Midwife-led units in community settings
Cape Peninsula, South Africa
Associate Professor Sheila ClowMr Jason Marcus & Mrs Carol AdamsUniversity of Cape Town & Mowbray Maternity Hospital, Cape Town, SOUTH AFRICA
6 June 2010
Country-specific contextLarge countryRural-urban divide Inequitable health services, e.g.
◦public sector per capita expenditure ~$158
◦private sector per capita expenditure ~$942 (6x)
Health indicators◦ IMR 42.8/1000 (Health Systems Trust, 2007)
◦MMR 237/100 000 (Hogan et al, 2010)
High GINI co-efficientRedressing inequities
Specific challenges relative to midwifery skills
All midwives are trained as nursesProfile of nurses is most closely related
to the population profileNo distinction on the register for those
in current practiceNo requirement for relicensing Few posts designated for midwives Outreach programme to midwives ad
hocAccess to further training constrained by
shortage
Promising approaches – a promise that has delivered!
Free-standing midwife-run unitsfor “low risk” maternity care close to the people who require itand integrated in a defined referral system
◦8 midwife units◦2 secondary referral hospitals◦1 tertiary academic hospital
Initiated in the Cape Peninsula, South Africa in 1974 (prior to the Alma Ata Declaration)
Assumptions underpinning the Peninsula Maternal & Neonatal Service
Normal or low-risk pregnancies are well managed by suitably qualified midwives
Tertiary level hospitals focussed on ill patients ◦ inappropriate setting for a normal low-risk
pregnancy, and◦ inappropriate use of expensive resources and
infrastructureHealth services should be accessible,
acceptable and appropriate to the population, at a cost that is sustainable for the community
No poor options for poor people
Scope of Service
Full range from pregnancy diagnosis to 1st week post birth
Limited Emergency Obstetric Care (EmOC)
Advanced midwives are licensed to perform assisted deliveries – vacuum and forceps
Clinical guidelines are evidence based
Clinical guidelines are evidence based
Expectations are clear◦no inductions, continuous EFM, epidural
analgesiaBasic Antenatal Care (BANC) Better Birth Initiative – including doulas
Prevention of Mother-to-Child transmission (including HIV counselling and testing)
Kangaroo CarePhototherapyBaby-friendly Hospital InitiativePerinatal mental health
Total births in the Peninsula Maternal & Neonatal Service, 2008
Total births in PMNS
Total births at MOU's
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
38292
17515
Total Births in 2008
Mitchell’s Plain Midwives’ Unit – selected data
New b
ooking
s
Repea
t ant
enat
al a
ttend
ance
Admiss
ions
to M
OU
Tran
sfer
s fro
m la
bour
war
d
Tota
l del
iver
ies
0
5000
10000
15000
20000
25000
7195
21536
10403
1701
4193
5991794
866 141 349Total for yearMonthly average
Mitchell’s Plain staffing per shiftAntenatal clinic
◦2 registered midwives◦2 enrolled nurses◦1 enrolled nursing auxiliary
Labour ward & observation ward◦Day duty – 3 registered midwives◦Night duty – 2 registered midwives
Postnatal outpatients◦1 enrolled nurse
Maternal mortality rates for all 9 provinces
EC FS GP KZN LP MP NC NW WC0
50
100
150
200
250
81
234
114 118
78
143 147
102
70
MMR/100 000
MMR/100 000
Source : Health Systems Trust, 2003
PMNS data, 2008
38 292 deliveries22 Maternal deaths ~ MMR 57.5/100
000 ◦17 died in tertiary level care◦12 were postpartum◦5 = direct causes – 4 Hypertensive◦1 = co-incidental◦16 = indirect causes
12 Non-pregnancy related infections 11 known HIV+
8 with CD4 < 200Source : Fawcus, 2009
Before the advent of HIV and AIDS …
The PMNS MMR reached 31/100 000
The MMR for the midwife units was 20/100 000
Source : de Groot 1993
Lessons learntThe system worksHealth indicators are the best in the
countryCost effective and frees up higher
levels of the service to those requiring it
Some “medium risk” patients can be managed at this level
Creates a space for midwives to practice to their fullest potential
Cost effectiveness
13 years after the introduction of this initiative
the number of hospital births was the same
AND there were 9000 births occurring in the midwife units
The midwife units have 15% of the bed capacity of the entire service, yet account for 50% of all deliveries
Source : de Groot 1993
RequirementsSuitably qualified midwivesA tiered referral system to higher levels
of careClear and agreed referral criteriaCorrect use of evidence based clinical
guidelinesStandardised documentationGood communication systemsRegular clinical auditReliable transport
Suitably qualified midwives EducationRegulation
◦Professional◦Prescribing
Continuous professional development◦Perinatal update - referral hospital◦Total shutdown for staff training – 1 day
p.a.◦PEP (Perinatal Education Programme)
Clinical leadership
Added value!
