The 22nd 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

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Editor’s Note:

The articles included in these Proceedings were received electronically and have been included as submitted by the presenter/author. Some articles have been shortened. Abstracts are included in single spacing where articles were not submitted.

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INFORMAL COMMENTS FROM PROFESSOR WENDY GRAHAM, UNIVERSITY OF ABERDEEN, SCOTLAND

PreambleThe organisers of this 22nd conference are to be congratulated on a stimulating and vibrant meeting. The agenda was full and diverse, and there was lively discussion, both within and outside the formal sessions. As one of the keynote speakers, I found the audience engaged and engaging, and appreciated the opportunity to meet about the challenges to perinatal health currently faced by South Africa. The following comments relate primarily to possible areas for further research and future meetings, and are offered in as positive a spirit as no doubt they will be received. These suggestions are presented as bulleted points and in no particular order, but rather as they arose from the discussion and presentations.

Measurement of maternal mortality : although the latest CEMD acknowledges that the national estimate for the maternal mortality ratio of 150 per 100 000 live births is probably an underestimate this figure appears to still be widely used and quoted. Coming from the 1998 South Africa DHS, the figure strictly refers to a reference period of 1992-1998 and appears to be based on just 19 maternal deaths. It would perhaps be helpful to have this as a topic for specific discussion at the 23rd Priorities conference, both as bulleted points and in no particular order, but rather as they arose from the discussions and presentations.

Proportion of maternal deaths occurring outside health facilities : this appears to be a crucial “unknown” in the current picture for South Africa. Whilst one might expect this proportion to be significant where there is a high percentage of births at home, research in other countries has revealed this is not always the case. There are a number of possible approaches to gaining population-based estimates for the proportion of deaths outside of facilities, and some

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of these are also appropriate for exploring the reasons for home deaths.

Maternal death and other relevant explanatory factors or co- variates: during the meeting, several issues emerged which deserve further exploration, including:

o State on admission to institution where death occurred and in particular the proportion admitted in normal labour.

o Place of delivery relative to place of death.o Socio-demographic and particularly poverty status.o Time since discharge after delivery and subsequent admission

for serious complications.o Apparent increase in proportion of haemorrhage-related

deaths.o Postpartum deaths according to time since delivery.

Kangaroo Mother Care :o Several papers indicated considerable lengths of stay for

mother-baby pairs. Whilst accepting the impressive “health gains” for the neonate and the significant potential health service savings, it would be important to also explore the consequences for the mother in terms of family commitments, particularly in the case of dependent children.

o The PPIP database could usefully be explored to see if KMC is impacting upon survival rates for preterm/SGA babies.

Uptake of antenatal and delivery care :o A number of presentations appeared to be suggesting that

uptake was declining and it is important that this is reliably confirmed or refuted. The forthcoming DHS could provide an opportunity to establish this for all deliveries in the last 5 years.

o Changes in the characteristics of the “booked/unbooked” population: since the availability of free care in 1994, it was suggested that the booked cases now emcompass a wider socio-demographic and obstetric risk case-mix, whilst the

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unbooked now reflect a particular sub-group of high risk women. Research to confirm or refute this is important.

Cost-effectiveness, equity and sustainability : these issues cropped up on several occasions and future meetings could usefully include at least one session or paper which raises awareness of the relevance and measurement of these dimensions.

General observations on possible improvements to studies presented:

o Greater use of multivariate analysis.o Presentation of percentages should also indicate numbers

involved, especially where these are small.o Confidence intervals and/or power calculations as well as p

values should be presented where appropriate, again especially when the numbers are small.

o Where RCT have high refusal rates, it is important to explore wherever possible the characteristics of those omitted as this may have significant implications for the relevance of the trial findings to the general population.

o Studies using qualitative techniques should be encouraged to give more details on these methods and how quality and validity are assured.

o Research using alternative outcomes to just mortality and morbidity i.e. maternal satisfaction or anxiety, should be encouraged.

Organisational issues o Given the popularity of the conference and the limited time to

discuss papers, organisers may wish to revisit the use of parallel sessions. These should be configured to maintain the highly productive interchange between midwives, obstetricians and neonatologists.

o Greater multi-disciplinarity might be helpful, especially involvement of social scientists, health services researchers, economists, demographers, epidemiologists, and statisticians.

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o As Priorities’ remit is Southern Africa, would it be possible to encourage greater involvement from groups elsewhere in the region?

Congratulations and thanks to the Priorities in Perinatal Care Association for yet another successful meeting, and good luck for the conference in 2004.

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INDEX

THE OPTIMAL DOSAGE OF NIFEDIPINE IN PATIENTS WITH EARLY ONSET SEVERE PRE-ECLAMPSIA – A RANDOMISED CONTROLLED TRIAL. DW Steyn

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EARLY ONSET SEVERE PRE-ECLAMPSIA: EXPECTANT MANAGEMENT AT A SECONDARY HOSPITAL IN CLOSE ASSOCIATION WITH A TERTIARY INSTITUTION.

C Oettle 6

EXPECTANT MANAGEMENT OF SEVERE PRE-ECLAMPSIA IN THE MID-TRIMESTER.

DR Hall 10

HOW DOES HIV SEROPOSITIVITY AFFECT THE INCIDENCE OF PRE-ECLAMPSIA.

KA Frank 12

THE VARIATION BETWEEN THE NEW PC BASED DOPPLER WAVEFORM ANALYZER AND THE VASOFLOW DUPLEX DOPPLER. GB Theron

13

FETAL MOVEMENT COUNTING FOR ASSESSMENT OF FETAL WELLBEING: A SYSTEMATIC REVIEW. L Mangesi 16

VIOLENCE AGAINST WOMEN – IMPACT ON REPRODUCTIVE HEALTH AND PREGNANCY OUTCOME. J Schoeman

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PRE-ECLAMPSIA AT THE KALAFONG HOSPITAL (UNIVERSITY OF PRETORIA). A RETROSPECTIVE STUDY ILLUSTRATING SOME ASPECTS OF A TERTIARY REFERRAL CENTER PRE-ECLAMPSIA POPULATION IN SOUTH AFRICA.  J Cornette 23

THE GLOBAL PROBLEM OF MATERNAL MORTALITY: INEQUALITIES AND INEQUITIES. WJ Graham

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SOCIO-ECONOMIC INEQUALITIES AND MATERNAL HEALTH IN SOUTH AFRICA.

D Blaauw 27

EXPLORING THE JOURNEY TO MATERNAL DEATH: GENDER AND HUMAN RIGHTS PERSPECTIVES. N Mbombo

33

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50 YEAR AUDIT OF MATERNAL MORTALITY IN THE PENINSULA MATERNAL & NEONATAL SERVICE [1953 – 2002]. S Fawcus

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ADDRESSING MATERNAL MORTALITY IN A RURAL EASTERN CAPE HOSPITAL THROUGH MATERNAL DEATH AUDIT REVIEW: FINDINGS AND RESULTS.

D Jackson 45

MATERNAL DEATHS IN THE FREE STATE: STATISTICS FOR 2002. JBF Cilliers49

OVERVIEW OF MATERNAL MORTALITY FOR KWAZULU NATAL: 1998-2001.ND Nyasulu 55

IMPLEMENTATION OF KANGAROO MOTHER CARE: A SUCCESSFUL CASE STUDY IN KWAZULU-NATAL. A-M Bergh

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THE UKUGONA OUTREACH - IMPLEMENTATION OF KANGAROO MOTHER CARE IN KWAZULU-NATAL. I Arsalo

66

TELETUITION – AN OPTION FOR IN-SERVICE FACILITATION OF KANGAROO MOTHER CARE? M Patrick

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KANGAROO MOTHER CARE FROM BIRTH COMPARED TO CONVENTIONAL INCUBATOR CARE. Nils Bergman75

THE IRON STATUS AT 6 MONTHS CORRECTED AGE OF VERY LOW BIRTH WEIGHT INFANTS AFTER DISCHARGE FROM A KANGAROO MOTHER CARE UNIT.

G Kirsten 82

ECONOMIC IMPACT OF KANGAROO MOTHER CARE. R Ricardo Escobar85

THE VALUE OF A KANGAROO MOTHER CARE (KMC) UNIT AT KALAFONG HOSPITAL. E van Rooyen

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KANGAROO MOTHER CARE AT SEBOKENG HOSPITAL. NC Dlungwana93

A SURVEY OF THE SOCIAL, CULTURAL AND EDUCATIONAL BACKGROUND OF MOTHERS ADMITTED TO THE KMC UNIT AT KALAFONG HOSPITAL.

E van Rooyen 96

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MATERNAL HEALTH SERVICES IN SOUTH AFRICA, UGANDA, RUSSIA AND BANGLADESH: LESSONS OF A COMPARATIVE STUDY FOR SOUTH AFRICA.

L Penn-Kekana100

THE NURSING CRISIS: PROJECTIONS AND POSSIBLE RESPONSES. N Bergman 105

AUDIT OF DECENTRALISED ANTENATAL SERVICES IN BLOEMFONTEIN/MANGAUNG LOCAL MUNICIPALITY. WJ Steinberg

112

WHAT FACTORS ACCOUNT FOR EARLY ANC VISITS IN FIRST VISIT CLIENTS?B Ntsuntsha116

THE BETTER BIRTHS INITIATIVE (BBI): EVALUATION IN THE EASTERN CAPE.N Makinana117

BETTER BIRTH INITIATIVE IN THE PMNS. N Jam-Jam, P Barnes118

THE WHO REPRODUCTIVE HEALTH LIBRARY ISSUE 6, 2003. Z Mlokoti122

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A VISION OF PUBLIC-PRIVATE SECTOR CO-OPERATION IN COMMUNITY MATERNAL HEALTH CARE SERVICES: THE EFFECT OF INVOLVING PRIVATE PRACTITIONERS ON THE QUALITY OF ANTENATAL CARE OF THE INDIGENT POPULATION OF TEMBISA.

KR Mokhondo123

THE WOMAN’S HEALTH MANAGEMENT TEAM (WHMT) AS AN ESSENTIAL FOUNDATION FOR MANAGING MATERNAL HEALTH SERVICES AT MUNICIPAL LEVEL. A CASE STUDY. H Philpott

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A BASELINE ASSESSMENT OF THE QUALITY OF MATERNAL HEALTH SERVICES IN LIMPOPO PROVINCE: REFLECTIONS AND CHALLENGES IN IMPROVING THE RELIABILITY AND USE OF INFORMATION FOR PLANNING AND MANAGEMENT AT PRIMARY LEVEL. A Voce

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IMPROVING THE QUALITY OF RECORDS: USING A QUICK SCORING SYSTEM AND INTEGRATING SPECIFIC INDICATORS TO IMPROVE QUALITY FOR ANTENATAL CLINIC AND LABOUR WARDS. RB Mia

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CHALLENGES AND LESSONS LEARNT IN USING MODULAR TRAINING APPROACH TO IMPROVE QUALITY OF ANC SERVICES IN RURAL CLINICS IN ZULULAND.

WS Mbambo148

ASSESSMENT OF THE QUALITY OF CARE PROVIDED TO FIRST ANTENATAL CARE CLIENTS IN RURAL AREAS IN KZN. RS Sibiya

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MONITORING AND IMPROVING THE QUALITY OF THE PERINATAL AUDIT.H Philpott152

MONITORING PERINATAL DATA IN RURAL EASTERN CAPE HOSPITALS: IMPLICATIONS FOR MATERNITY SERVICES PROGRAMMES AND RESEARCH.

D Jackson159

IMPLEMENTING THE PERINATAL PROBLEM IDENTIFICATION PROGRAMME AS AN AUDIT AND OBSTETRIC INFORMATION SYSTEM IN A RURAL NAMIBIAN HOSPITAL.

A Paul164

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ANALYSIS OF PERINATAL DATA FROM ALL DELIVERIES IN TYGERBERG HOSPITAL OVER A FOUR MONTH PERIOD BY USING A SIMPLIFIED ICD-10 CODING MANUAL.

H van der Merwe171

RETROSPECTIVE ANALYSIS OF ALL DELIVERIES IN UNIVERSITAS HOSPITAL FROM 01/05/02 TO 31/07/02 AS A TERTIARY REFERRAL CENTRE IN CENTRAL SOUTH AFRICA. DJ Jordaan

175

NASAL CONSTANT POSITIVE AIRWAY PRESSURE: PRACTICAL ASPECTS.G Kirsten177

FETAL HYPOXIA AND BIRTH ASPHYXIA. D Woods 182

PERINATAL DEATHS FROM INTRAPARTUM HYPOXIA. DH Greenfield185

SERUM PROCALCITONIN AS AN EARLY MARKER OF NEONATAL SEPSIS.DE Ballot189

FETAL ALCOHOL SYNDROME: A SOUTH AFRICAN PERSPECTIVE. DL Viljoen193

FETAL EFFECTS OF IN UTERO EXPOSURE TO WARFARIN: PAST, PRESENT AND FUTURE. N Gregersen

197

CONGENITAL MALARIA: A CASE PRESENTATION. A Moodley201

THE ANTEPARTUM AND INTRAPARTUM COURSE OF MOTHERS DELIVERING BABIES WITH BIRTH ASPHYXIA AT TYGERBERG HOSPITAL. S Nosarka

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SKILLED ATTENDANCE AT DELIVERY. WJ Graham203

FIRST DELIVERY EXPERIENCES. (AN ANALYSIS OF STUDENT REFLECTIVE COMMENTARIES). G Draper

207

THE USE OF ANALGESIA IN LABOUR WARDS IN TWO DISTRICT HOSPITALS.L Penn-Kekana212

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EMPOWERMENT THROUGH THE ACTIVE BIRTH POSITIONS INTRODUCING PHYSIOLOGICAL BIRTHING POSITIONS INTO THE PUBLIC SECTOR.

B Rautenbach218

EVIDENCE-BASED CAESAREAN SECTION TECHNIQUE. GJ Hofmeyr225

THIRD TRIMESTER INDUCTION OF LABOUR WITH MISOPROSTOL: THE DURBAN EXPERIENCE. NF Moran

229

VAGINAL EXAMINATIONS DURING LABOUR: A SYSTEMATIC REVIEW.M Singata236

THE PERILS OF PRECOCIOUS PARTURITION. H Odendaal237

PLANNED DECISION MAKING FOR DELIVERY OF VERY LOW BIRTH WEIGHT BABIES MAKES FOR A BETTER OUTCOME. A Moodley

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STUDY ON THE OUTCOME OF EXTREMELY LOW BIRTH WEIGHT INFANTS (500-999G) BORN AT PRETORIA ACADEMIC HOSPITAL BETWEEN 1 JANUARY 2001–31 DECEMBER 2001. TW de Witt

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SURVIVAL RATES AMONG VERY LOW BIRTH WEIGHT INFANTS ADMITTED AT CHRIS HANI BARAGWANATH HOSPITAL IN 2000-2001. S Velaphi

244

PROPHYLACTIC ORAL STEROIDS IN TWIN PREGNANCIES – A RETROSPECTIVE COHORT ANALYSIS. SH Raymond

247

APNOEA AFTER IMMUNIZATION IN EX-PREMATURE INFANTS. PA Cooper

254

SAVING BABIES: A PERINATAL CARE SURVEY OF SOUTH AFRICA 2001: EXECUTIVE SUMMARY. RC Pattinson

257

OPTIMISING INFANT FEEDING IN THE CONTEXT OF HIV: A PUBLIC HEALTH PERSPECTIVE. A Goga

261

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EFFICACY OF TWO POST-EXPOSURE PROPHYLACTIC REGIMENS IN REDUCING MOTHER TO CHILD TRANSMISSION OF HIV-1 IN INFANTS BORN WITHOUT ACCESS TO ANTIRETROVIRAL THERAPY: A RANDOMIZED, OPEN LABEL, CONTROLLED CLINICAL TRIAL. M Urban

268

WHAT TYPE OF CLIENTS GO FOR VCT? EJ Buthelezi269

ABSTINENCE PRE- AND POST-DELIVERY: DOES IT HAPPEN; IS IT A POTENTIAL RISK FACTOR FOR STI & HIV/AIDS? B Kunene

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PERINATAL TUBERCULOSIS AND HIV-1 CO-INFECTION. M Adhikari277

PUERPERAL PYREXIA IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS INFECTION. IS CAESAREAN SECTION MORE RISKY? EJ Coetzee

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INTEGRATION OF STI/HIV SERVICES IN ANTENATAL CARE. HOW EFFECTIVELY IS THIS DONE IN RURAL AREAS IN KWAZULU NATAL. AT Sibiya 284

SERUM PROTEIN ELECTROPHORESIS IN HIV SEROPOSITIVE AND SERONEGATIVE PREGNANT WOMEN. MG Schoon

285

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THE OPTIMAL DOSAGE OF NIFEDIPINE IN PATIENTS WITH EARLY ONSET SEVERE PRE-ECLAMPSIA – A RANDOMISED CONTROLLED TRIAL.

DW Steyn, DR Hall, H OdendaalDepartment of Obstetrics and Gynaecology, Tygerberg Hospital and the University of Stellenbosch and the MRC Unit for Perinatal Mortality, Tygerberg

IntroductionExpectant management of selected patients with severe pre-eclampsia before 34 weeks’ gestation improves perinatal outcome without harming the mother. Careful control of maternal blood pressure is an integral part of this approach. We attempt to maintain diastolic blood pressure as measured by sphygmomanometer between 90 and 99mm Hg at all times. The results of a recent study performed in our unit indicate that nifedipine at a dosage of 10–20mg 8 hourly is the drug of choice to add where alpha-methyldopa (AMD) alone is insufficient to control the maternal blood pressure as required. However, it has been recommended that nifedipine be given as frequently as every six or even every four hours under similar circumstances. We therefore performed a randomised controlled trial (RCT) to determine the optimal dosage interval of nifedipine.

Patients and methodsA prospective open RCT was performed. Patients with severe early onset pre-eclampsia where AMD (750mg tds) alone has failed to control diastolic blood pressure as required were divided into two groups according to random numbers generated by computer. Women received nifedipine either 6 (Group A) or 8-hourly (Group B). Nifedipine was administered as short acting 10mg capsules. Management was otherwise according to departmental policy. Prazosin was added as third medication when required. Blood pressure was additionally monitored with the pregnancy validated Spacelabs 90207 monitor every 30 minutes between 09:00 and 09:00 the following day – these results were not available to managing clinicians.

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ResultsWe successfully recorded 124 24-hour records in 22 multigravidae and 20 primigravidae with severe pre-eclampsia before 34 weeks’ gestation. (Table 1). Four women were delivered before the first 24 hour record was completed. Twenty-two women were randomised to receive nifedipine 6-hourly. The two groups were comparable at time of randomisation.

Table 1 Patient characteristics at the time of randomisation.

Nifedipine6-Hourly (n = 22) 8-Hourly (n = 20)

Age 25.4 5.8 26.4 5.0Gravidity 2 2Parity 1 1Gestational age 30.3 2.2 29.9 2.4Systolic blood pressure

165 13.7 165 14.4

Diastolic blood pressure

102.7 7.0 106 9.9

Proteinuria ++ ++

The dosage of nifedipine was increased to 20mg in 6 women in the 6-hourly group, while prazosin was added in 9 cases. The corresponding numbers in the 8-hourly group were 9 and 7.

There were 2802 and 2870 successful individual systolic and diastolic blood pressure measurements in the 6-hourly and 8-hourly groups respectively. However, for the purpose of analysis, only the 1693 measurements of the first 24-hour recording of the 38 women who had at least one successful 24-hour recording were considered. The mean diastolic blood pressure was 81.7 14.8mm Hg in Group A and 84.7 14.8 mm Hg in Group B. (p < 0.05). There was no difference in the number of diastolic blood pressure values >110mm Hg. (19/876 vs. 17/817, OR = 0.96 (0.47 - 1.94)). However, there were significantly more values > 100mm Hg in women who received nifedipine 8-hourly. (12.6% vs. 9%; OR = 1.46 (1.06 - 2.01)). Correspondingly, there were more values below 70mm Hg (OR = 0.41 (0.31 – 0.54)) amongst women in the 6-hourly group

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(Figure 1). This was due to a significant fall in diastolic blood pressure following each dosage (Figure 2).

Figure 1 The distribution of diastolic blood pressure values in women receiving nifedipine either 6-hourly or 8-hourly.

Figure 2 The diastolic blood pressure patterns in women receiving nifedipine 6-hourly (at 06:00, 12:00; 18:00 and 24:00) or 8-hourly (at 06:00, 14:00; and 22:00).

There were no differences in neonatal outcome between the two groups. (Table 2).

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Nifedipine6 Hourly 8 Hourly

Days gained 6 (1 – 22) 6 (1 – 22)Weight 1547 341 1436 489Gestation 31.4 2.0 31.1 2.5Apgar at 1 minute 8 (1 - 9) 8 (1 – 9)Apgar at 5 minutes 9 (4 – 10) 9 (6 – 10)Apgar at 10 minutes 10 (7 – 10) 10 (8 – 10)ICU admission 3 5

When all values obtained during the study were analysed on a intention to treat basis, the mean diastolic blood pressure was significantly higher in those women randomised to receive their nifedipine 6-hourly. (86.6 14.4mm Hg vs. 83.4 13.9 mm Hg). The number of measurements above 110mm Hg (106/2763 vs. 44/2836) and above 100mm Hg (1260/2763 vs. 971/2836) occurred significantly more often in group A. The percentage of measurements above 110mm Hg in the 6-Hourly group increased as the number of recordings increased (Figure 3).

Figure 3 The percentage of diastolic blood pressure measurements > 110 mm Hg over time calculated on a intention to treat basis.

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DiscussionNifedipine given 6 hourly is associated with fewer diastolic blood pressure measurements >100mm Hg as well as more diastolic blood pressure measurements <60mm Hg. The study was not powered to assess the influence on pregnancy outcome and this remains uncertain. The 24-hour Blood Pressure pattern is influenced by time of administration of the drug and the order of the recording.

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EXPECTANT MANAGEMENT OF EARLY ONSET SEVERE PRE-ECLAMPSIA AT A SECONDARY HOSPITAL

Charl Oettle, Adele Roux, David HallDepartment of Obstetrics and Gynaecology, Eben Donges Hospital, Worcester; Department of Obstetrics and Gynaecology, Tygerberg Hospital; MRC Unit for Perinatal Mortality, University of Stellenbosch.

ObjectivesEarly onset severe pre-eclampsia is a disease with high risk to both mother and fetus, and is usually managed in a tertiary setting, with delivery being effected not later than 34 weeks, or earlier if maternal or fetal complications arise. This study addresses the question of whether it is possible to manage it safely at secondary level, in circumstances where easy referral to a tertiary centre is possible.

MethodsOver a 39 month period, from October 1998 to December 2001, all women of gestation 24-33 weeks presenting with early onset severe pre-eclampsia, who were stable (i.e. had no major complications) and who had no evidence of fetal distress, were admitted to Eben Donges Hospital, Worcester, Western Cape, for treatment and intensive monitoring of mother and fetus. Monitoring involved 6-hourly blood pressure measurement, daily urine testing, twice weekly blood tests (platelets, liver enzymes, renal functions) and 6-hourly cardiotocography from 28 weeks gestation onwards. Ultrasound was done on admission for mass estimation and amniotic fluid index, and to exclude fetal abnormalities and maternal ascites. It was repeated thereafter at two weekly intervals. Umbilcal artery Doppler was added if IUGR was suspected, but was not routinely available throughout the study period. Treatment included the following: Blood pressure was controlled with methyldopa, adding prazosin then nifedipine, if necessary. Blood pressure peaks of > 160/110 were treated with oral nifedipine or intravenous dihydralazine. Betamethasone was given on admission, 24 hours later, and weekly to 33 weeks. All patients were assessed twice daily by the consultant and/or registrar.

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Women were delivered on achieving 34 weeks, or earlier if the blood pressure was not controlled on three drugs, if the fetal heart rate pattern became non-reassuring, if intrauterine death occurred, or if the mother developed major complications, viz. ascites, HELLP syndrome, pulmonary oedema, renal failure, eclampsia or abruptio placentae. The route of delivery was that deemed appropriate by the consultant. Induction of labour with prostaglandins was attempted if there was no fetal distress; otherwise a caesarean section was performed. Women were transferred to the tertiary centre (Tygerberg Hospital) if it was felt by the attending consultant in consultation with the Tygerberg staff that they and/or their babies required tertiary care. The women were kept in hospital after delivery until stable, and then discharged on treatment. Well neonates weighing 1800g or more were kept with their mothers in the ward. Smaller and/or sick neonates were admitted to the high care neonatal unit until they had stabilised and gained weight. Kangaroo Mother Care was used where possible. Babies were transferred to Tygerberg Hospital if the attending paediatrician thought it necessary, in consultation with the neonatal ICU staff there.

Results A total of 131 women were included in the study, of whom 116 (88.5%) were managed entirely at the secondary hospital. Eighty-eight (67.2%) of the women were multigravidas, and there were four twin pregnancies. The median age was 26 years (range 15-41). The mean gestation on admission was 29.9 weeks (SD +2.4). One hundred and sixteen (89.9%) women were admitted with a diastolic blood pressure of > 110mmHg; the remaining 10.1% arrived at the hospital with their blood pressure already controlled with anti-hypertensive agents. The mean blood pressure on admission was 173/115mmHg [SD 20/8].

A mean of 11.6 (SD +12.5) and median of 8 days (range 1-89) were gained by expectant management. Ninety-two percent of the women gained 48 hours or more, allowing adequate time for the steroids given to

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work. The mean gestation at delivery was 31.8 weeks (SD +2.2). The indications for delivery are given in Table 1. Twenty-nine women (22.1%) reached 34 weeks gestation without complications. Of these 17 had labour induced electively, of which 12 (58.7%) delivered normally. Overall, 101 women (77.1%) required caesarean section.

Table 1 Indications for deliveryIndication N (%)Fetal distress 71 (54,2%)Elective delivery at 34 weeks 29 (22,1%)Spontaneous labour 12 (9,2%)Maternal reasons 10 (7,6%)Intrauterine death 4 (3,1%)Fetal reasons other than distress 3 (2,3%)Maternal/fetal reasons 2 (1,5%)Total 131 (100%)

Major maternal complications occurred in 44 patients (33.6%) and are shown in Table 2.

Table 2 Maternal complicationsComplication N (%)Abruptio placentae 30 (22.9%)HELLP syndrome 6 (4.6%)Ascites 5 (3.8%)Loss of BP control 4 (3.1%)Severe renal impairment 3 (2.3%)Eclampsia 3 (2.3%)Admission to ICU 2 (1.5%)Pulmonary oedema 1 (0.76%)Cerebrovascular accident 1 (0.76%)Maternal death 1 (0.76%)Patients may have more than one complication.

The maternal death was a 23 year old P2G3 who presented at 29 weeks gestation. She developed a HELLP syndrome and a DIC, and was transferred to Tygerberg Hospital, where she died two days later from sepsis and renal failure. One case included in the study, was not managed according to our protocol. She was a massively obese woman (136kg) admitted at 26 weeks gestation with a blood pressure of 220/130, and 302mg of protein in a 24 hour urine sample. Her blood pressure responded to therapy and she was discharged with a diagnosis of chronic hypertension, for high-risk

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out-patient follow-up. She presented in labour at 39 weeks and delivered a 3800g live baby.Women stayed in hospital for a median of 4 days (1-13) after delivery.There were 15 transfers to the referral hospital, of which 13 took place in the antenatal period. Five women were referred for purely maternal reasons that included HELLP syndrome, pulmonary oedema, renal failure and morbid obesity. Four cases were referred where an extremely low birthweight was anticipated in the face of imminent delivery, while in three cases there were combined reasons (ascites, HELLP, renal failure in the setting of very low estimated fetal weight). A single case was kept inadvertently by the referring hospital after being referred for a Doppler investigation. During the post partum period, one woman was referred for HELLP, ascites and a DIC, while another accompanied her infant who needed ventilation. A total of 135 babies were delivered, of which 4 (3.1%) were intra-uterine deaths. The mean birthweight was 1624g (SD+486) and 20 (15.3%) had five-minute Apgar scores of 6 or less. The mean birthweight of the 15 transfers to TBH was 1272g (SD 498). The male:female ratio was 44:56. Of the 117 live born babies delivered at the secondary hospital, 73 (62.4%) required admission to the neonatal high care unit, where the median stay was 18 days (1-72). Overall, 15 (11,5%) of the 131 live born babies needed ventilation.The perinatal mortality rate was 44.4/1000 (for all babies >1000g) and 59.2/1000 for babies >500g. A total of 14 (10,7%) live born babies died; four died within the first week, another six died in the next three weeks, and a further four died before discharge. This represents an early neonatal death rate of 30,5/1000 for babies >500g. Three of the four stillbirths occurred as a result of placental abruption. The remaining death was as a result of severe placental insufficiency with intra-uterine growth restriction.

Conclusions

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Expectant management of early onset severe pre-eclampsia at a secondary level hospital appears to be acceptably safe for mother and child, if a scheme of intensive monitoring is applied, and if referral to a tertiary centre is possible for the relatively small proportion of extremely high risk pregnancies. This approach substantially reduces tertiary centre workload and costs, and keeps patients closer to their communities. It does not require particularly complicated equipment, but it does need competent and highly motivated staff at the secondary hospital, as well as supportive staff at the tertiary unit. There is no room for complacency in the management of these very high-risk cases.

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EXPECTANT MANAGEMENT OF SEVERE PRE-ECLAMPSIA IN THE MID-TRIMESTER

DR Hall, HJ Odendaal, DW Steyn

Introduction Severe pre-eclampsia that develops in the mid-trimester is an uncommon but particularly challenging problem. The condition itself poses significant dangers to the mother such as intracerebral haemorrhage, renal failure, placental abruption and eclampsia, as well as being associated with high perinatal morbidity and mortality. A study by Sibai et al emphasised these points and concluded that expectant management across a wide spectrum of gestational ages in the mid-trimester was a futile exercise. In 1988 Pattinson et al, reported no fetal survival when mothers presented with severe pre-eclampsia before 24 weeks, but noted an improving survival rate from 24-27 weeks’ gestation. Thereafter Sibai et al, in a follow-up publication on the same subject, noted an improved maternal and fetal outcome when severe pre-eclampsia from 25-27 weeks was managed expectantly. Since the publication of Pattinson et al in 1988 from the Tygerberg unit, the practice of expectant management has been further refined, especially with regard to blood pressure management and fetal evaluation. The availability of surfactant has also improved the chances of perinatal survival although neonatal intensive care (NNIC) facilities at this unit remain a limited and expensive resource.

ObjectiveTo determine maternal and perinatal outcomes with expectant management of severe pre-eclampsia in the mid-trimester, using a defined entry point.

DesignProspective case series. Thirty-nine women admitted from 24-27 week’s gestation with severe pre-eclampsia, whose pregnancies were otherwise stable, were managed expectantly with careful clinical and biochemical

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monitoring of maternal and fetal status, together with careful blood pressure control, in a high-care obstetric ward. The aim was to safely prolong the pregnancies and thereby improve perinatal outcome.

ResultsGestation was prolonged by a median number of 12 (range 3-47) days, with greater periods gained at earlier gestations. The overall perinatal loss was 25.6% and the neonatal loss 17.1%. The relative rates of significant maternal complications were low.

Figure 1 Days gained at each entry gestation

Table 1 Maternal complicationsComplication Numbe

r%

Placental abruption 5 13Pulmonary oedema 2 5HELLP 2 5ICU admission 2 5Eclampsia 1Acute renal failure 1Death 0

Conclusion

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Expectant management of selected women with severe pre-eclampsia from 24-27 weeks’ gestation in a tertiary care unit is acceptably safe and improves perinatal outcome.

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HOW DOES HIV SEROPOSITIVITY AFFECT THE INCIDENCE OF PRE-ECLAMPSIA

KA Frank, EJ Buchmann, R SchackisUniversity of the Witwatersrand, Chris Hani Baragwanath Hospital

IntroductionRecent studies have demonstrated a lower rate of pre-eclampsia in women who are HIV positive, than that in HIV negative women, suggesting a strong immunological basis for the development of pre-eclampsia.

ObjectivesTo compare the rate of pre-eclampsia and other hypertensive disorders in HIV positive and HIV negative Sowetans.

MethodsA record review was undertaken, of women who delivered from January 2002 to October 2002 at Chris Hani Baragwanath Hospital and the Soweto clinics. Selection was by random cluster sampling. Non-Sowetans and women without HIV results were excluded from the study.

Results(These are provisional results)A total of 2603 records were reviewed. The rate of gestational hypertension for the study was 9.5%, with a rate of 5.7% having proteinuric hypertension.The rate of HIV positive patients was 27.1%. The incidence of gestational proteinuric hypertension in HIV positive patients was 5.8%, and 5.7% in HIV negative patients (chi-squared, P=089).

ConclusionThere does not appear to be a significant difference in the incidence of pre-eclampsia between HIV positive and HIV negative women, and while there may be an immunological basis for pre-eclampsia, HIV infection does not seem to be protective.

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THE VARIATION BETWEEN THE NEW PC BASED DOPPLER WAVEFORM ANALYZER AND THE VASOFLOW DUPLEX DOPPLER.

GB Theron, AM Theron, D Grove’, AE Bunn*, J Wallis#. Department of Obstetrics and Gynaecology and the MRC Unit for Perinatal Mortality, Faculty of Health Sciences, Stellenbosch University, Tygerberg.* Technology Developement and Transfer, MRC, Parow.# M+M Technology, CSIR, Pretoria.

ObjectiveTo determine the accuracy of the resistance index (RI) of flow velocity waveforms of the umbilical artery as measured by the PC based Doppler waveform analyzer (Umbiflow) both with regards to systematic and random variations when compared to the present gold standard (Vasoflow). It was important to include the gestational age range (24 to 40 weeks) and sufficient patients with abnormal values (>95th centile).

Study design: A cohort analytic study.

Study patientsAll patients referred to the Fetal Evaluation Clinic (FEC) at Tygerberg Hospital with suspected chronic placental insufficiency.

MeasurementsA single observer determined the RI using the best value as determined by auscultation followed by visualisation on a screen. The Vasoflow and the Umbiflow was alternated. The outcome of the pregnancies was determined. Patients with a RI of <75th centile were regarded as at low risk for complications of placental insufficiency not requiring test for fetal surveilance unless the clinical condition changed. Those >75 and <95th

centile required a repeat Doppler within 14 days and if >95th centile more intensive fetal monitoring. With absent or reversed flow patients were admitted to hospital for intensive fetal monitoring or delivery.

15

Results

A total of 249 patients were included in the study. Gestational age was confirmed by early ultrasound in 195 (78.3%) of the patients. The most common reasons for referring patients for Doppler were: poor symphysis fundus growth (34.1%), previous pregnancy complications (24.5%), hypertension (19.7%) and pre-eclampsia (14.9%). The median gestational age at referral was 30 (21-40) weeks.

The mean resistance index (RI) of the first Doppler assessment was 0.69 (S=0.11) and 0.67 (S=0.11) with the Vasoflow and Umbiflow respectively. A second test was done on 59 (36.7%) patients with continuing pregnancies because the RI was >75 centile. The mean RI was 0.69 (S=0.10) and 0.66 (S=0.10) with the Vasoflow and Umbiflow respectively. A third test was done on 13 (5.2%) patients with the mean RI 0.76 (S=0.12) and 0.75 (S=0.11) with the Vasoflow and Umbiflow respectively.

The correlation coefficient of the RI as measured with the Vasoflow and the Umbiflow were:

1st test 2st test 3rd testPearson 0.8465 0.8264 0.9571Spearman 0.7890 0.7307 0.7966

The mean differences and the distribution of these differences between the Vasoflow and the Umbiflow were:

1st test 2st test 3rd testN 249 59 13Mean 0.0234 0.0203 0.0054SD 0.0617 0.0580 0.0366+2SD 0.1468 0.1364 0.0659-2SD -0.0100 -0.0960 -0.0767

With the first assessment the following shift in categories occurred:Centiles Vasoflow Umbiflow<75 145 (58.2%) 131>75 and <95 14>75 and <95 78 (31.3%) 42<75 36>95 1>95 15 (6.0%) 11>75 and <95 3<75 0Absent 10 (4.0%) 10Kappa index = 0.7 (Good reproducibility)

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Antenatal admission was required by 110 (44.2%) and complications occurred in 152 (61.0%) of patients. The median gestational age of patients with viable fetuses was 38 (27-46) weeks. Spontaneous onset of labour ocurred in 129 (51.8%) of patients, induction of labour in 89 (35.7%), elective caesarean sections in 29 (11.6%) and 2 terminations of pregnancy. The overall caesarean section rate was 26.1%.

The mean birth weight of viable babies was 2712g (665-4294) with 30.1% light for gestational age. There were 5 intra-uterine deaths and 5 neonatal deaths (perinatal mortality rate 40.2/1000).

ConclusionThe mean RI of the Vasoflow and Umbiflow differed with <0.03 when tested on a group of patients at high risk for placental insufficiency, pregnancy complications and a poor perinatal outcome. However, very small differences may cause a downward shift on the centile chart and may eliminate a patient from further fetal surveillance (i.e. to <75th

centile). The appropriateness of the 75th centile need further investigation and possible adjustment to a lower centile. The accuracy of the Umbiflow has been proven and the next step will be to conduct field trials.

17

FETAL MOVEMENT COUNTING FOR ASSESSMENT OF FETAL WELLBEING: A SYSTEMATIC REVIEW

L Mangesi, GJ Hofmeyr*Research midwife and *Director, Effective Care Research Unit, East London Hospital Complex, University of the Witwatersrand and University of Fort Hare, South Africa.

BackgroundIt is every clinician’s goal to have a healthy baby and a satisfied mother at the end of each pregnancy. There are many ways of monitoring fetal condition but they differ in accuracy and reliability. Examples of these are auscultation with the fetal stethoscope, cardiotocography, ultrasound for biophysical profile, fetal scalp blood sampling and fetal movement counting (FMC). All these methods except for fetal movement counting are dependent upon a clinician to conduct the procedure. Fetal movement counting is a method of surveillance of fetal condition as perceived by the mother for early detection of fetal compromise. One of the fetal physiological responses to hypoxia is reduced body movements. Fetal activity is therefore used as a measure of fetal wellbeing. Pregnant women can detect 80–90% of fetal movements that are picked up by ultrasound (Sandovsky & Yaffle in Thomsen, Legarth, Weber & Kristenson, 1990).Most intrauterine fetal deaths occur unexpectedly in normal pregnancies. Most practitioners use the FMC method only in high-risk pregnant women or when there is already fetal compromise. It is surprising that this method does not form part of routine antenatal care.Women with normal pregnancies are able to report decreased fetal movements when given information and charts to monitor their fetal movements (Neldam, 1983).This method is thought also to promote attachment between mother and baby as they start bonding even before the baby is born. Formal fetal movement counting is commonly used when a woman complains of decreased fetal movements. According to Nel in Cronje, Grobbler and Visser (1999), quantitative recording is a useful parameter to indicate a

18

well functioning feto-placental unit. It is not known whether this method should be used routinely, or only when a potential problem is identified.Auscultation of the fetal heart with the fetal stethoscope is a method commonly used to monitor fetal well-being. This method has limitations as it will only give the fetal heart rate, not variability, and especially when the mother is not in labour, the response to the uterine contractions cannot be used as a measure of placental function. The other commonly used method is cardiotocography, which is expensive in terms of equipment and staff time.

Although fetal death is not always preceded by reduction of fetal movements, most of the time it is. Sometimes acting immediately when the patient complains of decreased fetal movements can prevent fetal death. Sometimes the period between the decreased fetal movements and the fetal death is too short for clinicians to act to prevent fetal death (Enkin, Keirse, Renfrew and Neilson, 1995). Although fetal movement is considered to be a helpful method, no clinician has suggested that this method be used in isolation. It is surprising that fetal movement counting is regarded as being very useful and yet is under-utilised. A systematic review was conducted to evaluate its usefulness.

ObjectivesThe main objective of this review was to assess the outcome of pregnancy when fetal movement counting is done routinely, selectively or not done at all.

Search strategyThe search strategy developed for pregnancy and childbirth group was used.

19

Selection criteriaRandomised clinical trials where fetal movement counting was assessed were selected. The methodological quality of the studies was considered. Participants were pregnant women who have reached fetal viability.

20

Data collection and analysis:

Relevant trials with good methodological quality were included. Studies where allocation was not random were excluded. Data were extracted from sources and Revman 4.1 computer software was used for analysis. Fetal and maternal outcomes like antenatal admissions, preterm labour, induced labour, assisted deliveries, caesarean section deliveries, stillbirths, low Apgar scores, hypoxic ischaemic encephalopathy, neonatal deaths and psychological effects of fetal movement counting were measured.

ResultsEleven trials were considered. Only 4 trials were included, two of which are still awaiting information from trial authors. Of the 7 that were excluded, one was not a randomised trial, 1 did not measure the same outcomes as measured in this review, and 5 made different comparisons.Two included studies measured different outcomes. Mikhail (1991) measured maternal fetal attachment using the Cranley scale in a study group using the Sadovsky or Cardiff fetal movement chart, and a control group. Neldam (1983) used alternate allocation to compare a group who were instructed to count fetal movements with a control group who were asked about fetal movements, but not instructed to count them. Two other studies are still pending information from trial authors.

The included studies suggested that fetal movement counting is associated with increased fetal maternal attachment, decreased respiratory distress syndrome, decreased stillbirths, decreased perinatal deaths, decreased asphyxia, a trend to increased caesarean section and a trend to increased assisted deliveries.

ConclusionOnly two studies were included, of which one used alternate allocation.

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No studies showed dangers from using the FMC, except a trend to more caesarean sections. FMC helped to detect fetal compromise in low risk pregnant women. The number of stillbirths decreased

RecommendationsBecause of the trial limitations, more research is justified. The importance of fetal movements should be explained to all pregnant women as they may not know when to report fetal movements as decreased.Women should count fetal movements from about 28 weeks.Two convenient methods are to count the first 10 movements from a set time daily and note the time of the tenth movement, or to count the number of movements over an hour.Women may be given fetal movement charts if more objective evidence of fetal movements is neededHeath care professionals should not withhold information about a procedure that appears effective and does not have any dangers associated with it.

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VIOLENCE AGAINST WOMEN – IMPACT ON REPRODUCTIVE HEALTH AND PREGNANCY OUTCOME

J Schoeman

Introduction Worldwide, up to 25% of women are assaulted during pregnancy, with estimates varying between populations. Violence has been associated with adverse pregnancy outcome, including preterm birth and low birth weight. Among the Coloured population of the Western Cape, the incidence of spontaneous preterm birth is 20%, compared to the global figure of 10%. Overall, the rate of preterm labour has not dropped over the past 40 years and no clearer answer as to a specific cause has been found. The objective of this study was to determine whether patients who deliver preterm experience more domestic violence than those who deliver at term.

Methods Two groups of patients were assessed. Firstly, patients who spontaneously delivered between 24 and 33 weeks (24w0d – 33w6d), who were admitted for suppression of active labour after 24 weeks, or who experienced placental abruption before 34 weeks, were screened for domestic violence using the “Abuse Assessment Screen”. A second group of women, attending a local Midwife Obstetric Unit with uncomplicated pregnancies, completed the same questionnaire. The questionnaires were all administered by the same person (J.S.) after written informed consent was given.

Results A total of 229 patients were interviewed, 99 in the low risk (LR) and 130 in the preterm labour (PTL) group, which included 23 women with abruptio placentae. The PTL group experienced significantly more violence throughout their lives than the LR group (59.7% vs. 40.4%, p = 0.038). Experiences of violence within the last year or during the pregnancy did not reach statistical significance between the two groups, although the

23

numbers were higher for the PTL group. The PTL group smoked significantly more cigarettes per day (p = 0.009), used more alcohol (p < 0.001) and had a higher incidence of syphilis than the LR group (p = 0.005). These differences remained the same when the abruptio’s were analyzed as a separate group.

Table 1 Cigarette smokingPTL

n = 130LR

n = 99 p - valueSmokers 73 (56.2%) 55 (55.5%) 0.92

Mean / day (+ SD)

5.7 (±4.7) 3.6 (± 1.6) 0.0019

Median / day (range) 4 (1 – 22) 3 (1 – 8)

PTL = preterm labour; LR = low risk; NS = not significant

Table 2 Alcohol use between the main groups and sub-groupsPTL

n = 130LR

n = 99 p-value

Alcohol use 55 (43.3%) 12 (12.1%) < 0.0001OR 5.32 (2.53-11.4)

PTL = preterm labour; LR = low risk

Table 3 Women who ever experienced violencePTL

n = 130LR

n = 99p - value

77(59.7%) 40 (40.4%) 0.0038OR 2.18 (1.24 – 3.86)

PTL = preterm labour; LR = low risk

Table 4 Women who experienced violence during the year preceding the interview

PTLn = 130

LRn = 99

p - value

41 (31.7%) 26 (26.3%) 0.36OR 1.31 (0.70 – 2.44)

PTL = preterm labour; LR = low risk

Table 5 Women who experienced violence during the pregnancy

PTLn = 130

LRn = 99

p – value

28 (21.5%) 12 (12.1%) 0.059OR 2.01 (0.91 – 4.48)

PTL = preterm labour; LR = low risk

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ConclusionsWomen who delivered preterm did experience more violence at some point in their lives and were also more likely to engage in high-risk behaviour. Violence alone does not seem to cause PTL directly, but is part of a low socioeconomic lifestyle. The fact that the alcohol use is so high among these women is a problem that needs to be addressed, but once again, it is possibly the result of deeper social problems. The need for education on values and respect, family planning use and low risk sexual behaviour is once again challenged.

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PRE-ECLAMPSIA AT THE KALAFONG HOSPITAL (UNIVERSITY OF PRETORIA). A RETROSPECTIVE STUDY ILLUSTRATING SOME ASPECTS OF A TERTIARY REFERRAL CENTER PRE-ECLAMPSIA POPULATION IN SOUTH AFRICA. 

J Cornette, R C Pattinson, B Jeffery MRC Maternal and Infant Health Care Strategies, Department of Obstetrics and Gynaecology, Kalafong Hospital, University of Pretoria

ObjectiveTo review perinatal mortality in patients with severe pre-eclampsia at Kalafong Hospital and determine the proportion of patients that qualify for expectant management of pre-eclampsia.

Setting Kalafong Hospital is a tertiary referral center in the vicinity of Pretoria. Data from 750 patients admitted in our institution for severe pre-eclampsia has been analysed. The results of the first 117 patients are presented in this abstract.

MethodDemographic details were determined. Patients were divided in two groups based on estimated gestational age of 34 weeks, and the proportion of those less than 34 weeks who achieved expectant management was calculated.The perinatal mortality as calculated in 500g categories.

ResultsOf the 117 patients, 56 potentially qualified for expectant management (< 34 weeks gestational age with a live baby at presentation) and of these 31 (55.4%) were managed expectantly for more than 24 hours. Mean number of days of expectant management was 11 days.

Table 1 illustrates the perinatal mortality per weight class.

Weight class

Perinatal mortality in %

0-499 g 100500-999 g 81.31000-1499 g

6.7

1500-1999 g

11.1

2000-2499 g

4.3

>2500 g 2.3

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THE GLOBAL PROBLEM OF MATERNAL MORTALITY: INEQUALITIES AND INEQUITIES

WJ GrahamDugald Baird Centre for Research on Women’s Health, University of Aberdeen.

The most recent global estimates of maternal mortality for 2000 provide few signs of major progress. Indeed the figures for the Africa region make depressing reading, with the number of deaths now exceeding those estimated for Asia, despite the latter’s much larger population. The risk of maternal death as expressed by the maternal mortality ratio shows a huge differential between the regions of the developing world, being more than 800 maternal deaths per 100,000 live births in Africa, compared to less than 400 in the next highest region – Asia. The proportion of the annual number of deaths that occur in developed countries remains less than 1%. By comparison with the picture for 1990, there is a slight decline, the majority of this being due to progress in the Asia region.

Given the inadequacies of health information systems in many parts of the world and thus the need to rely on projection methods, these figures for 2000 need to be used cautiously. Such caution is also needed owing to the enormous variability between countries - variability that is hidden by using crude averages for world regions. But the same can also be said for national figures. Thus, for example, monitoring progress towards the Millennium Development Goal for maternal mortality of a 75% reduction by 2015, without considering the equity of improvements may obscure widening gaps between population groups, and particularly between the richest and the poorest sections of society.

The patterns or inequalities in levels of maternal mortality within and between countries are not, however, solely due to economic factors. By controlling for a proxy marker of wealth – per capita GDP, very different levels are seen. For example, with a GDP of US$750 per capita, maternal mortality figures have been reported below a 100 maternal deaths per

28

100,000 live births in Sri Lanka, versus more than 700 in Cote Ivoire. In the United Kingdom, the three-fold difference in the maternal mortality ratio between different ethnic groups reported in the latest Confidential Enquiry (UK-CEMD), cannot be explained by differences in economic status. Similarly, data from the United States show a four-fold increase in the risk of maternal death in black versus white women, which again cannot be totally attributed to differences in wealth.

