
20
Students from both groups were evaluated after their clinical rotation in obstetrics in
the same, standard manner, i.e. to examine patients in labour and note their
findings.
All findings were documented on a standard data sheet and marked
according to the same memorandum. Two consultant examiners were used, after
ensuring that these two consultants were comparable in their clinical findings. No
patient had extra, unscheduled examinations in labour.
All examinations were
planned to coincide with the patient’s next pre-scheduled vaginal examination.
Patients were asked for verbal consent to examination, as is the routine practice at
the university in cases of clinical student evaluations.
Students were evaluated on the same skills that were taught during the skills training
sessions. These include: generic skills, skills required for abdominal palpation and
skills required for vaginal examination in labour. Table 1 reflects the datasheet used
for evaluation of students.
21
Table 1
Student
Generic (Maternal general examination)
o Mental condition
o Hydration status
o Pulse
o Blood pressure
o Respiratory rate
o Temperature
o Urine output
Specific (Pregnancy and labour)
Abdominal palpation

Uterus
 Contractions
o Frequency
o Duration
o Strength

Fetus
o SF measurement
o Lie
o Presenting part
 Cephalic/Breech
 Flexed, not flexed
o Head above pelvis
 5th HAP
 Over-riding
o Estimated size
o Fetal monitoring
Vaginal examination

Cervix
o Dilation
o Thickness

Membranes
o Intact/Rupture
o Liquor – Clear/Meconium

Fetus
o Position
o Moulding/Caput
o Station
Results
There was no difference found in the students’ ability to evaluate the mother’s
generic condition/general examination between the 2 groups of students. In both
abdominal palpation and vaginal examination, however, there were significant
differences between the 2 groups, with the study group performing much better at
both these skills than the control group. Table 2 depicts these results.
22
Examiner
Table 2
Skills Tested
Generic skills
Abdominal Palpation
Vaginal Examination
Study group (n=41)
87/123
350/451
238/328
Control group(n=47)
88/141
288/517
193/376
p-value
0.06389
0.000006
0.000047
Discussion
It is not unexpected that there was no difference between the 2 groups in terms of
their ability to do a general examination of the mother in labour, since this is a skill
that is taught by all departments in the school of medicine since the students’ first
contact with patients until the day they qualify as doctors.
The skills particular to the examination of the pregnant woman in labour, however, is
taught only during the rotation through the Department of Obstetrics, which
currently is a rotation that lasts 3 weeks of the entire 18 month student internship.
The limited exposure to obstetrics that the students experience in their third year of
study, is of almost no value by the time they reach their sixth year, since almost all
of it has been forgotten. The obstetrics rotation is a very busy one, and even though
the patient material for training is available in abundance, the ward is often too busy
to allow any time for actual skills training to take place.
Conclusion
In view of the results of this study, we feel that time should be made available in the
curriculum layout of sixth year medical students to allow for hands-on obstetrics skills
training using obstetric mannequins.
23
PREDICTORS OF UTILISATION OF MATERNAL HEALTH SERVICES IN
PAARL, RIETVLEI AND UMLAZI SITES IN SOUTH AFRICA
L Matizirofa1, 2, RJ Blignaut1 & D Jackson2
1Statistics Dept, 2School of Public Health, University of the Western Cape, South
Africa
Introduction
•
Maternal mortality and severe morbidity are currently major problems in
reproductive health worldwide.
•
Global maternal mortality rate is 400/100 000 whilst South Africa has 150/100
000.
•
Recognising consumer perceptions of healthcare services and incorporating
the client’s views to improve quality of care is widely acknowledged in
healthcare.
Study Sites

Paarl (Western Cape)

Rietvlei (Eastern Cape)

Umlazi (KwaZulu-Natal)

Sites were purposively selected to reflect different socio-economic regions,
rural-urban locations and HIV prevalence
Research Problem
Perceived quality of
maternal
health services
HIV/AIDS
Poor Utilisation of maternal health
care services
Knowledge of maternal
danger signs
24
Accessibility
Aim & Objectives
AIM: To determine factors that impact on the utilisation of maternal care
Objectives

To identify the predictors of utilisation of maternal services

To assess and compare the quality of maternal care services from the
perspective of the women

To compare the differences in the utilisation of maternal care services across
sites

To compare health seeking behaviour of HIV positive and HIV negative
mothers.
Research Methodology

Sample – 20 HIV+, 20 HIV- & 20 HIV-unknown women randomly sampled
from prior study or community lists in each site.

Cross sectional study

Data collection

Face-to-face
semi-structured
household
interviews
by
trained
interviewers between 10-34 months (mean 15 months) since last birth.

Questionnaire
–
adapted
from
WHO
Safe
Motherhood
Needs
Assessment
Data Analysis

Quantitative analysis was done using SAS

Scores were developed on perceived quality, knowledge, socio-economic
status, satisfaction and barriers to services variables.

Non-parametric tests (Kruskal-Wallis test) were used to find the differences on
the created variables across sites.

Simple linear regression analysis was used to assess independent predictors of
utilisation.
25
Study Results
Socio-Demographics
100
90
80
70
60
P ipe Wa t e r H o us e
50
F lus h T o ile t
E le c t ric it y
40
H H E m plo ye d
30
20
10
0
Paarl
Rietvlei
Umlazi
The study findings shown in the graph above indicates that Rietvlei is a rural, underresourced site. This is shown by the majority of households not having anyone
employed, with low percentages of women with piped water in their houses,
electricity and flush toilets.
Table1.
Comparisons of score variables in all sites
Score Variable
Paarl
Rietvlei
Umlazi
P-value
Socio-economic status
13
6
14
<0.0001
Utilisation of services
5
3
4
<0.0001
Barriers to services
2
3
2
0.4253
Perceived quality of services
17
9
12
<0.0001
Satisfaction with services
4
4
3
<0.0001
Knowledge of danger signs
31
45
52
<0.0001
Table 1 shows that women in Umlazi and Paarl have better socio-economic status
compared to Rietvlei. The perceptions of quality of maternal services are statistically
significant across sites.
26
Table 2.
Predictors of utilisation of maternal services – Simple Linear
Regression Analysis
Variable
R-square
Pr > |t|
Perceived quality score
0.2144
<0.0001
Knowledge of danger signs score
0.0684
0.0004
Socio-economic status score
0.0494
0.0030
Barriers to maternal services score
0.0453
0.0043
Satisfaction score
0.0216
0.0504
The coefficient of determination (R2) of perceived quality of maternal health services
score is 0.2144 which means that the regression line explains 21% of the total
variability in the utilization of maternal services (Table 2).
Utilisation of maternal health services by HIV status
•
Utilisation of maternal health services was not determined by HIV status
(Cochran-Mantel-Haensezel test, p=0.2615)
•
The insignificant difference in utilisation of services by HIV+ and HIV- women
is worrying because HIV+ women are at higher risk of complications
Conclusions

The factors contributing to poor utilisation of services pose serious threats to
women’s health in Rietvlei and Umlazi.

Development of score variables from WHO Safe Motherhood Needs
Assessment Tool may have wide applicability for assessing maternal health
services.
 Perceived Quality of Care is the strongest predictor of maternal health service
utilization – clients are more informed than we think??
27
EFFECTIVENESS OF THE IMPLEMENTATION OF THE BASIC ANTENATAL
CARE (BANC) PACKAGE IN THE NELSON MANDELA BAY METRO (PORT
ELIZABETH)
JS Snyman, J Strümpher, RC Pattinson, J Makin
Nelson Mandela Metropolitan University & MRC Maternal and Infant Health Care
Strategies Research Unit
Introduction
Unexplained stillbirths are the most common recorded category of perinatal death
according to the Saving Babies Report. The most likely causes of these deaths are
intrauterine growth restriction (IUGR), post-maturity, congenital abnormalities and
uro-genital infections in the mother. All of which can be detected during good
antenatal care.
According to Moran and Mangate as long as the woman attends antenatal care,
deaths resulting form IUGR, post-maturity and syphilis are usually avoided (Moran &
Mangate, 2004:23-37). Surveys indicated that 95% of women countrywide attend
antenatal care (Ijumba, Ntuli & Barron, Ed’s., 2003:94). Therefore the high
proportion of unexplained stillbirths is probably a good indication that the quality of
antenatal care is poor (Pattinson, 2003:4-22). Improving antenatal care can improve
maternal health, which in turn can improve the health and survival of the baby.
The aim of this study is to assess whether the implementation of a specifically
designed antenatal care package (BANC) does improve the quality of antenatal care
provided by primary health care nurses.
The World Health Organisation (WHO) produced a quality improvement package
known as Integrated Management of Pregnancy and Childbirth, endorsed by FIGO,
IPA and ICM.
Pattinson adapted these flow charts for South Africa’s conditions and
a multimedia Implementation Package for Basic Antenatal Care (BANC) was
developed. The implementation of the Basic Antenatal Care (BANC) package is seen
as a possible measure to improve the quality of antenatal care in primary health care
clinics.
28
Figure 1
The Basic Antenatal Care Package
The flow charts of the BANC package is a tool for clinical decision-making based on a
syndromic approach. The primary health care nurse identifies a limited number of
key clinical signs and symptoms, enabling her/him to classify the condition according
to severity; the classified condition is then managed and treated based on the flow
charts and clinic specific protocols.
The principles of basic antenatal care (BANC
•
Identification of women with special health conditions and/or those at risk of
developing complications using a simple checklist
•
Those women with special health conditions or risk factors should be referred
to higher levels of care. Care must be taken to ensure identification of all
women with special health conditions or risk factors.
•
Timing the visits such that the maximum benefit can be obtained, without
wasting human resources
•
Performing only examinations and tests that have been proven to be
beneficial, and at the most appropriate time
29
•
Wherever possible, rapid easy-to-perform tests should be used at the
antenatal clinic or in a facility close to the clinic.
The results should be
available the same day so treatment can be initiated at the clinic without delay
•
Health care providers should make all the pregnant women feel welcome at
their clinic, and it should be convenient for the pregnant women to attend the
clinic. This implies opening hours of the clinics should be as convenient as
possible to the women to come to the clinic.
In this study the quality of antenatal care is measured through reviewing the patient
held antenatal card using the Phillpottt/Voce (2001: 68-76) scoring system (figure 2).
This audit tool has 25 criteria divided into three main categories namely History,
Examination and Interpretation and Decisions. The gestational age at booking is
added.
Figure 2
Audit tool Philpott/Voce scoring system
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
History
Age, Parity, Gravida
History previous pregn
Previous illness
Hist present preg
LMP, EDD
SF Plot of first visit
Examination
Maternal Height, weight
BP at each visit
Heart
Correct plot of SF all visits
Able to interpret SF graph
Fetal presentation from 36 weeks
Fetal heart & movements
Urinalysis
Hb, Rh
Syphilis test results recorded
HIV counselled
Tet tox given
Interpretation & Decisions
Ident & recording risk factors
Action plan & interventions
Discussion of labour with mother
Transport arrangements
Family planning
1st & 36 week visit signed
Date of next visit
Total
%
Gestational age at first visit
Method
•
Ten primary health care clinics were randomly allocated to an intervention
group (BANC programme) or antenatal card audit group
•
Implementation was done in three steps:
–
Pre-implementation audit or scoring antenatal cards to determine
quality at baseline
30
–
Implementation of the BANC package through the Trainer of trainees
approach
–
•
Post–implementation audit three and six months after implementation
Focus group discussion and individual interviews were held to determine
experiences of individuals involved with implementation
Discussion of results
The results will be discussed as
º Short term achievements
º Audit results
º Discussion of the themes from the focus group and individual interviews
The short term achievements previously reported include
 A clinic retained checklist to assist identification of risk factors was introduced
 The new WHO schedule of visits was implemented
 Referral routes were defined
 Clinic specific protocols for patient management and referral criteria,
compatible with current national norms and standards were developed
 Ongoing audit was introduced
 Antenatal records were standardized
A discussion of the audit results will now follow. Results are given for baseline audit
(T1), three months (T2) and six months (T3) audit following intervention.
Providing the first antenatal visit at pregnancy confirmation
Attending late for the first visit has several implications in the care of the woman. If
the pregnancy is unwanted the opportunity to counsel the woman for a termination
of pregnancy can no longer be offered. Risks for the mother and fetus for example
syphilis, hypertension, diabetes, cardiac disease and nutrition status would not be
identified early for treatment and referral. Another important aspect of antenatal care
is providing health information to pregnant women for example the danger signs of
risk conditions for which the woman need to seek health care immediately. Without
31
this knowledge the woman may not report these risk factors if present, with a
detrimental effect on her own health and the well being of the fetus. This aspect of
care is reflected in the measurement of gestational age at first visit illustrated in
figure 3 below.
Figure 3
Comparison of gestational age at first visit for baseline, three
and six months after intervention.
Gestational Age at First Visit
28
27
26.9
26.7
25.9
Gestational age in weeks
26
25
Interventio
24.2
24.1
24
23.01
23
22
21
Intervention
Audit only
In the intervention group the gestational age at first visits declined significantly from
26.9 to 24.2 (T2) (p=0.001) and again to 23.01 at T3 (p=0). In the audit only group
the gestational age showed a reduction from 26.7 at T1 to 24, and remained
constant at T3 at 25.9 (p=0.14)
Comparison of total score between intervention and audit only groups
A total number of 462 cards were audited at baseline, 356 at T2 and 361 at T3. The
total score includes all 25 criteria presented in figure 4 below.
32
Figure 4
Comparison of total score for intervention and audit only
groups
Comparison of total score for intervention and audit only groups
22
T3 21.3
T2 20.3
20
T2 18.4
18
T3 18.6
T1 17.9
T1 16.1
16
14
12
10
Intervention
Control
The comparison of total score showed a significant increase in the intervention group
from baseline of 17.9 to 20.3 (T2) and again to 21.3 (T3) (p= 0.00); and also in the
audit only group from 16.1 at T1 to 18.4 (T2) (p=0.00), but then remained constant
at 18.6 (T3).
The three main categories history, examination and decision and interpretation
illustrated in figure 5 below are now discussed.
33
Figure 5
Comparison of three main categories for the intervention and
audit only groups
Comparison intervention and audit group for three main categories at T1, T2 and T3
12
10.3
10.6
10
9.3
9.1
9.4
7.7
8
6
5.3
4.9
5.6
5.3
5.2
4.8
4.8
5.1
4.02
3.7
4
3.7
3.8
2
0
Intervention
Audit only
History
Intervention
Audit only
Examination
Intervention
Audit only
Interpretation
History and Examination showed a small but significant increase in both groups.
History score (Max =6) was relatively high to start with and increased significantly in
both intervention group 4.95 T1 to 5.6 T3 (p= 0) and in the audit group from 4.8 T1
to 5.2 T3 (p=0). Examination (Max=12) showed a significant increase in the
intervention group from 9.32T1 to 10.8T3 (p=0) and in the control group from 7.7 to
9.4 (p=0). This improvement resulted from improved recording. Interpretation
(Max=7) showed a significant increase in the intervention group from 3.7T1 to 5.1
(p=0) but remained unchanged in the audit group at 3.7T1 and 3.8T3 (p=0.29).
Overall, audit resulted in the improvement of basic actions and better recording as
reflected in the significant improvement in both groups for the history and
examination. The audit indicated the category ‘Interpretation and decisions” as the
weakest area at baseline. Often risk factors were recorded, but no evidence was
available that it was recognized as a risk factor and no action was taken.
The
sustained significant improvement in quality illustrated with interpretation and
decision making in the intervention group is therefore a positive finding as it may
impact on the outcome of the pregnancy.
34
Focus group and individual interviews
In an attempt to understand the audit results a focus group discussion was held with
the trainers of trainees by an independent facilitator. Individual interviews were
conducted with managers and clinic staff of clinics where BANC was implemented. A
number of themes were identified. A few are briefly discussed.
Theme: Staff felt positive about training
The training was welcomed by the clinic staff, for some it was a first update in
antenatal care after many years in clinical practice; it was felt that the training
improved skills and built confidence as illustrated with the following quote.
“I have developed my skills from this training,…if you are supervising in those clinics,
you yourself, you should be well skilled, so this was of great help to me, it developed
me and I feel confident”
Theme: Training material was useful for training and implementation in
practice
The training material was found useful for the training and implementation in
practice. The checklist was implemented with no problems and assisted to classify
women for risk factors. It reminds the primary health care nurse of all the important
areas to focus on, and guided the implementation of the new WHO schedule of
visits. The WHO flowcharts assist to make the decision of what is a high risk
condition and needs further management and referral. The clinic specific protocols
assist to focus the actions on the important issues.
•
•
“The checklist particularly, gives you something to work from.”
“I like the guidelines (flow charts) that we use to set up the protocols; …they
have very clear differentiation between what is normal and what is
abnormal…”
•
“I think the training material was successful…one of the big things was the
protocols… it’s actually focused us, it’s made us more aware of the important
facets in pregnancy.”
35
Theme: Acting as a trainer is difficult
Acting as a trainer posed challenges. Trainers found it difficult to spend the same
time on training; this could have had an effect on the implementation and outcome.
“For me to do it at the clinic was a bit of a problem because I couldn’t take the same
two hours and spend it at the clinic…so it was really squashing in the training
sessions, I think that is actually detrimental to the whole thing, so it’s as if I was
always playing catch up, I was always a bit behind …”
Theme: Conflict exists between the original training and the new approach
Trainers and clinic staff hesitated to implement the new schedule of visits and
expressed their feelings of insecurity, despite the availability of evidence presented.
•
The trainers reported that “they (the clinic staff) found it very difficult to let go
of this seeing patients according to the council (SANC) rule, I must admit I
had some reservations myself…”
•
The second factor was fear that something would go wrong with patients in
the six weeks between follow-up visits. One sister expressed it as “I was
actually very scared, initially”,
Currently the South African Nursing Council in Government Notice
R.2488
recommends the following in 6 (2) ‘Where possible, the registered midwife shall visit
the patient at least once a month until the 28th week, thereafter at least once a
fortnight until the 36th week, and then at least once a week until commencement of
labour.” This could result in 12 visits during the antenatal period.
Theme: Staff has more time for other tasks like education
The implementation of the WHO schedule of visits had an impact on the patient load
and enabled nurses to spend more time with patients teaching them about amongst
for example danger signs and counseling them for HIV testing.

“So it was always full of patients…at least it is much better, but you know the
patient better.”

“I’m very happy because I’ve seen that it works and we’ve got so much more
time to spend with the patients...”
36
Theme: Managers knew the principles but are vague on utilization in
practice
Managers interviewed had a good understanding of the concept of the BANC
package. It was possible to give quite a detailed description as illustrated below. Yet
throughout the interviews no comments were made related to support or time
allocated for training in order to assist the trainer at clinic level.
“My understanding of BANC … it was an alternative to improve our antenatal care
services… to update some of our antenatal care sisters …and to decrease mortality
by detecting problems early in pregnancy…”
Theme: Managers have insufficient knowledge to effectively monitor
implementation
Even though in a managerial position it became clear that knowledge and expertise
in antenatal care was lacking amongst managers. Some managers have not worked
with pregnant women for some time and were not exposed to the latest
developments.
“I personally, it is long time that I was out of midwifery…I need some more
knowledge, especially with BANC.”
Summary
•
The BANC package contributed to pregnant women being seen earlier for the
first visit
•
The BANC package significantly improved the quality of care of antenatal
patients as measured by the scoring of antenatal cards. Audit alone had a
small effect to improve the quality of care.
•
With the BANC package the organizational platform is established for
improvement
•
The significant improvement noted in ‘Interpretation and decision making’
category is positive
•
BANC is well liked and accepted by primary health care nurses (Checklist,
flowcharts and protocols)
37
•
Schedule of visits decreased the number of patient visits enabling PHC nurses
to spend more time on patient education particularly danger signs and
counseling
•
Schedule of visits is perceived as conflicting with SANC rule
•
Support and supervision from managers is essential to facilitate structural
changes to enable BANC training and implementation; and again is needed for
sustainability
Conclusion
The BANC programme significantly improved the quality of care of antenatal patients
as measured by the antenatal card scores, and empowered clinics to comply with
national maternal care requirements. Audit alone had a small effect to improve
quality of care. The unexpectedly low increase in antenatal score could be due to the
inherent weaknesses of trainer of trainer methodology, mainly the dilutional effect at
each level and conditions at clinic level. The BANC package is well liked and accepted
by primary health care professional nurses, but support and supervision from
managers is essential to ensure effective implementation.
38
IMPLEMENTING A BASIC ANTENATAL CARE QUALITY IMPROVEMENT
PROGRAMME USING A TRAINING OF TRAINERS METHODOLOGY IN PRIMARY
HEALTH CARE CLINICS IN SOUTH-WEST TSHWANE
E Etsane, RC Pattinson
MRC Maternal and Infant Health Care Strategies Research Unit, Obstetrics and Gynaecology
Department, University of Pretoria
Objective
To evaluate the introduction of the basic antenatal care quality improvement programme in
the fourteen primary health care clinics of South-West Tshwane, South Africa
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 and one year 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. During the study interviews were conducted with the
facility managers, trainers and trainees at the clinics.
Findings
There was a slight improvement in the average score of the implementation group, from
68.0% to 71.0% (p=0.00) at four months and 74.0% (p=0.00) at one year. This was due to
quality improvement mainly in only 2 out of the 4 groups of clinics, mainly in the
‘interpretation and decision-making’ component of the antenatal visit. Improvement was
related to facility manager support and trainer motivation.
Conclusion
Using the training of trainer’s methodology to implement a quality improvement programme
is dependant on facility manager support and trainer motivation. More attention must be
focused on getting commitment of facility managers and selecting the appropriate trainers.
39
SIX SUPPLEMENTARY PEP MANUALS
Dave Woods
Perinatal Education Trust, Cape Town
Following the success of the two basic Perinatal Education Programme manuals (Maternal
Care and Newborn Care) a further six supplementary manuals have been developed. These
smaller manuals provide for four month courses.
The topics addressed by the
supplementary manuals are: Primary Maternal Care, Primary Newborn Care, Perinatal
HIV/AIDS, Saving Mothers and Babies, Mother and Baby Friendly Care, and Birth Defects.
The goal of the Perinatal Education Programme is to enable groups of professional health
care workers to take responsibility for their own continuing education in maternal and
newborn care. Approximately 50 000 doctors , nurses and medical students in Southern
Africa have used this learning opportunity over the past twelve years.
A very cost effective retrospective bursary system funded by MESAB has recently been taken
over by the Johnson and Johnson Pediatric Institute. This novel way of funding professional
development rewards success and builds health care capacity through positive reward.
Perinatal Education Programme learning material has been used in many other countries
both within and beyond Africa. Currently an Urdu translation is being undertaken in Pakistan
and a Spanish translation in Guatemala.
The number of manuals used and course certificates awarded to different carer categories in
the provinces of South Africa will be shown.
Recommendations of ways to make these learning opportunities available to a much wider
audiences will be given. This is of critical importance in the field of perinatal HIV infection
and antiretroviral prophylaxis and treatment.
40
EVALUATION OF THE RELIABILITY OF THE QUALITY CHECK FORM TO AUDIT
ANTENATAL CARDS
Jacobeth ML Malesela, Christa van der Walt*
SG Lourens Nursing College
*Department of Nursing Science
University of Pretoria
Reports on the systematic monitoring of maternal and perinatal deaths in South Africa
indicated that increased morbidity and mortality relating to maternal and perinatal care
resulted from a number of avoidable factors, missed opportunities and substandard care. An
initiative emanating from these reports was the development of the Quality Check Form
(QCF) that was used to audit decision-making and recording of antenatal care. Reports did
not comment on the reliability of the QCF as audit instrument. The objective of this study
was to determine the reliability of the QCF to audit antenatal cards, with specific reference to
inter-rater reliability (equivalence of results). A descriptive and methodological research
design was adopted. A sample of one hundred antenatal cards used in a tertiary hospital
was selected, and audited by three independent reviewers, using the QCF. The SAS
software package was used for data analysis. Statistical procedures such as the Friedman
test, chi-square and Kendall Tau coefficient of concordance were used to provide estimates
of the inter-rater reliability of the QCF. Results varied between three reviewers in terms of
total scores and scores per QCF item. Factors relating to reviewers, the QCF, and antenatal
cards could have influenced the inter-rater reliability of the QCF. Inter-rater reliability of the
QCF could be described as relative.
41
COMPARISON OF A PRIVATE MIDWIFE OBSTETRIC UNIT AND A PRIVATE
CONSULTANT OBSTETRIC UNIT
BA Seedat, D Blaauw
Centre for Health Policy, University of the Witwatersrand
Background
Midwife obstetric units (MOUs) have been in existence for decades. International
studies have shown that MOUs can function as well as consultant obstetric units
(COUs) for low risk pregnancies, yet have fewer intrapartum interventions. No
comparable studies were found in South Africa. Linkwood Clinic is a private 11-bed
obstetric unit in Johannesburg, with a MOU and a COU functioning independently on
the same premises. Linkwood Clinic had routinely collected data available for
analysis. This provided an opportunity to compare a MOU to a COU in a South
African setting.
Study Aim
To compare the functioning of a private MOU and private COU in Gauteng.
Study Objectives
1.
To compare intrapartum delivery procedures, methods of delivery, maternal
and-neonatal wellbeing for low risk pregnancies of a MOU and a COU at a
private obstetric unit in Gauteng for the period January 2005 to June 2006.
2.
To analyse the predictors of key outcomes related to intrapartum delivery
procedures, methods of delivery, maternal and-neonatal wellbeing for low risk
pregnancies.
Methodology
This was a retrospective cohort study undertaken via record review of routinely
collected data from Jan 2005-June 2006. Only low risk pregnancies, as defined by
regulations from the South African Nursing Council, were included in the study. A
total of 808 patients were included in study comprising of 212 COU patients and 596
MOU patients.
42
Epi-Info (Version 3.3.2, 2005) was used for data capturing and statistical analysis.
The χ² test was used for comparison of proportions between the groups. The Fisher’s
exact test was utilised for variables with low frequencies. The relative risk was used
to assess the strength of association for each of the variables. For multiple logistic
regression, the adjusted odds ratio was used to assess strength of association.
Results
Table 1
Methods of Delivery and Intrapartum Interventions
COU
C/S
UWB
Epidural
Induction of
labour
N
58
37
59
53
(%)
(27.4)
(17.5)
(27.8)
(25.0)
N
MOU
(%)
71 (11.9)
274 (46.0)
46 (7.7)
93 (15.6)
Relative
Risk
Total
N
129
311
105
146
(%)
(16.0)
(38.5)
(13.0)
(18.1)
2.3
0.4
3.6
1.6
p -value
p<0.001
p<0.001
p<0.001
p=0.002
Methods of Delivery and Intrapartum Interventions
With regard to methods of delivery, the C/S rate was higher for the COU at 27.4%,
with the MOU being 11.9% (Table 1). Similarly, the use of epidurals for pain relief
was higher for the COU at 27.8% compared to 7.7% for the MOU.
Table 2
Maternal and Neonatal Morbidity
Maternal
Morbidity
Any Tears
PPH
Retained
COU
N
(%)
69 (32.5)
5
(2.4)
4
N
MOU
(%)
224 (37.6)
18 (3.0)
(1.9)
5
(0.8)
Total
N
(%)
293 (36.3)
23 (2.8)
9
(1.1)
Relative
Risk
p- value
0.9
0.8
p=0.19
p=0.62
2.2
p=0.25
Relative
Risk
p- value
Placenta
Neonatal
Morbidity
Apgar <7 @
5min
NICU
admission
COU
N
0
5
Total
N
(%)
MOU
(%)
(0.0)
(2.0)
N
2
(%)
(0.3)
2
(0.2)
0.0
p=1.0
13
(2.0)
18
(2.2)
1.0
p=0.8
43
Maternal and Neonatal Outcomes
Overall, the COU and the MOU had similar maternal and neonatal outcomes (Table
2). There were no recorded cases of maternal or neonatal mortality for the COU and
MOU for the study period. In addition, there were no significant differences in
maternal and neonatal morbidity indicators between the COU and the MOU.
Table 3
COU
Primup
IOL
Age>30
Predictors of C/S
Multiple Logistic Regression
Odds Ratio
2.88
19.13
2.00
1.48
95% CI
1.9-4.4
8.2-44.6
1.2-3.2
1.0-2.2
p-value
p<0.001
p<0.001
p=0.005
p=0.065
Predictors of C/S
The COU, primup status and induction of labour (IOL) were independent positive
predictors of C/S, whilst age had no influence on C/S rates (Table 3). The risk of a
C/S was 2.88 times greater for the COU. Primup status increased the risk of a C/S
19.13 times.
Table 4
COU
Primup
Vacuum
Episiotomy
UWB
Predictors of Perineal Tears
Multiple Logistic Regression
Odds Ratio
95% CI
p-value
1.08
0.99
3.83
0.06
1.95
0.74-1.56
0.72-1.36
1.96-7.45
0.01-0.25
1.40-2.71
p=0.69
p=0.95
p<0.001
p<0.001
p<0.001
Predictors of Perineal Tears
UWBs and vacuum deliveries were positive predictors of perineal tears (Table 4). An
UWB almost doubled the risk of a patient experiencing a perineal tear, while a
vacuum delivery increased this risk by 3.83 times. An episiotomy was protective and
reduced the risk of a perineal tear, although these were mainly grade 1 and 2
perineal tears. Delivery in the COU and primup status had no statistical association
with perineal tears.Discussion
The MOU patients had fewer intrapartum interventions, more UWBs and fewer C/S
than the COU patients. Furthermore, maternal and neonatal outcomes were similar
44
for both units. The COU, primup status and IOL were all positive predictors of C/S.
Vacuum deliveries and UWB were the main predictors of perineal tears. Overall, the
findings of this study are in keeping with international literature, which show that
midwives have a less interventionist approach, yet can function just as effectively as
doctors for low risk pregnancies.
The main limitations of the study are that the review period may not be long enough
to compare mortality; data collection was limited to what could be obtained from a
retrospective record review; and that patients were not randomised to the two
groups.
Conclusion
The MOU at Linkwood Clinic is an excellent example of a private midwife unit, with
the potential for countrywide replication. This can have financial and human-resource
saving implications if future comparative studies can be carried out in the private and
public sectors. In this study, midwives functioned just as well as doctors for low risk
pregnancies. This may be explained by their level of training, standardised protocols
to follow, and an excellent referral system.
45
FETAL MOVEMENT COUNTING FOR ASSESSMENT OF FETAL WELLBEING: A
COCHRANE SYSTEMATIC REVIEW
L Mangesi and GJ Hofmeyr, Effective Care Research Unit, East London Hospital Complex,
Eastern Cape Department of Health, University of Fort Hare, University of Witwatersrand
Background
It is difficult to predict intrauterine death in women with normal pregnancies. Some clinicians
believe that fetal movement counting is a good method as it allows them to make
appropriate interventions in good time whilst others think that fetal movement counting may
cause unnecessary anxiety to women.
Objectives
To assess outcomes of pregnancy where fetal movement counting was done routinely,
selectively or was not done at all; and to compare different methods of fetal movement
counting.
Methods
Search strategy: We searched the Cochrane Pregnancy and Childbirth Group Trials Register,
the Cochrane Central Register of Controlled Trials (The Cochrane Library) and the reference
lists of relevant papers.
Selection criteria: We selected only randomised controlled trials. Trials where allocation
concealment was inadequate and no measures were taken to prevent bias were excluded.
Participants were pregnant women who had reached fetal viability. Interventions were
routine fetal movement counting, selective fetal movement counting, and studies comparing
different fetal assessment methods.
Data collection and analysis: The methodological quality of included studies was assessed.
Data were extracted from relevant studies and Review Manager computer software was used
for analysis. A cluster-randomised trial included could not be combined with other studies.
Subgroup analysis on routine fetal movement counting, selected fetal movement counting
and when fetal movement counting was mixed or undefined could not be done because of
the limited number of trials.
Results
Four studies were included. The only outcome that was measured in two studies was
compliance in two different counting methods and the results could not be combined
because of heterogeneity. The counting methods compared were once a day fetal movement
counting and the more than once a day fetal movement counting method. In one study
women were more compliant in the once a day fetal movement counting method and in the
other one there were no significant differences with regard to compliance. Non-interference
with daily life activity was reported as the main advantage of the once a day counting
method. There were no intrauterine deaths. In a study comparing the fetal movement
counting method and hormonal analysis with 1 191 participants, there were no significant
differences with respect to Apgar scores and umbilical artery pH. In a cluster-randomised
trial with 33 pairs of clusters of 1000 women each, that compared routine fetal movement
counting and selective fetal movement counting, there was a trend to increased use of other
testing methods and antenatal hospital admissions in the counting group and no difference
in perinatal outcomes between the two groups.
Conclusions
The largest trial to date (Grant 1989), the potential effect on perinatal outcome may have
been masked by contamination of the 'control' group. There was likely to be a heightened
awareness of the importance of fetal movements at the control sites because of their
participation in the study. The results neither confirm nor refute the effectiveness of fetal
movement counting as a method of fetal surveillance. Robust research is needed in this
area.
46
HYPERTENSIVE DISORDERS OF PREGNANCY: SAVING MOTHERS REPORT
2002-2004
J Moodley
National Committee on the Confidential Enquiries into Maternal Deaths, National
Department of Health, South Africa
Introduction
Deaths from hypertensive disorders of pregnancy (HDP) include mortality from preeclampsia, eclampsia, chronic hypertension, HELLP syndrome and liver rupture. In
the current triennium, HDP constituted the commonest direct primary cause of
maternal mortality in South Africa, contributing 19.1% of all maternal deaths
(n=628). Hypertensive disorders of pregnancy remain the commonest direct cause
since 1998. The present triennial report (2002-2004) indicates a dramatic increase in
deaths from HDP of approximately 34%. The primary obstetric causes of deaths in
sub-categories are shown in Table 1. The final and contributory causes of maternal
deaths for hypertension are shown in Table 2. There was an increase in the number
of deaths from the HELLP syndrome in this triennium.
Table 1
Primary obstetric causes of death in the sub-categories
Sub-categories






