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ADVANCED ANTENATAL
CARE MODEL – FREE STATE
(AANC)
Ms. W. Motlolometsi
24. AUGUST.2016
INTRODUCTION
• In South Africa, 4452 maternal deaths were
recorded in the 2011 – 2013 triennial report.
•The Free State province contributed to 6% of
these deaths.
• Decline in the mortality ratio compared to the
previous report (8.8%)
HISTORICAL BACKGROUND• In the 2008 – 2010 NCCEMD report, the Free State province rated
amongst the highest in the country with respect to maternal mortality
• 4/5 districts of the province were amongst the 10 worst performing districts in South Africa in terms of the high maternal mortality rates(NCCEMD 2008-2010: 210).
• All 5 districts within the province were listed among the 15 priority districts requiring support to achieve the millennium goals.
• Similarly, the province had the highest perinatal mortality rate of 39.7 per 1000 live births and the highest number of early neonatal deaths at 29, 9 still births /1000 deliveries, compared to all the other provinces (NaPeMMCo, 2008 – 2010 :11 – 13).
Strategies implemented to improve on
outcomes
• Inter-facility transport.
• Aggressive ESMOE training.
• Consolidation of services - Deliveries and CS done at facilities with appropriate capacity.
• Introduction of AANC programme.
The mortality rates decreased by 43% and is sustained since early 2012.
WHY AANC?
• Second South African Demographic Health survey
(2003:14) - 7756 households interviewed.
• 92% of pregnant women in South Africa, presented
themselves at the health care facilities for antenatal care.
• 89% per cent consequently giving birth at such facilities.
• The majority of women with no risks in pregnancy and
childbirth are attended to by the Nurse – Midwives, ADMs
and PHC nurses ( with Midwifery) as their core function.
WHY AANC cont….
• Scope of practice of a midwife - assumption that those who
qualify and are registered to render midwifery care and manage
pregnant women and newborn babies, possess the necessary
competence - knowledge, skills and professional behaviour to
function as independent and accountable practitioners who can
ensure that no woman dies whilst giving life.
• Environment - supportive and enabling (International Journal of
child birth 2011).
• At present, the pregnant women with no risk / low risk factors are
managed at primary health care (PHC) level.
CURRENT CHALLENGES WITH ANTENATAL CARE
• Various workshops and training platforms: Nurse-Midwives skills gaps in risk identification (BANC Implementation).
•Dilution of skills through structured rotation of staff
(PHC Policy – Comprehensive PHC package).
• Poor outreach programs from referral hospitals to primary care facilities within their catchment areas.
-
CURRENT CHALLENGES WITH ANTENATAL CARE cont
• Limited supportive supervision to PHC staff providing basic antenatal care.
• Some facilities provide this care only once per week.
• Many facilities have medical and nursing staff without appropriate knowledge to manage the referred problems.
• None / delay in treatment and referrals - “identified at risk patients” : Facility bottlenecks
- structural
- few doing ANC high risk clinics
- barriers wrt referrals
Demand for advanced antenatal care
• Estimated 20-30% of pregnancies - complication or condition that would
require some form of expert opinion or interaction.
• The AANC service demands - calculated per town in the province based
on a few simple factors:
- Population size (census provide the basis for the calculations and
future estimate using the national population growth rate = is 0.095
(Stats SA)
- Fertility rate- this indicates the number of births in a population=
2.06%.
- Potential problematic pregnancies 20 - 30% of pregnancies.
Plan for advanced antenatal care
10
District Subdistrict TownPopulation 2011
census
Estimated
pregnancies 2014
Estimated
pregnancies
referred to
AANC (High)
Estimated
Advanced ANC
low
Advanced
ANC/week
High
Advanced AANC
cases per month
Clinic days per
month (High)
Required clinic
days per week
(low)
Suggested
AANC clinics
per month
Fezile dabi Mafube Cornelia 2964 63 21 14 2.3 9.3 0.6 0.5 1
Fezile dabi Mafube Frankfort 31133 657 222 148 24.5 98.2 6.1 4.9 5
Fezile dabi Mafube Tweeling 6465 137 46 31 5.1 20.4 1.3 1 2
Fezile dabi Mafube Villiers 17315 366 123 82 13.7 54.6 3.4 2.7 3
0 11
Fezile dabi Metsimaholo Deneysville 19479 411 139 93 15.4 61.4 3.8 3.1 4
Fezile dabi Metsimaholo Oranjeville 5166 109 37 25 4.1 16.3 1 0.8 1
Fezile dabi Metsimaholo Sasolburg 124461 2628 887 591 98.1 392.5 24.5 19.6 20
0 25
Fezile dabi Moqhaka Kroonstad 119134 2516 849 566 93.9 375.7 23.5 18.8 19
Fezile dabi Moqhaka Steynsrus 9106 192 65 43 7.2 28.7 1.8 1.4 2
Fezile dabi Moqhaka Viljoenskroon 32293 682 230 153 25.5 101.8 6.4 5.1 6
0 27
Fezile dabi Ngwathe Edenville 6294 133 45 30 5 19.8 1.2 1 1
Fezile dabi Ngwathe Heilbron 37635 795 268 179 29.7 118.7 7.4 5.9 6
Fezile dabi Ngwathe Koppies 13803 291 98 66 10.9 43.5 2.7 2.2 3
Fezile dabi Ngwathe Parys 48169 1017 343 229 38 151.9 9.5 7.6 8
Fezile dabi Ngwathe Vredefort 14619 309 104 69 11.5 46.1 2.9 2.3 3
Principles of AANC training
• Ensure that there is an appropriate mix of knowledge and practical skills and the ability to apply the knowledge appropriately.