In developing countries, there is extremely limited reliable information on differentials in the risk of maternal death between population sub-groups. There is, however, considerable data, mostly from Demographic and Health surveys, which show major discrepancies in the uptake of maternal health services – both antenatal and intrapartum, between the poorest and richest groups. In this data source, poverty or wealth is measured in terms of household assets, and care is based on women’s self-reports. The findings of the 1998 South Africa DHS show a marked gradient in the proportion of deliveries attended by health professionals, from 70% amongst the poorest quintile to 99% in the richest. This inequity can be further “unpacked” by considering deliveries attended by doctors or midwives. The data suggest that in the poorest group 14% and 56% of deliveries were attended by doctors and midwives respectively, compared with 66% and 32% amongst the richest group.

These differences may be regarded as inequalities or as inequities according to perceptions of what is “fair” or “just”. An extensive literature has evolved over the last 10 years on health differentials, but there is still little clarity on definitions and concepts. In simple terms, “inequalities” refer to differences between geographical areas and/or socio-economic groups, but is a term with more of a political overtone than “differentials”. The distinction between inequality and inequity, on the other hand, is more complex. Inequity essentially relates to the concept of avoidability and to principles of fairness and justice, and thus also can be linked with ethics and human rights. Clearly, what is regarded as fair and just is

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influenced by the way in which a health problem is perceived in terms of priority and feasible solutions, and thus varies widely according to ideology and country.

If all inequities are acknowledged as avoidable or preventable differences in health outcomes that are unfair or unjust, it could also be argued that all avoidable maternal deaths are inequities. Regardless of the level of maternal mortality, there is evidence to suggest that significant proportions of deaths can be linked with substandard care from providers and/or failures in the health system. In Egypt, for example, a national enquiry into maternal deaths during 1992-93 found that 47% of cases could be related to poor care from the obstetric team. Similarly in the last UK-CEMD, half of the direct maternal deaths could be linked with major substandard care from professionals. The most recent South Africa Confidential Enquiry reports health care provider avoidable factors in 57% of deaths. Whilst, thankfully, effective services prevent every life-threatening complication from resulting in death, equally those avoidable deaths that do occur could be regarded as injustices and violations of human rights.

A rights-based approach to avoidable maternal deaths does not necessarily imply the involvement of laws or constitutions, since approaches through policy and social norms have also been advocated. Whether such a stance will be helpful in the continuing efforts to reduce maternal mortality remains to be seen. What is clear, however, is the importance of recognising that maternal death is not just a medical issue and that improvements are needed both within and outside of the health service. A stronger societal perspective must be fostered if safe motherhood is to be the equal right of all women.

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SOCIO-ECONOMIC INEQUALITIES AND MATERNAL HEALTH IN SOUTH AFRICA

D Blaauw, L Penn-KekanaHealth Systems Development Programme. Centre for Health Policy.

BackgroundSouth Africa is characterised by large inequalities in health status and access to health services. Unfortunately, most analyses have tended to use proxy measures such as population group, or geographical area so there is very little information on health indicators by socio-economic status in South Africa. The first Demographic and Health Survey (DHS) conducted in 1998 provides important population-based data on maternal health care in South Africa. Although the national figures for some maternal health indicators, such as access to trained attendants at delivery, were reasonably encouraging, the report also demonstrated that there are marked differences between different population groups and geographical areas. The objective of this study was to expand the existing analyses and to evaluate differentials in maternal health outcomes by socio-economic status.

MethodologyThis study was part of a rapid appraisal of maternal health services in South Africa. The database used was the 1998 South African Demographic and Health Survey (SADHS). Cluster sampling was used to select 12 247 households. 11 735 women between the ages of 15-49 were interviewed and information was collected on 4 992 births from 1993-1997.

The DHS does not collect adequate data on household income or expenditure, but does provide information on household assets. Principal Component Analysis (PCA) using 25 asset variables was used to construct an appropriately weighted asset index that serves as a measure of the household’s long run economic status. The asset index was then used to divide households into wealth quintiles, which formed the basis of all subsequent analyses. A relative measure of poverty was used whereby

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households in the lowest 40% of the population are classified as poor. Analyses were done in SPSS and SAS. ResultsThe complex pattern of inequality in South Africa is demonstrated by consideration of an indicator such as the proportion of women delivering without a trained attendant. According to the DHS, 14.2% of all births in the five years preceding the survey had been delivered without the help of a medically trained attendant. However, there are significant variations by area, province, race and socio-economic status (Figure 1). Only 1.6% of births to women in the richest quintile were delivered without a trained attendant compared to 29.2% of births to women in the poorest quintile, an 18 fold increase. Similarly, nearly a quarter of poor women delivered without an attendant whereas this was only true for 5.5% of non-poor women.

Broad geographical categories such as provinces may mask the considerable variation within provinces. In the Eastern Cape, for example, the overall proportion of women delivering without a trained attendant was 25.0% but this indicator was 5.2% for urban women and 34.1% for rural women in the Eastern Cape (Figure 2). Of concern is that over 40% of the poorest women in this province gave birth without trained assistance. shows a breakdown of race groups by wealth quintile for the country as a whole. Poor African women were 10 times more likely to have no attendant than African women in the top quintile, and only the very poorest white and Indian women do not have access to trained attendants at delivery.

Similar patterns were observed when comparing the type of trained attendant available. For example, 71.9% of births to women in the richest quintile had been delivered by a doctor compared to only 14.7% of deliveries in the lowest quintile. According to the DHS, 96% or women in South Africa have at least one antenatal care (ANC) visit few differences by area or socio-economic status. However, there is some variation in the

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average number of ANC visits between groups. For example, African women had an average of 5.7 ANC visits compared to 9.9 for Indians and 9.5 for white mothers. Women in the poorest quintile attended ANC an average of 5.2 times compared to 8.6 visits for the richest quintile.

ConclusionsThe DHS can provide good national indicators for access and utilisation of maternal health services. The first DHS survey suggests that access to ANC in South Africa is better than access to delivery services. Using a wealth index and wealth quintiles to re-analyse the data provides useful insights into socio-economic differentials and reveals the complex mix of socio-economic, geographical and racial factors that impact on access and utilisation of maternal health services. Although overall indicators are high in South Africa, this study clearly reveals that there are certain groups of women who have inadequate access and low utilisation of delivery services. Unfortunately, the DHS is not able to provide similar breakdowns for maternal mortality estimates.

RecommendationsMaternal health interventions need to prioritise the availability and access of delivery services for the poor in under-served areas. However without broader social development it is likely that access will remain a problem for the very poor.

The DHS provides useful information on health service access, utilisation and outcomes in South Africa and should be repeated at regular intervals.

It is necessary to develop a more detailed understanding of the impact of socio-economic factors on health status in South Africa. To be able to do this we need to move away from proxy measures such as race or province and increase the availability of socio-economic analysis of health outcomes. Finally we need to improve the quality of maternal mortality

33

data in this country in order to evaluate socio-economic differentials in mortality outcomes.

Acknowledgements

DFID for funding. National Department of Health for access to the SADHS database.

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Figure 1 No trained attendant by area, province, race and quintile

14.2%

23.0%

5.3%

25.0%

11.4%

4.8%

15.6%

18.5%

23.0%

8.0%

10.4%

3.3%

16.3%

4.7%

0.9%

0.8%

29.2%

17.8%

10.4%

2.8%

1.6%

23.5%

5.5%

0% 25% 50%

TOTAL

AREA Rural

Urban

PROVINCE Eastern Cape

Free State

Gauteng

KwaZulu Natal

Limpopo

Mpumalanga

Northern Cape

North West

Western Cape

'RACE' African

Coloured

Indian

White

WEALTH QUINTILE 1

2

3

4

5

POVERTY Poor

Non-Poor

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Figure 2 No trained attendant by province and quintile, for Eastern Cape and Gauteng

14.2%

25.0%

34.1%

40.6%

40.4%

15.6%

7.4%

9.0%

4.8%

4.8%

9.5%

5.3%

2.8%

3.5%

0.0%

5.2%

0% 25% 50%

TOTAL

EASTERN CAPE Total

Rural

Urban

Q1

Q2

Q3

Q4

Q5

GAUTENG Total

Urban

Q1

Q2

Q3

Q4

Q5

36

Figure 3 No trained attendant by race and quintile

14.2%

31.4%

19.8%

14.8%

6.6%

3.1%

12.8%

4.1%

1.9%

4.2%

4.2%

5.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0% 25% 50%

TOTAL

AFRICAN Q1

Q2

Q3

Q4

Q5

COLOURED Q1

Q2

Q3

Q4

Q5

INDIAN Q1

Q2

Q3

Q4

Q5

WHITE Q1

Q2

Q3

Q4

Q5

37

EXPLORING THE JOURNEY TO MATERNAL DEATH: GENDER AND HUMAN RIGHTS PERSPECTIVES (WORK IN PROGRESS)

N MbomboWomen’s Health & Advanced Midwifery Lecturer, Department of Nursing, University of the Western Cape, South Africa

IntroductionThe Saving Mothers report (1998) states that South Africa has a maternal mortality ratio that is 12 times more than that of the United Kingdom. The Western Cape province where this study was conducted, had the lowest maternal deaths since 1998, but there has been a 53% increase above the 1999 total in the year 2000. Both the South African Saving Mothers (1998) and Saving Babies reports (2000) identified the delay in seeking care and failure or infrequent attendance of antenatal care during pregnancy as the major contributory causes to these maternal deaths. In 1997, the WHO declared that maternal death should be addressed as a human rights issue because “every maternal death is an event that could have been avoided, and should never have been allowed to happen”. In cognisance with this WHO statement and South African consciousness on human rights and gender discourse that is influenced by South African constitution, a study on women’s accessibility to maternal health care by using these approaches was conducted.

Aim Of The StudyThe main aim of the study was to use Gender and Human Rights approaches to examine and analyse the major causes of maternal mortality, which result from delay in seeking maternity care and failure to attend antenatal care during pregnancy. Gender approach was used to identify and analyse inequalities that arise from belonging to one sex or from unequal power relations between sexes and how these impact on women accessing maternal health care. The Human Rights approach was to identify and analyse health system related factors that led women to delay to seek care and fail to attend maternal care.

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Study ObjectivesIn regard to maternity women the study intended to do the following:

1. Identify and describe the reasons of presenting late or failing to attend maternity care (antenatal, intranatal, postnatal) at a maternal health facility

2. Determine and analyse women’s gender roles and relations that impact on accessibility to maternal health care

3. Determine and analyse human rights issues that impact on accessibility to maternal health care

4. Elicit opinions and observations on the delivery of maternal health services as perceived by its recipients

Research MethodologyA qualitative multiple case study design was used, and to achieve this, twenty- one women who did not attend or who delayed attending maternity care (antenatal, intranatal and or postnatal) were interviewed by using semi-structured and open-ended face-to-face individual interviews. To refine the study hypothesis, women who booked at least from the second trimester and visited the health service up to postnatal care, were also interviewed. The study setting was all six Midwife Obstetric Units in the northern area of Cape Town Unicity. Data was analysed by verbatim transcription of taped recorded interviews, categorized and thematically analysed. Both deduction and induction analyses were applied using themes generated from both conceptual framework (human rights and gender approaches) and from participants’ interviews (Talbott,1995). For ethics, participants signed consent agreement which highlighted confidentiality among other things (MRC Ethic guidelines, 2001).

Reliability and ValidityThis was applied by ensuring trustworthiness which is determined by credibility, transferability, dependability and conformability (Yin, 1998).

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Credibility was ensured by peer debriefing, by reflexivity and by negative case analysis. Journal was kept throughout the research process to reflect on the researcher’s experiences and biases that may have impact on the findings. For negative case analysis, sampling included participants from booked clients. For transferability, a retrievable data base consisting of audio cassettes, transcribed data and field notes is kept for interested researchers to make use of the findings for generalization. For dependability and conformability, an audit trail was kept for an independent reviewer co-analysing the findings.

Major FindingsGender Perspectives1. Gender Roles1.1 Production Employed participants felt that not being given time off from work impacted on their delay in attending maternal health care. One indicated that when time permits, “Something Else Cropped Up”. Although half of the participants were unemployed, they had other responsibilities at home that prevent them from attending maternal health services on time. One responsibility, for example, that was highlighted was that of looking after husband’s informal business and cooking for his workers resulted in one woman presenting late for antenatal care.

1.2 ReproductionMost participants who delayed or did not attended maternal health care in the study had parity of more than one with youngest child still in foundation year of schooling. They felt that looking after the siblings had an impact on their attendance of maternal health services, “with small children I can’t take it, they give me headaches, children tire one. You are tired, you have to cook, do the washing, and have to do everything what a mother is supposed to do”. Arranging for babysitting was also a hassle. According to one woman who was late booked, “you have to pay more fees (babysitting) if you are going to stay the whole day in the clinic”

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2. Gender RelationsMost participants although half of them were not married, had partner as a decision-maker at home. Partners did encourage them to go to clinic to book, but were not available to take care of young children when the women wanted to go to clinic., “Husband has nothing to do with the children…I look after the children myself… he does not help me with anything”.

Human Rights Perspectives2.1 Availability of maternal health service:All participants, including the booked ones were concerned about clinic opening times. The unbooked participants had similar experiences in their previous pregnancies. “One has to go to stand early in the morning at clinic x. From 5 o’clock, one has to go and stand there, you have to stand outside, because they only open the gates at 7 o’clock… The sisters only come at 9 o’clock to help people, and they only help a certain amount of people”.“They say they open at 7 o’clock but start routine at 8 o’clock or past ten then they will go for tea and will be back past 12:00, you will go home very late”

2.2 Accessibility of maternal health service:Disrespectful and uncaring staff was highlighted as of concern by all but one participant. This is what one unbooked woman said “I didn’t feel like going there to deliver...The things I heard of how they leave mothers alone in the labour ward, and someone told of how her baby almost got born in the toilet”One who delivered on arrival at MOU, “I went to the labour ward twice and both times they sent me home…I mean now you do not have transport…you have to walk back, and you are alone”

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One who delivered at home, “I was scared that something can happen to my child…I thought I will rather finish at home, I am not going there with the second one”.

2.3 Right to Quality Care2.3.1 Unhealthy Environment:Participants were concerned about their health as pregnant women as they are exposed to sick people whom they share a waiting room, “Since everybody that’s ill sit in one area also the sufferers and the coughing, you sit there in a place which should be clean and hygienic” They felt that the physical environment is not conducive to accommodate pregnant women with small children, and this includes lack and poor conditions of public toilets, “sitting for long periods, then you want to change the baby’s nappy, and when you are pregnant you need to go often”“Where we deliver, you lie down alone, they are busy with their work, when you have to shout then they will come”.

2.3.2 Questionable Procedures Some participants questioned some procedures that were performed unto them, “When I went in, the doctor felt my chest over my jersey…and just like that, I was, I don’t think I was in there for 5 minutes, before I was done, yes without lifting my jersey, and then I said to myself, we sat here all day just for this…everybody complained about doctor who comes at 11 o’clock”

2.3.3 Right to non-discriminationTeenage Moms felt they were discriminated against because of their age. A 16-year old participant quoted what the nursing sister said to her, “You were not supposed to get pregnant at your age.” That only spouses of married people are allowed in the labour ward to give support put most women off. One 19-year old woman alluded to that pregnant women need support, “ A lot of women are afraid when pain starts, when they are

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afraid, when they are really afraid, when they think about when the baby must come, and then they are really afraid”.

2.3.4 Right to InformationFew women felt that the information given by nursing sisters was not enough, “HIV, nothing else, sisters do health education when there are students who need a mark or something”Another woman,“ They only told us not to smoke or use alcohol when you are pregnant and that we already know…”

2.3.5 Right to Human Dignity and RespectSome participants felt being seen in groups of three’s, with Blood Pressure, urine and so on being taken at the same time in the treatment room was not promoting privacy. Some did not regard that as a problem, “ …why be shy we are all women”. One woman was concerned about this lack of privacy, “I couldn’t ask about sterilization because it was such a crowd”. One home delivered woman was addressed with derogatory names, “You Hotnot, stand on the line”

3. Observations & Opinions On Delivery Of Maternal Health ServiceAll participants indicated that long waiting hours, rude and unfriendly labour ward staff, “Srs helpful become rude only when provoked” by clients. “Can see why other women do not want to go to clinics, it is for their own good and own health and it is dangerous”.Staff having no patience, “There are sometimes inexperienced mothers and youngsters and it is their first time and don’t know what is waiting for them, they need staff with patience”.“They take a lot of bookings, people, then they can’t attend to all of them”

ConclusionPregnant women’s gender roles such as taking care of other small children, and gender relations such as inequalities in a relationship in

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regard to whose responsibility to look after these small children impact on their delay in seeking maternal care. Maternal Health Services do not accommodate such gender aspects. There are no facilities such as places to change baby nappies for those pregnant with small children. Long clinic waiting times becomes a major issue when they have to spend whole day at the clinic when they have to pick up other small children from school, or to relieve a baby sitter whom they have to pay more fees.

Violation of human rights to access maternal quality health care, right to human dignity and respect, and violation of right to non-discrimination by health system as defined by WHO (2001) impact on the delay and failure to seek maternal health care by pregnant women. Women who did book for antenatal care and attended maternity care until postnatal shared the same sentiments. The reasons for this category booking, in spite of the fact that they share same sentiments with ‘unbooked’ category, is discussed elsewhere in the broader study.

Kwast (1991) supports these results by arguing that, “a woman, does not die because she has a post-partum haemorrhage, she dies because she has too many children, and she might have wished to prevent the pregnancy but had had no access to family planning due to the fact that she lived far away from the clinic in a poor, rural area with no roads, or because the last time she asked for contraceptives from health service she was badly treated by health workers”.

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50 YEAR AUDIT OF MATERNAL MORTALITY IN THE PENINSULA MATERNAL & NEONATAL SERVICE [1953 – 2002]

S Fawcus*, H van Coeverden de Groot#* Mowbray Maternity Hospital, University of Cape Town, Department of Obstetrics and Gynaecology# Formerly Head of Community Obstetrics, University of Cape Town, Department of Obstetrics and Gynaecology

Introduction U.K. confidential enquires into maternal death commenced 1952. South Africa: Confidential enquiry into maternal death commenced

1998 Focus on Peninsula Maternal & Neonatal Service: Cape Town.

Peninsula Maternal & Neonatal ServiceGSH MAT. HOSP

Mowbray Mat. Hospital New Somerset Hosp.

Khayelitsha, Guguletu , Mitchells Plain, Retreat, Hanover Park, HeideveldAnd VanGaurd Midwife Obstetric Unit.

Method DESCRIPTIVE AUDIT OF MATERNAL DEATHS IN PMNS

FACILITIES.1953 - 1996. Professor de Groot[annual maternal mortality reports , gynaecology death reports]

1997 - 2002. Dr. S. Fawcus. [annual maternal mortality reports, including early pregnancy deaths.]

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OUTCOMES ASSESSED: NO MATERNAL DEATHS

[Direct, Indirect, Coincidental] CAUSES OF MATERNAL DEATHS TOTAL NUMBER DELIVERIESAvoidable factors documented but not presented in this paper. DATA PRESENTED FOR TRIENNIA DETAILED COMPARISON OF THREE TRIENNIA

1954 - 19561981 - 19831999 - 2001

Results

Total Number Of Deliveries

1953 : 7315 2002 : 27,575

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Maternal Mortality Rate

1953 : 301 maternal deaths per 100,000 deliveries ( * 355 if include estimate of abortion deaths)

2002 : 112 maternal deaths per 100,000 deliveries.

Maternal Mortality Rate

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Trends in Causes of Maternal Death1954 – 1956Del. = 23,635 1981 – 1983

Del. = 70,717CAUSES Direct No MMR per No. MMR per100,000 del

100,000 delHypertensive 19 80.4 8 11.3DisorderAbortion 13 * 55 3 * 4.2Haemorrhage 9 38.1 2 2.8Sus.Pulm.Emb 6 25.4 2 2.8Trauma 3 12.7 1 1.4Preg. Rel. sepsis 2 8.5 3 4.2Anaesth.Complic 0 0 1 1.4* Estimate only

Indirect Cardiac 5 21.2 2 2.8Other med. dis 3 12.7 6 8.5Non pregnancyRelated infec. 0 3 4.2CoincidentalHead injury 0 0 1 1.4

Total 60 254 32 45

TRENDS IN CAUSES OF MATERNAL DEATHSCAUSES 1981-1983 1999-2001

[del. = 70,717] [del. 82.470]Direct No. MMR No MMRHypertensive dis. 3 11.3 12 14.5Haemorrhage 3 4.2 3 3.6Susp.Thrombo em 2 2.8 3 3.6Pregnancy related 3 4.2 6 7.3SepsisAbortion 3* 4.2 0 0Anaesthetic 1 1.4 1 1.2Complication

* estimate only

Indirect Cardiac 2 2.8 0 00Other medical 6 8.5 9 10.9disordersNon pregnancy 3 4.2 15 18.2related sepsisCoincidentalHead injury/Trauma 1 1.4 1 1.2Unknown 0 0 2 2.42 TOTAL 32 45 52 63.1

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Discussion(a) WHY DID MMR DECREASE 1953–1983 ?? – Possible reasons

(a)Development of district midwifery and then the midwife/obstetric units.

(b)Development of dedicated flying squad for emergency referrals.(c) Improvement in critical care of eclamptic patients.(d)Improvements in medical care of cardiac patients.(e)Reduction unsafe abortion practices.(f) ?? Increase number of low risk women in the denominator for

calculating MMR.

(b) WHY DID MMR INCREASE AFTER 1996 ? – Possible reasons(a)More comprehensive reporting of maternal deaths?(b)Influx of high risk patients from Eastern Cape?(c) Nursing shortages?(d)Increasing prevalence of HIV/AIDs in the pregnant population.(e)?? Change in the denominator ??

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ADDRESSING MATERNAL MORTALITY IN A RURAL EASTERN CAPE HOSPITAL THROUGH MATERNAL DEATH AUDIT REVIEW: FINDINGS AND RESULTSV George, P Gwexe, P Gwegwe, B Segese, S MasilelaDept. of Health, Eastern Cape Province; D Jackson, School of Public Health, UWC; S Verkuijl, ISDS, Health Systems Trust; HA van C de Groot, Dept of Obstetrics & Gynaecology, UCT

ISDS - Obstetric Support Programme Objectives1) Reduce maternal and perinatal mortality2) Improve the quality of obstetric services in Region E through the

introduction of: Perinatal audit Continuing in-service education & training Introduction of uniform maternal health guidelines Monitoring & evaluation

Monitoring & Evaluation• Hospital maternity statistics for 1999 through 2001 have been

collected on a monthly basis from 6 of the 9 hospitals with delivery services in this rural Eastern Cape Region.

• During early 2002 a sharp increase in maternal deaths was noted at one of the hospitals for the last 6 months of 2001, after a decrease in early 2001.

• This increase had also been noted by the Provincial Maternal Health Coordinator through the NCCEMD Reports and OSP was asked to follow-up.

Hospital Maternal MortalityAs part of the monitoring and evaluation component of the OSP, hospital maternity statistics for 1999 through 2001 have been collected on a monthly basis from 6 of the 9 hospitals with delivery services. Table 1 provides an overview of 2001 data from the six hospitals.

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Table 1 2001 Perinatal Statistics from Hospitals Participating in the ISDS-OSPHospital Number of

BirthsPerinatal Mortality Rate (per 1000 Births)

Maternal Mortality Rate (per 100 000 births)

Perinatal Care Index

A 1611 66 186 6.3B 1109 64 183 8.0C 1605 52 317 4.8D 2823 61 612 5.2E 2500 89 486 9.8F 1363 30 74 4.1

During the last round of data collection a sharp increase in maternal deaths was noted at one of the district hospitals for the last 6 months of 2001 after a decrease in early 2001. Data from 1999 through 2001 can be found in Table 2.

Table 2 Maternal Mortality at Rural District Hospital 1999-2001Time Period

Number of Deliveries

Number of Maternal Deaths

Maternal Mortality Rate per 100 000 Deliveries

Jan-Jun 99 1253 2 169Jul-Dec 99 1327 7 548Jan-Dec 99 2580 9 366Jan-Jun 00 1253 8 703Jul-Dec 00 136 5 416Jan-Dec 00 2569 13 556Jan-Jun 01 1328 1 159Jul-Dec 01 1448 10 826Jan-Dec 01 2776 11 486

This type of increase was not seen in any of the other hospitals in the region. While the index hospital had consistently had higher maternal mortality than the other hospitals, the hospital had taken steps to address maternal mortality and had seen a decrease in early 2001. This sharp increase which translated to a rate of 826 maternal deaths for every 100 000 deliveries was considered a serious crisis for the maternity care services.

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Response – Audit• This type of increase was not seen in any of the other hospitals in the region. • In consultation with the Medical Superintendent and Nursing Service

Manager, it was recommended that the OSP Obstetric Consultant would conduct a formal Maternal Mortality Audit Meeting to review the eleven 2001 deaths.

• This meeting was scheduled during April 2002 and was attended by hospital administration, hospital staff, and the ISDS Facilitator for the district.

Audit Results – Causes of DeathCauses of Death in 11 Cases included:• Eclampsia = 3 All admitted with fits & delay in seeking care• Postpartum Sepsis = 1• Ruptured Uterus = 2; Transfer delay, No hysterectomy capacity• HIV = 1• ?Infection=4; (Query HIV?) Poor records and management

Audit Results – Avoidable FactorsAvoidable Factors in 11 Cases identified were: • Patient = 7 (69%) including delay in seeking care and un-booked; • Administrative = 9 (82%) primarily transport, inadequate facilities,

and inadequate trained doctors; and • Personnel = 10 (91%) including nursing care in ANC and maternity,

inadequate doctor response or medical management, and poor records.

Audit Results – Key IssuesFour key issues which were identified included: 1) Impact of HIV – 45%?2) Inadequate training of doctors in managing maternity cases – 72%3) Quality of Nursing Care – 54%, and

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4) Transport – 54%

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Audit Results - Response• Doctor training – one of the Cuban doctors was sent for obstetric

training in-service in the tertiary hospital • Transport – transport for tertiary referral of maternity cases now

receives a higher priority • Nursing Care - the nursing sisters are participating in PEP with 21

sisters and midwives registering for the Maternal Care Module

The Role of HIV in Maternal MortalityHowever, the hospital doctors and maternity staff are still in need of training in the management of pregnancies complicated by HIV, not just PMTCT, but appropriate management for the mother to reduce mortality from HIV/AIDS and non-pregnancy related infections.

ConclusionThere was an excellent response by the hospital staff and administration to the audit process and 2002 saw a decrease in maternal deaths after the initiation of the audit process. Maternal Deaths: in 2002 = 9for MMR of 376/100 000 DeliveriesPost Audit/Intervention 2002 = 2for MMR of 164/100 000 Deliveries

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MATERNAL DEATHS IN THE FREE STATE: STATISTICS FOR 2002

JBF CilliersDepartment Obstetrics and Gynaecology, University of the Free State

IntroductionSince maternal deaths became a notifiable condition in 1997, the number of maternal deaths in the Free State have stayed fairly constant. There were a steady decline till 1999, but started to increase again reaching a high in 2001. If the deaths are broken down into the primary causes leading to the deaths there is an increase in especially two causes namely: Non-pregnancy related infections and AIDS. As in the rest of South Africa the “Big five” causes of maternal deaths in 2001 were: Non-pregnancy related infections (AIDS), hypertension related deaths, obstetric haemorrhage, pregnancy related infections and medical diseases in pregnancy. Although there were 108 deaths reported in 2002, this article will only present the first 82 cases. Due to delays in receiving the case files from the institutions only the first 82 cases could be assessed and reported on.

MethodMaternal deaths are reported to the provincial office by the institutions where the deaths occurred within 24 hours. The provincial notify the National office, namely the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). The NCCEMD will then assign a unique number to the case. The institution where the death occurred sends a copy of the file with a death notification form to the provincial office. This is then sent to the assessor who will assess the case to determine the cause of death and preventable factors. A report is completed and the file with the report is sent back to the provincial office that forwarded it to the NCCEMD. We used our own database to assess the cases before the information was forwarded.

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Results

Although in the Free State there were more deaths due to hypertension and not AIDS, this is probably due to the strict criteria to make the diagnosis of AIDS. This was defined as a positive HIV test plus a CD4 count of less than 200 or an AIDS-defining disease like cryptococcus meningitis. If the non-pregnancy related infections group are analysed most of them are probably AIDS related as well.The leading primary causes of death have stayed the same over the last 5 years. This corresponds with the rest in the provinces in South Africa. Obstetric haemorrhage is still the most preventable leading cause of death. Final cause of deathThe final causes of death were as follows. As can be expected from the high occurrence of non pregnancy related infections as the primary cause the most common final cause of death is respiratory failure

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Level of deathIf the referral system and transport routes are in place most deaths should have occurred at tertiary level. This was not the case in the Free State where most deaths occurred at secondary level. This could also mean that not enough tertiary beds are available. There seems to be an underreporting of deaths from primary institutions.

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Level of deaths for Haemorrhage, Hypertension and AnaesthesiaIf one looks at the level of death for the causes: obstetric haemorrhage, hypertension and anaesthetic related deaths were as follows:

Deaths due to obstetric haemorrhage occurred mostly at secondary level in spite of blood being available at all secondary level hospital. The primary anaesthetic incident occurred all at primary level.

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Age distributionIf we look at the number of deaths in women older than 35 years and we keep in mind the total pregnancies after the age of 35 years, this age group carries the highest risk.

DeliveryMost of patients were delivered vaginally (45%). 22% died before delivery. 32% had a caesarean section before her death.

Antenatal clinic attendanceMost of the mothers who died did attend their antenatal clinic

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HIV statusMost of the patients HIV status were unknown. If we ignore the unknowns, most of the patients were HIV positive (67%)

ConclusionSince the maternal death enquiry started in 1997 we haven’t really made any difference in the number of maternal deaths in the Free State or nationally. Obstetric haemorrhage is still the most important preventable cause of maternal deaths. The 1999–2001 report have just been released and new recommendations made to prevent mothers from dying. It is up to us if we are going to implement those recommendations.

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OVERVIEW OF MATERNAL MORTALITY FOR KWAZULU NATAL: 1998-2001

ND Nyasulu, G BartlettKwaZulu Natal MCWH Subdirectorate

IntroductionThe province of KwaZulu Natal is the most densely populated of the nine provinces in South Africa. It has a population of 8 417 021 - 20.7% of the South African population (Population Census 1996). The female population is 4.6 million (Population Census 1991). The province is divided into 10 health districts. There are 64 public hospitals, 18 Community Health Centers and 433 clinics providing maternal health care services.

Aim of the Presentation This paper presents the overview of the problems and the pattern of maternal deaths causes in KZN and how the NCCEMD recommendations have been implemented

ContentAs from the beginning of the Confidential Enquiries in 1998, up to 2001, 919 maternal deaths were notified in KwaZulu Natal. A small fraction of these deaths were reported from the private hospitals. The majority of deaths were reported from the Durban district where the province’s only tertiary and academic hospital is situated.During the period 1998-2001, the pattern of the direct causes of maternal deaths has not changed. Hypertensive disorders of pregnancy especially eclampsia remain the single major direct cause of maternal deaths. However, in this period a significant reduction in the proportion of direct causes was noted, with a concommitant increase in the proportion of indirect causes of maternal deaths. In contrast to the 1998-1999 reports which showed hypertensive disorders as number 1 of the “Big Five” causes of maternal deaths, non-pregnancy related infections have since become the major cause deaths. The number of maternal deaths occurring in the postpartum period is also increasing. In 2001, 78% of deaths occurred in the postpartum period.

ConclusionKwaZulu Natal has an effective notification system, however, the number of deaths that occur outside of health services is still unknown. HIV/AIDS related conditions continue to contribute to the majority of deaths, although hypertension in pregnancy is still an important direct cause. Implementation of the NCCEMD recommendations is ongoing.

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IMPLEMENTATION OF KANGAROO MOTHER CARE: A SUCCESSFUL CASE STUDY IN KWAZULU-NATAL

A-M BerghMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria

Introduction About 200 000 infants are born in KwaZulu-Natal (KZN) each year. Of these, 14% or about 30 000 infants weigh less than 2500 grams at birth. The perinatal mortality for infants over 1000 grams is high at 36 per 1000 births. The overall neonatal death rate is 14 per 1000. When small infants need to be transferred to a higher level of care, there are often difficulties with pathways, transport systems and bed space. In some cases transport is not available, or babies cannot be accepted by the nearest referral hospital because of overcrowding.

KMC is accepted as an integral part of the continuum of neonatal care, particularly for low birthweight infants. Various studies have indicated the advantages of KMC for babies, mothers and hospitals elsewhere in the world, advantages that go beyond the mere survival of the infant.

As part of its strategy to improve the care of neonates and relieve the pressure on neonatal services, the Sub-directorate: Maternal, Child and Women’s Health of the Department of Health in KZN committed itself to the systematic implementation of KMC in all health care facilities managing low birthweight and premature infants in this province. It is, however, known to be very difficult to implement new health care interventions in a sustainable way. Comprehensive implementation programmes using face-to-face communication and continuous on-site support represent an expensive option. This Sub-directorate approached the MRC Research Unit for Maternal and Infant Health Care Strategies to help devise a more affordable alternative. The basis of the approach was to use available resources in the province and to provide all hospitals with a well-researched, low-cost implementation package.

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AimThe main aim of this study was to test the effectiveness of three different outreach strategies for implementation. A further aim was to apply the lessons learned to other implementation programmes in future.

ApproachNowhere else in the world has there been a province-wide roll-out of KMC similar to that of the Ukugona Outreach. Some of the salient features of the programme were the following:

A core team of six managed various facets of the implementation process and the study.

Existing infrastructural, human and educational resources were used to implement a new health care intervention.

A participative, structured approach was followed and only hospitals who volunteered were to take part in the study. In the end, virtually all hospitals joined the programme.

Participants were encouraged to integrate KMC with existing programmes such as the Baby-Friendly Hospital Initiative (BFHI), the Better Birth Initiative (BBI), the Integrated Management of Childhood Illnesses (IMCI) and the Mother-to-Child Transmission Programme (MTCTP).

Solutions were not provided for participants; instead they had to find a solution that suited their own context and situation.

Ukugona is a development project in the field of health care provision that could be combined with research. It offered the opportunity to measure the effectiveness of different policy implementation strategies.

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Collaboration was an integral part of the programme and partners included the following institutions and organisations: Sub-directorate: Maternal, Child and Women’s Health, KwaZulu-Natal Department of Health (responsible for policy and for providing a programme coordinator); individual hospitals (identifying a group of people to drive the process of implementation and reallocating resources such as equipment and space); Department of Paediatrics, University of Natal (conceptualisation and planning of Ukugona); University of Cape Town (facilitator with vast experience in the implementation of KMC); Medical Research Council (MRC) Research Unit for Maternal and Infant Health Care Strategies (implementation package and technical support); Directorate: Health Informatics, KwaZulu-Natal Department of Health (technical support for the telefacilitation broadcasts); Italian Cooperation (sponsorship of posters and brochures, parts of the facilitation and progress monitoring)

Method

PackageThe implementation package was developed by the MRC Research Unit for Maternal and Infant Health Care Strategies. Two principles guided this process:

Health workers must find own solutions. Do not reinvent the wheel – use already available

resources.

A key component of this package is an implementation workbook that went through a participatory process of development and testing. It is based on adult learning principles and participants are not provided with ready-made answers or ways of implementing KMC. The questions in the workbook cover all levels of health care provision, from the provincial or ministerial level to the maternity or neonatal department to the provision

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of KMC in a separate unit or ward. The workbook is accompanied by a reader with nine carefully selected articles that provide health workers with keys to finding their own solutions and developing their own plans of action. The reader includes two units from the Perinatal Education Programme. During the pilot phase the need for an informative poster that could double as a teaching tool for groups was also identified and was included in larger poster format as well as in an A4 laminated format for individual bedside teaching. The package also includes a number of examples of policy documents, guidelines, brochures and forms that are already in use at the Groote Schuur and Kalafong Hospitals.

Study sites All hospitals that care for low birthweight infants in the province were invited to take part in the programme. Those who volunteered for the research component completed a baseline description form with basic information such as the number of births per year and the bed occupancy. Thirty-seven (37) of forty-seven (47) hospitals responded positively. Three of the hospitals had telemedicine facilities and they wanted to use this equipment for in-service staff training. A pilot study on the use of telefacilitation for implementing KMC was performed at these hospitals. These hospitals were called Group C.

As finances and human resources did not permit the introduction of the package with face-to-face facilitation to the rest of the hospitals all at once, the remaining 34 hospitals were paired according to geographical location (urban or rural) and the number of births they had per year (which varied between 350 and 10 000 births per year). One hospital in each pair was randomly allocated to Group A and the other to Group B. Those allocated to Group A received the implementation package alone, whereas Group B received the package plus three visits by a facilitator. During the launch a further ten hospitals indicated that they wanted to participate.

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These hospitals were each given an implementation package and formed a fourth group (Group D, also known as the “additional group”).

Contact with all hospitals was maintained through occasional communications (e.g. a questionnaire regarding their use of the package and a reminder of the progress-monitoring visit). All hospitals were given a date for their progress-monitoring visit in September/October 2002.

Facilitation The hospitals in Group B were grouped into four geographical clusters (Durban, South Coast, Drakensberg and Northern Inland ). Each hospital in Group B attended two sessions of group facilitation with the other hospitals in the cluster. Group facilitation was applied in order to save on costs. Each hospital also received one on-site visit by the facilitator at the end.

The two group facilitation sessions lasted about three hours each, during which the facilitator helped the participants to go through the workbook and answered questions. The idea was specifically not to give formal lectures during these sessions, but to facilitate discussion on issues raised by the workbook. The last visit at each hospital took about two hours. Here specific questions were answered and advice was given on issues raised by the site. The first facilitation visit took place in March 2002, the second in May and the third in July.

Each of the three hospitals in Group C was to receive, on an individual basis, the same number of hours of telefacilitation as hours of face-to-face facilitation received by Group B. Each scheduled broadcast would last one hour, with two-week intervals between broadcasts. Seven broadcasts were planned and three to five actually took place. Technical problems were the cause of missed broadcasts.

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Outcome Measures

Approach to monitoring and evaluation The progress of the implementation was followed on a continual basis by the core team. The approach behind all monitoring and evaluation was to support hospitals to continue on the path towards institutionalised and sustainable KMC practice. Hospital visits are not seen as “inspections”, but rather as peer review visits.

The toolA progress-monitoring model with six benchmarks described by indicators or progress markers was developed for scoring hospitals (Figure 1).

Provincial walk-through

All but one of the 47 hospitals received a site visit by the programme coordinator in September and October 2002, eight months after launching the process. The one hospital in Group D could not be reached on the appointed day because of washaways on the roads.

During the visit the progress-monitoring tool was completed and each hospital received a score out of 30. The score was then plotted on the progress-monitoring model to assess the level of implementation of each hospital.

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ResultsThe four groups of hospitals scored as follows on the progress-monitoring model (see Figure 2 for a diagrammatic representation):

Group A (package only): Twelve of the hospitals reached step 4 and demonstrated evidence of practice. Two of these hospitals reached step 5 and demonstrated evidence of routine and integration. The median score was 11.33 (range 1.08-21.13).

Group B (package plus face-to-face, regional facilitation): All 17 hospitals reached at least step 4 and demonstrated evidence of practice. Seven of these hospitals reached step 5 and demonstrated evidence of routine and integration. The median score was 15.44 (range 10.29-22.94).

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Group C (package plus telefacilitation): All three hospitals reached at least step 4 and demonstrated evidence of practice. One of these hospitals reached step 5 and demonstrated evidence of routine and integration. The scores of these hospitals ranged between 11.60 and 17.33.

Group D (additional participants): Three of the nine participants that were visited reached step 4 and demonstrated evidence of practice. The median score was 8.96 (range 1.63-13.54).

Hospitals that received face-to-face facilitation (Group B) fared significantly better than hospitals that only received an implementation package (p<0.05 for Wilcoxon paired ranked test).

Four hospitals in Group A performed better than their counterparts in Group B. All three hospitals that received telefacilitation achieved evidence of practice.

Apart from the quantitative measurement of the implementation progress of hospitals, the study also generated a wealth of qualitative data. A few

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preliminary findings from this seem to indicate that the success of implementation could, inter alia, be linked to:

Good internal communication Strong management Teamwork between doctors and nurses Integration with other initiatives

Some of the barriers to successful implementation appear to be: High staff turnover Too much rotation of key staff Lack of proper record-keeping on KMC

Discussion

In this case study, the implementation of KMC, using different outreach strategies, was tested over a large geographical area in many hospitals. It was clearly demonstrated that the use of an implementation package in conjunction with facilitation was more effective in getting hospitals to implement a new health care intervention than merely offering a package on its own.

There are major implications that result from this finding. First and most important, if it is decided to implement a new programme in an area, the best way to achieve this would be to incorporate on-site facilitation. This has major budget implications, as the facilitator and the process of facilitation must be funded. Furthermore it serves to confirm that the sending out of circulars or protocols from “Head-Office” without the back-up of on-site visits by an experienced facilitator is often a waste of time and money.

However, some hospitals in Group A achieved approximately the same score or better than facilitation hospitals in Group B. If the factors for this could be sufficiently elucidated by means of qualitative research, there is the potential of being able to identify some hospitals that may be able to

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implement new health care strategies without facilitation. Furthermore it might be possible to identify hospitals that would need more fundamental changes in, for example, management structures and approaches, before any change in practice could be attempted. This could allow for targeting specific types of hospitals with tailored implementation programmes, potentially achieving considerable cost reduction. With present knowledge, however, outreach strategies for implementation of new health care strategies will be expensive.

Telefacilitation proved a useful facilitation medium and all three hospitals in this group achieved evidence of practice. However, there were major logistical problems that needed to be overcome at each site to allow the broadcasts to take place. The significant number of “failed” broadcasts indicates this method of facilitation is not ready yet for general application. Considerable works still needs to be done on the technical side of this development.

The lower scores of the additional participants who joined the programme late - and although not part of the trial - illustrates the value of buy-in and commitment by management. Participants in this group also did not submit the baseline description form that had to be signed by the hospital manager.

The sustainability of these programmes still remains a question and hopefully information on this will be forthcoming in the next few years.

ConclusionImplementation of a programme over a large geographical area is possible and is best achieved by facilitation using an on-site, face-to-face strategy, combined with a carefully designed educational package.

Acknowledgements

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Without the commitment of the hundreds of health care workers involved in Ukugona at all the sites this remarkable achievement could not have been reached. Permission was granted by the KwaZulu-Natal Department of Health to adapt their report Giving life and love after birth - The story of the Ukugona Outreach for this publication.

How to obtain the implementation packageHealth care facilities interested in using the KMC implementation package should contact the MRC Unit for Maternal and Infant Health Care Strategies, Kalafong Hospital, Private Bag X396, Pretoria 0001. Tel / Fax (012) 373-0825; e-mail: matinfru@global.co.za.

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THE UKUGONA OUTREACH - IMPLEMENTATION OF KANGAROO MOTHER CARE IN KWAZULU-NATAL

I Arsalo*, A-M Bergh**, A Malan***, M Patrick*, N Phillips*, B Pattinson***Department of Health, KZN; ** MRC Research Unit for Maternal and Infant Health Care Strategies and University of Pretoria; ***University of Cape Town

IntroductionAbout 200 000 babies are born in KwaZulu-Natal (KZN) each year. Of these babies, 14% or about 30 000 babies weight less than 2500 grams at birth. The perinatal mortality for babies over 1000 grams is high at 36 per 1000 deliveries. The neonatal death rate is 14 per 1000. (Pattinson RC (ed). Saving Babies 2001. Second Perinatal Care Survey of South Africa. PPIP Sentinel Sites. Pretoria: MRC Research Unit for Maternal and Infant Health Care Strategies, 2002). When small babies need to be transferred to a higher level of care, there are often difficulties with pathways, transport systems and bed space. In some cases, transport is not available, or babies cannot be accepted by nearest referral hospital because of overcrowding. KZN is also struggling with serious shortage of nursing and medical staff.

In this reality, KMC as an integral part of neonatal services seems to provide an opportunity to improve the quality of neonatal care. Various studies have indicated the advantages of KMC for babies, mothers and hospitals elsewhere in the world. Advantages which go beyond the mere survival of the infant. It provides the optimal health outcomes especially for low birth weight babies and improves mother-child bonding. Full implementation of KMC also enables to use decreased resources more efficiently.

The Ukugona-Kangaroo Mother Care outreach, launched in 2002, is a project of the Maternal, Child and Women’s Health (MCWH) of the KwaZulu-Natal Department of Health. As part of its strategy to improve the care of neonates and relieve the pressure on neonatal services, MCWH

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committed itself to the systematic implementation of KMC in all health care facilities managing low birth weight and premature babies in the Province. In the first year of project, it was combined with a randomised trial testing the effectiveness of different implementation outreach strategies.

AimThe main aim of this study was to test the effectiveness of different outreach strategies built around a multimedia implementation package designed to facilitate the implementation of KMC in health care facilities.

Implementation packageThe implementation package was developed by the MRC Research Unit for Maternal and Infant Health Care Strategies and before use the package went through a participatory process of development and testing. A key component in this package is an implementation workbook that is based on adult learning principles. Participants are not provided with ready-made answers or ways of implementing KMC, but have to find their own solutions.

MethodAll provincial hospitals managing deliveries were invited to participate to the trial. Enrolment took place by means of completion of a baseline data sheet and written consent form from their management. So the project included hospitals currently managing premature infants and who volunteered to join the implementation process (n=47). Volunteer hospitals with telemedicine facilities (n=3) received the implementation package plus facilitation via telebroadcasts. The rest of the recruited hospitals were paired and then randomly allocated to two different strategies. The one group received the implementation package only (n=17), whereas the other group received the implementation package plus three regional facilitation visits by a neonatologist experienced in KMC (n=17). Additional group of hospitals (n=13) that expressed interest

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received an implementation package but were not included in the research trial.

Those hospitals who received regional face-to-face facilitation were visited three (3) times with 2 months intervals. The core teams from each hospital were invited to the first two workshops together. At the first workshop, the implementation process was introduced. In the second workshop a checklist was used to facilitate the implementation process. The third workshop took place in each hospital and then staff had opportunity to pose questions and their individual situation was analysed. The underlying approach was that implementation should take place in the broader institutional context where hospitals try to find their own solutions using available resources to find contextually appropriate answers. This approach was supported throughout the whole facilitation process.

Monitoring and evaluationThe process of Ukugona was monitored and evaluated in a comprehensive way. The progress of individual hospitals as well as the progress of

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Ukugona as a programme was followed during the course of the first year of implementation. This included an institutional audit by the province and a questionnaire on the use of the implementation package. A two-tier midstream evaluation exercise was carried out in October and November 2002:1. Internal evaluation: A walk-through visit to all 50

participating hospitals using a progress monitoring tool devised for this purpose and which could be used to compare the progress of the two groups of hospitals that were randomly allocated to different outreach strategies.

2. External evaluation: An in-depth evaluation of 11 hospitals. The purpose of this component was to identify contextual issues (strengths, weaknesses, enabling factors, barriers) to explain the results of the walk-through visits.

Also the use of implementation package was evaluated at the end of the first year.

ResultsThe four groups included in the outreach obtained the following mean scores according to the assessment model that was used:

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There was statistically significant difference between the mean scores of groups A and B, with the package plus facilitation group doing significantly better.

However, 12 of the 17 hospitals in the package only group also scored on the level of evidence of practise (step 4) or above > 10. Surprisingly, two hospitals in this group even demonstrated evidence of routine and

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integration (step 5). Thus, although facilitation with a package is better than a package alone, some hospitals did not require facilitation.

ConclusionImplementation of a programme over a large area is possible and is best achieved by facilitation using an on-site, face-to-face strategy combined with a carefully designed educational package.

Some hospitals need more support in order to be able to move towards sustainable practice. In the light of the finding that face-to-face facilitation is better than receiving package only, there is a need for continuous education, support and capacity building. It is also challenging to try to find new innovative ways to sustain the expertise gained and promote Ukugona in the future.

KMC is a vital component in good quality perinatal health care and complements other existing initiatives in the province such as Better Birth Initiative (BBI), Baby Friendly Hospital Initiative (BFHI) and prevention of Mother to Child Transmission of HIV (MTCT). Experience from Ukugona outreach will be valuable for planning the implementation of other initiatives involving health care interventions. Sharing of infrastructures, forming of partnerships, multidisciplinary collaboration and teamwork are all vital for the success of Ukugona.

On the way to maintaining good practices and to institutionalise new initiatives in such a way that they will be sustainable, hospitals need long-term support for further development of local capacity. Ukugona is well accepted and one of the biggest strengths of Ukugona was the commitment of the many health workers who wanted to make a difference. Any programme has its strengths and its weaknesses and no initiative lives alone on the enthusiastic people but needs a strong management support.

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TELE-FACILITATION: AN ALTERNATIVE TO THE REAL THING: THE UKUGONA EXPERIENCE

Mark Patrick1, Irmeli Arsalo1, Anne-Marie Bergh2, Bob Pattinson21KwaZulu-Natal Department of Health2MRC Research Unit for Maternal and Infant Health Care Strategies and University of PretoriaBackgroundThe Ukugona Outreach is the province-wide roll-out of Kangaroo Mother Care (KMC) into all institutions in KwaZulu-Natal (KZN) looking after new borns. Irmeli Arselo has described the major research component in her paper.In 1998, the National Department of Health decided to introduce tele-medicine into health services in South Africa. In KZN, the equipment has been installed in 12 hospitals.This and the Ukugona Outreach presented an opportunity to use video-conferencing as an alternative to conventional face-to-face facilitation, and to pilot its effectiveness in aiding the implementation of a new health intervention.Four hospitals participated in the tele-facilitation process, one as a broadcasting site and three as receiving sites.