A teaching and learning facility for undergraduate and postgraduate students in :
MidwiferyMedicineDentistryPhysiotherapyOccupational heathOccupational therapy
Future possibilitiesIncorporate into district health
serviceUltrasound scanning and
screeningPostnatal careTele-medicine / -midwifery
AcknowledgementsEmeritus Professor Herman De Groot, Dr John
Smith and the visionaries for decentralised primary health care, including maternity care
Miss Squires and the nurse managers who supported the initiative
The registered midwives, enrolled nurses and enrolled nursing auxiliaries which make this work
The mothers who have trusted our careThe medical teams at the Universities of
Cape Town & Stellenbosch and the referral hospitals who support this work
Programmes leading to registration as a midwife
Diploma course (1 year for RN or RPN, or 2 years for EN) (Reg. 254)
Comprehensive diploma / bachelor’s degree leading to registration as a nurse and midwife (Reg. 425)
Clinical requirements1 year diploma 4 year
diploma
960 hours 960 1000
ANC 60 hours Not specified
Antenatal women 30 30
Witness deliveries 5 5
Deliveries 15 15
Local Anaesthetic excluding pudendal block
excluding pudendal block + epidural
Episiotomy Performance 15
Perineal suturing suturing of 1 & 2 degree tears
Night duty at least 1/12 and no more than ¼ hours
Not specified
Clinical requirements1 year diploma
4 year diploma
pelvic assessments Not specified 5
conducting deliveries Not required 5
care of women in labour
Not required 25 (at least 3 through all 4 stages of labour)
internal examinations 15 sufficient number (no more than 5 rectal)
postnatal care Not specified 5 mothers & babies x 2 days5 mothers & babies x 5 days
exam at the routine postnatal visit
Not specified 3
Legal status of midwifery practice
Nursing Act No.50 of 1978 as amended
◦R1469 Scope of practice◦R2488 (26 October 1990) Conditions
under which registered midwives and enrolled midwives may carry on their profession
◦R387 15 February 1985 (as amended) Acts and omissions
Nursing Bill 2005 (31 August 2005)◦SANC Charter of Nursing Practice
R1469 as amended Scope of Practice
“The scope of practice will entail the following scientifically based acts or
procedures which apply to the practice of Midwifery and which relate to the mother
and child in the course of pregnancy, labour and the puerperium”
R1469 Scope of Practice Determine health needs
of mother and child Refer where necessary Prevention & promotion Monitoring progress of
labour, vital signs of mother & child, reaction to situations
Episiotomy, suturing of tears, local anaesthetic
Promote activities of daily living, e.g. exercise & sleep, oxygenation, hygiene, nutrition, elimination
Promote wound healing
Administration of medicine
Promote & facilitate breastfeeding
Establish a health promoting environment
Communication with parents
Assist with operative, diagnostic & therapeutic procedures
Co-ordination of health care
Provide effective advocacy
Care of the dying patient
Implications to considerStatus of regulation vis-a-vis protocol /
guidelinesChanges requiredNeeds to be evidence based, responsive to
changing evidenceNeeds to be responsive to changing health
care needs, yet maintaining safetyClarify who may do whatSkills trainingManagement of emergencies, e.g.
resuscitation, shoulder dystocia, prolapsed cordGuidelines required
Different models◦Free-standing birth unit (original
model)◦Unit linked to a comprehensive
health centre (primary level) (geographically close, but operationally still developing the relationships)
◦Unit on a secondary or tertiary hospital campus but operated separately