TOTAL
Chronic hypertension
proteinuric hypertension
eclampsia
HELLP syndrome
Rupture of the liver
Acute fatty liver
1999-2001
n
24
139
289
44
8
3
507
%
4.7
27.4
57
8.7
1.6
0.6
2002-2004
n
%
37
5.9
171
27.2
347
55.3
70
11.1
3
0.5
0
0.0
628
There was a decrease in the number of deaths from cardiac failure (pulmonary
oedema and cardiac failure) in 2002-2004 compared to 1999-2001. Deaths from
renal failure also declined while those due to cerebral complications remained the
same.
47
Table 2
Final and contributory causes of maternal
hypertension and a comparison with 1999-2001
ORGAN SYSTEM
1999-2001 deaths
n
%
39
7.7
18
3.6
81
16.0
179
35.3
Hypovolaemic shock
Septic shock
Respiratory failure
Cardiac failure
Pulmonary oedema
Cardiac arrest
90
38
255
6
57
65
8
2
for
2002-2004 % of deaths
n
%
49
7.8
16
2.5
155
24.7
14.2
89
17.2
18.9
Renal failure
Liver failure
Cerebral complications
Metabolic complications
DIC
Multi-organ failure
Immune system failure
Unknown
deaths
17.8
7.5
50.3
1.2
11.2
12.8
1.6
0.4
88
31
316
7
89
104
18
56
14.8
4.9
50.3
1.1
14.2
16.6
2.9
8.9
Note: a patient can have more than one final and contributory cause of death
Table 3 lists the age distribution and shows that with respect to eclampsia, 72 of the
105 women were under the age of 20 years. Eclampsia still occurs at all ages, e.g.
14 of 32 women in age group 40-44 years.
Table 3
Category
Chronic
hypertension
Proteinuric
hypertension
Eclampsia
HELLP
Liver rupture
Acute fatty liver
TOTAL
Age distribution and death due to hypertension in pregnancy
< 20
20-24
25-29
30-34
35-39
40-44
45+
Unknown
Total
0
4
5
9
8
7
4
0
37
28
39
42
32
18
9
3
0
171
72
5
0
0
105
85
15
1
0
144
66
21
0
0
134
71
23
2
0
137
34
4
0
0
64
14
2
0
0
32
4
0
0
0
11
1
0
0
0
1
347
70
3
0
628
The table on parity (table 4) shows that most deaths from HDP occur in
primigravidae but deaths from proteinuric hypertension and eclampsia occur in all
parity categories. There were 7 of 287 primigravidae who belonged to the chronic
hypertensive group.
48
Table 4
Parity and cause of death
Category
0
1
2
3
4
5
5+
Chronic hypertension
Proteinuric hypertension
Eclampsia
HELLP
Liver rupture
Acute fatty liver
TOTAL
7
80
167
32
1
0
287
7
34
60
15
0
0
116
6
20
46
11
2
0
85
8
21
16
7
0
0
52
2
11
13
4
0
0
30
2
1
10
0
0
0
13
5
2
8
0
0
0
15
Unknown
0
2
27
1
0
0
30
Total
n
37
171
347
70
3
0
628
Table 5 illustrates the avoidable factors, missed opportunities and substandard care
associated with HDP. There were no major changes except for the fact that the
current report suggests a slight decline in patient related problems; considerable
decline in administrative factors and slight declines in health worker related
emergency management problems.
Table 5
Avoidable factors, missed opportunities and substandard care
for hypertension and comparison with 1999-2001
Avoidable factors in assessable cases
Category
Patient Orientated
Administrative factors
Health Worker orientated
Emergency management problems
Level 1
Level 2
Level 3
Resuscitation problems
1999-2001
n
%
205
50.6
329
74.3
2002-2004
n
%
250
47.7
225
39.3
116
148
91
95
218
149
77
148
68.2
74.4
49.5
26.2
65.3
51.7
35.6
27.5
Discussion
Hypertensive disorders of pregnancy (HDP) and their complications remain the
commonest direct cause of maternal death, while eclampsia constitutes the
commonest primary cause of hypertensive related deaths. It is of extreme concern
that despite wide-spread provision of clear clinical protocols of management of
severe pre-eclampsia / eclampsia country-wide, intracerebral haemorrhage
remains the commonest final cause of deaths due to HDP. This once again implies
that due attention is not being placed on lowering of very high blood pressure values
or there is a lack of continued monitoring of blood pressure during the “referral
period”, labour and postpartum period. Health professionals must learn to lower
49
acute severe blood pressure levels on admission. This is a “problem” that occurs in
other countries as well. In the current 6th Report on “Why mothers die” from the UK,
cerebral haemorrhage was also the commonest cause of death in the HDP and a
similar recommendation is made in respect to the need to lower very high systolic
blood pressures.
A problem that is highlighted in this report is the increasing number of adverse
events in the postpartum period. In the last report (1999-2001) it was reported that
a constant avoidable factor was the lack of monitoring in the antenatal period during
the labour and particularly, the postpartum period. It must be emphasised that
monitoring of “vital signs” must be performed frequently at all times in the acute
phase of the condition. In practical terms, this implies that patients need to have
their blood pressures, pulse rate, respiratory rate, Glasgow Coma Scale (GCS), fluid
balance, urinary output, and blood coagulation parameters measured regularly.
Automatic blood pressure machines, which are used widely (even in South Africa)
need to be checked regularly as they tend to underestimate blood pressure values.
Antihypertensive therapy must be instituted early and not “stopped” abruptly, but
rather the dosage decreased in a step-down fashion. Most importantly, health
professionals must be made aware of the fact that delivery of the severe preeclampsia /eclamptic does not mean cure of the disease and those complications are
unlikely to occur in the immediate postpartum period. In fact, there are an increasing
number of deaths associated with eclampsia in the postpartum period. These women
MUST be managed in a high dependency area or if this is unavailable, an area set
aside in any general ward for this purpose and monitoring done at least every hour
for the first 24 hours post delivery.
Teenage pregnancy remains a major problem. Eclampsia seems to have a
predilection for this age group. A significant proportion of women < 24 years
contributed to deaths from eclampsia and a significant proportion again, had no
antenatal care, or infrequent attendance. The previous reports had recommended
that contraceptive services and information on termination of pregnancy need to be
made freely available and accessible. This is obviously not occurring.
This
recommendation is made again, and in addition, involvement of communities,
50
schools, technical universities, and universities in spreading the information about
this problem through newsletters, lectures and open forums must be considered.
Deans, University Principals and Heads of Midwifery Colleges should become involved
in disseminating information.
Two factors in the current report that need further investigation, monitoring and
comment are the decline in: (i) deaths from HDP in KwaZulu-Natal; and (ii) deaths
from pulmonary oedema. There may be contradictory messages in these findings.
Firstly, protocols for appropriate fluid balance might be working. This is also
indicated by the decline in deaths associated with renal failure. It probably indicates
better fluid balance management. On the other hand, there are more deaths from
respiratory and multi-organ system failures.
The decline in deaths from HDP in KwaZulu-Natal is difficult to explain and requires
an in-depth review of the management of hypertensive disorders in this province. On
the other hand, there appears to be an increase in hypertensive deaths in Free State
and Gauteng. This may be due to better reporting, but these provinces have always
provided quality maternal death notification reports. The UK has seen a drop in
deaths from HDP from 264 in their triennial reports in the 1950’s down to 14 deaths
in the 6th Report on “Why Mothers Die” This was probably achieved by:- (i)
promoting antenatal care and instituting a recall system for defaulters; (ii) instituting
regional centres and regional obstetricians to provide advice on, or caring for women
with severe pre-eclampsia / eclampsia; and (iii) educating health professionals
through audits and involving the general public about the dangers of pre-eclampsia.
Antenatal attendance and transport delays continue to be challenges and community
education on a continuing basis must be made a priority. Antenatal care free of
financial charge does not appear to solve the problem of attendance. It is known that
women confirm their pregnancies at an early stage in pregnancy by attending
general practitioner rooms or clinics. A breakdown in continued care is then
apparent, patients do not seek antenatal care or general practitioners do not provide
advice and continuing antenatal care. Due attention should be given to maternity
care in continuing professional education for general practitioners; and shared care
between general practitioners and health providers should be considered. Further,
51
more emphasis on antenatal care and contraceptive services must be emphasised in
health care education curricula. This information should be brought to the attention
of all heads of educational institutions.
The finding of high levels of avoidable health worker orientated problems,
particularly at level 1 hospitals, is extremely disturbing. It may imply that teaching at
undergraduate level and during internship, is of a poor quality. Emergency
resuscitation, failure to refer, substandard care, may indicate lack of protocols, but
may also be due to the fact that community service doctors, interns, medical officers,
etc do not have the prerequisite skills. Therefore, more effort needs to be based on
“face to face” on-site education for this category of health worker. Further, the
inclusion of “special focussed teaching” on resuscitative skills in the undergraduate
medical program must be considered and brought to the attention of the Committee
of Deans, and similar bodies involved in health care professional training. In respect
to patient avoidable factors, contact must be made at the community level to
heighten awareness of the advantages of antenatal care, through meetings in
community halls, the radio and newspapers.
Conclusion
In general, it is disappointing that many of the recommendations made in previous
reports have not resulted in significant changes in avoidable factors in relation to
patients, health care providers and administration. A greater commitment to
reduction of maternal deaths must be made by civil society (government, health care
providers and the public at large), if pregnancy is to be made safer.
52
COMPLICATIONS IN PRE-ECLAMPTIC PATIENTS ADMITTED TO THE
OBSTETRIC UNIT, UNIVERSITAS HOSPITAL
JBF Cilliers, LA Mahlalela, T Ralefala, L Rambau, MR Mohale, QJ Mosia
Universitas hospital, University of the Free State, Bloemfontein
Introduction
Hypertension is the most common medical disorder during pregnancy. Approximately
70% of women diagnosed with hypertension during pregnancy will have gestational
hypertension or pre-eclampsia. It is estimated that 6% to 8% of all pregnancies will
be
complicated
by
gestational
hypertension
or
pre-eclampsia.
Gestational
hypertension/pre-eclampsia will occur in 6% to 17 % in nulliparous women’s
pregnancies and 2% to 4% in multiparous women’s pregnancies. Traditionally preeclampsia had been diagnosed by the presence of hypertension with significant
proteinuria (300mg/24 h). If a 24 hour urine specimen is not available, then
proteinuria is defined as 30mg/dl (at least 1+ on dipstick) in at least 2 random urine
samples collected at least 6 hours apart. In the absence of proteinuria pre-eclampsia
should be considered when gestational hypertension is associated with persistent
cerebral symptoms, epigastric pain with nausea and vomiting, or thrombocytopenia
and abnormal liver enzymes or intra-uterine growth restriction.5 The diagnostic
criteria of Brown and De Swiet are used at Universitas hospital to diagnose preeclampsia.
Methods
As this was a student project a protocol was drafted and permission obtained from
the ethics committee to conduct the study. A database is kept for all obstetric
patients admitted to Universitas Hospital. This database was used to identify all
patients admitted in the period 1 June 2004 to 30 November 2004 with the diagnosis
of pre-eclampsia. After the patients were discharged from hospital the files were
used to extract the relevant information and complete the data forms. The following
information were obtained: Patients age, date of admission, delivery and discharge,
gravidity, parity, maternal complications, risk factors and delivery outcome.
53
Results
A total of 86 patient’s files were analyzed. During the same period a total number of
302 deliveries took place at Universitas Hospital, making the incidence of preeclamptic deliveries 28%. The age age of patients ranged from 17 to 41 years with a
mean of 26.8 years. From these patients 15% were over the age of 35, the group
most likely to suffer severe morbidity and mortality. Most of the patients were in
their first pregnancy confirming the fact that pre-eclampsia is most likely to occur in
primigravidae - Table 1.
Table 1
Gravidity
Percentage
1
42%
2
33%
3
9%
4
12%
>4
5%
From the 86 patients 88% were classified as pre-eclampsia and 12 as superimposed
pre-eclampsia. The average stay in hospital was 7.6 days (Fig 1) and 37% of
patients were delivered on the first day of admission, with a further 22% on the
second day. This concludes that 59% of the patients were delivered on the first 2
days of admission. Four of the patients admitted for complications of pre-eclampsia
were delivered elsewhere before admission (Fig 2).
54
Fig 1
Days admitted in hospital
16
14
Number of patients
12
10
8
6
4
2
0
2
3
4
5
6
7
8
9
10
11
12
13
14
15
17
18
20
23
29
Days
Fig 2
Days from admission till delivery
35
30
Number of patients
25
20
15
10
5
0
-2
-1
0
1
2
3
4
5
6
7
8
10
11
14
16
Days
Most of the patients were delivered by cesarean section (80.3%) versus vaginal
delivery 19.7%.
55
The most important risk factor was being of the black race, followed by nulliparity
and chronic hypertension. The following table show the percentage of the patients
where risk factors occurred.
Table 2
Demographic
Black race
Nulliparous
Family history of hypertension
Medical risk factors
Chronic hypertension
Obesity
Hyperthyroidism
Diabetes mellitus
Obstetric risk factors
Multiple gestation
96.5%
41.9%
2.3%
11.6%
4.7%
1.2%
1.2%
3.5%
Oliguria or renal failure was the most common complication that occurred in our preeclamptic patients. The next table shows the occurrence of complications in our
patients. Some patients had more than one complication. Hypertensive emergency
was diagnosed if diastolic blood pressure were listed as more than 120mm Hg.
Table 3
Complication
Oliguria/renal failure
HELLP syndrome
Eclampsia
Ascites
Hypertensive emergency
Pulmonary oedema
Cerebral complications
Abruptio placenta
DIC
Liver rupture
n
26
24
15
9
7
5
5
1
1
1
%
30%
28%
17%
11%
8%
6%
6%
1.2%
1.2%
1.2%
Three maternal deaths occurred in the six month period due to pre-eclampsia. Two
patients suffered inoperable cerebral hemorrhages and one patient died of
respiratory failure in ICU due to severe pulmonary oedema.
Conclusions
Hypertension in pregnancy remains an important cause of maternal morbidity and
mortality in South Africa. The occurrence of complications in these patients is
common when they are treated conservatively like we do in South Africa to reach a
56
gestational age where there might be a better neonatal outcome. The data shows
that patients are likely to be delivered in the first 2 days after admission. This is
probably due to late diagnosis and referral to the tertiary hospital. Another limiting
factor is the shortage of tertiary beds. Early onset pre-eclampsia is still managed at
secondary level and is only referred for neonatal care if delivery is imminent. The
high incidence of oliguria is probably due to care not being optimal at secondary
level, as many of these patients kidney function returned to normal shortly after
admission when they were actively resuscitated with fluids.
57
PERINATAL DEATHS IN HYPERTENSIVE DISEASE IN PREGNANCY - FOUR
YEARS OF EXPERIENCE WITH PERINATAL PROBLEM IDENTIFICATION
PROGRAMME AT TYGERBERG HOSPITAL
Wilhelm Steyn, David Hall, Gert Kirsten, Greetje de Jong, Colleen Wright. Perinatal
mortality group, Departments of Obstetrics and Gynaecology, Pediatrics and Child
Health and Anatomical Pathology, University of Stellenbosch and Tygerberg Hospital.
Introduction
Hypertensive diseases in pregnancy remain important causes of perinatal mortality in
Tygerberg Hospital.
Primary prevention of hypertension in pregnancy is not a
realistic expectation at present.
Caretakers should therefore address those
complications which contribute most significantly to the perinatal deaths in mothers
with hypertension.
Patients and methods
All perinatal deaths in Tygerberg Hospital are reviewed weekly at a combined
meeting attended by obstetricians, neonatologists, a geneticist and pathologists. The
folders of both mother and baby are summarized prior to the meeting and then
presented and discussed.
Each death with birth weight > 499g is categorized
according to the classification used in the Perinatal Problem Identification Program
(PPIP). We investigated the mechanisms of perinatal deaths of singleton babies born
between July 2002 and June 2006 where the primary cause of death was recorded
as either “Chronic Hypertension”, “Proteinuric Hypertension”, “Eclampsia” or
“Abruptio placentae with Hypertension” on the PPIP database.
We recorded
additional information on the mother and baby on a separate data sheet.
Results
There were 375 perinatal deaths of which 301 (80.3%) were stillbirths. Women with
eclampsia were significantly younger and of lower parity than those with
hypertension (Table 1). The mean gestational age at delivery in women with preeclampsia or eclampsia was less than 28 weeks.
The underlying hypertensive
conditions in 144 women with abruptio placentae were pre-eclampsia (93),
hypertension (46) and eclampsia (5).
58
The major associations with perinatal deaths were abruptio placentae (144 =
38.4%), termination of pregnancy (88 = 23.5%), intrauterine growth restriction (47
= 12.5%) and prematurity (49 = 13.1%) (Table 2) The cause of death remained
unknown in 41 (10.9%) cases. When cases categorized as abruptio placentae with
hypertension are included, 281 (74.9%) of women had pre-eclampsia, 34 (9.1%)
had eclampsia and 60 (16%) had hypertension, either chronic or pregnancy-induced.
There were 61 cases with HELLP syndrome.
Ten of these women also had
eclampsia. Two hundred ninety seven (79.2%) of women received some degree of
antenatal care.
Table 1
The distribution of final causes of perinatal deaths according to
the PPIP codes. (AP = abruptio placentae; Ecl = eclampsia; HT
= hypertension; PE = pre-eclampsia)
Age (years)
Gravidity
Primigravidae
(%)
Gestation at
delivery (weeks)
AP
(n = 144)
Ecl
(n = 29)
HT
(n = 14)
25.1 ± 6.2
22.5 ± 4.1 30.7 ± 6.7
PE
ALL
(n = 188) (n = 375)
26.7 ± 6.3
25.9 ± 6.3
2 (1-11)
1 (1-5)
3 (1-8)
2 (1-10)
2 (1-11)
43
59
29
40
42
26.7 ± 4.9
28.9 ± 5.3
31.9 ± 4.6
27.8 ± 3.9 30.2 ± 4.6
Antenatal care
(%)
80
72
93
78
79
Own area (%)
39
45
57
28
34
Metro (%)
73
62
64
50
60
59
Table 2
The distribution of perinatal losses according to underlying
hypertensive condition and final cause of death.
(SB =
stillbirth; ND = neonatal death)
Abruptio placentae
Termination of pregnancy
Intra-uterine growth
restriction
Prematurity
Unknown
Other
Total
Preeclampsia
SB
ND
88
5
Eclampsia Hypertension
SB
5
ND
0
SB
44
ND
2
Total
SB ND
137 7
72
4
12
0
0
0
84
4
30
5
3
1
6
2
39
8
0
28
0
218
43
0
6
63
0
10
0
30
4
0
0
4
0
3
0
53
3
0
0
7
0
41
0
301
49
0
6
74
The gestational age was below 34w in 308 (82.1%) cases and below 28w in 149
(39.7%) cases.
The mean gestational age at birth did not differ between
pregnancies complicated by stillbirths (29.3 ± 4.6w) and neonatal deaths (28.9 ±
3.1w). The stillbirth:neonatal death rates were 3.46 for deliveries before 34w and
12.4 for babies delivered later respectively (p = 0.005).
The birth weights of 209 (55.7%) babies were below 1000g, while 56 (14.9%)
weighed 2000g or more. Fifty-nine (80%) of the neonatal deaths had a birth weight
of below 1000g, while five babies weighed 2000g or more.
The final causes of
neonatal deaths were prematurity (61), asphyxia (6) and neonatal sepsis (6). The
birth weight was below 1000g in 150 (50%) of fetal deaths, while 51 (16.9%)
weighed 2000g or more.
The final mechanisms contributing to perinatal death
differed between the various weight groups (Table 3).
Table 3
Mechanism of death in stillbirths within birth weight
categories. (AP = abruptio placentae; Pl Ins = Placental
insufficiency; TOP = Termination of pregnancy).
Mechanism 500100015002000>2500g
Total
999g
1499g
1999g
2499g
AP
21
37
34
28
17
137
Pl ins
28
5
5
1
0
39
TOP
79
5
0
0
0
84
Unknown
22
9
5
1
4
41
Total
150
56
44
30
21
301
60
The gestational age and the birth weight at delivery were significantly higher in
women with abruptio placentae. Women with abruptio placentae were also more
likely to have had an intrauterine death and a baby weighing more than 2500g.
They were less likely to have had eclampsia or HELLP syndrome.
Termination of pregnancy was proposed to women with severe maternal disease at a
gestational age too low to expect neonatal survival only after consultation with a
consultant from the obstetric special care team. Both gestational age (25.1 ± 1.8 vs.
30.0 ± 5.5 weeks) and birth weight (712.0 ± 150.6 vs. 1359.5 ± 728.9g) were
significantly lower in women who underwent termination of pregnancy.
Forty nine (66%) of the 74 neonatal deaths were due to complications of severe
prematurity, while 11 (15%) were due to asphyxia following abruptio placentae and
another eight followed severe intrauterine growth restriction.
Discussion
Hypertensive diseases remain important causes of perinatal mortality. The majority
of cases were stillbirths. Two important goals of appropriately classifying stillbirths is
to help understand what went wrong and thus improve clinical practice and to assist
in counselling parents about the underlying reasons for the loss and the prognosis
for future pregnancies. Considering the intrauterine condition at time of stillbirth
improved our understanding of why fetuses died. Two major trends were evident.
Firstly, abruptio placentae is the most common cause of death, frequently occurring
as stillbirths at a gestational age where survival would otherwise be expected. The
remaining deaths mostly occur in very small babies and are caused by complications
of prematurity, placental insufficiency or termination of pregnancy for severe
maternal disease prior to fetal viability.
Interventions to improve outcome are not readily available, but research should
concentrate on efforts to postpone the onset of clinical disease, to further refine
absolute indications for delivery and to predict the risk of developing abruptio
placentae. While these results are awaited, perinatal outcome could be improved by
meticulous attention to proper antenatal care aimed at early detection of women at
risk of pre-eclampsia and optimal usage of referring systems to levels of care
appropriate to the underlying maternal condition.
61
DRINKING PATTERNS AMONG THE CAPE COLOURED: RESULTS FROM THE
SAFE PASSAGE STUDY
Hein J Odendaal1, Colleen Wright1, Lut Geerts1, Greetje de Jong1, Wilhelm Steyn1,
Amy Elliot2, Larry Burd2, Hannah Kinney3, Rebecca Folkerth3, Theonia Boyd3, William
Fifer4, Michael Myers4, Kimberly Dukes5, Ken Warren6, Marian Willinger6 and Gary
Hankins7.
1Department of Obstetrics and Gynaecology, Stellenbosch University, US sites
located in the 22Northern Plains, 3Children’s Hospital, Boston, 4Columbia University,
5DM-STAT,
6NationalInstitutes
New
York,
Boston,
of
Health
and
7University7University of Texas Medical Division – Chairman.
Introduction
The National Institute of Child Health and Human Development (NICHD) and the
National Institute of Alcohol Abuse and Alcoholism (NIAAA) of the National Institutes
of Health (NIH) are sponsoring a multi-center investigation to assess the effects of
exposure to alcohol on unexplained stillbirths, sudden infant death syndrome (SIDS)
and various other aspects of fetal and neonatal development. The rates of SIDS and
stillbirth are much higher in the Cape Town (SIDS: 3.41/1,000, Stillbirth 15/1,000)
and the Northern Plains (SIDS: 3.41/1,000, Stillbirth 15/1,000) as compared to the
US population (SIDS: 0.57/1,000, Stillbirth 6.5/1,000), thus, these two catchment
areas were selected for this study. The first phase of the study was a three year
pilot (n=380) focusing on developing an infrastructure to support a larger study
(Phase II, n=12,000, 7 year study), determining the feasibility of recruiting and
following women and obtaining estimates of stillbirth rates in the Northern Plains and
Cape Town. During Phase II we hope to understand the impact of environmental
and genetic modifiers on placental structure and function and central and autonomic
nervous system maturation which contribute to explained and unexplained stillbirths.
Methods
During Phase I in Cape Town, pregnant women completing a statement of informed
consent and meeting eligibility criteria were randomly selected at their first antenatal
visit to participate in the Screener portion of the study at which time a recruitment
interview was completed. After the recruitment interview was completed, women
were asked to participate in the longitudinal portion of the study and be followed
through the perinatal period (i.e., assessments completed at 20-24, 28-32 and 34-38
62
weeks gestation and at delivery) of their pregnancy through one year of infant life
(i.e., assessments completed at newborn, 2 months and 1 year). The scheduled
evaluations were extensive and included but are not limited to exposure information
(alcohol assessments included the Alcohol Use Disorder Identification Test (AUDIT)
and the time line follow-up and follow-back), physiology assessments (Fetal and
infant heart rate recorded continuously by a Toitu monitor for one hour),
neurological assessments (Amiel-Tison and Brazelton), dysmorphology assessments,
pathology (placental biopsies) and laboratory markers (e.g., at 20-24 week serum
alpha-fetoprotein (MSAFP) to access placental function). It is important to note that
during Phase II we will be performing ultrasound examinations to collect fetal
biometry and Doppler flow velocity waveforms in the uterine, umbilical and middle
cerebral arteries. In the case of a stillbirth or infant death, the mother was
approached for consent for autopsy at which the brain stem is removed and frozen
for later examination. Collected specimens were sent in batches to the Children’s
Hospital in Boston for further analyses.
Results
In Cape Town, as of October 19, 2006, 295 women completed the Recruitment
Interview and of those, 110 women participated in the longitudinal study.
Recruitment targets for both the Screener and Longitudinal portion of the study were
Jet. Approximately 28%, 60% and 12% were enrolled during the first, second and
third trimester of pregnancy, respectively and the mean age was 27 years old (std.
dev. = 5.7) and 100% of the women were Cape Coloured (Table 1).
Table I
Demographic Characteristics, n=330
Age (years)*
25.6 (18 – 46)
BMI*
Ethnicity†
Cape Coloured
Education†
Completed High School
Marital Status†
Married or Partnered
25.2 (16 –67)
*Median (min – max)
†
330 (100%)
88 (26.7%)
310 (93.9%)
n(%)
63
Approximately, 30%, 44% and 63% reported not drinking over the past year, three
months prior to becoming pregnant and at the time of the recruitment interview,
respectively. Of the women who reported drinking over the past year (70%), the
mean AUDIT score (range 0-40 and is comprised of 10 items) was 11.3 (std. dev.
=8.1) where scores greater than 7 indicate Risky to High Risk drinking behaviour
based on NIAAA guidelines. These results correlated well with the shorter AUDIT-C
score (Table II) which will be used to assess drinking in the second phase of the
study.
Table II. Alcohol Use Dependence Identification Test (AUDIT-C)
Audit-C
Question 1
How often did you have
a drink containing alcohol
in the past year?
Response
Never
Monthly or less
2-4 times per month
2-3 times per week
4 or more times per week
Score
0
1
2
3
4
Question 2
How many drinks did you
have on a typical day
when you were drinking
in the past year?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
0
1
2
3
4
Question 3
How often did you have
four or more drinks on one
occasion during the past
year
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
0
1
2
3
4
As for as the alcohol use before pregnancy is concerned, the median number of
drinks per occasion and per week was 5.0 and 7.4 respectively. 41.4 % of women
were high-risk drinkers (Table III).
Table III
Alcohol Use 3 Months Prior to Pregnancy N=330
Number of drinks per occasion
5.0 (0.6 – 43)
Number of drinks per week*
7.4 (0.6 – 147)
Number of binge drinking episodes*
6.0 (0 – 90)
Binge Drinker (>= 4 drinks per occasion) †
133 (40.8%)
High Risk (binge or >= 7 drinks per week) †
135 (41.4%)
* Median (min – max) (calculations exclude non-drinkers)
†
64
n (5%)
Although the drinking was less at time of recruitment (Table IV). The proportion of
binge drinkers and high-risk drinkers has not changed.
Table IV
Current Alcohol Use N=330
Number of drinks per occasion
3.8 (0 – 21.6)
Number of drinks per week*
4.0 (0.5 – 59.1)
Number of binge drinking episodes*
0.0 (0 – 84)
Binge Drinker (>= 4 drinks per occasion) †
121 (39%)
High Risk (binge or >= 7 drinks per week) †
121 (42.6%)
†
* Median (min – max) (calculations exclude non-drinkers)
n (5%)
A large proportion of pregnant women smoked (Table V), especially the drinkers
(74.1%).
Table V
Current Exposure to Drinking and Smoking N=330
n (%)
# Cigarettes*
# Drinks*
Participants who Smoke and Drink**
86/311
(27.7%)
Non-Drinkers who Smoke
94/195
(48.2%)
5 (1 – 20)
Drinkers who Smoke
86/116
(74.1%)
5 (1 – 40)
Smokers who Drink
86/180
(47.8%)
4.0 (0 –
21.6)
Non-Smokers who Drink
30/131
2.0
(22.9%)
(0 – 8.875)
* Median
(min – max)
**Note: n = 311 with current smoking and drinking information.
It is also obvious that few pregnant mothers had quit smoking when they became
pregnant. (Table VI).
65
Table VI
Tobacco Exposure N=330
Smoked, ever*
250 (75.8%)
Smoked, 3 months prior*
219 (66.4%)
Number of Cigarettes smoked per day**
6 (1 – 30)
Smoke, now*
188 (57%)
Number of Cigarettes smoked per day**
5 (1 – 40)
* Percent is out of number completing recruitment interview with available smoking
information.
** Median (min – max) (calculations exclude non-smokers)
Conclusions
A high proportion of women drink and smoke around the time of conception and
during pregnancy. Approximately 41% and 21% of women were considered high
risk drinkers based on NIAAA guidelines (drank more than 3 drinks per occasion and
greater than 6 drinks per week) at the time of conception and recruitment interview,
respectively. Although information is disseminated to women regarding the effects
of alcohol, many of them continue to drink at unhealthy levels.
programs must be developed to reduce these unhealthy life styles.
66
Intervention
COMMUNITY OBSTETRICS ULTRASOUND SERVICE: EFFECT OF CHANGING
FROM DATING AND DETAIL SCANS TO DETAIL SCANS ONLY
EJ Poggenpoel*, GB Theron#, L Geerts#, D Grové#
*Bishop Lavis Community Health Center; # Department of Obstetrics and
Gynaecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South
Africa.
Introduction
After a long period of negotiation between the Tygerberg Hospital Obstetric and
Gynaecology department and District Health Services in Cape Town, a primary
obstetric ultrasound service position was created at Bishop Lavis Community Health
Center (CHC). The service commenced in June of 2004 and initially five antenatal
clinics referred their patients for either a dating or a detail ultrasound.
In the
beginning of 2006, a sixth clinic started using the service. In order to accommodate
the increased number of patients, the referral protocol was adjusted to perform
detail scans only. With the use of both protocols, patients who were found to be less
than 18 weeks pregnant at the time of their first examination returned for a detail
ultrasound between 18 and 24 weeks gestational age (GA). Patients who were found
to have low lying placentae or any other conditions that require follow-up, returned
for subsequent scans. The new protocol was introduced in April 2006. The aim of
this study is to determine the effect of changing from a 2 scan policy to a single scan
only policy.
Methods
The time periods October 2005 to March 2006 and April 2006 to September 2006
were retrospectively compared. The statistical data was obtained from the monthly
registers at the Bishop Lavis CHC ultrasound department.
All patients who were
referred for routine antenatal ultrasounds were included in the study.
For the
purposes of this study, the data from the sixth clinic was omitted as they only started
referring patients after the introduction of the new protocol. The following data from
the two time periods were compared:

Number of examinations;
67

Percentage of GA determination scans, fetal anomaly (FA) scans, amniotic
fluid index (AFI) scans, other reasons for ultrasound examinations, repeat
examinations, patients receiving at least one ultrasound as well as abnormal
examinations;

Accuracy with which ultrasounds were requested.
GA determination scans are performed between 7 weeks 0 days and 17 weeks 6
days GA. FA scans are performed between 18 weeks 0 days and 23 weeks 6 days
while AFI examinations are all ultrasounds performed at or after 24 weeks 0 days
GA, at which time neither an accurate GA determination nor a reliable FA check is
possible anymore. Other reasons for ultrasound examinations include determination
of placental position, presentation, increased fundal height etc. Fetal abnormalities
and or pregnancy complications detected include all pregnancy conditions that
require referral or follow-up. Gestational ages 7 weeks 0 days to 13 weeks 6 days
and 18 weeks 0 days to 23 weeks 6 days are regarded as being the optimal time
periods for ultrasound. GA determination is performed most accurately during the
first time period and fetal anomaly detection during the second time period¹.
Statistical analysis was performed using the SPSS version 13 statistical package for
social science. Chi-square test were performed. A P-value of < 0.05 was considered
statistically significant.
Results
A total of 10 603 patients booked at the five participating ante-natal clinics. 5371
ultrasound examinations were performed of which 931 were repeat examinations.
Therefor, a total of 4400 patients (41.87%) received at least one ultrasound and
there was 190 (4.28%) abnormal examinations.
Tabel 1 domonstrates the
comparing data from the two time periods as well as the P-values obtained.
68
Table 1
Data and comparison between the two time periods
_________________________________________________________________
1st period
2nd period
%
Total bookings 5311 5292
50.08 vs. 49.91
Total ultrasounds
2833
2488
GA scans
655
294
22.72 vs. 11.82
FA scans
1989
1932
70.21 vs. 77.65
AFI scans
178
215
6.17 vs. 8.64
Other reasons for
ultrasound
61
47
2.12 vs. 1.89
Repeat examinations
614
317
21.67 vs. 12.74
Patients receiving at
least 1 ultrasound
2219
2171
41.78 vs. 41.02
Abnormal
examinations/number
of fetuses affected
99
91
4.46 vs. 4.19
Accurate referrals
1609 of 2190 1584 of 2048 73.50 vs. 77.34
P-value
0.0000
0.0000
0.0005
0.5549
0.0000
0.4288
0.5749
0.0035
The number of abnormal examinations was 190 and the total of abnormalities
detected was 211. Of these, 54.74% were confirmed at either Tygerberg Hospital or
at follow-up at Bishop Lavis CHC. 3.68% of cases were not confirmed and 2.11%
resolved at follow-up.
The remaining 39.47% of cases were directly referred to
Tygerberg Hospital for treatment and did not pass through the ultrasound
department. The most notable abnormalities and or complications detected were 38
sets of twins, 38 cases of liquor disturbances (oligo- or polyhydramnios), 25 cases of
renal abnormalities and 17 fetuses with absent fetal heart action.
Discussion
The total number of bookings and bookings before 24 weeks GA remained virtually
unchanged. However, the number of GA determination scans reduced significantly
resulting in a reduction in the number of scans performed in the 2 nd time period.
The reduction in the number of GA determination scans resulted in the decrease in
repeat examinations performed.
This in turn resulted in an increase in the
percentage of FA scans performed as the denominator, which is the total number of
scans, decreased.
The unchanged percentage of bookings before 24 weeks GA
resulted in the unchanged percentage of patients who are eligible for an ultrasound.
It also explains the unchanged detection rate of fetal abnormalities and or pregnancy
complications. The fact that one fetus can have more than one abnormality present
explains the discrepancy between the number of abnormal examinations and the
69
total number of abnormalities detected.
The majority of the 2.11% of abnormal
examinations that resolved at follow-up were liquor disturbances and cases of
pyelectasis.
The almost 40% of cases that were referred directly to Tygerberg
Hospital for treatment included all cases of absent fetal heart action and failed
pregnancies.
The ability to determine GA accurately by the referring staff depends heavily on a
known last menstrual period (LMP) date and or a palpable fundal height. With the
use of the first protocol, patients were referred for dating ultrasounds at a time when
the fundal height is not yet palpable and they only had the LMP to determine GA
with. It is therefore understandable that more patients will be referred accurately
with the use of the second referral protocol when they have both the LMP and a
palpable fundal height to assist them in determining GA.
Conclusion
Changing from a dating and detail scan protocol to a detail scan only protocol
allowed more patients to be examined during ideal sonographic time periods. Less
examinations achieved the same results as far as the percentage of patients
receiving at least one ultrasound is concerned as well as the fetal abnormality and or
pregnancy complication detection rate. The second protocol allows better utilization
of resources as the patient sonographer ratio increases and the examination
sonographer ratio remains unchanged.
70
POST PARTUM HAEMORRHAGE: THE INTRACTABLE PROBLEM
HA Lombaard, RC Pattinson
MRC Maternal and Infant Health Care Strategies Research Unit and Obstetrics and
Gynaecology Department, University of Pretoria
Introduction
Post partum haemorrhage (PPH) remains a mayor cause of maternal morbidity and
mortality not only in developing world but also in the first world. The problem is
further highlighted by the fact that for many physicians dealing with the problem it
appears that there is a fear to do hysterectomy and the effects of this on future
fertility. In this study the aim was to evaluate the effect of a strict protocol approach
in the management of women with PPH. The patients used in the study were
indigent patients managed in the tertiary hospitals of the Pretoria Academic Hospitals
which includes Pretoria Academic Hospital and Kalafong Hospital.
Methods
In the time period 1997 to 1998 Mantel and Patterson developed the definition of the
severe acute maternal morbidity (SAMM or Near miss). After there initial work and
evaluation of the outcomes a strict protocol was developed for the management of
women with PPH. The initial time period was used as the control and the times 20022003 and 2004 to 2005 was used because at this time the protocol was well
established. The protocol was implemented using morning meetings, special training
sessions with new people in the department, at ward rounds and also in some
instances at face to face discussions.
The outcomes that we measured were the number of SAMM, maternal deaths,
hysterectomies performed and the mortality index.
Near Miss markers were the following:

Cardiac dysfunction: Pulmonary oedema, Cardiac arrest

Vascular dysfunction: Hypovolaemia requiring > 5 units of blood products

Immunological
dysfunction:
ICU
admission
for
sepsis,
emergency
hysterectomy for sepsis

Respiratory dysfunction: Intubation and ventilation for any reason other than
general anaesthesia, Oxygen saturation of less than 90% for more than 60min
71
PaO2/FiO2 < 3

Coagulation
dysfunction:
acute
thrombocytopenia
requiring
a
platelet
transfusion

Cerebral dysfunction: coma lasting > 12 hours, Subarachnoid or intracerebral
haemorrhage

Renal dysfunction: oliguria, < 400ml/24hr Urea > 15mmol/l or of creatinine to
> 400mmol/l

Liver dysfunction: jaundice in the presence of pre-eclampsia

Metabolic dysfunction: diabetic keto-acidosis
Our strict protocol for the management of the patients is set out in the following
algorithm: Diagram 1. In theatre we would start with a manual examination of the
uterine cavity and if that is normal a evacuation of the uterus. If that does not
control the bleeding or if the uterus is well contracted we will proceed with a
laparotomy and step wise devascularization of the uterus. There after a B Lynch or
internal iliac ligation or a hysterectomy will be performed to control the bleeding.
Results:
Table 1 shows the results.
Table 1
No of deliveries
No of Near miss
No of Maternal deaths
Maternal mortality ratio/1000 deliveries
Mortality index
Number of hysterectomies performed
1997-1998
27025
36
2
7,4
5,2%
25
2002-2003
32814
61
5
15,4
7,58%
21
2004-2006
42187
78
4
9,5
4,87%
47
Over the time periods there was no significant change in any of the outcomes
measured. The question is how this compares to other units. Table 2 shows a
comparison of our results with other units.
72
Table 2
Units
Pretoria Academic Complex
1997-1998
Pretoria Academic Complex
2002-2003
Pretoria Academic Complex
2004-2005
Nigeria
2002-2004
Scottish Near miss study
2001-2002
Canada
1991-193
Canada
1998-2000
Near miss/100 deliveries
1,3
Rate requiring hysterectomies
0,9
1,9
0,6
1,8
1,1
20
No data available
1,9
No data available
1,51
0,26
1,04
0,46
From all the above it is clear that the intervention did not change any of the
outcome. Which is further clear is we compare well to the Scottish data, much better
to the Nigerian data but worse than the Canadian data. Our hysterectomy rate is also
much higher than the Canadian study.
This lead to the following questions regarding why there was no change in outcome
after the implementation of the strict protocol:
 Bias in our protocol: Are we doing hysterectomies easier on older patients and
women with high parity? Women less than 22 years had less percentage of
hysterectomies and women above 35 had a higher percentage of hysterectomies.
 Number of caesarean sections: Are we doing too many caesarean sections and
therefore this reflects in a high incidence of PPH and hysterectomies? There was
no real difference between route of delivery and percentage of SAMM and
maternal deaths.
 Fear of doing hysterectomies. Our hysterectomy rate is higher than that of other
units with published data.
 Management of the second stage of labour. Further studies are needed to evaluate
the management of the third stage of labour as a possible cause.
 Do we have a receptor problem in our population? Is there an inherit problem
causing our women to present with post dates and also with poorer contraction
post delivery that cause them too bleed. This needs further investigation.
73
Conclusion

The strict protocol did not reduce the mortality index.