AimThe aim of this presentation is to describe the tele-facilitation process, to report on the performance of the participating hospitals and to make some comments on the strengths and weaknesses of tele-facilitation.

Components Of Tele-facilitation ProcessTele-facilitation consists of the technical component and the facilitation itself.Health informatics installed and remains responsible for the very expensive equipment. At one hospital, the equipment was installed in a boardroom, and was moved to another room during the project. At the other hospitals, it was installed in ultrasound rooms in radiology departments.

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Informatics conducted training on use of the equipment at all 4 sites prior to onset of the project.The programme for facilitation was to be of the same duration as the regional face-to-face facilitation.The structure of each broadcast was based on the principles of self-directed learning and the need to find site-specific answers to problems encountered and the sequence would follow that of the workbook from the education package:

1. Introduction and icebreaker2. Topics request3. Discussion4. New discovery for KZN5. What did I learn today6. How can we improve tele-facilitation7. Date of next broadcast

From the outset it was emphasised that the broadcasts would not be lectures.The performance of each hospital was evaluated using the model for evaluation developed as part of the Ukugona Project. (See paper by Anne-Marie Bergh)

ResultsThere were 7 scheduled broadcasts. In all 3 hospitals, one broadcast was missed because the broadcast site was being moved from one room to another without notice. The other were missed either because the facilitator or the participants couldn’t make it. There was one failed connection, at hospital 2. Sound and vision failed once in hospital 1, and sound failed once in hospital 3.Using the same evaluation tool as all other Ukugona hospitals the tele-facilitation group scored 13. Statistical significance is not ascertainable in this pilot study but the tele-facilitation hospitals all scored reasonably and all reached step 4 on the implementation staircase.

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Discussion

Despite no prior tele-medicine experience by any of the participants, there were remarkably few technical failures.But there was a notable absence of on-site expertise and management, there are high infrastructural support needs, venues need to be matched to equipment usage, and issues of equipment ownership need to be addressed.It does appear that telemedicine equipment can be used for tele-facilitation, and this in itself works.But the process of tele-facilitation requires good preparation on the part of all participants, and the receiving participants need to stay the same during the process. From the viewpoint of the facilitator, it is worth noting that tele-facilitation sessions are quite intense, and require high levels of concentration and alertness.

ConclusionAll 3 hospitals showed evidence of implementation of KMC, but no statistical significance was ascertained due to self-selection and sample size. This study does seem to suggest that tele-facilitation in under-resourced areas may be a viable alternative to face-to-face facilitation. Tele-medicine facilities provide an opportunity to use advanced interactive telecommunication systems for staff training purposes. But for this to succeed:

management of the telecommunication equipment and infrastructure needs to be in place,

users need to know how to use the equipment, facilitation approaches and the structure of broadcasts needs to be

developed more formally, and tele-facilitators need to be selected and prepared.

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KANGAROO MOTHER CARE FROM BIRTH COMPARED TO CONVENTIONAL INCUBATOR CARE

Nils Bergman

Background

Worldwide, 5 million children die annually, and in half or more of these deaths, prematurity is either the direct or an associated cause for the mortality. Recently, Kangaroo Mother Care (KMC, meaning skin-to-skin contact and breastfeeding) has been promoted as a possible means of managing prematures. Up to now, KMC has generally been practiced only on stabilised newborns. There has been no trial conducted to show its safety or efficacy in prematures from birth.

Hypothesis

There is a considerable body of evidence from animal studies showing the maternal-infant separation has harmful effects, both immediate, short term and longterm. More recently similar findings are being found for the human newborn, where our Western culture separates mothers and babies.

If separated at birth, mammals exhibit a pre-programmed response, referred to in biology as the "protest - despair response". The “protest” response is one of intense activity seeking reuniting with the habitat/mother, the “despair” response is a withdrawal and survival response of decreased temperature and heart rate, mediated by a massive rise in stress hormones. This was first described in humans, in orphans after WWII, it was subsequently studied in monkeys and then in many other mammals. "Separation distress calls" have been documented in rats, very similar distress calls have been shown in human infants placed in cots, and such cot babies make 10 times as many cry signals as babies on skin-to-skin contact (SSC). The calls of SSC babies have a completely different character, and it has been suggested they are

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intended to elicit assistance from the mother to reach the nipple for suckling.

In human psychoneurobiological research (from a review by Schore), early abuse and neglect have catastrophic impact. The human infant’s psychobiological response to trauma is described in two separate response patterns – hyperarousal and dissociation. In hyperarousal, the sympathetic autonomic nervous system is suddenly and significantly activated, increasing heart rate, blood pressure, tone and vigilance, distress is expressed in crying then screaming … this state of “frantic distress”, also called “fear-terror”, is known as ergotropic arousal … with excessive levels of major stress hormone releasing factor … resulting in a hypermetabolic state in the brain. Dissociation is a second later-forming reaction in response to terror, and involves numbing and avoidance, … a state of conservation-withdrawal, a parasympathetic regulatory strategy that occurs in helpless and hopeless situations … a hypometabolic process used throughout the lifespan, in which the individual passively disengages “to conserve energies” … to foster survival by the risky posture of feigning death. These researchers suggest that separation of mother from infant is psychotoxic for the infant’s brain. Similar conclusions have been reached by others in other fields of research. "Separation causes changes in the fundamental efficiency of systems" writes anthropologist McKenna. "Early separation can produce major shifts in susceptibility to stress-induced pathology" says Hofer. "The origins of many behavioural deviations are unknown ... can some be traced back to violations of an innate agenda?”

Kangaroo Mother Care (KMC) provides an alternative to incubator care, without separation from the mother. KMC has been defined as having three components, namely continuous skin-to-skin contact (SSC), breastfeeding preferably exclusively, and support. In First World contexts,

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that support may include ventilation, surfactant and more. In Third World contexts, support may express itself as early discharge from hospital to ambulatory care, which is safe in KMC, as originally described from Colombia. However, most protocols for SSC stipulate that only infants stabilized after a period of incubator care are eligible. It has been estimated that 96% of the world’s premature infants are born in the Third World, where there are no incubators. With no known acceptable alternative these infants succumb before they stabilise, the major portion within the first 48 hours. A report using an historical control group from a Third World context without access to technology, reported a 5-fold increase in survival for babies between 1000g and 1500g using KMC from birth. This study sought to test this finding in a more rigorous manner.The hypothesis to be tested was formulated:Skin-to-skin contact from birth is superior to conventional or incubator care for prematures weighing 1200g to 2199g.

ObjectiveTo compare the use of incubators and mother's skin-to-skin contact. This was measured through newborns outcome at six hours, with a “stabilisation score”, and with individual physiological parameters.

Setting

Two secondary level urban obstetrical hospitals with neonatal intensive care units, part of a comprehensive maternal and neonatal service, with primary level midwife obstetric units.

Design

A randomised controlled clinical trial, in which mothers expected to deliver an infant between 1200g and 2199g were identified. Mothers had to be identified as likely to deliver a low birth weight infant before the actual birth, with enough time to ensure informed consent to the trial, and gather basic data. Mothers were excluded if: -

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1 delivering outside the unit 2 having Caesarian section, 3 too severely ill to be able to look after themselves or their infants, 4 known to have positive HIV status. 5 giving their babies up for adoption.Newborns were excluded if: 6 Below 1200g or above 2199g;7 Apgar score below 6 at 5 minutes;8 Congenital malformations detected at birth.

All infants of consenting mothers were provided standard care for the first five minutes, during which time the infant was screened for eligibility, then randomised. The intervention group was nursed naked on mother’s naked chests for six hours, the control group was nursed in incubators.

Apart from the “habitat” (skin-to-skin or incubator), all subsequent care and observations were strictly standardized. All infants were given continuous intravenous neonatal maintenance solution, 60 milliliters per kilogram per day, (4,17 mg dextrose/kg/min), started within 30 minutes, and the flow controlled by a volumetric infusion pump. An orogastric tube was placed within the first 30 minutes, and a gastric aspirate sent for “bubbles test”, Gram stain and culture. Theophylline was given through the orogastric tube, 5 mg/kg loading dose, then 1 mg/kg six hourly. If the gastric aspirate showed evidence of amnionitis (pus cells, bacteria) Ceftriaxone 75mg/kg was commenced. When oxygen therapy was required, according to routine monitoring, this was given by Argyle nasal cannulae, such that CPAP could be given via them if indicated. After the first six hours, the controlled part of the study, infants were monitored according to ward routines. Both groups of mothers were encouraged to do SSC beyond this period if their infants were stable. Gestational age was estimated on the first day.

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Bailout criteria were defined as “physiological parameters exceeding normal limits, requiring medical assessment and or intervention”, and required that the nurse researcher notify the medical officer to make an assessment.

1. Skin temperature remaining below 35.5oC for two consecutive recordings.

2. Heart rate <100; or >180 beats per minute for two consecutive recordings.

3. Apnoea longer than 20 seconds.4. O2 saturation below 87% for two consecutive recordings,

despite supplementation with nasal prong oxygen, FiO2 up to 0.6 and CPAP up to 5cm water.

5. Blood glucose below 2,6mmol/l, reading confirmed by laboratory, Fischer et al developed a “Stability of the Cardio-Respiratory system In Preterm infants” (SCRIP) score. The values of their score were modified to suit current local practice in the setting units, as follows.

SCRIP * 2 1 0Heart rate Regular Deceleration to 80-

100Rate <80 or >200 bpm

Respiratory rate Regular Apnoea <10s, or periodic breathing

Apnoea >10sTachypnoea >80 pm

Oxygen saturation

Regular >89%

Any fall to 80 – 89% Any fall below 80%

* The heart rate, respiratory rate and oxygen saturation is monitored continuously during a five minute period, and scores allocated accordingly, allowing a maximum of 6 points for the period. To gauge the stabilization during the controlled study time, the (5 minute) SCRIP was recorded every 30 minutes after the first hour, but every 15 minutes during the 6th hour, giving a maximum possible (composite) SCRIP score of 78. To gauge the final stabilization at 6 hours, the 4 periods of 5 minutes each in the final hour were analyzed separately, for a “last hour score” of 24.

A standard polygraph patient record was completed on each subject. Data from this was transferred by one nurse researcher to an Excel spreadsheet, and coded. A statistician blinded to the allocation performed the statistical analysis.

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Results

The baseline characteristics and the demographic profile was balanced for both groups, with the SSC group being insignificantly smaller and younger. Fewer than anticipated babies “bailed out” from either group, probably due to intensive monitoring not normally possible for all infants.Significantly more incubator babies exceeded the normal parameters. The major factor contributing to this was hypothermia, which was highly significant in the first hour, and which is in keeping with the protest despair behaviour described. The SCRIP scores (cardiorespiratory stability) showed the SSC babies to be significantly more stable. When measured throughout the six hours no trend towards stabilisation was seen for incubator babies, while 56% of SSC recorded perfect stability scores throughout. By the sixth hour, 100% of SSC babies were stable.

SSC CMC Signif’(n = 18) (n = 13)

Met bailout criteria 3 12 <0.001 *(17%) (92%)

SCRIP first six hours (mean)

77.11 74.23 0.031 #

(standard deviation) 1.23 4.19 Number perfect score (78)

10 (56%) 2 (11%)

SCRIP in sixth hour (mean)

24.0 23.0 0.012

(standard deviation) 0 1.22 Number perfect score (24)

18 (100%)

6 (46%)

* Chi square, # t-test

Discussion

These results support the hypothesis that skin-to-skin contact is superior to incubator care for newborn low birth weight infants.

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The possibility of selection bias exists: many prematures delivered quite unexpectedly or precipitously, (without a nurse researcher available) and the aetiology of such premature delivery may differ from those studied. The expected bailout rate in both groups was lower than that predicted, and is likely a direct result of closer observation and attention to treatment detail, which was strictly controlled. The findings from the stabilization scores are however probably generalisable to all infants between 1200g and 2199g.

KMC has generally been practiced only on stabilised newborns. This study has shown that skin-to-skin contact started immediately after birth, in place of incubator care, is both safe and effective for infants born between 1200g and 2200g. The infants in the study stabilised better in SSC than incubator. This provides strong support for the use of “Birth KMC” in third world settings in particular, where incubators are unavailable. Given the lack of alternatives, skin-to-skin contact from birth should in the interim be implemented urgently in the Third World. Even where incubators are available, as in South Africa, in many settings Birth KMC may be preferable.

Though advanced technology can save the lives of premature infants, it does so at considerable cost, both economic and human. These costs may be reduced through continuous care in skin-to-skin contact, even in the most technologically advanced setting. The third component of KMC, “support”, should include every available and appropriate technology, but be added to the first two components of KMC: skin-to-skin contact and breastfeeding (or breast milk).

Current practice of neonatal care relies on separation and the incubator, and a paradigm of care with an industry to support it has developed. The results of this trial, interpreted in the light of the evidence presented in the introduction, challenges this paradigm. Infants should not be separated from mothers, even if born with low birth weight.

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(References available from author: bergman@xsinet.co.za )

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THE IRON STATUS AT 6 MONTHS CORRECTED AGE OF VERY LOW BIRTH WEIGHT INFANTS AFTER DISCHARGE FROM A KANGAROO MOTHER CARE UNIT

G Kirsten, C Kirsten, E Thompson J van Zyl.Dept of Paediatrics, Tygerberg Children’s Hospital and the University of Stellenbosch, Cape, South Africa

Kangaroo mother care (KMC) and breast milk feeding have significantly improved the neonatal survival of very and extremely low birth weight infants in developing countries. There is concern regarding the long-term iron status of these very premature infants as many of them have limited iron stores at birth. The iron content of breast milk is low and could be insufficient for an extremely low birth weight infant. It is currently recommended that iron supplementation for premature infants should be started at 6 weeks of life.

AimTo determine the haemoglobin and serum ferritin levels as well as the red blood cell volumes at 6 months corrected age of infants <1600g who received intermittent KMC.

Study design: Prospective, cohort analytical.

Methods127 infants with birth weights <1600g not requiring intensive care were recruited upon admission to the KMC Unit. All infants were from lower socio-economic backgrounds. Breast milk feeding was actively supported. A multi-vitamin and iron syrup was prescribed once the infants were on full enteral feeds and at least 2 weeks old. This was continued after discharge. A post-discharge dietary history was obtained through weekly telephonic interviews and at follow-up. Serum ferritin and haemoglobin levels as well as mean corpuscular volumes were measured at the 6 months corrected age follow-up.

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ResultsEleven infants were excluded from the study before discharge while another 12 were excluded after discharge; 4 died, 1 moved away, 1 withdrew from the study and 6 were untraceable. 91 (83%) infants attended follow-up at 6 months corrected age. Ninety percent of the infants were breast fed on discharge from Tygerberg Hospital of which 75% were exclusively breast fed. Twenty two percent of the infants were still breast fed at 6 months corrected age. The haematological parameters of the infants are shown in Tables 1, 2 and 3.Table 1 The haematological parameters (mean, SD) of the

infants at 6 months corrected age

Number (91)

Normal value for age

Haemoglobin (g/dl)

11.4(0.97) > 9.4

MCV (fl) 75.4(4.5) > 70MCH(%) 25(1.9) >23Ferritin (ng/ml) 24.8(14.8) >12

Table 2 The haematological parameters at 6 months corrected age (mean, SD) of the infants with gestational ages and birth weights above and below 30 weeks and 1000 grams.

Hb(g/dl) Ferritin(ng/ml)

MCV(fl)

<30 wks gestation

11.6(0.9) 29(17.6)# 76(4)

>30 wks gestation

11.3(0.9) 23(12)# 75(4)

<1000g birth weight

11.8(0.8)*

29(12) 77(4)**

>1000g birth weight

11.3(0.9)*

23(15) 74(5)**

*p=0.05**p=0.055#p=0.045

Table 3 Percentage of infants with low ferritin and haemoglobin levels and low MCVs at six months corrected age.

Percentage

Haemoglobin (<9.4g/dl)

2.2

92

MCV (<70 fl) 6.0Ferritin (<12 ng/ml) 20

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ConclusionsThe mean haemoglobin and ferritin levels as well as the mean corpuscular volumes of the infants were within the normal range at 6 months corrected age regardless of birth weight or gestational age. Early and continuous iron supplementation in these infants was effective in preventing iron deficiency at 6 months corrected age. Of concern was the fact that 20% of the infants already had low ferritin stores at this age.

Recommendations:1) Active support of breast feeding of VLBW infants at clinics must be developed.2) Introduce iron supplementation earlier than the recommended 6

weeks of age in VLBW infants to prevent iron deficiency anaemia after 6 months of life (20% already iron depleted at 6 months of age).

3) Screen VLBW infants at 9 months for anaemia.

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ECONOMIC IMPACT OF KANGAROO MOTHER CARE.

R Ricardo Escobar, G MaleteWarmbaths Hospital, Bela-Bela, Limpopo Province, South Africa.

Kangaroo mother care (KMC) is a health intervention that improves the quality of care and reduces the mortality rate of these babies, with savings in all scenarios, public or private, primary or tertiary, in developed countries and developing as well. This KMC was initiated in Bogotá, Colombia by Drs Rey y Martínez, as an answer to the limited staff and the lack of resources in their hospitals. This method is named after the kangaroo by the similarities in how marsupials care for their offspring.KMC consists of: Direct skin-to-skin permanent contact between the mothers and VLBW, exclusive breast feeding and early discharge from the hospital.Motivated by the clear advantages in health and cost benefit impact, we decided to do this clinical descriptive-retrospective research with 21 LBW babies in Warmbaths Hospital, Limpopo Province, South Africa in the trimester February-April 2001. Comparing the resulting data between these babies and a control group of 21 babies treated with the standard procedure before this method was implemented in our hospital. A special room was prepared with 8 beds where the mothers were admitted with their babies and the KMC was applied. This KMC was used with those LBW babies that were stable and did not need oxygen supplementation, at any age when they achieved 1600g of weight. These babies were discharged with a weight around 1800g and were followed in outpatient clinic at 1 week and again at 1 month. While in KMC they were weighed and seen by the paediatrician daily. The register book of the ward and patient’s files from both groups were revised to obtain the relevant data as weight gain, and hospitalisation days. In spite of the small amount of studied patients the results are consistent.With other author’s reports, the average birth body weight of the KMC babies was 1339g and the control group 1335g. The KMC group daily weight gain was 27g and on the control group only 20g. The KMC stayed

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at the hospital for an average of 7,5 days being discharged 1800g and the control group stayed average of 20 days and were discharged with 2000g. The cost was considerably lower in the KMC related to hospitalisation days, expenditures in breast milk substitutes, incubators, electricity, maintenance, bottles, rubber teats and sterilization procedures. On the other hand they were also savings when no bassinets or incubators or specialized transport were used. The amount of total savings was R360615.53 in that trimester with the implementation of KMC.We conclude that this method is highly beneficial in reducing the hospitalization time and obtaining exclusive breast feeding in those babies were the KMC was used. It is recommended that with the support of the health units this KMC should be used at all neonatal units at all levels and specially in those places were incubators are scarce and the budget is limited.

TABLE IKangaroo Control(N=21) (N=21)

Average Birth body weight 1339 1335Weight in grams at the beginning of 1600 *Method(g)Weight on discharge (g) 1800 2000Inpatient days ( to gain from 1600 to 7,5 201800 or 2000)Daily weight gain 27 20Breast feeding:On discharge (%) 100 71On Follow up (%) 100 57

TABLE II COSTSKangaroo Control

Patient/day (Rands) 465,38 465,38Days needed to gain weight from 7,5 201600 to 1800 or 2000Expenses in breast milksubstitutes 0 30,93( Prenam , 500g can ) RandsIncubators (Rands) 0 485000Electricity per Incubator ( Watts/hour) 0 350Incubators servicing (Rands/Month) 0 5000Bottles, Rubber teats, ( Rands per unit) 0 22Sterilizers (Rands) 0 90

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Baby transport (Rands) 600 2066Bassinet, (one) (Rands) 0 1740.

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TABLE III KMC Savings.Per Patients/Day 122 162.25(12.5 p/d x 21pt x 465.38 Rands)Breast milk substitutes 7 500.00(3 x 2500 Rands)Bottles and rubber teats 1 386.00(3 x 21 x 22 Rands)Sterilizers 1 890.00(21 x 90 Rands)Incubators 194 000.00(4 x 48 500 Rands)Incubators maintenance 15 000.00(3 x 5000 Rands)Electricity (Incubators) 1 345.00(21 x 12.5 x 24 x350/1000/0.61)Transportation 3 412.00(2 x 2066 –2 x 360)Savings in Bassinets 13 920.00(8 x 1740 Rands)Total in Rands: 360616.00

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THE VALUE OF A KANGAROO MOTHER CARE (KMC) UNIT AT KALAFONG HOSPITAL

E van RooyenDepartment of Paediatrics, University of Pretoria, Kalafong Hospital

IntroductionKalafong Hospital is a large regional teaching hospital serving a mainly black urban indigent population. It is also a referral hospital and manages high-risk pregnancies. A large number of high-risk LBW infants are delivered annually.

Previously high-risk LBW infants were taken care of in a 15-bed High Care Unit (HCU) and a 12-bed low-care Low Birth-weight unit (LCU). The LCU functioned as a step-down facility to receive infants from the HCU. In the LCU they were cared for in incubators and bassinets in a conventional manner.

During 1998 to 2000 an increasing number of high-risk LBW infants were taken care of in the HCU. During 1998 up to July 1999 all these infants could not be transferred to the LCU due to a lack of resources. Some infants had to be taken care of in the General Paediatric wards where care and conditions were not optimal. Due to the limited number of step-down beds, increased numbers of high-risk LBW infants, outbreaks of severe nosocomial infections in the HCU and the general lack of resources and equipment, it became necessary to consider an alternative method of caring for the infants.

The relatively simple and novel method of KMC was considered to be the best method of resolving the demand for LBW infant care at Kalafong Hospital and a 25-bed Kangaroo Mother Care (KMC) unit was opened on 6 July 1999, which replaced the LCU. A total of 20 mother-and-baby pairs can be accommodated in the unit as well as 5 bassinets for conventional nursing care.

Subsequently an improvement has been experienced in the flow of patients between the HCU and KMC. This has relieved the pressure for

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beds in the HCU allowing for an increased number of infants to be accommodated in the HCU during 2000.The KMC unit at Kalafong Hospital provides intermittent, continuous and conventional care to the LBW infants. The same number of nursing staff that rendered conventional care to the previous LCU now provide care in the KMC unit. The unit is a low care facility and infants with signs of possible infection are transferred back to the HCU or one of the General Paediatric wards for further management. In order to apply the kangaroo discharge principle, namely discharge irrespective of weight, a follow-up clinic functioning within the KMC unit was established.

The KMC unit admits LBW infants as soon as the infants are in a stable condition and receive full oral feeds. There are no special weight requirements for admission to the unit. Stable infants less than 1000 grams are (have been) admitted. Oxygen dependent infants who previously had to be admitted to the General Paediatric wards due to lack of space in the LCU are also cared for in the unit. The oxygen is administered via a nasal cannula and the mothers practice intermittent KMC.

Infants whose mothers are unavailable to take care of them, are placed in bassinets and cared for in the conventional manner. Apart from the exceptions, most of the mothers practice 24-hour KMC and are empowered to become the primary care givers of their infants.

Before admission to the KMC unit most of the infants receive expressed breast milk via an oro- or naso-gastric tube. In the unit other feeding methods are introduced, for example, cup feeding before proceeding to breast feeding. Most infants are breast fed but formula feeds are given to infants whose mothers are HIV infected and choose not to breast feed.

Infants were discharged from the previous LBU as soon as they reached a weight of 1800 grams. This practice changed with the implementation of KMC and a new discharge strategy was introduced. Infants are discharged regardless of weight, as long as they breast feed successfully and

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maintain weight gain. After discharge all babies are seen within one week at the follow-up clinic, which is held weekly in the KMC unit.

This study was undertaken to assess the effect of the KMC unit, on the care of low birth-weight infants at Kalafong Hospital.

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Method

An audit was performed on all admissions to the KMC unit over an 3 year period from August 1999 to January 2001. An audit form was completed for each admission and provided the basis for analysis.

Data was collected on the number of infants admitted each month and the average length of stay in the unit, the admission and discharge weight of infants, breast feeding practices of the mothers, deaths and infections that occurred, the follow-up clinic attendance rate and the average weight gain per day for each infant.

ResultsDuring the 3-year period of the study, a total of 1020 infants were admitted to the KMC unit with 302 admitted during year 1, 352 during year 2 and 366 during year 3. On average, 28 infants were admitted per month for the 3 years. The average length of stay was 13-14 days. The shortest stay was 1 day and the longest was 135 days. Infants who stayed for longer periods were oxygen dependent due to chronic lung disease of prematurity. Bed occupancy - The average bed occupancy was 63% but it increased from 52% in year 1 to 70% in year 3.The average number of patients daily in the unit was 12–13. (See Table 1)

Table 1

KMC unitYear 1 (1999/2000)

Year 2(2000/2001)

Year 3(2001/2002)

Year 1-31999 -2002

Number of infants admitted 302 352 366 1020Average length of stay (days) 12,75 13,5 14 13-14Bed occupancy rate in unit 53% 65% 70% 63%Average patients daily in unit 11 13 14 12-13Admission weight < 1500g 38% 47% 50% 45%Discharge weight < 1 700g 22% 45% 39% 35%Infant deaths 0 3 5 8(0.8%)Possible nosocomial sepsis 16 31 21 68 (7%)Infants abandoned 0 0 1 1Attendance at follow-up clinic 71% 73% 81% 75%

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Readmissions from home 5 15 7 27 (2.6%)

The admission weight of infants admitted to the unit decreased since the opening of the unit as experience in the KMC method of care increased. In year one, 38% of infants weighed 1500g and less while in year 3, 50% infants weighed 1500g and less. (See Table 1) With the support of the nursing and medical staff the mothers coped admirably with these small infants.

Under our previous policy infants were not discharged until they reached a weight of 1750-1800 grams. Since the implementation of KMC, 360 infants (35%) could be discharged earlier resulting in a higher turnover of patients and enabling us to accommodate an increasing number of LBW infants at Kalafong hospital

Mortality and infection data. Only 8 infants died in the unit during the 3 year study period. Four of the deaths were expected, 3 due to congenital defects and one due to complications of AIDS. Four deaths were not expected. The possibility of infants developing a nosocomial infection in the KMC unit was the reason why 68 (7%) infants were transferred back to the HCU. Only one infant in the KMC unit was abandoned during the period of the study.

Feeding methods in the KMC unit: Breast feeding is an important component of KMC. It was found that 83% of mothers breast fed their infants and 17% gave formula feeding. Of mothers who chose formula feeds, 96% were HIV exposed. Since August 2001, HIV exposed mothers used the Pretoria Pasteurisation method to pasteurise their own breast milk and feed their infants the pasteurised milk. Thus formula feeds were given to only 4% of infants, which included infants for adoption. (See Fig 1) Breast feeding has important anti-infective properties, which play an important role in the prevention of infections and necrotising enterocolitis (NEC). There has been a noticeable decrease of NEC outbreaks in the neonatal unit.

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One of the benefits of KMC is adequate weight gain (>15 grams/day). The results of the study proved that an average weight gain of 23 grams per day was achieved.

Fig 1 Feeding methods in the KMC unit

As the infants were discharged much sooner than the conventional practice, it was essential to monitor closely the progress of the infants following discharge. It was important to gather statistics of clinic attendance in order to ascertain how trustworthy the mothers will be in bringing back their infants for evaluation and growth monitoring. The KMC Follow-up Clinic: The Clinic attendance during the first year was 71% and it improved to 81% in year 3. The infants evaluated at the clinic had good weight gain and thrived at home. Only 27 infants needed readmission to the unit, due to poor weight gain at home. (See Table 1)

ConclusionThe cost effectiveness of the KMC unit is considerable. The same number of nursing staff that rendered conventional care to the previous 12-bed LCU are now providing care to twice the number of infants as well as providing support to mothers.

Very LBW high-risk infants were cared for successfully in the unit. A large number of infants (1020) were managed in the KMC unit which relieved the accommodation pressure upon the HCU and has improved the morale

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of the nursing and medical staff. The mortality rate of the unit is low. And no infants were abandoned. The establishment of the KMC unit is of great value and has improved the general care of LBW infants in Kalafong Hospital.

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KANGAROO MOTHER CARE AT SEBOKENG HOSPITAL

NC DlungwanaSebokeng Hospital

Background InformationOn the 4th of April 2000, Sebokeng Hospital was visited by the Provincial Perinatal Task Team, specifically to review activities in obstetrics and paediatric departments based on the 1998/99 Saving Babies Report.

Sebokeng Hospital had the highest neonatal death rate when compared to other Gauteng Hospitals in the 1998/99 Saving Babies Report, and a serious concern was the 1000-1400g weight category.

Problems Identified During 2000 to 2001, several problems of premature infant care at

Sebokeng Hospital were identified. These problems consisted of high mortality rates among the infants and prolonged hospitalisation which added to the problem of an overcrowded premature unit.

Staff shortages and poor morale due to the general circumstances did not improved the situation.

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Protocol in existence at the time required premature babies to be discharged at 1.9kg body mass and follow-up until 2.5kg.

RecommendationsBased on the problems mentioned Kangaroo Mother Care (KMC) was recommended due to it’s many known benefits as a solution to decrease neonatal mortality rates and improve the life of infants in the region.

Need for KMC Unit at Sebokeng HospitalNote: Perinatal audit done by Gauteng Dept of Health 1998/99 Saving Babies Report.

PNMR NNDR LBWR PCISebokeng Hospital 32/1000 30% 3.94 13.56/10

00Gauteng Province 63/1000 11.69% 1.74 18.41/10

00

Objectives for implementation: To decrease infant mortality rates; To improve the rate of weight gain in premature babies; To shorten the average period of stay of mother and baby; To improve mother/child bonding; To involve the father/husband in the unit.

KMC Implementation Intermittent KMC was implemented in June 2001 and continuous

KMC was implemented in a 10-bed unit from October 2001. The KMC unit was created in the previous lodger mother rest room

which was converted and renovations done to accommodate KMC activities.

Mother given permission to room-in for continuous KMC.

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Criteria for admission Infants with body mass of 800-1700g in a satisfactory condition i.e.

breathing well, no medical condition or congenital abnormalities and feeding well on either tube, cup or breast.

Babies of HIV-positive mothers are not excluded. Mother must be prepared and agree or be able to room-in in hospital

for continuous KMC. New protocol to discharge infants at 1500g and follow-up weekly

until 2000g.

Outcome The report of the audit conducted from October 2001-December

2002. All patients admitted to the KMC unit were included in the audit. The

data was recorded in a special book. The admission data for 2001-2002 was taken from the neonatal

ward documentation available in the neonatal ward.

Findings2001 2002

Admissions

Deaths Admissions

Deaths

Neonatal KMC Unit 1322 196 (15%) 1105 (13%)Infants weighing 750-999g 56 160 (33%) 75 119 (25%)Infants weighing 1000-1799g

426 400

Infants weighing >1800g 840 36 (4.3%) 627 28 (4.5%)

KMC Statistics: 1 October – 31 December 2002Total admissions to KMC Unit 164Patients transferred out of neonatal unit 11 6.7%Deaths 5 3%Follow-up clinic 148 90%Re-admission from home 1

Conclusion Since the introduction of KMC, the mortality rate among the low birth

weight infants has been reduced by 8%.

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The average bed occupancy has decreased, the staff morale has improved and the mother is supported to care for her infant with improved mother-to-child bonding.

The average length of stay of infants has been shortened. Before the implementation of KMC, infants were discharged at 1.9kg but since the implementation infants are discharged at 1.7kg.

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A SURVEY OF THE SOCIAL, CULTURAL AND EDUCATIONAL BACKGROUND OF MOTHERS ADMITTED TO THE KMC UNIT AT KALAFONG HOSPITAL

E van RooyenDepartment of Paediatrics, University of Pretoria, Kalafong Hospital, MRC unit for Maternal and Infant Health Care Strategies

A survey of the social, cultural and educational background of mothers admitted to the KMC unit at Kalafong Hospital was performed in 2002. The information from the survey will be helpful to health care workers in order to develop personalised culturally appropriate health care and educational programs. The concept of social, cultural and educational background includes the beliefs, values and actions, which may influence the health care practices of the mother as primary care giver to her infant.

There has been no previous study of this kind in our unit. Health care workers should recognise the importance of social and cultural influences as well as specific cultural values. Understanding cultural rules allows for the interpretation of behaviour and will help the health care workers act appropriately.

Health education is a vital part of neonatal care and it is important that mothers understand the health care requirements of their new infants, especially when taking care of premature infants. Health education assists mothers and their families to deal with past, present and future health problems of their infants. This knowledge enables them to make informed decisions, to cope more effectively with alterations in their infant’s health and to assume greater responsibility for their infant’s well being. It is thus important that effective and appropriate educational health care programs are developed.

The RESEARCH problems that were identified: Mothers admitted to the unit are from a variety of social, cultural and educational backgrounds and health care workers do not always have a clear understanding of the beliefs, values and customs, which may influence the health care practices

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of the mother and therefore they do not always render culturally appropriate care or develop effective educational health care programs.

Research Design - It is a descriptive study

Research Method

Study population: Mothers admitted to the KMC unit over a period of 6 months in 2002 are included in the study.

Data Collection: Data was collected from mothers by means of a structured questionnaire. The questionnaire was completed by a trained research assistant during a personal interview. A written informed consent was obtained from each participant. One hundred questionnaires were completed. The Questionnaire consisted of 70 questions pertaining to the social, educational and cultural background of the mothers.

The ages of the mothers admitted to the unit varied. The youngest was 16 and the oldest 42 years, with a median of 26 years and a mean of 28.9 years.

The mothers resided in the following areas: 58% in town suburbs, 25% in squatter camps, 14% on small holdings and 2% on farms.

Kalafong Hospital is a referral hospital and 25% of the mothers in the unit did not reside in Gauteng Province. The mothers from Gauteng were further subdivided into the greater Tshwane area. Kalafong is situated in the West of Tshwane and thus Western Tshwane area had the largest presentation namely 55%.

The survey included the different languages spoken by the mothers. Before the survey we realized that the mothers in the unit represent a variety of language groups. The city of Tshwane is situated in an area where most of the local people speak Northern Sotho but big metropolitan areas do not always reflect this. Sixty five percent of mothers spoke Northern Sotho well, while 58% spoke Zulu well and 88% were able to speak English and 59% Afrikaans.

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The marriage status of the mothers reflects that only 32% were married while 67% were single. Only 29% mothers worked while 75% of their partners worked.

Looking at who the financial providers were, it was found that 49% of mothers were financially supported by either the partner or themselves and 51% were dependent on other family members. If we look at the average monthly income 46% of the mothers had an income of less than R1000. The 12% who did not know their income may also fall into this category.

The mothers’ educational qualifications: 4% of mothers had no school education, 23% had a primary education, 37% Grade 8-10, 22% Grade 11-12, and 14% a higher education.

Housing and facilities at home: 66% mothers live in brick houses while 34% live in corrugated housing; 48% has water supply in the house while 52% have tap water close by, only one mother obtained water from a river; 72% of mothers had electricity and 22% had a phone in the house; 60% had flush toilets and 38% had pit toilets; 1 mother did not have any toilet facilities.

The following section was to ascertain how mothers obtain information; do they watch TV, listen to the radio, read a newspaper, magazine or books. TV or Radio is watched and listened to most frequently. Ten percent of mothers never listen to the radio and 13% never watch TV. Only one mother did not have access to a radio or a TV. Only 11-20% mothers read every day while 11–28% never read.

The smoking habits of the mothers and partners are portrayed as follows. One mother admitted to smoking. Three said that they used snuff, 38% of their partners smoke. Only 11% of mothers admitted to drinking alcohol, namely beer and 46% of the partners drink alcohol, also mainly beer.

Religious background of mothers: 95% of mothers admitted that they were members of a church. One mother belonged to the Moslem faith, 27% were members of African Christian churches and 72% members of

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mainstream Christian churches. Forty eight percent of mothers regularly attended church services and were involved in their congregations.

In the questionnaire, several questions with different scenarios were asked about whether mothers will consider consulting a traditional healer. The three questions were whether they would consult a traditional healer if they have a social problem or if they have a medical problem or whether they would take their baby to a traditional healer to protect it against diseases. The majority of mothers said that they would never go to a traditional healer.

Ninety eight percent of mothers indicated that they would take their infants to the local clinic for immunization and 63% said that they would transport their infants by carrying them on their back, while 22% said they would push their infants in a push chair.

Information on the previous and current maternity history of mothers as well as the number of children, miscarriages and child deaths were as follow: First pregnancy for 34% of mothers and second pregnancy for 26%, 22% had been pregnant 4 times or more, 27% had had previous miscarriages, 14% had had an older child who had died. Fifty nine percent of mothers had one child alive, 18% had 2 children alive and 15% had 3 children alive.

In conclusion, the study is giving us interesting insights into the social, cultural and educational backgrounds of the mothers admitted to our unit and this information will help us develop appropriate health care and educational strategies.

A survey has limitations in that it is not possible to analyze the links between cause and effect. Some aspects are also difficult to interpret because by using a structured questionnaire one is restricted in the deductions that can be derived from different findings. A survey does enable one to recognize behavioural patterns and attitude trends and this survey may be the first step to possible further research studies.

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MATERNAL HEALTH SERVICES IN SOUTH AFRICA, UGANDA, RUSSIA AND BANGLADESH: LESSONS OF A COMPARATIVE STUDY FOR SOUTH AFRICA

Loveday Penn-Kekana, Justin Parkhurst*, Duane Blaauw.Health Systems Development Programme - funded by DFIDCentre for Health Policy. Univeristy of the Witwatersrand, *London School of Hygiene and Tropical Medicine.

The maternal health outcomes of any country are often used as an indicator, in the health systems literature, to indicate whether the health system in that particular country is well or not. It is widely recognized that with a functioning health system the vast majority of maternal deaths can be averted (Graham, 2002). However, it is still the case that much of the work that is done in the maternal health field is to try and decrease levels of maternal mortality and morbidity, focus on relatively narrow technical issues in care provision and not on wider health systems issues.

The Health Systems Development Programme is a five-year multi-country programme funded by DFID, which aims to look at understanding how health systems function in developing countries, with maternal health services being one of the focus areas. Under this programme, a situational analysis of maternal health services from a health system perspective, was undertaken in four very different countries, Russia, Bangladesh, Uganda and South Africa. Work was then done to identify cross-cutting themes.

The methodology consisted of a detailed literature review of both published and grey literature in the four countries, as well as doing some secondary data analysis on key data sets such as the Demographic and Health survey and a range of facility surveys. A number of key informant interviews in each country were also carried out. Dissemination workshops were also carried out where results were presented for comment, and key research questions for future work was developed.

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Key Findings In The Four Countries.

Russia

Maternal health care is over-medicalised with high numbers of ANC visits per pregnancy and high levels of hospitalization of women during pregnancy. This reflects perverse incentives within the system, as well as overstaffed institutions and a history of an emphasis of facility-based care. Another issue raised in Russia was the variability in practice between facilities and regions with, for example, huge variations in the caesarian section rates or the episotomy rates. Despite near universal services both in terms of abortion services and maternal health service, it also emerged that there are some groups that appeared to be consistently marginalised from using the service. For example, although abortion services are over-utilised generally, there are still women who are dying from backstreet abortions. These groups appear to be adolescents, migrants and the destitute.

Table 1 Key maternal health indicators in four countries (most recent data or estimates)

Russia South Africa Bangladesh Uganda

Maternal Mortality Ratio (deaths per 100,000 live births)

40 150 440 505

CommonCauses (%)*:

Haemorrhage 11 13.5 19 25

Sepsis 5 12.4 8 15

Eclampsia N/A 22.7 11 12

Abortion 25 N/A 14 13

Others of note (country specific)

9 (ectopic

pregnancy)

29.7 (non-pregnancy sepsis, mostly

AIDS)

14(Injury/

violence)

8(recorded as

‘labour’)

Total Fertility Rate

1.2 2.9 3.3 6.9

Trained Attendance at

Assumed near 100%

84% 12% 37%

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Russia South Africa Bangladesh Uganda

BirthBirths in Health Facilities

? 83.7% 8% ?

Antenatal Coverage (at least one visit)

Assumed near 100%15-19 visits are common

95.1% 37% 92%

Abortion StatusLegal

(widely used with

estimated 1.5-1 ratio of abortions to

births)

Legal (On request to 12 weeks, up to 20

weeks with additional

reasons. Problems with access to

services in some areas)

Illegal(but ‘menstrual

regulation’ used to

terminate many early-stage

pregnancies)

Illegal(used if health of woman at risk)

Public Sector User Costs

Free‘Informal’

payments to providers are

common

Free FreeHidden charges common - often

asked to pay for drugs and

supplies

FreeFees for services

eliminated in 2000

‘Informal’ payments common

Private Sector Service Provision

Small 9% of DeliveriesHigh % of national health spending in

private sector(wide economic

and ‘racial’ division on use)

SmallBut ‘private practice’ by

public workers common)

Small

* These do not add to 100% as it is not meant to be a comprehensive list – many indirect causes or categories of ‘other’ have been excluded.

Source: National statistics and Demographic and Health Surveys – Details available in {Penn-Kekana, 2002 #210; Danishevski, 2002 #209; Ssengooba, 2002 #207; Rahman,

2002 #208}

BangladeshThe key health system issue identified in Bangladesh maternal health services was that although on paper facilities are available they are under utilized. There is considerable debate about the explanation for low levels of utilization. Some have argued that cultural norms in the communities and a range of cultural taboos around childbirth mean that families do not like women to go to medical institutions. Others have argued that poor quality of services at the clinics with unreliable opening hours, and

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shortages of staff and drugs are a more important explanation. Also identified in the Bangladesh study are very poor levels of management and policy support in the maternal health field. This results in processes such as the building new facilities despite the fact that existing ones are not effectively managed nor used by the community.UgandaOne of the key findings in Uganda was the discrepancy between the high utilisation of ANC services (92%) and the relatively low levels of births at facilities. Although detailed work had not been done on this, it is suggested that there were significant differences in local social norms about how births should be handled and practice at the clinics. Perceptions about lack of skilled staff at clinics was also important. Another key finding was the inappropriate distribution of midwives both in terms of geographical area and service level which meant that some midwives were extremely overworked and some were only doing a few deliveries a year. At the same time some untrained nurses were faced with having to do deliveries.

South AfricaIn South Africa a number of key themes from a health system perspective were identified. The first one was that overall high levels of utilization of ANC services and births at utilization masked considerable socio-economic variations. For example, 27% of the poorest women in South Africa give birth at home. Other key issues identified were issues of provider behavior. Although considerable effort had been extended at a policy level with the development of the Confidential Enquiry into Maternal Deaths, the liberalization of the abortion legislation, and development of comprehensive guidelines for practice at all levels of the health poor provider practice has been identified as contributing to the majority of maternal deaths in South Africa. (NCCEMD 2003). Other studies that have not focused on mortality but on women’s experiences of childbirth has also identified problems with provider practice, especially to poor women and teenagers (Jewkes, Brown & Smith etc). The devasting impact of AIDS

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was also identified as a key health system issue. Finally, the private sector needs to be very investigated.

Conclusions: Lessons For South AfricaThe findings of this research supported the argument made by Graham (2002) and others that it is possible to have good guidelines, good policies, trained staff, facilities available, and a number of technical interventions in place, but if the health system as a whole is not functioning well then high levels of maternal mortality and morbidity will remain. More research is needed to understand what the key health system issues are, how they should be tackled and how maternal health services are affected by the major reforms that are taking place in the South African health system.

Although overall South Africa has high levels of utilization of both ANC care and facilities for childbirth, these overall figures mask huge inequalities. We need to understand more about the nature of barriers that women face to utilizing services and the complex interaction between health seeking behaviour, access, quality of care and utilization. In South Africa, we need to know which women aren’t using the services and why. For example, are the poorest women not using services because they can’t afford to get to them, or because they are not confident that they will be treated well when they get there – or a combination of the two.

In South Africa, as in the other countries, relatively little is known about the role of the private sector in providing maternal health services. We do not have enough information about who uses the private sector, who moves between the private and public sector, public-private partnerships and the quality of care provided in the private sector. Although a number of small scale research projects have been carried out, more work needs to be done.

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THE NURSING CRISIS: PROJECTIONS AND POSSIBLE RESPONSES

N Bergman

Background.In many hospitals and health services, nursing numbers have fallen to levels at which current services are threatened with collapse. Losses to the VSP were catastrophic at the time in terms of numbers, but also in terms of quality and experience lost. Losses to the private sector and to foreign countries exceed the numbers being trained by nursing colleges. HIV/AIDS has already started impacting nursing numbers in the Western Cape, having done so very hard in other provinces already.

At Mowbray Maternity Hospital, Western Cape, increasing numbers of patients are arriving from the Eastern Cape, and are flooding our service. Furthermore, there is an increased acuity of problems, partly due to socio-economic background of these patients, and partly due to indirect effects of HIV and AIDS: patients who are sick select to come, and many who know they are HIV positive come for the MTCT programme.

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ResponsesA process of re-engineering the service has been started, (and is ongoing and far from completed!) Some examples of this experience will be described. Interventions can be broadly divided into three:

Personnel interventionsNursing Bank – is essentially an internally run Nursing Agency, which pays nurses more!VAP’s (Value Added Posts, or ward assistants) employed to do jobs that free the nurse to nurse.Flexible contracts – accommodates the domestic and social circumstances of part-time nurses.Consultant contracts – specialised “nurse” tasks: breast feeding consultants, active birth, NIDCAP.Education focus – “the fewer the nurses are, the MORE they must be sent for ongoing education”.Employee Assistance Program – conscious investment of money and effort in staff well-being.

Service interventionsQuality of Care Focus - Waiting times reduced by appointments and rearranging clinic times.Better Births Initiative – Positive approach to making changes, alternative birthing positions.Kangaroo Mother Care – focus on mothers as extra hands and nurses for their own babies.MTCT and “Mothers to Mothers” – community involvement in support and care in HIV.Baby Friendly Hospital Initiative – aiming at excellence, despite difficult circumstances.Protocol reviews and “tiering care” – providing care according to available level of nurse ratios.

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Administrative interventionsReorganisation of meetings and support structures – meetings changed to be more effective.Liesbeeck MOU and Active Birth Unit – Revenue Generating Projects, new thinking.Complaints mechanisms – complaints invited and encouraged, and used to improve.Cost center initiative – meaningful and actual delegation of nurse management to ward level.

Following are some further details on particular interventions.Nursing Bank: Due to the extreme shortage of nurses, there has been an increasing reliance on use of nurses from external Locum Agencies. The agencies charge a 10% fee, as well as 14% VAT, the extra expense to the hospital is huge. Many of the nurses provided by these agencies are our own nurses, working for extra income, sometimes in preference to immigrating. These nurses are, in fact, preferred for the service, as they know the ward routines. The Nursing Bank enrolls the hospital's own nurses in an agreement, which allows them to be paid what the agency would have paid, plus half the saving from the fee and VAT. This is a benefit as well as an incentive to get them back "home", while at the same time the hospital makes a 12% saving. The Nursing Bank has been piloted since July 2002, and has operated under administrative difficulties, but has been extremely successful for the service.

V A P's (Value Added Posts) - is a slightly offbeat term (to rhyme with VIP's) for a group of workers perhaps better termed "ward assistants". These are employed at the lowest level of pay (one vacant senior nurse post funds four of these), and two are allocated to each ward. Their function is determined in each ward, and is expressly to do those tasks that nurses are doing which prevents them from doing nursing work. The intention (and the result) is that the nurse has twice as much time to do real nursing. This has been piloted since August 2002, and has worked

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extremely well, though with varying impact in different wards. The need and intention in the coming year is to expand the functions of the V A P's to specific tasks, skills and competencies, for which training will be required. Existing ENA’s and EN’s will be primarily selected for such up-skilling. In time, such tasks can be evaluated for more appropriate remuneration. One group of V A Ps have been trained as doulas, and have been greatly appreciated in the labour ward.

Flexible contracts have been introduced for professional nurses, to accommodate the domestic and social circumstances of people who are unable to work the usual nursing shifts. The disadvantage with this system is perceived to be that it places unfair stress on the nurses working fulltime, and for this and other reasons, it was refused in the past. The experience has, however, been that it can work very well. It does place additional demands on the management and administration of nursing schedules, but it has resulted in the retention of services of numbers of nurses who would otherwise have left. The contracts vary from nearly fulltime work, to a few hours a week, to being able to respond for specific cases. The Liesbeeck MOU operates to a high degree on this basis, having recruited new midwives as a direct result of this kind of option.