• Training groups need to be small enough to allow individual attention for
practical support.
• Entry requirement – either advanced midwife or experienced and interested midwife.
• The individuals must have the ability to apply the knowledge in practice.
• Training done over a period of 3 months ( 4 sessions – 3 days).
• Staff recruited for this process must attend all the scheduled training
sessions.
Principles of AANC - Training
• Active reading and preparation prior to the training sessions.
• Participants wrote an exit exam to test the skills transfer and assist
with the privileging process.
• Support structure - Participants will earn CPD points.
1st group of advanced and / experienced midwives from all
five districts within the province were identified and trained as
advanced antenatal care practitioners in October – December
2014. (28)
2nd Group August – October 2015 (42)
WORKSHOP 1 22-24 October Tutor days (6h30min) 2.833333333
(total hours) 18.41666667
(Total Minutes) 1105
DAY 1
Time Theme topic Tutot/ Tutoring type Duration (min) Aims/objectives 07:30 Registration
08:30 General
Overview of maternal and neonatal outcomes in the province Dr. De Beer Lecture/overview 45
Understanding of challenges in maternal health
09:15 General- BANC Basic antenatal care strategy and tools use Ms. W. Motlolometsi Lecture/discussion 45
Understand Basic ANC PHC policy and challenges relating to current strategy
10:00 TEA
10:15 General - BANC Routine antenatal care screening Ms. W. Motlolometsi Discussion/debate 30
All screening including BMI, HCT, genetics
10:45 General - BANC
The antenatal patient at risk- risk identification Ms. W. Motlolometsi Lecture/discussion 30
All basic risk factors that should be identified at ANC
11:15 Anaemia Dr. T. Nondabula Lecture/discussion 105
Understand basic physiology, causes and treatment of anaemia in pregnancy
13:00 LUNCH
14:00 Fetal frowth Normal fetal growth Dr. De Beer Lecture/discussion 60
Understand physiology, calculating gestational age, Direct- indirect measurement of growth,
15:00 Fetal frowth
The placenta and fetal nutrition and oxygenation Dr. De Beer 60
DAY 2 Time Theme topic Tutot/ Tutoring type Duration (min) Aims/objectives
08:00 Fetal frowth Fetal well-being Dr. De Beer Lecture/discussion 60
Understand various aspects of fetal well being including movements, fetal heart, amniotic fluid
09:00 Fetal frowth Placental pathology Dr. De Beer Lecture/discussion 60
Understanding the placenta during normal pregnancy, PET and factors resulting in placental pathology and disease
10:00 TEA
10:15 Fetal frowth
Practical evaluation of fetal growth and well-being Ms. W. Motlolometsi Discussion/ practical 45
Understand methods to document movements and fetal heart. SF measurements
11:00 Fetal frowth Fetal growth restriction Dr. M. Schoon Lecture/discussion 60
Understand causes of growth restriction - fetal malnutrition
12:00 Fetal frowth
Clinical manifestation of fetal growth restriction Dr. M. Schoon Lecture/discussion 60
Understand how to identify growth restriction clinically
13:00 LUNCH
14:00 Fetal growth Consequences of growth restriction Dr. T. Nondabula Lecture/discussion 60
Be able to link growth impairment with stillbirths and small for gestational age babies
15:00 Fetal growth Fetal maturity Dr. M. Schoon Lecture/discussion 60
Understand definitions of maturity, pre-term post term pregancies. Understand lung maturity and fetal maturity
DAY 3 Time Theme topic Tutot/ Tutoring type Duration (min) Aims/objectives
08:00 Fetal growth Premature labour Dr. De Beer Lecture/discussion 60
Understand diagnosis and management of premature labour at clinics
09:00 Fetal growth Poly hydamnios Dr. T. Nondabula Lecture/discussion 60 Cause of and clinical actions to be taken
10:00 TEA
11:15 Maternal age
Risks associated with advanced maternal age Ms. W. Motlolometsi Lecture/discussion 60