The implementation of conservative surgery did not reduce the number of
hysterectomies.

The time period with the lowest percentage of hysterectomies had the highest
MI.

Further studies are needed to look at the possible causes and possibilities to
reduce post partum haemorrhage.

Until we have clear answers we should be diligent in our management of
women with PPH.
74
Postpartum bleeding: (Diagram 1)
Assess
1)
2)
3)
Call for Help
the patient:
Rub up the uterus
Empty the bladder
Bimanual examination
1) Resuscitate
2) Document Observations
3) Collect blood for FBC, Clotting profile,
Compact
Establish a cause
Atonic uterus
1) Add 30U Pitocin to
vaculiter
2) Misoprostol 600μg pr stat
if still bleeding
3) Prostaglandin F2α
Well contracted uterus
1) Examine vagina and
cervix for possible cause
2) Suture any cause of
bleeding
If no response:
Do bimanual compression and
get patient to theatre
Bleeding from cervical or no local cause:
Compress the aorta and get patient to
theatre.
75
SAVING MOTHERS 2002-2004: DEATHS FROM OBSTETRIC HAEMORRHAGE
S Fawcus, N Mbombo, L Mangate
Obstetric Haemorrhage
•
Accounted for 442 maternal deaths in South Africa during 2002 – 2004.
•
It was the third most common cause of maternal death.
•
These 442 deaths accounted for 13% of the total (3406) maternal deaths.
MATERNAL DEATHS FROM OBSTETRIC HAEMORRHAGE 2002 – 2004
1999 - 2001
2002 – 2004
NOs
MMR
NOs
MMR
APH
100
4.0
129
5.6
PPH
240
9.6
313
13.5
TOTAL
340
442
The proportion of maternal deaths due to obstetric haemorrhage per
province
PROVINCE
EASTERN CAPE
FREE STATE
GAUTENG
KWAZULU / NATAL
LIMPOPO PROVINCE
MPUMALANGA
NORTH WEST
NORTHERN CAPE
WESTERN CAPE
TOTAL
1999-2001
Number
of
deaths reported
41
31
65
71
41
44
27
9
8
340
% of deaths
reported
15.6
12.4
15.3
10.3
28.5
17.3
13.2
14.5
6.9
14.1
2002-2004
Number
of
deaths reported
60
43
93
75
54
48
38
10
21
442
% of deaths
reported
16.2
10.0
13.9
10.3
19.2
16.4
11.7
9.4
10.1
13.0
Demographics - Comments
1) Maternal Age over 35 years is a Risk Factor for APH and PPH.
2) Over 75% of haemorrhage deaths occur at level 1 and level 2 hospitals.
3) In 2002–2004, 42.9% of PPH deaths occurred at level one hospitals(40.9% in
1999–2001.
4) Several women arrived at facility “in extremis” or “died en route”. Level where
death occurred does not necessarily reflect quality of care at that level.
76
Causal Subcategories: APH
SUBCATEGORIES
NO
%
Abruptio Placentae with HPT
14
10.8
Abruptio Placentae
37
28.7
Placenta Praevia
13
10.1
Other
17
13.2
Not Specified
TOTAL
48
129
37.2
Causal Subcategories: PPH
SUBCATEGORIES
NO
%
A). RETAINED PLACENTA (incl. 6 “accreta”)
73
23.3%
B). UTERINE ATONY (incl. 31 “overdistension” & 43
74
“prolonged labour”)
C). UTERINE RUPTURE (incl. 41 – previous CS & 43 –
84
unscarred uterus)
D). OTHER UTERINE TRAUMA
(predominantly bleeding during & following C/section.
78
E) INVERTED UTERUS
4
23.6%
26.8%
24.9%
1.7%
FINAL & CONTRIBUTORY CAUSES
HYPOVOLAEMIA
– APH (76%)
– PPH (88%)
Majority of women died within 24hrs from onset of haemorrhage. Many died within
6hrs.
AVOIDABILITY OF MATERNAL DEATH
CLEARLY AVOIDABLE
– 76% APH
– 83% PPH
FREQUENT AVOIDABLE FACTORS
“PATIENT”
- No antenatal care
(42%APH and 32%PPH) - Delay seeking care.
“ADMINISTRATIVE”
- Transport delay between institutions
(55% APH and 61.4% PPH)
- Lack sufficient blood.
- Lack health care facilities
- Lack appropriately trained staff.
FREQUENT AVOIDABLE FACTORS
HEALTH WORKER RELATED (2/3 - ¾ all cases)
(NB. Level 1 & Level 2 : Skills, Training)
•
Problem recognition / Diagnosis.
(eg. Missing diagnosis of ruptured uterus.)
77
•
•
Substandard Management
eg. – excessive delay in removal of retained placenta
– excessive dosage oxytocin in multigravida
– inadequate further management of uterine atony.
– inadequate surgery for complicated CS.
Monitoring problems – Lack of monitoring
– Inadequate response
Bleeding after caesarean section
STORY 3
14 years old, P0G1, rape survivor had an emergency caesarean section at a level one
hospital following a prolonged labour of 17 hrs in which no partogram was used. The
surgeon was informed by the theatre sister in the recovery area that the patient was
bleeding profusely vaginally. The surgeon did not assess the patient, ordered an
oxytocin infusion of 10u per 1000mls and allowed the patient to be transferred to the
ward within 30mins of the caesarean section. The patient was found dead in her bed
4 hours later. No post mortem was done but it is likely that the she died from an
inadequately treated atonic uterus following prolonged labour or inadequate surgical
haemostasis at surgery.
Other causes of PPH
STORY 5
A 30 year old P2G3, at a level 1 hospital was induced with oxytocin following
prelabour rupture of membranes at term. The membranes had ruptured 24 hours
prior to the induction, during which time there had been 7 vaginal examinations.
There was good progress of labour and a normal vaginal delivery. The patient then
had postpartum haemorrhage. She was resuscitated with intravenous fluids and
antibiotics, given an oxytocin infusion and intravenous syntometrine. Also the vagina
and cervix were inspected for tears .The placenta was thought to be complete. The
patient continued to bleed. There was no blood available in the hospital and no one
available who could perform a hysterectomy, so the patient was referred to the level
2 hospital. However she died en route in the ambulance
78
Quote
from
Senior
professional
nurse
M.M.
Pelonomi
hospital,
Bloemfontein:
“When someone does something wrong, they get on her like all hell. They ask, ‘Why
did you not do A, B, and C?’. They don’t ask whether it was physically possible to do
A, B, and C. It’s always ‘Sister , you failed to do this, you failed to do that.’.
But how can I do it all??” Mail and Guardian.05/10/06.
Recommendations
1.
Broaden availability and accessibility of contraceptive services for women over
35 years.
2.
Research the barriers to women accessing care, the determinants of survival
from massive haemorrhage, and the impact of HIV on deaths from
haemorrhage.
3.
Promote Massive Obstetric Haemorrhage into the status of a Major Incident,
requiring facility to be on high alert in terms of blood, anaesthetic support,
ambulance transport etc. This would need to be rehearsed in the form of
drills.
4.
Define Skills in resuscitation and management of obstetric haemorrhage
required at each level of care.
5.
Define fluids, bloods products, oxytocic agents, surgical equipment necessary
at each level of care.
6.
Ensure managers enable the constant availability of the above.
7.
Ensure managers and lead clinicians institute adequate training systems,
including surgical training.
8.
Facilitate doctors and midwives to undergo training in resuscitation on
accredited courses eg. ATLS
9.
Training to encompass prevention of haemorrhage:
Antenatal treatment of anaemia.

Partogram to prevent prolonged labour

Precautions in use of Oxytocin and Misoprostol in Multi gravida.

Active management of third stage of labour.

Monitoring in first 2 hours after birth, including after Caesarean section
79
10.
Training to encompass practical training on additional surgical and medical
measures required in PPH not responding to oxytocin infusion:
Use of second line oxytocic agents

EUA for retained products and repair of cervical tears

Manual removal of placenta

B-Lynch suture.

Uterine artery ligation

Use of balloon tamponade as possible temporising measure.

Hysterectomy ( level 2 and 3 )

Anti-shock garment
Conclusion
•
Obstetric haemorrhage remains a major preventable cause of maternal
mortality in South Africa, particularly at level one and two facilities.
•
The recommendations tell us ‘what to do’.
•
The challenge is ‘How to do it’
80
DELIVERY AFTER A PREVIOUS CAESAREAN SECTION AT THE CHRIS HANI
BARAGWANATH HOSPITAL
MS Sayed, EJ Buchmann
Background
The incidence of caesarean sections (CS) peaked in the mid 1980's, which led to an
increase of vaginal birth after caesarean section (VBAC). This trend followed
evidence of safety and efficacy of trial of labour (TOL), in an attempt to curb rising
CS rates.
However, data from large series and meta-analyses indicated that the relative risk of
uterine rupture and associated maternal morbidity and severe perinatal morbidity or
mortality was increased in women undergoing a TOL, rather than an elective repeat
CS (ERCS). This risk appeared to be higher in patients who attempted a TOL and
failed.
Subsequent studies were aimed at identifying patients most likely to succeed with
TOL, with the lowest likelihood of uterine rupture, revealing possible predictors of
VBAC success.
A South African study highlighted lower success rates for VBAC with lower birth
weights in developing versus developed countries. These factors appear to vary
according to the time, place and population being studied. A recent study concluded
that it was very difficult to predict uterine rupture in TOL. Given the paucity of data
on VBAC from developing countries and these unanswered questions, we felt a local
study on delivery after CS was warranted.
Introduction
The Chris Hani Baragwanath (CHB) hospital has over 20,000 deliveries per annum.
Current CS rates of 25% are rising. A recent audit showed that 13% of the antenatal
population has had one or more previous CS and 33% subsequently had a VBAC. We
questioned the reasons why the VBAC success rate was lower than expected,
following a TOL at CHB hospital, in comparison to VBAC success rates reported in the
literature.
81
Objectives
The primary objective of this study was to determine the proportion of patients with
one previous CS who attempt a TOL and the VBAC success rate. Secondary objectives
were to establish reasons for failed VBAC, analyse predictive factors for VBAC and
indicators of maternal and neonatal morbidity and mortality.
Methodology
This was a retrospective cohort study from January 2003 to December 2005. A
sample size of 326 was calculated using standard formulae. The study population of
60 000, included all patients who delivered at CHB hospital, with an expected
prevalence of prior CS of 13% and a VBAC success rate of 33%. A desired precision
of 5% with 95% confidence was chosen. A random sample of 3600 hospital records
yielded 383 files of patients with one prior CS. Demographic, obstetric and delivery
outcome data was captured and analysed with Epi-Info and SPSS.
The primary outcome was final mode of delivery. In order for the results of this study
to be comparable to others in the literature, only patients with no clear indication for
ERCS are included in the secondary analysis (n=340). Comparison between the
successful (n=148) and failed VBAC (n=139) groups, is carried out to identify
predictors of VBAC success.
When analysing adverse events, further confounding factors (eg. severe preeclampsia) and other outliers (eg. prematurity and low birth weight) were first
removed. A comparison of maternal and neonatal morbidity and mortality was made
between the ERCS (n=43) and TOL (n=198) patients, and was repeated for
successful (n=99) versus failed (n=99) VBAC patients.
The uncorrected Chi squared test (χ²) was used to evaluate statistical differences
between the groups. The Student’s t test was used for numerical variables while the
Mann-Whitney test was used to compare differences in parity. The odds ratio (OR)
was used to assess the strength of the associations of the variables analysed, with a
95% confidence interval (CI). Where appropriate the Fisher’s exact test was used,
expressed by the relative risk (RR) with a 95% CI.
82
Results
Delivery outcomes of the 383 patients studied were as follows:
 ERCS 57
 emergency CS 39
 TOL 287
Almost 75% of patients with a prior CS attempted a VBAC (287/383). The VBAC
success rate was 51.6% (148/287).
Prelabour rupture of membranes (PROM) and prolonged latent phase of labour
(PLPL) together made up 40% of the reasons for a failed VBAC. Successful VBAC
patients had a higher parity, lower birth weight (BW) and lower gestation.
Table 1
Comparison of failed and successful VBAC
Failed VBAC n=139
Successful VBAC n=148
P value
Age
Parity
Gestation
28.3 (±5.5)
1.43 (±0.8)
38.7 (±2.0)
29.5 (±5.9)
1.80 (±1.0)
37.2 (±3.0)
0.060
<0.001
<0.001
Birth weight
3207 (± 507)
2909 (±654)
<0.001
Positive predictors of VBAC success were:
 previous vaginal birth (OR 2.32, p=004)
 previous VBAC (OR 1.93, p=0.038)
 previous CS for malpresentation
(OR 2.62, 95% CI 1.15-6.12, p=0.012)
 birth weight < 3500g (OR 2.30, p=0.003)
gestation ≤ 39 weeks (OR 2.84, p<0.001)
83
Table 2
Predictors of VBAC success
HIV+
Failed
VBAC
n=139
44
Successful
VBAC
n=148
39
Unbooked
5
11
No CHB ANC
25
23
Antenatal sonar
72
70
RR
95% CI
P
value
1.05
(0.81 – 1.35)
0.63
(0.30-1.32)
1.09
(0.81-1.48)
1.10
(0.86-1.39)
0.72
0.16
0.58
0.45
Negative predictors of VBAC success were:
 P1G2 patient (OR 0.34, p<0.001)
 previous CS for cephalo-pelvic disproportion (CPD) (OR 0.48, p=0.003)
TOL had an increased adverse maternal outcome (RR of 1.24, 95% CI of 1.16-1.32,
Fisher’s exact p=0.038), which was higher in the failed VBAC group (RR of 1.87,
95% CI 1.47 -2.39, χ² =9.79, p=0.002) (Table 3). There was no maternal mortality.
Failed VBAC patients had 2 uterine ruptures (0.7%) and 2 recognised asymptomatic
uterine dehiscences. There were 4 hysterectomies (1%), 2 with uterine rupture
(failed VBAC) and 2 with haemorrhage (1 failed VBAC and 1 EmCS).
Table 3
The effect of previous vaginal birth on VBAC
Failed VBAC
n=139
Success VBAC
n=148
22
45
18
33
103
73
Prior Vaginal delivery
2.32
(1.31-4.13)
1.93
(1.03-3.62)
0.34
(0.20-0.58)
Prior VBAC
P1G2
OR 95% CI
P value
0.004
0.038
<0.001
Finally, after correcting for a gestational age <32 weeks and a birth weight <2000g,
we compared 43 ERCS with 198 TOL patients (Table 4).
The VBAC success rate was 50%. There was one intrapartum fetal death in the TOL
subgroup. TOL had an increased adverse neonatal outcome with a RR of 1.23 when
compared with ERCS patients (15/198 compared to 0/43), 95% CI of 1.16-1.32,
84
Fisher exact p=0.048. There were no statistically significant differences in neonatal
outcomes between the failed and successful VBAC groups (p=0.420).
At a gestation of <34 weeks the VBAC success rate was 89%, and this decreased to
56% at ≤39 weeks. At >40 weeks gestation the ratio of VBAC success to failure
reversed (33%) (Fig 1).
VBAC success at a BW<2000g was 93% and steadily declined to 52% at a
BW≤3499g. The ratio was reversed at a BW>3500g (38%), and was lowest at a
BW>4000g (22%) (Fig 2).
Discussion
Limitations of this observational study arise from the retrospective nature of data
collection. This meant that some key data, related to TOL and VBAC success, was
insufficiently recorded in patients’ hospital records. Therefore maternal body mass
index, symphysis-fundal height measurements, pre-delivery birth weight estimates,
cervical dilatation on admission, labour duration, long term neonatal data, CD4
counts and ARV therapy are absent and not studied.
Table 3
Maternal Morbidity, before and
gestation<32 weeks and BW<2000g
Observed
EmCS
n=39
ERCS
n=57
Ut Rupture
Uterine
Dehiscence
Hysterect
0
0
Blood T/F
Sepsis
after
exclusions
0
0
VBAC
failure
n=139
2
2
VBAC
Success
n=148
0
0
Corrected
ERCS
VBAC
n=43
failure
n=99
0
2
0
2
1
0
3
0
0
2
0
2
0
0
0
6
5
1
3
0
0
4
4
0
2
85
for
VBAC
Success
n=99
0
0
Figure 1
Gestation & VBAC success. p<0.001
100
84
80
65
60
53
40
20
Count
VBAC
26
20
16
19
Success
0
Failure
< 34
34 - 36
37 - 39
> 40
Gestational Age
Figure 2
Birth wt & VBAC success. p<0.001
60
54
50
50
40
42
35
30
30
23
20
VBAC
14
Count
10
12
Success
8
7
0
Failure
< 2000g
2500 - 2999g
2000 - 2499g
3500 - 3999g
3000 - 3499g
> 4000g
Birth Weight
We had a 0.7% uterine rupture rate (separate from asymptomatic uterine
dehiscence), and a 1% hysterectomy rate. These adverse outcomes occurred in
patients who attempted a TOL and had a failed VBAC. This incidence is comparable
to the literature.
The RR of maternal morbidity with TOL was 1.24. This effect is more marked (RR
1.87) with failed VBAC. Therefore the patient who attempts a TOL and fails has a
further increase in maternal morbidity.
TOL patients had a RR of 1.23 of having an adverse neonatal outcome when
compared with ERCS patients.
86
This synopsis of morbidity and mortality with TOL reflects the evidence in the current
literature.
This study is relevant to our unique patient profiles and the various constraints under
which we work in the South African public health sector.
Table 4
Neonatal Morbidity, before and
gestation<32 weeks and BW<2000g
Observed
EmCS ERCS
n=39 n=57
Apgar 0-3
Apgar 4-6
Neonatal
ICU
admission
Intrapartum
fetal
death
Early Neonatal Death
after
exclusions
VBAC
success
n=148
1
7
19
Corrected
ERCS
VBAC
n=43 failure
n=99
0
1
0
2
0
3
0
4
14
0
1
3
VBAC
failure
n=139
1
3
4
VBAC
success
n=99
0
4
4
0
0
2
1
0
0
1
0
0
0
2
0
0
0
for
Therefore the overall results are reassuring that VBAC is relatively safe at CHB.
However, the failed VBAC rate is too high. An improved VBAC success rate is the key
to minimising maternal and neonatal morbidity and mortality. Contrary to developed
countries, more of our patients opt for TOL (75% vs 50%). This might explain the
lower VBAC success rate (52% compared to 60-74%).
A high repeat emergency CS rate is associated with increased maternal and neonatal
complications, emergency anaesthetic and theatre requirements, maternal highcare/ICU admissions, neonatal ICU admissions and long term morbidity secondary to
neonatal neurological disabilities. This ultimately escalates costs to the health-care
system.
This highlights a need for more stringent selection of patients for TOL and earlier
referral for elective CS by 40 weeks gestation. P1G2 patients, estimated BW>3500g
and previous CS for CPD must be informed about the low likelihood of VBAC success.
Furthermore, 40% of failed VBAC (PROM or PLPL) may be amenable to induction or
augmentation of labour with oxytocin.
87
Conclusion
The VBAC success rate at CHB hospital is lower than that in developed countries.
More patients attempt a TOL in our setting. We need strategies to deal with a high
number of failed VBAC due to PROM or PLPL. Predictors of VBAC success were: birth
weight of <3500g, gestation ≤39 weeks, prior vaginal delivery or prior VBAC and
previous CS for malpresentation.
Patients having a TOL, particularly those with a failed VBAC, are at increased risk of
maternal and neonatal morbidity.
88
WHO SYSTEMATIC REVIEW OF THE PREVALENCE OF UTERINE RUPTURE
WORLDWIDE, AND DEATHS FROM UTERINE RUPTURE IN SOUTH AFRICA
GJ Hofmeyr,1* L Say,2 AM Gülmezoglu,2
Department of Obstetrics and Gynaecology, East London Hospital Complex;
Effective Care Research Unit, Eastern Cape Department of Health/University of the
Witwatersrand/University of Fort Hare, South Africa
1
2
UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and
Research Training in Human Reproduction, Department of Reproductive Health and
Research, World Health Organization, Geneva, Switzerland.
Background
A major factor in uterine rupture is obstructed labour. Black African women have a
high incidence of contracted pelvis. Juveniles in a population with a high incidence
of contracted pelvis were found to be at high risk of obstetric complications.
Other risk factors for uterine rupture include multiparity and particularly grand parity,
the use of uterotonic drugs to induce or augment labour, placenta percreta and
rarely intrauterine manipulations such as internal podalic version and breech
extraction.
In less and least developed countries, uterine rupture is an important cause of
maternal mortality, as high as 9.3% in one Indian study. In the Second Report on
Confidential Enquiries into Maternal Deaths in South Africa 1999-2001, ruptured
uterus caused 6.2% of deaths due to direct causes and 3.7% of all deaths (1.9%
due to rupture of an unscarred uterus and 1.8% due to rupture of a scarred uterus).
Ruptured uterus was the only cause other than sepsis to have increased since the
previous report, possibly due to the widespread use of misoprostol in uncontrolled
dosages for labour induction (misoprostol was identified as the cause in several
cases). There have been reports of uterine rupture when misoprostol was used in
dosages above 25µg vaginally.
No estimates exist to assess the magnitude of this potentially life-threatening
condition. We conducted a systematic review of available data on the prevalence of
ruptured uterus with an emphasis on the contexts in which the primary studies were
89
conducted. The systematic review aimed at establishing the global prevalence of this
problem.
Methods
We searched 10 electronic databases, WHO regional databases, internet and
reference lists, contacted experts in the field, and hand-searched relevant articles in
the WHO Library. Criteria for inclusion of studies in the review were: inclusion of data
relevant to pre-defined conditions, specified dates for data collection period,
including data from 1990 onwards, sample size >200 and a clear description of
methodology.
Nearly 65 000 reports were screened initially by titles and/or abstracts of which more
than 4500 were retrieved for full-text evaluation. More than 2500 of these were
included in the review. Data extracted were entered into a specifically constructed
database and tabulated using SAS software.
Studies were grouped according to the clinical criteria for inclusion in the study, and
the UN classification of the country (developed, less developed or least developed).
Raw data from all the included studies were tabulated and reported, and summary
statistics reported as median values and range of percentages. This allows readers
to have a clear picture of the spread of results, without studies with large numbers
dominating the summary statistics.
Results
Eighty-three reports of uterine rupture rates are included in the systematic review.
Most are facility based using cross-sectional study designs. Prevalence figures for
uterine rupture were available for 86 groups of women. For unselected pregnant
women, the prevalence of uterine rupture reported was considerably lower for
community-based (median 0.053, range 0.016-0.30%) than for facility-based studies
(0.31, 0.012-2.9%). The prevalence tended to be lower for countries defined by the
United Nations as developed than the less or least developed countries. For women
with previous caesarean section, the prevalence of uterine rupture reported was in
90
the region of 1%. Only one report gave a prevalence for women without previous
caesarean section, from a developed country, and this was extremely low (0.006%).
In the SA NCCEMD reports, the proportion of maternal deaths from PPH which were
attributed to unscarred uterine rupture increased from 6% in 1998 to 14% in 19992001, and concern was expressed about the number related to misoprostol use. In
the 2002-2004 report, this proportion remained constant (14%). Ruptured uterus
was the commonest cause of death from postpartum haemorrhage (14% unscarred
+ 13% scarred = 27%).
Conclusion
In less and least developed countries, uterine rupture is more prevalent than in
developed countries. In developed countries most uterine ruptures follow caesarean
section. Future research on the prevalence of uterine rupture should differentiate
between uterine rupture with and without previous caesarean section.
Ruptured uterus is an important cause of maternal mortality in South Africa, and the
rate from ruptured unscarred uterus is unusually high. Inappropriate use of uterine
stimulants may be a causative factor.
91
Figure 1
Median and range of prevalence of uterine rupture in subgroups of studies
Median and Range of Prevalence of Uterine Rupture
# of Studies
Population Based
8
Developed
5
Less/Least Developed
3
Facility Based
44
Developed
3
Less Developed
30
Least Developed
11
Previous C-Section
15
Developed
12
Less Developed
3
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Prevalence of Uterine Rupture (%)
92
3.5
4.0
4.5
5.0
HANDS AND KNEES POSTURE IN LATE PREGNANCY OR LABOUR FOR FETAL
MALPOSITION (LATERAL OR POSTERIOR POSITION)
Sandy Hunter, G Justus Hofmeyer,* Regina Kulier
Effective Care Research Unit, University Witwatersrand, University of Fort Hare, EC.
Department of Health; *Geneva Foundation for Medical Education.
Introduction
Lateral and posterior position of the baby’s head may be associated with a more painful,
prolonged or obstructed labour and difficult delivery. Assuming a “hands and knee” position
may help the baby modify its position.
Method of the Review
Trials were assessed on quality of the studies based on allocation concealment, generation of
random allocation sequence, blinding of outcome assessment, completeness of data
collection, including differential withdrawal of participants or loss to follow-up from different
groups; and analysis of participants in randomised groups (analysis by intention to treat).
Data were extracted from the sources and entered into the Review manager computer
software (Revman 2003). For dicotomous data we calculated relative risks and 95%
confidence intervals. For continuous data, weighted mean differences with 95% CI were
used.
Methodological quality of included studies.
Andrews (1983)-The randomised assignment was not specified, yet in other respects
methodologically sound. Palpation was used as the only measure to obtain an outcome
which may be subject to error, but as evaluation was made “blind” to group allocation, the
outcome assessment was probably unbiased. Kariminia (2004)-Telephone randomisation
was done by an independent service. There was a discrepancy in numbers allocated to each
group (1292vs1255) in spite of using permutated blocks of size 4. Approximately 16% of the
intervention group withdrew compared to 3.5% of the control group. This may be an
indication of acceptability of the intervention treatment. However the analysis was by
intention to treat. Stremler (2005)- There was centrally controlled telephone-based
computerised randomisation. No withdrawls were recorded and compliance of women in the
study group was excellent. Clinicians who were involved in the telephone call in order to
obtain group allocation were excluded from performing the final ultrasound in order to obtain
the primary outcome. This appeared to be the only measure carried out to ensure blinding.
Results of the 3 included trials
Andrews (1983) reported that lateral or posterior position of the presenting part of the fetus
was far less likely to persist following 10-minute “hands and knee” position than in the
control position. Kariminia (2004) reported clinical outcomes in women using “hands and
knee” posture with pelvic rocking for 10mins, twice daily, for the last few weeks of
pregnancy. There was no difference in position at delivery or other outcomes. Stremler
(2005) found that 11 of the women using “hands and knee” positioning experienced fetal
head rotation from Occipitoposterior to Occipitoanterior after 1 hour, compared to 5 women
in the control group. The secondary outcome of persistent back pain was recorded as the
mean differences of pre-intervention and post-intervention scores. This showed a significant
difference between the intervention and control group.
93
Reviewer’s conclusion: Implication for practice
The use of “hands and knee” posture in late pregnancy to correct occipitoposterior position
of the fetus cannot be recommended as an intervention. This does not suggest that women
should not adopt the position if they find it more comfortable. With regards to the “hands
and knee” posture in labour, there was a significant reduction in persistent back pain,
without evidence of harm to either fetus or mother when assuming this position. Women are
therefore encouraged to use this position for comfort in labour, though evidence is still
limited regarding effectiveness in promoting fetal head rotation.
94
MIDWIFERY MODELS? WHAT KIND OF MIDWIFE DOES SOUTH AFRICA NEED?
Dippenaar JM
Nursing Science, Medunsa Campus University of Limpopo.
Problem Statement
The World Health Organization (WHO) 2006 states that the ability of healthcare-systems
to cope with the challenges during transformation is based on appropriately trained and
supported health professionals where needed. Midwives are major contributors to the
realization of health care targets for a given country and are undermined by various
issues. Failure to address these will have serious implications on the accessibility and
quality of care, the well being of health practitioners and the ability to reach the
Millennium Development Goals.
Differences in models or content of midwifery care within a given healthcare setting are
one of the issues. International Confederation for Midwives found the core functionalities
of midwives globally similar with differences in form/ style of service delivery. Frances
Day –Stirk in Midwives asks in ‘Uniting midwives across Europe’ whether “Europe needs
its own definition of a midwife”.
In the 21st century the role and function of the midwife globally is under investigation.
The question is: “What kind of midwifery is needed for the 21st century?” and for us, “
what kind of midwife does SA needs?
Purpose
The in-depth literature as part of a PhD study in progress re midwifery practice and service
delivery within the SA healthcare context investigates and benchmarks models of midwifery
practice globally within different healthcare contexts.
Methodology
An in-depth literature review investigates the differences in midwifery models
Conclusions
The recommendation of the “Brief of the global network of collaborating centres for nursing
and midwifery development 2002-2008” (2006) is that healthcare systems should develop
frameworks that work for the particular context and challenges SA about midwifery.
95
MIDWIFERY IN THE DUAL SOUTH AFRICAN HEALTHCARE SYSTEM
Dippenaar JM
Nursing Science, Medunsa Campus University of Limpopo.
Problem Statement
Midwifery service-delivery, midwife/doctor ratios, quality, equity and outcomes within the
dual healthcare system of South Africa vary between the public (74%) and private sector
(16%). Since 1891 South African midwives enjoyed state-registration but today only 30
private midwives (0, 4%) are conducting deliveries. In the public sector 77% of midwiferycare is in the hands of midwives within a fragmented healthcare system [including 28
Midwife Obstetric Units (MOU’S]. Only 30% of women (SADHS 1998) report seeing a doctor
once during childbirth. Transformation of the Healthcare system in SA affects midwifery
services and requires equity, equality and value for stakeholders pursued in this study in
terms of improved midwifery service delivery measured through sustainability.
Purpose
This study purposes to develop a conceptual framework for midwifery services in SA.
Methodology
An explorative, descriptive theory-generation research-design in this inquiry developed a
conceptual framework for the sustainable in midwifery in view of drafting and validating a
model. (Phase 1)
Results
The conceptual framework for a sustainable midwifery service delivery includes the
contextual aspects of role players, and purpose of the model, related processes and
underlying dynamics. This paper focuses on the dimension of a sustainability model used as
a conceptual framework. The dimensions of sustainability relates to the triple bottom-line
test, (economic prosperity, social justice and environmental) as ultimate measure for
corporate success in the 21st century.
Conclusions
The conceptual framework related to sustainability of midwifery service delivery and refers to
the integrated and balance performance of dimensions of sustainability, (industry,
stakeholders, value and profit) as derived concepts of Olson‘s (1998) framework for
sustainability in healthcare.
96
NON-PREGNANCY RELATED INFECTIONS: SAVING MOTHERS REPORT 2002-2004
RE Mhlanga, P Tlebere, Dr Nkuna
National Committee on Confidential Enquiries into Maternal Deaths, National Department of
Health, South Africa
Non-pregnancy related infections (NPRI) remain the leading cause of maternal deaths at all
levels of care in this triennium with AIDS deaths being the biggest challenge for the health
sector. A total of 1246 deaths from non-pregnancy related infections were reported for the
triennium 2002-2004. HIV testing of women improved from 37.6% in 1999-2001 to 50% in
the 2002-2004 triennium. Of all women who died because of NPRI, AIDS contributed 53.1%,
followed by pneumonia contributing 25.4%, TB 8.3% and meningitis 6.3%. Malaria deaths
declined from 5.3% in 1999-2001 to 1.3% in 2002-2004. AIDS continues to be
underestimated as a strict definition of AIDS is used, as many women die before results of
HIV testing are known. In order to make a diagnosis of AIDS, a positive HIV test plus an
AIDS defining condition must be present.
There are provinces that need to improve access to counselling and voluntary testing.
AIDS remains the main cause of death in all age groups followed by pneumonia, tuberculosis
and meningitis with the age category 25 – 29 being at most risk for all four. The commonest
final and contributory causes of death were respiratory failure or immune system failure
which occurred in more than 50% of patients. Deaths occurring at level 1 hospitals increased
sharply. Deaths in level 2 hospitals were second highest. Patients presented with an
emergency equally in the antenatal period (44.2%) and in the postpartum period (43.7%).
Patient-related factors decreased from 68.8% in 1999-2001 to 46.2% in 2002-2004. They
were reported as the commonest avoidable factors. Delay in seeking help was the main
contributor followed by lack of antenatal care. Lack of specific health care facilities, shortage
of doctors and midwives and transport problems between institutions, and from home to
health facilities are the main administrative avoidable factors. The use of CD4 cell count is
not yet universal. There are personnel related factors, such as fatalism and non-caring
attitude once a diagnosis of HIV infection is suspected or made. Delay in providing care is
the other factor in the management of many women with HIV and other infective conditions.
There is also lack of utilisation of the ethical guidelines for the management of women with
HIV infection.
97
HAS THE PROVISION OF ANTIRETROVIRALS AT PRIMARY HEALTH
CARE LEVEL INFLUENCED THE MATERNAL MORTALITY RATE IN A
RURAL SUBDISTRICT IN NORTHERN KWAZULU NATAL?
JL Nash
Mseleni Hospital
Introduction
There is a bewildering number of statistics on the past, present and future
predictions of the HIV pandemic. Although many countries are facing
increasing rates of HIV, by far the burden of the disease is found in SubSaharan Africa. It has been estimated that at the end of 2003 25-28 million
people were infected in Sub-Saharan Africa, with a global estimate of 34-46
million.
In South Africa, the Department of Health has been monitoring the
prevalence of HIV amongst antenatal women since 1990. Although these
statistics do not include those women attending private clinics and hospitals,
they have shown that over the last 15 years there has been a disturbing
increase in the HIV prevalence amongst antenatal women. In 2005 this was
reported to be 29.5%. There is considerable variation between the provinces,
with KwaZulu Natal having the highest prevalence.
HIV prevalence trends in South Africa 19902005 (DoH annual antenatal data – HST)
35
30
25
20
15
10
5
0
1990
1992
1994
1996
1998
2000
2002
2004
Mseleni hospital is a rural district hospital in the UmKhanyakude district, in
northern KwaZulu Natal. The area it serves is 110 km by 30 km. The hospital
98
has 190 beds, has 8 residential clinics and 32 mobile points, and serves a
population of 95 000 people.
The area consists of scattered rural dwellings, with unemployment estimated
to be as high as 70%. The provincial antenatal survey over the last four years
has indicated that 32-35% of antenatal women are HIV positive.
Background to the provision of antiretroviral therapy at Primary
Health Care level
Antiretroviral therapy was introduced to the subdistrict in July 2004. From the
outset, the work-up of patients and the provision of the drugs were based at
the clinics. The question was asked: why should antiretrovirals be based in
primary health care facilities? There are a number of problems with a
centralised programme. Firstly, are equity issues. Remotely situated clients
have as much right and need to access treatment. Secondly, experience
issues at the central point may not extrapolate down to the referral point.
Thirdly, “down referral” of clients breaks continuity in care and may
jeopardise long term adherence.
There are a number of points in favour of antiretrovirals being provided at
primary health care facilities. Firstly, HIV is common. In northern KwaZulu
Natal perhaps 11% of the population is infected. Secondly, the provision of
antiretroviral drugs does not require specialised equipment, only a reliable
drug supply. Thirdly, the major cost to the client is in terms of time and
transport, travelling to the provision point. Fourthly, the long term issue with
antiretroviral drugs is adherence, which is an issue relating to the client and
the provider. For these reasons, the primary health care facility has the power
to provide these drugs, due to its immediacy and the personal quality of
relationship.
The advantage of this approach at Mseleni is that each residential clinic and
the hospital serves between 5000 and 15 000 people as primary care point.
99
Each clinic is situated so that 75% of the population is within 5 km of the
clinic, and 95% of the population are within 10km. The clinic team consists of
health care professionals based at the clinic, and who are visited on a weekly
or twice weekly basis by doctors and paramedics. The clinics use support
groups. There is good integration of services, such as antenatal clinic, PMTCT
programmes, well baby clinic, TB services, etc.
The Antiretroviral programme functions by using VCT and PMTCT counselling
as entry points. Following counselling and testing, CD4 counts are taken at
the clinic on those clients who test HIV positive. A date is given to the client
to return after two weeks for the results. Following the CD4 result,
subsequent bloods are also taken at the clinic, while the CXR is requested at
the hospital. Once work-up is completed (module training and bloods), a date
is given for dispensing of antiretrovirals at the clinic on a doctor’s visiting day.
Doctors visit clinics on set days, and usually the same doctor visits the same
clinic weekly. Subsequently, clients are seen by the doctor or professional
nurse, as according to the national guidelines.
Currently, there are 2100 clients on antiretroviral therapy in the Mseleni
subdistrict, with 196 paediatric clients. These clients are followed up at their
respective clinics found throughout the subdistrict.
Study Design
A retrospective audit of all maternal deaths was conducted between 2001 and
2006. These deaths were analysed, with the use of the Perinatal Problem
Identification Programme (version 2).
Results
Between 2001 and 2006 there were 27 maternal deaths. Those who were
tested HIV positive were 23 (85%). There were three of unknown HIV status
and 1 refused HIV testing. Fifteen of the deaths (56%) were directly related
100
to HIV associated infections and complications on clinical grounds, since no
post mortems were performed.
The main causes of maternal deaths were as follows: pneumonia, including
TB
(29.6%),
meningitis,
including
cryptococcal
meningitis
(18.5%),
hypertension related including eclampsia (14.8%), embolus (11.1%), chronic
gastroenteritis (7.4%), and other, which included malara, ectopic, PPH,
lightening strike and suspected lymphoma.
Causes of maternal deaths
•
•
•
•
•
•
P: pneumonia including TB
(29.6%)
M: meningitis including
cryptococcal meningitis
(18.5%)
H: HPT related including
eclampsia (14.8%)
E: Embolus - pulmonary
(11,1%)
G: Chronic gastroenteritis
(7.4%)
O: other, including malaria,
ectopic, PPH, lightening strike
and ?lymphoma
30
25
20
15
%
10
5
0
P
M
H
E
G
O
The maternal mortality rate between 2001 and 2006 was calculated, and has
shown a decreasing trend (580/100 000 in 2003, to 172/100 000 in 2006).
Maternal mortality rate 2001-2006
600
500
400
300
MMR per 100 000
200
100
0
2001
2002
2003
2004
2005
2006
101
Discussion
The prevention of mother to child transmission programme started in the
subdistrict in November 2000 with private overseas funding. From 2000 to
2003, ELISA tests were used for testing of HIV. These bloods were sent to
the district laboratory, with results taking between two and three weeks to
return. The HIV quick tests were introduced in 2003, thus increasing ease of
testing. In 2006, antenatal HIV testing at Mseleni was 94%, with a district
average of 91%. Those testing positive in the Mseleni subdistrict was 29.5%,
with a district result of 31.9%.
In 2001 and 2002, the maternal death rate was 143/100 000 and 144/100
000 respectively. It is thought that this was probably under-reporting of
actual deaths. Although all four maternal deaths in 2001 and 2002 were HIV
tested (100% HIV positive), HIV testing had just commenced in earnest.
From 2003, there were improved methods of reporting maternal deaths.
There was less rotating of maternity ward staff, leading to greater stability.
There was also increased effort to record deaths from the medical and
surgical wards. In 2006, the district office and Mseleni hospital obtained data
capturers, in addition to a number of clerical staff working at the hospital and
clinics.
Antiretroviral drugs were introduced into the district in July 2004. In order to
access a CD4 count, an ID book was required. This was problematic as many
people do not posses ID books. Since the latter half of 2006, an ID book is no
longer required for CD4 count testing, or for starting antiretroviral drugs. This
has increased accessibility to testing and to treatment.
There are a many challenges of providing antiretroviral drugs at primary
health care facilities. There are severe staff shortages in the subdistrict. There
is also a high-turner of staff, especially amongst senior members of staff and
at management level. This interrupts programme functioning and means that
there needs to be ongoing staff training, especially at distant sites. As the
102
programme has expanded there is increasing demand for office and clinic
space. The pharmacy has also had to cope with increasing numbers of
patients on antiretroviral drugs and have had to ensure that there is reliable
drug supply to the clinics. The collection of bloods specimens involves
transport visiting clinics on a scheduled basis. These specimens are packaged
at the Mseleni laboratory, and then sent to the district or provincial
laboratories for the necessary tests. A good system is required to then
process results back to the respective sites timeously. The province has not
provided a data base for monitoring individual programmes, so this has had
to be done at local level, with sometimes less than ideal expertise. Human
resources and time is required to constantly monitor and evaluate these
aspects of the programme, and interact with the various stake-holders to
facilitate changes. Finally, there has been limited expertise available, which
needs to be shared throughout the sites in order to continue to manage
complex patients.
Conclusion
A retrospective audit of maternal deaths from 2001 to 2006 revealed 27
deaths. The numbers are too small to make too many conclusions. Accurate
statistics have not been kept over the years with respect to HIV testing.
However, from national statistics it is obvious that the HIV prevalence has
been increasing and is at alarmingly high levels, especially in KwaZulu Natal.
From the retrospective audit of maternal deaths, it appears that the maternal
mortality rate is decreasing. However, ongoing monitoring and evaluation is
needed over the subsequent years. It is hoped that the approach of providing
antiretroviral drugs at primary health care level will enable this trend of
decreasing maternal mortality rate to continue and to be sustainable.
103
ESTABLISHING AN ANTIRETROVIRAL CLINIC WITHIN AN ANTENATAL
CLINIC
Vivian Black1,2, Patricia Okeyo2 , Helen Rees1,2
Institution: 1Reproductive Health and HIV Research Unit and the 2Department of
Obstetrics and Gynaecology, University of the Witwatersrand
Introduction: The HIV epidemic in South Africa is one of the fastest growing
epidemics in the world with 30.2% of all women attending ante-natal clinic being
HIV sero-positive. This has a significant impact on families in our community. Not
only are the unborn children themselves at risk of acquiring HIV infection from their
mothers, but the burden of disease often renders the mothers incapable of looking
after their families effectively due to ill health. In addition, without antiretroviral
therapy, many women with AIDS progress to death rapidly. This leaves many
children orphaned and poses a huge burden on extended, grieving families and the
community at large.
In July 2004, the ante-natal clinic (ANC) at the Johannesburg Hospital began treating
HIV positive pregnant women with a CD4 count less than 200 × 109 with highly
active anti-retroviral therapy in line with the Department of Health’s antiretroviral roll
out programme. The benefits to HIV infected pregnant women include reduced HIV
related mortality and morbidity. The benefits to the fetus include reduced HIV
transmission from the mother to the fetus, and the survival and well being of the
mother which impacts positively on the survival of the baby.
Methods: An ongoing data base of all patients who attend the clinic is kept. Data of
patients who attended the clinic between July 2004 and end June 2006 was entered
into Excel. Where information was missing, patient information was retrieved
retrospectively. Information included age, CD4 count, viral load, haemoglobin, TB
diagnosed, RPR, age of fetus at initiation of ART, complications experienced while on
ART both in terms of the mother and the fetus, growth of fetus. Reported
compliance of the women of ART therapy, backed up with pill counts, complications
experienced during delivery, fetal outcome and mode of delivery.
Results: 597 women had attended the clinic between July 2004 and June 2006.
There was sufficient information on 527 women to include in this analysis. The
average age was 28.9 years, (range 18-48). The starting CD4 count average was
153 × 109 and increased to 268 on treatment. The average initial viral load in 198
women was 125 338 copies/ml, 87.5% of women’s, who had a VL tested around the
time of delivery, VL < 400 copies/ml. Anaemia, (haemoglobin ≤ 10.5mg/ml) was
present in 38% of women, predominantly normocytic. Screening syphilis serology
was positive in 5.3% of women. Most women were treated with nevirapine, and 2
nucleoside reverse transcriptase inhibitors. 11.9% patients who were treated with
nevirapine developed a grade 1 hepatits and 1% (3 women) developed nevirapine
hepatitis with liver failure. There were no ART related deaths. Most of the women
were diagnosed HIV positive for the first time in the current pregnancy and they may
not have accessed ART therapy if not for this integration of services.
Conclusion: Integration of antiretroviral services into an ANC clinic is feasible and
beneficial to patients.
104
APPROPRIATENESS OF PRENATAL INFANT FEEDING CHOICES BY
HIV POSITIVE WOMEN: IMPLICATIONS FOR INFANT OUTCOMES
Tanya Doherty1,3, Mickey Chopra 2,3, Debra Jackson2, Ameena Goga4, LarsAke Persson5 and the Good Start Study Team
1Health
Systems Trust, 2University of the Western Cape, 3Medical Research
Council, 4Columbia University, 5Uppsala University
Background