Consultant contracts are conceptually related to the V A P's, but are paid at higher levels. They perform specialized functions that directly support the midwives. Currently there are two breast feeding consultants, both with ILCBC status (International Lactation Consultant Board Certified). They provide a focus on breast feeding throughout the hospital, working with both staff and newly delivered mothers to support breast feeding. Particular focus areas include the Labour ward (to encourage self attachment and early breast feeding) and the Nursery (to help mothers with premature and sick infants, for whom mothers milk is essential). Another consultant is employed to teach the midwives principles of Active Birth, as well as different birthing positions. The old method of delivering

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on her back is unphysiological for mothers and babies! A fourth consultant is tasked with developing NIDCAP in the Neonatal ICU and High Care area, and also linking this with KMC. There was some initial scepticism when these consultants started, but their value has been very well proven at an early stage.

Reengineering of Nursing Care

In an article reviewing the development of Infant Mental Health, A.N. Schore writes“maladaptive functioning is specifically manifest as a lack of variability when faced with environmental demands that call for alternative choices and strategies for change.”This statement applies as well to a civil service, as to the nursing hierarchy. The severe shortage of professional nurses requires alternative strategies for change. The changes initiated and planned are summarised in the following diagram.

The V A Ps and contracts described above fit into this scheme. The changes proposed will significantly increase the size of the workforce, but

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will remain within the budget allocation. Protocol reviews and "tiering of care" are linked processes which have just been started. Given the extreme shortage of nurses, the increasing number of admissions and the increasing acuity or complexity of patients being admitted, a critical mind and eye is being applied to the details of care in the clinical protocols, and specifically in what the required nursing input is to ensure the recovery and wellbeing of the patient. Wards can thus be managed in which the nurse bed ratio is tiered, with some beds having a higher ratio than previously, but an increasing number of beds having a lower nurse bed ratio, for which the nursing demand has then been carefully assessed as being less. This is not difficult for KMC beds, where the mother provides "nursing" care for her own infant, but is more complex in other areas. Linked to this is a critical appraisal as to the length of stay of patients. During the year, length of stay was significantly reduced for both neonatal and obstetric patients. The following diagram illustrates a proposed model for neonatal beds

Impact of HIV/AIDSIn coming years, a strategy for dealing with the impact of HIV (community acquired) on our nursing workforce will be required. Projections are that between 2 –3% of the South African nursing workforce will die every year

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from AIDS in the year 2010, amounting to 3000 nurses per year, and with it an equivalent loss in terms of HIV illness. With the steadily decreasing cost of HAART, urgent programmes for the medical management of HIV in the workforce are viable even at current prices. The cost of training one single professional nurse far exceeds the cost of keeping an already qualified professional nurse alive, quite apart from the value of that nurse’s experience. Support programmes that will offer VCR and regular CD4 testing of positive staff with timely HAART should be urgently implemented.

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ConclusionThese interventions have made it possible to improve the standard of service delivery and the quality of care, despite the critical shortage of nurses.

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AUDIT OF DECENTRALISED ANTENATAL SERVICES IN BLOEMFONTEIN/ MANGAUNG LOCAL MUNICIPALITY

WJ Steinberg#, NM Nkone*, M Ried*#Department of Family Medicine, *Mangaung Local Municipality

IntroductionPrior to 1997, all antenatal care in the public sector took place in either Universitas or Pelonomi Hospitals in Bloemfontein. Antenatal services have been "devolved" to amongst others, ten Mangaung Local Municipality clinics since 1998. An "antenatal" forum is functional and attempts to connect the clinics, community health centers and the Hospitals with respect to antenatal issues. This forum also provides a vehicle for the initial and continuous training.

As these ten Mangaung Local Municipality clinics had not provided these services before, the forum initiated an audit in 2000 to ensure the basic minimum requirements for the services where in place. By means of a checklist and "peer review", the clinics were audited with respect to: a) Minimum necessities (equipment) available in the examination room;b) Usage of health educational checklists and pamphlets;c) Usage of antenatal registers;d) Completion of the patient retained antenatal card (H10 card in the FS).

The audit of the antenatal record was repeated in the second halves of 2001 and 2002 to assess improvement. These ten Local Municipality clinics cover 3800 first antenatal visits per annum (50% of the first visit load in Bloemfontein, the other half of the first visits are seen at the community health centers and the district Hospital). These clinics perform the antenatal consultations as part of more comprehensive services and therefore do not exclusively provide only antenatal services.

Resultsa) Minimum necessities (equipment) available in the examination room: The things that were checked for in each clinic included:

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Blood-pressure apparatus, Urine testing strips, Scale for weight measurement, Tet-toxoid injections, Pap smear facilities, Blood testing facilities, Record keeping, Gestational calendar

All ten clinics had functional equipment when checked in 2000 and 2001. The equipment was being maintained and used and lack thereof could not be used as a reason for not providing the service.

b) Usage of health educational checklists and pamphlets Use and completion of health educational checklists and available pamphlets was assessed, considering appropriate choice of language as well for the location of the clinic. The checklist of health topics to be covered included: personal hygiene, balanced diet, nausea and vomiting, tiredness, frequency of urine, heartburn, constipation, oedema, backache, breasts and breast feeding, vaginal discharge, danger signs, signs of labour.

Three of the ten clinics did not utilise the Health education checklists, nor did they make use of pamphlets available to their patients in 2000. The situation was much improved in 2001.

c) Usage of antenatal registers . This audit was performed to ensure that the correct registers were present and the layout was correct. The completion of the relevant data in register was also ensured.It needs to be noted that a first antenatal visit patient may be required to be filled in six! registers at this stage.

Four of the ten clinics (40%) did not have the correct registers and/or did not fill in all the necessary information. Five out of the ten clinics (50%) did not follow the guidelines or information was incomplete this, however, was corrected with subsequent visits in 2001.

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d) Completion of the patient retained antenatal card (H-10 card in the FS) A scoring system was applied to evaluate the antenatal record of the patients visiting the clinic on the day of the evaluation. A weighted points system was developed as a checklist for notation. The maximum was 36 positive points. Some negative marks for important omissions were also given. There was a maximum of 12 negative points. The sample was not a large one and the cards were “peer” reviewed and subjected to panel discussion to ensure completeness. The results are reflected in Figure 1. Six clinics scored reasonable on the H-10 card notation, whereas four clinics had major deficiencies. However, there was improvement shown one re-evaluation with subsequent visits. The same clinics that performed poorly on the positive point also scored significantly worse on the negative points (Figure 2). There was also good improvement over the years with respect to important omissions.

This exercise improved awareness of the basic requirements and showed correction took place especially in Clinic C, but also for Clinics A, B, H and to a lesser extent F and G.

DiscussionWith this exercise, deficiencies were highlighted and corrected over time. It was also clear that services were affected by staff rotation as well. The clinics that had the most improvement over the time were clinics A, B, C, and H. These clinics carry 56% of the first antenatal visit workload of these ten clinics and are clearly stretched with resources. Main issues requiring improvement included: Poor notation, No risk grading, No planning, Incorrect chronology on Belizan curve, No results for special investigations, No sonar's done. The encouraging aspect of this audit is that with some attention to certain deficiencies, significant improvement can be achieved.

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RecommendationsThis audit was a useful exercise to create awareness and identify deficiencies. The repeat audit showed improvement and was a good positive reinforcement to the staff, and reassuring for the service. It is hoped that the simple audit tool will be used by more “peripheral” clinics as much deficiency is noted in the service.

Figure 1Positive marking of the antenatal record of the ten Mangaung clinics.

Figure 2Negative marking of the antenatal record of the ten Mangaung clinics.

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WHAT FACTORS ACCOUNT FOR EARLY ANC VISITS IN FIRST VISIT CLIENTS?

B Ntsuntsha*, J Chege^, N Mosery^, S Mbambo*KZN DOH Maternal, Child and Women’s Health*, Population Council^, Reproductive Health Research Unit, Nelson Mandela School of Medicine, Natal

IntroductionThe 1998 Report on the Confidential Enquiry into Maternal Deaths and the 2000 National Antenatal Care Survey all underline antenatal care clients’ health seeking behaviour as one of the factors that contribute to maternal and prenatal mortality in South Africa. To address some of the quality of care issues associated with high maternal and prenatal mortality, the Department of Health Maternal, Child and Women’s Health Unit in KwaZulu Natal in collaboration with Frontiers programme of the Population Council, Reproductive Health Research Unit and Department of Microbiology, Natal Medical School, is piloting the feasibility and the effectiveness of a new comprehensive antenatal and postnatal care package in KwaZulu Natal Province. To perform the intervention and collect baseline measure, we collected data to assess the quality of ANC services in sample clinics and clients’ reproductive health and health seeking behaviour in Ulundi and Umzinyathi districts between April and July 2002.

MethodThe operations research study has a quasi-experimental design that compares matched pairs of clients in intervention and control sites. Data was collected through observation of client-provider interactions and exit interviewer administered interviews with clients. We observed 249 service provision interactions between providers and clients and had interview administered exit interviews with 116 first and 115 repeat visit clients seeking antenatal care services in the study’s 12 clinics. This paper will present findings from analysis of exit interviews with the 116 clients seeking antenatal care services for the first time during their current pregnancy. We conducted descriptive data analysis using frequency tabulations and cross-tabulations and chi-square statistics to test the significance of association or differences between variables.

ResultsFifty percent of the first visit antenatal clients had their first visit during the required period of between 4 to 20 weeks gestation period and 50% sought care later. Forty two percent had their first visit during their gestation period of between 21 and 28 weeks, 7% between 29-33 weeks and 1% between 33 and 39 weeks. To identify factors associated with early antenatal care seeking behaviour, we compared clients who came for their first visit during the required time and those who came late in terms of their socio-demographic characteristics. This paper will present findings on the relationship between client’s age, education, employment,

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marital status, pregnancy experiences, and the clinic providing them with services. The findings present a challenge to prevailing explanations of the type of clients at risk of late ANC first visit. The paper will discuss the implications of these findings on programme strategies to encourage early antenatal care seeking behaviour.

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THE BETTER BIRTHS INITIATIVE (BBI): EVALUATION IN THE EASTERN CAPE

N Makinana, Z Jafta, G J Hofmeyr, B Maholwana, S Masilela*Effective Care Research Unit, East London Complex/University of Witwatersrand/Fort Hare and Eastern Cape Dept of Health*.

IntroductionThe Better Births Initiative is a global initiative developed by the Effective Care Research Unit in collaboration with Liverpool School of Tropical Medicine and the Reproductive Health Research Unit. It promotes humane and evidence-based care for women during childbirth. BBI is based on 4 principles: Humanity, Benefit, Commitment and Action. The partnership to promote BBI in E Cape is Maternal and Child Health, HIV/AIDS Directorate, Effective Care Research Unit, Cecilia Makiwane/Frere Hospitals, Department of Nursing Sciences, University of Fort Hare.

ObjectivesTo promote evidence-based care.To reinforce the principles of BBI.To evaluate the effects of changes implemented.To keep all staff updated with up to date information.

MethodsThe BBI materials include a workbook, posters, video presentation, a slide Powerpoint presentation of best evidence for procedures during labour, a reference booklet, and a self-audit mechanism. The video programme shows real experiences of implementing companionship in labour wards in South Africa. The BBI materials are available free of charge on the WHO Reproductive Health Library, from rhl@who.int, and on the BBI website: http://www.liv.ac.uk/lstm/EHCP.html. Our email address is ecru@global.co.za.

BBI has been implemented throughout Eastern Cape (24 districts) in 2002 in the form of workshops where all maternity staff were invited, including doctors. Posters to monitor progress and reference booklets were distributed during workshops and the Reproductive Health Library for up to date information. Follow-up after 6 months has been done to all the districts. Contact is maintained by telephone. The programme will be evaluated one year after implementation.

ResultsFeedback from the six-month audit will be presented at the conference.

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BETTER BIRTH INITIATIVE IN THE PMNS

N Jam-Jam, P BarnesMowbray Maternity Hospital

The Peninsula Maternal and Neonatal Services (PMNS) consist of one level 3 hospital – Groote Schuur, two level 2 hospitals - Somerset and Mowbray Maternity and 6 Midwife Obstetric Units in the communities.

In May 2002, Prof Justus Hofmeyr was invited to come and introduce the concept to the PMNS. A workshop was held at Mowbray where each maternity unit was represented. Each unit was asked to work on at least one of the following practices, which were:

With-holding food and fluids in labour; Birthing in the supine position; No companion whilst in labour; Strict bedrest in labour.

The other practices that have already been abolished are: Amniotomies; Enemas; Shaving of the pubic area; Performing of episiotomies especially on all primigravidas; Not allowing partners in labour ward.

It was decided to meet every two months to monitor the progress. The meetings were attended by all the units, except for Groote Schuur and Somerset Hospitals.

The poster depicted the results of the progress reported at the three meetings viz. July, September and November 2003.All the participating units concentrated on three (3) practices instead of only one, in spite of severe staff shortages and ever increasing work loads.

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The three practices are: Companions in labour Fluids and food in labour Alternate birthing positions

July 2002Birth companions – Partners were always encouraged but did not materialize in practice for various reasons. Volunteers from the communities were recruited but proved to be not very reliable and as volunteers no money for conveyance became an issue.The Mothers–to-Mothers –to Be from the HIV support groups assisted at the MOU’s in this regard.Videos and information pamphlets were made available to inform the public and our patients.

July 2002 Fluid and food – At MMH, the Rooibos lemon tea has proved quite popular. All other areas encouraged patients to bring their own drinks and a light snack and women in our care welcomed this enthusiastically.

Alternate Birthing positions – At this point no one was prepared to attempt this without some guidance. The Liebeeck MOU was the only unit where staff started introduction of this practice. It was, however, not possible to go around training staff in other units.

September 2002All units were now offering the women in labour fluid and light snacks without problems. The Rooibos tea is paid for by the hospitals. Companions in labour was still difficult to establish as a rule as the volunteers were unreliable in that they could not come to the health facility on a regular basis. Efforts were made meanwhile at all facilities to educate the clients about the importance of having support with them in labour.

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The Alternate Birthing positions were, at this stage, still quite daunting to attempt without proper instruction. Only one unit, Liesbeeck MOU, was well on their way of making this the norm for their clients.

November 2002Birth companions were seen to be part of the labour ward staff at this stage. MMH managed to employ Doulas on contract and they were available to women during day times. The effect was remarkable and in spite of increased workloads, the stress levels of labour ward staff improved. No more unattended births! The other units managed to recruit more volunteer Doulas and some women were accompanied by a friend or partner who remained throughout the labour.

Fluids and snacks were no longer an obstacle and was encouraged throughout.

In October, a Midwife with extensive experience alternate birth position was employed on contract to introduce staff to the concept. She first started at MMH labour ward and then went around to the MOUs training midwives and students. The lateral birth position was preferred by most women and staff.The changed positions demanded a changed approach to work surface. The mats used for antenatal classes, became quite useful for deliveries on the floor. There also were requests for more comfortable clothing for assisting birthing on the floor.One unit introduced the public to alternate birthing positions at an Open Day. There were great enthusiasm and anticipation from prospective clients!

Planning AheadThe contract of the midwife, Bev Rautenbach who taught birthing positions, was extended to ensure that all staff are trained regarding

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alternate birthing positions. She was also commissioned to make a video for training purposes and to draw up guidelines to maintain this practice in the region.Regular bi-monthly meetings are essential to support each other and iron out problems.We are also planning more workshops to introduce other units to the BBI. Together with MCWH directorate, we hope to take the concept to the rural areas of the Western Cape.Antenatal education to women now routinely includes information on BBI and the Doulas are the presenters at most centers.

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THE WHO REPRODUCTIVE HEALTH LIBRARY ISSUE 6, 2003

Z Mlokoti, L Mangesi, G J Hofmeyr, Z Jafta,, M Singata, N Makinana,.Effective Care Research Unit, East London Hospital Complex/University of Witwatersrand/Fort Hare and Eastern Cape Dept of Health

IntroductionThe best way to use scarce resources is by basing practice on the evidence from randomised trials, and the best source of such evidence is the Cochrane Library. Since the Cochrane Library is very expensive and often unaffordable for developing countries, the WHO has developed the Reproductive Health Library (RHL), which includes Cochrane reviews of relevance to reproductive health problems in developing countries and is distributed by free subscription (rhl@who.int). MethodsCochrane reviews follow strict methodology. A protocol is written and peer-reviewed. Randomised trials are included in or excluded from the review according to objective quality criteria. Data are extracted from included trials and expressed as relative risks or weighted mean differences with 95% confidence intervals. Results are synthesized (meta-analysis) using a fixed effects model provided there is no significant heterogeneity.

For the WHO RHL, Cochrane systematic reviews are accompanied by a commentary by a person with experience of working in a low-income country, as well as a document on practical aspects of the intervention. Teaching materials such as videos on ECV and childbirth companionship are included.

ResultsNew information included in the 2003 issue of the WHO RHL will be presented. ConclusionThe RHL provides a useful source of up to date evidence on which to base practice.

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A VISION OF PUBLIC-PRIVATE SECTOR CO-OPERATION IN COMMUNITY MATERNAL HEALTH CARE SERVICES: THE EFFECT OF INVOLVING PRIVATE PRACTITIONERS ON THE QUALITY OF ANTENATAL CARE OF THE INDIGENT POPULATION OF TEMBISA

KR MokhondoMRC Unit for Maternal and Infant Health Care StrategiesIntroduction The perinatal mortality rate in Tembisa and surrounding areas is far too high, at 50/1000 deliveries. The health seeking behaviour of the indigent pregnant women is to confirm their pregnancies with medical practitioners within the first three months of pregnancy and only initiate antenatal care in the latter half of the pregnancy.

Studies conducted in the Pretoria region have shown that most women will confirm their pregnancy early with a general medical practitioner, average of 13 weeks, and only attend an antenatal clinic at a later stage in their pregnancy. A study by Jeffery, Tsuari, Pistorius, Makin and Pattinson indicated that approximately 20% of pregnant women attending antenatal care clinics have problems that require immediate attention and the earlier health intervention is started the better the pregnancy outcome. This study has led to a reduction in gestational age of initiating antenatal care from an average of 22 weeks to an average of 12 weeks. The results showed that behaviour of all women who think they are pregnant is to have their pregnancy confirmed by a general medical practitioner within the first three months. Once they are satisfied about the confirmation of pregnancy, they initiate antenatal care at a later stage of gestational age when complications have already set in which require immediate attention. Most women will only start attending public antenatal care in the late second trimester (average 22 weeks). The behaviour of women to confirm their pregnancy with general practitioners could be utilized to improve the gestational age at which antenatal care is started and the subsequent quality of care. The early commencement of antenatal care has the potential to make a major impact on the pregnancy outcome.

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Initiating PartnershipsWith respect to this study the private medical practitioners offered to provide antenatal care services free of charge to those women who approached them for confirmation of pregnancy. These pregnant women were all referred to the public health care facility for special investigations and delivery. The Department of Health’s focus changes from managing the inputs to managing the outcomes, this includes managing quality of care. The Guidelines for Maternal Health of the Gauteng Department of Health were followed as standard to manage quality antenatal care.

Measurement for Quality Antenatal Care The following criteria were set to measure the quality of antenatal care provided to participating women. The criteria were identified from the Guidelines of Maternal Care, which was used as the standard for providing antenatal care to women. The antenatal care was recorded on the safe motherhood cards, which was provided to all participating clinics and general medical practitioners. These motherhood cards were in the possession of the women during the antenatal care period and collected upon delivery, and thereafter audited using a valid and reliable instrument for auditing antenatal care records. If an aspect was not recorded, the principle of “not recorded, not done” was followed. Each card received a score (Philpot Score), using the following criteria. The criteria for assessment of quality of care are:

1. Antenatal Care visits planned according to guidelines2. Assessment performed at first visit

a. History takingb. General and medical historyc. Assessment of blood pressure, weight, height, d. Risk assessmente. Gestational age f. Problems identified and appropriate action taken g. Future family planningh. Method of plotting

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i. Symphysis Fundal (SF) Height measurement3.Assessment performed at follow up visits

a. Progress of the pregnancy at each visit, assessment of: blood pressure, urine, SF measurement, fetal lie, fetal movements, hemoglobin, presenting part

b. Problems identified and appropriate action taken4.Routine special investigations performed

a. Urine test at each visit for protein and glucoseb. Blood test performed on all women: hemoglobin (Hb), Rhesus

blood grouping (Rh) c. RPR or equivalent (e.g. VDRL) for syphilis screening, at the first

visit, using card tests or sending blood to laboratories according to policy

d. Problems identified and appropriate action taken5. Tetanus vaccination

All pregnancy women should receive tetanus toxic to prevent neonatal tetanus, according to standard protocol

6. Information provided to women should includea. A delivery plan with the estimated date and place of delivery

(EDD)b. When woman should immediately report to the planned place

of delivery: severe headache, abdominal pain, reduced fetal movements, passage of liquor from the vagina, or ante-partum hemorrhage

c. Preparation for childbirth and motherhood d. Future family planninge. Information leaflets on above mentioned

AimThe aim of the study was to investigate the feasibility of this approach by introducing a public-private sector co-operation to the Tembisa community for antenatal care. Two outcome measures were stated:

The gestational age at initiation of antenatal care. The quality of antenatal care.

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Research Design A cohort analytic study was conducted.

Study PopulationPregnant women of the indigent population of the Tembisa community.

Research MethodTwo antenatal care training workshops were held at the local public hospital for all the participating doctors and public clinic midwifes. Provincial Antenatal Care Policy Guidelines were distributed to all the participants.

The women were divided into two groups, Group A and Group B. A randomised sample of antenatal cards (n=100) was drawn from Group A and Group B, a total of two hundred antenatal cards. Group A were participants from Private General Medical Practitioner Care (GP-care) and Group B were participants from Public Clinic Care (Clinic Care).

Group A (GP-care)The group consisted of the women who consulted GP’s to confirm their pregnancy. The GP’s confirmed the pregnancy and initiated antenatal care, for those women who wished to continue with the pregnancy. A full assessment was performed at first visit, and included a full obstetric, medical and general history and recorded according to the motherhood card. All participating GP’s were issued with motherhood cards by the MRC Research Unit for Maternal and Infant Health Care Strategies, University of Pretoria.

The participating women were referred to the antenatal care clinic at the local public hospital to obtain a hospital number and for routine special investigations. The women were referred back to the GP to retrieve the special investigation results from the hospital laboratory using the hospital

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number. The findings were recorded on the motherhood card. The GP continued to perform routine antenatal care follow-up according to the Provincial Antenatal Care Policy Guidelines. Routine antenatal care was recorded on the motherhood card. Any complications that arouse were referred to the public hospital for further assessment and management. All the women were referred to the public hospital for delivery. The motherhood cards were collected upon delivery at the public hospital and pregnancy outcome recorded.A register was kept at the Antenatal Clinic of the Public Hospital to record data of women referred by different participating GP’s.

Group B (Public Clinic-care)Group B is the control group. This group followed the standard antenatal care policy already established at the public hospital and local public clinics, and the Provincial Antenatal Care Policy Guidelines. The motherhood card was used by all the participating clinics. The participating women’s pregnancy was initially confirmed at the public clinic and routine antenatal care initiated, as Group A.

Results A sample of two hundred (n=200) women was randomly selected for the study, hundred (n=100) in each group. Data obtained from the motherhood cards were statistically analysed.A P-value of less than 0.05 was considered statistically significant.

History. The history of the mothers is depicted in Table 1. According to the history, both groups presented with similar characteristics with regard to age and parity. The gestational age at the initiation of antenatal care for women in Group A were significantly better, ranging from 12 to 39, with a median of

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19 and a mean of 19.91, whereas Group B ranged from 12 to 38, with a median of 27 and a mean of 25.96.

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Table 1 Presenting history of participants: Group A (GP-Care) vs. Group B (Public Clinic-Care)

Presenting history Group A(GP-Care)

Group B(Public Clinic-Care)

Age of participants (years) Range 13-45 15-43Median 27 26Mean 27.79 26.5

Parity (number) Range 0-6 0-6Median 1 1Mean 1.29 1.24

Gestational age at first visit (weeks)

Range 12-39 12-38

Median 19 27Mean 19.91 25.96

Results of assessment performed, problems identified and action taken

The results of the problems identified and appropriate actions taken is depicted in figure 2-6.

Philpott Antenatal Care Quality Assurance Worksheet ScoreThe Group A scored significantly higher (mean of 19%) in the Phillpott Score than Group B (mean of 16%), refer table 3.

Table 3 Comparison of Philpott ScorePhilpott Score Group A Group BScore/20Range 13-20 6-20Median 18 17Mean 19 16

DiscussionThe results confirmed that general practitioners could be utilized to improve the gestational age at which antenatal care is started and the subsequent quality of care. The study confirmed the hypothesis that women confirm their pregnancy at an earlier gestational age with the general medical practitioners, a mean of six weeks earlier than the Clinic-care group. The early commencement of antenatal care has the potential to make a major impact on the pregnancy outcome. The two groups were similar in characteristics of age and parity. The

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results of the study indicate that general medical practitioners comply with the guidelines of the provincial government guidelines for antenatal care, and deliver quality antenatal care. The quality of the assessment, identification of problems and appropriate actions at the first antenatal visit performed by the GP’s were significantly better than the Clinic-care group. The assessment performed at follow up visits for the progress of the pregnancy regarding assessment of blood pressure, urine, SF measurement, fetal lie, haemoglobin, presenting part were significantly better in the GP-care group except for fetal movement. The identification and appropriate management of problems pertaining to blood pressure and urine was well managed by the GP-care group. The quality of care provided to women by the GP were significantly better in the criteria of antenatal care booking examination, providing of an antenatal care plan and labour plan with the estimated date and place of delivery (EDD). The outcome of the two groups was similar with an infant mortality (4%). There was an 8% higher incidence of caesarian sections in the GP-care group. The APGAR in both the groups were similar with a mean of 9.46 and 9.34. The outcome with regard to birth mass were similar, an average of 2.99kg reported for the Clinic-care group and 3.02kg reported for the GP-care group.

ConclusionThe study supports the hypothesis that if general practitioners were included in the antenatal care system by initiating antenatal care immediately when pregnancy was diagnosed the average age of starting antenatal could be greatly reduced. It is feasible to use a public-private sector co-operation to improve the accessibility of antenatal care to the indigent women of Tembisa community, which may contribute to the initiation of antenatal care at an earlier gestational age, improved pregnancy outcomes and quality antenatal care. In the long term, the effectiveness of this Public-Private Sector co-operation could also

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substantially lower the mortality rate in this area. The quality of antenatal care given by the general practitioners was significantly better to warrant further investigation of this method in other places. The partnership between the Department of Health and the Private Medical Practitioners may lead to accessable, relevant, viable, safe and beneficial antenatal care service delivery to pregnant women in the Tembisa community.

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THE WOMAN’S HEALTH MANAGEMENT TEAM (WHMT) AS AN ESSENTIAL FOUNDATION FOR MANAGING MATERNAL HEALTH SERVICES AT MUNICIPAL LEVEL. A CASE STUDY.

H Philpott, A VoceCentre for Rural Health, University of Natal

Background to the Municipality and its maternal health servicesThe concept of the District Health System in South Africa has had a chequered history, starting and stopping for unknown reasons at district level. Currently there are eleven districts in KwaZulu Natal, each with a number of municipalities. Most of these municipalities have one or two level 1 hospitals with a varying number of satellite clinics. It has become manageable to form management structures at municipal level and to include all maternal health services within the municipality as their responsibility, whether the women deliver in the hospital, health centre, clinic or at home.

The concept of a WHMTIn the past, the management of the maternal health services within a municipality has been fragmented, to the disadvantage of the clients and to the quality of their care. In discussion with the Maternal, Child and Woman’s Health (MCWH) Directorate in the province of KwaZulu Natal, it was decided to form Woman’s Health Management Teams (WHMTs), and to train these Teams to manage the maternal health services in the municipality as a complete entity. The Centre for Health and Social Studies (CHESS), now known as the Centre for Rural Health (CRH), was contracted to do this training in one District over a two-year period. The WHMTs in the 5 municipalities in the District each consisted of the doctor and the midwife in charge of the maternity unit in the hospital, the midwife in charge of the satellite clinics, the Community Health Facilitator (in charge of the Community Health Workers in the municipality, the Midwifery Trainer plus a few other midwives from the hospital and the clinics, giving a total of 6 to 8 members.

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The case study and the key issues that emergeThis presentation looks at a case study of one of the municipal WHMTs, that of Filidi, as two CHESS facilitators worked with the Team over a two-year period. The key issues in the Team’s development, and commentary on them, are recorded in standard font while the case study is presented within the text in italics

The degree of support provided by Provincial and District Health Management

In the beginning, the Province gave CHESS the mandate to form and train functional WHMTs, but thereafter the two CHESS facilitators were left to work very much on their own. Monthly reports were submitted to the Provincial MCWH Directorate, but with their very considerable province-wide responsibilities, the Directorate was not able to participate very actively in the programme. However, they did intervene very effectively when crisis intervention was requested.The sub-district health management team came to the early meetings but soon lost interest. At their early stage of development as a team they did not give recognition to the WHMT as a responsible management structure within the sub-district.The facilitators need to do more to encourage acceptance by the Provincial MCWH and the District and Sub-district Management Teams of the role of the municipal WHMTs, in order to promote sustainability of the WHMT as effective municipal level managers. This takes time and requires regular interaction with the district and sub-district management teams as they advance to greater acceptance of their own management roles.

The facilitating role of the NGOThe facilitators saw their role as pioneers in a new initiative and, as they endeavoured to focus on the facilitation of team learning in management, they found themselves learning with the teams. The provision of two

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facilitators for the project proved to be ideal and strategically important. They complemented each other in their contributions to the programme, one providing obstetric experience and the other a community health and adult education background. A negotiated conceptionThe facilitators met for a whole day with a group of 20 people, with representatives from the hospital and sub-district management, the maternal health staff in the hospital and the satellite clinics, two months before the commencement of the project. Together they analysed the available maternal health services and the major deficiencies and then planned a training programme for the emerging WHMT of Filidi.

Choosing the right teamIt is interesting that, though a number of the members of the Team chosen by the planning group left to work overseas, the Team itself chose enthusiastic replacements for those who left, and undertook to orientate the new members. There was never a time during the two years of training that there was a lack of continuity and active engagement in management by the Team; this despite the problems of dissatisfaction with the conditions of service that were outside of their control, and consequent emigration by many.

Leadership in the management of maternal health services at municipal level.

A number of months prior to the commencement of the training programme, a midwife working in the clinics in the Filidi municipality, chosen unofficially as a leader by her peers, who had already developed a Midwives Discussion Group, came to another municipality where training was taking place and invited the facilitators to come and work with the midwives in her municipality. She became the official co-ordinator of the new Filidi Team. She was a dynamic and dedicated leader, but for financial and family reasons had to leave the service in order to earn sufficient money to support her family. When she left, the Team chose

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another coordinator who was equally as dedicated and worked hard for the development of the Team, but she was not sufficiently senior in the eyes of the sub-district health management team. The S-DHMT isolated her and made it difficult for her to participate in the activities of the Team, leading eventually to the need for the Team to choose another coordinator. Fortunately, at that time a senior midwife from another municipality in the district transferred to Filidi and was chosen by the Team as their new coordinator.Each of the three coordinators in succession made their own strong contribution to the Team’s development.The choice of the right leader, who functions as a role model to others, is crucial to the life of the Team. When the leader is chosen by the members of the Team, rather than by the officials, there is greater likelihood of commitment by the other Team members.

The role of the hospital management teamIn Filidi, the hospital management team carried with them the relics of South Africa’s painful history. They had become used to forms of management that gave priority to a privileged private sector ahead of the needs of the underprivileged in their society. They held on as long as they could to prime accommodation for the few while the majority suffered in an overcrowded ward with limited facilities. It was only when the WHMT challenged the hospital management and provincial officials intervened and called a halt to the unnecessary delays in proceeding towards equity that spacious accommodation for all was provided.

The promotion of advocates and the impetus that comes from achievement

The success gained by the WHMT in advocating for change to an equitable provision of accommodation for the majority of the patients in the maternity unit gave them considerable confidence in themselves that has been vital for their growth as an effective management Team.

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The relationship between hospital staff and clinic staffIn the early days, when the Team first came together, there was suspicion of each other’s motives and this resulted in many conflicts. However, healing took place just as a result of being together and working together for two years. Eventually the hospital midwives came to appreciate the value of the Midwives Discussion Group developed by the clinic midwives and they started to participate in their activities. In turn, the clinic midwives appreciated the openness of the hospital midwives as they related their own shortcomings in patient management at the Perinatal Review Meetings.There is concern that policy makers in health services in South Africa are reverting to the traditional separation of clinic and hospital services, to the detriment of patient care. The concept of a District Health System promotes the development of a seamless service, linking clinics and hospitals, for the patient’s benefit.

The relationship between doctors and midwivesThe relationship between doctors and midwives has taken longer to heal. They trained separately and they have continued to work separately. Doctors have been socialised to become the decision-makers, even though many of the midwives have considerably more experience and capability. Fortunately, a white, senior doctor was prepared to meet an experienced and gracious senior African midwife half way and together they have helped to create an improved working relationship in the hospital maternity unit. Gradually this has served to improve the readiness of midwives in the hospital and the clinics to recognise their own professional standing and to take more initiative, and for more of the doctors to relate professionally to the midwives. Trust is improving.With the increasing shortage of experienced doctors, particularly in the public service in the rural areas, there is the possibility of giving good midwives more and more responsibility in the management of obstetric services.

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Building management capacity over a long period of time.It has been fortunate in Filidi that the Team has been ready to absorb more and more management responsibility, starting with conducting a baseline assessment of the existing services and the unmet needs, to establishing priority issues, objectives and action plans to bring about improvement in the quality of care for the whole municipality. This sequence has enabled the facilitators to meet the Team where they are and help them create a vision of where they can be. They have learned management by managing and have celebrated their successes. There have been months when there has been need to go back and pick up skills that have not been adequately acquired, while on other occasions there have periods of rapid progress.

The provision of support for the carerIn the existing circumstances there is no ethos of caring for the over stressed carer and many have succumbed to the attractions of emigration. At one workshop, the facilitators had to scrap the planned agenda and listen to the trauma being experienced by the Team from neglect of their concerns and the departure of key members of staff to overseas employment. We found ourselves weeping with them in their grief and attempting to rebuild from a fragmented remnant.Personal development is an essential component of team building and this takes quality time and considerable patience. It also calls for an identification with health workers as they attempt to carry burdens that are not described in any text book. Failure to do so means that health workers are unable to provide the care their patients need.

The growth of a learning organisationMany of the midwives in Filidi came into the WHMT with the experience of being part of a self-generated Midwives Discussion Group. This led naturally to the further development of the Team as a learning organisation. They quickly accepted the discipline of assigning to each other topics that arose from problems highlighted in Perinatal Review

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Meetings. They would then research these topics in the literature and present their learnings at a subsequent workshop. A number of the more senior midwives applied successfully for enrolment in the Advanced Midwifery training programme in Durban. The facilitators have been able to meet with them on some Saturday mornings during their course to further support their learning.

Responsible monitoring and supervision of the quality of care

The facilitators have developed check lists to assess the quality of antenatal care records and labour records. Midwives in the Team who work in the antenatal clinics have applied these to the practice in their clinics and reported marked improvement in management of antenatal patients. One midwife reported that she applied the check list to patients she had seen personally and as a result had been able to reach scores of 100% accuracy in her own work.The midwife in charge of the labour ward in the hospital had decided to use the check list to assess the accuracy each morning of record keeping for the previous 24 hours. Midwives whose records had been assessed expressed appreciation for the standards that were being set by their supervisor.Midwives from night and day duty regularly attended Perinatal Review Meetings held at 08h00 once a month and contributed to the discussion of the causes and avoidable factors in the deaths reported. This system of perinatal audit has resulted in the gradual reduction in perinatal mortality rates in the municipal service over the past two years from a high of 70 per 1000 births to the present figure of 25 per 1000.

The relationship between the private and public sectorsFor most of the time this has been a distant relationship, partly because they are very busy in their practice and partly because the private service in the hospital has been amalgamated with the public sector. At a meeting held at the request of the CHESS facilitators, in an endeavour to

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recruit the general practitioner’s support for the changes taking place in the hospital, an attempt was made to allay their fears of dropping standards and cleanliness by challenging the G.P.s to participate with the full-time doctors and midwives in working towards high standards of quality of care throughout the unit. It will take more time to attain those standards, but it would certainly be to the benefit of everyoneOne of the general practitioners has commenced a research project in the labour ward and is learning what it means to work with the midwives.

The role at District level of the community obstetrician and the MCWH Coordinator

This rural District in KwaZulu Natal has no district obstetrician, which makes it very difficult to maintain the quality of Perinatal Review Meetings and to raise standards in the service. In an endeavour to fill the gap, the facilitators have used the opportunity of travelling around the district with the Maternal Health Coordinator, who is an Advanced Midwife, to coach her in methods for supporting the WHMTs. This has proved to be very positive and has also helped to advance the understanding of the facilitators with regard to the problems faced by the Teams.

Conclusion1. The Woman’s Health Management Team is essential to effective and

efficient management of maternal health services at municipal level2. The WHMT helps to promote the concept of the District Health

System whereby all pregnant women in the municipality are the responsibility of the WHMT and their related health workers.

3. The WHMT is accountable to the hospital management team and to the Sub-district Health Management Team. These two management teams need to be strengthened in order to assist them to fulfil their role.

4. The WHMT can assist in strengthening links between those working in the clinics and the hospital, and between doctors and midwives.

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5. The WHMT is responsible for accurate auditing of the quality and the equity of care in maternal health services for the whole municipality

6. The WHMT should become an active learning organisation.7. Given the shortage of staff at provincial and district levels, NGOs can

assist in facilitating the strengthening the WHMTs8. Quality midwives, given advanced training, will form the backbone of

maternal health services in South Africa in the future.

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A BASELINE ASSESSMENT OF THE QUALITY OF MATERNAL HEALTH SERVICES IN LIMPOPO PROVINCE: REFLECTIONS AND CHALLENGES IN IMPROVING THE RELIABILITY AND USE OF INFORMATION FOR PLANNING AND MANAGEMENT AT PRIMARY LEVEL

A VoceCentre for Rural Health

IntroductionThe Limpopo Province MCWH Directorate initiated this research process with a request to the Centre for Rural Health to develop and implement a programme of management training, facilitation and support for Reproductive Health Management Teams (RHMTs) throughout the province, for the purpose of improving the quality of maternal health care, particularly at primary level (inclusive of clinics, health centres and level 1 hospitals). The broad goals and content of the programme of training, facilitation and support were negotiated with the Directorate and with the National MCWH Directorate, who extended the purpose of the study to developing a useable and replicable model of intervention that could be applied in other provinces. The overall study period is from January 2002 to March 2004.

The research objectives are to:1. Identify the indicators and method for a baseline assessment of the

quality of maternal health care at primary level.2. Develop indicators to analyse factors that influence the key issues

emerging from the baseline assessment.3. Design and implement a programme of intervention, with

monitoring and evaluation processes.4. Design a strategy for replicating the training and facilitation of

RHMTs.

This paper presents the method, results, reflections and recommendations pertaining to Objective 1.

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MethodThe nature of this study called for a co-operative, action-research design. The main aim of action-research is the development of effective action, the improvement of practice and the implementation of effective change as measured by specific outcomes. (Sarantakos, 1993; Hamilton, 1994; Baum, 1995; Waterman, 1998; Dick, 1999; Hampshire, 2000). In co-operative inquiry “all those involved in the research are both co-researchers, whose thinking and decision making contribute to generating ideas, designing and managing the project, and drawing conclusions from the experience, and also co-subjects, participating in the activity being researched.” (Reason, 1994 p. 326) Thus the research team in this study comprises the principal investigator, the co-facilitator and the Limpopo Province RHMTs.

In action-research designs, the research is conducted through a cyclical process that alternates between action and reflection, a constant iterative process of collecting data, feeding it back, acting on the information, reflecting on the action, evaluating it and modifying action where necessary. The phases in the research process used in this study are an adaptation of those described by Elliott (1991, in Smith 1994) and involve: proposal, planning, implementation, observation, recording, reflecting, modifying, and write-up.

In the proposal phase, based on a review of the published literature, consultations with experts, existing computerised information systems, and personal experience, the principal investigator and co-facilitator identified a preliminary ‘long list’ of indicators. Criteria for including indicators were developed through a review of the literature, and these were applied to arrive at a proposed essential list of indicators. These indicators were presented to the RHMTs, who analysed, discussed and modified them and then applied them to conduct a baseline assessment of the quality of maternal health care in the health facilities in their respective geographical areas. The findings of the baseline assessment

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were compiled and interpreted, and recorded, together with observations made during the implementation phase. The indicators, their use and the results obtained were reflected upon the principal investigator, co-facilitator and RHMTs and recommendations for modifying the indicators were made. The final list of indicators was written up, as well as the issues and challenges in ensuring reliable information for planning and decision-making in the management of a primary level maternal health service.

ResultsCriteria for inclusion of indicatorsDonabedian (1988) describes a three-part approach to measuring quality of care in which structure, process and outcomes are assessed. The Primary Health Care Management Advancement Programme presents a systems approach to measuring the quality of care that is similar to, but expands the Donabedian model. In order to allow for greater precision in selecting indicators, they propose that the dimensions of quality to be measured include inputs, processes, outputs, effects and impact.

There are differing opinions reported in the literature with regards to the use of impact measures. Pattinson et al (1995) maintain that reductions in mortality must indicate a reduction in morbidity, and that an analysis of the causes of death and the avoidable factors will lead to the identification of prevention measures and areas of intervention. Other authors report problems in using impact indicators, mainly due to underestimations in mortality and morbidity rates, and the long time it takes to demonstrate changes at this level. (Garner et al, 1990; Bobadilla, 1992; Maine et al, 1997; McGinn, 1997; UNICEF/WHO/UNFPA, 1997; Kwast, 1998, Pathak et al, 2000). Thus a combination of indicators produces the best results, but the inputs, processes, outputs and outcomes measured must be linked to the desired impact. Input, process, output and outcome indicators are useful when explaining why a programme is not achieving the expected impact.

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Maine et al (1997) propose a series of questions that would guide the assessment of the quality of maternal health care. The questions indicate a public health orientation and deal primarily with inputs, process, outputs and outcomes. These were later adopted by UNICEF/WHO/UNFPA (1997) and provided the framework for categorising the indicators used in this study.

Wardlaw and Maine (undated) state that indicators must register changes in the quality of care and yield useful information over relatively short periods of time. This is in order to initiate actions that will improve the quality of care, and achieve prompt feedback on their effectiveness. For this monitoring to be an ongoing exercise, indicators need to be calculated from data that is relatively inexpensive to gather, and must provide the minimum amount of information needed for decision-making by programme planners and policy makers. To this end they propose that it is best to select indicators that rely on data collected in health facilities, rather than on population-based surveys, as then indicators can be measured at lower cost, more frequently, and through routine collection and reporting. Indicators should serve several purposes so that they can be used for a situation analysis, periodic evaluation and for ongoing monitoring of progress.

Moodley et al (2001) state that at national level indicators must be able to track improvements in health status. At a local level, indicators must enable effective monitoring an evaluation of programmes. For this, a core set of local indicators is needed in order to monitor and evaluate and provide minimum information for planning and decision making by programme managers.

Final list of proposed essential indicatorsAs stated above, the indicators used to conduct the baseline assessment in Limpopo Province were categorised according to the planning questions

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they helped to answer (UNICEF/WHO/UNFPA (1997). Impact indicators were also included. The indicators used are as follows:

Are essential obstetric services available? Availability, distribution and functionality of Basic- and Comprehensive-

Essential Obstetric Care (EOC) facilities (per 100 000 population)

How many women are using essential obstetric services? Antenatal Care (ANC) coverage (as measured by the percentage of

pregnant women in the target population who have attended ANC at least once)

Percentage 1st ANC visits before 20 weeks Institutional delivery coverage Percentage of women in labour admitted before 5 cm cervical dilatation Percentage women with listed obstetric complications who are treated

in a Basic–EOC or Comprehensive–EOC facility

How many essential activities/procedures are being performed? Percentage 1st ANC visits tested for syphilis and blood results returned

within 2 weeks Percentage requests for emergency services met within 1 hour Caesarean section rate per total population

What is the quality of care provided? Quality of user education at the 1st ANC visit (as measured against

predetermined criteria) Quality of record-keeping during ANC (as measured against a record

review checklist) Quality of record-keeping during labour (as measured against a record

review checklist) Average time between decision and commencement of caesarean

section in Comprehensive – EOC facilities Case fatality rate

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Anaesthetic death rate

Impact measures Perinatal mortality rate Percentage perinatal deaths due to avoidable causes Perinatal care index Maternal mortality rateLessons learned from the application of indicators Conducting the baseline assessment was an introduction for the

Reproductive Health Management Teams (RHMTs) to their management responsibilities. For most teams, it was the first time that hospital- and facility-based personnel met to evaluate and plan jointly for comprehensive service delivery

The indicators selected added a public health dimension to the work of clinic and hospital workers. The indicators extended the involvement of the RHMTs beyond the health facility to the population living in the geographic area served by their health facilities.

The RHMTs were able to identify gaps and areas of unmet need. They themselves were surprised by some of the findings: “We discovered the reality in service provision.” “It made us aware of the real situation of our services.” “It gave us a clear picture of what is happening around us concerning maternal health, (even though) not all the findings are accurate.”

Measuring the indicators through the baseline assessment necessitated the definition of targets and standards against which the findings of the baseline assessment would be compared. For most RHMTs, this was the first time that service and targets and standards had been discussed

Recommendations for modification to indicators The availability and distribution of Basic- and Comprehensive-EOC

facilities per 100 000 population needs to be assessed at provincial level, across municipal and district boundaries. The functionality of the

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facilities needs to be monitored at primary level and corrective actions implemented with immediate effect to restore the functionality of a facility.

The results on the coverage indicators were difficult to interpret due to questions about the completeness of the data, and client health-seeking behaviours. With regards to the coverage for obstetric complications, there were a number of problems: RHMTs did not fully understand what the indicator measured (and therefore were looking for low percentages rather than the expected high percentages); obstetric complications were not well defined and were under reported and under recorded.

The percentage of syphilis results returned within 2 weeks and the emergency response time were not routinely collected, therefore prospective studies were set up to monitor these indicators over a 3-month period. The introduction of an onsite, rapid test for syphilis will eliminate the need for this indicator. Emergency response time may need to be monitored routinely, and delays analysed in order to determine the causes of the delays and to identify corrective actions.

With regards to the case fatality rate, the number of deaths at primary level related to listed obstetric complications and emergencies were too small to calculate a reliable and accurate case fatality rate. It is recommended that Severe Acute Maternal Morbidity be measured at level 2 and level 3 hospitals.

Data to calculate the waiting time was not available from patient records. A prospective study would need to be set up. Alternatively a record needs to be kept of the number of deaths in an institution resulting from delays in the commencement of emergency caesarean sections.

Challenges in improving the reliability and use of information for planning and decision-making Clinic-based services fall under the district office, whereas hospital

based services are directly accountable to the provincial level. This

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administrative fragmentation demonstrates itself in functional fragmentation. Thus service managers often have a narrow, facility-based management focus. The challenge is to enable the RHMTs to plan, monitor and evaluate a full maternal health service for a target population in a designated geographical area.

The fragmentation mentioned above is perpetuated in the fragmentation of information systems. There is not yet consolidated reporting on a common set of municipal and district level maternal health indicators.

Quality of data is related to use – amongst most health workers, there is not yet a culture of using information for decision-making. Thus the full value of accurate and timely information is not appreciated, and as a result there is very little effort put into ensuring good quality data.

Many health workers still struggle with the tension in their role of providing quality individual care and ensuring equity in service provision to a population. Thus they often find it difficult to understand, interpret and use population based indicators.

Management responsibilities with the health system are not yet fully decentralised and thus managers are not being called on to really manage. Thus managers are not yet placing due importance on the need for complete, reliable and timely information in support of their management role.

ConclusionA contribution has been made towards defining a common essential list of indicators for a baseline assessment of maternal health care at primary level. These indicators need to be refined through continued application, analysis and discussion. The proposed indicators need to be evaluated with regards to their usefulness in the ongoing monitoring of maternal health services.

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AcknowledgementI would like to gratefully acknowledge the contribution of Hugh Philpott, co-facilitator in Limpopo Province, in the identification of the indicators and in the reflection of their use.

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IMPROVING THE QUALITY OF RECORDS: USING A QUICK SCORING SYSTEM AND INTEGRATING SPECIFIC INDICATORS TO IMPROVE QUALITY FOR ANTENATAL CLINIC AND LABOUR WARDS

RB Mia, D Roussot, E BuchmannUniversity of Witwatersrand, Johannesburg. Coronation hospital and CH Baragwanath Hospital

ObjectiveTo assess the quality of current antenatal and labour records, identify areas of sub-standard care, discuss possible solutions and enforce the implementation of quality checking system on a regular basis.

Methods and DesignA randomized retrospective study of antenatal clinic and labour ward records for the period January 2002 - May 2002 at Coronation hospital and January 2002 – October 2002 for CH Baragwanath hospital. A modified Hugh Philpott scoring system was used. Categories looked at in the Antenatal records were history, examination, interpretation and decisions. Categories looked at in the Labour records were admission form, partogram, and assessment of progress of labour.

SettingCommunity based teaching hospitals, Coronation hospital (Phase one) and CH Baragwanath hospital (Phase two), which on average has 6000 and 18000 deliveries respectively per year and comprises of consultant-based care, shared care, team midwifery, registrar and medical officer/intern care.

