The 36th Conference on Priorities in Perinatal Care in South Africa was held under the auspices of the Priorities in Perinatal Care Association and sponsored by

Abbvie (Pty) Ltd.

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Editor’s Note:

The articles included in these Proceedings were, mostly, received electronically and have been included as submitted by the presenter/author.Abstracts were included where articles were not submitted.Articles have not been included for presentations which were withdrawn and not presented at Priorities.In some cases, hyperlinks have been provided to .pdf files as this is how the articles have been submitted for the Proceedings. Click on hyperlinks (different colour) in the index to take you to the article as the article is not in the Proceedings.Late submissions received after the Proceedings had been compiled and passwords allocated are included at the end of the Proceedings.References have been excluded due to the numerous different forms of referencing. References are available directly from the presenters.

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INDEX

HOW DID REDUCED ANTENATAL CARE VISITS IMPACT STILLBIRTH RISK IN SOUTH AFRICA? (Abstract). T Lavin

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STILLBIRTHS IN THE RURAL EASTERN CAPE – RESULTS FROM A LONGITUDINAL COHORT STUDY OF 1330 WOMEN (Abstract). Karl le Roux

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THE INCIDENCE AND CAUSATIVE FACTORS ASSOCIATED WITH STILLBIRTHS AND CLINICAL PRESENTATION OF MOTHERS WHO DELIVER STILLBIRTHS AT NELSON MANDELA ACADEMIC HOSPITAL. XB Mbongozi

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THE PRESENCE OF INFECTION IN STILLBIRTHS IDENTIFIED WITH MINIMALLY INVASIVE TISSUE SAMPLING. Yasmin Adam

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EXPOSURE TO SECONDHAND SMOKE AMONG PREGNANT WOMEN IN SOWETO, SOUTH AFRICA. (Abstract). Joanne Pottow

15

IS FETAL FOOT LENGTH THE MOST APPROPRIATE TOOL FOR DETERMINING GESTATIONAL AGE IN STILLBIRTH? (Abstract). Lucy Brink

16

A 3-FOLD COMBINED ANALYSIS OF CAESAREAN SECTIONS AT A RURAL REGIONAL HOSPITAL IN KZN, TO DETERMINE TARGET GROUPS FOR INTERVENTION. P Smit 17

ROBSON TEN GROUP CLASSIFICATION SYSTEM OVERALL AT NMAH FOR FINANCIAL YEAR 2015/2016. Dr S Mandondo

21

FUNDAL PRESSURE DURING THE SECOND STAGE OF LABOUR (COCHRANE SYSTEMATIC REVIEW). (Abstract). Mandisa Singata

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COULD INDICATIONS OF UTERINE ACTIVITY AT 34 WEEK’S GESTATION IDENTIFY RISKS OF PRETERM DELIVERY? (Abstract). Carlie du Plessis

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A PROSPECTIVE STUDY OF THE INDUCTION OF LABOUR AT RAHIMA MOOSA MOTHER AND CHILD HOSPITAL. (Abstract). Hatel Laloo

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LIGHT AT THE END OF THE TUNNEL: REDUCTION IN MATERNAL MORTALITY IN ZIMBABWE 2010-2014. Munjanja SP

30

OBSTETRIC HAEMORRHAGE-RELATED SEVERE MATERNAL OUTCOMES IN HIV-INFECTED WOMEN. Kwadwo Atobra Antwi

34

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SKILLS2CARE : PIONEERING A PERINATAL PROGRAMME OF LEARNING FOR COMMUNITY HEALTH WORKERS IN THE EASTERN CAPE. Dr Paul Cromhout

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INTRODUCING ESMOE INTO A PRIVATE HEALTHCARE GROUP. Hall, AP43

WARD BASE OUTREACH TEAMS(WBOTS), PILLAR IN IMPROVING MATERNAL AND CHILD HEALTH: LESSONS FROM VHEMBE DISTRICT, LIMPOPO PROVINCE. (Abstract). Shisana Baloyi

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QUALITY OF CARE: IS THERE CONSENSUS FROM WOMEN, HEALTH CARE PROVIDERS AND KEY INFORMANTS INTO WHAT CARE WOMEN WANT TO RECEIVE WHEN THEY ATTEND FOR BIRTH IN A HEALTH CARE FACILITY?Jaki Lambert

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SIZE-FOR-GESTATIONAL-AGE AND TIMING OF STILLBIRTHS IN THREE SOUTH AFRICAN PROVINCES. (Click on title in abstract for hyperlink to article in .pdf format.Tina Lavin 59

CAUSES SECOND TRIMESTER MISCARRIAGES AS DETERMINED BY PLACENTAL HISTOLOGY AND AUTOPSY. (Abstract). Coen Groenewald

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PREMATURE INFANT CARE IN THE CONTEXT OF KANGAROO MOTHER CARE IN SOUTH AFRICA: LESSONS FROM THE FIELD. (Abstract). Elise van Rooyen

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SUCROSE AS PAIN RELIEF: A RANDOMIZED CONTROLLED STUDY OF TWO DIFFERENT DOSES OF SUCROSE DURING VENIPUNCTURE. (Abstract). Laila Kristoffersen 62

MATERNAL AND FETAL OUTCOMES IN THE CONTEXT OF OPTION B+ STRATEGY IN EASTERN CAPE: FINDINGS FROM PROSPECTIVE COHORT STUDY. (Abstract).Nonkosi Selanto-Chairman

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COMPARING MATERNAL TRIPLE ANTIRETROVIAL AND INFANT NEVIRAPINE PROPHYLAXIS FOR THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV DURING BREASTFEEDING. GB Theron

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BENEFITS OF FEEDING HUMAN MILK EXCLUSIVELY TO VERY LOW BIRTH WEIGHT INFANTS ADMITTED TO THE NEONATAL UNIT AT KALAFONG HOSPITAL. SD Delport 67

FACILITATING THE USE OF DONOR MILK IN RESOURCE LIMITED SETTINGS THROUGH THE DEVELOPMENT OF THE PIASTRA, SIMULATED FLASH HEATING, PASTEURISATION SYSTEM. Penny Reimers

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OPPORTUNITIES AND IMPLICATIONS FOR PERINATAL SERVICES ARISING FROM RECENT SCIENTIFIC ADVANCES IN EARLY CHILDHOOD DEVELOPMENT (ECD) AND THE NATIONAL INTEGRATED ECD POLICY: MOVING FORWARD – EXPERIENCE FROM THE WESTERN CAPE FIRST 1000 DAYS INITIATIVE. E Malek

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MODELLED EPIDEMIOLOGICAL DATA FOR CONGENITAL DISORDERS IN SOUTH AFRICA.H Malherbe 79

THE KNOWLEDGE OF BASIC NEONATAL RESUSCITATION AMONG MIDWIVES AT DISTRICT HOSPITALS. Fezeka Mafisa

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NEONATAL BRAIN MR IMAGING IN NEONATAL ENCEPHALOPATHY. (Abstract). Mary A Rutherford 90

PREVALENCE OF HYPOTHERMIA ON ADMISSION TO A NEONATAL UNIT AT A TERTIARY HOSPITAL: A PRELIMINARY REPORT. (Abstract). M Mayer

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PREVALENCE AND CAPSULAR TYPE DISTRIBUTION OF GROUP B STREPTOCOCCUS (GBS) AMONG PREGNANT WOMEN IN WINDHOEK, NAMIBIA. (Abstract) SR Moyo

92MATERNAL AND NEONATAL VITAMIN D STATUS AND ITS ASSOCIATION WITH EARLY-ONSET NEONATAL SEPSIS IN BLACK SOUTH AFRICANS. (Abstract).Sithembiso Velaphi 93

RETINOPATHY OF PREMATURITY IN INFANTS <1250G AT KALAFONG HOSPITAL OVER FIFTEEN YEARS. K Masemola

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TREND IN SURVIVAL AMONG VERY LOW - BIRTH WEIGHT INFANTS AT A SEMI-RURAL HOSPITAL. (LURWMH). M. Malahleha

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POSTNATAL AGE AT DEATH AMONG INFANTS WHO DIED DURING THE NEONATAL PERIOD. (Abstract). N. Xhinti

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PLACENTAL INSUFFICIENCY AMONG HIGH-RISK PREGNANCIES WITH NORMAL UMBILICAL ARTERY RESISTANCE INDEX AFTER 32 WEEKS GESTATION. (Abstract).L Geerts 102

SCREENING AND MANAGING LOW RISK PREGNANT POPULATION USING CONTINUOUS WAVE DOPPLER ULTRASOUND IN A MIDDLE-INCOME COUNTRY. (Abstract).Spencer Nkosi

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COST-EFFECTIVENESS OF THE UMBIFLOW DOPPLER TO SCREEN AND MANAGE A LOW-RISK PREGNANT POPULATION IN A MIDDLE-INCOME COUNTRY. (Abstract).

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Laura Rossouw104

MATERNAL HEART RATE PATTERNS UNDER RESTING CONDITIONS IN LATE PREGNANCY. (Abstract). Hein Odendaal

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POSTERIOR AXILLA SLING TRACTION AND ROTATION FOR INTRACTABLE SHOULDER DYSTOCIA: DATA AND VIDEO. (Abstract). GJ Hofmeyr

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THE ODON DEVICE. Valerie Vannevel107

TSHWANE MOTHERS’ EXPERIENCES OF CHILDBIRTH. (Abstract). Sarie Oosthuizen 108

A QUALITY IMPROVEMENT INTERVENTION PACKAGE IN MIDWIFE OBSTETRIC UNITS IN TSHWANE DISTRICT, SOUTH AFRICA. (Abstract). Sarie Oosthuizen

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UNDERSTANDING MATERNAL MORTALITY: ETHEKWINI METRO KZN. Dr T Ibrahim 111

REDUCING MATERNAL AND PERINATAL DEATHS FROM HYPERTENSION USING FACILITY HELD TRACER FORM FOR DCST TO MONITOR COMPLIANCE TO CLINICAL GUIDELINES.Dr SD Mandondo

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THE TRAIN-THE-TRAINER MODEL FOR SCALING-UP ESSENTIAL STEPS IN THE MANAGEMENT OF OBSTETRIC EMERGENCIES (ESMOE) IN KWAZULU-NATAL PROVINCE, SOUTH AFRICA: FEASIBILITY AND PERCEIVED IMPACT. Neil F. Moran

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IMPROVING PERINATAL OUTCOMES AND QUALITY OF NEONATAL CARE AT BUTTERWORTH HOSPITAL: A QUALITY IMPROVEMENT PROJECT. Yose-Xasa B

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RESPONDING TO PROBLEMS IN LONG TERM REVERSIBLE CONTRACEPTION UPTAKE AMONG TEENAGERS AT MADWALENI HOSPITAL EC USING AN IUCD VIDEO IN XHOSA AS AN INNOVATIVE COUNSELLING TOOL. (Abstract) Dr A Miller

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HIGH INCIDENCES OF IMPLANON SUB DERMAL IMPLANT PREMATURE REMOVALS IN FAMILY PLANNING CLIENTS: A CONCERN IN EKURHULENI DISTRICT.Nomvula Maseko 133

FACTORS ASSOCIATED WITH TB SCREENING FOR PREGNANT WOMEN LIVING WITH HIV IN UTHUNGULU DISTRICT IN 2012. (Abstract). Miss Sthandwa Mngayi

136

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BARRIERS TO PROVIDING QUALITY MATERNITY CARE IN AN URBAN SETTING IN SOUTH AFRICA; A QUALITATIVE DESCRIPTIVE STUDY. Jaki Lambert

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MOMCONNECT AND NURSECONNECT: POSSIBILITIES FOR PERINATAL IMPROVEMENT.L Bamford 147

LISTENING TO MIDWIVES. Barbara Hanrahan 150

MATERNITY WAITING HOMES (MWH) IN THE FREE STATE PROVINCE: A REVIEW OF EXPERIENCES (2006-2016). (Abstract). Shisana Baloyi

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CORRELATION BETWEEN NUMBERS OF EOST DRILLS REPORTED FOR CPD POINTS AND CHANGE IN IMMR PER DISTRICT. RC Pattinson

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A STANDARDS-BASED APPROACH TO IMPLEMENTING PERINATAL PROBLEM IDENTIFICATION PROGRAM IN SEVEN PUBLIC HOSPITALS IN DAR ES SALAAM, TANZANIA IN 2016 (Abstract). Magembe G

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HOW DID REDUCED ANTENATAL CARE VISITS IMPACT STILLBIRTH RISK IN SOUTH AFRICA?

Tina Lavin 1 & Robert Pattinson21 Centre for Health Services Research, School of Population Health, The University of Western Australia; 2 SA MRC Maternal and Infant Health Care Strategies Unit, School of Obstetrics and Gynaecology, University of Pretoria, South Africa

BackgroundIn 2001 the World Health Organization Antenatal Care Trial concluded that four focused antenatal care visits were adequate to ensure good birth outcomes for mother and child. However, a recent Cochrane review found that perinatal mortality was higher in reduced antenatal care visit groups receiving five or fewer visits compared to standard antenatal care visits. In South Africa in 2008 all provinces but one adopted the reduced antenatal care schedule, giving the unique opportunity to compare the timing of stillbirth across gestation between provinces.

MethodsData were analysed from South Africa’s Perinatal Problem Identification Programme between October 2013 and August 2015 between Western Cape, Limpopo and Mpumalanga (n=4211). In Limpopo and Mpumalanga antenatal care visits occurred at booking, 20, 26, 32, 38 weeks; in Western Cape visits occurred at booking, 20, 26, 32, 34, 36, 38weeks.