Understand the mortality risk as well as genetic risk
12:15 Maternal age
Counselling and screening of women with advanced maternal age Ms. W. Motlolometsi / DCST ADM Lecture/discussion 45
Understand what could be offered to older women
13:00 LUNCH
14:00 ANC THE SECOND VISIT Dr. M. Schoon Lecture/discussion 60
Understand the importance of a detailed risk assessment during the second visit including risk assessment and appropriate referral systems
15:00 ANC Counselling/ advice to pregnant women Dr. M. Schoon Lecture/discussion 40
WORKSHOP 2 4-6 November Tutor days (6h30min) 2.769230769 (total hours) 18 18.1 (Total Minutes) 1080 (Total Minutes) 1080
DAY 1 Time Theme topic Tutor/facilitator Tutoring type Duration (min)
09:00 TEST MCQ test testing knowledge from previous session 30 09:30 Hypertension Anormalities of blood pressure in pregnancy Schoon Lecture/discussion 15
09:45 Hypertension Physiology of blood volume, cardiac output and blood pressure in pregnancy Motete Lecture/discussion 75
11:00 TEA
11:15 Hypertension Clinical diagnosis of hypertention and strategies to prevent HT Ramalitsi Lecture/discussion 45
12:00 Hypertension Drugs affecting blood pressure Schoon Lecture/discussion 45
12:45 Hypertension Pre-eclampsia- eclampsia Schoon Lecture/discussion 45
13:30 LUNCH
14:00 Hypertension Chronic hypertension in pregnancy Schoon Lecture/discussion 30 14:30 Hypertension Hypertension, placental changes and fetal growth Schoon Lecture/discussion 30
15:00 Hypertension How should hypertension be managed at clinic level and when to refer Ramalitsi/Motete Schoon Structured discussion 60
DAY 2 Time Theme topic Tutor/facilitator Tutoring type Duration (min)
08:00 Fetal loss Bleeding in early pregnancy Schoon Lecture/discussion 30 08:30 Fetal loss Miscariage Schoon Lecture/discussion 40
09:10 Fetal loss Women with history of previous pregnancy losses De Beer Lecture/discussion 50 10:00 TEAS
10:15 Fetal loss Management of women with a previous congenital abnormality De Beer Lecture/discussion 45
11:00 Counselling PHYSIOLOGICAL Changes in pregnancy Schoon Lecture/discussion 75 11:45 Counselling Minor ailments Motete
13:00 LUNCH
14:00 COUNSELLING Nutrition during/after pregnancy Ramalitsi Lecture/discussion 45
14:45 Counselling Patient's responsibilities, transport and maternity waiting areas Motete Lecture/discussion 45
DAY 3 Time Theme topic Tutor/facilitator Tutoring type Duration (min)
08:00 Medical condition Cardiac disease Schoon Lecture/discussion 60 09:00 Medical condition Lung disease Schoon Lecture/discussion 60
10:00 TEA
10:15 Medical condition HIV in pregnancy Dr Mngumezulu Lecture/discussion 120 12:15 Medical condition Diabetes in pregnancy De Beer Lecture/discussion 45 13:00 LUNCH
14:00 Medical condition Other endocrine diseases in pregnancy De Beer Lecture/discussion 45 15:00 Medical condition Disorders of other organs Schoon 45
PRINCIPLES OF THE AANC PROGRAMME
• Provide advanced antenatal care support to BANC by appropriately skilled personnel
• Strengthen the referral system - direct access to the referral system.
• Screen every pregnant women for risk by appropriately skilled staff
• Provide the advanced support services as close as possible to the client residential area whenever possible.
THE AANC PRACTITIONER
Programme outcomes • The trained AANC practitioners are expected to;
(1) Conduct outreach and visit the identified PHC clinics
(2) Screen and Identify pregnant women at risk during the 2nd antenatal visit consultation
(3) Evaluate the” potential risk pregnancies” identified through BANC screening.
(4) Develop and implement a midwifery management plan
(5) Make a clinical decision regarding the proper place of delivery for the pregnant women assessed. In order to achieve this, direct communication lines between AANC practitioners and the senior professionals in their catchment referral facility will have to be established and maintained.