Postnatal transmission accounts for at least half of all mother-to-child
transmission of HIV.

Proportion of infections
occurring postnatally
is
increasing
as
intrapartum regimens improve.

Postnatal HIV transmission can be eliminated through exclusive
replacement feeding; however, there are substantial risks to not
breastfeeding under unsafe conditions – therefore making an
appropriate choice is important.
WHO/UNICEF recommendation “avoidance of all breastfeeding if replacement
feeding is acceptable, feasible, affordable, sustainable and safe. Otherwise
exclusive breastfeeding for the first months of life is recommended followed
by early breastfeeding cessation as soon as feasible, when conditions for safe
replacement feeding can be met.”

These guidelines are difficult to apply in operational settings.

Defining ‘safe’ and ‘feasible’ etc in practice is a challenge for health
workers and counsellors.

No assessment to date of the implementation of the WHO/UNICEF
guidelines in operational settings and consequences for infant
outcomes.
Aims & Objectives

To identify criteria that could be used to guide appropriate infant
feeding choices.

To assess the appropriateness of infant feeding intentions amongst
HIV positive women in 3 sites in South Africa.
105
To determine the effect of inappropriate choices on infant HIV-free

survival.
Research Design

Prospective cohort study from birth to 36 weeks postpartum.

Three project sites: Umlazi (KZN)-urban, Rietvlei (EC-KZN)-rural, Paarl
(WC)-peri-urban farming.

Final Sample 665 HIV positive women.

Data collected by trained field researchers at (3, 24 and 36 weeks &
community health workers every 2 weeks until 9 weeks, then monthly
until 36 weeks.
Infant feeding assessed at each visit: previous 4-day (yesterday +

previous 3-days) recall - Yes/no questions also asked about ever
breastfeeding in the past.
Dried blood spots collected by heel prick (baby) at 3, 24 and 36 weeks

to determine HIV infection and finger prick (mother) at 3 and 36 weeks
to measure viral load.
Results
Socio-demographics
100
80
80
60
40
Piped water into house
flush toilet
Electricity
67
45
42
53 55
20
3
Rietvlei
Umlazi
Paarl
0
12
2
106
Infant feeding Intentions of HIV positive women
90
80
70
60
50
%
40
30
20
10
0
Exc Breastfeeding
Exc Formula
Paarl
Umlazi
Rietvlei
Infant feeding intentions according to 5 key
criteria
80
70
60
50
% 40
Formula feeders
Breast feeders
30
20
10
0
Piped water
Fuel
Main income
in house or
(electricity,
provider
yard
gas, parrafin)
regular
employment
Use of a
fridge
Disclosed
HIV status*
Do the WHO/UNICEF guidelines improve infant HIV-free survival?
5 criteria assessed as measures of appropriateness of feeding choice:

Piped water in house or yard.

Electricity, gas or paraffin as a source of fuel.

Disclosed HIV status.

Access to a fridge to store prepared formula.

Someone in the household in fulltime employment.
107
Defining appropriate choice
Score of
appropriateness
(A) Piped water in house or
yard
(B) Piped water in house or
yard plus fuel (electricity,
gas or paraffin)
(C) Piped water in house or
yard, fuel and disclosure of
HIV status
n(%)
women
choosing
to
formula feed who
had these criteria
152 (52.6)
Adjusted Hazard ratio 36
week HIV transmission/
death (95% CI)
146 (50.5)
0.53 (0.32-0.88)
94 (32.5)
0.32 (0.16-0.62)
0.51 (0.31-0.84)
Consequences of choices
Feeding choice according to defined
criteria - presence or absence of piped
water, fuel and HIV disclosure
(n=600)
Adjusted Hazard Ratio 95% CI
for
36
week
HIV
transmission/ death
Met criteria - choice to formula feed
(referent group) (n=94)
Did NOT meet criteria - choice to breastfeed
(n=216)
1
2.74
(1.48-5.05)
Did NOT meet criteria - choice to formula
feed (n=195)
Met criteria - choice to breastfeed (n=95)
3.45
(1.89-6.32)
2.72
(1.38-5.35)
Discussion

WHO/UNICEF guidelines are not being used effectively in operational
settings to guide feeding choices.

The home circumstances of mothers do not appear to influence
choices.

Inappropriate choices are being made in both directions:

95 (31%) of women who chose to breastfeed had access to
piped water, fuel and had disclosed their HIV status. The risk of
HIV transmission or death is 2.7 times higher in this group
compared to women with the same conditions who chose to
formula feed.

A considerable number of infant infections could have been
prevented if these women had chosen to formula feed.

Only 3/93 women in rural Rietvlei site who chose to formula
feed met the three criteria.
108

Inappropriate choice in a rural area may carry more risk (water
from rivers, wood for fuel).

Rietvlei most similar to other parts of Africa. More research
needed to assess risks in rural areas.
Conclusions

WHO/UNICEF guidelines need to be applied in a practical manner in
operational settings.

Advocacy needed to increase women’s access to conditions that will
enable safe formula feeding.

Infant HIV free survival could be improved if women choosing to
formula feed have at least 3 criteria (piped water, fuel, HIV disclosure).

Without these, a choice to breastfeed would result in a better outcome.
109
GROWTH OF INFANTS BORN FROM HIV POSITIVE MOTHERS FED WITH
ACIDIFIED STARTER FORMULA CONTAINING BIFIDOBACTERIUM LACTIS
PA Cooper, M Mokhachane, KD Bolton.
Department of Paediatrics, University of the Witwatersrand
Introduction
The choice of formula for infants born to HIV positive mothers in developing
countries who choose not to breast feed must be made with the aim of ensuring the
least risk of infection and optimal growth. We investigated the effects of acidification
and addition of probiotics in two separate but similar studies. Acidification of the
milk creates a less favourable environment for the growth of bacteria and potentially
makes it safer from the possibility of contamination, whereas feeding a milk
containing probiotics should result in colonization of the gut with flora closer to that
found in breast fed infants which in turn may protect against infective diarrhoea.
Methods
Full term healthy infants (37-42 wks) with birth weight >2500g born to HIV positive
mothers who had decided not to breast feed were randomized in two separate
studies within a week of birth to one of the trial formulas.
probiotics contained Bifidobacterium lactis 2X107 cfu/g.
The formulas with
The studies were double
blind as the tins containing formula in powder form were colour coded.
Anthropometric measurements were performed at each visit up age 6 months and
biochemical monitoring was done on a regular basis. HIV PCR tests were done at 6
weeks and again at 4-6 months for confirmation.
In the first study, infants were randomized to one of the following formulas:
• Standard formula
• Biologically acidified formula
• Biologically acidified with probiotics
In the second study, they were randomized to one of:
• Standard formula
• Directly acidified formula
• Biologically acidified formula
• Directly acidified with Probiotics
110
Results
A total of 333 infants were enrolled in the two studies of whom 93 received standard
formula, 142 received one of the acidified formulas without probiotics and 98
received a formula with probiotics.
The rates of gastrointestinal and respiratory
disease were low (only a few required hospital admission – more commonly HIV
positive infants) and there were no differences between the groups. No significant
biochemical differences between the groups and acid-base status of those on
acidified milks was normal throughout.
Of those enrolled, 271 were followed for at least 4 months so that HIV status and
growth parameters could be analyzed. There were no differences in growth between
those fed standard formulas and acidified formulas without probiotics and, in the
second study, no differences were seen with respect to the method of acidification of
the milk.
The 98 infants fed formula containing probiotics gained an average of
2.6g/day more than those without probiotics (95%CI=[0.5;4.7]; p=0.015).
Table
Comparison of weight gain between those receiving milk with
probiotics and those receiving a formula without
Probiotic Effect
95% C I
p value
All infants
2.6 g/d
0.5; 4.7
0.015
HIV Neg
4.1 g/d
2.0; 6.2
<0.001
HIV Pos
-4.3 g/d
-11.3; 2.7
NS
A total of 34 infants were HIV positive and there was no effect on weight gain when
only HIV positive infants were compared, but when the analysis was confined to
infants who were HIV PCR negative, the difference was highly significant.
No
differences in length were seen, but the infants on probiotics had a mean increase in
head circumference 0.24mm/week greater than the others (p=0.03).
The
differences in Z-scores between the two groups of infants can be seen in the Figure.
It is noteworthy that the mean weight of both groups of infants became positive
during the course of the study (i.e. >the 50th percentile) and the group receiving
probiotics almost reached one standard deviation above the mean.
111
Figure
Comparison of Z-scores between infants receiving milk with
probiotics and those receiving a formula without
Weight for Age Z Scores
1
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
baseline
4 wks
8 wks
17 wks
26 wks
Probiotics
No Probio
Conclusions
Both groups of infants in these studies demonstrated satisfactory growth and the
acidified milks appeared to be well tolerated clinically and biochemically, but
conferred no obvious advantage.
No reduction in gastrointestinal or respiratory
infections could be demonstated for either acidification or addition of probiotics.
Addition of probiotics resulted in better weight gain, but this improvement was
confined to infants uninfected with HIV.
Head circumference increase in HIV
negative infants on formula with probiotics was also significantly greater than those
not receiving probiotics. Further studies are required to investigate the mechanisms
by which probiotics improve weight gain.
112
ARE WE SAVING BABIES? A CHILD PIP REVIEW OF UNDER-1 DEATHS
CR Stephen and Child PIP Group
MRC Maternal and Infant Health Care Strategies Research Unit, Department of
Paediatrics, Pietermaritzburg Hospitals Complex
Introduction
In March 2007, the Saving Children 2005 report was launched, which by careful
review of child deaths, provided information on child healthcare in South Africa
during that year. Five key areas of importance were identified and recommendations
developed to provide a framework for their implementation. The continuum of care
for mothers, babies and children is vital for child survival and the following Child PIP
data highlights some of the experiences of infants, who constitute an important
group in that continuum.
Aim
To review the under-1 deaths in infants admitted to hospital, with particular
reference to their HIV context, causes of death and the occurrence of modifiable
factors (MF’s) in the care of those who died, using the Child Healthcare Problem
Identification Programme (Child PIP).
Setting
The data were gathered from 15 of the 21 public hospitals using Child PIP during
2005. These represented all 9 provinces of South Africa. The data collection period
was from January to December 2005.
Methods
The Child Healthcare Problem Identification Programme, a mortality audit, provided
the structure and tools for careful review of all inpatient hospital deaths by:
1. ensuring all deaths were identified;
2. assigning a cause for each death;
3. determining the social, nutritional and HIV context of each child who died; and
113
4. determining modifiable factors in the caring process for each death.
The findings, with particular emphasis on the under-1 deaths, were then analysed
using the Child PIP software.
Results
Core Data
The total number of all child deaths from the 15 sites included in the analysis was 1
543, with modifiable factors being recorded 3 610 times, giving an occurrence rate of
2.3 per death.
The overall hospital mortality rate for all children admitted was 6.8 deaths per 100
admissions (*using incomplete admission data, due to software problems, of 20 891
admissions and 1 416 deaths).
Admissions
Deaths
Hospital mortality rate (HMR)
Under-one year HMR
Modifiable factors
Modifiable factor rate per death
20 891*
1 416* (1 543)
6.8*
9.9
3 610
2.3
Profile of Deaths

Age distribution
Almost 90% of deaths occurred in children under 5 years of age, and 56%
(862) occurred in children under one year of age (i.e. infants), reflecting that
younger children have a higher risk of dying.

Weight distribution
Data from infants showed that 55% of those who died weighed under the 3rd
centile, and almost half of these had severe malnutrition (i.e. kwashiorkor,
marasmus or marasmic-kwashiorkor). It is well described that undernutrition
increases the case fatality rate for infectious diseases, more than doubling the
risk of dying, thus underweight infants constitute a particularly vulnerable
group.
114
*
HIV
The HIV data collected by Child PIP included an interpreted laboratory HIV
test result as well as whether or not the child was clinically staged for HIV.
Information was also gathered about nevirapine administration, infant feeding
choice and cotrimoxazole prophylaxis, as indicators of the PMTCT programme.
Access to anti-retroviral treatment for both child and mother was also
determined.
Laboratory Status (infants)
100%
8
29
75%
Negative
Exposed
19
50%
Infected
Unknown
25%
45
0%
< 1 year
Figure 1: Under-1 deaths by HIV laboratory category (n=862/1543)
It was striking that the HIV laboratory status of nearly 50% of infants who
died in hospital was unknown. Thus only half were tested, and of these,
nearly one third were HIV infected and one half were HIV exposed.
PMTCT Programme

Nevirapine administration
Information about nevirapine administration was NOT available in 60% of
all infant deaths, thus in virtually two out of three deaths there was no
information on whether a mother-baby pair accessed the PMTCT
programme or not.
Figure 2 represents all children where information was available (450/1543
deaths). Both the ‘Given’ and ‘Not given’ groups were eligible for PMTCT. It
was clear that many children were dying from preventable HIV infection as
only 30% of eligible babies received nevirapine.
115
150
No. of
deaths
100
Infected
Exposed
Lab
Negative
Category
50
0
Mother -ve
Given
Not given
Nevirapine
Figure 2: Perinatal nevirapine and HIV status (n= 450/1543)

Infant Feeding Choice
Information about feeding choice in infants was unknown in almost 50% of
deaths. This is cause for concern given the emphasis on feeding choice, as a
component of the PMTCT programme. Figure 3 represents those infants on
the PMTCT programme where infant feeding information was available. Only
56% of babies eligible for the PMTCT programme experienced safe feeding
practice (i.e. either exclusive breast or exclusive formula). The figure also
shows that when eligible infants did not receive nevirapine they were more
likely to be mixed fed, suggesting that a breakdown in one component of the
PMTCT programme increases the likelihood of a breakdown in other
components.
80
60
No. of
40
deaths
Mixed
20
Formula
Exclusive breast
0
Mother -ve
Given
Not given
Nevirapine
Figure 3: Perinatal nevirapine and infant feeding (n= 372/1543)
116

Cotrimoxazole prophylaxis
Cotrimoxazole prophylaxis to prevent PCP is another important component of
the
PMTCT
programme.
However,
information
about
cotrimoxazole
prophylaxis was unknown in 52% of all children who died with PCP. Further,
26% of these eligible children never received cotrimoxazole. Also of concern
is that almost 20% of children dying from PCP were in fact on cotrimoxazole
suggesting further inadequacies in this facet of HIV management.

Causes of Death
The profile of causes of death in the under-1 year age group was similar to
that in all children as shown in Figure 4. These were: acute respiratory
infection (21%), sepsis (13%), diarrhoeal disease (12%), PCP (15%) and
tuberculosis (5%). Although acute respiratory infections was the commonest
cause of death in all children, PCP accounted for significantly more deaths in
infants than in older children.
25
20
21
15
18
15
%
10
13
12 13
11
5
9
8
LRTI
DD
Sepsis
TB
PCP
5
0
All ages
< 1 year
Figure 4: Cause of death (all diagnoses)
Modifiable Factors (MF's)
Modifiable factors are those instances where a missed opportunity or substandard
care may have contributed to the death of a child. Child PIP categorises these into
‘where’ they occur and ‘who’ is responsible, as illustrated with examples in Figure 5.
117
The 2005 Child PIP data showed the following breakdown of modifiable factors:

By place (‘where’): the highest rates were recorded in hospitals, with 60 per
100 deaths in the Wards, 64 in the Emergency section, 35 in Clinics and 50 at
Home.

By person (‘who’): Clinical personnel were responsible for 123 MF's per 100
deaths, Administrators for 52 and Caregivers for 59.
For infant deaths, 74% of modifiable factors were related to the health system and
26% to the home/family.
Figure 5: Examples of categorisation of modifiable factors
Family/Caregiver
Delay in seeking care,
child taken to clinic with
advanced disease
Home
Administrator
No transport from clinic to
hospital
Clinic
Insufficiently trained staff
on duty
No pulse oxymeter for
child
with
severe
pneumonia
Outpatients
Inpatients
Health worker
IMCI
guideline
not
followed in child with
severe diarrhoeal disease
Volume
expander
not
given to shocked child
Oxygen not given to child
with severe pneumonia
Discussion
Child PIP information gathered during 2005 identified gaps in five key areas of
healthcare and was used to develop the following recommendations:
1.
2.
HIV/AIDS
-
Prevention: strengthen PMTCT services
-
Identification and treatment: strengthen ART services
Nutrition
-
At clinic level, underweight children must be identified, assessed and
referred earlier
3.
At hospital level, severe malnutrition must be managed effectively
Gold standards
-
At clinic level, IMCI needs to be strengthened and sustained
-
At hospital level, standard paediatric guidelines must be developed, and
implemented
118
4.
Norms to be established and implemented
-
for Staffing, Equipment and Transport of sick children
5.
Improve paediatric quality of care
-
Paediatric mortality review (Child PIP) to be used at every institution
Furthermore, data from the under-1 age group also highlighted inadequacies in the
PMTCT programme, showing the impact of perinatal care on paediatric care as well
as the importance of an integrated approach to caring for mothers, babies and
children.
For each recommendation an attempt was made to identify who in the health system
was responsible for its implementation at different levels (policy, administration,
clinical
practice
and
education).
When
looking
at
infants,
most
of
the
recommendations were relevant but prevention of HIV infection seemed the most
important and its suggested implementation is further expanded as follows:

Policy – universal testing must become the norm; pregnant women with CD4
counts under 300 should be provided with ART; all PMTCT interventions must
be clearly documented by healthworkers and follow-up of HIV-affected
children must be integrated into immunisation services. These activities are
seen as the responsibility of the Department of Health.

Administration - of vital importance is the development of capacity, by
managers (provincial, district and institutional) for implementing the policy
components of the recommendation.

Clinical Practice - all nurses and doctors should be able to provide
comprehensive perinatal HIV care. This is the responsibility of unit managers,
as well as individual health workers.

Education - responsibility to ensure that students are properly trained to
provide comprehensive and high quality care lies with heads of medical
schools and nursing colleges.
119
Conclusion
The Child PIP audit continues to provide information about paediatric deaths and the
quality of paediatric healthcare. It is now the responsibility of health workers and
managers to respond to the challenges posed. Child PIP offers some suggestions on
how to respond in the form of the recommendations contained in the Saving Children
2005 report and it is hoped that this report will be a useful tool in empowering
people to act.
120
PMTCT INTEGRATION IN SOUTH AFRICA
Joy Lawn, Saving Newborn Lives/Save the Children and Debra Jackson, School of
Public Health, University of the Western Cape
PMTCT INTEGRATION
The Current Policy Environment:

At the National Department of Health – PMTCT has been moved from the HIV
Directorate to MCWH.

The policy environment is set for integration of PMTCT into MNCWH services

What is happening at the local level?
o Missed Opportunities
Examples of these missed opportunities documented in the Good Start Study include:
Risk factors for transmission suggest poor quality antenatal and intrapartum services,
Table 1
Rates of syphilis testing and ROM greater than four hours.
Syphilis test not done
Rupture of membranes > 4
100
hours
80
72.4
60
40
23
16.8
Rietvlei
1.6
Paarl
0
33
Umlazi
20
23.1
As well as poor quality postpartum/newborn services, such as number of postnatal
infant visits, Bactrim prophylaxis and immunization coverage.
121
Table 2
Proportion of children with >4 post-natal visits in 6 months
120.0
99.0
100.0
79.0
80.0
60.0
38.0
40.0
20.0
0.0
Paarl
Table 3
Um lazi
Rietvlei
Bactrim Prophylaxis
100.0
80.0
77.3
74.4
60.0
40.0
28.6
20.0
0.0
Paarl
Table 4
100.0
Umlazi
Rietvlei
Completed Immunisation @ 24 weeks
88.3
80.0
68.9
60.0
42.4
40.0
20.0
0.0
Paarl
Umlazi
122
Rietvlei
The Good Start Study Recommendations highlight the need for integrated
services:

Address Inequities – Disadvantaged areas may need more resources
(technical assistance, staff, funding) per mother/baby served to assure
success (quality) of the PMTCT programme.