ResultsStillbirth risk (26-42 weeks gestation, >1000g) peaked unexpectedly with antenatal care visits at 38 weeks in Mpumalanga and Limpopo. In Western Cape, no peak was observed at 38 weeks. In all provinces, a peak was observed at 41 weeks. The greatest disparity in stillbirth risk was seen at 38 weeks where the relative risk of stillbirth was 3.11(95%CI2.40-4.03; p<0.001)for Limpopo and 3.09(95%CI2.37-4.02;p<0.001) for Mpumalanga compared to Western Cape.

Conclusion It is difficult to ascertain from the current study why the peak at 38 weeks only occurred in the provinces where there were no antenatal care visits during 32-38 weeks of pregnancy, however this finding in conjunction with the new advances in the current literature call us to re-focus our attention on how third trimester antenatal care visits may impact on stillbirth.

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STILLBIRTHS IN THE RURAL EASTERN CAPE – RESULTS FROM A LONGITUDINAL COHORT STUDY OF 1330 WOMEN

Karl le RouxZithulele Hospital

IntroductionThe 2016 Lancet Series on Stillbirths remarked that the worldwide attention into the issue of stillbirths is growing, but that data around stillbirths continue to be poor, especially in low- and middle-income countries where 98% of stillbirths occur. Ambitious goals have been set to bring the stillbirth rates in all countries down to 12/1000 by 2030, but these goals will be difficult to realize if data remains poor.

In the South African context, we have fairly good data of perinatal deaths in government hospitals through the Perinatal Problem Identification Program (PPIP), and estimates of stillbirths are primarily drawn from it. However, there is very little data about stillbirths that occur outside of government facilities, as many of these are not registered, and data is especially poor in rural areas.

BackgroundThe Zithulele Mothers-to-be Assessment (ZiMBA) is a prospective cohort study, which was initiated in August 2014 in the communities covered by 4 feeder clinics of Zithulele Hospital, near to Coffee Bay in the rural Eastern Cape. The study is ongoing and is examining the impact of a group of community health workers, called Mentor Mothers, on the health and wellbeing of children in the intervention area and comparing outcomes for infants in a control area.

1330 women have been recruited so far - at their first or second antenatal clinic visits or at birth, and mother-infant pairs are being followed up for 1 year after the birth of the baby.

Results and discussionTo date, there have been 33 infant deaths, 32 stillbirths, 23 miscarriages and one ectopic pregnancy out of the 1330 women recruited, indicating a stillbirth rate of 24/1000 in this area. The presentation will further describe where stillbirths occur and compare the number of stillbirths and neonatal deaths in the study with registers and PPIP data available through Zithulele Hospital and attempt to quantify the number of stillbirths where the mother has not presented to a health facility.

Finally, I will suggest ways in which stillbirths can be picked up in the rural South African context, so that a more accurate quantification of the problem can be made, and which will allow for appropriate interventions to improve outcomes for mothers and babies.

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THE INCIDENCE AND CAUSATIVE FACTORS ASSOCIATED WITH STILLBIRTHS AND CLINICAL PRESENTATION OF MOTHERS WHO DELIVER STILLBIRTHS AT NELSON MANDELA ACADEMIC HOSPITAL

XB Mbongozi, GAB Buga and JN WandabwaDepartment of Obstetrics and Gynaecology, Walter Sisulu Universityxbmbongozi@yahoo.com

IntroductionStillbirth is one of the most serious adverse outcomes of pregnancy. A stillbirth is defined as the delivery of a foetus after the age of viability (which is 22 weeks of gestation or 500g of weight) with no signs of life such as breathing, heartbeats, pulsation of the umbilical cord or definite movements of voluntary muscles. A stillbirth can either be fresh or macerated. A macerated stillbirth is defined as the intrauterine death of a foetus sometime before the onset of labour, where the foetus shows degenerative changes, whereas fresh stillbirth is an infant born dead with its skin still intact implying that the foetus has been dead for less than 12 hours.Deaths that occur in the clinic or hospital after admission but before labour commences may indicate a problem in the antenatal monitoring of the woman. In contrast, intrapartum death may point towards a problem of monitoring during labour. The occurrence of an intrapartum stillbirth in developed countries is considered as the result of inadequate obstetric care whereas in developing countries it may represent both inadequate access to essential obstetric care and inadequate care.Ninety-eight percent of stillbirths occur in low and middle-income countries.The estimated incidence of stillbirths worldwide is 19.1 per 1000 births. In South Africa, the stillbirth rate is estimated to be about 22.5 per 1,000 births and this also varies according to the provinces and districts. In 2011 the district with the highest stillbirth rate in the Eastern Cape province was O.R. Tambo District, with a rate of about 26 stillbirths per 1 000. This was the inspiration for this study.

The objective of the study was therefore to determine the incidence and causative factors associated with stillbirths and clinical presentation of mothers who deliver stillbirths at NMAH.

Materials and Methods

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This was a prospective cross-sectional study of stillbirths which were delivered at the Maternity Unit of Nelson Mandela Academic Hospital, Mthatha, between December 2012 and June 2013. All the mothers who delivered stillbirths at NMAH during the period of study were included in the study as long as the consent had been obtained from the participant. Stillbirth was defined as a foetus delivered after the age of viability (which is 22 weeks of gestation or 500g of weight), with no signs of life such as breathing, heartbeats, pulsation of the umbilical cord or definite movements of voluntary muscles. Mothers who declined to participate in the study were excluded from the study.The mothers who delivered stillbirths were personally interviewed, using a pre-designed questionnaire, for maternal socio-demographic details, history of pregnancy, and maternal medical and family history. Antenatal care and labour history was searched for from history and clinical notes.Laboratory investigations such as haemoglobin, HIV, Rh, RPR and TORCH were checked and those women without these investigations had them carried out.Examination of the baby for any visible abnormalities, especially congenital, was carried out. Due to shortage of workers to perform post-mortems in NMAH, post-mortems were not done. Variables were divided into different categories. Data were entered into MS EXCEL and then imported into SPSS statistical software package windows version 19.0 (SPSS Inc, Chicago, IL, USA) for analyses. Comparison was performed using chi-square test for categorical variables and Student’s t-test for continuous variables. In bivariate analysis, logistic regression analysis was performed using forward Wald method and calculating odds ratios (OR) with 95% confidence intervals (95% Cl). Level of significance was set at P< 0.05.

The approval to conduct the study was obtained from Walter Sisulu University Bioethics Committee and from NMAH before the research was started. Written consents were obtained from the participants. Participants were free to opt out of the study if they chose to and this would not prevent them from getting care offered from the hospital.

ResultsThere were a total of 2709 deliveries with 203 stillbirths during the study period, giving a hospital-based stillbirth rate of 75 per 1,000 deliveries. Majority (60.6%)

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of mothers who delivered stillbirths were between the ages of 20 and 34 years. The mean age of all women who had stillbirths was 26.3±7.8 years with a range of 14-51 years.

Most (68%) of the mothers with stillbirths were not married. Married women had a mean parity of 4±2 deliveries and the unmarried a mean parity of 2±1 deliveries (P<0.0001). Married mothers were also significantly older than the unmarried (31.4±7.1 vs. 24±7 years; P<0.0001).

Majority (82%) of mothers who delivered stillbirths attained secondary level of education. Age and parity were high among the non-educated and were decreased with rising level of education (Table 1).

Table 1. Maternal mean age and parity across the educational levels of women who delivered stillbirths.Level of education age (years) Parity (n)Non-educated 39±1.4

6±1Primary 35±7.4

4±2Secondary 24.8±6.9 2±1Tertiary 26.7±7.8 2±1

Very few mothers (9.9%) with stillbirths were employed.Among the 64 married mothers with stillbirths, 74.7 %( n=51) had unemployed husbands. 1% (n=2) of mothers with stillbirths were drinking alcohol and none of the mothers with stillbirth reported smoking or use of recreational drugs.Majority (91.13%) (n=185) of mothers with stillbirths were booked at the antenatal clinic.

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Figure 1. Booking status of mothers who delivered stillbirths

The mean gestational age at antenatal booking was 22.1±4.8 weeks with a range of 13-38 and the average number of antenatal visits was 2±2 with a range of 0-6. Low birth-weight was more frequent among mothers who had not booked (94.4% n=17/18, than in mothers who had booked (76.2% n=141/185)) and this was statistically significant (RR=1.2 95% CI 1.1-1.4; P=0.049). All mothers with stillbirths were RH positive. The mean parity was 2.3±1.7with a range of 1-10. The distribution of parity was asymmetric with 42.3% (n=88) reported primiparity (which was the mode).

Table 2. Obstetric complications associated with stillbirthsVariables n *%

Preeclampsia 11757.6

Abruptio 57 28.1Eclampsia 26 12.8Placenta previa 8 3.9*The percentage reported for each variable is out of the total women who had stillbirths.

Some patients had more than one obstetric complication: of the preeclamptic mothers 20.2% had abruptio placentae; 2.5% of the eclamptic mothers also had abruptio placentae.

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Preeclampsia was significantly more common in those mothers in whom a diagnosis of IUFD was made at the referring hospitals (67.3% n=72/107; P=0.003) than in those whose diagnosis was made at NMAH (46.3% n=44/95).

Eclampsia was significantly more frequent in unbooked mothers (38.9% n=7/18; P<0.001) than in booked mothers (10.3% n=19/185). The rest of continuous variables, including maternal age, gestational age, and parity were similar in prevalence (P>0.005) in mothers who had eclampsia and in those mothers who had no eclampsia.The mean gestational age was significantly higher in mothers with abruptio placentae (32.6 ±3.5 weeks; P=0.019) than in mothers who had no abruptio placentae (30.8±5.5 weeks).The mean haemoglobin level was significantly lower among mothers with abruptio placentae (9.4±2.3 vs. g/dL 11.6±1.8 g/dL; P<0.0001) than that of mothers without abruptio placentae. The rest of continuous variables, including age, booking and parity were similar (P>0.005) in mothers with abruptio and in those mothers who had no abruptio placentae. The infectious diseases associated with stillbirths were HIV (29.1%) and Herpes (2%). There were no stillbirths associated with Rubella and CMV.Mothers who delivered stillbirths and were HIV positive were significantly older than those who were HIV negative (table 3).

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Table 3. Comparisons of mean levels of age, parity and gestational age by HIV statusVariables of interest

HIV positive mean±SD

HIV negativemean±SD

P-value

Age 28.9±6.6 25.3±8.0 0.003Parity 2.53±1.5 2.24±1.8 0.282Gestational age 31.7±4.4 31.1±5.3 0.478

Mothers with stillbirths and HIV infection had mean level of CD4 count estimated at 354.2±198.6 cells/mm3 (range 40-884 cells/mm3).Out of mothers with stillbirths and HIV infection, 81.4 %( n=44) and 57.6 %( n=32) had a CD4 count <500 cells/mm3 and a CD4 count <350 cells/mm3, respectively.Out of all mothers with stillbirths, chronic hypertension and diabetes mellitus were reported in 3.9% (n=8) and 3.4% (n=7), respectively. Diabetic mothers were older (34.7±10.8 years vs. 26.1±7.5 years; P=0.004) and had higher parity (4±2 deliveries vs. 2±2 deliveries; P=0,004) compared to non-diabetic mothers. Obstructed labour occurred in 7.9% (n=16) of mothers with stillbirth, while uterine rupture was observed in 0.5% (n=1) of mothers with stillbirths.The gestational age (37.6±1.8 weeks vs. 31±5 weeks; P<0.0001) and foetal weight (3157.2±450 g vs. 1674.5±875.1g; P<0.0001) were significantly higher in those mothers who had obstructed labour. Stillbirth from the mother who had a uterine rupture had a foetal weight (3595 g) which was greater than that of the stillbirths from mothers who did not experience uterine rupture (1740.3±912.9g; P=0.041).2/3 of the total stillbirths were macerated stillbirths (n=135), and the remainder were fresh stillbirths (n=68) (Figure 2).

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Figure 2. Type of stillbirths delivered

There was a significant and higher risk of macerated stillbirths (73.5% n=86/117, RR=1.4 95% CI 1.1-1.9; P=0.014) in preeclamptic mothers than in non-preeclamptic mothers (26.5% n=31/117).Foetal sex ratio was 1 male (n=100): 1 female (n=103). Women who delivered male stillbirths had higher parity when compared with women who delivered female stillbirths (3±2vs. 2±1; p = 0.042). Out of all stillbirths, 3.5% (n=7) presented with congenital malformations. All these malformations were diagnosed by gross external examination of the stillbirths.Figure 8 presents a histogram of birth-weight among stillbirths: mean of birth weight of the stillborn babies was 1740.3± 912.9 g (range 500-4945 g). Two stillborn babies (1%) were macrosomic, and 77.8% (n=158) had low birth weight.Preeclampsia was a significant predictor (prospective risk factor) of low birth weight (85.5% n=100/117 in preeclamptic, RR=1.3 95% CI 1.1-1.5; P=0.002 vs. 67.4% n=58/86 in non-preeclamptic). IUGR was observed among 7.7% (n=16) of stillbirths. Diagnosis of IUGR was made when, on ultrasound, estimated foetal weight was less than the 10th percentile. The diagnosis was also made when the symphysis-fundal height was below the 10th percentile of a gestational age derived from the sure date or early ultrasound (less than 20 weeks). Only 2% (n=4) of stillbirths had cord prolapse. Non-reassuring foetal status was observed in 5.4% of all stillbirths who were still alive at the time the mother go to either the referring hospital or NMAH. Three stillbirths which had non-reassuring foetal

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status (n=11) weighed more than stillbirths which had not been found to have non-reassuring foetal status (3211.6±770 g vs. 1815.4±500g; P<0.01). Non-reassuring foetal status was diagnosed when, before delivery, a CTG tracing was found to be abnormal. Presents of meconium stained liquor reinforced the diagnosis. Indeterminate cause of stillbirths was reported among 3.8% (n=8) of stillbirths. 53% (n=108) of mothers with stillbirths were admitted in NMAH already having been diagnosed from a referring hospital as carrying intrauterine foetal deaths, and the remainder(47%) were diagnosed in NMAH.