(6) Act as mentors and do corrective training in cases where competency gaps are identified in relation the nurse-midwives and PHC nurses at PHC Clinics.
PRINCIPLES OF AANC - IMPLEMENTATION
18
TOWN 1
Clinic A
TOWN 1
Clinic b
TOWN 2
Clinic A
TOWN 3
Clinic A
TOWN 4
Clinic A
BASE
FACILITY
TOWN 1
Advanced ANC
professional
All 2nd Visits
At risk patientsManage referral chain
ROLES AND RESPONSIBILITIESDISTRICT MANGEMENT TEAMS
• Ensure that the identified pool are trained according the provincial training plan for AANC.
• Identify the most suitable location for providing AANC within existing PHC clinics with a base service at the dedicated community health centre or hospital in the sub-district
• Plan for outreach support transport of these individuals to the sites outside of their normal service point (dedicate appropriate budget for this process).
• Allocate the AANC staff as complementary to maternity units to ensure that the advanced ANC does not fail because the dedicated staff is expected to provide the essential maternity service.
• Staff shortages should not be sighted as a reason why this service could not be introduced and sustained.
How will this be operationalized?• Provision of transport to the facilities/Towns where required (cost
effectiveness and improve accessibility)
• Availability of appropriate equipment and infrastructure for AANC implementation.
• A medical practitioner in caesarean section sites to provide support for advanced antenatal care implementation.
• Budget allocation - Is the activities included in the district health plan?
• Monitoring programme implementation - Who in each district will be responsible for the data collection and forwarding the data to the DCST members?
• At what platform will the performance of the AANC clinics be discussed.
MONITORING AND EVALUATION:
COMPARATIVE AND DESCRIPTIVE STUDY - OBJECTIVES
1. Evaluate the PHC structures that should support the implementation of the
AANC program
Tool: Ideal clinic dashboard
2. Evaluate the performance of the AANC trained practitioners
2.1 Patients’ Records
(2.1.1) Women with low risk pregnancies at 2nd visit – (BANC Audit tool)
(2.1.2) Women with high risk pregnancies Identified, managed and treated by AANC
practitioners
(Tools: BANC principles of good care and IMPAC )
MONITORING AND EVALUATION
2.2 Interviews
• 2.2.1 Interviews Schedules -Interviews with the AANC practitioners.
• 2.2.2 Semi – structured questionnaires - One-to-one interview with Clinic supervisors and
functional midwives.
3. Evaluate and describe the outcomes of the AANC programme
MONITORING AND EVALUATION
• The key data elements to monitor;
- number of cases referred for AANC
- number of cases referred for hospitalisation.
- Mortality outcomes for the various sub-districts (still births and neonatal
deaths)
- Maternal complication rates (near-miss rates).
- A baseline data collection before the intervention is possible as all maternity
wards are currently collecting a standard set of maternity indicators.
MONITORING AND EVALUATION
4. Collaboratively develop a reproducible framework to
strengthen the implementation of AANC
Tools: Independently develop framework based on data and validate
with provincial team
AANC REGISTER ( DATA SHEET)
v3
VENUE TOWN
AANC
PRACTITIONER MONTH
DATEPATIENT’S NAME AND FOLDER
NUMBER
NUMBER
OF 1ST
VISITS
NUMBER OF
PATIENTS SEEN
BY
PRACTITIONER
NUMBER
OF 2ND
VISITS
NUMBER
OF HIGH
RISK
FOLLOW-
UP
NUMBER
OF
PATIENTS
REFERRED
COMMENTS
(REFERRAL SITE AND
DIAGNOSIS)VISIT CONFIRMED
BY CLINIC IN
CHARGE
TOTAL
MOBILE ULTRASOUND MACHINES
• Total number procured : 20
• Distribution per district
Exp clinic visits/month
Pregnancies/ month
1 sonar/ 213 patients
Actual distribution
FD 104 756 3.5 4
Lejw 141 998 4.7 4
MM 153 1157 5.4 4
TM 165 1140 5.4 5
Xhariep 42 226 1.1 3
605 4278 20.1 20
AANC IS ONE OF THE PROVINCIAL PRIORITY INTERVENTIONS
INVEST IN THE LIVES OF MOTHERS AND BABIES
ACKNOWLEDGEMENTS
•Prof. Yvonne Botma – Supervisor
•Dr. Martiens Schoon – Provincial Specialist and Co-Supervisor
•District Clinical Specialist Teams ( ADMs) – All Districts
•Advanced Midwives - AANC practitioners