Improve PHC/MNCWH – Comprehensive Approach e.g. Increase # & quality of
ANC visits, IMCI, increase immunisation rates, reduce malnutrition

Reduce maternal viral loads – HAART Therapy for mothers

Continue PMTCT Programme - Consider combination therapies to further
reduce early/perinatal transmission
When examining data from throughout Africa, it is clear that where the coverage of
basic care is low, then this will limit the scaling up of other interventions including
PMTCT
Coverage (%) for 46 countries in
sub-Saharan Africa
Table 5
Coverage of MCH services in 46 countries in sub-Saharan
Africa
100
75
50
69
25
65
42
30
8
0
A nt e na t a l
c a re ( a t le a s t
o ne v is it )
S k ille d
a t t e nda nt a t
birt h
P o s t na t a l
E xc lus iv e
c a re wit hin 2 bre a s t f e e ding
da ys f o r ho m e
<6 m o nt hs
birt hs *
DP T3
v a c c ina t io n
In addition there is a substantial drop off in services from the antenatal to the
postnatal period.
123
Table 6
Cascading Service Utilisation - 22 Sites in Tanzania
1st ANC visit
Pretest counseling
HIV test done
Institutional delivery
HIV Positive
Mother rec'd NVP
Baby rec'd NVP
Rec'd 1st immunization
Rec'd 6 wk cotrim
Rec'd 6 month cotrim
0
5000
10000
15000
20000
25000
Number of Clients
Table 6 suggests that a key focus on for PMTCT integration needs to be in the
Postnatal Care period. These include integration with:

MNCWH Services

General PHC Services

ARV & other HIV/AIDS services
o
Mother
o
Infant/Paediatric

TB Services

STI & Family Planning Services
Suggested questions for discussion
•
Integration easier to say than do particularly once working with multiple
programmes (MNCH, PMTCT and HIV treatment, STI, malaria etc)
•
–
Policy level, funding streams
–
Client interface level – same person doing everything
–
Are there examples where integration is working?
What are ways forward to address the gap of postnatal care? There is not an
existing effective package to integrate into….
124
DEVELOPING A PRACTICAL CLINICAL DEFINITION OF SEVERE ACUTE NEONATAL
MORBIDITY TO EVALUATE OBSTETRIC CARE: A PILOT STUDY
MTP Mukwevho, T Avenant, RC Pattinson
MRC Maternal and Infant Health Care Strategies Research Unit, Departments of Obstetrics
and Gynaecology and Paediatrics, University of Pretoria
Objective
To develop a practical clinical definition of severe acute neonatal morbidity that can be used
to assess the quality of obstetric practice.
Setting
All women delivering at Kalafong Maternity Unit. The unit provides secondary and tertiary
levels of care.
Method
A definition of severe acute neonatal morbidity was created using the need to support or
treat any of the neonates’ organ systems (within 3 days of delivery) as the point of entry.
The data was collected on a modified PPIP form and the same definitions of primary
obstetric cause were used. Data was collected from 1st April 2006 to 30th November 2006.
Results
Ninety-six neonates were identified according to the definition; and there were 18 neonatal
deaths in the same period. The neonatal mortality rate was 5.1/1000 live births, the
critically ill neonate rate was 32/1000 live births. The neonatal mortality index was 15.8%.
The most common neonatal near miss marker was respiratory dysfunction (64%), followed
by immunological dysfunction (22%) and central nervous system dysfunction (5%). The
most common primary obstetric cause of severe acute neonatal morbidity was classified as
‘no obstetric cause’ (25%) followed by preterm premature rupture of membranes (20%) and
spontaneous preterm birth (16%).
Conclusion
This new definition was simple to use and identified five times more neonates with problems
that could be used to assess the obstetric care provided. It was surprising that the category
‘no obstetric cause’ was the most common category of severe neonatal morbidity and these
needs to be examined in more depth. Immunological dysfunction was also more common
than expected, indicating a need to review our obstetric practice with respect to preterm
premature rupture of membranes.
The system might be of use for institutions with few neonatal deaths to assess the quality of
their obstetric care.
125
ANALYSIS OF THE PATTERN OF MORBIDITY IN A LIMPOPO DISTRICT
HOSPITAL OVER A 3 MONTH PERIOD (SEPTEMBER – NOVEMBER 2006)
E Reji
Introduction
The study was done as a result of an increase in the big neonates admitted in the
unit during the past 3 months.
Aim
To generate reliable and relevant information to guide health policy choices at the
hospital.
Objective
To establish the extent and the distribution of the disease pattern in neonatal ward.
To establish diseases patterns in terms of weight, gender.
Methodology
Retrospective data collected from Sept 06 – Nov 06 hospital records.
Patients records were used for data collection.
Sample size is 69 patients.
Lebowakgomo hospital
252 Approved beds
216 Usable beds
8 Usable beds Neonatal Unit
CEO:- Ms. MOHAPI MC
Racial and Gender Breakdown
Race
Male
Female
Total
Percentage %
Blacks
33
35
68
99%
Indians
1
0
1
1%
Total
34
35
69
100%
Only 69 patients were seen during the period Sept 06 – Nov 06
99% were Blacks
1% were Indians
126
Diseases/Problems by Gender Distribution
Gender
Disease
Female
Meconium aspiration
8
Asphyxia Neonatorum
7
Physiological Jaundice
8
Hypoglycemia
8
Prematurity
8
Sepsis
4
Respiratory Distress Syndrome
3
Congenital abnormalities
0
Anaemia
1
Pneumonia
0
Retroviral Disease ???
0
Diarrhoea
0
TOTAL
47
In this graph Males and Females are equally affected and
Male
TOTAL
Percentage
9
17
18%
9
16
17%
7
15
16%
5
13
14%
3
11
12%
4
8
9%
1
4
4%
2
2
2%
1
2
2%
2
2
2%
1
1
1%
1
1
1%
45
92
100%
Meconium aspiration is the leading cause.
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
18%
17%
16%
14%
12%
9%
4%
127
RO
VIR
AL
DI
SE
AS
E
1%
1%
DI
AR
RH
OE
A
2%
PN
EU
MO
NI
A
AN
AE
M
IA
2%
RE
T
P.
DI
ST
RE
SS
SY
ND
CO
.
NG
EN
ITA
LA
BN
OR
MA
L
IS
SE
PS
RE
S
IA
AT
UR
ITY
PR
EM
CE
M
OG
LY
HY
P
JA
UN
DI
CE
PH
YS
IO
LO
GI
CA
L
HY
X
IA
AS
P
IR
AT
IO
N
NE
ON
AT
OR
UM
2%
AS
P
CO
NI
UM
ME
%
LEBOWAKGOMO HOSPITAL
DISEASE PROFILE
SEPTEMBER 2006 - NOVEMBER 2006
Disease Breakdown According To Weight
Weight category
500g- 1000g- 1500gDiseases
999g 1499g 1999g
Hypoglaecemia
0
0
0
Meconium aspiration 0
0
0
Pneumonia
0
0
0
Sepsis
0
0
0
Prematurity
2
6
3
Retroviral Disease 0
1
0
Aneamia
0
1
1
Physiological
Jaundice
0
1
1
Respiratory Distress
Syndrome
0
0
1
Asphyxia
Neonatorum
0
0
1
Diarrhoea
0
0
0
Congenital
abnormalities
0
0
0
TOTAL
2
9
7
2000g2499g
1
1
0
3
0
0
0
2500g3999g
3
16
2
4
0
0
0
4000g and
above
Total Percentage
9
13
14%
0
17
18%
0
2
2%
1
8
9%
0
11
12%
0
1
1%
0
2
2%
0
12
1
15
16%
1
2
0
4
4%
2
0
12
1
1
0
16
1
17%
1%
0
8
2
54
0
12
2
92
2%
100%
This graph shows that 2.5 to 3.9 kg babies are mostly affected and they due to
meconium aspiration, physiological jaundice and asphyxia neonatorum.
Babies
above 4 kg had hypoglycemia. Statistics on patients with retroviral disease not clear
due to lack of proper PMTCT.
LEBOWAKGOMO HOSPITAL
TOP 5 MOST COMMON NEONATAL CONDITIONS
SEP 2006 - NOV 2006
20%
18%
17%
18%
16%
16%
14%
14%
12%
%
12%
10%
8%
6%
4%
2%
0%
MECONIUM ASPIRATION
ASPHYXIA NEONATORUM
PHYSIOLOGICAL
JAUNDICE
128
HYPOGLAECEMIA
PREMATURITY
Challenges
•
Poor Antenatal Care.
•
Poor monitoring of labour.
•
Poor PMTCT during ANC.
•
Poor health education.
Conclusion
•
Poor health education.
•
The most common conditions admitted during Sept & Nov 2006 are:
Meconium
aspiration,
physiological
jaundice,
hypoglycemia,
asphyxia,
prematurity.
•
The most affected neonates are the ones weighing between 2.5 kg and 3.9kg
•
Amongst the affected weight group the most common condition is meconium
aspiration and asphyxia.
•
The high rate of >4kg babies with hypoglycemia, are due to undiagnosed
diabetes during pregnancy.
•
Most term babies were comprised because of lack of good co-ordinate
antenatal or intrapartum care.
Recommendations
•
Proper antenatal care.
•
Proper monitoring of Labour.
•
Early detection and diagnosis.
•
Early resuscitation.
•
Early Caesarean section.
•
Midwife available 24 hours in the neonatal ward.
•
Ongoing care for the baby and health of the mother and child.
129
PERINATAL MORTALITY IN THE WESTERN CAPE PROVINCE: CHALLENGES
AND ACTION
DH Greenfield, EL Arends
MCWH Programmes, Western Cape
Information collected needs to be used to advise policy and action. This study was
done in order to assess the current situation regarding perinatal mortality in the
Province, and to assess the needs and propose actions to improve perinatal care.
Methods
The data used is that collected on the Perinatal Problem Identification Programme
(PPIP). The time period for the data collection was from October 2003 to March
2006, to conform to the data collection period to be used in the next National
“Saving Babies” Report.
Only data collected on PPIP was used.
The data was
compared at the different levels of care. The emphasis was on the outcomes in
infants with a birth weight of 1000g or more. Data was available from the Cape
Town Metropolitan District, the Boland/Overberg District, and the all the level 2
District Hospitals.
The Regional Hospitals provide level 2 care and the District
Hospital and Midwife Obstetric Units (MOUs) provide level 1 care.
Results
Delivery statistics, all infants birth weight 500g or more
Total births
Live births
FSB
MSB
Total SB
ENND
LNND
LBW
SB : NND
PCI
Comment:
W Cape
166261
162522
2575
1164
3739
1371
176
18.1
2.5 : 1
1.78
Tertiary
27897
26511
1178
208
1386
403
32
34.1
2.9 : 1
2.04
Regional
62845
61321
901
623
1224
556
63
17.9
2.5 : 1
1.88
District
15867
15596
178
93
211
174
22
19.9
1.4 : 1
1.48
MOU
50247
49689
318
240
558
238
19
10.0
2.3 : 1
1.59
The majority of births are occurring in MOUs and Level 2 (Regional) hospitals. The
district hospitals are mainly in the rural towns.
The overall low birth weight rate is higher than the National average.
The SB : NND ratio is high suggesting that newborn care is generally good. The
exception is in District hospitals and to a lesser extent, the MOUs.
130
Mortality rates by level of care
PNMR
(>499g)
PNMR
(>999g)
SBR (>499g)
SBR (>999g)
ENNDR
(>499g)
ENNDR
(>999g)
W Cape
Tertiary
Regional
District
MOU
32.2
69.6
33.6
29.4
15.9
18.6
23.0
13.8
36.8
51.8
28.0
20.5
24.1
15.7
18.0
17.4
11.1
9.6
11.0
6.8
8.4
16.0
8.8
10.9
4.6
4.2
7.7
4.2
5.9
2.6
Comment:
The rates are highest at the tertiary Hospitals and lowest in the MOUs. Of concern is
that the rates are higher in the District Hospitals than in the MOUs. This is particularly so as the
management in District Hospitals is mainly the responsibility of doctors.
Mortality in birth weight categories
Comment:
1000150020002500g+ Total
1499g
1999g 2499g
Total Births
3777
6844
16137
136214
162972
Live Births
3134
6307
15740
135282
160774
MSB
258
216
143
180
797
FSB
385
321
254
441
1401
ENND
204
110
86
291
691
LNND
55
17
12
10
94
There were nearly 800 macerated still births. This is probably related to problems
during antenatal care.
 There were a further 732 fresh still births and early neonatal deaths in the 2500g
+ birth weight category. These would be +/- term infants, and their deaths were
mainly due to hypoxia occurring during labour.
 There were over 300 neonatal deaths in infants with a birth weight of 1000 –
1999g. Two thirds of these were in the 1000 – 1499g birth weight category.
Top 5 primary obstetric causes
1.
2.
3.
4.
5.
BW > 499g
Spontaneous preterm labour
Unexplained intrauterine death
Antepartum haemorrhage
Hypertensive disease
Intrapartum hypoxia
25.3%
16.4%
15.6%
11.9%
7.5%
BW > 999g
Antepartum haemorrhage
20.7%
Unexplained intrauterine death 19.5%
Intrapartum hypoxia
12.8%
Spontaneous preterm labour
9.2%
Infections
8.3%
Primary Obstetric Cause of death: Fresh still birth and Early neonatal
death, Birth weight 2500g +
n
274
114
84
50
49
Intrapartum hypoxia
Antepartum haemorrhage
Intrauterine death, unexplained
No obstetric cause / Not applicable
Fetal abnormality
131
%
38.4
16.0
11.8
7.0
6.9
Primary Obstetric Cause of death: Early neonatal death, birth weight 1000
– 1999g
n
115
21
14
13
13
Spontaneous preterm labour
Antepartum haemorrhage
Hypertensive disorder
Fetal abnormality
Infection
%
56.9
10.4
6.9
6.4
6.4
Early neonatal mortality rates: BW > 999g
180
160
140
per 1000 live births
120
1000 - 1499g
1500 - 1999g
2000 - 2499g
2500g +
100
80
60
40
20
0
W Cape
Tertiary
Regional
District
MOU
Top 3 final neonatal causes
1. Immaturity related
2. Hypoxia
3. Infection
BW > 499g
51.7%
16.3%
12.5% I
BW > 999g
Hypoxia
Congenital abnormality
Immaturity related
30.6%
20.2%
19.9%
Proportion of deaths with avoidable factors
Patient-related:
Administrative-related:
Health-worker related:
No information / Could not be assessed:
Top 3
1.
2.
3.
BW > 499g
45.1%
11.0%
19.4%
3.8%
avoidable factors
Never initiated antenatal care
Booked late in pregnancy
Inappropriate response to decreased fetal movements
132
BW > 999g
49.1%
15.0%
27.2%
4.3%
Major problems
1.
High ENNMR 1000 – 1499g birth weight, more at level 1 facilities.
2.
High ENNMR and SB rate for FSBs in BW 2500g + group, more at level 1
facilities.
3.
Large numbers of MSBs – cause unknown. Possibly related to problems in
antenatal care.
4.
Avoidable factors:

Medical personnel: Management in labour is the most important. Others
were: Delays in taking action, and substandard neonatal care.

Administrative: Transport delays, inadequate neonatal facilities,
Insufficient or inadequately trained personnel.