DiscussionIn this study, the hospital-based stillbirth rate at NMAH was 75 per 1000 deliveries. This rate is much higher than the current South African stillbirth rate of 22.5 per 1000. It also exceeds the stillbirth rate of 26 per 1000 which was reported for O.R. Tambo in 2011 by Health Systems Trust. The high rate of stillbirths in this study can be explained by inadequate antenatal care which was evident in this study as there was increased number of macerated stillbirths. The other reason is that NMAH is a referral hospital. The current study indicates that most of the mothers who were referred to NMAH had already been diagnosed as carrying IUFDs. The stillbirths which resulted from those IUFDs were counted as part of the NMAH statistics without including the number of deliveries in the institutions from which these stillbirths were referred.Other factors that can possibly explain this high rate of stillbirths are poor transport facilities, long distances to the referral hospital, inadequate number of obstetric referring centres close to patient residences and shortage of doctors and nurses. In the O.R. Tambo district these other factors have been highlighted in the health statistics of South Africa as cause of maternal and perinatal morbidity and mortality.

About 9% of women with stillbirth in this study did not attend antenatal care. And most of those women who did attend antenatal care had late booking (mean booking age of 22.1±4.8 weeks). Furthermore the number of stillbirths with low-birth-weight in this study was much higher among mothers who did not attend antenatal care as compared to those who did. Antenatal care provides a critical linkage between the woman and maternity care services. Thus, if promoted, attendance of antenatal care in concurrence with delivery in skilled hands is an

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effective instrument to improve perinatal birth outcomes particularly in developing countries.The present study showed a remarkably high proportion of mothers who had preeclampsia and eclampsia. Preeclampsia was responsible for 57.6% and eclampsia 12.8% of stillbirths. These findings were much higher than those which were observed in other studies. The possible explanation for this difference is the fact that almost all women with preeclampsia in this region deliver in NMAH. The other possible reason is the fact that most of the mothers who had eclampsia in our study had not attended the antenatal clinic. Not attending the antenatal care clinic deprived these patients of opportunities for early detection of increased blood pressure and thus institution of appropriate intervention to prevent eclampsia from occurring.

ConclusionIn this study, the stillbirth rate was high. Hypertensive disorders of pregnancy and abruptio placentae were major contributors to this birth outcome. Provision of quality antenatal care, monitoring of labour, effective referral system and improvement in emergency transport services can reduce this rate of stillbirths. Health care facilities should be better equipped and have adequate number of staff. Government needs to assist in reducing teenage pregnancy and to facilitate reduction of unemployment rate.Furthermore, as preeclampsia and its complications were major contributors of stillbirth, hence early detection and appropriate management including referral of pregnancy induced hypertension needs to be strengthened in the primary health care level.

Limitation of the studyThis study had some limitations. Because of shortage of workers to perform post-mortems in our institution, post-mortems could not be done on stillbirths. Post-mortem is a useful investigation since it provides more accurate information in respect to the cause of stillbirth. Placental histology also could not be done due to financial constraints. Other limitations included absence of a control group, relatively smaller sample size and a limited study period. Moreover the figures in this study were not community based but were rather institutionally centred. However, as with prospective studies, information obtained in the study was more reliable.

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THE PRESENCE OF INFECTION IN STILLBIRTHS IDENTIFIED WITH MINIMALLY INVASIVE TISSUE SAMPLING

Yasmin Adam, Simpiwe Mose, Salome Maswime, Richard Chawana, Susan Nzenze, Jeanette Wadula, Clare Cutland, Shabir Madhi

INTRODUCTION:Stillbirths have been defined as “babies born without any signs of life”. The WHO limits these to babies that have a gestational age of at least 28 weeks or 1000g. In developed countries, this definition incudes babies at a gestational age of at least 22 weeks or 500g. There were 2.6 million stillbirths reported in 2015 with a SBR of 18.4/1000 births. The rate in South Africa for the years 2012-2013 was 17.2/1000 and the cause was unexplained in 35.5%.Attributing cause of death to a stillbirth may be difficult. Clinical assessment is fraught with problems as a mild infection or undiagnosed infection in the mother may cause stillbirth and a severe infection may not. Other difficulties may be that women with risk factors like diabetes and/ or smoking may be associated with stillbirth but is not always an attributable cause.

A case control study of placental histology found that all the abnormalities found were also associated with live-born babies. The commonest abnormality found was acute inflammation which was present in 30.4% in stillbirths and in 12% of live-births. Autopsy is the gold standard, but autopsy with histological examination of the placenta and cultures at various sterile sites may be the most sensitive method. Complete autopsies are expensive and parents may be reluctant to give consent due to religious and cultural reasons. Limited liver or lung autopsy specimens may be beneficial.

Infectious causes of stillbirths pose their own challenges with no single diagnostic test confirming causality. Serological tests are not always conclusive. Viral culture is difficult and Testing for viruses requires special tests, which are not readily available. There may be more than one cause attributable to a stillbirth, like chorio-amnionitis diagnosed on placental histology where there was an abruption.

The SBR at Chris Hani Baragwanath Academic Hospital (CHBAH) is 15.96/1000 deliveries and the causes are largely unknown. It is important to identify causes of SB, particularly in women with recurrent losses and also in those that are preventable. It is also important to identify sporadic causes in order to provide

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emotional closure. A study to ascertain the association of Group B Streptococcus infection with stillbirths was started in 2014. The present study included women from the first study and with consent to do Minimally invasive tissue sampling (MITS).

OBJECTIVES:

• To describe the proportion of women with Stillbirths associated with infection.

• To describe the types of infections associated with SB’s in this group.

METHODS:Setting: CHBAH is a secondary/ tertiary hospital which serves the population of Soweto and Southern Gauteng. All women with stillbirths are referred to a hospital for delivery. Women are referred from 4-7 midwife obstetric units to either CHBAH or a district hospital (Bheki Mlangeni). The unit at CHBAH delivered 20324 women in 2015. There were 324 women with stillbirths weighing more than 1000g in 2015.Study population:Women who had had a stillbirth >1000g/>28 weeks gestation were recruited for the V98_270BTP study from 2014 by using the labour ward register. Table 1 below summarizes the study procedures. Between July 2015 and June 2016, 126 women who had consented for the V98_27OBTP were also consented for minimally invasive autopsies of the liver, brain and lung. Nurses were trained to perform MITS. The tracheal aspirates were performed by a doctor. A trained councillor saw the patient immediately after delivery and again at between 4 and 12 weeks.

Table 1: A summary of study procedures

Specimens that were taken for the study: V98_27OBTP (Group B Associated with SB’s)

Additional specimens taken for this study

Cord blood (10-15mls) CSF (via the Cisterna Magna puncture)

Infant examined and weighed Brain biopsyDemographic and clinical information Liver biopsy

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from the medical notesTracheal/gastric aspirate Lung biopsySingle swab of the axilla, umbilicus and perineum

Blood via the femoral artery or a cardiac puncture

Placenta MC&S and histology

All specimens were sent to the NHLS for MC&S. The CSF, tissues and swabs were also sent for molecular diagnostic testing. The placenta and all tissue samples were sent for histology.A panel comprising of an obstetrician, an infectious disease specialist and a researcher looked at the pathology reports, the microbiological reports and the clinical information and then attributed a final cause of death.Ethics approval was obtained from the Human Research Ethics Committee at the University of the Witwatersrand.Funding:The study was funded by the Bill & Melinda Gates foundation

RESULTS:There were 126 women who consented to having a MITS procedure. The results of 94 are being presented. The stillbirth was diagnosed antepartum in 74 (78.72%) and during labour in 18 (19. 15%) women. It was not known when the diagnosis was made in 2 (2.13%) women. The median parity was 1 (IQR=0-2; range 0-5), the median gravidity was 2 (IQR=1-3; range 1-7). Many women had not booked yet, with 68 (72.35%) having been booked. The median gestational age at delivery was 33 (IQR=30-37; range 22-42). The proportion of women who were HIV infected was (n=24) 26.92%, the HIV status was unknown in 13 (13.83%). The blood group was Rh negative in 3 (3.19%) and unknown in 28 (21.28%). There were no women who tested positive for syphilis, but the results were unknown in 35.11% of women.

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Figure 1: A description of the final cause of deathInfection was attributed as a cause in 36 (38.30%) of stillbirths. Of these 16 (44.44%) were diagnosed as having a bacteremia, 7 (19.44%) had a CMV infection, 6 (16.67%) had a pneumonia, 4 (11.11%) had an aseptic chorio-amnionitis, 2 (5.56%) had a meningitis (Group B Streptococcus) and 1 (2.78%) had a chorio-amnionitis (Pseudomonas). The organisms cultured in the cases with bacteremia was E coli (11), Enterococcus (2), Staphylococcus aureus (1), Group B Streptococcus (1), and unspecified in 1 case.

Discussion and conclusion:It is possible to attribute cause of a stillbirth with histological examination of the placenta and minimally invasive tissue sampling of the liver, lung and brain. The proportion of stillbirths attributed to infection was higher than that reported by the Saving mothers report. The proportion of unknown causes was reduced. Infectious causes are associated with 10-25% of cases in developed countries and thought to be as high as 50% in developing countries. It may be that if we had included stillbirths of more than 500 g the proportion attributed to infection may have been higher.We were able to give more mothers a possible answer to the “what caused the stillbirth”, but preventing these is still difficult. Vaginal wipes have not been shown to reduce stillbirths. The use of antibiotics in women with Group B Streptococcus may be useful, but this is only used clinically at the time of delivery and with rupture of membranes. Antibiotics in women who have ruptured membranes have been shown to reduce chorio-amnionitis but has not reduced stillbirths.

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Limitations to this study was the large number of women with unknown results for syphilis and HIV infection. The panel determining the final cause of death should include a pathologist.

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EXPOSURE TO SECONDHAND SMOKE AMONG PREGNANT WOMEN IN SOWETO, SOUTH AFRICA.

Dr Joanne Pottow University of Witwatersrand

Tobacco second-hand smoke (SHS) has long being known for all its negative health effects. This work aimed to determine the SHS exposure rate in the pregnant population of Soweto. This was a prospective, cross sectional study undertaken at Chris Hani Baragwanath Academic Hospital. Soweto serves in excess of two million people, with more than 23 000 delivers annually in the hospital. This study used a questionnaire to survey a sample of pregnant women who were post caesarean section.A total of 100 women were interviewed. Twenty one percent reported to be exposed to SHS at home and 18% of the employed participants exposed at work. Forty three percent of the participants lived with a regular smoker and 73% had banned smoking in their house. However, even though the bans had been put in place, smoking still occurred in some of their homes. There was a statistically significant difference in the number of regular smokers that the participant lived with, with SHS-exposed participants being more likely to live with a regular smoker than with no regular smokers in the house. Ninety one percent of participants were aware that SHS could have a negative effect on their babies while pregnant, and knew about health risks with SHS. This study showed that in spite of strict anti-tobacco laws, a high percentage of pregnant women reported to be exposed to SHS at home and at work. Most were aware of the health risks of SHS, and tried to ban smoking in their homes.

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IS FETAL FOOT LENGTH THE MOST APPROPRIATE TOOL FOR DETERMINING GESTATIONAL AGE IN STILLBIRTH?

Lucy Brink a , MSc, Elaine Geldenhuysa, Nat Dip Med Tech, Jean Coldreya, Nat Dip Med Tech, Colleen Wrightb,c, MD, Pawel Schubertc, MD, Daan Neld , PhD, Coen Groenewalda, FCOG (SA), Drucilla Robertse, MD, Theonia K. Boydf, MD, Hein Odendaala, FRCOG, and the PASS NetworkaDepartment of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South AfricabLancet laboratories, Johannesburg, South AfricacDivision of Anatomical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africad Department of Statistics and Actuarial Science, Stellenbosch University, Stellenbosch, South Africae Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MAf Department of Pathology, Boston Children’s Hospital, Harvard Medical School, Boston, MA

Objective. Knowledge of gestational age (GA) at delivery is essential, but often estimated because early ultrasound is not readily available and birth weight is not an accurate indicator of GA. We assessed whether foot length could be a reliable indicator of GA in stillbirths. Methods. As part of the Safe Passage Study in Cape Town, all pregnant women who had a stillbirth were approached for autopsy. GA at delivery according to early ultrasound examination was then compared to the GA assessed using foot length and autopsy protocols. Results. Autopsies were done in 69 fetuses; placental histology was available in 65. In general, GA according to early ultrasound correlated very well with the GA according to the autopsy (Spearman r = 0.84) and foot length (Spearman r = 0.85). However, significant differences were found between these assessments when the fetus was macerated or when umbilical cord pathology or maternal vascular malperfusion was the cause of death, but not in cases of infection, placental abruption or congenital anomaly. Conclusion. Foot length is an excellent indicator of gestational age at birth but less so when the fetus is macerated or when maternal vascular malperfusion or cord pathology is the cause of death.

Financial Support: This research was supported by grants U01HD055154, U01HD045935, U01HD055155, U01HD045991 and U01AA016501 issued by the National Institute on Alcohol Abuse and Alcoholism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute on Deafness and Other Communication Disorders

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IntroductionCaesarean sections rates (CS) have become increasingly high over the last years, and it is well known that CS contributes largely to maternal morbidity and mortality. This increasing rate is not an isolated incident, but rather a national concern, as stated by the safe caesarean monograph of 2013 (1)

Trends as depicted by the saving mothers short report of tri-annum 2011-13 show an overall South African rate of 23.1%, with KZN being highest per province at 28.8%, and regional level hospitals accounting for 40% (also highest) of CS deliveries over the 3 consecutive years of this analysis(2).