PopulationA total of 600 for phase one and a total of 600 for phase two randomly selected post-partum women were selected after inclusion/exclusion criteria. These were randomly selected irrespective of age, parity, race, socio-economic status and outcome of pregnancy.

Results: Phase OneThe studied sample consisted of 152 (25.3%) primiparous women, 448 (74.7%) multiparous women, 48 (8%) teenage pregnancies, and 78 (13%) women of maternal age greater than 35 years. The significant areas of weakness in antenatal records, identified using the scoring system included, record of details of complications that occurred in previous pregnancies (7.35%), record of details related to the cause of previous pregnancy loss (12.5%), record of estimated foetal weight by palpation in relation to gestational age (7.3%), record of the amount of liquor in relation to size of foetus and period of gestation (2.5%), record of the risk factors and / or problem list (63.3%), record of transport arrangements when patient goes into labour (3%), and record of counselling irrespective of nature of counselling (12.5%). A significant population (61%) was late

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bookers of which teenage pregnancies, primigravida, parity greater than two, and maternal age greater than 35 accounted for majority. The labour ward records for phase one after exclusion / inclusion criteria showed deficiencies in the listing of risk factors (8.7%), incorrect decision (0.3%), failure to list risk factors on the top of the labour graph (100%), and failure to plot partogram (14.5%).

Results for phase two will be available at time of presentation.

ConclusionObstetricians make good decisions based on good and structured information. The systematic and critical analysis of quality, results in better outcomes for mother and baby, if regular auditing is done to identify problem areas. Regular auditing of areas such as record keeping should remain high on the agenda as an area of practice in need of improvement. Although the results of audits cannot be generalized it does have educational and disciplining value to lower the chance that deficiencies will be repeated. Recommendations for improvement and intervention include, regular audits of records, consultation with seniors, education programs, improve clinical interpretation, group discussions, feedback to health workers, and improvement in participation of perinatal review meetings.

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CHALLENGES AND LESSONS LEARNT IN USING MODULAR TRAINING APPROACH TO IMPROVE QUALITY OF ANC SERVICES IN RURAL CLINICS IN ZULULAND

WS Mbambo

BackgroundIn 1998, the report on Confidential Enquiries into Maternal deaths and the 2000 National Perinatal Care Survey all highlight the existence of quality of care issues and missed opportunities that contribute to maternal and perinatal mortality in South Africa. To address some of these issues the MCWH Unit in KZN, in collaboration with other stakeholders, is pilot-testing the feasibility and effectiveness of a comprehensive ANC and PNS package. This package integrates STI, HIV management and prevention, FP and on-site RPR testing into routine ANC service. These services are offered in 5 goal-directed ANC and 2 PNS visits.

Reasons for Modular TrainingIt is not appropriate for clinic staff to leave clinics for long period to be trained somewhere for a week or so.

Training Master Trainers Training started in April 2002. Trainees were to attend a module, train providers on the same

module in their respective areas and continue to the next module. 22 Master trainers from different municipalities in DC26 attended

training. 5 Trainers did not complete, 3 left the country for overseas

opportunities and 2 resigned to join the private sector. New people replaced them but could not be trained on the past

modules and therefore received incomplete training. Not all trainers who left were replaced. RPR-test training was conducted directly at the clinics.

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Reasons for on-site RPR Testing There is poor transportation of blood specimens from clinics to

hospital laboratories. Reactive clients end up not getting full syphilis treatment before

delivery due to lost specimens and delayed results.

Challenges Training was not cascaded because trainers were not released from

their duties as providers in the clinics. Trainers who managed to start training had no target group to train

because of the shortage of providers i.e. 1 provider in a facility could not leave clients and attend training.

In remote clinics, there were no providers at all to be trained when the trainer arrived due to conditions in rural areas which do not attract staff to work there.

Logistical problems e.g. transport for trainers. Some trainers lack commitment during training e.g. missing some

modules by absenting themselves from training sessions. Other trainers attend training to gain the skill and be marketable but

lack interest in training other providers.

Summary and Recommendations Master trainers should be people who are not service-providers. Trainers-posts to be created at district level to ensure on-going

training on maternal health issues. The issue of incentive for staff in rural areas to attract personnel

should be considered. Staff shortage and high turnover are still a major problem.

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ASSESSMENT OF THE QUALITY OF CARE PROVIDED TO FIRST ANTENATAL CARE CLIENTS IN RURAL AREAS IN KZN

RS SibiyaBenedictine Hospital

Data collection from first visit from 18-20 weeks. Screening for pregnancy risks. Assessment of pregnancy risks. Management of problems that may arise during the antenatal

period. Administration of medications that may improve pregnancy

outcomes. Provision of information to pregnant women. Physical and psychological preparation for childbirth and

parenthood. All women who attend antenatal care should be issued with an

antenatal card and it should be completed at each visit. Pregnant women are encouraged to book for antenatal care as soon

as pregnancy is detected from 4 weeks. Urine pregnancy tests should be available at all rural clinics. Investigations are done to prevent complications e.g.:

o Blood pressure to detect hypertension.o Blood for HB.o Blood for WR and HGT.

The above investigations are done at the clinics. History is also taken for current pregnancy and for previous

pregnancies.

Any Complications and Outcomes Medical conditions. Previous operations. Psychiatric problems. Familial and genetic disorders. Allergies.

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Use of medication. Use of alcohol, tobacco and other substances. Family and social circumstances. General examination includes weight, heart rate, colour of mucous

membranes, blood pressure and oedema and also systematic examination.

Final assessment is done to include the following:o Risk status and plan for further antenatal care and delivery.o A plan for management of any problems.

A patient should be told about the danger signs in pregnancy e.g.:o Severe headacheso Abdominal painso Drainage of liquor from the vaginao Vaginal bleedingo Reduced fetal movement

Self-care in Pregnancy Diet and exercise Personal hygiene Abuse of alcohol, tobacco Training of all staff on ANC packages who are working in rural clinics.

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MONITORING AND IMPROVING THE QUALITY OF THE PERINATAL AUDIT

H PhilpottCHESS

Introduction If we do not audit the quality of our work on a regular basis, the quality

of human endeavour deteriorates. If we do, and the relevant lessons are learned and the necessary adjustments to practice are made, then improvement in outcomes, and even the morale of the staff, should follow.

This presentation provides the means to audit the audit process in a maternal health care service in a municipal (sub-district) health system.

A municipal maternal health care service:- Is responsible for maternal health care for the entire

population in the municipality, whether the clients deliver in hospital, health centre, clinic or at home.

- Should be managed by a Reproductive (or Woman’s) Health Management Team (RHMT) with a named coordinator of the Team.

- Is accountable to the Hospital Management Team, the District Health Management Team (DHMT) and the District Council.

- Must be monitored in a regular Perinatal Review Meeting (PRM).

In the Zululand District of KwaZulu Natal and in Limpopo Province, quality checklists have been introduced to monitor and improve the quality of antenatal records and labour records. These exercises have proved to be very effective in improving the quality of antenatal care and labour management.

More recently a questionnaire has been used to evaluate Perinatal Review Meetings. This paper focuses on the monitoring of the perinatal review process, recognising that the process is fundamental to the improvement of perinatal care and the knowledge, skills and attitudes of the participant health workers.

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MethodA questionnaire was prepared (see Appendix A) to check on the most important components of the perinatal review process. This was given to the representatives of 34 level 1 and level 2 hospitals (with their satellite clinics) in Limpopo Province during workshops run for the municipal Reproductive Health Management Teams (RHMTs) in the Province in February, 2003. This followed twelve months of bi-monthly training workshops held for the RHMTs during which the Teams had received coaching in the running of the perinatal review process, plus other management topics.

The check list looked at: The first review of perinatal and maternal death records, held within 24

hours of a death The preparatory meeting held a few days before the Perinatal Review

Meeting The Perinatal Review Meeting The use of the Perinatal Problem Identification Programme (PPIP).

ResultsAt the beginning of 2002, before the training workshops commenced, 5 (15%) hospitals (were holding Perinatal Review Meetings (PRMs). In February 2003, 27 out of the 34 (79%) hospitals were holding regular, monthly PRMs. The scores for the items on the check lists for the 27 returns were added together.

First review of records1. Was a meeting held within 24 hours of every maternal

and perinatal death, with a doctor and senior midwife present plus those involved in the management of the patient, to ensure the completeness of the patient’s records? 13 hospitals out of the 27 (48%) did not hold this review.

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If this meeting is not held, essential information is often not available at the PRM and, in consequence, analysis of the problems and valuable decisions on future management of similar problems cannot be taken. The ideal time for this meeting is at 08h00 in the morning following the death.

The Preparatory Meeting2. Was a Preparatory Meeting held between the doctor in

maternity, the midwife in charge of maternity and the midwife in charge of the clinics a few days before the Perinatal Review Meeting? 24 out of 27 (89%) held a preparatory meeting. Time must be taken to review all the statistics and all the deaths. This is the real audit meeting – there is insufficient time to complete this in the PRM. 89% is very good, but it needs to be 100% if the PRM is to be worth while.

3. Were the patient’s records sufficiently complete for an adequate review? 15 out of 27 (55%) had complete records. This is a reflection on the low percentage of first review meetings (within 24 hours of the death). In addition, the use of the labour record check list is leading to an improvement in the completeness and quality of all labour records.

4. Were the statistics for the month completed and reviewed? 23 out of 27 (85%) did this completely. They reviewed the following:- Number of 1st ANC visits before 20 weeks- Number of 1st ANC visits after 20 weeks- Number of subsequent ANC visits- RPR results- Number of deliveries- Caesarean section rate- Perinatal Mortality Rate- Maternal deaths- Low Birth Weight Rate

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When population figures are available, the teams are calculating the caesarean section rates for the total population in addition to the rates for the institutions. The total number of births can be estimated for the denominator by multiplying the birth rate by the total population. Perinatal Mortality Rates include those for deliveries in the hospital, in clinics and at home. Information on home deliveries is available from the Community Health Workers through the PHC Facilitators.

5. Was the form summarising all deaths completed and reviewed? This was completed by 24 out of 27 hospitals (89%). This information can be obtained from the PPIP statistics. It gives a valuable overview of all the deaths, for presentation at the PRM.

6. Were all the deaths reviewed and causes discussed? 22 out of 27 (81%).

7. Were avoidable factors discussed for all deaths? 22 out of 27 (81%). Failure to discuss causes and avoidable factors is usually a result of inadequate information in the records. This is the opportunity for senior members of the Maternity Unit to discuss ways of improving the service.

8. Was the relevant action considered and carried out? 18 out of 27 (66%). This calls for attention, otherwise the perinatal audit is just an academic numbers game.

The Perinatal Review Meeting9. Was a Perinatal Review Meeting held at least once

during the month? 27 out of 34 hospitals are holding regular monthly PRMs. District obstetricians are encouraged to visit the PRMs in the hospitals in their district in order to provide an outside presence and also to encourage good quality critical thinking in the analyses of the statistics and deaths that are reviewed.

10. Was at least one doctor present at the PRM? 22 out of 27 hospitals (81%) had a doctor present at their PRM. This is encouraging as, in many institutions, doctors are known to avoid meetings where midwives are present. Ideally, all doctors who do

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calls in maternity need to be at the PRM, including private and sessional doctors. Where doctors are not present, medical avoidable factors tend to be repeated.

11. Were midwives from the hospital present? 26 out of 27. This is to be expected but not taken for granted. The conduct of the meeting must ensure that these midwives are included in the discussions and decisions taken.

12. Were midwives from the clinics present? 19 out of 27 (70%). Their absence tends to mean that antenatal aspects of management are not discussed as most antenatal care takes place in the clinics. Major reasons for their absence include availability of transport, shortage of staff in the clinics and the traditional view of the District Health System that tends to separate thinking about the clinics from the issues in the hospital. Some progressive institutions are subsidising the cost of transport for the clinic midwives, or arranging that the PRM is held on the day that the clinic midwives come to the hospital for their in-service training.

The following three items refer particularly to the educational values of the PRM:13. Was at least one clinical management problem, arising

from a maternal or perinatal death case study, discussed? 23 out of 27 (85%). These represent the core of the teaching material in the PRM and serve as educational opportunities as well as for discussion on current practice in the Unit. It is here that the District obstetrician can play a crucial role. If there is insufficient experience in the group, educational topics can be highlighted and, if necessary, given to individuals to prepare in readiness for the next monthly meeting.

14. Were ‘lessons learned’ listed? 20 out of 27 (74%). This needs to be 100%. This gives valuable insight into the quality and amount of learning during the PRM, and is a good opportunity for reinforcement of learning.

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15. Were any research topics identified? 12 out of 27 (44%). There are two types of research that can be identified. Firstly, questions raised during discussion at the PRM which call for further study and analysis and which can lead to improved management of maternal and neonatal health problems. Some of these topics have provided research opportunities for midwives doing higher degrees. Research has not been a significant part of the culture of rural health practice, but more health workers are now looking for opportunities to explore ways of improving service provision. Then, secondly, items which call for further literary review and presentation at subsequent meetings.

16. Were the minutes of the last monthly PRM circulated and discussed at this meeting. 7 out of 27 (26%). This figure is very low and more needs to be done to document decisions and lessons learned during the analysis of maternal and perinatal deaths. This can be the opportunity to pass on to senior management decisions that they need to consider.

17. Were the statistics, the form summarising all deaths, and the summaries of the case studies presented on overhead transparencies or handouts? 25 out of 27 (93%). When these are well done, they add to the learning that takes place in the PRM. However, coaching is often needed.

18. Did the majority (more than ¾) participate in the discussion at the PRM? 22 out of 27 (81%). This requires good facilitation skills. At a recent PRM, the facilitator arranged for the presentation of the case study and then, in small groups, the participants discussed the causes, avoidable factors and prepared protocols of management for the condition under consideration. These protocols were then placed on the wall of the maternity unit to guide future management.

Perinatal Problem Identification Programme (PPIP).19. Were all the statistics for the month entered on the

PPIP? 27 out of 27 (100%). The PPIP has been very well taught in

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Limpopo Province and there is an excellent presentation each year at provincial level. However it has not been employed to full advantage at municipal level. Usually it has been the responsibility of one or two individuals to capture the data without a full team analysis.

Conclusions Audit of a municipal perinatal service is absolutely essential. If there

are not enough staff to have a PRM – there are not enough staff! The audit has to be of high quality and the audit process has to be

audited regularly. The Perinatal Audit provides an excellent opportunity for

teaching/learning that is relevant to the needs of the moment. However, this calls for a teacher with considerable educational skills in addition to knowledge and experience in obstetrics and neonatology.

Each District needs a good community obstetrician and a good MCWH Co-ordinator (with Advanced Midwifery training).

There is considerable value in having an outside resource person to be present at the PRM in order to ensure constructive critical comment.

Appendix A Perinatal Review: Quality Check ListIt is recommended that this checklist be completed for each hospital, with its satellite clinics, each month. Give 1 mark for each ‘Yes’ answer.

Hospital…………Municipality……………District…………Month….Year……A. First review of records1. Was a meeting held within 24-hours of every maternal and perinatal

death, with a doctor and a senior midwife present, to ensure the completeness of the patient’s records?

Y N

B. The preparatory meeting 2. Was a preparatory meeting held between the senior doctor and the

senior midwife a few days before the Perinatal Review Meeting (PRM)?

3. Were the patient’s records for each of the deaths sufficiently complete for review?

Y NY N

At the preparatory meeting, were the following done?4. Were the statistics for the month completed and reviewed? Y N

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Did these statistics include data from all deliveries from:-5. The hospital Y N6. The health centres and clinics Y N7. Home deliveries Y N

8. Was the form summarising all deaths completed and reviewed? Y N9. Were all the deaths reviewed and causes discussed? Y N10.Were avoidable factors discussed for all deaths? Y N11.Was the relevant action considered and carried out? Y N12.Were case studies selected for discussion at the coming PRM? Y NC. The perinatal review meeting (PRM)13.Was a PRM held at least once during the month? Y N14.Was at least one doctor present at the PRM? Y N15.Were midwives from the hospital present? Y N16.Were midwives from the clinics present? Y N17.Was the form summarising all the deaths presented and discussed? Y N18.Was at least one clinical management problem, arising from a

maternal or perinatal mortality case study, discussed?Y N

19.Were “lessons learned” listed at the end of the meeting? Y N20.Were any research topics identified? Y N21.Were the minutes of the previous PRM circulated, and discussed? Y N22.Were the statistics, the form summarising all deaths, and the

summaries of the case studies presented on overhead transparencies or handouts?

Y N

23.Did the majority (more than ¾ ) participate in the discussion? Y N24.Was a letter listing the recommendations from this meeting, plus the

minutes of the meeting, sent to the CEO, Medical Manager and Nursing Service Manager?

Y N

D. PPIP25.Were the statistics for the month recorded in the PPIP? Y N

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MONITORING PERINATAL DATA IN RURAL EASTERN CAPE HOSPITALS: IMPLICATIONS FOR MATERNITY SERVICES PROGRAMMES AND RESEARCH

D Jackson, School of Public Health, University of the Western Cape; HA van C de Groot, Department of Obstetrics & Gynaecology, University of Cape Town; S Masilela, Dept. of Health, Eastern Cape Province

Background: The Obstetric Support ProgrammeThe Obstetric Support Programme (OSP) began in 2000 as a component of ISDS in the former Region E of the Eastern Cape Province, now Alfred Nzo, and parts of Ukhahlamba and OR Tambo Health Districts, to address the quality of maternity services in the region. The objectives of the OSP are to:1) Reduce maternal and perinatal mortality, and2) Improve the quality of obstetric services in Region E through the

introduction of: Perinatal audit Continuing in-service education & training Introduction of uniform maternal health guidelines Monitoring & evaluation

This paper reports on the perinatal data collected as part of the monitoring and evaluation component.

Participating hospitals included: Mary Terese – Umzimvubu, Alfred Nzo District* Sipetu – Qaukeni, OR Tambo District Rietvlei – Umzimkulu, Alfred Nzo District* Mt. Ayliff – Umzimvubu, Alfred Nzo District* Taylor Bequest - Ukhahlamba District* St. Patricks - Qaukeni, OR Tambo District* St. Elizabeths - Qaukeni, OR Tambo District* Holy Cross - Qaukeni, OR Tambo District Greenville - Qaukeni, OR Tambo District Bambisana – Nyandeni, OR Tambo District

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Data Collection Methods:Collection and monitoring of perinatal statistics has continued from a sample of the participating hospitals, which are indicated with an * in the above list. The OSP Facilitator visits these hospitals twice a year to collect the following monthly data:

# of Deliveries # of Births # of Caesarean Sections # of Stillbirths (macerated, fresh and total) # of Neonatal Deaths # of Maternal Deaths # of Low Birth Weight Infants

The data is collected directly from the maternity ward delivery register and monthly tallies maintained by the maternity nursing staff. These numbers are then used to calculate the necessary rates and indices including the following:

Stillbirth Rate (SBR)=Stillbirths/1000 Births Neonatal Mortality Rate (NMR)=Neonatal Deaths/1000 Live Births Perinatal Mortality Rate (PNMR)=Perinatal Deaths/1000 Births Maternal Mortality Rate (MMR)=Maternal Deaths/100 000 Deliveries Percentage of Low Birth Weight Births (LBW%)=%Births<2500gm Perinatal Care Index (PCI)=PNMR/LBW%

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Aggregate Perinatal Data from Sample OSP Hospitals 1999-2001Data Item 1999 2000 2001# Deliveries 11038 10432 10865# Births * 10578 11011Caesarean Section Rate

8 11 10

Perinatal Mortality Rate

56 62 63

Maternal Mortality Ratio

172 297 359

Low Birth Weight Rate

* 9.0 9.8

Perinatal Care Index

* 6.9 6.4

*Missing Data

Discussion

This report reviews perinatal data from the period 1999-2001 for a sample of hospitals participating in the OSP, which started in August 2000. The report provides monitoring data only, and does not contain the necessary data to explain the causes behind any changes in data noted during this period. Such explanations would require additional study with more in-depth data collection and analysis. However, several interesting points can be noted from this data and observations available from the situation analysis and on-going programme.

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1. Hospital F consistently has the best perinatal statistics of all the hospitals in the region. Assuming that the data from the registers is as accurate as at other sites, what might be the reasons for these good outcomes? Interestingly, Hospital F is no better resourced in terms of nursing, transport, supplies or other support than the other hospitals, but has two resources which may contribute to these data - a) it is the only hospital in the region which has a fully functioning Waiting Mothers Home for low-risk mothers on the hospital campus, and b) it is the only hospital which has local private doctors on contract to provide consistent medical staffing (1/2 to 2/3 of calls) compared with the other hospitals who rely on foreign doctors (mostly Cuban) and Community Service Doctors, both of which work on short term contracts and often have limited obstetric experience.

2. The increased maternal mortality is of great concern. Data from maternal mortality audit reviews both in the region and nationally suggests this increase may, in part, be due to the increasing prevalence and impact of HIV/AIDS in this region.

3. The slightly improved perinatal care index is encouraging. However, the reduction appears to be due to increasing rates of low birth weight rather than reductions in perinatal mortality. Factors that may be increasing LBW in the region, such as increased poverty, need to be identified and addressed.

4 Examination of perinatal data is very useful for monitoring perinatal care. It is also noted that improved data is being seen from the three hospitals participating in the Perinatal Problem Identification Programme (PPIP), being supported by the Province and the OSP.

5. Many hospitals in the area are beginning to use the new Eastern Cape hospital information system delivery registers. However, there is still some confusion over the use of the new registers, not all hospitals have them, and these registers do not provide the data necessary for the nationally and provincially recommended perinatal statistics (i.e. PPIP).

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Recommendations1. Expand the PPIP to include more hospitals in the region to increase

the use of perinatal data and perinatal audit.2. Expand the use of maternal mortality audit to investigate the causes

behind the increase in maternal mortality, and consider programmes to address the care and health of HIV+ mothers (beyond PMTCT which only targets the infants health).

3. Consideration should be made to rationalise the new delivery registers with recommended data needs from the National and Provincial MCWH Directorate.

4. Further investigation into a) potential success factors from Hospital F; and b) potential causes of increasing low birth weight in the region.

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IMPLEMENTING THE PERINATAL PROBLEM IDENTIFICATION PROGRAMME AS AN AUDIT AND OBSTETRIC INFORMATION SYSTEM IN A RURAL NAMIBIAN HOSPITAL

A Paul, Gobabis Hospital, Namibian Ministry of Health and Social Services; D Jackson, School of Public Health, University of the Western Cape

BackgroundPerinatal and maternal mortality rates are sensitive indicators of the quality of obstetrics care in any country or institution. In Gobabis Hospital, both perinatal and maternal mortality are high and increasing. No research has been conducted on these problems. Through audit programmes it is possible to reduce mortality rates as well as to improve the quality of care (Pattinson 2001). This study evaluates the implementation of an audit programme, which investigates the causes of death and avoidable factors by applying the Perinatal Problem Identification Programme (PPIP) format, and also evaluates the PPIP as a perinatal information system.

The Health Information System (HIS) report in Gobabis Hospital from January 1999

to August 2002 showed the following statistics:

Year Perinatal mortality rate Maternal mortality ratio1999 37.30/1000 deliveries 233/100000 live birth2000 42.52/1000 deliveries 258.73/100000 live birth2001 41.20/1000 deliveries 693.64/100000 live birth2002(till Aug) 52/1000 deliveries 363/100000 live birth

Study areaGobabis hospital is the only district hospital in Omakehe region. The catchment area is 87700 km2 and has a population of 67496 (2001 census). It lies to the eastern part of Namibia which borders with Botswana to the east, Otjozondjupa region to the north, Khomas region to the west and Hardap region to the south. This region has 11 clinics and one health center. Most of the deliveries are conducted in this hospital and very few cases are referred to the tertiary hospital (Windhoek Hospital Complex). This hospital is well equipped for obstetrical intervention and emergencies, anesthetic & surgical facilities to perform caesarean section, blood transfusion, basic laboratory, radiographic equipments and four incubators

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for the premature babies. There are only four general medical state practitioners, two volunteer doctors, and a shortage of midwives in the hospital. No obstetric or paediatric consultants visit in this region. Antenatal clinics are all over the region and can provide efficient screening and referrals. Transport is a big problem due to vast areas and gravel roads.

Research aimsThe study aims are that in Gobabis Hospital are:1) What are the causes of perinatal death (PND) and maternal death (MD)?2) What are the avoidable factors associated with perinatal and maternal death?3) Will the implementation of the PPIP audit system reduce PNDs and MDs?4) Will the PPIP system be accepted and usable by the maternity staff?5) Does PPIP meet the standard requirements as an information system for perinatal and maternal health?

Study Design Case Studies Audit - structured review of all perinatal and maternal

deaths. Descriptive Participatory Action Research - qualitative notes from

audit meetings and semi-structured staff questionnaire.

Sample size All perinatal and maternal deaths from Jan 1999 to Dec 2001 (total

102 PNDs & 10 MDs) and deaths from January 2002 to August 02 (total 29 PNDs & 2 MDs).

Maternity service health workers in the hospital (4 doctors and 8 midwives).

Data Collection PPIP Total Deliveries Form, Perinatal Death Form and Maternal Death

Form;

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Qualitative audit meeting minutes/notes; Investigator developed questionnaire on perceived causes of death

and response to the PPIP.

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Data AnalysisData were entered into PPIP and statistics were produced using PPIP standard reports. Qualitative notes analysed using content-theme analysis. Staff questionnaires entered and analysed in EpiInfo v6.04 for descriptive frequencies.

Results PPIP DataTable 1 PPIP statistics during the study period

Weight grams of babies

Jan 02 Feb02 Mar 02

Apr 02 May 02

Jun 02 Jul 02 Aug 02

Totals

500-999 g 1 0 0 1 0 0 0 1 31000-1499g

0 1 5 1 0 2 1 0 10

1500-1999g

3 2 2 3 2 1 2 1 16

2000-2499g

4 8 5 5 10 5 11 9 57

2500+ grams

69 50 48 74 48 72 51 56 468

Totals 77 61 60 84 60 80 65 67 554

DeliveriesNormal vaginal delivery

65 (84%)

52 (85%)

51(85%)

68(81%)

50(83%)

72(90%)

51(77%)

60(90%)

469(85%)

Caesarean Section

12 (16%)

9 (15%)

8 (13%)

16(19%)

10(17%)

8(10%)

8(13%)

6(10%)

77(14%)

Breech delivery

0 0 1 0 0 0 4 0  

Antenatal visit/careLocal clinic 67 58 53 71 54 75 54 50 485

(88%)Elsewhere 3 2 4 2 1 2 4 5 23

(4%)None 7 1 4 11 0 3 5 11 42

(8%)

Teenage pregnancy< 17 years 6 3 12 3 3 1 4 4 36

(5%)17-19 years

13 7 6 12 12 19 8 9 86(16%)

Referral Received 3 4 3 3 3 2 4 3 25

(5%)Sent 1 1 2 0 1 1 1 1 8

(1.5%)

Perinatal death

1 0 6 7 3 4 4 4 29

Maternal death

0 0 1 1 0 0 0 0 2

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Table 2 Obstetric cause of perinatal death from January to August 2002

Spontaneous preterm labour 35.70%Infections 17.90%Antepartum haemorrhage 7.10%Hypertensive disorders 7.10%Intrapartum asphyxia 7.10%Maternal disease 7.10%Intrauterine death 7.10%IUGR 3.60%Fetal abnormality 3.60%Trauma 3.60%

Table 3 Final cause of neonatal death from January –August 2002.

Prematurity related 62.50%Asphyxia and birth truama 18.80%Infection 12.50%Unknown causes of death 6.30%

Table 4 Avoidable factors of perinatal death (Jan-Aug 2002)

Patient's doing 53.10%Medical personnel's doing 25%Administrative doing 18.80%Insufficient notes to comment 3.10%

*Data from January 1999-December 2001 showed similar results to 2002 study period. Data not entered into PPIP as considered less reliable and substantial missing data.

Fig 1 Maternal death from January 1999 to August 2002.

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Table 5 Avoidable factors for maternal death identified (Jan 99-Aug 2002)Avoidable factors No Percentage Patient oriented problems 6 50.00%Administrative problem 0 00.00%Medical personnel 6 50.00%Total 12 100.00%

Results Audit Meetings & Staff Questionnaires:Staff Questionnaire: On whether audit meetings are helpful for the improvement of our knowledge, all those surveyed answered “yes’ (100%). It was also suggested that it is not only for the research purpose but more important to know the causes of death, mistake, solution and improve the knowledge for the management of newborn baby and mother.For the question on merit and demerit of audit meetings: 75% were of the opinion that it improves the quality of care, 25% that it identifies the mistakes and is also good guidance for the standard of care. The following quote is similar to most of the comments on merit of the programme:“One can evaluate your outcome standard and see where you fall short of doing right”In the demerit, most of them had nothing to say but some were of the opinion that it exposes the mistakes and the meeting takes too long. However, all seemed interested in continuing the audit meetings. One respondent noted:“Time is limited and not all midwives attend the meetings. It must not stop”The last question was how they know the PPIP system. None of them knew about this system until this project, but after the audit meetings their opinion is that it is a good system, which keeps the records properly, avoids missing files, provides recent statistical reports including all the information on babies and mothers.

Audit MeetingsThere were four audit meetings carried out during the study period. The participants were hospital superintendent, admin clerk, and most of the midwives and doctors. In addition, there were the following

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representatives from the regional office: acting regional management team chairperson, control registered nurse and reproductive health programme officer. Examples of recommendations from the audit meetings included:

Pregnant mother and the community need education to encourage the mother to have delivery in the hospital or clinics.

ANC check-ups need to be strengthened and should be done by only midwives, not assistance nurse.

If any resuscitation instrument not working properly, it should immediately be reported to the admin clerk or superintendent.

Problems have been identified in the management of premature, low birth weight, asphyxiated baby, etc. It was suggested that some of the midwives be sent to Windhoek for further training in neonatal resuscitation, and that there should be a separate neonatal unit so the nurses can give special attention to the sick babies.

In different local languages, health education to be provided through local media (radio) and the control registered nurse already took the initiative and began these media information programmes.

These audit meetings should continue to update knowledge and to identify where the problems lie and try to solve them with local resources.

There needs to be continuous in-service training for the midwives and doctors.

Results: Assessment of PPIP as a Perinatal Information System:

Table 6 Under reporting and missing file - 1999 to 2001=Pre-PPIP & 2002 PPIP

Year Reported File discovered

Missing file

Extra file discovered

1999 Stillbirth= 25Neonatal death=12

2715

00

23

2000 Stillbirth=17Neonatal death=15

1218

50

03

2001 Stillbirth= 13Neonatal

621

70

02

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death=192002 Stillbirth= 13

Neonatal death=16

00

00

00

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ConclusionsThis study was unable to evaluate the impact of the PPIP system on mortality rates due to missing files, under-reporting and poor data in the years prior to implementation (1999-2001) and the short duration of the study. However, there was a substantial improvement in the quality of the perinatal data, and the enthusiasm by staff and resulting actions based on data and discussion suggest that the PPIP audit programme was acceptable and usable by the maternity staff.

PPIP was also evaluated in terms of its information system components according to the following criteria: purpose, easy to use, relevance, redundancy; and for the PPIP maternity indicators: reliability, appropriateness, validity, ease to measure and sensitivity. PPIP as a computer-based programme, and perinatal information system is easy to use and, capable of collecting data from the clinic to the national level. The data is relevant as it provides a substantial number of the Namibian MOHSS maternal health indicators. Its focus on avoidable factors is an ideal framework for meeting the overall purpose of monitoring care. The indicators used in PPIP were found to be reliable, appropriate, valid, easy to measure and sensitive measures of maternity data.

Recommendations: Evaluate the implementation of PPIP in 1-2 years to assess

sustainability and long-term impact on perinatal and maternal deaths.

To implement or establish an independent confidential enquiry committee for maternal deaths at the national level

To consider expansion of the PPIP to other hospitals in Namibia.

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ANALYSIS OF PERINATAL DATA FROM ALL DELIVERIES IN TYGERBERG HOSPITAL OVER A FOUR MONTH PERIOD BY USING A SIMPLIFIED ICD-10 CODING MANUAL

H van der Merwe, H Odendaal, D GroveDepartment of Obstetrics and Gynecology, Tygerberg Hospital

IntroductionThis simplified ICD 10 coding manual was compiled by the FIGO, after identifying perinatal factors that may increase fetal and neonatal morbidity and mortality. It was envisaged that this coding manual will be applied by health carers regularly, particularly in developing countries, to facilitate the establishment of standards of reference.

The obstetric unit of Tygerberg Hospital participated in the pilot study. The hospital serves as a secondary hospital for the surrounding areas and as a tertiary referral centre for its region in the Western Cape. Approximately 4 500 deliveries are managed per year, with the majority of the patients coming from a poor socio-economic background.

Aims of StudyTo study the effects of antenatal care, abruptio placentae and pre-eclampsia on pregnancy outcome and to identify the risk factors for preterm delivery.

Materials and Methods Data from all deliveries over two periods for a total of 4 months

(February 2000 and July-September 2000) were collected using the simplified ICD 10 coding manual by FIGO

Files of all patients who delivered in this period were scrutinised after discharge from hospital.

All information collected from gravidograms, all doctors’ and nursing notes and partograms for which there was an ICD-10 code, were entered in the database.

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In addition, all women who received no antenatal care prior to delivery were identified.

Data were collected by a single observer. Only data collected as described above were used for analysis.

ResultsDuring the study period, 109 (7.5%) mothers received no antenatal care (unbooked mothers).

Table 1 Comparison between booked and unbooked mothersCLINICAL DIAGNOSIS

UNBOOKED (n=109)

No. %

BOOKED (n=1338)

No. %

P OR (95% CI)

Chronic HT with superimposed P.E.

0

0 7 0.5 NS

Moderate P.E. 0

0 47 3.5 NS

Severe P.E. 9 8.3 91 6.8 NSEclampsia 7 6.4 14 1.0 <0.001 6.49 (2.31-

17.65)TOTAL 16 14.7 159 11.9 NSPrevious C/S 6 5.5 182 13.6 0.016 0.37 (0.04-0.89)Intrauterine death

14 12.8 41 3.1 <0.0001

4.66 (2.33-9.21)

Abruptio placentae

5 4.6 33 2.5 NS

Preterm delivery

32 29.4 221 16.5 <0.001 2.10 (133-3.32)

Fetal distress 12 11.0 133 9.9 NSC/S 18 16.5 301 22.5 NSPuerperal sepsis

4 3.7 19 1.42 NS

Wound infection

1 0.9 8 0.6 NS

Syphilis 8 7.3 80 6.0 NSHT=Hypertension, C/S=Caesarean section, P.E.=Pre-eclampsia

Of the 1447 women, 255 (17,6%) had spontaneous preterm deliveries.

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Table 2 Comparison between preterm and term deliveries

CLINICAL DIAGNOSIS

PRETERM DELIVERY (n=255)

TERM DELIVERY (n=1192) P OR (95% CI)

No. % No. %Unbooked 34 13.3 75 6.3 <0.00

1 0.44 (0.28-0.69)UTI 25 9.8 119 10.0 NSGTI 10 3.9 40 3.4 NSDiabetes mellitus

2 0.8 16 1.3 NS

Twin pregnancy 13 5.1 16 1.3 <0.00

1 3.95 (1.77-8.79)Polyhydramnios 0 3Chorioamnoinitis 2 0.8 5 0.4 NSPlacenta praevia

4 1.6 8 0.7 NS

A.P. 8 3.1 30 2.5 NSFetal Distress 10 3.9 135 11.3 <0.00

1 0.32 (0.16-0.64)C/S 25 9.8 294 24.7 <0.00

10.33 (0.21-0.52)

Syphilis 14 5.5 74 6.2 NSAnaemia 11 4.3 79 6.6 NS

UTI=Urinary tract infection, GTI=Genital tract infection, A.P.=Abruptio placentae

There were 38 (2.6%) cases of abruptio placentae.

Table 3 Outcome measures of abruptio placentaeOUTCOME MEASURE

ABRUPTIO PLACENTAE(n=38) No. %

NO ABRUPTIO PLACENTAE(n=1409) No. %

P OR (95% CI)

Intra-uterine death

12

31.6 43 3.1 <0.00001 14.66 (6.49-32.79)

Fetal distress

13

34.2 132 9.4 <0.0001 5.03 (2.37-10.54)

Emergency C/S

13

34.2 258 18.3 0.01 2.32 (1.11-4.50)

P.P.H. 6 NSP.P.H.=Postpartum haemorrhage

There were 173 patients (12%)in the pre-eclampsia/eclampsia group.

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Table 4 Outcome measures of pre-eclampsiaOUTCOME P.E. NO P.E. P OR(95%CI)MEASURE (n=173) (n=1274) No % No % PFG 11 6.4 28 2.2 <0.01 3.02(1.35-6.47)A.P. 14 8.1 24 1.9 <0.0001 4.59(2.20-9.46)I.U.D. 15 8.7 40 3.1 <0.01 2.32(1.22-4.38)Fetal distress 65 37.6 80 6.3 <0.0001 8.89(5.97-13.26)C/S 97 56.1 222 17.4 <0.0001 6.05(4.28-8.56)

PFG=Poor fetal growth, I.U.D.=Intrauterine death

Conclusions Absence of antenatal care seems to put the fetus at risk for

intrauterine death and being delivered preterm. Although there is no simple explanation for the higher incidence of

preterm delivery, pregnant women should be encouraged to attend antenatal clinics, as this would present a unique opportunity to solve the many problems that may arise in pregnancy

Many of the known risk factors for preterm delivery were absent in this study, which increases the concern due to the high incidence of preterm delivery. Further research in this area is indicated.

Abruptio placentae and pre-eclampsia affects a large proportion of women in our obstetric unit.

The association between these two conditions and adverse maternal and perinatal outcome is confirmed.

The simplified ICD 10 coding manual allowed collection of data on some of the most important perinatal factors affecting obstetric outcome.

This may be of particular value for developing areas and countries, where maternal and perinatal mortality and morbidity is very high, in an attempt to improve perinatal care.

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RETROSPECTIVE ANALYSIS OF ALL DELIVERIES IN UNIVERSITAS HOSPITAL FROM 01/05/02 TO 31/07/02 AS A TERTIARY REFERRAL CENTRE IN CENTRAL SOUTH AFRICA

DJ Jordaan, OBG UFSJBF Cilliers, OBG UFS

138 Patients delivered 124 Live Births (Including multiple preg.) 14 Stillbirths 8 Miscarriages (Weight less than 500g) 2 Maternal Deaths 6 ICU admissions Caesarian sections: 61% of live babies delivered by c/sec. HIV: 28% +; 64% -; 8% ?

Maternal Deaths 25 Year old G3P3 with pre-eclampsia, HELLP syndrome and

eclampsia, kidney failure, also HIV+, CD4 410 25 Year old Primigravida with pre-eclampsia with heart failure and

pulmonary oedema and ARDS, HIV –

ICU Admissions Both the maternal death patients were admitted in ICU 30YR G3P3 Patient with eclampsia, HELLP sx, pulm. oedema, HIV – 23YR Primigravida, pre-eclampsia, ascites, probably pulm.

embolia,HIV – 20YR Primigravida, pre-eclampsia, cardiomiopathy, pulm. oedema,

HIV – 31YR G3P3 Patient with pneumonia, previous PTB in 95,96, HIV –

Diagnoses49% Pre-eclampsia 4% Hypertension2% DM

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3% Rh negative incompatibility4% PPROM5% Premature labour4% Poor obstetric history12% Cardiac problems5% Multiple pregnancies4% Congenital abnormalities2% AFL syndrome3% Respiratory conditions4% OtherPre-Eclampsia

49% of patients who delivered during this period had pre-eclampsia 6 of these patients had eclampsia 13 had HELLP syndrome 9 of them had some form of cardiac problem eg. heart failure, valve

problem Both the maternal deaths were pre-eclampsia patients 56 Live births from pre-eclamptic patients (2 twins) 10 Stillbirths 3 Miscarriages 79% of the live births from pre-eclamptic patients were delivered by

c/sec. Neonatal ventilation required for 35 out of these 56 babies = 63% Asphyxia 20 out of the 56 = 36% Average birth mass: 1372g Average gestation at delivery: 30,5 weeks Average time in Universitas prior to delivery: 2,5 days

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NASAL CONSTANT POSITIVE AIRWAY PRESSURE: PRACTICAL ASPECTS

Gert KirstenTygerberg Hospital and the University of Stellenbosch

The use of nasal continuous positive airway pressure (nCPAP) in very low birth weight (VLBW) infants with respiratory distress syndrome (RDS) has resulted in a reduction of chronic lung disease, death, mean duration of ventilation and the use of surfactant at Tygerberg Hospital.

CPAP has the following effects on the lung:1) Conserves surfactant2) Reduces upper airway collapsibility3) Prevents alveolar collapse4) Increases lung fluid absorption5) Improves chest wall stability6) Increases activity of the diaphragm7) Improves thoraco-abdominal asynchrony

nCPAP can be administered in the following ways:1) face mask2) nose mask3) endotracheal tube4) nasopharyngeal tube5) nasal prongsThe face mask method has been abandoned due to serious complications such as facial necrosis, posterior fossa haemorrhage and aspiration pneumonia associated with its use in neonates. CPAP applied through an endotracheal tube is associated with a significantly increased work of breathing and the tube is easily obstructed by secretions.

CPAP is classified according to gas flow in the system. The gas flow through the CPAP system can either be provided as:

a) continuous flow, or

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b) variable gas flow.

a) Continuous flow nCPAP:During continuous flow CPAP, oxygen is administered through a ventilator or blender by means of:

endotracheal tube nasal prongs nasal cannula.

The least effective way of providing CPAP (increased work of breathing) is by endotracheal CPAP or by nasopharyngeal CPAP through a shortened endotracheal tube while the variable gas flow method is the most effective.

A basic continuous flow nCPAP system can be built using an oxygen blender, nasal prongs and an under water seal system (bottle used for chest drainage) (see cartoon).

b) Variable gas flow nCPAP (Infant Flow Driver).With the Infant Flow Driver system, air flow is redirected away from the nasal prongs during expiration into the expiratory limb of the circuit. This results in a significant reduction in the imposed work of breathing compared to continuous flow nCPAP.

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Indications for nCPAPnCPAP is indicated in newborn infants with clinical signs of increased work of breathing such as:

increased respiratory rate retractions, grunting and flaring increased need of inspired oxygen

Specific indications include:1) mild to moderate RDS2) wet lung syndrome (transient tachypnoea of the newborn)3) meconium aspiration (selective)4) pneumonia5) apnoea of prematurity (not responding to aminophylline/caffeine)6) pulmonary oedema7) recent extubation8) tracheomalasia9) atelectasis10) phrenic nerve palsy

Contra-indications for nCPAP include:1) Severe cardio-respiratory instability2) Unstable respiratory drive with frequent apnoea and bradycardia3) Cleft palate, micronathia4) The need for intubation:

pH < 7.2 ( 7.25) PaCO2 > 8kPa (>60mm Hg)

Approach to applying nCPAP in newborn infants:1) Appropriate indications (RDS, wet lung, pneumonia, etc.)2) ECG/respiratory monitoring, invasive or non-invasive blood pressure monitoring, saturation monitoring3) Keep the infant nil per mouth initially and give intravenous fluids

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4) Nasogastric tube must be left on open drainage to prevent abdominal distension. It is important to monitor meconium passage.5) Select a nasal prong that will just fit into nasal passages. Tape Granuflex to septum and dorsum of nose tip and fix expiration tube to cap6) Set humidifier at 37C7) Start nCPAP at 4-6cm water. Observe response: oxygenation, retractions and if necessary, increase nCPAP to a maximum of 8-10 cm water.8) Obtain a chest X-ray and determine lung volumes (number of posterior ribs at level of diaphragm should not be more than eight)9) Keep oxygen saturation levels between 90 - 93% in premature infants and 94 –96% in term infants.

Failed nCPAP is characterised by:1) A pCO2 >8kPa (60mm Hg) or rapidly rising2) An intractable metabolic acidosis (BE > -10)3) Marked retractions not improving on nCPAP4) Frequent episodes of apnoea and bradycardia on nCPAP

Most babies who require >60% oxygen by 4 - 6 hours of age (unless very stable) will ultimately require intubation

Hazards associated with nCPAP in newborn infants- nasal obstruction – secretions or improper position of nasal prongs;- over-distention and reduced tidal volume, leading to:

pneumothorax (2%)CO2 retentionincreased work of breathing; impeded pulmonary blood flow.

- abdominal distension - swallowing air;- nasal irritation, septal and mucosal erosion or necrosis.- inadvertent decannulation

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Agitation of the infant during the administration of nCPAP may be reduced by:1) swaddling2) non-nutritive sucking3) breastfeeding4) therapeutic touch by parents and nurses

Weaning from nCPAP can begin when:1) The infant’s general condition is stable2) The FiO2 requirements are minimal and stable3) The nCPAP level required is minimal and stable (<2 cm)4) Consider nasal cannula oxygen at < 1 litre/minute rather than head box oxygen5) It’s a matter of trial and error!

In summaryIf used correctly and for specific indications, nCPAP is an effective method to manage newborn infants with mild to moderate respiratory distress and may prevent unnecessary intubations and ventilations. Monitoring of oxygen saturation levels during nCPAP is essential to prevent retinopathy of prematurity.

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FETAL HYPOXIA AND BIRTH ASPHYXIA

D WoodsDept of Paediatrics and Child Health, University of Cape Town

IntroductionIntrapartum hypoxia and birth asphyxia are both important causes of perinatal mortality and morbidity, especially in developing countries. Intrapartum hypoxia is defined as an inadequate oxygen supply to the fetal tissues during labour while birth asphyxia is defined as an inadequate breathing effort after delivery with the newborn infant requires resuscitation. These two terms are often confused with each other and therefore misunderstood. Measuring the burden of disease caused by intrapartum hypoxia and birth asphyxia is difficult in many developing countries where most infants are born at home, skilled attendants are not available and where data are collected by village health workers.

MethodTo address this problem and find simple, clinical markers of perinatal death due to intrapartum hypoxia we prospectively collected perinatal mortality data from the Peninsula Maternal and Neonatal Service in Cape Town. We reviewed all stillbirths and early neonatal deaths for the four year period from January 1999 to December 2002. Mortality details had been prospectively recorded using the Perinatal Problem Identification Program or PPIP data codes. We asked how the burden of intrapartum hypoxia and birth asphyxia could be measured in a developing country, and hypothesised that the two following criteria could be use as clinical markers of fatal intrapartum hypoxia:

1. The first hypothesis was that many fresh stillborn infants weighing 2000g or more at birth would have been coded as having died due to intrapartum hypoxia.

2. The second hypothesis was that liveborn infants weighing 2000g or more who had a one minute Apgar of 6 or less and subsequently died on days one or two would have also been coded as having died

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due to intrapartum hypoxia. These asphyxiated infants with low Apgar scores could be clinically recognised as they would not have cried or breathed well after delivery.

ResultsDuring the four year study period, 105 017 infants were born in our perinatal service, with a stillbirth rate of 24/1000 (2560) for infants weighing 500g or more. 28% (404) were fresh stillbirths and of these 345 met the weight criteria for inclusion into the study. During the same period, there were 951 early neonatal deaths giving an early neonatal mortality rate of 9/1000 for infants weighing 500g or more at birth. 21% (197) of these infants weighed 2000g or more at birth and of these 134 met the study criteria in that they had low 1 minute Apgar scores and died on day 1 or 2.

When the PPIP mortality codes of fresh stillborn infants of 2000g or more were reviewed, fetal hypoxia was the commonest recorded cause of death in 83% (287) of infants. An additional 17 infants probably also died from fetal hypoxia. The remaining infants died of infections (11) such as syphilis, congenital abnormalities (11), maternal illness (12) such as diabetes, and other less common causes (7).Using these PPIP codes, hypoxic fetal deaths could be divided into hypoxia during labour and hypoxia before labour. It was difficult to decide where hypoxic deaths due to placental abruption should be placed.The cause of stillbirth in 24% (69) of infants was coded as labour related hypoxia while a further 8% (22) were coded as other causes of intraparum hypoxia such as uterine rupture. Therefore a total of 32% of fresh stillbirths weighing 2000g or more were coded as having died of intrapartum hypoxia. If placental abruption (168 or 58%) is added to these, 90% of infants would have died of hypoxia during labour. The remaining 10% (28) probably died of antepartum hypoxic complications such as post maturity. These findings suggest that a high proportion of fresh stillborn infants of 2000g or more die from intrapartum hypoxia.

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The PPIP codes for the obstetric causes of death in liveborn infants of 2000g or more who had low one minute Apgar scores and died in the first two days of life. 35% (47) of these infants were coded as having died of intrapartum hypoxia. The remaining infants were coded as dying of congenital abnormalities (45), infection (12), antepartum haemorrhage (8), preterm labour (8) or other causes (14). If infants with obvious major congenital abnormalities were excluded from the analysis of these early neonatal deaths, intrapartum hypoxia now explained 60% of the deaths. Of interest, if the selection criteria were changed to only include infants with a one minute Apgar score of 0-3, the percentage who died of intrapartum hypoxia was almost the same at 58%. Therefore, these simple clinical criteria can be used to identify most early neonatal deaths due to intrapartum hypoxia.