Patient related: As above. They are mainly in the Macerated stillbirths
and low birth weight infants.
Plans to solve these problems
1.
Visiting and assessing neonatal facilities, training staff in newborn care.
2.
Training in monitoring and managing of labour – progress and fetal condition.
3.
Improving the screening for IUGR, infection and post dates at antenatal
clinics.
133
STILLBIRTHS AMONG THE CAPE COLOURED: THE SAFE PASSAGE STUDY
Hein J Odendaal1, Colleen Wright1, Lut Geerts1, Greetje de Jong1, Wilhelm Steyn1,
Amy Elliot2, Larry Burd2, Hannah Kinney3, Rebecca Folkerth3, Theonia Boyd3, William
Fifer4, Michael Myers4, Kimberly Dukes5, Ken Warren6, Marian Willinger6 and Gary
Hankins7.
1Department of Obstetrics and Gynaecology, Stellenbosch University, US sites
located in the 22Northern Plains, 3Children’s Hospital, Boston, 4Columbia University,
New York, 5DM-STAT, Boston, 6NationalInstitutes of Health and 7University7University
of Texas Medical Division – Chairman.
Introduction
The National Institute of Child Health and Human Development (NICHD) and the
National Institute of Alcohol Abuse and Alcoholism (NIAAA) of the National Institutes
of Health (NIH) are sponsoring a multi-center investigation to assess the effects of
exposure to alcohol on unexplained stillbirths, sudden infant death syndrome (SIDS)
and various other aspects of fetal and neonatal development. The rates of SIDS and
stillbirth are much higher in the Cape Town (SIDS: 3.41/1,000, Stillbirth 15/1,000)
and the Northern Plains (SIDS: 3.41/1,000, Stillbirth 15/1,000) as compared to the
US population (SIDS: 0.57/1,000, Stillbirth 6.5/1,000), thus, these two catchment
areas were selected for this study. The first phase of the study was a three year
pilot (n=380) focusing on developing an infrastructure to support a larger study
(Phase II, n=12,000, 7 year study), determining the feasibility of recruiting and
following women and obtaining estimates of stillbirth rates in the Northern Plains and
Cape Town. During Phase II we hope to understand the impact of environmental
and genetic modifiers on placental structure and function and central and autonomic
nervous system maturation which contribute to explained and unexplained stillbirths.
Methods
During Phase I in Cape Town, pregnant women completing a statement of informed
consent and meeting eligibility criteria were randomly selected at their first antenatal
visit to participate in the Screener portion of the study at which time a recruitment
interview was completed. After the recruitment interview was completed, women
were asked to participate in the longitudinal portion of the study and be followed
through the perinatal period (i.e., assessments completed at 20-24, 28-32 and 34-38
134
weeks gestation and at delivery) of their pregnancy through one year of infant life
(i.e., assessments completed at newborn, 1 month and 1 year).
The scheduled
evaluations were extensive and included but are not limited to exposure information
(alcohol assessments included the Alcohol Use Disorder Identification Test (AUDIT)
and the time line follow-up and follow-back), physiology assessments (fetal and
infant heart rate recorded continuously by a Toitu monitor for one hour),
neurological assessments (Amiel-Tison and Brazelton), dysmorphology assessments,
pathology (placental biopsies) and laboratory markers (e.g., at 20-24 week serum
alpha-fetoprotein (MSAFP) to access placental function). It is important to note that
during Phase II we will be performing ultrasound examinations to collect fetal
biometry and Doppler flow velocity waveforms in the uterine, umbilical and middle
cerebral arteries. In the case of a stillbirth or infant death, the mother was
approached for consent for autopsy at which the brain stem is removed and frozen
for later examination. Collected specimens were sent in batches to the Children’s
Hospital in Boston for further analyses.
Results
As of October 19, 2006, there have been 99 live born deliveries in Cape Town and 4
intrauterine deaths at 20 week’s gestation or later from women participating in the
prospective Phase I study. Specifically, MSAFP, fetal heart rate patterns, placental
histology and autopsy have been collected on these women. Phase I, afforded us
the opportunity to demonstrate feasibility in collecting this information and we have
been successful in this endeavour. Phase II will afford us the opportunity to analyze
the associations among all factors as we will have enough observations to perform
statistical analysis. In Phase II, we anticipate 49 cases of unexplained and 49 cases
of explained stillbirths based on 12,000 women enrolled in the study.
135
Figure 1
Fetal heart rate pattern at 20-24 weeks, followed by
later intrauterine death.
Figure 2
Fetal heart rate pattern at 20-24 weeks, followed by
later intrauterine death. Note the tachycardia and
wandering baseline.
136
Figure 3
Fetal heart rate/fetal movement ratio
Conclusions
As a result of this effort, at the end of Phase II, the Safe PASSAGE study will have
enough cases to determine the association between explained and unexplained
stillbirths and environmental and genetic factors and their impact on placental, CNS
and ANS function.
137
PERINATAL CARE SURVEY OF SOUTH AFRICA: 2003-2006 - OVERVIEW
RC Pattinson
MRC Unit for Maternal and Infant Health Care Strategies
Introduction
On the 8th September 2000 the global community (including South Africa) declared its commitment to
“create an environment – at the national and global levels alike – which is conducive to development
and to the elimination of poverty”. This led to the adoption of eight goals, the Millennium
Development Goals (MDG). Two of these directly impact on the maternal and child health namely;
MDG-4: reduce child mortality; and MDG 5: improve maternal health. Specific targets were set for
each goal; for MDG 4 it is a reduction by two-thirds, between 1990 and 2015, in the under-five
mortality rate; and for MDG-5 it is a reduction by three-quarters, between 1990 and 2015, in the
maternal mortality ratio (MMR).
Since 2003 there has been the realisation that without a substantial reduction in deaths in the first
month of life (neonatal) MDG-4 will not be met. This has given renewed interest in neonatal mortality
rates and most importantly on improving neonatal care. A reduction in the neonatal mortality rate
(NMR) will also result in a reduction in the perinatal mortality rate (PNMR) that includes both early
neonatal deaths (babies born alive and dying in the first week of life) and stillbirths (babies born dead
after at least 22 weeks of pregnancy or weighing >500g). Achieving the MDG-4 and MDG-5
necessitates significantly improving the coverage and quality of care received by pregnant women and
their infants as well as ensuring the health system is appropriately structured and functions well.
Progress in South Africa towards achieving the MDG-4 is disturbing. A new paediatric health care
survey has come into being (Saving Children 2004: A survey of child healthcare in South Africa2)
since the last Saving Babies report. The second report (Saving Children 20053) report suggests the
infant mortality rate is increasing. The increase in child mortality is closely linked to the HIV epidemic.
Saving Children 20042 reported that three out of five children under 5 years that died were associated
with HIV infection and in Saving Children 2005 that ratio has risen to four out of five deaths being
associated with HIV infection.
Similarly progress towards MDG-5 is not on track and progress is being affected by the HIV epidemic.
The Saving Mothers 2002-2004 reported that AIDS was the most common primary obstetric cause of
death being responsible for two of five maternal deaths. In the face of these challenges, a major
concern expressed in Saving Mothers 2002-20044 has been the lack of progress in the implementation
of the recommendations given in the 1999-2001 Saving Mothers5 report. The National Committee for
the Confidential Enquiries into Maternal Deaths (NCCEMD) adjusted their recommendations in Saving
Mothers 2002-2004 to address the lack of progress in implementing the recommendations by making
them far more specific and by implication indicating who is responsible for doing what.
This current Saving Babies report reviews the perinatal care indices, the causes of perinatal deaths
and outlines the most common areas of avoidable factors, missed opportunities and substandard care
for the period October 2003 to March 2006. We will be able to assess where improvements can be
made in the care of pregnant women and their babies and suggest strategies to implement these
improvements. The recommendations in the current report have followed the style of the Saving
Mothers 2002-2004 report to ensure they are clear and indicate at what level changes need to be
made.
Methods
This fifth report on perinatal care in South Africa analyses data submitted to the national database
from the end of the last report (30th September 2003) to 30th March 2006. During this period 164
sites from throughout the country have submitted data and 576,065 births have been entered. This
comprises approximately twenty percent of all births in South Africa during this time period. Details
of the methods and definitions used are given in Appendix 1 (available at www.ppip.co.za) .
138
Comparisons between the various perinatal mortality indices between the various Saving Babies
reports is difficult as new sites are continually being added and some of the sites included in earlier
reports have ceased submitting their data to the national database. Some sites only contributed their
minimum perinatal data set (first section of PPIP). This data was included in the analysis and called
the total delivery data. The pattern of disease was taken from the sites that allocated causes and
avoidable factors to their perinatal deaths and called the detailed perinatal death data. The total
delivery data recorded 21525 perinatal deaths 500g or more, of these deaths detailed data was
available on 15294 perinatal deaths. When calculating the rates of death per disease category a
falsely low rate would have been obtained if only data from the detailed perinatal death data was
shown as the denominator for these rates came from the total delivery data. (PPIP always calculates
rates from the total delivery data set because in amalgamated data it cannot differentiate which
perinatal deaths were allocated a cause or not). Therefore rates of death per disease category were
adjusted for the population studied by a correction factor to compensate for the lack of deaths in the
detailed perinatal death data set. Dividing the rates obtained from the total delivery data by the rates
obtained from the detailed perinatal data gave this adjustment factor. The rate obtained per disease
category was multiplied by this factor to obtain the corrected rate. This rate is closer to reality for the
population for which data was available in PPIP.
As before the country is divided into metropolitan areas, city and towns and rural areas.
Perinatal care indices
Table 1 lists the perinatal care indices for the various groupings.
Table 1 Perinatal care indices for South Africa, metropolitan, city and town and rural areas in the PPIP
database (Sept 2003 to March 2006) showing available national data and estimates for 2006
South
National
Africa6
PPIP
Metro
C&T
Rural
2006
database
All births
576065
251092 178739 146234
19,500
Stillbirths
14001
6238
4420
3343
1,093,000
562064
244854
174319
142891
Early neonatal deaths
17,250
6872
2734
2204
1934
Late neonatal deaths
5,750
752
406
210
136
Perinatal mortality rate/1000 births
37.5
37.3
38.2
37
Stillbirth rate/1000 births
Early neonatal death rate/1000 live
births
Neonatal death rate/1000 live births
24.3
24.8
24.7
22.9
12.2
11.2
12.6
13.5
21
13.6
12.8
13.8
14.5
Perinatal mortality rate/1000 births
33.6
27.9
24.8
30.2
30.5
Stillbirth rate/1000 births
Early neonatal death rate/1000 live
births
Neonatal death rate/1000 live births
18
18.6
16.9
20.2
19.4
8.5
6.8
9.3
10.5
-
9.5
8.0
10.2
11.3
Low birth weight rate (%)
15
15.5
16.5
15.9
13.3
1.12
1.8
2
1.8
1.6
1.8
1.5
1.9
2.3
Live births
Indices 500g+
16
Indices 1000g+
Stillbirth:Early Neonatal death ratio
-
Perinatal Care Index
Sources for the South African national data and estimates6
It is important to note that there are almost twice as many stillbirths as there are neonatal deaths in
the PPIP dataset, although it is possible that this is partly due to complicated pregnancies resulting in
stillbirths being more common in site that are collecting PPIP data.
The perinatal care indices are very similar to those reported in the fifth Saving Babies report. Figures
1-4 illustrate the differences in the mortality rates per area and birth weight category.
139
Figure 1. Comparison of perinatal mortality rates per area 500g+
45
40
30
25
20
15
10
5
0
SA
Metro
C&T
PNMR
SBR
Rural
ENNDR
Figure 2. Comparison of PNMR in weight categories per area
900
800
700
Deaths/1000 births
600
500
400
300
200
100
0
500-999g
1000-1499g
1500-1999g
Metro
C&T
2000-2499g
2500g
Rural
Figure 3. Comparison of Stillbirth Rate in weight categories per area
500
450
400
350
SB/1000 births
Rate/1000 births
35
300
250
200
150
100
50
0
500-999g
1000-1499g
1500-1999g
Metro
C&T
2000-2499g
Rural
140
2500g
Figure 4. Comparison of Neonatal Death Rate in weight categories
per area
700
Neonatal deaths/1000 live births
600
500
400
300
200
100
0
500-999g
1000-1499g
1500-1999g
Metro
C&T
2000-2499g
2500g
Rural
The stillbirth rates are slightly higher and the neonatal death rates are slightly lower in this report
compared with the last Saving Babies report. This information is difficult to interpret, as there are
some differences in the sites included.
Primary obstetric causes of perinatal death
Table 2 lists the primary obstetric causes of death for South Africa and Figure 5 illustrates the
differences in rates per area. (The detailed data is available in the appendices).
Table 2 Primary causes of perinatal deaths in South Africa (500g+)
Primary causes
N
% Total
Rate/1000
Unexplained intrauterine death
3766
24.6
9.28
Spontaneous preterm labour
3750
24.5
9.24
Intrapartum asphyxia
2062
13.5
5.08
Trauma
272
1.8
0.67
Hypertensive disorders
1647
10.8
4.06
Antepartum haemorrhage
1535
10
3.78
Infections
785
5.1
1.94
Fetal abnormality
592
3.9
1.46
Intrauterine growth restriction
338
2.2
0.83
No obstetric cause / Not applicable
268
1.8
0.66
Maternal disease
193
1.3
0.48
Other
86
0.6
0.21
Total Births
576065
141
37.70
Figure 5. Comparison of mortality rates per primary obstetric causes
(500g+)
10.00
9.00
Rate/1000 births
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
Unexp.
SB
S PTB
IPA+T
HT
APH
Metro
Inf
C&T
Fet.
Abn.
IUGR
MD
Other
Rural
Causes of stillbirths
Table 3 lists the primary obstetric causes of stillbirths and this is illustrated in Figure 6. The stillbirths
are divided into macerated stillbirths (indicating antenatal death and fresh stillbirths and those alive on
admission (indicating intrapartum stillbirths).
Table 3 Primary causes of stillbirths in South Africa
500g+
Number
% Total
Rate/1000
Unexplained stillbirth
3747
37.7
9.24
Hypertension
1398
14.1
3.45
Antepartum haemorrhage
1321
13.3
3.26
Intrapartum asphyxia and birth trauma 1111
11.2
2.74
Spontaneous preterm birth
1030
10.4
2.54
Infections
510
5.1
1.26
Fetal abnormality
Idiopathic
intrauterine
restriction
Pre-existing maternal disease
296
3
0.73
285
2.9
0.70
156
1.6
0.38
89
0.9
0.22
growth
Other
Table 4 Primary causes of macerated stillbirths in South Africa
500g+
Number
% Total
Rate/1000
Unexplained Intrauterine death
735
60.1
1.81
Hypertensive disorders
124
10.1
0.31
Antepartum haemorrhage
85
7
0.21
Infections
65
5.3
0.16
Maternal disease
58
4.7
0.14
Intrapartum asphyxia
64
5.3
0.16
Intrauterine growth retardation
49
4
0.12
Fetal abnormality
25
2
0.06
Spontaneous preterm labour
7
0.6
0.02
Other
11
0.9
0.03
142
Table 5 Primary causes of fresh stillbirths in South Africa
500g+ (Alive admission or fresh
Number
SB)
Antepartum haemorrhage
872
% Total
Rate/1000
22.1
2.18
Intrapartum asphyxia and birth trauma 922
23.3
2.31
Unexplained stillbirth
715
18.1
1.79
Spontaneous preterm birth
552
14.0
1.38
Hypertension
444
11.3
1.11
Fetal abnormality
148
3.8
0.37
Infections
147
3.7
0.37
Idiopathic intrauterine growth restriction 66
1.7
0.17
Pre-existing maternal disease
40
1.0
0.10
Other
40
1.0
0.10
The vast majority of macerated stillbirths were unexplained, whereas intrapartum asphyxia and
antepartum haemorrhage account for almost half of the fresh stillbirths and only 18% were
unexplained.
The stillbirth rate for fetuses 1000g or more was 18.6/1000 births. The stillbirth rate for fetuses alive
on admission and fresh stillbirths more than 1000g was 7.5/1000 births and is an indirect measure of
intrapartum stillbirths. The rate for macerated fetuses (1000g or more) was 11.1/1000 births and this
is a measure of antepartum deaths. Forty percent of the stillbirths over 1000g were intrapartum.
Figure 6. Primary causes of Stillbirths (500g+)
40
35
Percentage
30
25
20
15
10
5
0
Unexpl.
SB
HT
APH
IPA+T
S PTB
Inf.
Fet.
Abn.
IUGR
MD
Other
Figure 7. Primary causes of fresh stillbirths
(500g+)
25
Percent
20
15
10
5
0
APH
IPA+T
Unexpl. S PTB
SB
HT
Fet.
Abn.
Inf.
IUGR
MD
Other
Neonatal Deaths
The primary obstetric causes of neonatal death are shown in Table 6 and illustrated in Figure 8.
143
Table 6 Primary causes of pre-discharge early neonatal deaths in the National PPIP database
500g+
Number % Total
Rate/1000
Spontaneous preterm birth
2720
50.8
6.92
Intrapartum asphyxia and birth trauma 1223
22.8
3.11
Fetal abnormality
296
5.5
0.75
Infections
275
5.1
0.70
Hypertension
249
4.7
0.63
Antepartum haemorrhage
214
4
0.54
Idiopathic intrauterine growth restriction 53
1
0.13
Pre-existing maternal disease
37
0.7
0.09
Other
284
5.4
0.72
Figure 8. Primary causes of neonatal deaths (500g+)
60
S PTB
IPA+T
Fet. Abn.
Inf.
HT
APH
IUGR
MD
Other
50
Percentage
40
30
20
10
0
Primary causes
Table 7 lists and Figure 9 illustrates the final causes of neonatal death in the National PPIP database.
Table 7 Final causes of pre-discharge early neonatal deaths in the National PPIP database
500g+
Number % Total
Rate/1000
Immaturity
2706
50.6
6.88
Hypoxia
1375
25.7
3.50
Infection
528
9.9
1.34
Congenital abnormality
399
7.5
1.02
Other
174
3.3
0.44
Unknown
99
1.9
0.25
Trauma
51
1
0.13
144
Figure 9. Comparison of final causes of neonatal death
(500g+)
8.00
Rate/1000 livebirths
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
Immaturity
Hypoxia
Infection
Cong. Abn.
Metro
C&T
Other
Unknown
Trauma
Rural
There were 89402 low birthweight babies born comprising 15.5% of all births in the dataset. The
PNMR for these low birth weight babies was 178.4/1000 births, stillbirth rate 115.4/1000 births and
neonatal morality rate 71.2/1000 live births. The PNMR was 11.7/1000 births, the stillbirth rate
7.6/1000 births and neonatal mortality rate 4.1/1000 live births for babies 2500g or more. Figures 1015 illustrate the different pattern of primary causes of death for each weight category.
Figure 11. Primary causes of death 1000-1499g
Figure 10. Primary causes of deaths 500-999g
60
60
APH
APH
50
Inf.
Percentage
Percentage
HT
40
Inf.
IPA+T
30
IUGR
MD
20
40
HT
IPA+T
30
IUGR
MD
20
S PTB
S PTB
10
Fet. Abn.
50
Fet. Abn.
10
Unexpl. SB
Unexpl. SB
Other
0
Other
0
Figure 12. Primary causes of death 1500-1999g
Figure 13. Primary causes of deaths 2000-2499g
60
APH
50
60
Fet. Abn.
APH
HT
50
Fet. Abn.
Inf.
IUGR
MD
20
S PTB
HT
40
Percentage
IPA+T
30
Inf.
IPA+T
30
IUGR
MD
20
S PTB
Unepl. SB
10
Other
Unexpl. SB
10
Other
0
0
Figure 14. Primary causes of deaths 2500g+
60
APH
Fet. Abn.
50
HT
Percentage
Percentage
40
40
Inf.
IPA+T
30
IUGR
MD
20
S PTB
10
Unexpl. SB
Other
0
145
To summarise the overview of causes of stillbirths and neonatal deaths, the top three causes in each
birth weight category (namely unexplained stillbirths, spontaneous preterm labour and intrapartum
asphyxia and birth trauma) remain the same throughout although their order changes. Unexplained
stillbirths are most common between 1500g-2500g. Spontaneous preterm birth is important in the
lower birth weight categories (500g-1500g) but for the higher birth weights (2500g and above) deaths
due to intrapartum asphyxia and birth trauma (prolonged or obstructed labour) are most common.
Hence the two top priority causes of death to address are preterm birth and intrapartum hypoxia.
Infections remain an important, and also the most easily preventable cause of neonatal deaths, but do
not show up in PPIP datasets and so cross linking with Saving Children data is crucial.
Missed opportunities, avoidable factors and substandard care
Tables 8-11 list the common probable avoidable factors, missed opportunities and substandard care.
All tables list only the probable factors. This means the clinicians assessing the case felt that the
factor listed was directly related to the death of the infant. Had the factor been avoided the infant
would probably have lived.
Table 8 Comparison of the main categories of missed opportunities, avoidable factors and substandard care
SA
Metro
C&T
Rural
N
%
N
Deaths
%
N
Deaths
%
N
Deaths
%
Deaths
Patient associated
2447
16.0
641
10.2
1073
20.1
820
22.2
Health worker associated
2245
14.7
561
9.0
986
18.5
611
16.6
Administrative problems
963
6.3
182
2.9
441
8.3
340
9.2
Insufficient notes
108
0.7
10
0.2
64
1.2
34
0.9
The metropolitan area has the least probable avoidable factors compared with city and towns and
rural areas. Overall within the health system (health worker related and administrative) clinicians felt
that one-in-five deaths could have been clearly avoided. That varied between approximately one-infour for city and towns and rural areas and one-in-eight in the metropolitan areas.
Table 9 Common patient related modifiable factors
Probable
Number
% Deaths
Inappropriate response to poor fetal movements
586
3.8
Never initiated antenatal care
557
3.6
Delay in seeking medical attention during labour
486
3.2
Booked late in pregnancy
300
2.0
Infrequent visits to antenatal clinic
109
0.7
Lack of transport - Home to institution
102
0.7
Inappropriate response to rupture of membranes
57
0.4
Inappropriate response to antepartum haemorrhage
56
0.4
Failed to return on prescribed date
45
0.3
Declines admission/treatment for personal/social reasons 40
0.3
Attempted termination of pregnancy
27
0.2
Alcohol abuse
20
0.1
Delay in seeking help when baby ill
7
0
Infanticide
7
0
146
Table 10
Common administrative related modifiable factors
Probable
Number
% Deaths
Inadequate facilities/equipment in neonatal unit/nursery
228
1.5
Delay in medical personnel calling for expert assistance
94
0.6
Personnel not sufficiently trained to manage the patient
84
0.5
No accessible neonatal ICU bed with ventilator
76
0.5
Lack of transport - Institution to institution
68
0.4
Insufficient nurses on duty to manage the patient adequately 67
0.4
Insufficient doctors available to manage the patient
46
0.3
Personnel too junior to manage the patient
39
0.3
Result of syphilis screening not returned to hospital/clinic
35
0.2
No response to positive syphilis serology test
32
0.2
No syphilis screening performed at hospital / clinic
28
0.2
No on-site syphilis testing available
27
0.2
Anaesthetic delay
26
0.2
Inadequate theatre facilities
25
0.2
Lack of adequate neonatal transport
14
0.1
No dedicated high risk ANC at referral hospital
12
0.1
Staff rotation too rapid
7
0
Table 11
Common health worker related modifiable factors
a. Antenatal care
Probable
Number
% Deaths
No response to maternal hypertension
214
1.4
No response to history of stillbirths, abruptio etc.
62
0.4
No response to poor uterine fundal growth
73
0.5
Multiple pregnancy not diagnosed antenatally
40
0.3
No response to apparent post-term pregnancy
40
0.3
Fetal distress not detected antenatally; fetus monitored
38
0.2
Physical examination of patient at clinic incomplete
38
0.2
Antenatal steroids not given
28
0.2
Fetal distress not detected antepartum; fetus not monitored 36
0.2
No response to history of poor fetal movement
22
0.1
Inadequate / No advice given to mother
21
0.1
Incorrect management of antepartum haemorrhage
18
0.1
No response to maternal glycosuria
16
0.1
Incorrect management of premature labour
14
0.1
No antenatal response to abnormal fetal lie
10
0.1
Iatrogenic delivery for no real reason
9
0.1
b. Intrapartum care
Probable
Number
% Deaths
Fetal distress not detected intrapartum; fetus monitored
235
1.5
Fetal distress not detected intrapartum; fetus not monitored
157
1.0
Management of 2nd stage: prolonged with no intervention
114
0.7
Management of 2nd stage: inappropriate use of vacuum
23
0.2
Management of 2nd stage: inappropriate use of forceps
4
0.0
Medical personnel underestimated fetal size
72
0.5
Medical personnel overestimated fetal size
50
0.3
Poor progress in labour, but partogram not used
50
0.3
Poor progress in labour - partogram interpreted incorrectly
49
0.3
Poor progress in labour, but partogram not used correctly
48
0.3
Breech presentation not diagnosed until late in labour
42
0.3
Multiple pregnancy not diagnosed intrapartum
33
0.2
Incorrect management of cord prolapse
9
0.1
147
c.
Neonatal care
Number % Deaths
Probable
d.
Neonatal care: management plan inadequate
85
0.6
Neonatal resuscitation inadequate
57
0.4
Neonatal care: inadequate monitoring
37
0.2
Inadequate resuscitation equipment
33
0.2
Baby managed incorrectly at Hospital/Clinic
22
0.1
Nosocomial infection
10
0.1
Baby sent home inappropriately
3
0
Health worker related delays
Probable
Number
% Deaths
Delay in referring patient for secondary/tertiary treatment
168
1.1
Delay in doctor responding to call
50
0.3
Doctor did not respond to call
22
0.1
No response to poor fetal movements is the most frequent patient related modifiable factor. A
randomised trial performed in developing countries is urgently needed to ascertain the real value of
observing fetal movements in pregnancy. No antenatal care, infrequent visits or starting antenatal
care late was the most common patient related avoidable factor. It is still uncertain how many deaths
antenatal care would have prevented and how many is the result of victim blaming by the clinicians.
Delay in seeking medical attention during labour is mostly due to lack of transport from home to a
health care institution and not because of an unwillingness to seek help. If this is coupled with lack of
transport – home to institution and from institution to institution, then there were about 656 instances
where transport played a direct role in the death of an infant.
Discussion
Opportunities for Africa’s Newborns6 states:
“Each year in Africa, 30 million women become pregnant, and 18 million give birth at home without
skilled care. Each day in Africa
 700 women die of pregnancy-related causes.
 3,100 newborns die, and another 2,400 are stillborn.
 9,600 children die after their first month of life and before their fifth birthday
 1 in every 4 child deaths (under 5 years) in Africa is a newborn death”
and
“Every year in sub-Saharan Africa 1.16 million babies die in the first month of life, and another million
babies are stillborn.”
148
How does South Africa compare with Africa and other countries?
Table 12
*
Comparison of rates of stillbirths between countries7
SB
rate/1000
Region
Country
(BW 
1000g)
Developed countries
Australia
6.4
Canada
6.9
Denmark
5.6
Latin America
Argentina
19
Bolivia
44
Brazil
22
Middle East
Egypt
19
Jordan
15
Saudi Arabia
9.6
South Asia
India
39
Nepal
40
Pakistan
24
Asia/Pacific
China
13
Malaysia
12
Papua New Guinea
22
Sub-Saharan Africa
Cote d’Ivoire
34
Malawi
39
Mauritius
11
Zambia
31
South
Africa
25
(DHIS)*
National PPIP
19
Intrapartum
SB
rate/1000g
(BW  1000g)
0.74
0.41
0.44
2.3
5.3
2.6
6.4
4.1
3.1
9.8
19
14
8.8
3.2
4.2
4.2
10.0
3.0
10.5
7.5
- South Africa (DHIS) data is from the National Department of Health, Department of Health Information System
Table 12 lists the different stillbirth rates of various countries. In this comparison South Africa has
rates that are comparable with other middle-income countries. However, it appears the intrapartum
stillbirth rate is higher than other comparable countries.
Table 13 gives a comparison of the neonatal mortality rates and low birth weight rates with other
countries. It is not certain what weight cut off was used for other countries but data for South Africa
is for babies  500g. In comparison with other middle-income countries the National PPIP data has a
high low birth weight rate, whereas its neonatal mortality rate is lower than similar countries. This
lower rate is probably due to the lack of capture of deaths of neonates after discharge from hospital
(see below).
Table 13
Comparison of neonatal mortality rates and low birth weight rates between countries
Region
Country
Developed countries
Australia
Canada
Denmark
Argentina
Bolivia
Brazil
Egypt
Jordan
Saudi Arabia
India
Nepal
Pakistan
China
Malaysia
Papua New Guinea
Cote d’Ivoire
Malawi
Mauritius
Zambia
South Africa*
Latin America
Middle East
South Asia
Asia/Pacific
Sub-Saharan Africa
*
- Live born infants  500g,
149
NMR/1000
live births
4
4
4
12
34
19
30
19
10
43
50
49
23
12
65
32
12
37
21
(14 in PPIP)
LBW (%)
6
6
6
7
5
8
10
10
7
33
27
25
6
9
23
17
16
14
12
12
(16 in PPIP)
There is often bias as to classifying intrapartum deaths as stillbirths or early neonatal deaths. It is
easier for clinicians to say a baby is stillborn rather than a neonatal death because of burial policies
and ease of administration. Hence it is best to combine intrapartum stillbirths with neonatal deaths to
compare regions and countries (see Table 14). South Africa is compares adequately with other
middle-income countries.
It is estimated that 94% of pregnant women in South Africa attend antenatal care and 74% attend
four or more times6. Further 84% have a skilled attendant at birth6.
Table 14
Comparison of early neonatal death mortality rates and intrapartum stillbirths between
countries
Region
Developed
countries
Latin America
Middle East
South Asia
Asia/Pacific
Sub-Saharan
Africa
*
Country
Australia
Canada
Denmark
Argentina
Bolivia
Brazil
Egypt
Jordan
Saudi Arabia
India
Nepal
Pakistan
China
Malaysia
Papua
New
Guinea
Cote d’Ivoire
Malawi
Mauritius
Zambia
South Africa
NMR/1000
live births
4
4
4
12
34
19
30
19
10
43
50
49
23
12
Intrapartum
SB ( 1000g)
0.74
0.41
0.44
2.3
5.3
2.6
6.4
4.1
3.1
9.8
19
14
8.8
3.2
-
4.2
65
32
12
37
21
(14 in PPIP)
4.2
10.0
3.0
10.5
7.5
- Live born infants  500g
How does the PPIP care compare with other South African data?
Table 15 gives the rates of deaths from the “Opportunities for Africa’s Newborns” report and from the
PPIP sites. The data from the “Opportunities for Africa’s Newborns” is quoted as coming from the
Demographic and Health Survey. The National District Health Information Systems reports a stillbirth
rate of 25/1000 births and a PNMR of 34.9/1000 births, (the neonatal death rate was not reported).
The PPIP data consistently records lower neonatal deaths.
Table 15
Comparison of mortality rates from different data sources in South Africa
DHS
(1998)
Maternal Mortality Ratio
(/100000 live births)
Annual maternal deaths
Stillbirth rate /1000
births
NMR /1000 live births
U5MR /1000 live births
NMR as percentage U5MR
NDHIS
(2005)
PPIP
(500g)
PPIP
(1000g)
SubSaharan
Africa
230
-
940
2500
-
247 300
18
25
21
67
31%
24
19
32
14
-
10
41
164
25%
NMR - Neonatal mortality rate
U5MR - Under 5 mortality rate
Table 16 compares the causes of neonatal deaths globally with the different South African data sets.
Infections appear much lower in the PPIP data than elsewhere, partly due to a lower incidence and
death rate in South Africa, but also because most late neonatal deaths are not captured in PPIP most
infection deaths occur in the late neonatal period.
150
Table 16
Comparison of causes of neonatal deaths globally and in South African national estimates
compared with PPIP national dataset
Estimated
Estimated
PPIP
PPIP
distribution
distribution
SADHS
 1000g
 500g
Cause
for sub
for South
(%)
6
Saharan Africa
Africa
(%)
(%)
(%)
(%)
Infections
37
23
12
9
21
Sepsis/pneumonia
28
21
18
Tetanus
6
>1
1
Diarrhoea
3
2
2
Preterm
25
38
32
51
38
Asphyxia
24
21
37
26
21
Congenital
6
10
10
8
10
Other
7
6
9
5
6
Global estimates and South African estimates based on work by the WHOs Child Health Epidemiology Reference Group for 192
countries for the year 2000, updated for 2006.1,6,9,10
This lower neonatal death rate is due to PPIP not capturing neonatal deaths once the mother and
baby have been discharged from hospital. The Saving Children 20053 report (which uses the Child
Healthcare Problem Identification Programme – ChIP) found that approximately 16% of all child
deaths occurred in the neonatal period and 82% of these deaths were due to infections. These deaths
occurred in “paediatric” wards and excluded those neonates that died in the nursery. Hence the true
neonatal death rate would be a combination of the neonatal deaths from the ChIP and PPIP. Data
from Kalafong Hospital where both databases (PPIP and ChIP) are used (Table 17) the pattern of
disease is similar to the estimated global distribution.
Table 17
Pattern of neonatal deaths at Kalafong Hospital for 2005 where PPIP and ChIP databases are
combined
%
%
 1000g
 500g
Cause
(n=14)
(n=41)
Infections
35
14
Preterm
7
58
Asphyxia
21
7
Congenital abnormalities
21
7
Other
14
12
The figures available from PPIP accurately reflect the pattern of disease for early neonatal deaths and
the early death neonatal death mortality rates.
Overall, South Africa is clearly a leader in Africa, but given our gross national income, per capita of
US$3630, we should be doing much better. If care for pregnant women and their children continues
as it is now, we will not get close to achieving the Millennium Development Goals 4 and 5.
151
PERINATAL STATISTICS FROM THE DISTRICT HEALTH INFORMATION
SYSTEM, 2003-2005
Lesley Bamford
National Department of Health
Introduction
Data on key perinatal outcomes, such as stillbirth, perinatal mortality and low birth
weight rates, are now available for every district and sub-district in South Africa
through the District Health Information System (DHIS). Many health workers and
health service managers however are not aware of, or do not have access to, this
valuable source of information.
The DHIS which is a system for collecting, collating and analysing routine facilitybased health information is implemented in all public sector health facilities in South
Africa. Data are collated at district, provincial and national levels.
Systems for ensuring that information flows up the system from facility to national
levels are in place.
For the 2006/7 financial year the DHIS contained data on
1,097,072 births which indicates excellent coverage. The quality of the data is
variable – however the best way to address concerns regarding data quality is for
health workers and managers to start interrogating and using the data.
Other aspects of the system such as provision of feedback to lower levels of the
system are much weaker. Data from the DHIS are also often not readily available to
health managers, policy makers, researchers and other stake-holders. As a result the
data are not used to identify problems regarding the quality of service delivery, nor
to monitor the effectiveness of efforts to improve service delivery.
152
Perinatal statistics
Stillbirth and perinatal mortality rates
Figures for 2003-2005 are shown in the table below.
Stillbirth Rate
28 per 1000
25 per 1000
25 per 1000
2003
2004
2005
Perinatal Mortality Rate
38.4 per 1000
38.2 per 1000
34.9 per 1000
It should be noted that these figures include all deliveries regardless of weight
category. The figures correlate well with those collected in sentinel sites through the
Perinatal Problem Identification Programme (PPIP).
Figures for each province are shown in the graph below. Perinatal mortality rates are
highest in the Eastern Cape, Mpumalanga and Kwazulu-Natal.
50
45
40
35
30
25
20
15
10
5
0
E
as
te
rn
C
ap
Fr
e
ee
S
ta
te
G
au
te
ng
K
w
az
ul
u
Li
m
p
M
pu op
o
m
al
N
an
or
th
ga
er
n
W
C
es
ap
te
e
rn
C
ap
S
ou
e
th
A
fr
ic
a
Stillbirth rate
PNMR
The perinatal mortality for metropolitan areas was 34.5 per 1000 deliveries compared
with a rate of 44.7 per 1000 for the rural nodes (which represent the 13 poorest
rural districts in the country). Once more these figures are consistent with those
collected through the PPIP, which also demonstrate higher perinatal mortality in rural
as compared with urban areas.
153
Low Birthweight Rates
Low birth weight (LBW) rates reported through the DHIS appear to be unrealistically
low with rates of 10% or more being reported in only three provinces, namely
Western Cape, Northern Cape and Eastern Cape. The problem appears to be that in
a number of provinces whilst the births which take place in large hospitals are
included in the denominator, low birth weight neonates born at these hospitals are
not included in the enumerator. Review of LBW rate data for each district and facility
should assist provincial coordinators in identifying where the data collection problems
lie and addressing these problems.
Access to the data
Data for each district is available from a number of sources including the South
African Health Review and the District Health Barometer which are both published by
the Health Systems Trust (http:// www.hst.org.za). Health workers, managers and
others should also be able to obtain data directly from the DHIS from health
information officers at district, provincial and national levels. DHIS software is all
open-source and easy to use, so data users should be able to access and manipulate
data contained on databases.
Conclusion
Perinatal data contained in the DHIS provides a reasonably accurate picture of
perinatal mortality and morbidity in South Africa.
The challenge is to ensure that the quality of data is improved, and that the data are
used to identify facilities and districts which require support in improving the quality
of care they provide, and in monitoring the impact of interventions which aim to
improve the quality of maternal and neonatal care.
154
PERINATAL AND NEONATAL MORTALITY IN MTHATHA IN THE PERIOD 20032005. COMPARATIVE STUDY.
Dr. Ricardo F. Fernandez, Nelson Mandela Academic Hospital
Prof. Alexis Cejas. Walter Sisulo University.
Dr. Z. M. Nazo. Nelson Mandela Academic Hospital.
Introduction:
Many changes had being taken place after moved the neonatal services from the old Umtata
General Hospital (UGH) to the new neonate units at Nelson Mandela Academic Hospital
(NMAH). Those changes had being affecting in one way or other the Perinatal indicators in
our area.
Methods:
A descriptive study using the statistics from neonate unit at UGH (2003) and NMAH (2005)
has being reviewed, in order to made possible the comparison between the 2 periods in
different settings.
Graphics and tables will be release from the data collected and the analysis will be made
interdepartmental, Power Point and Excel is use for the presentation.
Results:
The Mortality Infant Rate has being increase since 2003 gradually. 41 x 1000 to 46.5 x 1000,
in 2005. The number of total births has being increase from 6827 until 10336 in 2005.
Hypoxia as cause of death has being increase but Infections is dropping down.
New ICU services are not modifying the situation yet.
Detailed indicators are presenting.
155
IS BABY-FRIENDLY, FRIENDLY TO THE BABY?
HM Kunneke
Worcester Regional Hospital
Introduction
What is the baby-friendly hospital initiative? It is the worldwide initiative to establish
hospitals were the needs of a mother and baby are met in the most natural way
possible. The only data I could find regarding Baby friendly hospitals was the ten
steps to breastfeeding, ignoring all other needs of the mother and baby pair. My
feeling is to not concentrate on zero-tolerance towards bottles or teats, but rather
concentrate on entire service delivery to a mother and newborn baby in hospital.
One should listen to the mother’s needs and be accommodating in difficult or
different circumstances and not live blindfolded as to the challenges in the real
world.
The Ten Steps to breastfeeding
Written breastfeeding policy, routinely communicated to all staff.
Train all health care staff in skills to implement policy.
Inform all pregnant women about benefits and management of breastfeeding.
Help mothers to initiate breastfeeding within half an hour of birth.
Show mothers how to breastfeed and maintain lactation if separated from babies.
No food or drink other than breastfeeding to newborn unless otherwise indicated.
Practice rooming-in; allow mothers and babies to remain together 24 hours a day.
Encourage breastfeeding on demand.
Give no artificial dummies or teats to breastfeeding infants.
Foster the establishment of breastfeeding support groups and refer mother to them
on discharge from hospital.
Experiences in Intensive Care Unit
Neonatal units are always very noisy, with monitors, alarms, loud music, cleaning
and talking contributing. Lights are almost always on and phototherapy and heaters
and often a TV for the staff, contribute to the light pollution. Painful procedures are a
156
daily occurrence like drawing blood, blood gases and doing heel pricks for
hemoglobin and glucose values. Uncomfortable and often painful procedures e.g.
catheters, NG tubes, umbilical catheterization and intubation, ventilation and CPAP
are all done on neonates without often thinking about the trauma or emotional
effects.
Often mothers have unique needs like a working mother, a baby with inborn error of
metabolism, cleft lip or palate, or other congenital abnormalities. Difficult home
circumstances like living in informal settlements without any power or running water
or cooking facilities in the house. HIV positive mothers with the above, often find it
very difficult to pasteurize milk, especially at night.
Challenges we have experienced in our unit are the following:
Scholars going back to school shortly after delivering their babies.
Farm workers having to start working soon after delivery and babies going to ‘farmcrèches’. Adoption babies. Often families are living in informal settlements with no
electricity, water, sanitation and more than one family sharing a very small dwelling.
Some
mothers
especially
after
delivering
premature
babies
struggle
with
breastfeeding and even when pharmacologically stimulated cannot produce milk.
Our unit is more often than not overcrowded, low and high care babies share the
same space, there are few nursing personnel.
Our Policy is to:
Promote and initiate breastfeeding in all patients delivering in the unit.
Listen to the mother and her specific needs and problems she faces.
There are daily discussion groups in communal wards with mothers by senior nursing
personnel.
Exclusive breastfeeding options are communicated to the mother or pasteurization if
HIV positive.
There is a definite problem with HIV- positive mother’s already informed at antenatal clinics that they will not be breastfeeding and we find it very difficult to
convince them to breastfeed.
157
Our babies room-in with the mother’s 24 hours a day and there are no nursery
facilities.
Breastfeeding is always on demand.
Babies with jaundice, PROM and other non-severe problems are treated in labor ward
with the mom.
We also feel that the mode of feeding that will be used at home should be
established in the hospital.
In the high care nursery we promote breast-feeding only; by breast, cup or even the
mother’s finger if on the ventilator or CPAP.
We will also help the mother to breastfeed, express, care and store breast milk and
bottles.
If formula will be used at home, we feel it is our responsibility to ensure the correct
management of bottles, preparation, mixing and storing of formula and bottles.
NO nasogastric tube feeds are administered in the unit. Normally we smell, see and
handle food before starting to eat, the GIT is thus prepared to digest the food. A
baby would see, smell and feel the breast before starting to breast feed. If a baby is
sleeping and milk is administered by NG-tube without preparation of the GIT, it leads
to rapid distention of the tummy, there is no enzyme preparation, no vagal
stimulation and this leads to vomiting, aspiration, food intolerance and feeding
problems.
We do not use any teats or NG-tubes and would thus cup or finger-feed only.
Discussion
We therefore accommodate the mother and the babies’ needs as far as possible.
Unfortunately this is extremely difficult with sleeping space for only 4 mothers and
instances where the mother has to go home to take care of other children. We do
administer medication to enhance milk production. The mothers’ are encouraged to
even KMC babies on CPAP to enhance bonding, milk production, establish the mom
as the primary caregiver and obviously all the positive effects of KMC for the baby.
We do bottle-feed if breastfeeding is impossible or not feasible and if we know the
baby will be bottle-fed at home.
158
The reality is thus that we do have bottles in the unit and not only use them to
bottle-feed in rare occasions but also to express and store breast milk and to mix
milk with Vitamins, Iron and FM-85. The milk is always administered to the baby by
cup. HIV positive mothers bottle-feed, even when pasteurizing and if adoptive
parents choose to use bottles, where we know a grandmother will raise a baby and
where babies will be going to crèches, babies will receive bottle feeds.
Results
We have over 90% breastfeeding rate in the general labor ward. In the private
patients, we only see about 50% rate, but we try to initiate breastfeeding in all.
There is a 100% breastfeeding rate in the high care nursery with pasteurization of
milk if the mother is HIV- positive. We do see a very low rate of feeding problems
and very rarely use agents such as motilium or Gaviscon for reflux. We have proved
that is possible to feed even ELBW babies with cup or breast and feeding whilst in
CPAP or Ventilator is possible if NG-tubes are not being used. Bottle-feeding is used
when the primary caretaker is in the unit and it will be the mode of feeding at home.
Discussion
The baby-friendly hospital initiative is a good, solid basis for natural mothering and
exclusive breastfeeding and works well in general labor ward setting, where we have
above 90% breastfeeding rate.
Unfortunately with poverty, low-cost baby-care, teenage pregnancies, HIV and few
boarding spaces for mothers we are to often forced to make do and compromise.
However a breast is best even with HIV policy is followed.
Overall we have a happy unit with low mortality rate and by accommodating babies’
needs and listening with empathy to mothers, we achieve a high breast feeding rate
even in a overcrowded high care setting with good compliance from mothers in
difficult and recourse-limited settings.
We are not labeled a baby-friendly hospital, but by abolishing NG-tubes, KMC as far
as possible and support as much as we can, we feel strongly that we are friendly to
the babies’ needs even if sometimes met by using a bottle or formula.
HOWEVER:
We have happy compliant mothers and thriving babies.
159
IMPLEMENTATION OF DEVELOPMENTAL CARE FOR HIGH-RISK NEONATES:
AN INTERVENTION STUDY
A Hennessy (Tygerberg Children’s Hospital), C Maree (UP – Department of Nursing
Science) & Dr C van der Walt (UP – Department of Nursing Science)
Introduction
As technology in the field of health sciences improves, the patient mortality rate
decreases. Although this presents as a positive advancement, the pre-term infant
still commonly experiences short- and long-term effects that are not as positive as
we would like.
These babies experience a range of morbidity related to the
immaturity of their organ systems and concurrent disease states (Symington &
Pinelli, 2002: 1).
In spite of improved technology which reduces the mortality rates of pre-term
infants, these infants are commonly exposed to more stressors and present with
stress levels above their ability to cope. The pre-term infant’s rapidly developing
brain is known to be particularly vulnerable to a stressful environment.
The
detrimental effect of environmental stress has both short- and long-term implications
for the already compromised neurobehavioural development of the pre-term infant
(Symington & Pinelli, 2002: 3).
Developmental care provides a simple and effective method of reducing negative
sequelae by modifying the environment to which the pre-term infant is exposed.
Developmental care, a relatively new concept in the South African NICU, is described
by Symington and Pinelli (2002: 1-2) as a broad category of interventions designed
to minimise the impact of the NICU environment so as to decrease a variety of
stressors.
The principles of developmental care include individualised infant care, familycentred care with minimal and appropriate handling and touch of the pre-term infant,
initiation of cluster care for nursing activities, specific positioning and swaddling,
kangaroo-mother care (KMC), non-nutritive sucking, pain management and
manipulation of the external environment to reduce negative stimuli (including noise
and light reduction) and introduce positive smell stimuli. These interventions may
include control of one or more elements of the external environment influencing the
160
vestibular, proprioception, gustatory, olfactory, tactile, auditory, and visual systems
(Kenner & McGrath, 2004: 14-27).
Background
Developmental care (DC) reduces short- and long-term sequelae for pre-term and
sick infants, but implementing developmental care in South Africa seems
problematic. This study documents how DC can be implemented successfully in the
context of a South African public NICU by changing the multidisciplinary team’s
approach to neonatal care.
Problem Statement
The implementation of developmental care has been documented and reported as a
new way of providing care, but barriers are evident in overcoming the theorypractice gap. Based on undocumented reflections made during a previous study, the
researcher observed problems in the implementation of developmental care,
including KMC. The problems identified included resistance to change, a non-caring
attitude, unfavourable working conditions, public financial restraints, negative
attitudes of some multidisciplinary team members, low levels of knowledge about
developmental care and a lack of training on the topic.
Research question: How can DC be implemented successfully at a South African
public NICU setting?
Purpose:
To develop guidelines for the implementation for DC in a particular
setting.
Setting: A South African public hospital’s neonatal intensive care unit (NICU).
Research method: The study was done based on the Intervention Design and
Development research model (Rothman & Thomas, 1994: 9). The model has six
phases: (1) problem analysis and project planning, (2) information gathering and
161
synthesis, (3) design, (4) implementation, (5) evaluation and advanced development,
and (6) dissemination. The sixth phase fell outside this study’s scope.
Phase One involved analysing and describing the level of DC practiced at the
research site before implementation, and planning the implementation of DC in the
site. Planning involved consulting relevant literature and the multidisciplinary team
of the NICU (March - May 2004). Concerns of the population were identified by
collecting data via questionnaire (1) (n=48) and analysing identified problems. Goals
and objectives were set.
Environmental audits (n=3) were also collected to
determine the level of DC practiced before the implementation phase.
Phase Two identified the factors involved in DC implementation from national and
international examples of such implementation, and from available literature, to
provide a contextual framework for the intervention plan (June – August 2004).
Elements of success were identified through conducting 27 in-depth individual
interviews with role-players who participated in the implementation of DC (national
n=2; international n=25). Environmental audits (n=4) were also conducted at the
Eastern American hospitals to determine the level of DC practices in their units.
The intervention plan for DC implementation, involving guidelines for this
implementation (Table 1), was designed in Phase Three.
The plan involved
descriptive representations of the realities of clinical practice combined with
applicable theoretical perspectives on the practice of DC (September 2004 –
November 2005).
162
Table 1: Guidelines for the implementation of developmental care
Guideline number
Guideline
Guideline one
Planning and preparation should take place before the intervention
phase
Guideline two
A programme coordinator or developmental care specialist should
drive the implementation process
Guideline three
Management support and involvement is essential
Guideline four
Resources are needed to facilitate the intervention plan
Guideline five
A developmental care committee should be established
Guideline six
Practice guidelines for the principles of developmental care should be
developed
Guideline seven
Education and empowerment of staff are critical for success
Guideline eight
Good communication pathways are vital for positive implementation
Guideline nine
Policies and procedures should be altered to include DC
Guideline ten
Monitoring and evaluation of the intervention plan are essential
Guideline eleven
Re-enforcing tactics are useful
Phase Four involved executing the intervention in a South African public NICU, with
participation of the multidisciplinary team.
The plan was refined and developed
further in Phase Five, through evaluating DC principles in the NICU. Evaluation of DC
principles
was
done
by
completing
bi-monthly
checklists,
collecting
the
multidisciplinary team’s opinion of success via questionnaire (2) (n=48), and
environmental audits (n=4) were done by an independent evaluator. Focus groups
(n=2) were held to conclude the evaluation phase.
The guidelines for the
implementation of DC were based on previous international research and one South
African NICU. The guidelines were validated by a focus group interview consisting of
South African neonatal experts and the implementation plan was re-evaluated.
Trustworthiness
The study used Lincoln and Guba’s model (1985: 305) to ensure trustworthiness. No
experimental and control groups were used as DC was implemented uniformly in the
NICU. Harm to research participants was not expected. Confidentiality was ensured
for all participants and institutions, and informed consent for participation obtained.
Clearance was obtained from the ethics committee of the University of Pretoria, and
institutional consent obtained from the necessary organisations.
163
Limitations
The NICU is a dynamic environment that cannot always be controlled, due to the
nature of the intensive care delivered to the high-risk and critically ill neonate.
Existing circumstances are not predictable and could have influenced the progress of
the implementation, and the results of the evaluations of this progress.
The
prescribed scope of the study limited the time period over which sustainability of the
intervention plan could be observed.
A recommended time period for the
implementation of DC should be between two and three years.
Conclusion
This intervention study targeted the multidisciplinary team where medical, nursing,
allied health profession and non-medical support personnel implemented DC.
Evidence of change was seen with the achievement of set goals that included
improving the quality of care at the research setting, reducing developmental delays
for the infants, improving the multidisciplinary team’s working environment,
increasing staffs’ knowledge and skills, improving staff morale and attitudes, and the
level of job satisfaction increased.
The intervention design and development method was used to answer the research
question of how DC could be implemented in a public NICU in South Africa, by using
the methodology to implement DC at the research site and develop guidelines for the
implementation of DC in the South African context. The effects of this project are of
ongoing benefit to the staff and patients at the research site, and should contribute
greatly to the effectiveness of neonatal intensive care throughout South Africa.
164
ACCREDITATION PROCESS
AF Malan, DH Greenfield. L Mashao, BA Robertson
Introduction
The Limpopo Initiative for Newborn Care (LINC) curriculum allows for definable
objectives which can be tested. Our accreditation process, which provides a holistic
evaluation of newborn care as seen fin figure 1, has evolved over several years.
Figure 1
Statistics
Quality of Care
Facilities
PNM Reviews
Equipment
Resource Material
Staffing
Newborn Care
Training of Personnel
Support Services
Kangaroo Mother Care
Guidelines
Baby Friendly Hospital
Records
Policies
Methods
Hospitals are only evaluated after they have made a written application.
Senior
management is involved in setting up a suitable date, obtaining all the required
documentation, and in interviews. A standardised check-list is used for evaluating
the neonatal areas including Kangaroo Mother Care. Statistics are reviewed and an
audit done on random patient records. A score sheet is used to assess quality of
care (as documented in the LINC admission record). Points are added up to provide
a percentage.
Interviews provide useful clarification on staffing, training, and
interpretation of statistics.
Categories of Care
In order to be more flexible and especially to encourage smaller facilities while
recognizing advanced care, a grading accreditation is used. These are Silver, Gold
and Platinum. The criteria for each are given in tables 1, 2 and 3.
165
Table 1



SILVER
Basic facilities, staffing, equipment and care for the newborns as per LINC check-list
Records score >60%
Essential for level 2 – CPAP
- apnoea
Table 2
GOLD

Basic care as for Sliver plus:
- interpret statistics
- apnoea monitor
- infusion pump / regulator
- CPAP
- Mobile X-ray
- All 12 steps KMC
- Decrease NMR 1500 – 1999g
Table 3
PLATINUM

Criteria
-
for Silver and Gold plus:
in-service training for staff
outreach to district
records score >80%
decreased NMR 1000 - 1499
Where a hospital does not achieve the basic accreditation, they are given a detailed
report specifying items that can be rectified thus encouraging a re – application for
accreditation.
Discussion
The accreditation tool has been used in 13 hospitals and is working well. We believe
it is practical, objective, and reproducible. Whether it will work in other services that
do not follow the LINC training programme, is uncertain. Modifications will probably
allow for a wider use.
Summary
The desirable goal of a system of accreditation of newborn care has been achieved.
We trust it will be further refined and encourage others to perform similar
evaluations.
166
OUTCOME OF HOSPITAL ACCREDITATION FOR NEWBORN CARE IN
LIMPOPO PROVINCE
PL Mashao, AF Malan, D Greenfield, NC Mzolo and BA Robertson.
Centre for Rural Health (University of KZN), Department of Paediatrics & Child Health
(University of Limpopo)
Introduction
We report our experience of the neonatal accreditation done in Limpopo hospitals. 12
out of 37 hospitals applied for accreditation and were evaluated. 7 hospitals were
successful, 5 succeeding after the first evaluation and 2 after a second evaluation.
Outcome
Accredited hospital
Mokopane
Elim
Dr CN Phatudi
Kgapane
Lebowakgomo
Malamulele
Donald Frazer
Status achieved
Platinum
Silver
Silver
Silver
Silver
Silver
Silver
The reason behind the successful accreditation of hospitals was invariably the
presence of someone acting as a “change agent”. In different hospitals, different
people were the change agents, a Medical Officer, Paediatrician, Midwife or the Unit
manager/Matron. Other success factors were the availability of equipment, good
facilities including kangaroo mother care unit and the reduction in neonatal mortality.
Hospitals were not accredited for the following reasons:
 Poor records
 No driver of the process
 Inadequate facilities
 Lack of essential equipment
 Statistics – no reduction
 PNM meetings
 Labour & postnatal ward staff
 Level 2 hospitals not using CPAP
167
The majority of hospitals received silver status, none gold and only one platinum.
These hospitals got all the basics right such as staffing, facilities including KMC,
equipment, records and perinatal audit. The reason they did not achieve gold status
was due either an inadequate decline in neonatal mortality rates over a year period
or inability to adequately interpret their perinatal data.
One hospital a level 2 hospital achieved platinum status. The success was due to the
following:

Motivated Paediatrician & supportive deputy manager

Good records scored >80%

Excellent KMC

Good equipment

Committed team with Permanent Doctors, Midwives, & EN/ENA

Reduction in neonatal mortality

Use of CPAP

District outreach and support

Management support
This hospital had failed the first round due to poor records, but managed to turn this
around in 6 months.
Another secondary level hospital was not accredited f due to

Inadequate medical staff

No regular perinatal review meetings

PPIP captured but neonatal deaths not entered and information not properly
utilized

No supervision in KMC, mothers not practicing continuous KMC

CPAP available but never used, staff not skilled on its use
Why others not applied
A number of hospitals have not applied for accreditation. This includes 2 level 2
hospitals that have completely inadequate facilities for level 2 services. They are
awaiting revitalization, but it is taking time.
168
22 district hospitals still need to apply for accreditation. The reasons for the delay are
either that they lack a change agent, the equipment is not adequate, or the hospital
is undergoing renovation. There are a number of very small hospitals which can
provide dedicated permanent staff for newborn care.
Conclusion
The Accreditation of hospitals for Newborn Care was found to be effective tool for
evaluating improvement in newborn care in Limpopo hospitals. The objective nature
of this process enabled the team to identify gaps in practices in some hospitals. Most
hospitals realized their gaps in newborn care. This process is seen as an incentive for
further improvement.
169
MINCC (MPUMALANGA INITIATIVE FOR NEONATAL AND CHILD CARE):
STANDARDISATION OF MORTALITY DATA
Elmarie Malek, Department of Paediatrics, University of Pretoria at Witbank Hospital
Marie Muller, Middelburg Hospital
Sophie La Vincente. Centre for International Child Health, University of Melbourne
Introduction
Neonatal and child mortality remain high in many areas of Mpumalanga province
(population approx 3.5 million), with great disparity between hospitals. Audit and
feedback as part of a quality improvement approach is a widely used mechanism to
understanding and improving the delivery of health services. The availability of
routinely collected neonatal mortality data through the Perinatal Priority Identification
Programe (PPIP) and Child Priority Identification Programme (ChPIP) provides an
opportunity to establish reliable baseline mortality rates and characteristics.
MINCC is a quality improvement initiative based on a program in an adjacent
province (Limpopo Initiative for Newborn Care (LINC). MINCC is a new initiative
recently embarked on by the Mpumalanga Provincial Health Department towards
reducing mortality and improving quality of health care for newborns and children at
all 25 provincial hospitals. A perinatal audit tool was designed based on
recommendations in the Saving Babies 2003 Report.
The MINCC Project
The objectives of MINCC are:
•
To implement and evaluate the impact of audit and feedback as part of an
quality improvement process on neonatal and child care and outcomes in
provincial hospitals.
•
To establish baseline rates and causes of neonatal and child mortality in
Mpumalanga hospitals.
•
To explore the use of routinely collected mortality data as an outcome
indicator in evaluating the intervention.
•
To facilitate better utilisation by hospitals and managers of routinely collected
mortality data.
170
MINCC follows implementation of LINC in 2003, which was designed to effect
improvement of neonatal care in a geographically large province with many rural
hospitals. The MINCC project is aimed at a similar target group for both the Neonatal
Phase and the Child Phase. MINCC project elements for the Neonatal Phase include a
full-time project coordinator, a series of workshops with hospital staff and managers
to raise awareness at various levels using the Perinatal Priority Identification Program
(PPIP) audit process and PPIP feedback reports, fact sheets and norms and
standards, with activities such as hospital teams completing a situational analysis and
action plan, conducting of hospital visits, providing training on the use of a newborn
admission record, neonatal care guidelines and observation tools, and accreditation
of hospitals. Experience during MINCC Neonatal Phase will serve to inform the Child
Phase which will provide opportunity for tools like the National EDL and WHO
Pocketbook and be linked to the Child PIP audit process. MINCC implementation is
designed for formal evaluation. For the Neonatal Phase, MINCC incorporates the use
of PPIP to track trends in neonatal mortality. For the Child Phase, the ChPIP will be
used. Neonatal mortality data are routinely collected across all provincial hospitals as
part of the PPIP program. For the MINCC project, data are being used from 20002005 for the baseline. PPIP data provides a baseline for neonatal mortality and can
be used to assess inter- and intra-hospital variability in mortality (given existing bias
i.e. referrals, late neonatal deaths after discharge, etc).
Standardisation of PPIP data
Standardising adjusts for the confounding effects of case mix on mortality.
This
enables more valid comparison of mortality between and within hospitals over time.
This concept has been introduced in South Africa in the past in relation to perinatal
mortality (see references).
There are many factors that may impact on Neonatal Mortality Rate (NMR) that are
not related to quality of care (i.e. may confound the relationship between NMR and
quality of care) and not all of these can be known or controlled for. Birth weight
distribution is a major factor that impacts on NMR, and can be controlled - for most
171
hospital deliveries birth weight is known. For neonates in our setting, low birth
weight is a good indicator of risk and a useful predictor of mortality (ie a high risk
delivery is a low birth weight delivery). For a hospital with a high proportion of low
birth weight (high risk) deliveries, you would expect the NMR to be high (e.g. expect
higher NMR in tertiary hospitals because high risk patients are referred to them). In
this respect, the birth weight for a hospital is a confounding factor (NMR may be high
because of the profile of patients, not because of the level of care). Gestational
age is the other factor that would be controlled for - question about reliability of this
information. This is not collected in many cases, and those for whom this information
is available are likely to differ in a systematic way from those for whom we do not
have this information. By standardising for birth weight distribution you adjust
for variation in the burden of high-risk deliveries among hospitals, and within a
hospital over time. The standardised (adjusted) rates are more valid than crude
rates, although not perfect, but is probably as valid as we can get in this setting
How are standardised rates calculated?
Take a standard birth weight distribution; in this case, the distribution for South
Africa using the PPIP national data base and this is considered the overall “norm”.
Calculate what the number of deaths in each weight category would have been (for
the standard) if the individual hospital mortality rates are applied. Sum the total and
calculate the standardised mortality rates (total number of deaths divided by total
number of deliveries X 1000)
Results
•
For
2000-2005,
the
Mpumalanga
Provincial
PPIP
database
contains
information on approx. 124 000 live deliveries, and 1700 neonatal deaths.
•
We have calculated crude and birth weight standardised neonatal mortality
rates over time for each hospital (n=20), and mean rates by hospital level
•
These data have been stratified by weight, year and hospital level to provide a
detailed baseline description of mortality.
•
Annual standardised NMR (2000-2005) ranged between 4.3 to 34.3 per 1000
live births; median 16.8 (SD 7.8)
172
•
Standardised neonatal mortality rates differ between hospitals with higher
rates at Level 2 hospitals and Level 1 hospitals with more than 100 deliveries
per month
•
In 2005, 52% of all neonatal deaths were immaturity related, while 28% and
6% were attributed to hypoxia and infection, respectively.
Table 1
Standardised mortality rates: Mpumalanga Province 2005 by
Hospital Level of Care
N. PPIP Level 1
deaths# CNMR
Level 1 Level 2
deaths* CNMR
Level 2
deaths*
Level 3
CNMR
Level 3
deaths*
<1000g
1-1.5kg
1 510 500
3 018 290.8
755
878
793
212.9
1198
643
358.5
19.9
541
60
1.5-2 kg
6 260 85.9
538
40.4
253
10.5
66
2-2.5 kg
18 069 14.7
266
7.0
126
4.3
80
866
4.2
774
4.1
756
>2.5 kg
184 288
4.7
Total
213 145
3302
2994
1503
CNMR
12.5
13.0
10.1
SNMR
15.5
14
7.05
* = nr deaths if this hospital level’s rates are applied to the standard distribution#
CNMR: crude neonatal mortality rate
SNMR: standardized neonatal mortality rate
Discussion
Standardisation of NMR using birth weight distribution implies a measure of care
directed at the low birth weight baby rather than the asphyxiated full-term newborn.
This bias could be addressed by also simultaneously tracking intrapartum asphyxia
related mortality (i.e. intrapartum stillbirths and early neonatal deaths due to
asphyxia). Standardised NMR is useful as a measure to interpret the quality of overall
neonatal care provided - it implies that if outcome for LBW is good at a hospital, then
care for asphyxiated and other babies should also be good.
Lessons learnt and recommendations
Standardisation of neonatal mortality rates to enable comparisons between hospitals
(using LBW) will be used in the MINCC project for baseline and ongoing evaluation of
the impact of the intervention. Recommendations for National will be directed to the
National PPIP Technical task team. Collaborative research toward developing a
Standardised Paediatric Mortality Rate Index is already under discussion.
173
ANTIBIOTIC AND MICROBIOLOGICAL AUDIT – KING EDWARD HOSPITAL
NURSERY - JANUARY – SEPTEMBER 2006
S Singh, M Adhikari
Neonatal Unit, King Edward VIIIth Hospital and Department of Paediatrics, University of
KwaZulu Natal
Background
Audits on antibiotic and drug usage form a regular part of practice in the nursery.
Aim
1.
2.
To determine whether the current empiric cover is appropriate in view of the
Klebsiella outbreaks and the commonly cultured organisms.
To determine the cost effectiveness of current and alternative treatment modalities.
Antibiotic Policy
First line: antibiotic policy includes Penicillin and Gentamycin.
Second line: cover prior to 2002 was Claforan and Amikacin. This was subsequently
changed to Tazocin and Amikacin to cover the increasing number of ESBL positive Klebsiella.
Third line: agents are Meropenem and Ciprobay according to organism susceptibility.
Results
Spectrum of organisms cultured – in total 272 positive blood cultures
Gran negative make up 28% of all positive blood cultures. Klebsiella is the most common
gram negative organism cultured in blood (19% of total) and endotracheal aspirates (ETA)
(45% of total). Acinetobacter cultured frequently in blood and ETA’s. E.coli makes up 6% of
gram negative organisms cultured. Other gram negatives make up 6% of total gram
negatives. Gram positive organisms make up 69% of total positive blood cultures.
Coagulase negative staphylococcus (38%) is commonly cultured organism mainly due to
contamination. Group B streptococcus makes up 3% of total positive blood cultures. Fungal
infections – Candida cultured very infrequently on blood.
Inventory of antibiotics
Currently we use large amounts of antibiotics for first line, second line and third line cover.
Cost
Total antibiotic cost for the months analysed was R48 861. Of this cost, Tazocin,
Meropenem and Ciprobay contributed R32 867 (68%). Cefotaxime made up only 3% of
total intravenous antibiotic cost (R1521).
Conclusions
Based on the list of blood cultures, Klebsiella Pneumoniae is the most common gram
negative organism cultured and coagulase negative Staphylococcus is the most common
cultured gram positive organism. Group B streptococcus is very infrequently cultured.
Fungal sepsis is not a major problem.
It is difficult to make any definite change in our current antibiotic policy based on a list of
blood cultures without knowing sensitivities and which organisms are actually significant. If
we do consider changing back to our original 2nd line agents (Claforan and Amikacin), it
would be a less expensive option. This policy would need 6-12 monthly review.
For a more accurate assessment of the organisms implicated in disease, we require a
retrospective or prospective study of the significant positive cultures and appropriate
antibiotic sensitivities.
174
HOW DID THE ESTABLISHMENT OF A NICU IMPACT ON A FAMILYCENTRED PRIVATE MATERNITY UNIT?
DV Bowling
Linkwood Clinic
Background
Linkwood Clinic was opened in 2001 in order to accommodate clients who wished to
have a natural, family-centred birth experience. Initially, the clinic was opened as a
midwife-only unit, with obstetric backup and a license for caesarean sections. In
2003 the clinic obtained a full maternity license.
Unique aspects of Linkwood Maternity Clinic include the following:

The feeling of being in one’s own home. Clients have attractively decorated
private rooms, with rooming in facilities for partners and siblings. Visiting is
unrestricted.

A philosophy of minimal intervention during normal childbirth, but with all the
technology and expertise available for high care births, caesarean sections, or
medical emergencies on a 24hour basis. Midwives and obstetricians enjoy a
complementary working relationship that allows clients a wide choice of
traditional or modern birth options and pain relief.
The need for a NICU became obvious since approximately 3% of newborns required
transfer to a NICU at another hospital. Parents were distressed at being separated
from their baby, especially when the hospital admitting the baby did not have a bed
for the mother, thus negating the concept of a family-centred birth. The NICU was
therefore opened in July 2004, using pre-existing space in the Maternity Unit (MU)
that was adapted to form a self-contained unit, licensed for 7 ICU beds.
A typical NICU often has a highly controlled and technical environment, with visiting
restrictions that allow minimal involvement of the extended family or other support
systems. Nurses become the primary care givers rather than the parents.
While
Linkwood NICU has all the modern technical equipment necessary to support the sick
newborn, the following measures were planned and implemented to make the
environment more family-centred:
175

Parents are shown around the NICU prior to delivery, on request, or, whenever
possible, NICU staff visit parents admitted to the MU with a high-risk pregnancy,
so as to establish contact and answer any questions.

Staff encourage progressive parent participation-from holding the hand of sick
microprem to kangaroo care, bathing and breast or bottle feeding.

Parents and extended family are actively involved in education regarding baby
care and parenting skills.

Mothers are encouraged to room in when baby is near discharge or if a baby is
admitted from home (if maternity bed state allows).

There is unlimited but controlled visiting: every person must wash their hands
regardless of whether they touch the baby or not, only 2 persons allowed at the
bedside at a time, visitors must be well (parents are to wear masks if they have
colds), baby is not disturbed between handling times.
None of these measures are possible without the co-operation of the NICU staff.
Therefore staff applying for a job in the NICU should be:

willing to spend a lot of
time with parents answering questions,
demonstrating skills and observing parents’ interaction with their baby.

willing to accommodate the extended family, have the patience to repeat
information, but also maintain confidentiality (parents must give permission as
to who gets information).

able to maintain a balance between control of patient care, maintaining
excellent practice standards and encouraging parental involvement.
Objectives
To assess how the establishment of the NICU impacted on the family-friendly
Maternity Unit in terms of patient profile and outcomes, and parent satisfaction.
Methods
This study is retrospective and descriptive. The patient profile and patient outcomes
of the NICU were compiled from research forms that were filled in for each patient
176
admitted to the unit. Parents were asked to complete an evaluation form on
discharge of their baby.
Results
The results relate to the first 2 years after the NICU was opened, i.e., July 2004 to
June 2006.
Patient Profile
 TOTAL NUMBERS: 276 patients
MALE: 159 (57.6%)
FEMALE: 117 (42.4%)



ADMISSIONS FROM MATERNITY UNIT: 239 (86.6%)
TRANSFER FROM OUTLYING CLINIC:
1 (0.4%)
ADMISSIONS FROM HOME:
36 (13%)

SINGLE/MULTIPLE PREGNANCY:
SINGLETONS: 210 (83 75%)
TWINS:
30 (12.5%)
TWIN II ONLY
3 (1.25%)
TRIPLETS:
6 (2.5%)

Types of deliveries
C/S
152 (63.3%)*
NVD
52 (21.7%)
UWB
19 (7.9%)
VENTOUX 13 (5.4%)
FORCEPS
4 (1.7%)
*Three patients requested C/S, the remainder were done mostly for obstetrical
reasons, probably a reflection of the increase in high-risk cases. The 4 most frequent
reasons were multiple pregnancies, poor progress, foetal distress and premature
births.

Gestational Age
<26 WEEKS:
3 (1.2%)
26-30 WEEKS:
7 (2.9%)
31-36 WEEKS:
77(32%) TOTAL PREMS: 87 (36.1%)
37-40 WEEKS:
141 (58.9%)
41-42 WEEKS:
12 (5%)
177
Diagnoses:
 ADMISSIONS FROM MATERNITY UNIT/OUTLYING CLINIC:
RESPIRATORY
171 (71.2%)
HMD
65 (27%)
Congenital Pneumonia
54 (22.5%)
TTN
43 (18%)
MAS
3 (1.25%)
OTHER
6 (2.5%)
CONGENITAL SEPSIS
24 (10%)
FEEDING PROBLEMS
17 (7%)
BIRTH ASPHYXIA
11 (4.6%)
HYPERBILIRUBINAEMIA
6 (2.5%)
GENETIC DEFECTS
4 (1.7%) (Downs: 2; Hydrocephalus:1; Encephalocoele:1)
OTHER
8 (3%)
 ADMISSIONS FROM HOME:
RESPIRATORY
13(36.%)
HYPERBILIRUBINAEMIA
11(30.6%)
SEPSIS
7(19.4%)
FEEDING PROBLEMS
3(8.3%)
OTHER
2(5.5%)

Ventilation Profiles: 77 Patients
Babies who needed oxygen only were not included in these statistics
No. pts.
Gest. age
1
2
24wks
25wks
2
26/27wks
1
4
28wks
30wks
15
31-32wks
26
33-36wks
27
37-42wks
Hours./Days of ventilation/O2
SIMV
HFOV NCAP
NC/Inc O2
24hrs *
588hrs
229hrs 828hrs
586hrs
24.5d
9.56d
34.5d ** 24.4d **
351hrs
188hrs
980hrs
14.6d
7.8d
40.8d
27hrs ***
106hrs
55hrs
15.5hrs
108hrs
4.4d
2.3d
4.5d
54.7hrs
13.4hrs
72.6hrs
2.3d
3.02d
65.3hrs
160hrs 20.8hrs
77.3hrs
2.7d
6.7d
3.2d
95.4hrs
188hrs 25.8hrs
179hrs
3.97d
7.8d
7.5d
NC=nasal cannula
* Baby died (hypoplastic lungs)
** Estimated times as baby had alternating NCPAP and NC O2
*** Baby died (Maternal APH)
Comment: Babies of 37-42 wks mostly had pneumonia/birth asphyxia
178
Outcomes
AVERAGE LENGTH OF STAY: 12.9 days
As can be seen from the ventilation profile, the premature babies had the longest
stay, many were weaned off oxygen shortly before discharge.
DISCHARGES to Maternity Unit or home:
264 (95.7%)
TRANSFERS -financial/location: 3; surgery : 3
6 (2.2%)
DEATHS: -hydrocephalus, encephalocoele,
hypoplastic lung, 28/40 mat. APH, SIDS
5 (1.8%)
RHT:
1 (0.3%)
Outcomes For The 240 Pts From MU/Outlying Clinic
IVH: Grade 1: 2 (0.8%)
Grade 2: 8 (3.3%)
Grade 3: 1 (0.4%) 26 week prem, maternal APH
Grade 4: 1 (0.4%) severe birth asphyxia, also had PVL
ROP needing laser therapy – 2 (0.8%)
Nosocomial Infections
2 (0.8%) staphlococcus epidermidis (both had central lines)
1 (0.4%) klebsiella (baby had NEC)
Poor Outcomes –3 of 271 survivors (1.1%)
1. Term baby with severe birth asphyxia and Gr. 4 IVH: cerebral atrophy, mental
and motor deficit
2. 30/40 prem, Gr. 2 IVH: CP with motor deficit but mentally normal
3. 32/40 prem with craniostenosis-some lower limb motor deficit
Parent Evaluation
Parents were asked to complete an evaluation form when their baby was discharged.
Of the total number of patients (276), 192 evaluation forms were completed, i.e.
73.5% -corrected for multiple pregnancies. Two were excluded from analysis as one
was incomplete and the other included the Maternity Unit in the evaluation. Parents
were asked to choose ratings of excellent, good, satisfactory or poor for 5 aspects of
neonatal care: standard of nursing care, technology available, timely response to
requests, appropriate information given and attitude of caring.
Results
169 (88.9%) gave an evaluation rating of ‘excellent’ for all 5 aspects
179
19 (10%) gave a rating of ‘excellent’ for some aspects and ‘good’ for
nursing care-8%, technology-16%,timely response-25%,
information-36% and caring-14%,
2 (1.1%) gave a rating of ‘poor’ for 2 aspects, one about the air conditioning and
the other about a lack of caring attitude of a specific staff member.
Comments include the following:

parents expressed appreciation for ‘tours’ of the unit before delivery, giving
them some idea of what to expect

“..an otherwise unpleasant experience has been made much easier by the
very kind staff who always acted professionally and in a very caring manner”

“All sisters were excellent and made us always feel at home and not at a
clinic”

“Thank you for explaining everything step by step over and over again, for
teaching me, comforting me, caring for us. Thank you for allowing me to bond
with my tiny baby girl.”

“As a prospective mother, you worry about many things during your
pregnancy but I never for one moment thought about the possibility of having
a baby in intensive care after the birth. All your staff seem to understand this
and they all helped us to deal with it and remain with our baby as much as
possible.”

“Could improve communication between the Maternity Unit and NICU”

Need more space in the unit and extra lodging facilities for parents / a lounge
for in-between feeds
Conclusions
The NICU appears to have had a positive impact as indicated by the patient
outcomes, which compare favourably with those of other neonatal units. The high
percentage of satisfied parents indicates that the adaptations made by the NICU in
order to promote a family-friendly approach have largely been successful. In spite of
the increased numbers of visitors, the nosocomial infection rate has been low.
180
THE PREVALENCE OF GROUP B STREPTOCOCCUS IN THE PREGNANT WOMEN OF
BLOEMFONTEIN
M du Toit, S Brand
Department of Obstetrics and Gynaecology, University of the Free State, Bloemfontein
Introduction
Group B Streptococcus (GBS) is the most frequent cause of early onset neonatal infection.
10-30 % of women are colonized, leading to 80 neonatal deaths annually in the USA. The
Centre for Disease Control thus recommends screening and treatment.
Objective
To determine the prevalence of maternal GBS infection in Bloemfontein
Method
100 women were screened at 35 weeks gestation. They were recruited at Pelonomi Hospital
and district clinics. Swabs of the rectum and vagina were obtained and plated onto culture
mediums.
Results
GBS-20/100 women, with 11/100 positive for Candida.
admission due to early onset Group B Streptococcus.
There was only one neonatal
Conclusion
Screening resulted in a decreased prevalence of GBS in the USA. In the UK, it was estimated
that 204 000 women had to be screened to prevent only 272 cases of EOGBS. Therefore,
some workers will approach the problem by selective screening or universal treatment
without screening. Since the prevalence of GBS was significantly high (20%), we recommend
intra partum antibiotics in our community.
181
ARE BACTERIAL INFECTIONS RESPONSIBLE FOR UNEXPLAINED STILLBIRTHS?
Mashabane NC, Jeffery BS, Pattinson RC
Department of Obstetrics and Gynaecology (University of Pretoria)
Aim
It is clear that unexplained stillbirths are a major issue in perinatal care in South Africa. We
did a study to look for the causes of unexplained stillbirths, particularly bacterial infections by
looking at bacterial 16SrDNA polymerase chain reaction (PCR) which has been used to detect
early sub clinical intra-amniotic infection.
Settings: Kalafong and Pretoria Academic Hospitals
Methods:
All pregnant women presenting to labour wards with intrauterine fetal deaths either of a
known or unknown cause were recruited by the project leader. All patients who gave
consent to the study were entered into the study. Upon delivery of the baby, amniotic fluid
was collected from the baby by nasogastric aspiration. Under sterile conditions three (3)
millilitres (ml) of fluid was collected into a sterile glass tube. The samples were stored in a
freezer and transported to a private laboratory in Pretoria within eight (8) hours. It was then
frozen at -70°C, then batched and tested for bacterial 16SrDNA PCR.
Results:
The results will be available between the 17th and the 18th of January 2007.
Conclusion:
Will be available between the 17th and the 18th of January 2007.
182
PREVALENCE AND RISKS OF ASYMPTOMATIC BACTERIURIA AMONG HIV
POSITIVE PREGNANT WOMEN
TA Widmer, GB Theron, E Carolus, D Grové
Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Stellenbosch
University and Tygerberg Hospital
Introduction
Urinary tract infection (UTI), which may be symptomatic or asymptomatic, is one of
the most common bacterial infections requiring medical treatment during pregnancy.
Infections are common in HIV disease and it is thought that the HIV positive
pregnant patient may be at a higher risk for UTI’s. Information on opportunistic
infections in HIV is plentiful, but data on common infections such as UTI’s is scarce,
and most of it results from studies of men.
Antibiotic treatment, compared to
placebo or no treatment, effectively eradicated asymptomatic bacteriuria (OR 0.07,
95% CI 0.05-0.10), and reduced the incidence of pyelonephritis (OR 0.24, 95% CI
0.19-0.32) and the rate of preterm delivery or low birth weight babies (OR 0.60,
95% CI 0.45-0.80).
Aim
To determine whether the prevalence of asymptomatic bacteriuria and subsequent
complications occur is higher in HIV positive pregnant women.
Methods
A cohort analytical study whereby asymptomatic pregnant women who booked
before 24 weeks gestation were recruited at the Bishop Lavis Community Health
Center. 120 consecutive HIV positive women and 240 HIV negative controls were
screened for asymptomatic bacteriuria by collecting a mid stream urine sample for
culture. The urine was then immediately plated onto Agar plates provided by the
laboratory using 1 l Quadloop loops.
The Agar plates were delivered to the
laboratory at the end of each day, where they were incubated and processed in the
usual manner. Patients with positive cultures were treated with 4 standard dose cotrimoxazole tablets taken as a single dose. A follow-up sample was collected two
183
weeks after treatment to evaluate success of treatment. Pregnancy outcomes were
compared between the two groups.
Results
A total of 125 HIV positive patients and 247 HIV negative control patients were
recruited.
There was no significant difference found in patients’ age, parity,
gestational age at delivery and birth weight (Table 1).
However HIV negative
patients were significantly younger (p=0.003) and had their first ultrasound at a
significantly earlier gestation (p=0.014). 9.2% (n=11) of HIV positive patients and
7.9% (n=19) of HIV negative patients had positive urine cultures (p=0.68).
Persistent bacteriuria after initial conventional treatment with stat dose of cotrimoxazole was found in 3 of the 11 HIV positive patients, and 3 of the 19 HIV
negative patients with asymptomatic bacteriuria (p=0.45; Fisher’s exact test). 7.5%
of HIV positive patients had CD4 cell counts <200/mm3, 53% between 200/mm3 and
499/mm3, and the remainder >500/mm3. Microorganisms were similar in both groups
(Table 2). The incidence of preterm labor was 6.7% in HIV positive, versus 11.3% in
HIV negative patients (p=0.17).
Significantly more HIV positive patients had
prelabour rupture of membranes, namely 14.2% compared to 5.4% in the HIV
negative controls (p=0.004). ASB was present in 4 out of 17 HIV positive and 1 out
of 12 HIV negative patients that had prelabor rupture of membranes. The presence
of ASB in the HIV positive group significantly increased the risk for prelabor rupture
of membranes (p=0.049; Fisher’s exact test). Pyelonephritis developed in only 2
patients in the entire study. Both of these patients were HIV negative and neither
had ASB. There were no cases of sepsis antenatally or postnatally in either group of
patients.
Conclusion
The prevalence of asymptomatic bacteriuria in HIV positive study patients did not
differ from HIV negative controls.
increased risk for preterm labour.
Likewise HIV positive patients were not at
However, asymptomatic bacteriuria was
associated with an increase in prelabour rupture of membranes especially in HIV
positive patients. Other studies have shown an increased risk of ASB in HIV and that
184
this may be related to immune status. The relatively few patients in our study group
with CD4 cell counts below 200/mm3 may have influenced the rate of ASB. One
other study performed in Pretoria, found that the incidence of ASB was higher among
70 HIV positive patients, namely 18.5%, compared to 12.9% in 163 HIV negative
controls (p=0.35; our own statistical analysis).
Both of these percentages are
noticeably higher than the incidence of ASB studied previously in our population. In
1991, a study determined the prevalence of ASB to be 10% and in 1996 an
evaluation in the same area found it to be 6.2%.
Table 1
Summary data of study patients
HIV negative
HIV positive
Patients
Age
Parity
GA at booking (weeks)
GA at first ultrasound (weeks)
GA at delivery (weeks)
Birth weight (grams)
Caesarean Section
Normal vaginal delivery
Table 2
120
240
1.75 [1-6]
15.1
19.5
38.5
2928
27 [22.5%]
89 [74%]
1.79 [1-6]
14.3
18.2
38.6
2985
30 [12.5%]
204 [85%]
Microorganisms cultured from patients with ASB
Escherichia coli
Proteus mirabilis
Klebsiella pneumoniae
Staph. Saprophyticus
Enterococcus faecalis
Staph. aureus
HIV Positive
7
HIV negative
13
2
0
2
1
1
0
1
1
1
1
185
p-value
0.69
0.15
0.01
0.74
0.44
0.01
THE EFFECT OF MATERNAL HIV INFECTION ON PERINATAL DEATHS IN
SOUTH WEST TSHWANE
L van Hoorick, RC Pattinson
MRC Maternal and Infant Health Care Strategies Research Unit, Department of
Obstetrics and Gynaecology, University of Pretoria,
Maternal HIV infection is the most common underlying cause of maternal and infant
deaths in South Africa. AIDS is the single most common cause of maternal death
reported as being responsible for 20.1% of all deaths. Eighty percent of the children
who died and their or their mothers whose HIV status was known were either
infected or HIV exposed.
The effect on perinatal deaths in South Africa is less clear.
A review of the
worldwide literature has demonstrated a clear association between HIV infection and
stillbirths, the latter being almost four times more likely in an HIV-infected pregnant
woman than in one who is not. An association has also been found with low birth
weight babies.
To help determine this relationship in our region, a study was carried out in south
west Tshwane.
The aim was to examine the relationship between maternal HIV
infection and perinatal death and determine the primary obstetric causes responsible
for those perinatal deaths.
Methods
South west Tshwane has a low to middle income urban population and is served by
Pretoria West and Laudium Midwife-Obstetric Units (MOU) and Kalafong Hospital.
There are 14 primary health-care clinics that refer to those institutions. Only data
from women from south west Tshwane between 1st January and 31st December 2006
was used in the study.
As part of routine audit the maternal HIV status was recorded as HIV negative,
infected or unknown in all women who gave birth from the area. All perinatal deaths
were also recorded in the Perinatal Problem Identification Programme (PPIP) and the
186
primary obstetric cause and HIV status was allocated to each death. The causes of
perinatal deaths from HIV infected, negative and unknown were analysed.
Standard statistical techniques were used to analyse the data. All forms of patient
identification were removed after data cleaning had occurred.
The hospital
superintendent has inspected the security of the databases and is satisfied with the
anonymity of the women.
Results
There were 6272 births in south west Tshwane in 2006. 4585 (73.1%) of these
pregnant women were counselled and 4187 (66.8%) women were tested. Table 1
illustrates the results of HIV testing in the pregnant women. The HIV positive rate
was 21.2% of those women who tested. The HIV positive rate for Gauteng in 2005
was 32.4% in anonymous antenatal testing. Thus the prevalence of HIV infection
must have been about 50% for the group that was not tested. (32.4% of 6272 =
2032; minus 888 = 1144; 1144/2085 = 54.8%). 9.9% of the 888 HIV positive
women were taking highly active antiretroviral therapy (HAART). Because of the
small number we did not compare the perinatal outcome between mothers with or
without HAART, nor did we include CD4 count as a criterion.
Table 1
Maternal HIV testing in southwest Tshwane
HIV +
HIV Not Tested
Declined
Total
Number
888
3299
2085
398
6272
%
14.2
52.6
33.2
19.1% of not tested
100
The mean birth weight of the babies from the HIV infected women was 2808.7g
(707g) and for the HIV negative mothers was 2942.4g (675g)(p<0.0001). The low
birth weight (LBW) rate for HIV infected women was 19.9% compared with 13.3%
with HIV negative women (p<00001; OR 1.62, 95% confidence intervals 1.33 and
1.97) and 16.8% for the unknown status group.
187
The mortality rates are shown in Table 2 and the mortality rates per primary
obstetric cause are shown in Table 3.
Table 2
Mortality rates (500g+) for HIV status
HIV + HIV - Unknown
*
SBR
26.3 17.2
NNDR 17.2 4.7
PNMR 40.5 22.7
Comparison between HIV positive
Table 3
Odds Ratio*
27.4
1.54
7.4
3.61
36.9
1.81
and HIV negative groups
95%
Confidence
Intervals*
0.93-2.54
1.76-7.44
1.21-2.72
Perinatal mortality rate per primary obstetric cause (500g+)
Primary Obstetric Cause
HIV + HIV -
*
Unknown P
Unexplained stillbirth
11.3 7.6
8.6
Spontaneous
preterm
12.4 3.6
12.9
birth
Infection
4.5
0.0
1.4
Intrapartum asphyxia 4.5
0.9
1.0
Trauma
1.1
0.9
0.0
Antepartum
1.1
1.2
4.8
haemorrhage
Hypertension
3.4
4.2
3.4
Medical Disease
0.0
1.2
1.0
Congenital
1.1
1.2
1.0
abnormalities
IUGR
0.0
0.3
1.0
Other
0.0
0.3
0.0
No Obstetric cause
1.1
1.2
1.9
Total
40.5 22.7
36.9
OR, 95% CI – Odds Ratio and 95% confidence intervals
*
Comparison between HIV positive and HIV negative groups
OR, 95% CI*
0.28
1.5, 0.71-3.11
0.004
3.43, 1.51-7.81
0.0012
0.02
NS
5.0, 1.1-22.2
NS
NS
NS
NS
NS
NS
NS
0.0049
1.81, 1.21-2.72
Discussion
HIV infected women had a significantly lower mean birth weight than HIV negative
women, but this appears to be due to more premature deliveries rather than growth
restricted babies.
A recent South African study performed in KwaZulu Natal has found similar results.
They showed a 75% increased risk of an HIV infected woman having an adverse
pregnancy outcome (antenatal death, spontaneous abortion or stillbirth).
The PNMR was significantly higher due to an excess of unexplained stillbirths,
spontaneous preterm delivery, intrauterine infection and intrapartum asphyxia. The
188
lack of significance of unexplained stillbirths in the HIV infected group was most
likely due to the lack of HIV testing in women who delivered unexplained stillbirths.
Most of these women delivered macerated stillbirths and the clinicians were reluctant
to request women to have an HIV test at that time. This is supported by the high
prevalence of unexplained stillbirths in the unknown HIV status group. The relatively
low rate of unknown HIV status in women with neonatal deaths is due to clinicians
being more active in counselling women for HIV testing where infant feeding choices
become urgent and relevant.
The finding of more preterm births in HIV infected women has been well recorded
and it appears that these babies are mostly appropriately grown premature infants
than growth-restricted infants. Three other studies in South Africa have failed to
show an association between growth restriction and the HIV positive status. Preterm
labour can be explained by the probable greater prevalence of amniotic fluid
infection in HIV infected women.
The significant increase of intrapartum asphyxia in HIV infected babies was
unexpected and unexplained. A possible explanation is that these fetuses had severe
congenital infections that was mistaken for intrapartum asphyxia.
Alternatively,
previous intra-amniotic infections made the fetus more susceptible to hypoxia during
labour. The numbers of fetuses involved are small and this observation will need to
be confirmed by other studies.
Conclusion
In south west Tshwane, an HIV positive mother has a double risk of having a
perinatal death compared to a HIV negative mother. There was also a different
pattern of primary obstetric causes of perinatal deaths in HIV infected pregnant
women.
Unexplained
stillbirth,
spontaneous
preterm
labour,
infection
and
intrapartum asphyxia occurs more in HIV infected women. Knowing that 24.3% of all
perinatal deaths in South Africa remain unexplained these findings can open new
perspectives on the underlying causes.
189
A LONGTERM REVIEW OF PERINATAL AND NEONATAL INDICES AT MADADENI,
1990 TO 2006
FS Bondi
Madadeni Hospital
To determine if HIV positive mothers have a higher rate of premature deliveries and an
increased rate of intrauterine growth restriction (IUGR) babies.
There has been a variety of changes in health care programmes and policies. These include
on the spot syphilis serology and treatment, free ANC, ’universal’ breastfeeding and better
births initiative. The primary objective of these interventions are quality care and ultimately
better outcome for mother, foetus and the neonate. This audit was performed to ascertain
the impact of these changes on the perinatal and neonatal outcome at Madadeni Hospital
and it’s 9-midwifery run clinics.
Hospital and clinic data on all deliveries (500g or more) and babies admitted to our nursery
were collected for the period 1990 to 2006. The table below shows the yearly PNMR and
NNDR respectively.

