Lower Umfolozi Regional War Memorial Hospital (LURWMH) is a regional level mother and child only hospital based in KZN, and as suggested by the Saving Mothers Report by demographic evidence is in fact dealing with a strikingly high CS rate. Rates as captured by the department of health information service

(DHIS) show an overall tri-annular rate of 53.6% at LURWMH (3).

Structured auditing of CSs assist to identify groups that contribute to the high rates and interventions may bring change.

A 3 month pilot study has been done in 2015 in this same institution (LURWMH), but no interventions were proposed or followed. The results yielded (using the Robson 10 criteria) identified the groups ‘primary CS’, and ‘CS for previous CS’ as the highest contributors. (4).

A study done (presented at the 2006 priorities) at a different hospital in a different province using the same Robson 10 method yielded similar results, but again,no proposed interventions were noted (5)

Objective/aim:To determine the main contributors to the high CS rate at LURWMH (A regional rural hospital in KwaZulu-Natal Province, South Africa) and identifying potential areas for intervention

Methods:Retrospective data was collected of all women delivered by C/S over 9 consecutive months. As concluded by the article; Classifications forCaesarean Section: A Systematic Review, there are different means to classify CS’s, under broader classification groups, namely; by women, by indication, by urgency and by other. (6) In this audit, the same sample/number of cases was analysed using all the first 3 abovementioned methods. One can ask: Who? Why? And when are CS’s doneWomen: Robson 10 methodIndication: NICE evidence based method Urgency: Lucas 2000 method (6).

Robson method was used (table 3) and cases were grouped using a flow diagram to prevent any confusion. (See image above)The evidence based indications were categorized into broader groups for analysis, as depicted by (table 2) The same indications were then redistributed into the appropriate urgency category. (See table 1)Urgency Category

Definition Timing of Delivery Targeted Table 1 delivery time

1 Immediate threat to maternal or fetal life

Emergent 15 minutes

2 No immediate threat to life Urgent 45 minutes3 Requires early delivery Unscheduled Within hours

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3 fold combined analysis of caesarean sections at a rural regional hospital in KZN, to determine target groups for interventionAuthor: P. Smit. B.Med (clin prax )UP. (Supervisor: Dr. N. Mayat. (FCOG)) Lower Umfolozi Regional War Memorial Hospital, Department of Obstetrics and Gynaecology.

4 Elective At a time to suit the mother and health services

Normal working hours

Results:(n= 3295) CS delivery cases reviewedDelivery trends: January 2016 - September 2016 Total deliveries: 6044Vaginal: 2706 44.7%Assisted: 43 0.7%CS: 3295 54.5%Elective: 710 11.7%Emergency: 2585 42.8%Women:Robson 10 grouping criteria identified the Primary CS group with (n1170=35.8%) as leading, (Group 1 (n663=20.1%) & 3 (n507= 15.7%) combined) followed by CS for previous CS with (n723=21.9%) as the highest contributors. See graph 1

Indication:Previous C/S, (both elective and emergency combined) accounted for (n1052= 31.9%) of all CS’s. Conditions pertaining to foetal compromise followed with (n881= 18.4%), and conditions associated with failure to progress accounted for (n600= 10.9%) see graph 2.

Urgency: Elective CS accounted for (n710 =21.5%) (Scheduled category 4) and emergency CS (overall) accountedfor (n2585= 78.5%) -noting that urgent (category 2) is the highest among the emergency categories. See graph 3.

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35.8

78.5%

No

Robson criteria Table 3

1 Nullipara, above 37/40 Cephalic Spontaneous

2 Nullipara, above 37/40 Cephalic induced/elect

3 Multipara, above 37/40 Cephalic Spontaneous

4 Multipara, above 37/40 Cephalic induced/elect

5 Multipara, above 37/40 Cephalic Prev C/S

6 Nulliparous, Breech 7 Multipara, Breech8 Multiple pregnancy9 Transverse lie10 Preterm (less 37/40)

NRCTG: non reassuring CTG. MSL: meconium stained liqor. FD: foetal distress. CPD: cephalopelvic disproportion. PP: Poor progress. ECL: eclampsia. IE: imminent eclampsia. SPET: severe pre-eclampsia. PET: pre-eclampsia. PIH: pregnancy induced hypertension. IOL: induction of labour. P/PROM: preterm premature rupture of membranes. VBAC: vaginal birth after caesarean. IUGR: intra uttering growth restriction.

Evidence based group

Indications Table 2

Foetal compromise NR CTG, MSL, FDPrevious CS Prev C/S- elective and

emergencyFailure to progress CPD, PP, Prolong 2nd stg,

Big BabyHPT HELLP, ECL, IE, SPET, PET,

PIHHaemorrhage Previa, Abruption, APH,

Rupture Multiple pregnancy Twins/Triplets/moreMalpresentation Breech, TransverseMiscellaneous Failed IOL, Oligohydramnios,

P/PROM, Cord prolapse, Failed VBAC, IUGR, Other

Tool 1

Tool 2

ConclusionBy using the 3 different categories we could isolate the target group for intervention to: 1. ‘emergency’ CS for (urgent conditions that merit an emergency CS booking) the (previously un-operated) spontaneous labouring women; with signs of foetal compromise or failure to progress 2. As well as, a CS for the previously operated women.

Intervention

As concluded by the article severe hypertension in pregnancy: Using dynamic checklists to save lives it has been researched and acknowledged that checklists improve safety and outcome in patient care. Implementing such tools is a starting point to securing standardized assessments of these conditions. (9) In the aforementioned study, the focus was on hypertension in pregnancy. The proposed methods for intervention will therefore be by use of checklists but in the areas now identified: 1 .Practical prevention the primary CSFocusing on standardized diagnosis and management of foetal compromise and failure to progress.

2 .Reducing the CS for previous CS rateVaginal birth after caesarean (VBAC) should within safe parameters be emphasized

*Preventing the primary CS will also directly result in the decline of CS for previous CS and in an adjunct to the VBAC

1. Standardized diagnosis and management of a) failure to progress and b) fetal compromise.

a) The group of failure to progress mainly involves the diagnosis of poor progress and CPD.The 4 p’s of ESMOE is designed to clinically assess the possible causes for slow progression of labour.By using ESMOE intra partum care Module (7)A checklist tool has been devised to aid in recognizing these conditions. See tool 1

b) The group of foetal compromise mainly involves the diagnosis of foetal distress, MSL or Non reassuring/pathological CTG.

By standardizing the analysis of the CTG, in conjunction with MSL grading and dilatation, one may easier asses the appropriateness of the decision for CS, as well as aid in the interpretation of the CTG itself.

Classification of CTG by ESMOE 2016Features: Contractions, Heart rate, Variability, Accelerations, DecelerationsCategories: Normal: all 5 features fall into reassuring categorySuspicious: 1 non-reassuring categoryPathological: 2 or more non-reassuring or 1 abnormal category (8)

Using 2016 ESMOE CTG Module (8), again, a checklist (stamp) tool has been devised, that will be printed on to all CTG’S. See tool 2

*The full supporting ESMOE guidelines are placed in the labour ward

2. The safety of the VBAC and the maternal consent should always be considered.

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Tools to strengthen this may lead to more agreeable VBAC’s and more success, by looking at the safety parameters of VBAC by the safe caesarean monograph of 2013(1) A VBAC safety and consent checklist tool has been devised, (using below guide of the safe CS monograph, also printed on back of the form.) see tool 3

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Assessing suitability for VBAC by safe C/S monograph:History:-Number of previous CS, Indications & complications. -Any other surgical procedures involving the uterus.-Any previous notes/verbal instructions about the mode of delivery.-Number and outcome of previous vaginal deliveries & birth weight.-Any problems in the current pregnancy.

Examination:-Check for type and number of laparotomy scars.-Exclude multiple pregnancies.-At 36 weeks and beyond: check the SFH to estimate fetal size, the lie, presentation and liquor volume.

Contraindications to Vaginal Birth after Caesarean section (VBAC):-Multiple previous CSs -Previous classical CS, DeLee, inverse T, and J type incisions, gynae surgery; cornual ectopic, myomectomy, perforation or evacuation, or uterine rupture.-Previous stillbirth or neonatal death related to problems during labour-Grossly contracted pelvis, obvious by clinical pelvic examination-Large foetus. Suggested weight/SFH of < 3.2kg/38cm-Breech presentation or transverse lie, or abruption.-Any other maternal or foetal condition which would normally require a caesarean section for safe delivery (1)

The above intervention plans are to be instituted at Lower Umfolozi Regional War Memorial Hospital in due course, and an audit following implementation should by hypothesis show changes in the CS rate, comparable with this first audit cycle.

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Can we safely reduce the rates in each given area without compromising maternal and fetal wellbeing?

Tool 3

RO B S O N T E N G RO U P C L A S S I F I C A T I O N S Y S T E M O V E R A L L A T N M A H F O R F I N A N C I A L Y E A R 2 0 1 5 / 2 0 1 6

S M a n d o n d o

Background NMAH is a national central hospital in OR Tambo that renders L1 ,L2 and L2 services to the OR Tambo region due to failure of district hospital to offer complete district hospital with 24 hour Caesarean section . NMAH has high MMR,PNMR and 70 % C/S rates. OR Tambo district is one of the deep rural district, composed of 146 clinics, 10 CHCs, 9 district hospital, 2 regional hospitals and 1 National central hospital. All hospitals are performing 24 hours caesarean section except for 1 district hospital. NMAH RECEIVES obstetric emergency cases from All Saints in Chris Hani, Madwaleni part of Amathole, Maclear part of Joe Gqabi and All Alfred Nzo district hospitals . The transfer distances are 30 – 350 Km from even for foetal distress. Mthatha regional is functioning like a district hospital with 1 consultant with high no referrals to NMAH. Table 1 illustrates Facility delivery by C/S trends in all hospitals in OR Tambo.Indications for referrals varied but Mthatha regional hospital clients including previous CS were referred despite facility being 1km away from NMAH where with improved consultant cover cases could be managed at MRH.

Facility, Jan to December, delivery by C/S

2013 2014 2015 2016

Bambisane 35 54 74 23Canzibe 118 89 158 103Malizo 786 729 735 557Holycross 542 603 352 268Isilimela 67 63 121 60NMAH 2168 2651 2873 2503Mthatha 1140 1279 1147 941Nessie 98 229 197 198SBH 874 827 760 618SEH 2038 1743 1351 1107Zithulele 296 397 473 380

Table 1. Facility delivery by C/S trends

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HPT Disorders

Prev C/S APH CPD/ Obstr labour

PROM/ PPROM

Other

Mthatha regional

135 39 42 8 12 16

St ElizabethRegional

81 36 15 9 4 31

St Barnabas 83 21 7 7 11 7Canzibe 45 15 7 4 6 12

DMMMH 77 32 15 12 8 2Holy Cross 31 17 6 4 5Madwaleni 48 22 8 6 9Alfred Nzo 21 12 4 3

521 194 104 53 46 77

Table 2: Indications for referrals from hospitals to NMAH in 2016

Situational analysis and Data on maternal and neonatal outcomes Around 60 % of neonatal deaths in OR Tambo occur in NMAH although they conduct 30% of districts deliveries .

Facility, jan to December,Inpatient death 0-7days

2013 2014 2015 2016 to oct

Bambisane 0 5 6 6Canzibe 16 9 2 6Malizo 21 17 13 7Holycross 12 2 13 0isilimela 3 6 4 7NMAH 263 287 335 279Mthatha 35 27 20 22Nessie 3 6 11 5SBH 19 23 18 5SEH 97 57 52 39Zithulele 22 8 32 29

Table 3: Facility Inpatient death 0-7days Neonatal deaths

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Facility, Jan – December, maternal death

2013 2014 2015 2016 2016 Maternal death Referrals to NMAH

Bambisane 0 1 0 0 1canzibe 2 1 3 0 1Malizo 2 1 1 0 3Holycross 3 2 0 1 3Isilimela 0 2 0 0 4NMAH 38 46 51 42Mthatha 3 6 8 3 6Nessie 1 1 0 0 0SBH 1 1 2 0 3SEH 7 9 4 1 3Zithulele 2 0 2 1 1

Table 4: Maternal deaths and trends

More than 70% of maternal deaths were referred from district hospitals but died at NMAH . 15 of 42 maternal deaths came from other districts 11 from Alfred Nzo .Mortality from caesarean section was however not high less 10% .There were however few cases of sepsis were noted .Competency and skills for CS was not a factor .

MethodsA scientific approach to classifying CS called the Robson classification was conducted as a baseline to identify groups of CS that could be redirected to cluster and regional hospital hospitals. (RTCGS) is a structured auditing method that has been used for monitoring CS ratesA 2011 systematic review by Torloni of 27 caesarean section classification systems identified the ten-group classification system proposed by Robson in 2001 as the most appropriate to compare surgery rates. The system is said to be easily reproducible and is not dependent on whether the population is at low or high risk.Purpose was to identify CS that could be done L1 for fetal reasons, build capacity in district hospitals and review referral criteria to reduce CS rate and improve neonatal outcomes .The analysis of medical records was conducted from 1 April 2015 to March 2016 on request by Dr Mandondo a DCST O&G supporting the district. The analysis was conducted by Dr Mda and Dr Gonya a specialist at NMAH.