ConclusionsIt is concluded that simple, easily recorded data on fresh stillbirths, and early neonatal deaths who do not breathe well after delivery and die during the first two days of life, can be used as reliable markers of the burden of perinatal mortality due to intrapartum hypoxia. This information could be collected by village health workers to monitor the impact of new interventions aimed at reducing the incidence of perinatal deaths due intrapartum hypoxia by better management of labour or better infant resuscitation at delivery.

Finally, a comment about ways of improving the ability of staff at hospitals and clinics to manage their own audits of perinatal deaths. In 2002, together with Bob Pattinson and David Greenfield, I wrote a supplementary manual for PEP on Saving Mothers and Babies. This increases the number of PEP manuals to 5. The 5 units in this latest manual cover all aspects of identifying causes and avoidable factors of maternal and perinatal death, how to manage mortality audits, and how to find solutions to the problems identified. With better audit of the outcome

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of pregnancy in South Africa, interventions can be instituted to lower both maternal and perinatal mortality and morbidity. Simple clinical markers of death due to intrapartum hypoxia could be monitored at sites not yet using the PPIP codes. Further information can be obtained from the Perinatal Education Trust at phone/fax: 021) 671 8030.

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PERINATAL DEATHS FROM INTRAPARTUM HYPOXIA

DH Greenfield, S FawcusDepartments of Neonatal Medicine and Obstetrics, UCT

IntroductionIn the Peninsula Maternal and Neonatal Service (PMNS) intrapartum hypoxia is the commonest cause of neonatal death and the 3rd commonest primary obstetric cause of perinatal death in infants with a birth weight of 1000g or more. In this study, Midwife Obstetric Unit (MOU) associated perinatal deaths related to intrapartum hypoxia, occurring between 1/7/2001 and 30/6/2002, were assessed. It forms part of a larger study of perinatal hypoxia in the whole of the PMNS. A similar study was done in 1992, making it possible to assess changes, if any, which have occurred.

MethodsAll the perinatal deaths of term infants, with a birth weight of 2500g or more, which were born before arrival at a MOU, were born at a MOU, or were transferred in labour from a MOU to hospital, were identified and the records requested. A control group of normal term infants without evidence of perinatal hypoxia was identified and their records also requested. These infants were selected as being the next normal delivery after the “case”, and who in other respects fitted the selection criteria for the “cases”.The records were assessed for the quality of antenatal and intrapartum care, infant resuscitation, and the condition and management of the infant. Maternal and infant profiles were also recorded.

ResultsTwenty three deaths due to intrapartum hypoxia were identified in the 19 192 deliveries during this period. In 8 of these patients the patient records could not be found, and in a further 2 patients the notes were incomplete. Thus 13 patient records were available for assessment. Fifteen of the 23 records of the control patients were obtained.

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In 1992, there were 36 perinatal deaths related to intrapartum hypoxia in the 17 707 deliveries. There was therefore a 36% reduction in the number of cases.

Eleven of the 13 “cases” spoke Xhosa as a first language. This ratio of Xhosa speaking to English/Afrikaans speaking patients in the whole service is approximately 50%/50%.

Maternal profilesThere was no significant difference between cases and controls for maternal age, parity, height or body mass index. However, the mothers of the affected infants were somewhat older and of greater parity than the cases studied in 1992.

Infant profilesCases Controls

Mean birth weight 3201 3151Not statistically significant

Mean head circumference 34,1 33,9

In 1992 the cases were significantly bigger than the controls.

LabourCases Controls

Cervical dilatation on admission (cm) 6.6 4.8Rate of cervical dilatation (cm / hr) 1.2 1.7Descent of the head (1/5 per hr) 1.4 0.7

In 1992, the rate of cervical dilatation was significantly slower than in the controls. However, as in the present study, the rate of dilatation was still faster than I cm / hour – the “alert” line on the partogram.

Fetal heart rate monitoring in labourIn both cases and controls, the fetal heart rate was monitored infrequently (sometimes there was no record at all) and decelerations were often not assessed. There was no difference between the cases and controls.

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Complications in labourProlonged latent phase 1“Poor progress” 2Prolonged active phase 1Unexplained APH 1Hypertension 1Breech 1Prolonged second stage 3Breech with delay in after-coming head 1

In the control patients, there was 1 patient with “poor progress” in the 1st

stage and 1 patient with a prolonged 2nd stage.

Avoidable factorsPatient related

Coming late in labour 1

Medical staff relatedPoor progress: partogram not used correctly 1Fetal distress not detected: not monitored 1Prolonged 2nd stage – no intervention 3Delay in referring to 20 / 30 hospital 2No response to post term pregnancy 1Inadequate neonatal resuscitation 1

ConclusionsThere has been a 36% reduction on the number of cases of perinatal death from intrapartum hypoxia since 1992

There has been a change in the patient profiles of both mothers and infants. In both mothers and their infants, there was very little difference between the cases and controls.

In labour there was less difference in the length of labours between cases and controls than was the case in 1992, though the labours do tend to be longer in the cases. However the mean rate of cervical dilatation in the cases is faster than 1cm/hour – ie when plotted it would be to the left of the alert line on the partogram.

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There was generally poor monitoring of the fetal heart rate during labour.

The improvements may be due to a heightened awareness of the problem and therefore earlier interventions.

It is also possible that even though the mortality has decreased, these patients may have been added to the morbidity figures. This assessment will be part of the larger study on hypoxic ischaemic encephalopathy.

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SERUM PROCALCITONIN AS AN EARLY MARKER OF NEONATAL SEPSIS

DE Ballot, O Perovic, J GalpinUniversity of the Witwatersrand and National Health Laboratory Service

IntroductionNeonatal sepsis presents a diagnostic and therapeutic dilemma, signs of sepsis are vague and non-specific and there is no single reliable laboratory marker of sepsis available at the time of presentation. Thus many infants are evaluated and treated with parenteral antibiotics for suspected neonatal sepsis while awaiting final blood culture results. Less than 10% of these babies have culture proven sepsis. This results in unnecessary hospital admissions and use of expensive drugs. Various markers of inflammation, including IL6 and C reactive protein (CRP) have been evaluated as a means to rule out sepsis at the time of presentation. The best prediction is obtained over time using a combination of markers.

Procalcitonin (PCT) is a protein preferentially induced in bacterial sepsis, especially in severe sepsis and septic shock. PCT levels remain low in patients with systemic inflammation of non-bacterial origin. PCT can therefore be used to discriminate systemic inflammation due to bacterial sepsis from that due to other causes. PCT has been reported to be a valuable marker for the diagnosis of neonatal sepsis. The present study was to evaluate procalcitonin as a single early marker of neonatal sepsis.

Subjects and MethodsThe study was conducted in the Neonatal unit of Johannesburg hospital between April and August 2002. All neonates undergoing sepsis evaluation were eligible for inclusion in the study. The baby was entered on to the study after written informed consent was obtained from the parent or guardian. The sepsis evaluation included a full blood count (FBC) with total and differential white cell count, platelet count, C reactive protein (CRP 1) and blood cultures. The CRP was repeated after 12 to 24 hours after presentation as per the unit policy (CRP 2). Cerebrospinal fluid

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and urine cultures were done as clinically indicated at the discretion of the attending physician. All babies were started on parenteral antibiotics pending repeat CRP and / or final blood culture results. A serum procalcitonin was done at the time of the initial sepsis evaluation.

Statistical analysisBabies were grouped into different categories of infection, without knowledge of the procalcitonin results, as follows: No infection– negative blood cultures with normal CRP1, CRP 2, platelet

count and WCC. A single low platelet count or abnormal WCC was not considered to be a reliable marker of infection and such babies would be included in this group.

Possible infection– negative blood cultures with abnormal CRP1 and CRP 2 or a combination of at least two of abnormal platelet count, WCC, CRP1 and CRP 2. Definite infection – positive blood cultures with any abnormal CRP 1, CRP 2, platelet count or WCC.

Contamination –positive blood cultures with normal CRP1, CRP 2, platelet count and WCC.

The serum PCT levels were then evaluated between the different categories of infection.

Descriptive statistics included mean and standard deviation for continuous variables and proportions for categorical variables. The distribution of the data was skewed so non-parametric statistics were used. Kruskal Wallis one-way analysis of variance was done to determine whether any variables differed significantly among infection categories. Spearman rank correlation and logistic regression were also done to determine the best predictors of infection. ROC analysis was done to evaluate the predictability of procalcitonin for infection.

ResultsTwo hundred and sixteen patients were entered on to the study – 28 were excluded due to incomplete data (e.g. missing blood culture results, no

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procalcitonin levels obtained). A further 5 babies classified as having contaminated blood cultures were also excluded. There were thus 183 babies in the final analysis. The mean birth weight was 1996 grams (SD 893) and gestational age 34.6 weeks (SD 4.3). There were 13 babies with definite infection, 52 with possible infection and 118 with no infection. The PCT levels for the various categories of infection are shown in Table 1.

Table 1: Procalcitonin levels among the different infection categories

Category

PCT level (Mean)

SD

None 1.68 4.15Possible 13.69 30.11Definite 8.53 9.79

One-way analysis of variance (Kruskal Wallis) showed that the birth weight, gestational age, platelet count and procalcitonin differed significantly among the different infection categories. (CRP 1 and 2 were used to determine the infection category and can therefore not be included in the analysis). Spearman rank correlation showed that procalcitonin correlated significantly with CRP 1 (p = 0.000 correlation coefficient 0.404) and with CRP 2 (p = 0.000 correlation coefficient 0.343). Logistic regression was done using no infection versus any infection (possible/definite) and no infection vs. definite infection. PCT alone correctly predicted 72.5% of any infection and 89.2% of definite infection. If birth weight, gestational age and platelets were added into the equation, the prediction improved to 79.1% and 90.4% respectively.

Using a cut off of < 0.5 ng/ml for procalcitonin, the following results were obtained (Table 2).

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Table 2: Predictive values for PCT < 0.5 ng / mlInfection category

Sensitivity

Specificity

Positive predictive value

Negative predictive value

None vs. possible / definite

0.78 0.5 0.46 0.8

None vs. definite

0.769 0.5 0.14 0.95

ROC analysis using PCT to predict no infection vs. any infection gave an odds ratio of 1.148 (95% confidence intervals 1.06 to 1.23) with an area under the ROC curve of 0.75. The odds ratio for no infection vs. definite infection was 1.145 (95% confidence intervals 1.05 to 1.25). The area under this ROC curve was 0.778.

Discussion and ConclusionsAlthough PCT differed significantly among the different categories of infection, the PCT level in those with definite infection was in fact lower than those with possible infection. More detailed evaluation of the value of PCT in the diagnosis of neonatal sepsis showed that PCT is not a sufficiently accurate predictor of neonatal sepsis to be used as a reliable single marker on presentation of the patient. The sensitivity of PCT considering no infection versus any infection was only 78% and the negative predictive value 80%. These values are too low to allow PCT to be used reliably to rule out sepsis and withhold antibiotic therapy and admission to those infants with suspected neonatal sepsis.

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FETAL ALCOHOL SYNDROME: A SOUTH AFRICAN PERSPECTIVE

DL ViljoenDivision of Human Genetics, National Health Laboratory Service, Faculty of Health Sciences, University of the Witwatersrand

IntroductionFetal alcohol syndrome (FAS) is the most common preventable cause of mental retardation worldwide. In South Africa, amongst socio-economically comprised populations of the Northern Cape, Gauteng and Western Cape Provinces, the prevalences of FAS have reached endemic proportions. Maternal risk factors associated with FAS have been ascertained and are presented in this paper.

MethodsThe communities under study were invited to participate in the various projects and evaluated by clinicians, neuropsychometrists and persons trained in interview techniques and who were culturally sensitive to the populations being evaluated. Ethics and Review Committee approval from either the University of the Witwatersrand or Cape Town were obtained for each project as were I.R.B approvals from Collaborating Institutions in the USA. (University of New Mexico, Wayne State University, UCSD, National Institutes for Health and Centres for Disease Control and Prevention). School-entry children were evaluated in high risk populations from the three provinces by means of :-

1) Screening:Using data obtained from the original study undertaken in the Western Cape, it was ascertained that “cut-points” for height, weight and head circumference on or below the third centile were extremely accurate in defining the population at risk for FAS (only 1 child of 48 ascertained with FAS escaped the screening criteria). The screen positive children (i.e. those on or below the 10th centiles per height, weight and head circumference) were then further evaluated by:

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2) Dysmorphic evaluationThis was undertaken separately by two clinicians previously trained in the recognition of FAS. The children evaluated were then categorized as:- having FAS- not having FAS- deferredThe “deferred” children were those with multiple clinical stigmata but insufficient for a full, confident diagnosis of FAS. Notes were compared between the clinicians if any discrepancy greater than 2mm in the facial measurements occurred, or if one clinician made a diagnosis different from the other. After consultation, the child would then be catergorised into one of the above 3 diagnoses.

3) Neurodevelopmental AssessmentsThe FAS and “deferred” groups would then undergo neurodevelopmental assessment using a panel of tests administered by a trained psychometrist. The table of tests administered are shown in Table 1.

4) Maternal InterviewsEach mother of a child previously designated as “FAS” or “deferred” would be interviewed by a skilled, trained interviewer in her first language using a standardized questionnaire which had been previously piloted in the community under study. Demographic details and substance abuses of any kind were recorded and analysed.

5) Control ChildrenControls were randomly selected for each of the “FAS” or “deferred” children and matched for age, ethnicity and sex. These children also underwent physical examination, neurodevelopmental testing and maternal interview. Their data formed the normal values for that population against which the “FAS” and “deferred” children were compared during the Case Conference.

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6) Case ConferenceAll the data for the above children was presented at a case conference and children were finally re-allocated to the categories: FAS, not-FAS, or deferred. Approximately 60-70% of “deferred” cases then qualified for the category of full FAS.

ResultsThese are summarised in Table II for more than 5000 children (and their controls) evaluated in the 3 provinces.

As can be seen, the mean of screen positive children in the Northern Cape (NCP) amounted to approximately 55% of the evaluated population whereas only approximately a third of children in the Western Cape and Gauteng Provinces were stunted or undergrown. This reflects the poor nutritional status of children in the NCP and, perhaps, their propensity to demonstrate signs of FAS if their mothers abused alcohol.

The school-entry children of all three provinces demonstrate very high prevalences for FAS. These are greater than for any other population groups reported elsewhere in the world. The public health implications for South Africa are, therefore, immense as the frequency of FAS exceeds the burden of disease for all other birth defects and genetic disorders combined. It is strongly urged that prevention and intervention modalities should be introduced as an emergency in all at risk communities in this country.

Finally, the 3 studies in the WCP were all undertaken by the same research personnel, amongst the same communities using the same methodologies. Alarmingly, the prevalence of FAS has increased steadily from 46,4/1000 in 1997 to an estimated 100,2/1000 in 2002 suggesting an increasing prevalence of alcohol related birth defects in this population. Health planners should be aware of this catastrophic situation.

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Table 1All deferred or FAS-affected children and a normal control selected for each with the same sex and ethnic group and from the same class, were then evaluated by trained psychometrists using the following panel of tests:1) Draw A Person (Good enough Version)2) Raven Coloured Progressive Matrices3) Visual-Motor Integration Test4) Visual Perception Test5) Motor Coordination Test6) Test for Reception of Grammar (TROG)7) Subtests of the Junior South African Individual Scale (below 7 years):8) Subtests of the Senior South African Individual Scale (7-18 years);

Table II: Prevalence Of Fetal Alcohol Syndrome In Three Provinces

PROVINCE CHILDREN SCREENED

SCREEN POSITIVE

FAS DEFERRED

FAS PREVALENCE

WESTERN CAPE

1997 988 (not calculated)

46 7 46,4/1000

1999 863 (not calculated)

64 11 74.7/1000

2002 818 360 (44%) 32 76* 100.2/1000**GAUTENG (2000)AREA 1

161 58 (36%) 3 1 19/1000

AREA 2 176 40 (22.7%) 0 3 0/1000AREA 3 253 84 (33.2%) 3 0 12/1000AREA 4 244 98 (40.2%) 9 1 37/1000NORTHERN CAPEAREA 1 (2001)

534 291(54.5%) 55 10 103/1000

AREA 2 (2002) 1354 755 (55.8%) 71 29* 52/1000**GRAND TOTALS 5391 1635

(46.2%)283 93** 65.5/1000

* NOT FULLY APPRAISED AS YET** ESTIMATED

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FETAL EFFECTS OF IN UTERO EXPOSURE TO WARFARIN: PAST, PRESENT AND FUTURE.

N Gregersen, D Viljoen, Division of Human Genetics, National Health Laboratory Services and the University of the Witwatersrand

IntroductionAnticoagulation in pregnancy can be achieved with oral anticoagulants like warfarin, or with parentally administered drugs like unfractionated heparin (UFH) or low-molecular weight heparin (LMWH). Warfarin crosses the placenta and is a known human teratogen, and can cause either the warfarin embryopathy or central nervous system (CNS) abnormalities. Heparin does not cross to the fetus, but is not without side effects to the mother.

The most consistent feature of warfarin embryopathy is nasal hypoplasia due to underdevelopment of the nasal cartilage, and choanal atresia may occur. It also encompasses other skeletal abnormalities; stippling of the epiphyses of the axial skeleton, calcanii and proximal femoral epiphyses is common, and other skeletal defects noted include hypoplasia of the extremeties (from rhizomelic limb shortening to mild brachydactyly), dystrophic nails, and abnormal skull development. The fetal CNS sequelae of maternal warfarin ingestion in pregnancy include perinatal fetal cerebral haemorrhage and structural abnormalities. These structural abnormalities include hydrocephalus, dorsal midline dysplasia of the brain (resulting in agenesis of the corpus callosum, Dandy – Walker malformations, encephalocoeles, and midline cerebellar atrophy), and ventral midline dysplasia (resulting in optic atrophy). Complications of these malformations include seizures, mental retardation, spasticity, deafness, and blindness. Most babies born with CNS malformations after in utero warfarin exposure do poorly, while 50% with warfarin embryopathy do well.

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PastPreviously, warfarin was prescribed in pregnancy for thrombophlebitis, pulmonary embolic disease, hypertension, pre-eclampsia, antithrombin III deficiency, and anticoagulation in the presence of prosthetic heart valves. The first report of warfarin embryopathy was published in 1966 by DiSaia, who described a fetus, exposed to warfarin in utero, with nasal hypolplasia, respiratory distress, stippled epipyses, optic atrophy and mental retardation. Hall et al published a review of 471 cases of in utero exposure to warfarin in 1980. They concluded that warfarin embryopathy only occurred if the fetus was exposed to warfarin between 6–9 weeks of pregnancy, but that the CNS malformations could be produced by fetal warfarin exposure throughout pregnancy. They found that warfarin exposure in pregnancy resulted in spontaneous abortion in 10% of cases, stillbirth in 8%, and warfarin embryopathy/CNS effects in 10% (overall 28% deleterious effects). A study published in 1989 from Baragwanath Hospital, South Africa, showed that in a group of 49 women taking warfarin throughout pregnancy, 40% had a poor pregnancy outcome.

PresentWorldwide, the following are the current recommendations for anticoagulation in pregnancy:1. For the prevention and treatment of venous thromboembolism

(VTE), UFH or LMWH should be used.2. For prophylaxis of VTE in women with a known thrombophilia (eg.

Antithrombin III deficiency), UFH or LMWH can be used effectively.3. Prevention of pregnancy loss in women with antiphospholipid

antibodies can be achieved with low-dose aspirin and heparin.4. For anticoagulation in the presence of prosthetic heart valves:

4.1) warfarin may be used throughout pregnancy and then heparin substituted from 35 weeks, or

4.2) heparin may replace warfarin from 6 – 12 weeks and again from 35 weeks, or

4.3) unfractionated heparin or low-molecular weight heparin may be

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used throughout pregnancy.Anticoagulation in the presence of prosthetic heart valves is the commonest reason for pregnant women in South Africa to be on warfarin since rheumatic heart disease is still prevalent and often results in heart valve replacement.

A recent review by Ginsberg et al, published in 2001, showed that the risks of maternal thromboembolic complications in women with prosthetic heart valves are higher when warfarin is not used in the first trimester (regimen 4.2 above) or at all in pregnancy (4.3 above), but that the fetal risks for malformation are lower in these categories than when warfarin is used.

Table 1 Maternal and fetal effects of anticoagulation in women with prosthetic heart valves. (adapted from Ginsberg et al, Chest 2001; 119: 122S – 131S)

Regimen Fetal wastage* Fetal anomalies Maternal TEC OA throughout, with/without heparin at 35 weeks

33.6 % 6.4 % 3.9 %

OA initially, heparin before/at 6 weeks, OA 2nd trimester, heparin >35 weeks

16.3 0 9.2

OA initially, heparin > 6 weeks, OA 2nd

trimester, heparin >35 weeks

35.7 11.1 9.2

Heparin throughout (4.3)

42.9 0 33.3

*Fetal wastage includes spontaneous abortion, stillbirth and neonatal death.Abbreviations: OA = oral anticoagulation, TEC = thromboembolic complications.

A retrospective analysis of pregnant Italian women requiring warfarin for anticoagulation of mechanical heart valves, published in 2002, showed that the fetal effects of warfarin may be dose-related. Forty- six percent of the study group was taking >5 mg warfarin/day, and a poor pregnancy outcome (spontaneous abortion, stillbirth or congenital defect) occurred in

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90%. The remaining patients, taking ≤ 5mg/day, only had a 10% incidence of the same poor outcome.

It appears that heparin is suboptimal in preventing TEC in pregnant women with prosthetic valves. When it is used, high dose regimens are recommended, with careful monitoring of anticoagulant effect to ensure adequacy of treatment. Since warfarin provides adequate anticoagulation in this group of patients and is cheap and easy to administer, and appears to be less teratogenic in low doses, it makes sense to find ways to tailor patients’ medication to ensure the lowest dosing possible. This may be achievable in the future with genotyping of patients. FutureRecently, genetic variants have been found in the CYP2C9 hepatic microsomal enzyme that primarily metabolises warfarin. Patients with alleles of the CYP2C9 gene different to the wild-type genotype metabolise warfarin less efficiently, and are therefore at higher risk for overanticoagulation and bleeding on standard doses of warfarin. One hypothesis is that women homozygous for the wild-type CYP2C9 allele, who require the highest maintenance doses of warfarin, are at most risk for having fetuses affected with warfarin embryopathy, particularly where the fetus has one variant CYP2C9 allele.

A study performed in the United States of America found different allelic variants in the Caucasian and African American populations, and the variants are therefore specific to the ethnicity of the patient. We are currently determining the variants in the CYP2C9 gene specific to the black South African population. This information will be used in a larger study where we hope to correlate the obstetric outcomes and prevalence of warfarin embryopathy in women on warfarin, with the CYP2C9 genotypes of these women and their offspring. This future study will be an international collaborative research project involving the University of California, San Diego and the Department of Human Genetics (Wits).

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It is probable that in the future warfarin therapy may be tailored to a patient’s genotype, and the prediction of a couple’s risk of having a baby affected by warfarin embryopathy may be possible based on their CYP2C9 alleles.

* References available from Dr Gregersen on request.

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CONGENITAL MALARIA: A CASE PRESENTATION

A Moodley; MA AdhikariNeonatal ICU, King Edward V111 Hospital/Dept of Paediatrics, University of Natal –Durban

Congenital malaria, especially in the premature infant is rare. Plasmodium falciparum is the organism most commonly implicated. Pregnant women are at greatest risk of developing malaria, with an often atypical and more severe presentation.

ObjectiveTo describe a case of congenital malaria.A set of non-identical 30 week premature twins were delivered vaginally to a 25 yr old Gravida 2 Parity 1. Mom was diagnosed with malaria 3 days prior to delivery and treatment with quinine was initiated. She gave a history of recent travel to Nongoma [malaria endemic area]. Both twins had similar clinical presentations of a non-specific respiratory illness, requiring ventilatory support, and a persistent metabolic acidosis. Twin 2 demised from a major intraventricular haemorrhage on D4. Twin 1 tested positive for malaria on the third screening. He was treated with quinine and cotrimoxazole for 5 days. Repeat smears were negative for malaria. The patient was thought to have cardiac side effects of quinine and recovered well on withdrawal of the drug. Mom was later found to be HIV infected.

DiscussionMaternal malaria and more specifically, placental infection, has an impact on fetal and neonatal survival survival, decreases mean birth weight and contributes to neonatal and infant anaemia. Time to presentation varies from a few hours to weeks. Common clinical presentations are fever, anaemia, hepato/splenomegaly, jaundice and respiratory distress. Intravenous quinine is the drug of choice in resistant areas, but safety and dosing has not been studied in premature newborns.

ConclusionThis presentation discusses some aspects of congenital malaria and highlights the difficulty in diagnosing and treating premature newborns. Consideration must be given to the impact of HIV infection in our context.

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THE ANTEPARTUM AND INTRAPARTUM COURSE OF MOTHERS DELIVERING BABIES WITH BIRTH ASPHYXIA AT TYGERBERG HOSPITAL

S Nosarka, GB Theron, D GrovèUniversity of Stellenbosch, Dept. of Obstetrics and Gynaecology, Tygerberg Hospital.

ObjectivesTo identify potential antenatal and intrapartum maternal risk factors for birth asphyxia. To evaluate the antenatal course of all babies whose mothers met the inclusion criteria.

Study DesignA retrospective, descriptive study over a 1 year period (1 July 2000-30 June 2001). Inclusion criteria: Mothers of all inborn babies with a birth weight 1800 grams and a 5 minute Apgar score 6.

Data AnalysisThe Tygerberg labour ward register was examined, all relevant patient folders were obtained and a data sheet was completed.

ResultsA total of 136 mothers met the inclusion criteria. The incidence of birth asphyxia at Tygerberg Hospital was 3.7%. Most mothers resided locally (91%), were booked (97%) and had regular clinic attendance (average seven visits). Primigravidas constituted 48.5% of the study population. The average gestational age (GA) at delivery was 38 weeks. Prior to delivery 35 (26%) patients had non- reassuring fetal heart rate patterns. The incidence of caesarean sections in this group was 97%. A prolonged first stage of labour occurred in 10 (25%) primigravidas and 4 (10%) multigravidas. One caesarean section was performed in this group and this baby died neonatally. A prolonged second stage of labour occurred in 8 (22%) primigravidas and 3 (8%) multigravidas. No caesareans sections were performed or neonatal deaths occurred in this group. The overall caesarean section rate was 41.9% with fetal distress the indication in 68.4% of these patients. Normal vertex deliveries occurred in 62 (45.6%) patients. Eight (5,9%) ventouse and seven (5,1%) breech deliveries occurred. Twelve neonatal deaths occurred (8.8%). The average GA at delivery in this group of patients was 36.7 weeks. This was significantly lower (p=0.03) than the group whose babies were discharged alive. The average 5 and 10 minute Apgar score was statistically significantly lower in this group.

ConclusionThis study did not identify any significant antenatal risk factors. Non-reassuring fetal heart rate patterns prior to delivery were found to be a very important risk factor for intrapartum asphyxia. Prolonged first and second stage of labour are also definite risk factors for asphyxia and need

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to be evaluated correctly. Perhaps more instrumental deliveries should be performed in the group with a prolonged second stage.

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SKILLED ATTENDANCE AT DELIVERY

WJ GrahamDugald Baird Centre for Research on Women’s Health, University of Aberdeen

“Ensure skilled attendance at delivery” is one of the ten action messages from the Tenth Anniversary conference of the Safe Motherhood Initiative held in Colombo in 1997. Since then many governments and international agencies have acted on this message and re-focused their programmatic priorities for maternal health. The importance of skilled attendance was further emphasised through the United Nations Millennium Declaration, with the “proportion of deliveries with skilled attendants” proposed as a proxy indicator to measure progress in reducing maternal mortality. In practice this indicator translates into measuring the proportion of deliveries with health professionals since these data are available on a population basis for a large number of developing countries through the Demographic and Health Surveys. A target has been set for this indicator for 2015 of 90%. Recent projections for major world regions suggest that only Latin America and the Caribbean are likely to achieve this, whilst the situation for the African region as a whole is expected to remain static. This is perhaps not surprising given the acute shortage of health professionals in many sub-Saharan African countries – a shortage arising from a complex of factors, including losses owing to migration overseas and, in some parts, to HIV/AIDS. Under these challenging circumstances the options for improving skilled attendance in specific health settings need to be re-examined, as well as the evidence for prioritising this strategy for safe motherhood.

Correlational analysis of the maternal mortality ratio and the proportion of deliveries with health professionals (doctors, nurse and midwives) at the national level shows a weak negative relationship when only developing countries are included. This type of analysis suffers from the problem of the ecological fallacy, and cannot be used to infer causation – in other words, that by increasing deliveries with health professionals, maternal

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mortality will decline. Correlation techniques can still be informative if sub-analysis is conducted according to, for example, place of delivery and category of health professional. For example, using DHS data from 56 developing countries reveals a strong positive correlation (R2=84%) between deliveries with health professionals and deliveries in health facilities, thus indicating that for many countries the vast majority of doctors and midwives only attend births in clinics and hospitals. Similarly, correlational analysis of national proportions for deliveries with midwives and with doctors shows interesting patterns when stratified by estimates of the maternal mortality ratio. The indicator generated by examining deliveries in relation to these two categories of health professionals has been named the Partnership Ratio.

Although some useful insights can be gained from international comparisons, it is crucial that differentials within countries are also explored. Again using DHS data, differences in the uptake of delivery with a health professional can be explored according to demographic, reproductive, geographic and socio-economic co-variates. The 1998 South Africa DHS, for example, shows wide variations in the proportions of those receiving professional attendance between provinces, ranging from 75% in Eastern Cape to 97% in Western Cape. A number of publications have also shown huge variations within countries by poverty quintiles as measured through asset ownership by the DHS, with up to 18-fold differences in the proportion of deliveries attended by health professionals between women in the poorest versus the richest groups.

The concept of skilled attendance, however, embraces much more that just the presence at delivery of a health professional. There is evidence from any studies indicating that possession of a professional label – be this doctors, midwives or nurses, does not guarantee the possession of the skills necessary to manage normal or complicated cases. Thus measuring progress in terms of deliveries with health professionals is not necessarily equivalent to deliveries with skilled attendants. Moreover, no matter how

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skilled providers are, they also need to be supported by a functioning health service that includes the required equipment, supplies, drugs and infrastructure as well as a referral system. Similarly services need to be accepted and acceptable to communities. Skilled attendance at delivery encompasses all these elements and progress should ultimately be judged for this composite rather than the separate components. Unfortunately, there are few measurement tools currently available that capture this holistic concept of skilled attendance. One recently-developed approach uses an adaptation of criterion-based clinical audit to derive an index of quality of care encompassing both the provider and the service components. This Skilled Attendance Index (SAI) was developed as part of an international research partnership and involved reviewing delivery case-notes at all service levels. The SAI has been used in five developing countries, and is now available as part of a comprehensive guide to facilitate the development of strategies to improve skilled attendance at delivery.

Having accepted the concept of skilled attendance, further specification of the content depends on the context – nationally and for specific geographic or service provision units. Options for improving skilled attendance will also need to be identified according to the barriers and facilitators of progress in specific situations. Acute shortages of skilled attendants, for example, may be addressed by update courses where professionals are available but lacking required skills, or by considering the sharing between cadres of roles and responsibilities for different aspects of care where there is an absolute lack of professionals. The latter may in some instances necessitate the training of a non-professional cadre to work alongside doctors, midwives and nurses. History shows a variety of models by which delivery services have developed in different countries and health systems – models which involve a balancing type of birth attendant and place. Both dimensions encompass a continuum from lay attendant through to consultant obstetrician, and between home through to tertiary level services.

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Regardless of the strategy adopted for improving skilled attendance it is essential that mechanisms are put in place to monitor progress. This requires tracking not only indicators of the inputs and processes, but also the outcomes. There is currently inadequate evidence to indicate which strategies for achieving skilled attendance are most effective and cost-effective in specific health systems and country settings. Without reliable information on health outcomes, policy-makers and programme managers will continue to make crucial decisions regarding resource allocation without confidence in expected health gain. Demonstrating the effectiveness and cost-effectiveness in alternative safe motherhood intervention strategies, including skilled attendance, in specific contexts, is the primary rationale for a major new international research initiative – IMMPACT (Initiative for Maternal Mortality Programme Assessment).

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FIRST DELIVERY EXPERIENCES(AN ANALYSIS OF STUDENT REFLECTIVE COMMENTARIES)

G DraperUniversity of Cape Town

IntroductionIt is possible to learn from life’s experiences irrespective of whether they are good or bad. It is increasingly recognised in an academic environment that formal reflection on experience gained can play a role in enhancing both learning and professional practice (Butler, 1996). This was explored in a 4th year obstetric training programme at the University of Cape Town. This paper reports on the results of that exercise.

What is reflection? According to Boud, Keogh and Walker (1985), reflection “in the context of learning is a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations” There are 3 modalities, each of which can assist learning in a particular manner. On the basis of reflection to action one can design actions and reactions. Whilst reflecting in action one can modify actions and learn within the carrying out of designed action and by reflecting on action one can retrospectively evaluate and learn from remembered actions (Butler 1996). Hatton and Smith have described various types of student writing (Pee et al, 2002). Only three are regarded as being truly reflective. There is descriptive writing which is not reflective but merely reports events with no attempt to provide reasons. Descriptive reflection provides reasons (often based on personal judgment) although only in a reportive way. Dialogic reflection is a form of discourse with one’s self, mulling over reasons and exploring alternatives. Critical reflection takes account of the sociopolitical context in which events take place and decisions are made (roles, relationships, responsibilities, gender, ethnicity, etc)

Various qualitative methods of analysing written (or verbal) material are available. These included textual analysis, discourse analysis and critical

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discourse analysis. Just what constitutes discourse depends on which discipline is being quoted. For speech act theorists any utterance longer than a sentence is a discourse. Others see discourse as much more than that and regard Discourse as a saying (writing) – doing – being – valuing – believing combination (Gee, 1996). Critical discourse analysis is an attempt to go beyond linguistic description to attempt explanation and to show how social context and inequalities within that context are reflected in language. It is a combination of a micro analysis of text and a macro analysis of social formations, institutions and power relations that are indicated and described in the text (Luke, 2002).

MethodIn order to explore this aspect of learning, medical students were asked to reflect on their first delivery experiences and record this in the form of a written reflective commentary. Brief guidelines were provided (See Appendix A). Participation was voluntary and was portrayed as an exercise for the benefit of the student rather than the teacher. It was not part of the formal assessment process.

ResultsAt the time of writing 50 of the total group of 139 students responded (36%). The male/female ratio was 11/39 (1:3.5). The M/F ratio for the larger group was slightly different 41/98 (1: 2.4). The difference is not statistically significant. Table 1 shows the level of reflection.

Table 1 Level of Reflection

Level of reflection No of studentsCritical reflection 22Descriptive reflection 15Descriptive - not reflection 10Dialogic reflection 1

Table 2 reflects the issues that were reflected on.

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Table 2 Issues Reflected On (N = 50)

Issues No of studentsOwn role in the management of patients

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Pain and suffering 36The actual birth 34Midwife’s role in caring for the patient

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Gender issues 10Life and death and coping with loss 9Personal identity 9Own birth or whether to have children

9

Awareness of HIV 3

Regarding their own role in the management of patients students variously felt unsure, encouraged, amazed at patient trust and demoralized by nursing staff. When faced with the pain and suffering of the patients they wanted to help but felt helpless and at times were disturbed by the lack of care. In their comments about the actual birth fifteen were positive, fourteen made more neutral comments and four were negative. When commenting on the role modeling provided by midwives the group of responders was more or less evenly divided between those who saw the midwife as being supportive and a good role model and those who felt a negative model had been portrayed. Comments on gender issues indicated a new appreciation for what women went through during the process of labour. Some students clearly had to face issues related to life and death and how to cope with loss. Generally it was the need to respond to obstetric loss but in some instances it was previous personal loss that came to the fore. Issues of personal identity also came up and this related mostly to an affirmation of their decision to study medicine. Some personalized the birth experience and related it to their own birth, their mother’s experience or whether or not to have children of their own. A surprisingly small number revealed an awareness of HIV/AIDS and this was limited to the Mother to Child Transmission aspect.

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DiscussionThe process of reflection and the commitment of that to paper created an opportunity to do analysis that led to a reflective process of its own. A number of insights have been gained and lessons learnt. These relate to the teaching process, student support, the assessment of students and a various power issues.

With regard to teaching we need to look at what we are teaching to ensure that we equipping students adequately, who is teaching and the quality of the professional role modelling provided

There needs to be an awareness of the fact that students are dealing with personal issues and an appropriate support system that recognises and helps students in crisis needs to be in place.

The reflective commentaries represent a new “way of knowing” for both student and assessor and should ultimately become part of the formal assessment process.

In an obstetric situation power relations become evident in interpersonal relationships. These include teacher/student, health worker/patient, mother/baby and gender issues. Problems identified in these areas need to be faced honestly and dealt with more appropriately and directly than they have been up to now.

ConclusionThe main focus of the comments above has been the student. Clearly there have also been insights that relate to the patients and the quality of care provided to them. The reflective commentaries provide a unique insight into the lives of the students and the service of which they have become a part. The insights can and should translate into benefits for all the role players. It is a tool that should be used with great wisdom and sensitivity.

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It is appropriate that a student should have the final word. She writes:

ON REFLECTION - An experience that has changed my lifeIt has been these moments that have changed me.It hasn’t been pretty. It’s been beautiful and ugly and bewildering and very, very real. A classroom of life.And what it’s taught me most is that to be with someone in their pain, really with them, touches both mourner and comforter with a divine presence that reminds us what it is to be human.

APPENDIX A

BECOMING A R EFLECTIVE PRACTITIONER

Drawing on your recent experience, reflect and discuss how your first delivery experience has:

1. Affected you as a person 2. Shaped your understanding of the role of the midwife as teacher and

model 3. Given you insight into the needs of mothers in labour

You are welcome to share any other insights that you have gained. This assignment is not for marks. It is intended to make you stop and think about your experience in the knowledge that this facilitates learning. Keep it simple – not more than 400 words

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THE USE OF ANALGESIA IN LABOUR WARDS IN TWO DISTRICT HOSPITALS

Loveday Penn-Kekana, Duane Blaauw, Helen SchneiderCentre for Health Policy. School of Public Health. University of the Witwatersrand. Health System’s Development Programme. Funded by DFID.

Introduction & Background

Although the majority of the attention in the maternal health field has been on avoiding maternal mortality and morbidity, there is an increasing recognition that good quality maternal health care should be more inclusive and consider care that “satisfies the women, their families and care providers” (Pitroff et al, 2002). Giving analgesia to women who request it must therefore be seen as part of providing a good quality service for women.

In the Guidelines for Maternity Care in South Africa which were produced for clinics, CHC and District Hospitals (DOH 2002) it is stated that “analgesia should not be withheld from women in labour”. Methods that it recommends are support and companionship, inhaled entonox (50/50 oxygen/nitrous oxide mixture) by mask especially in the late first stage and pethidine 100mg IM with promethazine 25mg IM 4 hourly both in latent and active phases, even up to full dilation.

Pain relief for women is however “often neglected in public maternity hospitals” (Fawcus et al 2002). A study conducted as part of the Better Birth Initiative found that 84% of women were given no pain relief (Smith & Brown 2001). Fawcus found that in a Level 2 hospital where women were expected to have extra analgesic requirements that 35.4% of woman received no method of pain relief. Over a third of these women had asked for pain relief but had not received it (Fawcus et al 2002). Problems that she identified to explain this finding were lack of staff, lack of an adequate epidural service and problems with staff attitude.

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MethodologyThe work presented is part of a larger ethnographic study looking at factors that affect health care providers’ practice in two district hospitals, one urban and one rural. The study is exploratory in nature, designed to be able to identify factors that the researchers did not know about at the beginning of the study. A medical anthropologist spent a number of months in the two labour wards observing the staff and numerous deliveries, getting involved in a number of ward activities, going to meetings and training workshops with staff, and socializing with staff. This methodology has the advantage over surveys and questionnaires in that it gives the researcher the opportunity to carry out a “micro-sensitive analysis of practice” (Spiegal, 1997). It also enables the researcher to begin to be able to identify the nature of what Giddens calls people’s ‘practical consciousness’. People’s practical consciousness “consists of all the things that actors know tacitly about how to ‘go on’ in the contexts of their lives without being able to give them direct discursive expression (Giddens, 1994).

FindingsIn both hospitals, inhaled entonox and epidurals for vaginal deliveries were not available. In the urban, hospital women were allowed to have someone who accompanied them during labour but most women did not have anybody. In the rural hospitals companions were not allowed. In the urban hospital, pain relief was given to some women, but it depended to a large degree on who was managing the labour. In the rural hospital, the nurses could only remember two cases in recent history – one being the labour of the wife of one of the doctors who worked in the hospital – where any form of pain relief was given. In both hospitals, the nurses had been trained in using various forms of analgesia, the requisite drugs were available and the use of analgesia when needed was included in the protocol for normal delivery that was clearly displayed on the wall.

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To explore why women were not given pain relief, even when they had requested it, two cases studies will be discussed.

1. Teenager With An Intra Uterine- DeathA teenager was referred from a clinic at 38 weeks gestation because the nurses at the clinic could not detect a fetal heartbeat. The nurses and doctor at the hospital confirmed that it was an IUD. The teenager was told and then the labour was induced. She was alone, as it is the ward policy that people are not allowed to accompany women. Visitors are not even allowed in the ward. The whole delivery was extremely difficult for both the woman and the nurses. The nurses get upset that she is being ‘troublesome’, ‘non-compliant’ and demanding too much attention. She pushes when she shouldn’t push. She asks for pain relief and she is refused.

When asked why the teenager was not given pain relief the nurses involved gave a range of answers. One nurse stated that if you make the birth too easy for a teenager then she will just go away and have another baby so she can get another child care grant. Other nurses stated that it was not hospital policy and that pain relief is only given to women who have c/sections. The one advanced midwife working at the hospital stated that she had been taught at Bara that you should offer women pain relief, “ it was their right under the constitution”. She had also observed that it made labour much easier to manage. Women were often ‘difficult’ because they were in such pain. She said that in cases of an IUD when you don’t have to worry about the baby you really should give pain relief. The problem was that pethidine wasn’t on standing order so they couldn’t administer it and there were so few doctors at the hospital that they didn’t want to bother them about this issue. She also complained on this and a range of other issues that the other nurses thought that she was too ‘proud’ and so didn’t want to learn about what she had been taught during the advanced midwifery course. Also when they evaluate your performance they don’t ask whether you were nice to the women, it is how

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you filled in the records, did you come on duty on time, do you respect your superiors and such like. The sister in charge of the ward wasn’t sympathetic to giving women pain relief; she said that here wasn’t like Bara, it was “the culture of women in rural areas to bear the pain without complaining”. The community doctors who worked on the labour ward in rotation didn’t realise that pethedine wasn’t on standing order; it always had been in the hospitals in which they worked before. They just assumed that the women were being given pain relief. Because they only did ‘spot rounds’ where the nurses took them to patients with problems, or came when they were called they didn’t have a feel for what everyday practices were going on in the ward.

37 Year Old Multigravida A 37-year-old woman giving birth for the 4th time in the urban hospital. All the previous labours had been quick and relatively pain free according to her, but this one was painful and she wanted pain relief. This was taking place at night, in a busy labour ward with only two professional nurses on duty, neither of them CPN’s and neither of them had had any kind of advanced training in midwifery. The nurses refused her pain relief. The reasons that they gave were that it was her 4th labour – “she should be more sensible and not make a fuss – she knows it will be quick”. One of the nurses, who was the more junior, was more sympathetic than the other. She had really suffered with her third delivery, and the nurses where she delivered had scolded her and told her she was a ‘Sister’, this was her third delivery and she should know better.

The other reason that both nurses were unwilling to give pain relief is that they had a fear of ‘floppy babies’. They said that they weren’t confident in dealing with floppy babies, and also they weren’t confident of the abilities of the doctor who was on call that night - that they would come, and if they did come that they would be able to resuscitate a newborn. They were already struggling to get a doctor to come to deal with a woman with prolonged labour. They also knew that constant problems they had with

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the referral hospital, and with the availability of ambulances, meant it would be difficult to refer a sick baby quickly. A colleague of theirs was in trouble for calling a private ambulance to take a sick baby to the nearest tertiary hospital when she was desperate. They said they knew that narcan usually worked but they had heard of a case where it hadn’t worked and the baby had died. When asked where this incident had taken place it wasn’t this hospital, it wasn’t anywhere else these nurses had trained or worked, it was just a story that they had heard somewhere. They heard also that the nurse involved had got into trouble and been reported to the nursing council.

This refusal to give the woman pain relief was despite the fact that a very clear protocol for pain relief was pinned up in big letters in the nurses’ station, pethedine was on standing order and the nurses had recently received in-house training around pain relief. The next morning I asked the sister in charge, who is also an advanced midwife about the policy around pain relief. She told me that she had been going to prioritize the issue in the ward, and that is why she had printed the protocol in such big letters and pinned it on the wall. But then the budget committee had come to her and told her that she must remember under the PFMA she can go to jail if she overspends on her ward budget. On reviewing her ward budget they thought that the spending on schedule 7 drugs; so as a consequence she had abandoned the plan, as she knew it would lead to an increase in use of drugs.

DiscussionUsing these two case studies it is possible to identify a number of issues that have been mentioned time and time again in the literature in terms of provider practice. Issues such as staff training, staffing levels of doctors and nurses, nurses’ personal attitudes, problems with referrals, and problems with senior staff not allowing trained staff to implement what they have learnt. But what also emerges from these case studies is broader health system issues that are often not addressed in the

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literature. For example, what impact are major health system and public sector reforms such as decentralization, increased financial accountability through the PFMA and new performance management policies having on everyday practice of nurses in maternity wards. Why is it that providing women with as good as experience of childbirth as possible not on anybody’s priority list, and what impact does this have on women’s future utilization of facilities? Why is it that some reforms such as financial accountability are taken more seriously than reforms such as the Patient’s Rights Charter aimed at improving the quality of service given to women? There are also some very important issues raised about the ‘soft issues’ in health services, i.e. the relationships between patients, staff and managers in the health system.

ConclusionThere are a range of factors at a personal, institutional, health system and wider societal level that impact on whether or not women were provided with analgesia during labour. None of these factors operate unilaterally but instead interact in a range of complex ways.

To be able to understand complex issues around provider practice a range of research methodologies – both qualitative and quantitative - need to be used. To be able to change provider practice interventions must take account of the environment in which health providers work, and the range of complex interactions that take place within health system. All planned interventions to improve the quality of maternal care need to recognize these issues and tackled them if they are to be successful and sustainable.

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EMPOWERMENT THROUGH THE ACTIVE BIRTH POSITIONS INTRODUCING PHYSIOLOGICAL BIRTHING POSITIONS INTO THE PUBLIC SECTOR

B Rautenbach

Active Birth is nothing new although Janet Balaskas, who was one of the founder members, of the Active Birth Association with Dr Yehudi Gordon, coined the phrase in the early 1980’s. For many years, women have endured the delivery of their babies by doctors and midwives in the “stranded beetle” position, i.e., in the supine/ lithotomy position.

Active Birth is instinctive. It describes physiological labour and birth where a woman follows her own instincts and body’s urges, being in control of her own body during labour and the birth of her baby.

Active Birth is an attitude of mind. It involves both the midwife and the labouring woman accepting and trusting the natural physiological process of childbirth, beginning in pregnancy (or before conception) and unfolding in the birth and beyond, and the involuntary nature of the birth process combined with appropriate positioning of the body.

Stranded Beetle Position - insisting that a woman labours and births on her back (supine/lithotomy position) causes her to become:

Powerless, Dependent, Vulnerable and Undignified,Resulting in HEAVIER WORKLOAD for staff,

Active Birth - when a woman is encouraged to labour and birth in upright/lateral positions, she becomes:

Empowered, Independent, Controlled and Dignified, Resulting in DECREASED WORKLOAD for staff.

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What can we do? Empower ourselves as caregivers: In order for caregivers to

empower women to have gentle and joyful birth experiences, we need to empower ourselves by shifting our attitudes and actions accordingly.

Shifting mindset – the needs and comfort of each woman to be put before those of the caregiver,Examples:From: “But I was taught the SUPINE WAY” To: “How about adding some well-tried alternatives to my Bag-of-Tricks”, andFrom: “I am in control when I deliver babies”,

To: “I am willing to encourage and facilitate each woman to birth her own baby”.

Upgrading basic birthing skills – the theory and practical of Active Birth to become an integral part of each midwife’s bag-of-tricks.

Implications of shifting mindset: For care givers Creativity and flexibility come out of the woodwork of

the right brain and they start to have fun with birthing women, Workload decreases:

Less procedures (not less routine observation) Less intervention Less damage Less transfers No extra staff required

For labouring women Better Birth experiences:

More humane treatment + support Less routine intervention Physiological labour

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Allowed to listen to own urges Less painful labour and bearing down Reduced perineal/vaginal trauma Duration of labour shorter Gravity Larger space – pelvis opens 26-30% Greater intensity of contractions

For Baby Improved Apgar scores Healthy babies stay with their mothers Encourages earlier bonding, skin-to-skin and

Kangaroo Mother Care. Attaches to breast faster Therefore feeds better and gains weight faster

= earlier discharge.