Year
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
PNMR
50.7
55.1
49.1
45.9
48.2
47.1
47.3
49.0
56.7
55.3
56.3
59.1
53.7
61.5
65.1
59.1
50.1
NNDR
16.8
21.3
15.1
16.2
19.5
17.5
22.7
22.3
20.4
24.7
27.4
26.1
230
21.9
27.9
24.0
23.2
Other Parameters
 Deliveries = 75,946
 Births
= 77,620
 Multiple births = 2.2%
 SB rate = 4.6%
 SB : NND = 1.6:1.0
 PNMR = 71
LBW rate = 15.0%
PCI = 4.76
NNMR = 20.6
MMR = 117
CS rate = 21%
Assisted delivery = 1.1%
Our data illustrates two prominent features. Firstly, the poor socio-economic and health
status of the community we serve. Secondly, there has not been a major impact of the
series of health programmes on our perinatal and neonatal indices.
190
OUTCOME OF PREGNANCY IN HIV INFECTED WOMEN
Alberts BC. Jeffery BS, Makin JD, Pattinson R C.
MRC Maternal and Infant Health Care Strategies Research Unit, Department of Obstetrics
and Gynaecology, University of Pretoria
Aim:
To determine if HIV positive mothers have a higher rate of premature deliveries and an
increased rate of intrauterine growth restriction (IUGR) babies.
Introduction
The outcome of pregnancy in HIV positive women is associated with premature delivery,
intrauterine growth restriction, spontaneous abortions and stillbirths. Most of the currently
available data is retrospective and many studies are small.
Method:
A prospective cohort observational study was conducted at Kalafong and Pretoria-West
Hospitals. The study population consisted of all women of less than 24 weeks gestation,
consenting to have HIV testing. Consenting women had a dating ultrasound examination
and follow up at 32 weeks and outcome data was collected for all pregnancies after delivery.
Results:
A total of 360 women were included in the study with 128 HIV positive women and 155 HIV
negative women had outcome data available. Preliminary analysis showed no significant
difference between the two groups in terms of prematurity and IUGR. Final results will be
presented at the Priorities Conference in March 2007.
Conclusion
This study has shown no difference in pregnancy outcome between HIV positive and HIV
negative women. Possible factors contributing to this result will be discussed.
191
PREVENTING SERIOUS NEONATAL AND MATERNAL PERIPARTUM
INFECTIONS IN DEVELOPING COUNTRY SETTINGS WITH A HIGH
PREVALENCE OF HIV INFECTION: ASSESSMENT OF THE DISEASE BURDEN
AND EVALUATION OF AN AFFORDABLE INTERVENTION IN SOWETO,
SOUTH AFRICA
CL Cutland1, SJ Schrag 2, SC Velaphi 3, MC Thigpen 2, RM Patel 2, ML Kuwanda 1, ER
Zell 2 , SA Madhi 1
1 Respiratory and Meningeal Pathogens Research Unit, CHBH 2 Centers for Disease
Control, Atlanta, USA, 3Department of Neonatology, CHBH.
Sepsis in the newborn is a clinical syndrome characterized by systemic signs of
infection; it may be associated with bloodstream infection, meningitis, and/or
pneumonia caused by bacteria or other microorganisms. Neonatal sepsis is a major
cause of morbidity and mortality among newborn infants, particularly in developing
country setting. For example, incidence of neonatal bacterial sepsis in sub-Saharan
Africa has been reported to range from 6 to 21 per 1000 live births, with case-fatality
rates of 27% to 56%, compared to estimated incidence rates of 1 to 7 per 1000 and
case-fatality rates of 3% to 19% in the United States. Among residents of one health
district in Soweto, South Africa, the neonatal mortality rate from infection was
reported to be 2 per 1000 live births in 1995, with infection being the second most
common cause of neonatal mortality. The incidence of sepsis within the first week of
life due to Group B streptococcus (GBS), one of the most common causes of
neonatal sepsis worldwide, has been measured as 1.2-2.8 per 1000 live births in two
recent hospital-based studies in Johannesburg, South Africa. This is over twice the
current estimated rate of 0.5 per 1000 live births in the United States, and similar to
rates seen in the United States before GBS prevention policies were implemented.
The burden of neonatal sepsis in developing countries is often poorly described with
limited information on disease incidence, etiology, and risk factors for infection.
Moreover, strategies that have been successful at preventing neonatal infections in
developed countries, in particular the use of intrapartum antibiotics to prevent
mother-to-infant transmission of GBS, are often not affordable or feasible to
implement in resource-limited settings.
192
Surveillance of invasive pathogens in infants less than 3 months of age is being
conducted at CHBH. In 2004, 559 infants <3 months of age were admitted with
sterile site pathogens. The most common pathogen was Staphylococcus aureus
(76/559= 13.6%), followed by Streptococcus agalactiae (69/559= 12.3%) and
Eschericia coli (63/559= 11.3%).
Figure 1
Infants <3 months of age with sterile site isolate (n=559).
CHBH January to December 2004
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Prevention of perinatal infections by chemoprophylaxis
Some perinatal infections are preventable. In the United States, implementation of a
GBS chemoprophylaxis strategy that called for provision of intravenous penicillin or
ampicillin intrapartum to women with positive prenatal screening cultures or
development of specific risk factors was associated with a decrease in the incidence
of EOS due to GBS by 65% from 1.7/1000 live births in 1993 to 0.6/1000 live births
in 1998. However, the recommended use of penicillin for GBS chemoprophylaxis does
not provide broad coverage for other pathogens such as gram-negative bacteria,
which are also important causes of sepsis in newborns, and may in fact be more
important causes of neonatal sepsis than GBS in many developing countries. The
implementation of an intrapartum chemoprophylaxis strategy is not currently feasible
in many countries with limited financial and laboratory resources, and less welldeveloped health care infrastructures and information management systems. This is
particularly true for a strategy based on screening of all pregnant women at 35-37
193
weeks through culture of genital tract specimens, which has been shown to be most
effective for GBS prevention in the United States, but which requires prenatal care
visits during late pregnancy in addition to fairly complex specimen processing and
coordination between prenatal care sites, laboratories, and obstetric hospitals or
birthing centers. Alternate, inexpensive, easily implementable interventions to
decrease rates of neonatal sepsis and maternal peripartum infection are therefore
needed.
Chlorhexidine vaginal disinfection during labour as a prevention strategy
Chlorhexidine is an inexpensive and widely used topical antiseptic solution with an
established safety profile in neonatal and adult populations. Vaginal or perineal
applications of chlorhexidine in concentrations ranging from 0.05 to 4% have been
shown to have broad antimicrobial effects within 60 minutes of application, lasting up
to at least 6 hours. Because chlorhexidine is safe, inexpensive, and easy to
administer, and does not contribute to the development of antibiotic resistance, it
could potentially be administered to all parturients, obviating the complex process of
identifying a subset of women to receive intrapartum prophylaxis. Several clinical
trials have examined the impact of vaginal disinfection with chlorhexidine during
labour on neonatal and maternal peripartum infectious disease outcomes. These
trials have used different chlorhexidine concentrations, application methods, and
delivery schedules, as well as different primary outcome measures, and have
produced conflicting results A large Swedish trial showing a significant decrease in
the primary endpoint of neonatal special-care unit admissions with chlorhexidine
vaginal flushing has been criticized because criteria for admission were not
standardized among the ten hospitals participating in the trial, and this could have
introduced an important source of bias. The only such trial conducted in a developing
country setting, prior to initiation of the ‘Prevention of Perinatal sepsis’ trial was
performed in Malawi, and compared manual chlorhexidine wipes of the vagina every
four hours during labour plus a single wipe of the neonate at birth with usual
standard of care. Chlorhexidine vaginal and neonatal wipes were shown to have a
significant protective effect on the outcomes of neonatal admissions for and mortality
from clinically defined sepsis as well as maternal post-partum infection. This trial,
194
however, had several limitations. Instead of random allocation of subjects to the
intervention or control arm of the trial, the intervention was administered to all
consenting women who delivered during months designated as intervention months.
Outcomes in these women and their infants were compared to those in women who
delivered in adjacent, non-intervention, months. Thus, differences in outcome
between the treatment and control groups cannot be cleanly attributed to the
intervention.
Furthermore,
while
consent
was
obtained
during
labour
for
administration of chlorhexidine vaginal wipes, consent for enrolment into the study
was sought only after delivery, and may have been influenced by events related to
the intervention. Finally, sepsis and peripartum infection were defined based on
subjectively determined clinical criteria, and were diagnosed by individuals who could
not be effectively blinded as to what treatment the subjects received. Perhaps due to
these limitations, the promising results from the two trials described above have not
been viewed as sufficient demonstration of effectiveness to yield widespread
recommendation and/or adoption of the intervention. Bakr & Karkoer have recently
published results of their trial conducted in Egypt.
Previous trials of chlorhexidine vaginal disinfection during labour suggest a protective
effect for neonatal and maternal peripartum infectious outcomes, but have not been
conclusive. The protective effect may be dependent upon concentration, dosing
interval, or application method.
We are conducting a randomized, controlled clinical trial in Soweto, South Africa to
evaluate the efficacy of 0.5% chlorhexidine wipes of the birth canal during labour
and of the infant at birth in reducing 1) vertical transmission of leading pathogenic
bacteria from mother to child during labour and delivery, and 2) incidence of
neonatal sepsis and maternal peripartum infection. In conjunction with this, we will
compare vaginal carriage of bacteria commonly associated with neonatal sepsis and
maternal peripartum infection among HIV-infected and non-infected pregnant
women who deliver at the only public hospital in Soweto, and will characterize the
burden of disease and risk factors for maternal peripartum infection and serious
neonatal infections in this population by conducting active prospective surveillance.
195
Determination of outcome measures is done in a blinded fashion, by individuals not
involved with delivery of the intervention. Objective outcome measures, utilizing
clinical and laboratory, including microbiologic, criteria are used. Demonstrating the
effectiveness of this intervention using clearly defined objective outcome measures
will help clarify whether this intervention can prevent infections in mothers and
newborns. If the results of such a trial look promising, it would provide a strong
foundation for a public health recommendation for the strategy in this and similar
settings.
The ‘Prevention of Perinatal Sepsis’ (PoPS) trial was initiated on 1 April 2004.
Pregnant women are informed about the trial and sign consent form at the antenatal
clinic, antenatal wards or labour admissions ward of Chris Hani Baragwananth
Hospital, Soweto. Study midwives are based in labour ward complex of CHBH 24
hours/ day, 7 days/ week. The midwives identify consented women on arrival in
labour, assess them for eligibility, randomize them if eligible and conduct study
wipes. To date (3 May 2007), 6846 women have been randomized. The colonization
substudy to assess transmission of pathogenic bacteria, was initiated in May 2005
and will continue until trial completion. Approximately 4000 mother-infant pairs will
be included on the colonization cohort.
An interim analysis of the first 6000 randomized maternal participants and their
infants is planned for May 2007. Recruitment of the required 8000 maternal
participants will be completed by October 2007. We expect to be able to disseminate
the results of the ‘PoPS’ trial in the first half of 2008.
Several articles on chlorhexidine interventional studies to reduce neonatal sepsis/
morbidity have been published since the initiation of the POPS trial. Bakr et al
reported a significant reduction in infection-specific neonatal admissions and
mortality, and all cause mortality in Egyptian infants following maternal vaginal and
infant skin cleansing with 0.25% chlorhexidine.
Mullany et al reported a 24%
reduction in neonatal mortality and significant reduction in omphalitis in Nepalese
infants who received 4% chlorhexidine umbilical cord care compared to dry cord
196
care. Tielsch et al also reported an 11% reduction in neonatal mortality in Nepalese
infants who received a 0.25% chlorhexidine skin wipe.
Mullany et al have also reviewed Chlorhexidine antisepsis trials for improving
neonatal health in developing countries, and concluded that maternal vaginal
cleansing combined with newborn skin cleansing could reduce neonatal infections
and mortality in hospitals in sub-Saharan hospitals, but have recommended further
trials to determine the individual impact of these interventions, particularly in
community settings.
Goldenberg et al have reviewed the use of vaginally administered chlorhexidine
during labour to improve pregnancy outcomes, and concluded that chlorhexidine
vaginal and newborn treatments show a large potential benefit for improvement of
maternal and neonatal outcomes in developing country settings. They suggest that a
definitive clinical trial is warranted to clarify the potential of this promising
intervention.
197
THE SUCCESS OF CPAP AND CUROSURF IN A LEVEL II HOSPITAL
HM Kunneke
Worcester Regional Hospital
Introduction
Worcester Regional Hospital is a Level II hospital situated in Worcester in the BolandOverberg region draining 7 Level I hospitals and various MOU’s as well as primary
clinics and referrals from GP’s. The non-medical aid population was estimated as 586
425 in 2001, with a 2% growth per year. This amount excludes approximately 200
000 seasonal workers and immigrants.
A revitalisation project was started in 2004 to upgrade and expand the hospital.
Present facilities consists of only 1 high care unit bed shared with obstetrics and
gynaecology department, with only two ventilation beds for the entire hospital. The
neonatal high care and nursery was combined during building and consists of a small
space with 16 beds. We have 3 KMC beds and midwives with no neonatal or high
care training run the nursery. There is not a permanent doctor available for the
neonatal high care and nursery.
The medical staff consists of 2 paediatricians, 1 registrar, 1 senior medical officer and
1 medical officer with 1-2 houseman.
Patient load as inpatients about 3500 paediatric patients per year and 3500 deliveries
en Worcester and 9200 in the region. 37% of babies admitted in the unit are either
low or extreme low birth weight. 25% babies delivered in labour ward weigh less
than 1500gram.
Previously we managed the unit on a first come first serve basis and babies were
only accepted from other hospitals if we had space. Often low birth babies were
either not treated or rerouted to larger centres e.g. Tygerberg, Groote Schuur or
Mowbray. They could only be ventilated at our facility for very short periods of time
and then referred.
All HMD babies were intubated and ventilated and if the ventilator was in use, no
support could be rendered. We tried to compromise by intubation, Surfactant
administration and extubation, a route that had a very poor outcome with high
morbidity.
Finding a ventilation space in overcrowded and understaffed tertiary
198
centres often posed and immense problem with literally hours spend on the phone,
stress and arguments, misunderstanding and overall very unsatisfying working
circumstances. Stress of intubation by junior staff, failed intubation and poor nursing
care due to lack of training led to poor outcome. We also had no compressed air and
had to run the ventilators on large and very difficult to manoeuvre cylinders.
Disasters during transfers were common with babies becoming hypoxic and died.
The main reason being, those small babies were not previously managed with
intubation and transferred. Paramedics had to be trained to transfer intubated
children, a process that could not happen overnight.
The transfer of mothers immediately post delivery away from their family when they
need the most support was very upsetting to all. Families are suddenly split and
mothers stayed away from home for very long periods of time. Older children were
often left without care, as fathers are either absent or working.
Method
Since 2003, certain changes were made to improve care and circumstances. We
obtained more regular space and it was accepted that children had a right to
intensive care (ICU) and children could stay for up to 5 days. Compressed air was
also installed but only in ICU and neonates. A CPAP was bought but we did not
understand the process, initiated support too late and had a high rate of failure. A
second machine was obtained in 2005 but intubation for HMD was still the preferred
mode of management. In October 2006, we bought more CPAP machines, had
training and changed our vision and policy for small babies with respiratory distress.
Policy
All babies <1500g are started on CPAP at birth and assessed an hour later with
arterial blood gas, CXR and need of Oxygen. Children who are still on >40%O 2 is
given a dose of Curosurf by a NG-tube placed under direct vision through vocal
cords.
All children with meconium at or during delivery are started on CPAP immediately
and their blood pressure and acid-base balance kept normal with inotropes, fluid and
Sodabic infusion.
199
Distressed babies with congenital abnormalities as well as HIE are managed on CPAP
and assessed throughout re further management. This approach is valuable in the
sense that a tertiary opinion can be sought via telemedicine as to the diagnosis,
prognosis and management of these children whilst respiratory support are given in
an not sedated state.
Babies with TTN, congenital pneumonia and mild sepsis are also started on CPAP.
Very low birth weight babies <1000g are also given a lease on life and a human
being no more disqualified on weight only.
Babies are much more frequently accepted from the region and weight cut-offs are
shifting to smaller babies as services are more readily available.
Results
I had help from Debbie Grove from Tygerberg with the statistical process and in the
period of effective use of CPAP the following results were obtained.
120
100
80
Series1
60
Series2
40
20
0
Total
CPAP
Vent
Table 1
T/F out
Comparison in the use of CPAP for Oct-Dec 2005(first
column) vs Oct-Dec 2006(second column).
x-axis: Number of patients
y-axis: Totals, CPAP, Ventilation and Transfers
Increase in CPAP: 20-40
p=0,002(OR:0,38; CI:0,2-0,75)
Decreased Ventilation: 24-11
p=0,12(OR:2,49; CI:1,09-5,77)
Less transfers 14-4
p=0,00879(OR:4,14; CI
Increase T/F in: 14-29
200
Exogenic Surfactant Use
Oct - Dec 2005 vs 2006
7
6
5
4
3
2
1
0
Curosurf 120
Curosurf 240
Survanta
Oct - Dec
'05
Table 2
Oct - Dec
'06
Decline in exogenic surfactant use.
period as above.
Compared to the same
A marked reduction in the use of Survanta as well as Curosurf was seen in the study
period. Currently no surfactant is used and the decline in the use of Curosurf led to a
cost saving of R24 000 in the reported period.
The cost of transfer of patients reduced markedly as less intubated babies were
transported to tertiary centres. The cost of an intubated, ventilated, para-medic
assisted transfer is R3900/ hour.
With the decrease in intubation and ICU care the cost of consumables and of the
care of these babies decreased remarkably. Fewer syringes, drugs for intubation and
sedation, NG tubes, ET-tubes, catheters, elastoplast, etc is used.
An incidental finding was, that much fewer CXR’s were done, as the children do not
need pre and post intubation XR’s and the complications of ventilation are less.
Discussion
Compared to articles from experiences in other centres in the USA and Europe in the
early 2000’s, our experiences were the same and mirrored the following:
There was no significant decrease in mortality among the ELBW babies. At this stage
we feel that the mortality among this group is decreasing and our experiences in the
earlier part of this year, is that they have increased survival, but need to evaluate
this data objectively.
201
The use of CPAP increased over time.
The use of exogenic surfactant decreased over time.
Ventilator days decreased and we also experienced fewer kids being intubated.
Incidence of BPD decreased. As we have not yet evaluated this data, we cannot
report objectively and have to see what happens over time.
Incidence of sepsis decreased. Unfortunately on occasions where formula feeding is
used we do still see occurence NEC.
VLBW babies failing CPAP and being ventilated decreased over time. We definitely
saw much less intubation and ventilation in total and as we understood the process
better after early CPAP was started.
Frequency of CPAP use increased over time, as proved by our data.
Intubation, surfactant administration and extubation are unsuccessful. This is very
interesting to see that units in the USA made the same mistakes we did, and we also
found in 2003-2004, this definitely does not work!
Most units wean slowly and have no specific way of weaning from CPAP.
Conclusions
I conclude by sharing a success story of saving money and time, less ventilation and
less disruption of families, by the increased use of NCPAP, a cost-effective way of
managing respiratory distress in the newborn; mirroring the experiences of units in
the USA and Europe in the early 2000’s.
By gut-feel and little academic back-up, we embarked on a different way of
managing newborns 4 years ago and through trial and error have arrived… but still
on a learning curve.
Our vision is of thriving healthy premature infants and happy mothers enjoying the
support of the family in their own environment.
202
KMC AND NCPAP: OUTCOME AT 12 MONTHS OF INFANTS <1250G
TREATED IN A STATE HOSPITAL
JI van Zyl, Kirsten GF
Department of Paediatrics and Child Health, Tygerberg Children’s Hospital and the
University of Stellenbosch
Introduction
In the mid 1990’s, the high nosocomial infection and necrotizing enterocolitis rates in
the neonatal wards (NW) of Tygerberg Children’s Hospital (TBCH) resulted in
overburdening of neonatal intensive care unit (NICU) beds. This necessitated
admission criteria to the NICU for ventilation of infants <1250g. A long term follow
up study was done to determine the effect of these criteria on the short and long
term outcome of infants with BW <1250g born during 1994 and admitted to
Tygerberg Children’s Hospital (TBCH). Since 1994, in spite of a yearly exponential
increase in admissions, the number of beds available in the NICU and the Level 2
Neonatal Wards (NW) was reduced because of a reduction in nursing staff. To solve
this problem, the management of very low birth weight (VLBW) infants with
respiratory distress in TBCH was changed to nCPAP and cannula oxygen which
replaced headbox oxygen in the NW. Kangaroo Mother Care (KMC) and breast milk
was introduced to replace formula feeding. This proved to be so effective that the
admission criteria to the NICU could be relaxed and now all infants with BW ≥1000g
and/or gestational age ≥28 weeks can receive NICU care if needed. A second study
was done to compare the outcome until discharge of infants with BW 500-1249g
born during 2004, with those of 1994. Infants were divided into two groups: Those
that were managed exclusively in the neonatal wards (NW group) and those who
were admitted to the NICU at any time during their stay in TBCH (NICU group).
This comparison showed that the number of inborn admissions in this birth weight
category increased by 61% and the number of inborn extremely low birth weight
(ELBW) infants admitted increased by 81%. Significantly more infants were managed
exclusively in the NW during 2004. Despite the decrease in available beds and the
increase in admissions, the overall survival rate did not change significantly (74% in
2004 vs 67% in 1994) and the survival rate for the BW group 800-999g improved
203
significantly (65% in 2004 Vs 45% in 1994; p=0.02). The overall survival rate for
infants treated exclusively in the NW improved considerably and specifically for the
800-999g and 1000-1249g BW groups (Tables 1, 2 and 3).
Table 1
TBCH inborn admissions and management of infants 5001249g birth weight: 2004 Vs 1994
500-1249g birth weight (No)
800-999g birth weight (No)
Managed exclusively in NW
Table 2
1994
186
68
48%
 61%
 81%
p = 0.00
Neonatal survival until discharge from TBCH inborn infants:
2004 Vs 1994
Survival per birth weight group
500-1249g
1000-1249g
800-999g
500-799g
Table 3
2004
299
125
74%
2004
74%
88%
65%
37%
1994
67%
81%
45%
31%
p value
0.07
0.08
0.02
0.67
Neonatal survival until discharge of inborn infants exclusively
managed in the NW: 2004 Vs 1994
per birth weight 2004
1994
p value
Survival
group
500-1249g
1000-1249g
800-999g
500-799g
81%
97%
70%
35%
57%
77%
38%
30%
0.00
0.00
0.00
0.75
It is important to determine the intact survival rate and whether the improved
survival rate for infants exclusively managed in the NW and especially infants with
BW of 800-999g did not result in a higher disability rate.
Aim
To determine the neuro-developmental outcome at one year corrected age of inborn
infants 500-1249g birth weight treated with nCPAP and KMC in the NW.
Study setting:
Level 2 NW, TBCH
Study design:
Prospective cohort analytical
204
Patients and Methods
All inborn infants with BW 500-1249g admitted between 1/1/2004 and 31/12/2004
and who survived to discharge from TBCH were studied. They were assessed at 12
months corrected age with the Grifiths Mental Developmental Scales (GMDS), the
Peabody Developmental Motor Scales and a neurological examination. Disability was
diagnosed in children with Cerebral Palsy (CP) or a general quotient > 2 Standard
Deviations below the mean on the GMDS indicating a significant developmental
delay. Not all final audiology test results were available therefore the incidence of
sensory-neural deafness is not reported.
Results
Two hundred and twenty two infants were discharged from TBCH. Twenty three
infants died before 12 months of age: 3 died at secondary hospitals before discharge
home and 20 died after discharge home. 161 (81%) of the survivors were followed
up at 12 months corrected age. Nine infants with serious congenital defects such as
foetal alcohol syndrome, hydrocephalus, etc were excluded from the final analysis.
The overall neurodevelopmental outcome is shown in table 4.
Table 4
The neurodevelopmental outcome at 12 months corrected age
of inborn infants 500-1249g: 2004 cohort
Group (number)
Total assessed (152)
NW survivors (120)
NICU survivors (32)
Table 5
Group
NICU group (4)
NW group (3)
Developmental
CP: no (%)
11 (7%)
6 (5%)
5 (16%)
delay
and/or
Cerebral
no (%)
7 (4.6%)
3 (2.5%) *
4 (12.5%) *
Palsy
Types of CP and the infants’ General Quotient according to the
Griffiths Mental Developmental Scales at 12 months corrected
age
Cerebral Palsy Type
Spastic Quadriplegia
Hypotonic
Spastic Diplegia
Spastic Diplegia
Spastic Diplegia
Spastic Hemiplegia
Spastic Hemiplegia
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General Quotient
25
59
62
76
48
79
96
Table 6
CP rate at 12 months corrected age: 2004 Vs 1994
All
NICU survivors
IPPV treated infants
NW survivors
p=0.03
2004
4.6%
12.5%*
12%
2.5%*
1994
6%
10%
10.5%
0
p
0.7
0.4
0.5
The overall CP rate of 4.6% in 2004 was statistically similar to the 6% in 1994. The
NICU survivors of 2004 had a significantly higher rate of CP than the NW survivors of
2004: 12.5% Vs 2.5% (* p= 0.03)
Table 7
Developmental delay and CP according to type of ventilatory
support: 2004 cohort
Ventilation type (No)
IPPV (25)
nCPAP in NW or NICU (71)
nCPAP in NW (67)
No ventilatory support (56)
Developmental Delay and/or CP
No (%)
4 (16%)
5 (7%)
4 (6%)
2 (3.5%)
Cerebral
No (%)
3 (12%)
3 (4%)
2 (3%)
1 (2%)
Palsy
In the BW group 800-999g the overall CP rate for the infants followed up at 12
months corrected age was 9%. Only 1 infant (4%) of those treated exclusively in the
NW had CP. None of these infants who were treated with nCPAP in the NW had CP.
Conclusions
In spite of a 61% increase in admissions and a reduction of beds the survival rate for
inborn infants 500-1249g remained the same between 1994 and 2004. Significantly
more infants were managed exclusively in the Neonatal Ward but this management
with nCPAP and KMC did not increase the overall rate of CP in the survivors at 12
months corrected age. Extremely low birth weight infants 800-999g treated with
nCPAP in the NW had a good outcome with no CP diagnosed in those followed up at
12 months.
Comments
Twelve months corrected age is very young to assess developmental delay to predict
long term outcome. These infants will be followed up and assessed until pre-school
age.
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THE OUTCOME OF VERY LOW BIRTH WEIGHT INFANTS BORN TO HIV
POSITIVE WOMEN AT TYGERBERG HOSPITAL
GF Kirsten, CL Kirsten, A Theron
Departments of Paediatrics and Child Health and Obstetrics, Tygerberg Hospital and
the University of Stellenbosch
Compared to term and >2500g infants a higher HIV mother-to-child transmission risk
has been reported for premature infants (29%) and those <2500g (33%). The HIV
positive prevalence rate for pregnant women in the Western Cape was 13.1% and
15.4% during 2003 and 2004 respectively and the mother-to-child HIV transmission
rate for 2005, 6%.
Limited information exists on the outcome of very low birth infants born to HIV
positive women.
Aim: To determine the outcome of VLBW infants born to HIV positive women.
Study design: Retrospective descriptive study.
Study location: Kangaroo Mother Care ward, Tygerberg Children’s Hospital.
Patients and methods
A pilot MTCT prevention programme was introduced in the Western Cape in 2002.
Pregnant women were screened for HIV at the antenatal clinics. Neverapine (NVP)
was administered to the HIV positive women before delivery and to their infants
within 48 hours of birth (Cohort 1). From July 2004, HIV positive pregnant women
and their infants received Neverapine and AZT (Cohort 2). Unbooked mothers were
counselled and screened for HIV post delivery. The infants received either own
pasteurised or pasteurised donor breast milk or a semi-elemental milk formula. The
maternal and neonatal information of infants ≤1500g born to HIV positive women
between 1/5/2003 and 31/12/2005 was obtained from their folders.
Results
The combined study cohort consisted of 141 VLBW infants born to 122 HIV positive
women, 44 in Cohort 1 and 97 in Cohort 2.
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Table 1
Maternal and infant data (Mean, SD)
Number of Mothers
122
Infants: Cohort 1
44
Infants: Cohort 2
97
All infants
141
Birth weight(g)
1196.9, SD 226.5
Range
540-1500
Gestational age(weeks)
30.1, SD 2.1,
Range
26-35
Delivered by C/section (%)
86(75.5)
Table 2
Neonatal outcome
Number of infants
141
Survived(%)
113(84.4)
Died in hospital(%)
17
Died at home (%)
4(19)
Died <48 hours (RDS or IVH)(%)
8(47)
Died in hospital <800g (%)(%)
8(47)
Died in hospital <1000g (%)
11(65)
Died in hospital >1000-1500g(%)
6(35)
Table 3
Infants HIV+ at 14 weeks of age
Number of infants
All
Cohort 1
141
44
Cohort 2
97
Number screened at 14 weeks 87(71.7)
(%)
Number HIV+(%)
13 (14.9%)
6(21%)
7(11.9%)
<1000g(%)
0
0
0
1000 – 1500g(%)
13(14.9)
6(21.4)*
7(11.9)*
HIV+
*p = 0.33
Eighty eight (72%) women received either NVP or NVP and AZT. Only 2 infants did
not receive either Neverapine or AZT. One hundred and eleven (78.7%) of the
infants received pasteurised breast milk. Eighty seven (71.7%) of the infants that
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survived were screened for HIV at 14 weeks. Of these, 13 (14.9%) were HIV
positive.
Conclusions
Eighty percent of HIV exposed VLBW infants who received either NVP and/or AZT
survived until discharge. The majority that died, did so from severe prematurity and
RDS within 48 hours of birth. Thirty percent of the infants failed to attend follow-up
and probably returned home to a rural area.
The 15% HIV transmission rate is lower than that reported for premature and low
birth weight Malawian infants (33%) but higher than the 6% reported for all infants
in the Western Cape.
Recommendations
1.
HIV status of women must be confirmed before pregnancy.
2.
Intra-uterine and intrapartum transmission can only be decreased if maternal
antiretroviral therapy is started early in pregnancy.
3.
Current MTCT prevention programme does not protect premature infants as it
starts at 34 weeks gestation.
209
THE BURDEN OF MAJOR CONGENITAL ABNORMALITIES IN NEWBORN INFANTS
MANAGED IN KALAFONG HOSPITAL
GJM Wolmarans, SD Delport, EM Honey
Department of Paediatrics, Kalafong Hospital and the University of Pretoria
Introduction
Globally, around 7.6 million children are born annually with congenital abnormalities, the
majority in mid- and low-income countries. The incidence at Kalafong Hospital two decades
ago was 11.9 per 1000 live births. With no available genetic service this poses a
management and economic burden on a level 2 hospital.
Aim
To determine the current incidence of major congenital abnormalities in newborn infants.
Patients and methods
In- and outborn live newborn infants with major congenital abnormalities – i.e. abnormalities
needing intervention and long term follow-up – were enrolled prospectively after informed
consent was obtained. Relevant clinical maternal and infant data were documented for the
group as a whole and infants with birth weight < 2500g and ≥ 2500g. Diagnosis was
assigned a code from the International Classification of Diseases (ICD-10).
Results
Sixty-eight consecutive infants were enrolled over a period of one year (1/1/2006 –
31/12/2006) of whom 61 were inborn. The median maternal age (n = 62) was 26 years
(range 17 – 41 years), 24 years (range 17 – 36 years) for infants < 2500g and 29 years
(range 18 – 41 years) for infants ≥ 2500g (P < 0.00). The median birth weight was 2592g
(range 840 – 4240g) and 29/68 were low birth weight (LBW) (median 1900g, range 840 –
2460g). The median birth weight of the remaining 39/68 infants was 2895g (range 2500 –
4240g). Cardiovascular (11/68) and musculoskeletal abnormalities (10/68) were predominant
in the group as a whole. Cardiovascular (5/29), urogenital (5/29), gastrointestinal (4/29) and
musculoskeletal abnormalities (4/29) predominated in LBW infants. In infants ≥ 2500g
cardiovascular (6/39), musculoskeletal (6/39) and chromosomal abnormalities (6/39)
predominated.
Conclusion
Cardiovascular and urogenital abnormalities are common. These conditions are diagnosed
clinically, are potentially life-threatening and demand level 3 facilities for diagnosis and
management as well as acute and long term genetic support.
In the light of the unchanging incidence of major congenital abnormalities economic
resources should be earmarked for urgent implementation of a genetic service until such
time that infants can be transferred to a level 3 facility.
An encouraging finding is that the incidence of central nervous system abnormalities has
decreased as compared with two decades ago. This finding has to be substantiated by a
larger study sample.
210