Explanation of system

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The Robson Ten Group Classification system is that all groups are mutually exclusive and it covers the whole pregnant population. The Robson Ten Group Classification system allows the possibility of improving perinatal care by comparisons of CS over time in one unit and between different units. This classification system incorporates all the parameters used in the other classification system i.e. overall rates, previous CS, indication for previous CS as well as other parameters such as presentation, parity, lie and gestational age. By including all these parameters and dividing it into ten groups, it allows for the calculation CS rates within each group thereby identifying specific groups of patients to which modifications can be made in order to decrease the overall CS rate. The 10 groups are given below in Table .The groups where one can monitor the quality of care in labour are Group1 (nulliparous, single cephalic, ≥ 37 week, in spontaneous labour) and Group 3 (multiparous (excluding prev. CS), single cephalic, ≥ 37 weeks, in spontaneous labour). In Group 3 one would expect the lowest CS rate and would expect it to be well under 10%, Group 1 will have a slightly higher CS rate but it should still be lower than 15%, if labour is managed properly.Group 5 indicates how active the hospital is in encouraging a vaginal delivery following a previous caesarean delivery. Groups 2 and 4 give an indication of the induction success rate and elective CS rates. It is best to separate these out into sub-groups ‘a’ induction of labour and ‘b’ elective CS as this will automatically give the induction success rate and might indicate where a problem lies.

ResultsAs a national hospital receiving preterm babies it is appropriate that 60 .5 % of CS are in category 10.Also the seems to be missed opportunities to do repeat elective for previous CS at District and Regional Hospital .Group 1 primigravida in spontaneous labour at > 37 weeks could include foetal distress as well as by passers or self referred cases.Operating with a single elective and emergency theatre and high burden of pre-eclampsia with IUGR a number of babies could be lost while waiting for caesarean section of delays in doing CS though fetal distress is diagnosed. The overall Caesar rate in NMAH is high due to failure of district hospitals to offer comprehensive services resulting in overcrowding of labour wards and high care.

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ROBSON TEN GROUP CLASSIFICATION SYSTEM OVERALL AT NMAH FOR FINANCIAL YEAR 2015/2016

Robson

Group

Robson Ten Group Classification System NVD C/S Total

Total C/S

over total

women

C/S rate (%)

% of all

1 Nulliparous, single cephalic, 37 weeks, in spontaneous labour

81 215 296 =215/296

72,6 6,0

2 Nulliparous, single cephalic, 37 weeks, induced or C/S before labour

37 188 225 =188/225

83,5 5,2

3 Multiparous (excluding prev. C/S), single cephalic, 37 weeks, in spontaneous labour

121 128 249 =128/249

51,4 3,6

4 Multiparous (excluding prev. C/S), single cephalic, 37 weeks, induced or C/S before delivery (elective C/S)

85 215 300 =215/300

71,7 6,0

5 Previous C/S, single cephalic, 37 weeks 21 477 498 =477/498

95,8 13,3

6 All multiparous breeches 3 22 25 =22/25 88 0,6

7 All multiparous breeches (including prev. C/S) 9 36 45 =36/45 80 1,0

8 All multiple pregnancies (including prev. C/S) 37 123 160 =123/160

76,9 3,2

9 All abnormal lies (including prev. C/S) 0 17 17 =17/17 100 0,5

10 All single cephalic, 36 weeks (including prev. C/S) 672 2 174

2 846

=2 174/2 846

76,4 60,5

Total   1 066 3 595

4 661

100

Recommendations Low Risk referrals should be transferred from CHC and District, e.g. foetal distress, CPD, previous CS to MRH and only tertiary care clients accepted at NMAH.MTHATHA regional hospital (MRH) needs to be strengthened with staff both dedicated anaesthesia and maternity doctors with specialist cover from NMAH. An On-site Midwife Birthing unit (OMBU) is recommended at MRH.Criteria for L3 need to be drafted and workshopped to hospitals and implemented as soon as MRH is ready to accept L2 cases .To optimise patient outcomes a second daytime theatre needs to be prioritised in NMAH as well as increase in number of theatre staff and midwives in maternity . Early down referral would decongest postnatal ward improving quality of care. Future plans include matching Robson classification with indications for CS in each group .

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FUNDAL PRESSURE DURING THE SECOND STAGE OF LABOUR (COCHRANE SYSTEMATIC REVIEW)

G Justus Hofmeyr1, Joshua P Vogel2, Anna Cuthbert3,** Mandisa Singata 4 1Walter Sisulu University, University of the Witwatersrand, Eastern Cape Department of Health, East London, South Africa2UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland3Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK4Effective Care Research Unit, University of the Witwatersrand/University of Fort Hare/East London Hospital complex, East London, South Africa

Background: Fundal pressure during the second stage of labour involves application of manual pressure to the uppermost part of the uterus directed towards the birth canal, in an attempt to assist spontaneous vaginal birth and avoid prolonged second stage or the need for operative birth. Fundal pressure is widely used, however methods of its use vary widely, and the indication is often unclear. Despite strongly held opinions in favour of and against the use of fundal pressure, there is limited evidence regarding the maternal and neonatal benefits and harms of fundal pressure. Objectives: To determine if fundal pressure is effective in achieving spontaneous vaginal birth, and preventing prolonged second stage or the need for operative birth, and to explore maternal and neonatal adverse effects related to fundal pressure.Search method: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016) and reference lists of retrieved studies.Selection criteria: Randomised and quasi-randomised controlled trials of fundal pressure (manual or by inflatable belt) versus no fundal pressure in women in the second stage of labour with singleton cephalic presentation. Fundal pressure is defined as manual pressure on the fundus of the uterus towards the birth canal in the second stage of labour, with the aim to expedite birth of the baby. This fundal pressure is also known as the 'Kristeller manoeuvre'. Fundal pressure applied by means of an inflatable belt was assessed as a separate comparison.Data collection and analysis: Two or more review authors independently assessed for inclusion all the potential studies. We extracted the data using a pre-designed form. We entered data into Review Manager software and checked for accuracy.Main results: Nine trials were included, involving 3948 women. Five trials (3057 women) compared manual fundal pressure versus no fundal pressure, and the other four trials (891 women) compared fundal pressure by means of an inflatable belt versus no fundal pressure. It was not possible to blind women and staff to this intervention. Two trials were assessed as being at high risk of attrition bias and another was at high risk of reporting bias. All other trials were low or unclear for other domains of risk of bias. Most of the trials had design limitations. Heterogeneity was also high for the majority of outcomes.

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COULD INDICATIONS OF UTERINE ACTIVITY AT 34 WEEK’S GESTATION IDENTIFY RISKS OF PRETERM DELIVERY?

Carlie du Plessis a , Coen Groenewalda, Lucy Brinka, William Fiferb,c,d, Michael Myersb,c,d, Hein Odendaala, and the PASS Network aDepartment of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South AfricabDepartment of Psychiatry, Columbia University Medical Center, New York, NYc Department of Pediatrics, Columbia University Medical Center, New York, NYd Extraordinary Professor, Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa

Objectives: To determine whether increased activity in the electrohisterogram, as assessed noninvasively from five electrodes on the anterior abdominal wall at 34 weeks’ gestation could indicate risks of preterm deliveryStudy design: Data from the Safe Passage Study were used for this study. Data from fifty participants using an abdominal recording of the electrohisterogram for ~50 minutes had been collected at 34 weeks’ gestation and who subsequently delivered before 37 weeks were compared with fifty participants’ recordings at exactly the same gestational age, but who delivered at 37 weeks or later. The monitoring device was used to select uterine activity, expressed in microvolts, in 250 millisecond epochs. The mean of all the epochs was used for comparison between the two groupsResults: Information from three participants was not used as inclusion criteria were not met. The two groups were comparable regarding age, gravidity, parity gestational age at recruitment, gestational age at and duration of the recording (Table I). The groups differed significantly regarding uterine activity, recording-delivery-interval, gestational age at delivery and birth weight (Table I).

Preterm birth group (N=49)

Comparison group (N=48)

Mean SD 95% CI Mean SD 95% CI p*

Age (years) 24.8 5.5 23.2-26.3 24.7 5.6 23.1-26.3 0.86Gravidity 2.1 1.0 1.8-2.4 1.9 1.1 1.6-2.2 0.18Parity 1.1 1.0 0.8-1.4 0.9 1.1 0.6-1.2 0.23GA at recruitment (days) 138.4 55.3 122.5-154.2 136.3 48.8 122.1-150.4 0.86GA at recording (days) 241.1 3.6 240.0-242.1 240.9 4.3 239-7-242.2 0.96Duration of recording (min) 54.2 5.3 52.7-55.7 54.7 3.4 53.7-55.7 0.93Uterine activity (µV/epoch) 59.2 8.9 56.7-61.8 50.4 10.3 47.3-53.4 <0.01Recording delivery interval (days)

5.98 3.92 4.85-7.1 35.79 9.62 33.0-38.6 <0.01

GA at delivery (days) 247.0 4.0 245.9-248.2 276.7 9.1 274.1-279.4 <0.01Birth weight (gram) 2440.1 394.8 2326.7-2553.5 3117.9 442.0 2989.6-3246.2 <0.01

GA=gestational age; *p from Mann-Whitney U test

Table 1. Background information on patients.Conclusions: There is an association between activity at 34 weeks’ gestation and delivery before 37 weeks, but more research is still needed to determine the clinical use of electrohisterography.

Financial Support: This research was supported by grants U01HD055154, U01HD045935, U01HD055155, U01HD045991 and U01AA016501 issued by the National Institute on Alcohol Abuse and Alcoholism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute on Deafness and Other Communication Disorders.

32

A PROSPECTIVE STUDY OF THE INDUCTION OF LABOUR AT RAHIMA MOOSA MOTHER AND CHILD HOSPITAL

HATEL LALOO, UNIVERISTY OF THE WITWATERSRAND, OBSTETRICS AND GYNAECOLOGY SHASTRA BHOORA (SUPERVISOR), UNIVERSITY OF PRETORIA, CRITICAL CARE

Background Induction of labour implies the artificial initiation of regular uterine contractions before the onset of spontaneous contractions with the purpose of achieving a vaginal delivery.This study aimed to compare the use of oral misoprostol and vaginal dinoprostone to determine differences in the labour process, delivery methods, maternal and fetal outcomes.

Methods This is a prospective cross-sectional analytical study using medical record review. This study was undertaken at the Rahima Moosa Mother and Child Hospital, a tertiary hospital complex in Newclare, Johannesburg.This study included all women undergoing the induction process who met inclusion criteria over a period of 4 months from 01 January 2016 to 30 April 2016.

ResultsThis study included 100 women who underwent the induction process of which 5 were excluded from the final results. 49 women received prandin and 46 women received oral misoprostol. There was minimal heterogeneity between the demographics of the two groups. The differences in the indications for induction were statistically significant (p = 0.001). There was no statistical difference in the time from induction to delivery (p= 0.18), the duration of labour (p=0.10) or in the time from induction to onset of labour (p= 0.37). 32.7% of patients required a caesarean section in the prandin group and 43.5% in the oral misoprostol group (P=0.30). There was no statistical significance between fetal and maternal outcomes.

ConclusionsThis study yielded no difference in time to onset of labour, time to delivery, caesarean section rate or maternal and fetal complications between the two groups. These results, even though from a small study group, differed from that of other larger studies that proved that misoprostol had a lower caesarean section rate. Thus, at the Rahima Moosa Mother and Child Hospital with current protocols in place, there is no difference in the use of prandin versus oral misoprostol.

33

LIGHT AT THE END OF THE TUNNEL: REDUCTION IN MATERNAL MORTALITY IN ZIMBABWE 2010-2014.

Munjanja SP, Manjeya F, Magwali T. College of Health Sciences, University of Zimbabwe, Mazowe Street, Harare.

BackgroundThe maternal mortality rates rose in Zimbabwe from 168 per 100,000 live births (LB) in 1990 (Mbizvo et al., 1993) to 880 per 100,000 LB in 2005 (WHO/UNICEF/UNFPA and The World Bank, 2007). In 2010/11 the Zimbabwe Demographic Health Survey (DHS) reported that the MMR had risen to 960 per 100,000 LB (Zimbabwe National Statistics Agency and ICF International, 2012). Even given the qualification that these estimates had wide confidence limits, and that they should not be used to determine trends, there was no doubt there had been a rise in the MMR. A population based survey conducted by the Ministry of Health and Child Care (MOHCC) estimated that the MMR was 725 per 100,000 LB (95% CI 648-810) (Ministry of Health and Child Welfare, 2009). This figure had narrow confidence limits and was in the same range as the high figures mentioned above.The causes of the rise of MMR were the severe socioeconomic deterioration, the lowering of standards and quality of care in health institutions, the rise in maternal mortality from HIV/AIDS and the introduction of user fees for maternity care. There was denial that HIV/AIDS was a significant cause of maternal deaths but the population based survey by the MOHCC clearly showed this to be the case. A list of the main causes of maternal deaths in that survey showed that HIV/AIDS was responsible for a quarter of all deaths (Ministry of Health and Child Welfare, 2009).Table 1. Causes of maternal deaths (MOHCC 2009)

Cause of death %HIV/AIDS 25.5PPH 14.4Hypertension/Eclampsia 13.1Puerperal sepsis 7.8Abortion complications 5.8Malaria 5.8Obstructed labour 3.3Ectopic pregnancy 2.0Suicide 2.0

Programme response to high MMR

34

There was a programme response to high MMR in 2009-10. The first was acceptance of the seriousness of the problem at high levels in the MOHCC. This resulted in dissemination of the results to health providers at national scale, sensitisation of legislators and mass media campaigns.The next programme response was genuine removal of user fees in rural areas. Previously this policy had been enunciated but not implemented. In rural areas this has caused a drop in skilled attendance to 48% by 2007 (Ministry of Health and Child Welfare, 2009). From 2009 onwards, the public statements on the policy matched the practices at rural facilities and district hospitals.The third and significant change in the programme was the creation of the Health Transition Fund (HTF). This was a fund of pooled resources from several partners, whose main purpose was to improve maternal, newborn and child care.