Introduction of Active Birth Positions into the Public Sector

Since joining Mowbray Maternity Hospital (MMH) in mid-October 2003, midwives, medical and midwifery students, doctors, doulas and paramedics have been shown, hands-on with some theory, the advantages of assisting women to birth in Active Birth positions. These positions and concepts have been greeted with excitement and enthusiasm by many of the midwives, some of whom are forging ahead with encouraging the women under their care to use these physiological positions.

With the advent of the initiating of the Better Birth Initiative into the public sector by Prof Justus Hofmeyr and a returning awareness in some women of how they feel they want to birth their babies, doctors and midwives are starting to look at the reasons why they demand that labouring women assume the supine/lithotomy position during 1st and 2nd stages of labour.

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Women instinctively go into squatting, kneeling or lateral position to birth their babies when they are encouraged to hear and listen to the urges of their bodies. The fact that: gravity works with the contractions to bring the baby’s head down

quicker; when the body tilts forward the pelvic outlet opens 26 –30%, thereby

creating a larger space through which the baby can navigate; the intensity of the contractions is greater; labour often progresses much quicker; labour is much less painful; backache due to the posterior position of baby’s head is much less; vaginal trauma is reduced; babies are born with improved Apgar scores; and augmentation is less likely, because the intensity and frequency of

contractions is increased,shows us that women know instinctively how to birth their babies. These facts are borne out in the WHO’s “Care in Normal Birth, a practical guide” and in studies reviewed by the Cochrane Collaboration in “Effective Care in Pregnancy and Childbirth”.

By observing women in labour, midwives and doctors are able to renew their confidence that birthing women actually DO KNOW WHAT TO DO, and in so doing they can support and assist women to execute this most empowering event of their lives.

When caregivers stand back and use all their powers of observation, they will note that: instinctive active births are much calmer and quieter; interventions are most often unnecessary; women do not have to push so hard, as gravity is assisting; women are better able to manage strong contractions when upright,

thereby shifting perception of pain;

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women experience much less pain when bearing down; the perineum stretches long and thin out of the anus, and the pubo-

coccogeous muscle moves out of the way, against the anal sphincter; when women are given the space to listen to their own perineal-

stretching pain messages, the perineum is given the chance to stretch much more slowly, thereby reducing perineal/vaginal trauma; and

babies are usually much more alert and are able to rid their mucous without suctioning when placed on the mother’s chest.

I have been able to observe the above facts in operation – first hand - in birthing my 3 children instinctively, actively taking control of my own birth experiences, and assisting well over 100 women in the past 18 months to do the same. I found that the more one observes these women, the less one has to intervene with ones hands, and the quieter and gentler the births became.

Theory and demonstrationPart of my function has been to work with the midwives in five of the MOU’s serviced by the PMNS. This was greeted with as much excitement and enthusiasm. These midwives are beginning to feel much more empowered, as they are now able to support the many women who instinctively go into the squatting, kneeling or lateral positions when their bodies urge them to push. The midwives, student midwives and medical students are given some theory behind the Active Birth concepts and positions, and shown, hands-on, how to observe, communicate (when necessary) gently and quietly, and keep their hands off the perineum of these women, while they push according to their own urges.

Antenatal educational talks have also being given on Active Birth and the AB positions for the women attending Antenatal Clinics at MMH and the five Midwife Obstetric Units (MOU’s) of Retreat, Hanover Park, Mitchell’s Plain, Guguletu and Khayelitsha, with a view to reminding more women of the natural instinctiveness of pregnancy, labour and childbirth and

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reducing some of their fears. When women remember their role in the birthing process, they feel empowered to be firm about the way they want to give birth to their babies.

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StatisticsWithin 2 months of working with the midwives, on one of the duty shifts assisted 12 women, who did not have any antenatal preparation, to birth their babies in the kneeling or lateral positions, without any hands-on support from me. This is very encouraging, although there is a very definite resistance by some of the midwives to allowing themselves to change their thought processes and routines.

It is very encouraging to note, that from mid October 2002 to 30 March 2003, 462 women have been assisted to birth their babies in the upright and lateral positions in the public sector! One could take this to imply that there is a very definite returning awareness on the part of some women and midwives as to the natural instinctiveness of labour and childbirth.

What the future holdsAt present, Midwifery Protocols, incorporating the Better Births and the Active Birth Principles and Concepts, are being compiled. These protocols will be linked with the Management Protocols to create a well-rounded set of protocols that will, it is hoped, also decrease the workload of the doctors in the Secondary Hospital scenario.

CD-ROM educational tools, Active Birth videos and an Active Birth Training Module for assisting midwives to upgrade their basic midwifery skills, are in the pipeline.

ConclusionWhether women labour and birth in public or private hospitals, MOU’s, rural clinics or at home, they want to know that their caregivers are able to support them to birth their babies in whatever way and position they choose (with adequate information), in order that their birth experiences meet their own expectations. It is important for caregivers to have a clear picture of the natural physiological process of labour and what can disturb

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it. This will allow for a much more hands-off approach of allowing and experiencing the unfolding of the birth process, not only ‘actively managing’ labour according to statistics. Each and every woman, and her labour, is UNIQUE. The Better Births Initiative is giving caregivers a platform from which to support women through this process incorporating both instinct and evidence.

BIRTH IS A NATURAL EMERGENCE.Not a medical emergency!

PROGRESS in Active Birth Positions

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EVIDENCE-BASED CAESAREAN SECTION TECHNIQUE

GJ Hofmeyr, Z Jafta, B Maholwana, D Jacobs, A BamigboyeEffective Care Research Unit, East London Hospital Complex/University of Witwatersrand/Fort Hare and E. Cape Dept of Health

IntroductionConsiderable progress in the technique of caesarean section has been made in recent years. In South Africa, junior doctors are often required to perform caesarean sections at poorly-staffed hospitals. It is important for doctors to be trained in safe techniques of caesarean section. Caesarean section is often needed as an emergency, life-saving procedure for mother and/or baby. Lack of doctors skilled in caesarean section may contribute to maternal and perinatal morbidity and mortality. It is important that the technique used for caesarean section, as for any other health care intervention, is based on the best available evidence of effectiveness.The most reliable evidence of effectiveness of health care interventions is that from systematic review of randomized trials, such as are published in the Cochrane Library. Cochrane reviews of particular relevance to reproductive health in resource-poor countries are also published annually in the WHO Reproductive Health Library.

ObjectivesTo demonstrate new techniques of caesarean section based on evidence from randomized trials in a video presentation.

MethodsA systematic review of randomized trials of technical aspects of caesarean section was performed. A technique based on best evidence was video recorded, transferred to CD format (MPEG), and presented, with discussion of the technical points.

Results

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The method outline here is based on systematic review of randomized trials. Pre-operative preparations are important, but not covered in this paper. Once in the operating theatre, check that the baby’s heartbeat is still present, that the indication for caesarean section is still valid; Check the position of the baby and whether the woman has requested tubal ligation.General anaesthesia carries particular risks in pregnant women, such as difficult endotracheal intubation and aspiration of stomach contents. Using spinal anaesthesia, the main risk is hypotension, which can be reduced using intravenous fluid preloading, leg elevation and compression, and left lateral tilting. The one randomized trial comparing vertical with transverse abdominal incisions was too small to be conclusive. Many prefer transverse incisions for routine caesarean sections because of the good functional and cosmetic results. However, when complications are anticipated or the surgeon is inexperienced, the vertical incision has the advantage of speed, simplicity and easy extension upwards to improve exposure. The vertical incision can also be performed using local analgesia when general or regional analgesia are unavailable or unsafe. Complications such as placenta praevia, transverse lie and obstructed labour require careful planning of the operative procedure to be prepared for potential problems. The transverse abdominal incision developed by Joel Cohen is made about 2cm below the line of the anterior superior ileac spines. The subcutaneous tissues and anterior rectus sheath are incised by scalpel only in the midline. The anterior rectus sheath incisions are extended laterally, deep to the subcutaneous tissues, with slightly opened scissor-tips, or with digital stretching. The rectus muscles are separated and the parietal peritoneum opened by digital stretching. The abdominal opening is stretched laterally to separate the rectus muscles and stretch the subcutaneous tissues and peritoneum. Compared with the Pfannansteil incision, randomized trials found the Joel-Cohen incision to be quicker, with less morbidity and fewer subsequent adhesions.

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The loose visceral peritoneum over the lower uterine segment is opened.Omitting the separation of the peritoneum from the lower uterine segment had short-term benefits in one randomized trial, but the numbers studied were too small to exclude the possibility of rare complications such as bladder injury.Blunt compared with sharp lateral extension of the uterine incision resulted in less further wound extension and less bleeding in one large randomized trial.Use of a soft vacuum cup for delivery of the head was found to be beneficial in two small randomized trials. When the baby’s head is deeply engaged in the pelvis, as in the case of obstructed labour, the head must be elevated to above the level of the uterine incision and rotated to the occipito-anterior position before it is delivered through the incision. Sometimes per vaginal elevation by an assistant or uterine relaxation is necessary to elevate a deeply impacted head.In the randomized trials reviewed, delivering the placenta by cord traction rather than by manual removal resulted in less blood loss and postoperative endometritis.Removing the uterus from the abdominal cavity had no clear benefits or disadvantages over intra-abdominal repair in the reviewed randomized trials. If the uterus is exteriorized to improve access, this should be done gently, because isolated cases of torn ovarian vessels have been reported.For suturing the uterus, randomised trials have shown no clinically important differences between a single layer of locking sutures or addition of a second layer. In a recent large non-randomised comparison, subsequent uterine rupture was less common when a second layer was used. There is thus at present inadequate evidence to clearly support either method.In the numerous randomised trials reviewed, non-closure of both the visceral and the parietal peritoneum resulted in reduced operating time, postoperative fever, wound infection, analgesia use and length of hospital stay. There is no evidence to justify closing either peritoneal layer. The

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anterior rectus sheath is usually closed with a continuous absorbable suture.No clear benefits have been shown for routinely draining or suturing the subcutaneous tissues. Possible benefits have been shown when the subcutaneous layer was thicker than 2 cm. In one small randomized trial in vertical skin incisions, an absorbable subcuticular skin suture gave better results than metal staples.The Misgav-Ladach technique developed by Stark and colleagues includes use of the Joel Cohen abdominal incision, single layer closure of the uterus, non-closure of the peritoneum and 2 or 3 mattress sutures to approximate the skin (2). Tissue forceps are applied to the intervening spaces for about 5 minutes, and removed just before application of the wound dressing.Randomised trials of combinations of several of these modifications, for example in the Misgav-Ladach technique, compared with traditional techniques, have shown reduced operating time and improved postoperative recovery. A benefit of particular relevance to resource-poor countries is that only two lengths of suture material are necessary: one such as chromic catgut on a round-bodied needle for the uterus, and one such as polyglycolic acid on a cutting needle for the rectus sheath and skin.The rapid recovery demonstrated with these techniques enables women to become mobile soon after the operation and interact with their babies. Randomised trials have shown no benefit for withholding oral fluids or food after straightforward caesarean section operations.

ConclusionBasing both our decision to undertake caesarean section and our caesarean section technique on the best available evidence of effectiveness will ensure the lowest possible complications and mortality from this common and essential operation.

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THIRD TRIMESTER INDUCTION OF LABOUR WITH MISOPROSTOL: THE DURBAN EXPERIENCE

NF MoranDepartment of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, Durban

IntroductionAnecdotal evidence suggests that there are many hospitals in South Africa, which are using misoprostol for induction of labour (IOL) in the third trimester, although the drug is not yet registered for this use. There are clear advantages to using misoprostol rather than the other available prostaglandin preparations (PGE2 gels and tablets): misoprostol is much cheaper, has a longer shelf-life, and does not need refrigeration. Studies have suggested that, compared to the other preparations, misoprostol is at least as effective as an induction agent, but also that it is more likely to cause hyperstimulation of the uterus. Thus it is a potentially dangerous agent. There is no uniformly accepted protocol for the mode of administration or the dose that should be used for third trimester IOL with misoprostol. This makes it difficult to evaluate misoprostol as an induction agent using randomised controlled trials, as a whole range of different dosing regimens would need to be evaluated against a more established induction agent. Furthermore, clinically important complications of IOL, such as rupture of the uterus, are relatively rare, and to demonstrate significant differences in the rate of such complications between misoprostol and another agent would probably require very large numbers of study participants.Against this background, in 2002, a series of meetings was held in Durban, attended by representatives from the obstetrics and gynaecology departments of most of the state hospitals in the Durban Metropolitan area. At these meetings, it was decided by consensus that misoprostol should become the first-line agent for third trimester IOL (at least where cervical ripening is required) in the Durban hospitals. The main motivation which the Durban group found for changing from the prostaglandin E2 gels, which were the previous first-line agents for cervical ripening, to

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misoprostol was cost. It was estimated that an induction using the gels would often be several hundred times more expensive than a misoprostol induction. The group felt that there was adequate evidence regarding the efficacy of misoprostol as an induction agent to justify this change in policy on the basis of cost.It was agreed that misoprostol could also be used as an alternative to amniotomy and/or intravenous oxytocin for IOL in cases where the cervix was already favourable. In such cases, possible advantages of using misoprostol include the fact that an intravenous infusion would not need to be set up and monitored; in addition amniotomy could be delayed which would reduce the chance of vertical transmission of HIV.A uniform protocol for induction of labour with misoprostol was agreed upon for all the Durban hospitals. The group was concerned about the safety of misoprostol, specifically the risks of hyperstimulation syndrome, and uterine rupture. For this reason, a non-intensive dosing protocol was decided upon. The principle underlying this non-intensive protocol was that safety should be ensured even if it results in a longer induction-to-delivery interval. It was also decided that the regimen should be adjusted according to parity, the state of the cervix, and whether or not membranes ruptured.Since August 2002, the Durban hospitals have been using this “Durban protocol” for third trimester IOL. It was agreed that the hospitals should audit this new protocol, and review the results after about six months. If necessary, changes could then be made to the protocol. This paper presents the Durban protocol, as well as the results of an audit of misoprostol IOL using the Durban protocol, from Mahatma Gandhi Memorial Hospital (MGMH), Phoenix, Durban. MGMH runs a level 2 obstetric service for the North of Durban, and conducts 6000-7000 deliveries per year.

The Durban protocol for third trimester induction of labour using misoprostolSpecific exclusions: parity greater than 3, previous uterine surgery.

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Monitoring regime: a CTG should be done before starting the induction and repeated 1-2 hours after the first dose of misoprostol is given or earlier if contractions occur. Thereafter a CTG should be repeated if contractions occur at any stage.1. Unfavourable cervix, membranes intact:

Para 0: vaginal route, 50g, single dosePara 1-3: oral route, 20g solution, every 2 hours until contractions occur, up to a maximum of 4 doses (80g). The solution can be made by dissolving half a tablet (100g) in 100mls of tap water.

In both cases, if labour does not occur, the case is re-assessed 24 hours after starting the induction. Further management is then decided upon by the obstetrician in charge. The protocol does not specify a time limit within which the woman must deliver. Repeat courses of misoprostol are allowed. For the para 0, either the vaginal regimen can be repeated, or the oral regimen can be tried. For the para 1-3, the only option is to repeat the oral regimen. Misoprostol should never be given if contractions are already present. Oxytocin can be administered, but not less than 6 hours after last dose of misoprostol.

2. Favourable cervix, membranes intact:Para 0-3: oral regimen described above

3. Membranes ruptured:Para 0-3: oral regimen described above

MethodsClinical details were recorded prospectively for all women 28 weeks gestation undergoing misoprostol IOL at MGMH over a six-month period (August 2002-January 2003). All women and their neonates were followed

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up until discharge from hospital or death. There was no follow-up after discharge. Major outcomes recorded included: mode of delivery, fetal/neonatal complications, and maternal complications and side-effects. Data were entered into a computerised database for statistical analysis (Epi Info 6). A successful induction was defined as one which ended in a vaginal delivery without either maternal or neonatal complications occurring subsequent to the induction being started. The induction to delivery interval was not regarded as being an important outcome, except in the case of inductions for intra-uterine death (where the woman is often distressed at carrying a dead fetus in utero, and requires it to be removed as soon as possible), and in the case of social inductions.

ResultsThe total number of inductions in the series was 220. Of these, 72 were induced using the vaginal regimen. According to the protocol, the vaginal regimen was exclusively for nulliparous women. However, three of those induced vaginally had a parity > 0. The oral regimen was used for 148 women, consisting of 115 with parity > 0, and 33 nulliparas (either with a favourable cervix or with ruptured membranes or both). Table I shows the indications for induction of labour, according to the regimen used. As would be expected from the protocol, almost all women with rupture of the membranes were induced via the oral route. There were no social inductions.Table II shows the mode of delivery, according to the regimen used. The higher caesarean section rate in the vaginal group, does not necessarily reflect on the route of administration itself, but may reflect the fact that the two groups of women have a different profile, with there being a far higher proportion of nulliparas in the vaginal group. Table III shows the mode of delivery according to parity, irrespective of route of induction, and demonstrates that the caesarean section rate for all nulliparas, including those induced by the oral route, was as high as the rate for women induced by the vaginal route.

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No side-effects of the misoprostol were documented for any woman. Specifically asked for were shivering, pyrexia, and diarrhoea.Table IV shows the maternal complications that occurred following the IOL, according to the route used. Hyperstimulation (six or more contractions in a ten minute period) occurred significantly more often in the vaginal group. This complication was probably underestimated, as contractions were not consistently monitored in all labours, due to lack of staff and equipment. The one case of uterine rupture occurred in a woman who was para 2 and was induced because of an intra-uterine death. Against the protocol, she was given vaginal misoprostol in an excessive dose of 200μg. Furthermore she was given oxytocin for an unspecified period. The woman required a hysterectomy, and was discharged in a healthy condition.Table V shows the fetal or neonatal complications according to the route of induction used. The cases of IOL for intra-uterine death were excluded from this analysis. The first neonatal death was a case where the mother had been induced for post-term pregnancy. Only after delivery was it found that the baby had a diaphragmatic hernia, and this was the cause of death. The second neonatal death occurred in a baby whose mother had been induced for intra-uterine growth restriction. The baby required ventilation for respiratory distress syndrome, and subsequently died of nosocomial sepsis two weeks later. Thus neither of these deaths were necessarily related to the induction itself. The three neonates requiring intensive care included one with pneumonia and jaundice, another with jaundice, and a third was asphyxiated. All were well at discharge. The incidence of meconium staining of the liquor according to route of induction is shown in Table VI. Again, the cases of IOL for intra-uterine death are excluded from the analysis. The lower rate of meconium in the oral group could at least in part be explained by the fact that this group included 46 women with ruptured membranes at the outset, as opposed to only one in the vaginal group. All of these women with ruptured membranes had clear liquor at the outset, as the induction would not have been initiated had there been meconium. A proportion of the women with

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intact membranes no doubt already had meconium at the time the induction was started.There were 16 inductions performed for intra-uterine death, seven via the vaginal route and nine via the oral. Of these, 15 ended with a normal vaginal delivery, and one ended in a rupture of the uterus as described above. For the 15 cases which ended in vaginal delivery, no oxytocin was required, and no repeat course of misoprostol was used. The mean induction to delivery interval was 19.5 hours, with 12 of the 16 (75%) delivering within 24 hours, and all but one delivering within 48 hours.Overall, for all the inductions in the series, oxytocin was only used in 19 cases (8.6%). The mean total dose of misoprostol used for those who delivered vaginally was 61μg (range 25 to 260) for the vaginal regimen, and 72μg (range 20 to 240) for the oral regimen.Overall the rate of successful induction (normal vaginal delivery without complications) was 147 out of 220 (67%); for the vaginal regimen, it was 41 out of 72 (57%); for the oral regimen 106 out of 148 (72%).

Table I Indications for induction of labourVaginal Route No(%) Oral Route No(%)

Hypertension 29 (40.3) 37 (25)Post-term 24 (33.3) 41 (27.7)IUGR 6 (8.3) 12 (8.1)IUD 7 (9.7) 9 (6.1)Prelabour ROM at term 0 24 (16.2)Preterm Prelabour ROM 1 (1.4) 22 (14.9)ROM = rupture of membranes

Total No(%) Vaginal route Oral routeNVD 151 (68.6) 41 (56.9) 110 (74.3)Caesarean 68 (30.9) 30 (41.7) 38 (25.7)Laparotomy 1 (0.5) 1 (1.4) 0

Table III Mode of delivery according to parityPara 0 (102 cases) Para >0 (118 cases)

NVD 59 (58%) 92 (78%) Caesarean 43 (42%) 25 (21.2%)

Table IV Maternal complicationsTotal (220 cases) No(%)

Vaginal Route (72 cases) No

Oral Route (148 cases) No (%)

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(%)Hyperstimulation 8 (3.6) 6 (8.3)* 2 (1.35)* APH 1 (0.5) 1 (1.4) 0Uterine Rupture 1 (0.5) 1 (1.4) 0Other 2 (1) 1 (1.4) 1 (0.7)Nil 209 (95) 64 (88.9) 145 (98)*p=0.016

Table V Fetal/neonatal complicationsTotal (204 cases) No(%)

Vaginal Route (65 cases) No(%)

Oral Route (139 cases) No(%)

Stillbirth 0 0 0NND 2 (1) 0 2 (1.4)NICU care 3 (1.5) 2 (3) 1 (0.7)Other 1 (0.5) 0 1 (0.7Nil 198 (97) 63 (97) 135 (97)

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Table VI Meconium staining of the liquorTotal (204 cases)

Vaginal Route (65 cases)

Oral Route (139 cases)

Meconium 19 (9.3%) 10 (15.4%) 9 (6.5%)No Meconium 184 (90.2%) 55 (84.6%) 129 (92.8%)Unknown 1 (0.5%) 0 1 (0.7%)

ConclusionThis is the first audit that has been performed to evaluate the new Durban protocol for induction of labour with misoprostol. The results suggest that the protocol is an adequately effective method of IOL, with a success rate of 67% overall. The somewhat higher success rate for those induced orally rather than vaginally may just reflect the different patient profile of these two groups, the vaginal group having a much higher proportion of primigravidas. The results also demonstrate a reassuringly low rate of complications for both mother and baby. The hyperstimulation that undoubtedly occurs in a significant proportion of those induced with 50μg of misoprostol inserted vaginally is still a matter of concern, and further audit of this aspect would be important. The audit also demonstrated the importance of making sure that all staff in any department using this protocol understand the need for the protocol to be adhered to strictly. Had this been done, the one case of rupture in this series would probably not have occurred. We feel that these results justify us to continue for the time being with the Durban protocol as it stands. We await the results of further audits of the same protocol being conducted in other centres.

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VAGINAL EXAMINATIONS DURING LABOUR: A SYSTEMATIC REVIEW

M Singata, G J Hofmeyr.Effective Care Research Unit, East London Hospital Complex/University of Witwatersrand/Fort Hare and E. Cape Dept of Health

BackgroundFrequent vaginal examinations have become a routine part of care during labour. The objective of these examinations is to assess the progress of labour. Women may find these examinations unpleasant, particularly when in pain during labour. Antiseptic lubricants are frequently used.

ObjectivesTo assess the benefits and disadvantages of frequent compared with less frequent vaginal examinations during labour, and the use of antiseptic lubricants.

Search strategyThe search strategy developed for Pregnancy and Childbirth Group of the Cochrane Collaboration will be used.

Selection criteriaRandomised clinical trials comparing frequent with less frequent vaginal examinations during labour, and the use of antiseptic lubricants, will be selected. The methodological quality of the studies will be evaluated. Participants will be pregnant women in labour.

Data collection and analysisTrials considered will be included or excluded according to methodological quality. Revman 2000 computer software will be used for data analysis. Fetal and maternal outcomes will be measured. Results will be presented as relative risks and weighted mean differences. Trials will be combined by meta-analysis using a fixed effects model.

ResultsResults will be presented at the conference.

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THE PERILS OF PRECOCIOUS PARTURITION

H OdendaalUniversity of Stellenbosch

It is well known that gestational age at birth plays a significant role in neonatal survival. Crucial gestational ages in developed countries range between 24 to 25 weeks and 28 to 29 weeks. A week longer in utero may determine the difference between life or death for the fetus at 24, or, to a lesser extent, at 28 weeks. For South Africa, depending on the facilities of the hospital, gestational ages between 26 and 29 weeks are crucial. One should therefore only deliver when labour can’t be suppressed any longer or when there is a very good maternal or fetal indication for the delivery.

Although there is a continuous improvement in the survival of fetusses between 501 and 1500g, there is also an increase in the prevalence of cerebral palsy (CP). In a descriptive longitudinal study, where suspected babies with CP were examined by a developmental paediatrician, 584 cases of CP were found. The number of babies with CP rose from 1.68/1000 in 1964–1968 to 2.45/1000 in 1989–1993, giving a 77% increase.

In a recent study in Finland, 529 extremely low birth infants were followed up for a short term. For babies born at 22–23 weeks, 100% showed at least one disability. It then gradually decreased to 62% at 24–25 weeks and 51% at 26-27 weeks. For babies born at 28–29 weeks, 45% had at least one disability.

In another study, 54 extremely low birth weight (< 1000g) infants were compared with normal controls, matched for race, gender and socio-economic status. They were followed up until they reached school and compared on teachers’ reports and tests for motor, language and visual-motor integration. Only 50% of the extremely low birth weight babies were in regular classrooms and 20% of them had significant disabilities.

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In another study, 1185 infants, born between 20–25 weeks gestation at 276 maternity hospitals in the United Kingdom and Ireland were followed up to a mean age of 30 months. The mean Bayley Mental index was 84; 19% of children were severely delayed and 11% delayed. 10% showed severe neuromotor disability.

The University Medical Centre in Leiden examined all babies born at 23-24 weeks in 1996 and 1997. 66% of them died. 50% of the survivors had severe physical or mental handicaps by the age of 2 years. Following this analysis, they increased the limit of viability from 24 to 25 weeks.

A similar trend was seen in another study, where 249 premature babies were born before 29 weeks gestation. Survival without any neurological sequelae was seen in only 52% of babies born between 24 and 25 weeks. Only 72% of babies born at 26–28 weeks did not have any neurological sequelae.

In Sweden the incidence of cerebral palsy is 86/1000 for the extremely preterm baby, 60/1000 for the preterm baby, 6/1000 for the moderate preterm baby and 1.3/1000 for the baby born at term. It is alarming that the probable etiology for the cerebral palsy was a peri/neonatal event in 61% of children.

Vermeulen et al studied 185 neonates who had adverse events such as a Griffith’s developmental score < 85, major disability or perinatal death. Gestational age at birth protected against adverse outcome and abnormal cranial ultrasound increased the risk (OR 6 – 33; 95 % CI 2.16 – 18.52). They concluded that the most important way of preventing neurological damage in infants is to increase gestational age at birth and to avoid the development of intra-ventricular haemorrhage and peri-ventricular leucomalacia. This finding was also confirmed by Han et al in their study of 437 survivors of preterm infancy which demonstrated that the existence

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of peri-ventricular leucomalacia was the strongest and most independent risk factor for the subsequent development of cerebral palsy.

From these studies it is very clear that one should not deliver before term without a well-accepted reason. This principle was followed in the research project on the expectant management of mothers with severe pre-eclampsia when patients who were admitted at 24 weeks gestation, gained a medium number of 32 days. For all gestational ages at admission, the mean number of days gained was 11. The perinatal mortality rate of patients with severe pre-eclampsia improved from 97/1000 in 1987 to 24/1000 in 2000.

In spite of the 18–20% risk of abruptio placentae in patients with early onset severe pre-eclampsia, we found a perinatal mortality rate of 8.7% in these patients who developed an abruption, compared to the 35.5% perinatal mortality rate of patients in the MAGPIE trial who developed abruptio placentae. This means that regular 6 hourly fetal heart rate monitoring is sufficient to prevent almost all intra-uterine deaths in patients who develop abruptio placentae in hospital. Modern methods of fetal assessment are therefore very accurate and one should not deliver just because of the fear of an unexpected intrauterine death.

A recent meta-analysis on the outcome of extreme prematurity showed impaired mental development in 17– 21% of survivors, cerebral palsy in 12-15%, blindness in 5-8% and deafness in 3-5%. Approximately half of the disabled survivors had more that one major disability. It is absolutely essential that obstetricians know exactly what the chances of handicap in prematures of different gestational ages are. These figures should be explicitly given to mothers when delivery of a severely premature baby is considered or is a possibility. If mothers are not counselled accurately or if proper informed consent is not obtained, the obstetrician may face litigation as delivery of a very premature baby could have been avoided. It is more likely that obstetricians rather than paediatricians face litigation

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as obstetricians are primarily responsible for the delivery although the paediatrician may have indicated that a good outcome was expected.

For the future, it will be very important to identify accurately which fetus is at risk of intrauterine death or cerebral palsy and which newborn is at risk of cerebral palsy. One will have to council better and make better decisions regarding the timing, method and place of delivery.

At Tygerberg Hospital a continuous reduction in perinatal mortality rate has been achieved without an increase in Caesarean section rate (Fig 1). Later studies demonstrated that a further decline in perinatal mortality rate has been achieved (Fig 2). It is therefore possible to improve perinatal outcome by being very careful about unnecessary early deliveries and without a rise in the caesarean section rate.

The late professor James Walker of the University of Dundee said many years ago “if infants are to be few, let them be fine”. This wish is just as true today.

Figure 1 Perinatal mortality rates, expressed per 1000 deliveries and Caesarean section rate (percentage) at Tygerberg Hospital.

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Figure 2. The continuous decline in perinatal mortailty rate at Tygerberg Hospital.

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PLANNED DECISION MAKING FOR DELIVERY OF VERY LOW BIRTH WEIGHT BABIES MAKES FOR A BETTER OUTCOME

HM Sebitloane; A Moodley; J Moodley; MA AdhikariDepartments of Obstetrics and PaediatricsUniversity of Natal-Durban

IntroductionIntrapartum and postnatal management of very low birth weight (VLBW <1500g) poses a serious challenge to the caregiver, despite recent advances in modern obstetric and paediatric practices. Survival is greatly influenced by the birth weight as well as gestational age, both of which exert independent effects. Despite difficulties in the determination of accurate gestational age, decisions about intrapartum care and neonatal resuscitation are usually based on this, though actual birth weight has been reported as preferable when reporting outcomes in small babies. The aggressiveness of interventions, both intrapartum and during resuscitation as well as intensive neonatal care rendered to these babies, also has a significant impact on the outcome, hence the importance of proper and adequate consultation and co-decision making amongst the obstetric and paediatric teams. This is especially important in tertiary centers as most pregnancies are terminated as a result of maternal complications.

AimTo determine whether planned delivery of very low birth weight babies improves neonatal outcome.

Design and MethodsThis was a prospective study involving all mother and infant pairs of babies delivered in our unit weighing less than or equal to 1500g. Maternal demographic data was analysed, as were the obstetric factors and mode of delivery. Methods of resuscitation, as well as duration of stay in nursery and outcome were noted.

ResultsWe enrolled 51 mother – baby pairs, with an average gestational age of 30 weeks. 88% of babies weighed 1000g to 1499g (47% - 1000g to 1250g; 41% - 1251g to 1499g). A third of the pregnancies were complicated by spontaneous onset of labour, and two thirds of pregnancies were terminated because of severe hypertensive disorders. Of the 51 babies, 78% were delivered by caesarean section, more than half of which were emergency sections. Mode of delivery did not influence neonatal outcome (deaths/live babies). Of the 51 babies, 41% required ventilatory support. In summary, this study suggests that despite optimizing ante- and postnatal care, a planned delivery does not guarantee improved neonatal outcome of very low birth weight babies.

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STUDY ON THE OUTCOME OF EXTREMELY LOW BIRTH WEIGHT INFANTS (500-999G) BORN AT PRETORIA ACADEMIC HOSPITAL BETWEEN 1 JANUARY 2001 –31 DECEMBER 2001

TW de WittPretoria Academic HospitalNeonatal Intensive Care Unit

IntroductionAdvances in perinatal and neonatal management have resulted in significant increase in the survival of ELBW infants born in the first world. Neonatal intensive care and surfactant therapy have shown an improvement in the survival of ELBW infants in developed countries, but due to restricted medical resources in developing countries the ELBW infant’s survival is still largely dependent on himself and survival rates can therefore not really be compared.

Patients and MethodsThis is a retrospective descriptive study with prospective continuation.The study population includes all babies born at the PAH with a birth weight between 500-999gA detailed profile of the study population will be presented, with regards to maternal characteristics, mortality, morbidity, referral patterns, growth and development to age 1 year.

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SURVIVAL RATES AMONG VERY LOW BIRTH WEIGHT INFANTS ADMITTED AT CHRIS HANI BARAGWANATH HOSPITAL IN 2000-2001

S Velaphi, M Mokhachane, R Mphahlele, E Beckh-ArnoldChris Hani Baragwanath Hospital.

IntroductionSurvival rates stratified by birth weight and gestation have an important role in evaluating perinatal services and in counseling parents about prognosis. Birth weight is so powerfully correlated with outcome, such that many proposals for deciding on management have focused on this easily obtainable measurement especially in areas with limited resources. Threshold birth weight below which it is inadvisable to apply the technology of newborn intensive care will vary according to the number of patients requiring intensive care, relative survival rates and availability of resources. Therefore it is vital that we have a continuing audit of outcomes for these infants. The objectives of this study were to determine the survival rates among VLBW infants admitted at Chris Hani Baragwanath hospital, and to determine factors associated with better survival rate.

MethodsChris Hani Baragwanath Hospital (CHBH) prospectively collects perinatal and neonatal data on discharge or death of the infant in hospital on all infants admitted for neonatal care. This is a retrospective review of the neonatal records from a computerized database on all VLBW infants admitted at CHBH from 1 January 2000 to 31 December 2001.

ResultsThere were 1373 VLBW infants admitted at CHBH over this two year period. They constituted 21% of total admissions, despite accounting for only 3% of total live births. The majority (82%) of these infants were inborn (CHBH born), 9% were born in the Soweto clinics or born on the way to the hospital or at home and only 5% were referred from other hospitals. Sixty eight percent were recorded as having attended antenatal clinic and this varied depending on the birth weight of the infant. 59%

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mothers of infants weighing less than 800g attended antenatal clinic compared to 75% among the mothers of those infants weighing more than 1400g. Only 3% were born to mothers who were RPR positive. The mode of delivery was caesarean section in 38% of VLBW. The caesarean section rate increased from 20% among those whose birth weight was <800g to 43% among those weighing >1400g.

Over this two year period, 12% of total admissions to the neonatal unit died and VLBW infants constituted 53% of these deaths. Among the VLBW infants, the overall survival rate was 70%. Infants weighing less than 1000g were not offered mechanical ventilation because of limited NICU facilities. The survival rate after excluding infants weighing less than 1000g was 82%. The survival rate increased with increasing birth weight (Table 1) and gestational age (Table 2).

Table 1. Survival rates (percentages) according to birth weight (in grams).500-599g

600-699g

700-799g

800-899g

900-999g

1000-1099g

1100-1199g

1200-1299g

1300-1399g

1400-1499g

0 10% 19% 22% 39% 70% 79% 78% 84% 89%

Table 2. Survival rates (percentages) according to gestational age (in weeks)<25 wks

25wks

26 wks

27 wks

28 wks

29 wks

30 wks

31 wks

32 wks

33 wks

34 wks

35 wks

36 wks

>36 wks

0 17%

29%

49%

57%

72%

78%

80%

85%

84%

85%

91%

85%

80%

Infants born to mothers who attended antenatal clinic (p<0.001), infants born by caesarean section (p<0.001) and those who were females (p=0.008) had a better survival rate. The survival rate among the infants who required mechanical ventilation within the first 3 days of life improved with increasing birth weight but this association was not seen among those who required ventilation after three days of life. The causes of death were related to prematurity in 59% of cases, due to sepsis in 29%,

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perinatal asphyxia in 5%, congenital abnormality in 3% and not recorded in 4%.

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DiscussionThough VLBW constitute a small number (3%) of total live births, they make up between a fifth to a quarter of all admissions and about a half of all deaths in our neonatal unit. In countries with high rates of low birth weight infants, VLBW infants take up a major portion of resources. Major cause of death is immaturity mainly among infants <1000g who did not receive assisted ventilation. This study confirms that survival improves with birth weight and gestational age. Antenatal clinic attendance, delivery by caesarean section, and female gender are associated with better outcome. While birth weight remains the most useful predictive measure of survival, other factors like gestational age antenatal clinic attendance, perinatal management, gender, postnatal age and severity of illness need to be considered especially in areas where resources are limited.

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PROPHYLACTIC ORAL STEROIDS IN TWIN PREGNANCIES – A RETROSPECTIVE COHORT ANALYSIS

SH Raymond, NC Kapongo, PW HodkinsonIntroductionTwin pregnancies are prone to premature labour and thus to deliver babies with hyaline membrane disease. The perinatal mortality of twin pregnancies in Empangeni Hospital in the year 2001 was 111/1000 and neonatal mortality 60/1000. This hospital delivers between 320 and 350 multiples per year. The cause of death of twins born alive in 2001 was immaturity related in 60% with hyaline membrane disease (HMD) making up only 8.6% of the total, whereas in 1999 the Perinatal Mortality was 113/1000 with HMD making up 23.5%. In the same period, the overall incidence for all babies (singletons and twins) of HMD as a cause of death was 12.2%.At a conference of the RNZCOG in 1996, one of the panellists in question time stated that it was his opinion that mothers with twin pregnancies should receive prophylactic steroids on the grounds that, in many cases, it would be too late to give an adequate standard “rescue” course of steroid treatment on admission in premature labour. It was suggested that the optimum time for this administration would be between 26 and 28 weeks. Various papers on the subject of prevention of HMD in twins in the past have shown varying results with some showing that standard regimes of betamethasone are ineffective, and others showing that dexamethasone is effective, while still others show no benefit from dexamethasone given intramuscularly.The following is a quote from the Cochrane Database: (Italics mine)“Implications for research:The benefits of antenatal corticosteroid administration have been established. Women and clinicians who, after considering the available evidence, remain unconvinced that the demonstrated advantages of these drugs outweigh their theoretical disadvantages as they relate to specific subgroups, such as hypertensive women, may wish to mount further placebo-controlled trials designed to generate evidence that will help to

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resolve their uncertainties. Trials comparing different doses or routes of antenatal corticosteroid administration may be worthwhile, for example in twin pregnancies.”

MethodWe instituted a regime of prophylactic steroid administration which was to have consisted of the standard intramuscular Betamethasone, but was changed to oral administration because of local difficulties for patients to return on the second day for their injections. Because Betamethasone is not available in an oral tablet form, Dexamethasone was chosen instead. The two clinics per week run by specialist obstetricians in this hospital are the responsibility of two separate specialists. The regime was not accepted by the second specialist so was applied in only one of the clinics thus creating two groups – those who received oral prophylaxis and those who didn’t – an automatic control group. There was considered to be no selection bias as it was entirely random as to which clinic any individual mother would attend on referral from a Midwife unit.The dose chosen was two tablets of Dexamethasone 0.5mg to be taken qid for two days. The total dose was thus 8mg. This dose was chosen, as it was mistakenly believed that it would be the equivalent of Betamethasone 12 mg. The instructions were that it should be prescribed by any of the doctors working in the clinic to all patients with twin pregnancies between 26 and 32 weeks. At first, the course was repeated at two weekly intervals, until it was shown in early 2001 that this was undesirable because of birth weight reduction.Those mothers who were subsequently admitted to the labour ward in premature labour and were considered to be at risk of delivering their babies before 34 weeks, but who had not been given Dexamethasone prophylaxis, were treated according to the standard protocol which, in this hospital, consisted of two doses of IM Betamethasone 12 mg, 12 hours apart.After several years of doing this intermittently we analysed, in May 2002, the notes of the previous 125 consecutive twin deliveries. Data gleaned

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from the notes and recorded in Epi-6 were chosen as follows: treatment received (i.m., oral or none); gestational age at treatment if any; gestational age at delivery; mode of delivery; apgar scores; birth weights; sex of infants; admission to neonatal nursery; paediatric diagnosis on discharge and perinatal outcome. The paediatrician (NCK) was then given the hospital numbers of each mother in the study and paediatric notes were searched for diagnosis, and perinatal outcome. Criteria for diagnosis of Hyaline Membrane disease were set by the specialist Paediatrician, NCK, and were as follows:

Newborn with gestational age <36 weeks Admission to nursery for respiratory distress Thoracic X-ray compatible with HMD

Results Initial preliminary analysis of 112 consecutive sets of notes revealed that the numbers in the three groups were startlingly dissimilar:

Table 1STEROIDS

Frequency

Percent

IM 15 13.4%None 61 54.5%Oral 36 32.1%Total 112 100.0%

Thus a further 13 sets of notes were chosen of mothers who had received intramuscular rescue treatment in order to make more comparable numbers.

The final cohort analysed consisted of 125 mothers with twin pregnancies who delivered in this hospital between August 2001 and May 2002. The distribution of treatment was:

Table 2STEROIDS

Frequency

Percent

IM 28 22.4%

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None 61 48.8%Oral 36 28.8%Total 125 100.0%

Gestational Age at Delivery62 of the 125 mothers delivered at less than 36 weeks, i.e 49.6%.

For each treatment group the distribution of gestational age at delivery is shown in the following graph:

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Because the indication for intramuscular treatment is acute, “rescue” of babies at immediate risk of premature delivery due to premature labour, the percentage of babies in the i.m. treatment group 85.7% (48/56) delivering before 36 weeks is higher than for the other groups.

Of the 124 babies delivering at 35 weeks or less, 56 (46% of the untreated babies) were not treated with steroids at all, through lack of time or oversight; 48 (85% of i.m. treated) had intramuscular betamethasone on admission; and 20 (27% of the orally treated babies) had been treated prophylactically orally with Dexamethasone in the clinic. This may indicate that the use of oral Dexamethasone decreases the chances of delivering prematurely, but another possible interpretation of this figure is that the attendance at antenatal care is responsible for less premature labour. The incidence of hyaline membrane disease and perinatal mortality in each of these three groups was as follows:

Table 3 Incidence of Hyaline Membrane Disease for each mode of treatment

Treatment Number of infants

HMD Percentage

Oral 20 2 10%Intramuscular

48 16 33.3%

None 56 18 32.1%

For all the babies admitted to the nursery the discharge diagnosis was recorded and built into a composite graph as follows to show the diagnosis for each birth weight category as distinct from gestational age. TTN stands for Transient Tachypnoea of the Newborn:

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Table 4 Perinatal Outcome for all babies of all gestationsTreatment Stillbirt

hNeonatal Death

Discharged alive (all gestations)

Oral 1 1 70(97%)Intramuscular

1 8 47(84%)

None 5 3 114(93%)

Two babies of 72 whose mothers received oral Dexamethasone had hyaline membrane disease (2.75%). Sixteen babies of 56 whose mothers received intramuscular Betamethasone had hyaline membrane disease (28.5%). The difference between the two groups is highly significant: p=0.00009; Relative risk 0.10; Odds ratio 0.07 (95% CL 0.01 to 0.33).The standard accepted regime of intramuscular Betamethasone 24mg at onset of premature labour has no clinical effect in our patients in reducing hyaline membrane disease.

DiscussionFor some as yet unexplained reason the standard intramuscular regime of betamethasone administration is not effective in multiple gestations. This is not a new finding, but it is as yet unexplained. The Cochrane meta-analysis comments “The small numbers of babies from twin pregnancies available for analysis here do not allow a confident statement to be made

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about the effectiveness of antenatal corticosteroid therapy in multiple pregnancy”. One possible explanation is provided by a paper from Balabh et al. This suggests that the double size of the placenta clears the steroid more quickly.

The findings in our analysis contradict those of Murphy and his colleagues in Bristol where an almost identical analysis was carried out using intramuscular dexamethasone prophylactically without showing any improvement in hyaline membrane disease. Our paper shows a clearly highly significant effect from prophylactic dexamethasone given orally before 32 weeks for twins.

The confounders in our paper are two: All orally treated patients had attended antenatal clinic and had

their twin pregnancies diagnosed before the end of the second trimester, while the other two groups contained patients with undiagnosed twins, thus having no benefit from antenatal care.

There was no formal randomisation into treatment groups, though a partial randomisation according to day of attendance did take place.

In order for this study to be confirmed it is planned to undertake a prospective randomised controlled trial in the near future.

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APNOEA AFTER IMMUNIZATION IN EX-PREMATURE INFANTS

PA Cooper, BJ Cory, SA Madhi, RE Huebner, KP Klugman, S Abdool Karim, I KleinschmidtDepartment of Paediatrics and Pneumococcal Research Unit, University of the Witwatersrand, and MRC, Durban.

Approximately 40 000 infants were enrolled into a double blind randomized controlled vaccine trial in Soweto, Johannesburg between June 1998 and October 2000. The main aim of the study was to test a new 9-valent pneumococcal conjugate vaccine. Infants received their regular immunizations at 6, 10 and 14 weeks of age and were randomized into two groups to get either the pneumococcal vaccine or placebo. At the time of the onset of the study, immunization against haemophilus influenza type B was not being given routinely and this was added to the schedule of immunizations for both groups. During the course of the trial, it was noted that a small group of infants were admitted to hospital with apnoea as the major presenting symptom at varying times after being immunized. As part of the evaluation of the safety of the pneumococcal vaccine, this group of infants was analyzed in detail.

MethodsAll of the infants presenting with apnoea were admitted to the paediatric wards of Chris Hani Baragwanath Hospital and records of these admissions were analyzed. However, the neonatal histories of these infants were not usually available. Therefore the records from the Chris Hani Baragwanath Hospital Neonatal Unit were searched for neonatal details and complications with respect to these infants. These records consisted of a computerized database and the original written records. However, only neonates with neonatal complications significant enough to warrant admission to a neonatal ward (i.e. prematurity, birth asphyxia, infections, etc) had such records – a normal term infant born at the hospital or one of the Soweto clinics would not have such a record.

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ResultsA total of 23 infants who were enrolled into the pneumococcal vaccine study with apnoea as their main presenting symptom were admitted. There was no difference in incidence between those who received pneumococcal vaccine and those who did not and thus the pneumococcal vaccine could not be implicated as a likely cause of the apnoeic episodes.

Of the 23 infants, the records of the neonatal admissions of 16 of these infants could be found. These infants had a mean birth weight of 1110g (range 800-1400g) and mean gestation of 29 weeks (range 26-32 weeks). Of the 16 infants for whom neonatal records were found, eight had required mechanical ventilation during the neonatal period, while four had developed a major intraventricular haemorrhage and/or post haemorrhagic hydrocephalus/leukomalacia. These figures were compared with those from a study conducted during 2000 over a three month period looking at the incidence of lung disease and neurological complications in very low birth weight infants where 14 of 52 infants had required mechanical ventilation (p=0.085) and one of 52 infants had similar neurological complications (p=0.01).

Only seven developed apnoea within two days of immunization and a further five within one week, but intercurrent illness was present in some of them at the time of their apnoea. In the remainder, apnoea occurred 8-33 days after immunization and was usually related to an intercurrent infective illness. Only one death occurred in this group in an infant who had apnoea 33 days after immunization and death was due to pneumonia and septicaemia.

DiscussionThere have been a number of reports in the literature regarding apnoea occurring after immunization, mainly in infants who were <1500g at birth, especially if they experienced major neonatal complications. Although the aetiology for this remains unclear, most have speculated that the pertussis

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fraction of the triple vaccine is responsible. Nevertheless, standard recommendations remain that very low birth weight infants should be immunized at their chronological age rather than their age corrected for prematurity.

In this study, all of the infants for whom neonatal records were available were <1400g at birth and there was a trend towards more severe lung disease (i.e. those requiring mechanical ventilation) and a significantly higher incidence of severe neurological complications associated with prematurity, all of which is in keeping with the published literature.

Previous studies have suggested that immunization related apnoea usually occurs within 48 hours of immunization. In this study, only seven infants developed apnoea within 48 hours and it is unlikely that there was any association with immunization with respect to the others. During the course of this pneumococcal vaccine study, a review of the hospital records indicate that close to 1000 very low birth weight infants (<1500g) were discharged from the neonatal unit over this time. The incidence of vaccine related apnoea in very low birth weight infants is thus extremely low. Thus, while it may be wise to exercise some caution with immunizing ex-premature infants who had significant neonatal complications, especially neurological, the standard recommendations for age of immunization should remain unchanged.

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SAVING BABIES: A PERINATAL CARE SURVEY OF SOUTH AFRICA 2001: EXECUTIVE SUMMARY

RC Pattinson on behalf of all PPIP Users

Aim1. To estimate a national perinatal mortality rate (PNMR) and to identify

the major causes of perinatal mortality and related avoidable factors, missed opportunities and substandard care in South Africa.

2. Recommend strategies to reduce the PNMR based on this information.

SettingAll Provinces in South Africa gave input, where possible, into the PNMR in their particular Provinces. Furthermore, 44 state hospitals throughout South Africa representing metropolitan areas, cities and towns, and rural areas were the sentinel sites for the documentation of the causes of perinatal death and the avoidable factors associated with the deaths.