Box 1. The Health Transition FundBudget: 235.222.354 USDDonors: DIFD, EC, Governments of Ireland, Sweden, Norway, Canada, UKGeographic Focus: Nationwide Target groups: Women of reproductive age, mothers and children under the age of five

yearsPurpose: To improve maternal, newborn and child health by strengthening health

systems and scaling up the implementation of high impact interventions through the health sector

Goal: To contribute to reduced maternal mortality and under five mortality and combat, halt and reverse trends in HIV and AIDS, malaria and other diseased by 2015

Intervention of the HTFThe HTF ensured the supply of essential medicines (oxytocics, sedatives, antibiotics), consumables and blood for emergency obstetric and neonatal care.Funds from the HTF were used to give a financial incentive to all midwives in the country working in maternity. This retention scheme also applied to doctors working in rural district hospitals.The fund also had a monitoring requirement, to ensure that essential medicines and consumables were being delivered to the rural facilities and district hospitals. Governance and accountability were promoted through the setting up of facility committees and District Health Executives.Other interventions included saturation training in comprehensive emergency obstetric and neonatal care (CEONC) in the five tertiary hospitals of Zimbabwe,

35

for midwives and doctors (LSTM). Basic emergency and neonatal care (BEONC) training was also conducted in district hospitals.Maternal and perinatal audit was recommended by the MOHCC and the first guidelines on this were published in 2011. HIV/AIDS was tackled by the massive national scale up of Option B+ of PMTCT.The last significant intervention was the expansion/ renovations of maternity waiting homes (MWH) for rural women.

Results of the evaluationsThe national MMR estimate in 2014 was 581/100,000LB (Zimbabwe National Statistics Agency (ZIMSTAT), 2014). Another estimate from the Zimbabwe DHS in 2015 was 651 (Zimbabwe National Statistics Agency and ICF International, 2016). These estimates are in the same range of magnitude, and represent a drop in the MMR from 2009-10. However, the wide confidence intervals around these estimates put a limit on how certain we can be about the level of the reduction.An examination of process indicators show that quality of care has improved during the 5 year period.

Table 2. Results of evaluations (process indicators)Indicators 2010 2014 ReferenceSkilled attendance 66% 80% ZIMSTAT 2014Caesarean section rate 4% 6% ZIMSTAT 2014CEONC 26% 78% HTF 2016At least 1 PN visit within 48 hours 77% ZIMSTAT 2015

Skilled attendance has gone up to 80%, the caesarean section rate is now 6% and 76% of district hospitals are now fully functional to provide CEONC.Contributory evidence to the reduction in MMR: data from Harare CityThe Greater Harare Maternity Unit is a collective name for the institutions which serve the public sector. It is comprised of 2 central hospitals (Parirenyatwa and Harare Central hospitals) and the 12 urban clinics which provide midwifery led care. During 1988 to 1997, the MMR of GHMU rose from 50 to 224/100,000 LB (Majoko et al., 2001).The MMR dropped from 361 (95% CI 307-415) to 166 (95% CI 148-184). This drop was statistically significant. The change in MMR is shown graphically in Fig 1.

36

Figure 1. Trends in MMR, GHMU

The caesarean section rate rose during this period from 9.5% to 13.7%. The cause specific MMRs for the major complications of pregnancy also showed improvement apart from puerperal sepsis.

Table 3. Cause specific MMRs, GHMU 201 and 2014Cause specific MMRCondition 2010 2014Obstetric Haemorrhage 108 69Sepsis 84 97Pre-eclampsia/ Eclampsia 83 61AIDS defining conditions 67 36

ConclusionThe interventions introduced into the programme in Zimbabwe from 2010 resulted in the reduction of the MMR nationally and also specifically in Harare City. A multi-intervention strategy of removing user fees, making resources available, training and retaining health providers in EONC skills, implementing Option B+ for HIV/AIDS and increasing the uptake of MWH led to the reduction in maternal mortality.

37

OBSTETRIC HAEMORRHAGE-RELATED SEVERE MATERNAL OUTCOMES IN HIV-INFECTED WOMEN

Kwadwo Atobra Antwi, Coceka Nandipha MnyaniDepartment of Obstetrics and Gynaecology, University of the Witwatersrand, South Africa

BACKGROUNDObstetric Haemorrhage (OH) includes both antepartum and postpartum haemorrhage from any cause, known or unknown. In the latest Saving Mothers Report prolonged labour and anaemia were found to be the commonest underlying factors for OH.A maternal near-miss or Severe Acute Maternal Morbidity (SAMM) is a woman who nearly died but survived a complication that occurred during pregnancy or childbirth, or within 42 days of termination of pregnancy. Similar inadequacies in healthcare systems contribute to both maternal deaths and near misses, together defined as severe maternal outcomes (SMO).By studying severe maternal outcomes information can be obtained about the processes that take place in healthcare systems responsible for maternal healthcare, and also identify obstacles that need to be overcome to prevent adverse outcomes. Therefore, assessing SMOs provides the most robust indicator for evaluating the quality of maternal health care.There is paucity of data on the contribution of HIV infection to OH-related severe maternal outcomes. Since the two commonest causes of adverse maternal outcomes in South Africa are non-pregnancy related infections, which are mostly HIV-related, and OH, there is the possibility of a relationship between HIV infection and OH-related severe maternal outcomes. Hence the aim of this study was to determine whether OH-related severe maternal outcomes are increased in HIV-infected women at Chris Hani Baragwanath Academic Hospital (CHBAH).

OBJECTIVESTo assess the proportion of SMOs and to compare the factors that affect severe maternal outcome SMOs from OH, that occurred in HIV-infected and HIV-uninfected women at CHBAH from January to December 2015

38

METHODSA retrospective record review of all cases of OH-related SMO at CHBAH, from January to December 2015 was conducted. The data was collected from 02 February 2016 to 10 August 2016. Further information was obtained from near-miss and maternal mortality audit reports conducted at the CHBAH.

RESULTSFrom 01 January to 31 December 2015 there were 73 patients with OH-related SMOs, and the HIV status was known in 68.A total of 18/68 (26.5%) women were HIV-infected and all of them were on the efavirenz-based fixed dose combination (FDC). Of the 18 HIV-infected women, 10/18 (55.5%) were diagnosed prior to the index pregnancy and 90% (9/10) were started on ART pre-pregnancy. The median CD4 count was 409 cells/mm3 (IQR 222, 636), and viral load results were available for three cases and these were less than 20 copies/ml for two of them and, 48600 copies/ml for the other. There were 65 near-misses, 16(24.6%) in HIV-infected women. There were three maternal deaths, two in HIV-infected women.

Table 1: Demographics and antenatal details HIV-infected

N=18HIV-uninfected

n=50p-value

Mean age (years) (SD) 32.5 (5.8) 29 (6.6) 0.02 Age category <18 0 3 (6%) 0.28

18-35 13(72.2%) 39(78%) 0.62≥35 5(27.8%) 8(78%) 0.27

Mean parity (IQR) 2(1,2) 1(0,2) 0.16Median gravidity 3(2,4) 1(2,3) 0.04

Booked 17(94.4%) 48(96%) 0.78Mean gestational age at booking (SD) 15(2.1) 17(6.4) 0.60

<20 weeks 8 (53.3%) 28 (62.2%) 0.54≥20weeks 7(46.7%) 17 (37.8) 0.55

Previous caesarean section 6 (33.3%) 9 (18%) 0.18Diagnosis of anaemia 8 (44.4%) 16 (66.7%) 0.47

Mean gestational age of anaemia diagnosis (SD) 23.5 (10.1) 20(8.69) 0.63Mean haemoglobin at delivery (SD) 9.6(1.8) 11.7 (2.1) 0.97

39

Table 2: Delivery and caesarean section detailsHIV-infected

n=18HIV-uninfected

n=50p-value

Median gestation age at delivery (IQR) 39 (34,40) 38(35,40) 0.80 Onset of labour Spontaneous

12 (66.7% 37 (74%) 0.60

Induced

0 1(2%)

Antepartum haemorrhage 6 (33.3%) 7(46%) 0.35 Mode of delivery NVD

6 (33.3%) 14 (28%)

Instrumental 0 1 (2%)EMCS 12 (66.7%) 33(66%)ELCS 0 33(66%)

Median duration of labour (minutes) (IQR) 720 (545,1165) 720( 350,1365)

0.83

Indication for caesarean sectionAPH of unknown origin 2 (11.1%) 7 (14%) 0.80

Abruptio placenta 2 (11.1%) 10 (20%) 0.41Placenta praevia 0 3 (6%) 0.08Prolonged labour 3(16.7%) 3(6%) 0.14

Cephalopelvic disproportion 1(5.6%) 3(6%) 0.97Median caesarean section duration mins

(IQR)87.5 (55,185) 100(50,189) <0.001

NVD: Normal vaginal delivery EMCS: Emergency caesarean section ELCS: Elective caesarean section

Table 3: Causes of postpartum haemorrhageHIV-infected

n=18HIV-uninfected

n=49p-value

Uterine atony 6 (33.3%) 28 (56%) 0.09Bleeding during or after caesarean section 7 (38.9%) 17 (34%) 0.71

Retained placenta 4 (22.2%) 9 (18%) 0.69Vaginal tear 2 (11.11%) 4 (8%) 0.68

Uterine rupture 3 (16.67%) 2 (4%) 0.07Cervical tear 0 3 (6%) 0.28

Figure 1: Prevalence of Organ system dysfunction in the study population

40

Massive

tran

sfusio

n

Relook la

parotomy

Artificial ve

ntilation

Hystere

ctomy

ICU admiss

ion

Hypoxe

miaSh

ock

Oliguria

Inotropic s

upport

Cardiac

arres

t/CPR

Need fo

r dial

ysis

Seizures

0%

10%20%30%40%50%60%70%80%90%

100%

HIV-infectedHIV-uninfected

41

Figure 2: Blood products received

Median

total

blood products

Median

red blood ce

lls

Median

fresh fr

ozen plas

ma

Median

platele

ts

Mean cr

yoprec

ipitate

0123456789

HIV-infectedHIV-uninfected

Table 4: Worst Blood resultsHIV-infected HIV-uninfected p-value

Haemoglobin Mean (SD) 6.0 (1.89) 5.9 (1.36) 0.19Platelets Mean (SD) 68 (23.2) 65 (23.5) 0.75pH Median (IQR) 7.2 (7.1,7.26) 7.25 (7.2,7.3) 0.004Bicarbonate Median (IQR) 15.5 (14,16.1) 14 (11.4,17.5) 0.97Lactate (Media, IQR) 5.5 (4.3,8.8) 4.3 ( 3.2,9.8) <0.001Creatinine Median (IQR) 147 (137,160) 137 (113,208) <0.001Base deficit Median (IQR) 12.6 (10.2, 15.8) 9.8 (7.2,114) 0.01

CONCLUSIONIn this study, there was no significant difference in obstetric haemorrhage-related severe maternal outcomes in HIV-infected women compared to HIV-uninfected women.This may be because it was a relatively healthy population of HIV-infected women with a median CD4 count of 409 cells/mm3 and all of them were on treatment.A major limitation is the small sample size and therefore larger studies are needed to elucidate these findings.

42

SKILLS2CARE : PIONEERING A PERINATAL PROGRAMME OF LEARNING FOR COMMUNITY HEALTH WORKERS IN THE EASTERN CAPE

Therese Boulle, Dr Paul Cromhout & Prof Dave Woods.Skills2Care: A project of the Small Projects Foundation in collaboration with Perinatal Education Programme of the Perinatal Education Trust

IntroductionIn order for Community Health Workers (CHWs) to function effectively within clinics and communities, they require skills and knowledge. During the past year, Small Projects Foundation (SPF), a non-profit organisation based in the Eastern Cape, in collaboration with the Perinatal Education Programme (PEP) has been pioneering a programme of learning to enhance CHW knowledge. Known as the Skills2Care Programme, the programme was initiated as a self-facilitated learning programme, with a set of four modules related to Perinatal Care. Learning material has been adapted from the PEP programme which had been successfully applied to midwives in the province for many years. After completion of the four modules, an independent assessment was conducted to determine CHW knowledge. It also explored CHW views of the programme. The goal of the assessment was to determine whether this cost-effective, group learning approach could be implemented to benefit CHWs.

Background to the ProgrammeSPF has been working with CHWs in the Eastern Cape since 2005. In 2015 SPF, in conjunction with Medicor, One to One Children’s Fund and Adventure Philanthropy, initiated a partnership with Prof Dave Woods who had pioneered the midwife PEP programme. The programme seemed to offer a model that could be implemented with CHWs. CHWs are people drawn from local communities who are without formal employment and are keen to render service to the community. Most of them are women. CHWs work four hours daily. From Monday to Thursday, they divide their time between the clinic and the community, with Fridays dedicated to administration, debriefing, attending meetings and training. Their work in the clinic provides for educational sessions, conducts HCT, supports staff and provides the conduit for communication to and from the community. Whilst in the community, CHWs check on patients, trace defaulters, educate and provide support. For their work they receive a stipend. Upgrading their skills and

43

knowledge is considered important so that they become a valued resource within the clinic and community. Four study modules were developed for the programme. Each module is about 15 pages in length. They complied with the requirements for the Department of Health in terms of content and practice. Modules related to Care of the Newborn, Exclusive Breastfeeding, Perinatal HIV and Maternal Care. The modules comprised knowledge related to the topic, case studies and a set of multiple choice questions for self-testing. Modules are written in a fairly simple English which makes the material accessible. This was important since most CHWs are not first language English speakers. CHWs were required to work through the modules on their own initially and thereafter they came together in clustered groups to consolidate their knowledge and understanding. CHWs elected a team leader who guided them through the modules. After the initial assessment, it was determined that the coordinators, mostly nurses, employed by SPF, would guide the groups through the content of the modules.

MethodsTo determine whether this was an effective model of learning for CHWs, an assessment of their knowledge and understanding was conducted. This included both quantitative and qualitative data collection. The quantitative component included a multiple-choice questionnaire (MCQ) determining CHW knowledge. Ten MCQs were asked of each module. A Likert Scale Questionnaire explored CHW perceptions of their learning experience and their work. The qualitative component included focus group discussions to understand CHW perceptions of the learning programme in greater depth; as well as interviews with professional nurses and clients.The assessments were carried out between June and December 2016. They were conducted in the geographic areas in which the CHWs were working, which included the districts of Nelson Mandela Bay, Sarah Baartman and Chris Hani (lukhanji). Ninety-seven CHWs were included in the study.