MethodThe Provincial Health Information Sections and the Maternal, Child and Women’s Health units of the provinces presented their available data. Users of the Perinatal Problem Identification Programme (PPIP) amalgamated their data to provide descriptive data on the causes of perinatal death and the avoidable factors, missed opportunities and substandard care in South Africa and comprised the sentinel sites. The sentinel sites were grouped into metropolitan, city and town, and rural areas. The metropolitan grouping reflects urban areas and a fully functioning tiered health care system with ready access to tertiary care. The city and town grouping reflects functioning primary and secondary levels of care, with limited access to tertiary care, and the rural grouping reflects primary care, with less accessibility to secondary and tertiary care.

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ResultsSome provinces have developed effective data collection systems at the time of the workshop and were able to provide accurate data for their whole province regarding births and perinatal deaths within state institutions. Accurate data was available for Gauteng and the Western Cape. The PNMR for Gauteng was reported as being 32.1/1000 births and for Western Cape reported as 18.4/1000 births.

A total of 3045 perinatal deaths of 1000g or more were reported from 78 343 births at the sentinel sites. The perinatal mortality rates for the metropolitan, city and town and rural groupings were 38.4, 43.4 and 25.5/1000 births, respectively. The neonatal death rate was highest in the City and Town groups (16.5/1000 live births) followed by the Rural and Metropolitan groups (11.1 and 10.7/1000 live births respectively). The low birth weight rate was highest in the Metropolitan group (21.4%), followed by the City and Town group (18.6%) and the Rural group (13.7%).

Unexplained intrauterine deaths were a common grouping of primary cause of death in all groups. The most common primary cause of perinatal death in the Rural group was intrapartum asphyxia and birth trauma (rate 6.28/1000 births) followed by spontaneous preterm delivery (6.07/1000 births). The most common primary cause of death in the City and Town group was spontaneous preterm delivery (7.48/1000 births) followed by antepartum haemorrhage (7.0/1000 births) and intrapartum asphyxia and birth trauma (6.8/1000 births). The Metropolitan group’s most common primary causes were antepartum haemorrhage (6.82/1000 births), spontaneous preterm labour (5.33/1000 births) and complications of hypertension in pregnancy (5.19/1000 births). Neonatal deaths due to complications of prematurity and hypoxia were the most common final neonatal causes of death in all groups.

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Patient related avoidable factors were reported to be present in 39.3% of perinatal deaths, followed by health worker related (24.6%) and administrative (14.0%). Lack of sufficient information to evaluate the case was present in 5.1% of cases. No, late initiation or infrequent attendance for antenatal care (present in 688 cases) was the most common avoidable factor. This was followed by an inappropriate responses by health workers to problems identified during antenatal care (305 occasions); inappropriate response by patients to poor fetal movements (227 occasions); delays in seeking medical attention during labour (177 occasions); delays in referring patients or calling for assistance (173 occasions); transport delays (162 occasions) and problems of monitoring the fetus during labour (106 occasions).

Conclusions

The current data is sufficient to state that the PNMR in South Africa is probably in the order of 40/1000 births, and some readily remedial problems have been identified. These are in the structure of antenatal care, management of labour, resuscitation of the asphyxiated neonate and care of the premature neonate. Focusing attention on these readily remedial priority problems, by ensuring that equipment, protocols and trained health workers are always available and by specifically introducing kangaroo mother care for the care of the premature infants, makes the reduction of perinatal mortality in South Africa feasible and inexpensive.

RecommendationsSolutions for improving pregnant women and their baby’s care and reducing the PNMR rate at institutions1. Ensure each site conducting births has the necessary equipment and

protocols and that the staff is appropriately trained to manage labour and are especially trained in the use of the partogram. Introduce a quality assurance tool to assess the success of the training.

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2. Ensure each site conducting births has the necessary equipment and protocols and appropriately trained staff to manage asphyxiated neonates. See that training programmes in neonatal resuscitation are accessible to all staff involved with conducting child birth

3. Ensure each site caring for premature infants has the necessary equipment and protocols and that the staff is appropriately trained in kangaroo mother care. See that implementation programmes are available to the staff.

4. Ensure each site performing antenatal care has protocols in place for where to and when to refer patients and the staff is appropriately trained therein. Introduce a quality assurance tool to assess the success of the training.

5. Move to a system where the time and point at which the woman confirms she is pregnant also becomes the woman’s first antenatal visit where she can be classified according to risk and where her further antenatal care is specifically planned. If this is not practice establish what barriers there are and attempt to overcome them.

Improve the process1. Continue to establish more PPIP sentinel sites.2. Hold regular Provincial MCWH – PPIP sentinels site meetings.

Research priorities 1. What are the barriers to implementing on-site screening for syphilis?2. What is the primary pathology related to unexplained IUDs?3. What is the feasibility of introducing nasal CPAP for managing

premature infants in cities and towns and rural areas?Advocacy Valuable information obtained from the Perinatal Care Survey must be conveyed to the appropriate bodies.

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OPTIMISING INFANT FEEDING IN THE CONTEXT OF HIV: A PUBLIC HEALTH PERSPECTIVEA Goga, E de Klerk, N Mazibuko, S Ngake, W LoeningNational Department of Health, South Africa

In May 2002 the Global Strategy on Infant and Young Child feeding was adopted by the World Health Assembly. This strategy has 4 broad focal areas: (i) promoting appropriate feeding for infants and young children (ii) exercising other options (iii) improving feeding practices and (iv) feeding in exceptionally difficult circumstances. HIV and infant feeding falls into the focal area: feeding in exceptionally difficult circumstances. It is crucial that HIV and infant feeding is seen within the broad context of infant and young child feeding so that correct, consistent and concise messages are delivered at various levels of the health care system and in the community.

This presentation briefly summarises the available evidence on postnatal (breastfeeding) transmission of HIV, then lists the international and national recommendations on infant feeding and discusses current interventions aimed at optimising infant and young child feeding in the context of HIV. The presentation focuses on the operational issues relating to training aspects, and not on the impact of the PMTCT programme.Transmission of HIV from mother-to-child can occur during pregnancy, during labor and delivery, and during the post-partum period, through breast feeding (See Figure I).

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0% 20% 60% 80% 100%

Proportion of all infections

In the absence of interventions and with prolonged breast feeding (i.e. greater than 12 months) 25 to 45 percent of all babies born to HIV positive mothers will become infected with HIV. A small proportion of this transmission occurs during pregnancy as shown in box A.However, more than half of the transmission occurs around the time of labor and delivery. The breast feeding period, depicted by box D, contributes to about one third of the total transmission. Postnatal transmission of HIV can occur as long as breast feeding continues.

Figure 1 Timing of Mother-to-Child HIV Transmission with Breastfeeding and No ARV

Early antenatal(<36 wks)

C: Labour and delivery

Late postpartum

(6-24 months)

Early postpartum

(0-6 months)

Late antenatal(36 wks to labour)

A B D E

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Comparing data from different studies, breast feeding may be responsible for 40-50% of HIV infection in the developing world.

Various factors related to the mother, the infant and breast feeding practices, increase the risk of postnatal transmission of HIV. Maternal factors include primary maternal HIV infection while breast feeding, maternal immunosuppression - as reflected by her CD4-CD8 cell counts, maternal plasma and breast milk viral loads, and breast pathologies, particularly sub-clinical or clinical mastitis, breast abscess, deep nipple fissures or cracks and bleeding nipples.Factors related to the baby and breast feeding practices include breast feeding duration and pattern, oral pathologies, age, and premature deliveries.

With regards to breast feeding duration, studies have found that the risk of HIV transmission through mixed feeding (breast milk in addition to other foods or fluids) for 6 months is approximately 5%. If breast feeding duration is increased to 12 months, this risk increases to 10%, and if this duration increases to beyond 15 months, risk of transmission increases to 15%.This means that if there are 100 HIV infected women, and all of them mix feed for 6 months, approximately 25 babies will probably be born with HIV (having acquired HIV during pregnancy or labour or delivery). Administering nevirapine to the woman during labour and to the baby within 72 hours of birth will decreased this risk by approximately half (approximately 13 babies will be born with HIV). Five babies will be infected through mixed feeding for about 6 months. This means that with nevirapine and mixed feeding for about 6 months approximately 18 babies will acquire HIV through vertical transmission.

Research suggests that exclusive breast feeding may decrease the number of babies infected through breast milk from 5 to 1. If this is true, it means that with nevirapine and exclusive breast feeding for 6 months,

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approximately 14 babies will acquire HIV through vertical transmission. One baby of the 100 babies born to HIV positive women may die from common infections in developing countries.Avoidance of all breast feeding removes the risk of HIV transmission through breastfeeding, but not the risk of transmission during pregnancy, labour and delivery. However, data suggests that 6 babies might die from common infections such as diarrhoea and pneumonia, as a result of not breast feeding.Hence the ideal feeding method for babies born to HIV positive women depends on balance of the risks involved.The Interagency Task team (IATT) states that breast feeding remains the best source of nutrition for the great majority of infants and should continue to be promoted and supported among mothers not known to be HIV infected. For HIV positive women, the IATT recommends that when replacement feeding is acceptable and feasible and affordable and sustainable and safe, avoidance of all breast feeding is recommended. Otherwise, exclusive breast feeding is recommended during the first months of life. The infant feeding options currently recommended by the World Health Organisation and United Nations Children’s Fund include: (i) exclusive breast feeding followed by early cessation of breast feeding; or (ii) exclusive breast feeding for the first 6 months and continued breast feeding thereafter; (iii) heat treatment of breast milk; or (iv) wet-nursing by tested HIV-negative women; or (v) replacement feeding options – either using home prepared formula and an enriched family diet or commercial infant formula. Currently, little information is available on the safety, feasibility and acceptability of most of these infant feeding options. However, several studies are underway nationally and internationally to determine this, and to investigate how breast feeding can be made safer. It is hoped that by end of 2003, preliminary results of ongoing and planned studies, will shed light in this area.

The next part of the presentation focuses on South Africa. The infant feeding options currently recommended for HIV positive South African

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women are exclusive formula feeding using commercial infant formula or exclusive breast feeding and stopping early. The HST report identified infant feeding as the weakest part of the South African PMTCT programme: (i) health workers seem to receive conflicting messages, (ii) neither exclusive breast feeding nor exclusive formula feeding are commonly practiced, and (iii) few mother-baby pairs enrolled in the PMTCT programme are followed-up appropriately and supported after birth. To address this, the National Department of Health has taken the following steps to ensure consistency between the PMTCT programme and routine child health interventions: (i) the Integrated Management of Childhood Illness Strategy (IMCI) has been adapted to include feeding of babies born to HIV positive women. The current adaptation includes recommendations on exclusive replacement feeding, for HIV positive women who choose not to breast feed (ii) training of health workers on infant feeding in the context of HIV has begun. This is a 5 days training course combining a module on PMTCT from the Perinatal HIV research unit with the WHO/UNICEF Breast feeding Counselling: A Training course and WHO/UNICEF/ UNAIDS: HIV and Infant feeding Counselling Course, and (iii) infant feeding issues are being raised and discussed - including the provision of free formula at PMTCT sites - at various forums.

The adapted IMCI course was piloted in September 2002; and is now being implemented in all provinces. Training is funded by the National Department of Health, WHO, UNICEF.Regarding the PMTCT and HIV and IF training courses, a national training course has been developed and is currently being implemented with funding from the National AIDS Directorate. This course has the following core content areas: (i) The epidemiology of HIV/AIDS – international, national and provincial perspectives (ii) HIV/AIDS basic science, (iii) Testing for HIV – mother and baby (iv) Overview of the SA PMTCT programme (v) Management of HIV negative women (vi) Risk factors for Mother to Child Transmission of HIV, including prenatal, intra-partum, and

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post-partum (infant feeding) (vii) Counselling principles and techniques (viii) follow up of mother and baby (ix) Care of low birth weight and sick babies (x) Community mobilization and (xi) Care of the carers. The course has a strong practical component so that health workers practice their counselling skills.During the course, 3 training manuals (the PMTCT manual produced by the Perinatal HIV research unit, and 2 WHO manuals) are used as training materials.The current model trains counsellors for 5 days. From this group, potential trainers are identified. These potential trainers undergo two attachments to a master trainer before becoming fully accreditated trainers. Potential course directors are identified from these trainers. They also have to undergo to two attachments to a master course director before becoming an accreditated course director. It is intended that this process would repeat itself, having a multiplier effect, and thus expanding training. The number of people that have been trained (between mid 2002 and February 2003) using this model are illustrated in Table 1.

Table 1

No. of training courses conducted 14No. infant feeding counsellors trained 401No. trainers identified 122No. trainers mentored 38 (fully); 40 (half)No. course directors trained 7 (fully); 10 (half)*No. of doctors trained 8*“Half” implies that the trainers have had one attachment only

The following lessons have been learnt: Although there is a short time allocated to infant feeding counselling in IMCI, the presence of messages consistent with PMTCT has been met very favourably. The current challenge is to scale up implementation of the adapted course, and update the 4000 health workers already trained in IMCI.With regards to the PMTCT and HIV and infant feeding course: Firstly, it is difficult to get the correct balance of the course content so that health

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workers gain theoretical information and clinical skills that enable them to conduct effective, non-biased infant feeding counselling and support women in their chosen feeding option. Secondly, the training model needs to be simplified: It is dependant on: (i) the availability of experienced master trainers who can supervise potential trainers or course directors; and (ii) release of staff for long periods of time -15 days - to become trainers.This model is currently being reviewed, and the possibility of a 5 day training course to train trainers (thus removing the need for the 2 attachments for 10 days) are being considered. Thirdly, the use of 3 different training manuals is cumbersome. One comprehensive training manual on PMTCT and HIV and infant feeding is currently being developed. Furthermore, the IMCI method of conducting facilitators courses to develop a pool of trainers is being explored.

It is crucial that exclusive breast feeding for the first 6 months of life and continued breast feeding thereafter is protected, promoted and supported in the HIV negative population, or in women of unknown HIV status. This needs to be accompanied by intensified training on PMTCT, HIV and infant feeding and IMCI and should be backed up by an Infant and young child feeding policy with implementation guidelines. These guidelines need to specify the procurement and distribution and storage of formula milk that is being used in the PMTCT programme, so that spillover of formula feeding into the general population is avoided.

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EFFICACY OF TWO POST-EXPOSURE PROPHYLACTIC REGIMENS IN REDUCING MOTHER TO CHILD TRANSMISSION OF HIV-1 IN INFANTS BORN WITHOUT ACCESS TO ANTIRETROVIRAL THERAPY: A RANDOMIZED, OPEN LABEL, CONTROLLED CLINICAL TRIAL

Gray GE1, Urban M2, Bolton C1, Chersich M1, Van Niekerk R1, Schultz D1, Violari A1, Mcintyre JA1 for the PEP Study Group.1 Perinatal HIV Research Unit, University of the Witwatersrand, South Africa2 Coronation Hospital, Department of Pediatrics, University of the WitwatersrandPEP Study GroupBaragwanath Hospital: Boris Jivkov, Lucy Connell, Deidre Josipovic, Lorna Jenkins, Eileen Botha, Busi Saba, Pascort Khela, Miriam Kunene, Gloria Tshabalala, Manko Coronation Hospital: Lucia Thomas, Edith RamorokanaMowbray Hospital: Mitch Besser,

BackgroundNevirapine (NVP) prophylaxis to mother and infant provides a feasible option for preventing mother-to-child transmission of HIV-1 (MTCT) in developing countries. The value of NVP in post-exposure prophylaxis (PEP) used in MTCT is undetermined. We compared the efficacy of two PEP regimens when administered to infants born to HIV-infected women with no prior antiretroviral therapy.

MethodsThis randomized, open-label, multi-centre clinical trial in South Africa, compared the use of single dose Nevirapine (NVP) to 6 weeks of Zidovudine (ZDV) commenced within 24 hours of delivery. Infants were followed up for 6 months. HIV-1 infection rates were ascertained at birth, 6 weeks and 3 months. Secondary analysis on infant feeding was done. We present HIV infection rates at 6 weeks by intention to treat analysis.

Results1040 infants who were randomized between October 2000 and September 2002. Of these, 196(18,8%) were lost to follow-up, 12(1,2%) died and 31(3%) withdrew. At week 6, 801(77%) infants were evaluable. Formula feeding rates were similar (NVP,68,4%; ZDV,72,5%). Excluding those infected at birth (NVP=XX%, ZDV=XX%), the additional infection rates were 7,4% (95% CI) in the NVP arm and 9,1%(95% CI) in the ZDV arm. Factors associated with transmission at 6 weeks were maternal CD4<500(OR 2.04; 95% CI 1.08;3.85); maternal viral load >50 000; and BF (OR 0.55; 95% CI 0.32;0.95).

ConclusionSingle dose NVP administered within 24 hours of birth was no different to 6 weeks to ZDV in reducing post-partum MTCT. Post-partum NVP should be given if an HIV-infected woman misses the ante-partum dose, and considered in settings where maternal HIV status is unknown.

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WHAT TYPE OF CLIENTS GO FOR VCT?

EJ Buthelezi, N Mosery, M Nxumalo, J ChegeDepartment of Health, Population Council, Reproductive Health Research Unit

BackgroundSouth Africa is experiencing a rapid increase in levels of HIV prevalence. According to the National HIV Prevalence Survey, KZN province has a 33.5% HIV prevalence among antenatal clients. VCT programs have been implemented and are being rolled out in

public sector clinics but little is known about the type of clients who go for VCT and the factors that encourage them to seek services.

KZN Department of Health (MBWH) is testing the feasibility of integrating STI and VCT services in antenatal care.

Data presented is from analysis of the baseline survey of this study.

Data Baseline data was collected in 12 study clinics based in Ulundi in 2

districts to assess the quality of ANC services and level of STI/HIV integration.

Data collected through observation of interactions between the client and provider and exit interviews with clients.

Client age range: 15-43 years.

Is there a demand for VCT among ANC clients? When looking at clients’ demand for VCT, out of 249 clients: 11%

ANC clients have had HIV tests, this is a small number compared to the number of clients dying from HIV/AIDS.

77% thought there was a need to test; 48% thought it is not good to know own status.

20% thought it was good to go for VCT as they will be able to protect their unborn babies.

17% said there is a need as they do not trust their partners. 6% said yes to VCT so as to prevent others from being infected.

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3% thought there is a need so as to get treatment.From those who were tested the results were as follows: as indicated in the attached graphs.

ConclusionsClients receiving information MTCT, VCT and referral for VCT are more likely to go for HIV tests.

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No Significant Occupation Difference in Client HIV Testing

Occupation Tested % Not tested %Unemployed/housewife (n=156) 14 86Salaried worker (n=20) 5 95Self employed/farmer (n=45) 9 91Other/student (n=20) 5 95Total (n=241) 11 89

Clients given information about HIV by provider are more likely to have had and support HIV Testing

Service provided during any visit

Had HIV test Think HIV test is important

YesN=27

NoN=214

YesN=185

NoN=55

Talked to about condom use 48 34 38 27Talked to about MTCT 67 39 50 18Talked to about VCT 67 32 43 15Offered referral for VCT 52 19 25 16

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ABSTINENCE PRE- AND POST-DELIVERY: DOES IT HAPPEN; IS IT A POTENTIAL RISK FACTOR FOR STI & HIV/AIDS?

B Kunene, M Beksinska, S Mullick, S ZondiReproductive Health Research Unit, Frontiers Program of Population Council and KZN Department of Health

BackgroundReproductive health information including STIs and condom use is primarily aimed at women yet they are not financially and culturally positioned to make decisions around many of these issues. Hence the need to have men involved in the reproductive health. It is becoming increasingly clear that every pregnancy in South Africa faces an element of risk, because men, as partners and decision makers, are not informed about reproductive health issues. In addition, women are not in a position to talk about sex or condom use with their partners. However, abstinence is one way of preventing sexually transmitted infections including HIV. Most people claim to do this at one stage namely during pregnancy and or post delivery. Studies have shown that 80% of HIV infections occurs in so called stable relations because of unprotected sex where a male partner gets the disease elsewhere.

Objectives To assess abstinence practices pre- and post-delivery; To determine the duration of abstinence; To find out reasons for abstinence; To assess the potential risk of acquisition of sexually transmitted

infections including HIV during this period.

Methodology The study has been conducted in twelve clinics in the Ethekwini Health district (Durban) in KZN Natal, South Africa. The design was a randomized, cluster, matched pair design involving twelve clinics. Interviews were conducted from June 2001-February 2003 including follow

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up for both arms. Only data from the control site was used for this paper: female 1077 pre- & 712 post-delivery male 633 post.

Results Women were asked during pregnancy whether they intend to abstain from sex at any stage of their pregnancy. Fifty eight percent said yes they were going to abstain during pregnancy and ninety percent were going to do so post delivery.

Figure1 Percentage of abstinence pre and post delivery

The period of abstinence varied from three months for those who said they were already abstaining to nine months.

Figure 2 Proportion of abstinence: pre delivery

Post delivery almost all women (98%) said they would abstain from sexual intercourse. The number was gradually decreasing as months post

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delivery increased. Only 8% said they were going to abstain even 10 months after the baby was born.

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Figure 3 Proportion of abstinence: post delivery

The pattern of abstinence was traced during pregnancy and post delivery. The following trend was established. The duration of abstinence varied from three months to more than twenty-four months.

Figure 4 Pattern of abstinence pre and post delivery

All those who were going to abstain were asked reasons for this. Several reasons were more common; social custom 40%, health of the mother or baby 47%, other reasons 11% such as not being able to have sex when pregnant, sperm being harmful for the baby or fear of making the baby undesirable (isidina) or dirty and 2% had no reasons for abstaining.

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Socio demographic status - women planning to abstain pre- and post-deliveryThese women were not different from the rest of the sample. Only ten percent of them were married the rest were either co-habiting or in a regular visiting relationship. Seventy-three were either unemployed or at school.

Table 1 Socio demographic statusAge 13 to 45 (mean 24)Marital status %Married 10 (1 not living with

partner)Living together 25Visiting relation 65Pregnancy planning Unplanned 78Employed 13

Attitude towards other relationships was assessed such as acceptability of men to have sex with other women while his partner is said to be abstaining post delivery. Four percent said it acceptable to have pre-delivery and the number increased to eight percent post-delivery. Same question was asked to men and ten percent said yes it was acceptable for men to have another partner at this stage.

Further analysis showed that 58% female and 44% male reported that they did not resume sex within first 3 months almost half of these were not sexually active at six months. 66% of these participants had had family planning immediately post delivery Sexual risk behaviour was then assessed: 53% had refused to have sex with their partners, 8 of these women were forced, 5 women had sex with 1-3 other partners and 2 of them did not use condoms. 17% men had sex with 1-10 other partners.

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Self-risk assessment was done, thirty percent women and thirty-eight percent men said they had no chance of getting infected with HIV and more than a quarter did not know or could not respond to the question.

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HIV self risk assessmentRisk perception Women MenNo chance 30 38Some chance 20 12High chance 7 4Do not know/ No response

43 46

Summary Period of abstinence pre- and post-delivery range from 1-24

months. Some women and men had sex with other partner during this

period. A few reported that it is acceptable for men to have other sex

partners during this period. Definition of abstinence is not clear. Is abstinence is a potential risk factor for STI including HIV/AIDS?

Recommendations Need for further studies to look at abstinence in relation to pre- and

post-delivery period. Need to educate people about abstinence, what does it mean to

abstain? To develop comprehensive package that involve men in the

reproductive health.

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PERINATAL TUBERCULOSIS AND HIV-1 CO-INFECTION

M Adhikari*, T Pillay*, J Moodley #

Department of Paediatrics* and Obstetrics and Gynaecology.# Nelson R Mandela School of Medicine, University of Natal Durban South Africa

BackgroundTuberculosis (TB) is the commonest chronic infection among HIV-1 co-infected individuals. Sub-Saharan Africa carries the brunt of co-infected TB and HIV-1 globally. Kwazulu Natal (KZN) is in the heart of both epidemics with a TB prevalence of 413/100 000 and an antenatal HIV prevalence of 40%. The highest case fatality rate is in women of the childbearing age. TB is generally regarded as being rare in pregnancy and there are sparse reports of TB and HIV-1 co-infection in pregnancy and none on perinatal outcome.In 1996, at King Edward VIIIth Hospital, Durban, South Africa, a number of ill neonates with symptoms of chronic infection were noted. These babies had persistent or chronic pneumonia, visceromegaly, growth impairment and associated infections of syphilis, cytomegalovirus and TB. The majority was HIV-1 co-infected. In concert with this it was noted that there was an increase in the number of mothers with TB and who were HIV-1 co-infected.

Aim of studyThe aim was to define the impact of active tuberculosis on maternal and perinatal health in African women in Durban, South Africa.

Ethical ApprovalEthical approval for the study for the study was obtained from the Ethics Research Committee of the Nelson R Mandela School of Medicine.

Clinical MethodsDiagnosis of TB

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The diagnosis of TB in the mother was made on clinical signs and symptoms of TB +

one or more of following: AFB on sputum microscopy, culture of AFB from sputum or other sample, histological evidence and chest radiology. Within 72 hours of delivery, clinical and radiological assessment was repeated and FBC, T-cell subset, viral load and endometrial samples taken. Mothers with active TB were treated with rifampicin, INH, pyrazinimide, ethambutol for two months followed by rifampicin and INH for four to seven months. In the newborn, because of the non-specificity of signs the diagnosis of TB was only made if the Mycobacterium tuberculosis was cultured or detected microscopically in the samples submitted. The tuberculin skin test is unlikely to be positive in the newborn so was not used. Similarly, the chest radiograph was not used for diagnosis as radiological signs are non-specific. Newborns were investigated for TB if the mother had proven or suspected TB in pregnancy or the postpartum period, a past history of TB or TB in a close contact. Clinical signs in the newborn are those of chronic infection – persistent hepatosplenomegaly, lymphadenopathy, failure to thrive, skin lesions, prolonged neonatal jaundice. Investigations included radiology, FBC, gastric washings X3 for AFB, cerebrospinal fluid for AFB, histology of liver, nodes. If the baby was HIV-1 exposed, T-cell subsets, viral loads and co-infections were investigated for. Mother and babe were followed for 24 months.

ResultsMaternalHIV-1 infection rate: 1996 – 16098 deliveries HIV prevalence 25%. 1997 - 16811 deliveries HIV prevalence 28%, 1998 – 16799 deliveries HIV prevalence 30%. 10% unbooked expected seroprevalence was 45%. One hundred and forty-six pregnant women were diagnosed with TB. The overall hospital rate of TB was 289/100 000 maternities. The TB prevalence for 1996 was 0.1% (11 women), 1997 0.24% (41 women) and 1998 0.6% (94 women). Of these 146, 115 (78.8%) were HIV-1 infected, 26 (17.8%) were HIV-1 non-infected and in 5 the HIV status was not

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determined. The minimum TB/HIV-1 co-infection rate in 1996 was 36.4% and rose to 88.3% in 1998 (p=0.001). 14849 (29.3%) of 50518 parturients were HIV-1 infected. The TB prevalence in the HIV-1 non-infected was 72.9/100 000 and in the HIV-1 infected 774.5/100 000. The RR of TB due to HIV-1 co-infection was 10.62 and the attributable fraction of TB related to HIV-1 infection in pregnant women was 71.7%.Pulmonary TB was the commonest form of TB occurring in 78.8%, sputum AFB positive in 39% in HIV positive and 27% in HIV negative women; pleural effusion in 16, miliary TB 2, CNS /spine 5 genital TB 6. Sixty-three mothers were diagnosed in the last trimester and 2 mothers had multi-drug resistant TB. Fifteen mothers died - mortality rate 103/1000 women with overt TB in pregnancy and 14 of these women who died were HIV-1 co-infected. One hundred and seven mothers had active TB in pregnancy.

Perinatal Outcome (107 mothers)Perinatal mortality rate was 80 in HIV-1 infected women with TB. There were 7 deaths, all were HIV exposed. Perinatal morbidity - 65 (57%) were LBW, 46 (40%) premature and 69 (61%) had IUG restriction. Within the neonatal unit, of the 107 live births 16 babies were diagnosed with TB, 12 on culture and 4 on smear microscopy. 11 were HIV-1 exposed (69%) and the vertical TB transmission rate was 13.4%. Babies who were smear positive were treated for 6 months with anti-TB treatment. Those who were smear negative were given INH and rifampicin prophylaxis and follow-up for culture results at 4, 6 and 12 weeks. If babies developed signs on follow-up full treatment was commenced.

Neonatal OutcomeNeonatal outcome was measured by morbidity and mortality, deaths were recorded in hospital or a field worker traced the families. Overall HIV-1 infection rates were compared to the vitamin A intervention cohort. Those babies who were HIV-1 non-exposed (n=5) [2 smear positive commenced therapy while in Unit, 3 smear negative, 2 developed splenomegaly on prophylaxis, signs resolved on full treatment). All well at 12 months. Of

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the HIV-1 exposed (n=11) 7, 64%, were HIV-1 infected by 3 months higher than the vitamin A intervention cohort of 24%. Clinical signs worsened in all and all were dead by 3 to 10 months of age with signs of rapidly progressive disease.DiscussionThis study has shown a dramatic increase in caseload over the study period, three of every 4 women with TB were HIV co-infected. The prevalence rate of active TB in HIV-1 infected mothers was 10 fold of non-infected mothers.TB and HIV contribute significantly to maternal mortality. In the study group, TB was the third leading disease associated with maternal mortality (14.9%) with sepsis (34%) and PIH (25%) being the leading two causes. The overall hospital mortality rate for TB was 102.7/1000, TB HIV-1 co-infection rate 121.7/1000 and TB in the absence HIV was 38.5/1000. Almost all deaths were HIV-1 related. All babies who were HIV negative and acquired TB vertically, when treated correctly, did well. In contrast, the HIV-1 infected group were all dead by 10 months of age and was associated with a rapidly progressive. The index of suspicion for TB has to be high throughout pregnancy, mothers must be screened for HIV. Babies of mothers with TB should be screened and given prophylaxis or fully treated if the AFB is seen on microscopy or cultured. The HIV exposed should receive the appropriate management till proven HIV negative.

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PUERPERAL PYREXIA IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS INFECTION. IS CAESAREAN SECTION MORE RISKY?

EJ Coetzee, E Simmonds

According to evidence-based studies in the developed world doing an elective caesarean section in women infected with Human Immunodeficiency Virus (HIV) halves the vertical transmission rate to the newborn. In these series, there was no extra morbidity to the mother. However, as most patients in the developed world are now being treated with Highly Active Anti-Retroviral Therapy (HAART) resulting in low rates of vertical transmission the benefits of elective caesarean section might be minimal.The American College of Obstetricians and Gynaecologists expert committee have advised that an elective caesarean section should be advised for all HIV mothers with a viral load greater than 1000 copies/ml.In the South African setting, where most women are not on any antiretroviral therapy during their antenatal period the majority of women with HIV infection would have a viral load above 1000 copies/ml.In addition (once again because of the absence of antiretroviral therapy), our patients are far more likely to have a low CD4 count reflecting their low immune status. The poor nutrition and social conditions further contribute to the burden of infection.

To determine the role of elective caesarean section in HIV positive patients in South Africa, a prospective randomised study should be done evaluating pyrexial morbidity, duration of stay in the postnatal ward and vertical transmission comparing patients randomised to elective caesarean section versus intention to have vaginal birth. As such a trial would be expensive and difficult to do in South Africa, we planned to evaluate a 6 month window of all HIV patients (approximately 250) who delivered in Groote Schuur Hospital Maternity Centre, a Level 3 referral centre for the Maternity Services in the Cape Peninsula.At the time of the 2003 Priorities meeting we had evaluated 70 patients.

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There were 5 stillbirths including one set of twins. All delivered vaginally. Sixty-six patients with viable babies were therefore evaluated according to their mode of delivery. Vaginal deliveries were achieved by 27 patients (41%).Of the 39 patients who had caesarean sections, 26 were elective and 13 had emergency caesarean sections. Twelve of the elective caesarean section patients mainly chose caesarean section because of their HIV status (and a desire to prevent vertical transmission to their babies) although in many cases they had other problems such as diabetes or pre-eclampsia. The rest of the elective caesarean sections were done for standard obstetric reasons.

Of the 24 patients who went into spontaneous labour and had vaginal deliveries 3 had puerperal pyrexia (temperature of 38 on at least 2 occasions) and one stayed in the ward for 10 days with frank puerperal fever (uterine endometrititis).Twelve patients were induced, but only 4 patients had a normal vaginal delivery.None of these 4 had a puerperal pyrexia. There was no puerperal pyrexia in the 12 patients who had elective caesarean sections mainly to prevent vertical transmission to the newborn.Amongst the 14 patients who had elective caesarean sections for obstetric reasons, one patient had a total abdominal hysterectomy following uncontrollable haemorrhage associated with placenta praevia while a patient with large uterine fibroids had puerperal pyrexia.There was one other case of puerperal pyrexia.Amongst the 13 emergency caesarean sections, 3 had puerperal pyrexia.All cases of prolonged puerperal pyrexia were due to uterine endometrititis, but where pyrexia was only for one or two days a specific diagnosis was seldom identified.

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Patients who had a vaginal delivery were virtually all discharged by day 4 while emergency caesarean sections had the longest ward stays.As expected patients who had an induction of labour had a poor success rate of achieved vaginal delivery. This is probably due to the policy of not rupturing membranes in patients with HIV infection.Table 1 gives the numbers in each category of delivery and the percentage and numbers who had puerperal pyrexia and percentage patients who were discharged by day 4.

These data are very preliminary and the numbers are too few to make any deductions. In addition, any final data are only applicable to a tertiary setting.However, it is pleasing to note that the prevalence of puerperal pyrexia was not as high as imagined especially in the group who had elective caesarean sections because of their HIV status.However, it must be noted that virtually all caesarean sections had a spinal anaesthesia and antibiotics were used liberally.

Table 1

MODE OF DELIVERY Puerperal Pyrexia % (n) % Discharged by Day 4 (n)Vaginal deliveries (27) 11.0 (3) 96 (26)Elec C/S for HIV (12) 0 85* (10)Elec C/S for Obstetric reasons (14) 14 (2) 50 (7)Emergency C/S (13) 23 (3) 61 (8)* Both patients stayed longer periods for medical diseases and not puerperal infection

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INTEGRATION OF STI/HIV SERVICES IN ANTENATAL CARE. HOW EFFECTIVELY IS THIS DONE IN RURAL AREAS IN KWAZULU NATAL

AT Sibiya*, N Mosery^, J Chege^KZN DOH Maternal, Child and Women’s Health*, Population Council^, Reproductive Health Research Unit, Nelson Mandela School of Medicine, Natal

BackgroundThe high prevalence of HIV/STI among ANC clients in KwaZulu Natal calls for a need to address HIV/STI in antenatal care service provision. The Department of Health Maternal, Child and Women’s Health Unit in collaboration with Reproductive Health Research Unit, Frontiers Programme of Population Council and Nelson Mandela School of Medicine (Department of Microbiology), Natal University are implementing an intervention study to test the feasibility and effectiveness of integrating the STI/HIV counselling, diagnosis and management into Antenatal care service provision.

MethodsThis is a matched pair randomised control trial study, implemental in 12 clinics in Ulundi and Umzinyathi districts of KwaZulu Natal. Six clinics attached to two referral hospitals that provide Voluntary Counselling Testing (VCT) services were randomly selected and matched according to client load in each district. The Ulundi district clinics are intervention and Umzinyathi are control clinics. Baseline data was collected in all 12 clinics on the quality of services and level of integration, observation of client provider interaction and client exit interview. Study covered 249 new and repeat antenatal care clients.

ResultsThis paper presented baseline findings on the level of integration of STI/HIV service in antenatal care. Apart from syphilis screening which is routine antenatal care practice, less than 10% of antenatal clients receive any kind of STI and HIV counselling and other services. The paper will also provide results that indicate the proportion of clients who receive services or information on Mother-to-Child Transmission of HIV, referrals for VCT, screening for STI and promotion of condom use in rural clinics.

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SERUM PROTEIN ELECTROPHORESIS IN HIV SEROPOSITIVE AND SERONEGATIVE PREGNANT WOMEN

LC Kapsenberg*, HS Cronjé, H van Jaarsveld, G Joubert†, MG Schoon, GM MeyerDepartments of Obstetrics and Gynecology, Chemical Pathology and Biostatistics†, University of the Free State, Bloemfontein, South Africa

The morbidity and mortality in human immunodeficiency virus (HIV) infected women is caused by the immunosuppressive effect of HIV. Progressive depletion of the CD4+ (helper-inducer) subset of T-lymphocytes is the dominant feature of HIV infection. The effects of pregnancy and HIV-infection will possibly lead to changes in the pattern of immunoglobulins. By experience we suspected a noticeable difference in the outcomes of serum electrophoresis between HIV seropositive and seronegative pregnant women. Protein electrophoresis has been performed on the serum of all newly admitted patients to the High Risk Obstetric Unit (HROU) of the Universitas Hospital in Bloemfontein, South Africa. The HIV status, the total CD4+-cell count as well as the serum levels of four different immunoglobulins (IgG, IgA, IgM and IgE) were determined on all these patients. The aim of this study was to document the differences in these investigations between HIV seropositive and seronegative women.

Patients and MethodsProtein electrophoresis was performed on the serum of every new patient on admission to the HROU of the Universitas Hospital in Bloemfontein since April 2001. We reviewed 235 patients admitted between 1 April and 30 November 2001. The study group consisted of all the HIV seropositive patients. The control group consisted of the previous and next tested eligible HIV seronegative patient in the database. In order to be included, serum protein electrophoresis must have been performed during pregnancy or within 48 hours after delivery. A standard inquiry form was used to collect these data from the patients’ records.

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CD4 counts were also done routinely on all the patients during the period of observation. This was done due to an interest of one of the physicians. Since CD4 counts are rarely done on HIV negative patients, we included these investigations into our study.Statistical AnalysisResults were reported as median (quartiles) or as numbers (percentages). To test for statistical associations between categorical variables the 2 test was used. However, in case of an expected cell size <5 the Fisher’s Exact test was used instead of the 2 test. Numerical variables were compared using the Mann-Whitney test. A p-value < 0.05 was considered statistically significant. 95% confidence intervals (CI's) for differences in percentages or medians were also calculated.

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ResultsInitially, 235 patients were identified. Of these, 13 were excluded because electrophoresis was performed more than 48 hours postpartum and 10 due to unknown HIV status. Subsequently, 153 patients were included into the study of which 51 were HIV seropositive (study group) and 102 seronegative (controls). On some of these patients, certain data were lost: CD4+-cell count on 10 patients (all seronegative), serum IgG on two patients (one seronegative and one seropositive), pregnancy outcome in 17 women because they delivered elsewhere or were still pregnant at the time of analysis (8 seronegative and 9 seropositive).

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Demographic, reproductive and clinical data are described in Table I. No statistically significant differences with regard to the data were found between the study group and control group. As expected, the CD4+-cell count was significantly decreased in the HIV seropositive group (p<0.01) (Table II). The serum concentrations of total protein and albumin differed significantly between the groups (Table II). In the HIV seropositive group the serum concentration of total protein was significantly higher (p<0.01, CI 2; 9) whereas the albumin concentration was significantly lower (p<0.01). Analysis of the electrophoretograms showed significant differences in the albumin and the -globulin fraction between the groups, while the other fractions did not differ significantly (Table II). The albumin fraction of the electrophoresis was significantly lower in the HIV seropositive group (p=0.01), whereas the -globulin fraction was significantly higher (p<0.01). Hypergammaglobulinemia (-globulin >13.7 g/l) was significantly more common in the study group (p<0.01) whereas hypogammaglobulinemia (-globulin <5.3 g/l) occurred more often in the control group (p<0.01) (Table II). Statistically significant differences were also found in the interpretation reports of the electrophoresis membranes. Multiple monoclonal bands and an elevated protein concentration in the middle of the -globulin fraction (Figure I) were seen only in the study group (p<0.01) whereas a normal electrophoresis pattern (Figure II) was seen more often in the control group (p<0.01) (Table II). Serum IgG and IgM levels were significantly higher in the HIV seropositive group (p<0.01 in both), whereas the serum IgA and IgE levels did not differ significantly (Table II). We divided the total population into a group with a CD4+-cell count < 0.4 x 109/l and a group with a CD4+-cell count 0.4 x 109/l, regardless of the patients' HIV status. The serum IgG and IgM levels as well as the level of the -globulin fraction and its percentage of serum total protein were significantly higher in the group with the lower CD4+-cell count (p<0.04). The albumin fraction did not differ significantly between the two groups, but when it was expressed as a percentage of total serum protein, the difference was again statistically significant (p<0.01).

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The results were also compared between the groups of HIV seropositive and seronegative patients with a CD4+-cell count < 0.4 x 109/l in order to evaluate the effect of the HIV infection in patients with low CD4+-cell counts (Table III). The albumin and -globulin fractions as well as their values expressed as a percentage of total serum protein were significantly higher in the HIV seropositive group (p<0.01, Table III). Furthermore, serum IgG and IgM levels were significantly higher in this group (p<0.01 and p=0.03), whereas no significant difference was found in the total serum protein concentration between the groups (p=0.76). In the HIV seropositive group, significantly more infections were diagnosed on admission (18 (35.3%) vs 20 (19.6%), p=0.03). Viral infections and tuberculosis were mainly responsible for this difference. No significant differences were found in the maternal outcome, though there seemed to be a tendency toward a more adverse outcome in the HIV seropositive group (complications in 57.1% of the HIV positive group vs 42.6% in the HIV-negative group, p=0.12) with a slight increase in infection, hypertensive disease and placental abruption (p>0.05 in all instances).In total, 134 patients gave birth to 151 infants in the Universitas Hospital before the end of November 2001. Significantly more miscarriages (5 (10.2%) vs. 1 (1%), p=0.01) and less discharges without complications (12 (24.5% vs. 45 (44.1%, p=0.02) were seen in the newborns of HIV seropositive mothers. There were no statistically significant differences in fetal loss (9 (18.4%) vs 19 (18.6%), p=0.97) and neonatal deaths (0 vs 3 (2.9%), p=0.55) between newborns of HIV seropositive or seronegative mothers. Newborns of HIV seropositive mothers had an average lower birth weight than newborns of HIV seronegative mothers (1410g vs 1590g, p=0.08). Furthermore, no significant difference was found in the occurrence of small for gestational age (SGA) infants between the two groups (5 (12.8%) vs 17 (18.5%), p=0.43).

DiscussionThere were no significant differences with regard to demographic data, obstetrical history and reason for admittance between the study and

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control group. Therefore it was justifiable to compare the results between these two groups. Our findings of an increased -globulin fraction in the study group are consistent with prior studies, which demonstrated an aberrant hyperactivity of B-cells in HIV infected individuals, including hypergammaglobulinemia. In our study, the hypergammaglobulinemia remained significantly more often observed in the HIV seropositive group when only patients with a low CD4+ cell count (<0.4x109/l) were taken into account. Therefore, the decrease in CD4+ cells in HIV infected patients does not seem to play a direct role in the etiologic mechanism of hypergammaglobulinemia. The mechanism leading to hypergammaglobulinemia in patients infected with HIV is not well understood, although several hypotheses were suggested. However, the proposal of a hypothesis is beyond the aim of this study.

Besides the already well-studied occurrence of hypergammaglobulinemia, we furthermore found significant differences in several other parameters. The higher serum IgG and IgM levels in the study group seemed to be responsible for the observed hypergammaglobulinemia. HIV related polyclonal B-cell stimulation most likely caused these elevated serum levels of IgG and IgM. Neither HIV infection, nor pregnancy itself seemed to influence serum levels of IgA and IgE. Two studies demonstrated a return to normal of the elevated -globulin and IgG levels after potent retroviral therapy. It is important to notice that due to economical and political circumstances none of the HIV seropositive patients in our study received antiretroviral medication.

Remarkable differences were also found in the interpretation reports of the electrophoretograms. Besides the noticeable elevated protein concentration in the middle of the -fraction, there were significantly more abnormal membranes seen in the HIV seropositive group with a higher occurrence of multiple monoclonal bands. An elevated protein concentration in the middle of the -fraction, which can be seen as a denser area in the -fraction on the membrane, is most likely caused by

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the polyclonal B-cell stimulation and their overproduction of IgG and IgM. The higher serum total protein concentration in the study group is directly related to these findings. In conclusion, in the HIV seropositive women, the -globulin fraction of the serum protein electrophoretogram was significantly different from seronegative patients. In the seropositive group, about 80% of the patients revealed a raised -globulin fraction compared to only 3-4% of the negative group (p <0.01, Table II). Most characteristic was the presence of monoclonal bands against a polyclonal background in addition to the raised -globulin (Figure 1). If a patient presents with a raised -globulin, IgG or IgM without known infection, and particularly when monoclonal bands are present, HIV infection should be suspected.

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Table I. Demographic and reproductive data according to HIV statusHIV status

p-value95% CI for differencesHIV sero positive

n=51HIV sero negative

n=102

Age (years)Race Black Coloured WhiteObstetric indices Gravidity Primigravida Reproductive failure*1

Gestational age (GA) (weeks) GA at electrophoresis GA at deliveryMain reasons for admittance Hypertensive disorder Cardiac disease Antepartum hemorrhage Diabetes mellitus (Imminent) Preterm labour

27 (22,3)

50 (98.0%)1 (2.0%)0 (0%)

2 (1,3)15 (29.4%)14 (38.9%)

30 (26,3)32 (29,3)

26 (51.0%)3 (5.9%)4 (7.8%)4 (7.8%)5 (9.8%)

27 (23,3)

90 (88.2%)8 (7.8%)4 (3.9%)

2 (1,3)36 (35.3%)26 (39.4%)

31 (27,3)32 (29.5,37)

59 (57.8%)12 (11.8%)6 (5.9%)5 (4.9%)10 (9.8%)

0.51

0.070.270.30

0.520.470.96

0.290.25

0.420.250.730.481.00

-3;2

1.0%, 16.5%-11.9%, 2.0%-7.7%, 1.8%

-3; 1-20.8%; 10.0%-19.7%; 19.2%

-3; 1-1; 0

-23.3%; 9.8%-14.2%; 4.2%-6.2%; 11.6%-5.1%; 12.4%-9.4%; 10.9%

Table II Laboratory data according to HIV status

HIV status p-value 95% CI for differencesHIV sero positive

n=51HIV sero negative n=102

CD4+ cell count (x 109/l)Total serum protein (g/l)Serum albumin (g/l)Serum electrophoresis Albumin fraction (g/l) % albumin of total serum protein(%) -globulin fraction (g/l) % -globulin of total serum protein(%) Hypergammaglobulinemia*1 Hypogammaglobulinemia*2Serum electrophoresis description Normal Monoclonal bands Elevated PC*3 in -globulin fractionSerum levels of immunoglobulins IgG (g/l) IgA (g/l) IgM (g/l) IgE (IU/ml)

0.34 (0.2, 0.5)62.0 (56.0, 77.0)21.0 (18.0, 27.0)

28.9 (24.1, 34.9)48.6 (41.1, 56.5)13.55 (10.3, 19.8)22.3 (17.3, 30.4)25 (49.0%)2 (3.9%)

8 (16.0%)15 (30.0%)26 (52.0%)

16.75 (14.3, 22.5)1.97 (1.2, 3.1)1.78 (1.2, 2.7)49 (20, 186)

0.69 (0.5, 1.0)57.0 (52.0, 63.0)24.5 (21.0, 28.0)

33.0 (28.0, 38.0)59.3 (54.6, 62.5)5.55 (4.1, 8.3)9.8 (7.4, 13.9)4 (3.9%)45 (44.1%)

52 (51.5%)0 (0%)2 (2.0%)

9.91 (8.1, 11.8)1.92 (1.6, 2.6)1.17 (0.8, 1.8)71 (19.157)

<0.01<0.01<0.01

0.01<0.01<0.01<0.01<0.01<0.01

<0.01<0.01<0.01

<0.010.82<0.010.85

-0.5; -0.32; 9-5; -1

-5.7; -0.7-13.0; -6.66.1; 9.59.5; 14.330.2%; 58.4%-49.7%; -27.5%

-48.2%; -20.2%17.2%; 42.5%35.1%; 63.0%

5.9; 8.9-0.4; 0.30.3; 0.8-23; 23

327

Table III Laboratory data according to HIV status in patients with CD4+-cell counts < 0.4 x 109/l

HIV status p-valu

e

95% CI for

differences

HIV sero positive n=31

HIV sero negative

n=16Immunoglobulines IgG (g/l) IgM (g/l)Serum electrophoresis -globulin fraction (g/l) %-globulin of total serum protein (%) albumin fraction (g/l) % albumin of total serum protein (%)Total serum protein (g/l)

15.70 (14.1, 21.2) 1.78 (1.2, 2.9)

13.18 (10.9, 19.5)21.2(18.3, 31.0)

28.81 (22.45, 34.34)47.7 (40.4, 54.6)60.0 (54.0, 67.0)

10.55 (9.1, 11.6)1.24 (0.9, 1.6)

5.47 (4.5, 7.1)8.8 (7.6, 12.2)

34.02(30.48, 38.47)59.4(54.4,

61.8)61.0 (56.5, 64.0)

<0.01 0.03

<0.01<0.01

0.01<0.01

0.76

3.7 ; 8.3 0.1 ; 1.2

5.3 ; 9.6 8.1 ; 17.4

-10.5 ; -1.8-16.4 ; -4.9 -4 ; 6

328