ResultsResults were overwhelmingly positive. For the MCQ questionnaire, a result of 80% and more is required to be successful. 93 CHWs (96%) achieved a score of 80% and more. 28 CHWs (29%) attained a score of 100%. Four CHWs (4%) scored below 80% and were

44

therefore considered unsuccessful. Test results are contained in the bar graph below.

'100 97 93 90 87 83 80 73 70 60'

28

23

1014

6 75

2 1 1

Test Results Four Modules

Percentage attained

Num

ber o

f CHW

s

Table 2 Bar Chart of the CHW Test Results

The graph indicates 96% of the CHWs have adequate knowledge of the four Perinatal Care modules.Pre-and Post-tests for the Maternal Care moduleIn Nelson Mandela Bay Health District, pre-and post-test assessments were conducted for the module on Maternal Care. Thirty-five CHWs participated. Results were relatively high for the pre-test with three CHWs achieving a score of 100% and 25 CHWs (71%) attaining above 80%. This was not surprising since most CHW work had comprised support for mothers and their babies, and in particular mothers living with HIV. Results of the assessment are included in the graph below.

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'100 90 80 70 60 50 40 30 20'0

5

10

15

20

25

Maternal Care Pre- and Post -Test Results

Maternal Care Pre-testMaternal Care Post Test

Percentage Attained

Num

ber o

f CHW

s

Table 3 Pre-and Post-test results for the Maternal Care Module

It can be seen that ten CHWs (28.5%) scored less than 80% in the pre-test, with two receiving scores of 40% and 30%. Scores improved considerably with all CHWs achieving above 80% for the post-test. The number of CHWs who attained 100% jumped to 22 (63%). Ten CHWs improved their score by 20%, with the two low scores improving from 30 to 80%; and from 40 to 90%.

Likert Scale QuestionnaireThe statement questionnaires provided for agree, disagree and don’t know answers to ten statements. Statements referred to CHW perceptions of the learning and their work. There was an overwhelmingly positive response from CHWs. Their knowledge had increased as a result of the PEP programme. The manual, modules and training had supported their learning. Focus Group Discussions and Interviews with Professional NursesFocus group discussions confirmed these results. CHWs indicated that whilst home study was not easy, their learning was enhanced when they worked systematically through the modules in their groups. Whilst the initial plan had promoted self-facilitated learning, it emerged that facilitated sessions, supported by SPF coordinators, enhanced their learning. The coordinator and CHWs thus formed a learning team. Facilitated learning was particularly important when new protocols were introduced such as the time of cord clamping, or for the facilitation of controversial topics. WhatsApp groups helped communication, with challenges and questions in CHW learning being raised in this forum. CHWs indicated that their confidence had grown and local community members afforded them recognition.

“To me these modules mean a lot. They were helpful. The modules teach me, especially about the newborn. Now we know to identify if a child is

46

malnourished, and we can go into the community with that knowledge.” CHW Nelson Mandela Bay“You can’t be a CHW with no knowledge. The community has expectations of us. The modules make us to feel stronger.” CHW Lukhanji“People in the community, they are coming to us. They see that we have knowledge. They ask us for help with their health issues.” CHW Lukhanji

Commenting on specific modules, CHWs noted the following:“It was difficult for some mothers to change their approach to feeding their newborn. But the modules, they helped us to understand and to explain to the mothers, especially if they were HIV, that they must now be exclusively breastfeeding” CHW Lukhanji“Sometimes it’s the first time that they[community members] have a health worker in their houses, especially for newborns. So you go and check on those babies and their mothers. You need to have good information to give those mothers. So these modules they are giving us that.” CHW Sarah Baartman

Interviews were held with professional nurses at the clinics where CHWs were deployed. These confirmed that CHW knowledge was important and guided the level of responsibility given to the CHWs.Clients too were generous in their praise of the CHWs and their knowledge. A young mother at a clinic in Uitenhage indicated the following:

“I knew I have to make sure that my baby does not develop HIV. So I took my medication. I also made sure she has her nevirapine. She was tested again today and she was negative and she will remain negative now. I am exclusive breastfeeding.. These women [CHWs] have really helped and supported me. They explained about exclusive breastfeeding. I can always turn to them.”

ConclusionThere is little doubt that the CHWs are of value to mothers and their babies in the community. Provisional data shows that providing CHWs with study modules for facilitated self-learning is an acceptable method for their continuing education. This method is a cost-effective way to improve the knowledge of CHWs. It is a method that can, with relative ease, be rolled out to all CHWs nationally.

47

AcknowledgementsThanks to One-to- One Children’s Fund, Adventure Philanthropy and Medicor for their generous support of this project.

48

INTRODUCING ESMOE INTO A PRIVATE HEALTHCARE GROUP

Hall, A.P. Clinical Quality Specialist: Mother and ChildMediclinic Southern Africa

Context:

Mediclinic Southern Africa (MCSA) is a private hospital group with 52 hospitals across South Africa and Namibia. There are 44 obstetric units which vary in size and currently just fewer than 400 midwives work in these units. The majority are combined units with the antenatal, postnatal and labour wards situated in one area, and caesarean sections performed in the general theatre suites. There are on average 40 000 deliveries per year in the group, with the smallest unit doing 5-10 deliveries a month and the busiest unit doing 280-300 deliveries a month. The caesarean section rate varies from 60% to 90% with the group average at 73%.

Specific outcomes for obstetrics have only been measured from 2016, utilising a Weighted Adverse Outcome Score (WAOS) which specifically targets the labour and delivery of a term pregnancy. The WAOS includes ten specific measures: six maternal measures (maternal death, uterine rupture, maternal admission to ICU, maternal return to theatre, blood transfusion and perineal tear grade 3+4) and 4 neonatal measures related only to the baby older than 37 weeks gestation: neonatal mortality, admission to a neonatal unit, APGAR of less than 7 at 5 minutes of age and significant birth trauma. Each event has a weight attached and the sum of all events is divided by the number of deliveries to give a score per hospital. The WAO score and each individual measure is then displayed on a dashboard, from which each hospital can view their results and set targets for improvement, and compare with other hospitals in the group.

49

Figure 1: Number of deliveries per region in 2016Figure 2: WAOS score in 2016 per region

Norther

n

Tshwane

Centr

al

Cape

Inland

Cape

Coast

al0

5000

10000

15000

Region

Num

ber

Norther

n

Tshwane

Centr

al

Cape

Inland

Cape

Coast

al0

24

6

Region

WAO

S

Problem:Obstetrics is an area of high risk, with ever increasing litigation, and obstetricians no longer want to practise in the private sector. Additionally, a critical midwife shortage is experienced, due to current training not meeting the demands. In an investigation into some of the challenges facing the obstetric units in MCSA, it was noted that some of the current midwives have poor skills in identifying and reporting early warning signs in both the antenatal and labour period. Similar to other specialities, there is a lack of critical thinking and problem-solving skills evident amongst our current nursing population. This is also evident in the documentation and record keeping. In the private sector, the caesarean rate remains high and continues to rise year on year. This in turn leads to a loss of skills of both midwives and obstetricians, as the normal labour and delivery is done infrequently.

Figure 3: Mediclinic Caesarean Section Rate 2016

Northern Region

Tshwane Region Central Region Cape Inland Region

Cape Coastal region

60

65

70

75

80

85

74.92

67.46

79.32

75.0772.51

50

A significant degree of burnout was noted among more experienced midwives who are facing this lack of skills in some of their counterparts, and the ever-increasing caesarean section rate decreasing their opportunities to do what they are trained and skilled to do.

Figure 4: Distribution of hospitals by average number of vaginal deliveries per month

0 to 10 10 to 20

20 to 30

30 to 40

40 to 50

50 to 60

> 1000

4

8

12

16

Vaginal deliveries per month

No.

of

hosp

itals

Aim statement: The aim was to develop a skills enhancement training course for the midwives working in the units to increase risk awareness, redevelop some of the lost skills and allow the skills to be practised utilising simulation.

Intervention: A few of our midwives and obstetricians had been exposed to the “Essential Steps to the Management of Obstetric Emergencies” (ESMOE). As ESMOE was locally developed and used the ‘local lingo’ this had the added advantage that agency staff from the public sector working in our hospitals, would be familiar with ESMOE.

When reviewing adverse obstetric events for MCSA the causes were found to be similar to the national data. The leading causes of maternal deaths in MCSA (0.04% of total deliveries) are obstetric haemorrhage, hypertensive disorders and pulmonary embolism. For the three year period 2014-2016 there were 101 adverse events reported in MCSA that directly affected the foetus/baby, leading to intrauterine/neonatal death, birth asphyxia or significant birth injury (fractures/intracranial bleeds).

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ESMOE training was pursued and in August 2016 and February 2017 - 14 nurse practitioners from Mediclinic attended the master ESMOE training – which had been customized for the private sector.

Figure 5: Serious Adverse events reported over a 3 year period 2014-2016

Poor monito

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Measurement of Improvement and Results: ESMOE was piloted in a small, medium and large hospital utilising a single trainer. Enrolled Nurses working in the obstetric areas were included in the training.

Figure 5: Mediclinic ESMOE Skills test in 2 pilot hospitals

Midwife Enrolled Nurse0

102030405060708090

100

Pre Skills training Post Skills training

%

Challenges & Lessons Learned: The challenges include ensuring that ESMOE drills are done regularly and

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include the entire clinical team; failing of which the impact of the ESMOE training will be lost. The train-the-trainer method, whilst potentially effective, will be difficult to implement within the hospitals, as there are time constraints and concerns about the quality of the training in different units which will be trainer-dependent.

ESMOE will be co-ordinated and managed from corporate office and will be rolled out to the 44 Obstetric units utilising 2 master trainers only. They will travel to the different hospitals and will facilitate two day ESMOE courses. There are currently just on 600 staff that will be trained, and it will be compulsory for all midwives, professional nurses and enrolled nurses working in the Obstetric/Maternity units to be trained in 2017. By utilizing only 2 trainers the standards and quality can be maintained and a strict time frame and plan adhered to. All new staff joining MCSA will be required to have attended an ESMOE course within a specified time frame.

The ESMOE material and drills will not be changed for the private sector but the drills have been awarded points according to the Mediclinic Assessment Programme (MAP). This program is part of Mediclinic SA’s continued professional development and is a process of on-going competency assessments. ESMOE training will be awarded a number of MAP points and drill completion will be awarded with one MAP point, which will be added towards a yearly target.

The unit manager will be tasked along with the learning and development specialist to ensure that the drills are done and proof submitted monthly.

The percentage of staff successfully trained in ESMOE will be added to the Obstetric dashboard per hospital with a target of 100%. The second measure to be added to the dashboard will be the number of drills completed monthly per hospital. All this data will be automatically pulled from the data warehouse once loaded at the hospitals. All drills and training completed will be forwarded to the ESMOE administrators.

Whilst ESMOE will have a positive impact in decreasing adverse events, the ultimate goal will be to have both obstetrician and nursing team attending

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ESMOE training and doing drills as a team.

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WARD BASE OUTREACH TEAMS(WBOTS), PILLAR IN IMPROVING MATERNAL AND CHILD HEALTH: LESSONS FROM VHEMBE DISTRICT, LIMPOPO PROVINCE.

Shisana Baloyi 1 , Robert sirwali2, Tsakani Merriam Nefale3, Helen Mhinga4, Monica Mavhuti Machavana5.1Chief Specialist and Head of Clinical O&G Limpopo DoH, 2District Executive Health Manager Vhembe, Limpopo DoH 3District WBOT Co-ordinator Vhembe, Limpopo DoH 4DCST Midwife Vhembe,Limpopo, DoH 5.

Background.The delivery of effective quality maternal, children and women’s health services rely very strongly on a well-functioning primary health care system. To improve on the maternal, neonatal and child survival it is essential to reach every mother, newborn and child in every district using cost-effective interventions. WBOTs have been established as a component of the three strands of PHC re-engineering by the NDoH to strengthen and improve the functioning of PHC services and the district health system. The ward-based PHC outreach teams play a key role in delivering community-based MNCWH services to communities and household level, facilitate access to services at PHC and hospital levels. WBOTs are the first national attempt to formally integrate community health and care workers into the public primary health system. WBOTs were operational and functioning in the district health system in all the NHI sub-districts included in this study. Implementation of WBOTs began in 2011. These cadre of primary health care worker has been found to be effective.At the initial launching of the program the target for national coverage was to create about 7467 teams. By 2013 only about 1063 Municipal Ward Based Primary Health Care Outreach Teams (WBPHCOT) were established and reported their activities on the District Health Information System” (Department of Health. Annual Report 2013/2014:16).

Province District Year Sub-Districts

HealthFacilities

PopulationSize

Number ofHouseholds

Limpopo Vhembe 2013 165 1 294 722 335 2762013 Thulamel

a 69 618 462 156 594

2013 Makhado 67 516 031 134 889

Current WBOTs situations in Vhembe: 2014-2015/16(1) Total WBOT = (117 TEAMS X 6) = 1062(2) Total household =776790(3) Total number of WBOT required = 2877(4) Total number of household covered = 270(5) Stipend = R1600.00 per month Methods (6) More than a 1000 WBOTs members were included in the rapid review,

made up outreach teams of 110 of each led by an assistant or retired nurse. Researchers interviewed key informants, and held a focus group discussion in Venda, Tsonga and English with the WBOTs. Funders and community members were excluded.

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Program interventions by WBOTS: WBOTs are actively involved in campaigns, advocacy work and social mobilization around health, social, developmental and educational issues. They also are actively involved in networking and co-ordination with the government partner funders, NGO, CBO, and Traditional Health Care Practitioners and faith based organisations (FBOs) and to a limited extent with private sector organisations that provide services in communities especially the doctors who on NHI contract and owning limited private medical practice.WBOTs are engaged in education of community members, Traditional Health Care Practitioners and faith based organization about the current status of maternal and child health in Limpopo. Community is educated about maternal death; definition, causes, what can be done to reduce maternal mortality. Community Maternal death notification were initiated and monitored by the WBOT. Community were educated regarding issues about primary health care, importance of early ANC, postnatal visits care, HIV/TB information and encourage each member to know their HIV status, contraceptives choices, CTOP information –when, where, who it can be perform CTOP safely, promoting skilled birth attendance and discouraging home births, risk classification reduction by discussing the place of delivery and advising mothers who stay far to utilise maternity waiting homes in the hospital like Donald Fraser, exclusive breastfeeding, early referral of patients, motivating social workers intervention where necessary. Linking THP/FBH with Public Health Care Facilities and educating them about the dangers of the traditional herbal remedies mostly used in inducing labour. WBOTs negotiated with some of the patients who had Traditional Herbal Remedies to remove them from their possession and to encourage to stop using them until she has delivered. Establishing village health care watch groups within WBOTs who create a data of all pregnant women at the community, all HIV/TB patients and enforce compliance to treatment by Directly Observed Therapy (DOT). Promoting the access to reproductive contraceptive health services and for adolescents and adults, advanced maternal age, and those at risk of pregnancy related complications. WBOTs removed adverts about illegal abortion services and to report those to the authorities.

Observations:Community members trust the close and immediate service they receive from WBOTs, increasing their willingness to seek care, increasing the identification and management of cases such as hypertension, diabetes, un-booked pregnancies and child malnutrition. Preventable Maternal and perinatal deaths reduced significantly by 30% and 9% respectively.Maternal and perinatal morbidities were also reduced.

Highlights of Key Challenges and limitationsThis cadre faces challenging work conditions, constraining their potential to improve access to PHC services. WBOTs services are prone to be erratic or get disrupted as they depends on availability of funding from donors to get their stipend salary. All WBOTs employees must be accorded a status that is commensurate with the work they do. Community health and care workers should be considered as employees with the attended responsibilities, rights and benefits.

Conclusion and Lessons learned:WBOTs has identified considerable potential for ward based health care to substantially

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improve the health status of individuals, families and communities.Suggested to increase WBOTs area of community interaction to include the private sector organisations that provide services in communities (GP in cases like TOP) will add more value.

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QUALITY OF CARE: IS THERE CONSENSUS FROM WOMEN, HEALTH CARE PROVIDERS AND KEY INFORMANTS INTO WHAT CARE WOMEN WANT TO RECEIVE WHEN THEY ATTEND FOR BIRTH IN A HEALTH CARE FACILITY?

Jaki Lambert,1 Elsie Etsane,2 Nynke van den Broek,1 Anne-Marie Bergh,2 Robert Pattinson2 1 Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine2 SAMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoriae-mail address of author: jaki.lambert@gmail.com

Background : The World Health Organisation (WHO) defines quality of care as both the provision of technically competent care and the enhancement of women’s experience of care. (WHO 2016). Much of the focus of the Millennium development goals was on addressing those technical competencies, which remains an essential area of focus. however, in the drive to ensure a healthy mother and a healthy baby there is an increasing awareness that while that is the most important thing, ‘it is not the only thing.’ (Hill M 2015). With the focus on respectful maternity care to enhance women’s experience there is a need to identify what good quality care feels like from the perspective of the mother and understand if this differs from the perceptions of those providing or commissioning that care. While there are now educational approaches to improving women’s experience, it is important to not only think of this as a human rights approach but an essential part of enhancing birth physiology and therefore as important as any clinical approach. This will help in designing key questions for monitoring the care but also in ensuring that training is appropriate in addressing meeting the needs of women and families. This requires moving beyond an absence of disrespect and abuse, to find an asset based perspective to good quality of care.Research methods and designAim : The aim of the study is to understand what care women want in labour and is it different from what care providers believe women want. The findings will be used to develop key questions for monitoring women’s experience of care.Objectives

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To explore what quality of care and acceptability of care means from the perspective of both women, health care providers and key informants.DesignA qualitative descriptive study was carried out in Tshwane District, utilizing semi-structured interviews and focus group discussions (n=26). Participants included women of all risk levels and mode of delivery (n=18) who had given birth in the preceding 12 weeks in 4 hospitals in Tshwane Excluded from the study were women under 18, women who either did not wish to, or were unable to consent or who appeared too ill or unwell. A second group of participants included care providers of all cadres in the labour wards (n=16). Key informant interviews were conducted with (n=5) participants with an influential role regarding the care provided within health facilities. The sampling method was purposive and opportunistic to ensure that the sample chosen was representative of the chosen population. (Robson 2002)EthicsEthics approval was first gained from both the Liverpool School of Tropical Medicine (16-003RS) and the University of Pretoria (ref:81/2016). Individual permissions were then sought from all facilities identified for the study and from the Tshwane research committee(ref:09/2016).Data CollectionData collection methods included semi-structured individual or focus group interviews. The choice of method was determined by availability and by convenience to the identified participants, one to one interview was the preferred method as it elicited a richer level of data and reduced interruption. Women were invited to take part while they were waiting for appointments. Interviews took place in offices and consulting rooms off the main clinical area in order to preserve privacy, minimise disruption and allow for free discussion. Key informant interviews were prearranged at convenient times for the interviewees at one of the sites. An interview schedule was utilised for all interviews with the questions having similar content but with the questions appropriate to the participant group. An explanation of the purpose of the interview was given either in English or their preferred language and the patient information leaflet was reviewed and a copy offered to the woman. Consent was sought only after it was clear that the participant had understood the explanation and was happy

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to proceed, all interviews were audio taped. Interviews with the different participant groups continued until saturation was reached.Data AnalysisTranscriptions were independently reviewed by a second researcher and consensus reached over codes for analysis. The interviews were uploaded and coded in NVIVO 11 (mac version). The data was analysed using a framework thematic analysis, this methodology is used when analysing data from the perspective of informing health policy as opposed to from a more psychosocial perspective. The purpose was to deduce whether certain categories of acceptable care are confirmed and to use an inductive approach to identifying further categories (Gale et al 2013, Ritchie et al 2003). 5 interviews were open coded. Thirty-three codes were identified at this stage and categorised into seven categories. All interviewees were coded together as all participate in maternity services, separation into health care provider and recipient was carried out at the thematic analysis stage. An analytical framework of the seven categories: beliefs and attitudes; rapport/communication; human rights; organizational structures; leadership; professional issues; and use of mHealth (e.g. Momconnect/cell phone) was developed in excel. This facilitated analysis within and across categories to identify emerging themes: these were then examined to explore if they could be categorised according to existing frameworks and models (Freedman 2014, Bohren 2015).Results Tshwane: There were 33 codes identified which were then constructed into an analytical framework with 7 categories. Beliefs and attitudes, rapport/communication, human rights, organizational structures, leadership, professional issues, momconnect/mobile use. Seven themes were then identified across these categories. These were; 1. Alone and unsupported 2. Mutual Distrust due to Negative Perceptions. Media has influence 3. Paternalistic attitude to women in labour impacting on consent and choice 4. Procedure rather than patient centered, advocacy role of midwife not evident 5. Verbal abuse is normalized 6. Dissonance between knowledge and Practice and 7. Professional Hierarchy acting as a barrier to decision making and referral. In the previous paper on barriers to care all seven themes had a direct impact. In relation to women’s experience however, while all may impact

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on that care the women themselves receive, the woman is often not directly aware of the more organisational or professional factors just on the interaction between herself and her care provider. Therefore, in relation to her direct experience the following themes were key:1.Alone and unsupported: Companion throughout labour, while a known part of respectful care, this was not common practice and was negatively perceived by many care providers. It was the most important single intervention that could make a difference to women’s experience. Particularly when staffing is a challenge.The link was made to including men in antenatal education so that they too were prepared for labour and birth as their presence was often perceived as an additional burden due to lack of preparation.Partners should be educated at antenatal clinic with woman, so they can teach them what to expect. Line 28.p5 (nurse/mw) Tsh_N_FG5_H3_20160511There is a perception that it is valuable to link with communities both as a means of raising the profile of midwives in communities and reducing negative perceptions. The WOBOT is known about but as a means of following up patients, rather than a conduit for understanding what communities want or to advocate for communities. Of those women who did not want a companion, when explored further, it was clear that it was common practice for a companion only to be offered in second stage. The support and companionship was therefore absent, in two hospitals this relates to the structure of the ward, but not in all. Women understood that there was pressure on the staff and did not expect constant care however when a care provider took time with them it was appreciated.‘I was crying and I don’t know … the only thing good was the doctor who made time for me, she takes time and my heart was feeling so down, that was the only one. line 17 p1 Tsh_PNM5_11_H1_20160509 Women and care providers want to feel safe and supported; In valued attitudes and beliefs there was a difference between what women valued and what midwives valued or thought women valued. Women were most concerned with taking time, listening in order to develop a deeper understanding of the woman by asking questions. The welcoming nature of the midwives and a positive, friendly attitude was valued. There was

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some mention of a more abstract side to care in terms of having heart and prayer but also for care providers that their spirit requires support and sustenance to help cope with the daily challenges. Therefore, while both women and care providers described the same things, it was more about the feeling and the attitude that these action conveyed that was valued. This links to the limbic system being linked with labour, therefore making sense of care relates more to feelings and emotions rather than the language governed by the neocortex. (Swenson 2006)Feel comfortable, feel safer. People that know what they are doing. Tsh_PNM_FG2_H2_20160510‘I thought that people should have a heart. I know they are doctors but they need to have a heart.’ p3 line 1 Tsh_PMN5_11_h1_20160509 ‘They supported me and they listened to me, [wanted normal delivery after previous cs]. I was terrified about having another one. ‘line 10 p1 pnm 4 Tsh_PNM_FG2_H2_20160510Questions womenQ-were you welcomed into the labour ward?Q- Did you feel safe and cared for at all times?Q-Could you have a companion with you whenever you wanted one, in labour?2. Mutual Distrust: To overcome the Distrust and fear, women wanted to be reassured by their care provider. Therefore, how the carer communicates is key. Midwives and women both know that women want good caring communication.‘during training we are trained to greet the patients, ask their name, introduce ourselves. And that is what they do when they get here and then and then go to the patient every now and then and ask them are they fine, ‘Do you want water?’ ‘Do you want food?’, ‘What do you need?’ So that care, that is something, we must carry on doing because after training. We don’t usually do that anymore and that is the best care ever. It shows that people are concerned about you, people care about you, want to know about your wellbeing. Adv./MW Tsh_FG1_H1_20160509More than just words again it is the intention behind the communication that is important to women. This was more evident in H1.

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The nurses they treat us with respect, even the doctors they know how to talk to us and if we don’t understand something. Tsh_PNM4_11_H1_20160509Q: Did you feel reassured by those providing care?3. Paternalistic attitude to women in labour impacting on consent and choice. Women wanted to be treated with respect and as an individual, some midwives and key informants could clearly describe the appropriate care and attitude that reflected what women expressed that they wanted, this was particularly evident in hospital 1. ‘we need to inform them that in everything we do we need to involve them in the care they need to be part of everything we do because to me it’s a special.’ Tsh_KII2_II_H1_20160513‘you don’t understand something they will explain very nice’ Tsh_PNM4_11_H1_20160509 ‘They asked me permission and gave me a form to sign…... I think that is right then, I need to know everything before they touch me and explain to me each and everything that they are going to do.’ Tsh_PNM4_11_H1_20160509’ If you have a good sister who asks for permission, it feels good Tsh_PNM_FG3_H1_20160510When this was absent it was also clear that women then felt uninvolved in the process;‘I was afraid [pause]. Didn’t expect and didn’t get explanation and consent.’ Tsh_FG4_H2_20160510No one came to talk to me and tell me. Tsh_PNM5_11_H1_20160509They [nurses] didn’t explain anything, nothing at all. It’s only the doctors who come who explain anything. Tsh_PNM6_11_H1_20160509I had too many questions to ask them, but they didn’t give you attention. But they are too busy if they come to you, they will just come and just do their duties. So you don’t even have time to ask questions. They even tell you are not the only one there, they have other people. Tsh_PNM6_11_H1_20160509Therefore, taking time to listen and value the woman’s thoughts was important to her experience.Q-Did your care provider take time to talk with you so felt supported to make decisions about your care?

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4. Procedure rather than patient centred, advocacy role of midwife not evident.This was described as a staffing problem by most staff, therefore while they recognised that women wanted more care given they did not feel able to provide it. While staffing is an evident challenge, it was also noted by women and Key informants that there was a culture to spend time ‘at the nursing station’ if a procedure was not required. Midwives and key informant could list the known values of; explaining, consenting describing but more as a means of achieving a clinical procedure. Whereas women want a nurse with them particularly as a doula or support person this option was not there for them.‘want one nurse with you attending to you. That’s what I want’. Tsh_PNM1_II_H2_20160512 Think they are going to handle me like a queen but they didn’t [laughter] line 6 p1Tsh_PNM7_11_H1_20160

‘So when we are well staffed, I think you can go to patients and ask, ‘Are you okay?’ ‘Do you need some?’ So we don’t have enough time to do that; we concentrate on those things, ya’. Tsh_FG1_H1_20160509‘So because of that timeframe you know what you must do and you do it you say I am here to do 1, 2 3 and you do it and you leave you don’t explain why you want to do it because there is no time for that you need to attend to someone else so I feel I am not giving what I need to or what I would wish [emphasis] to be giving’. Tsh_N2_11_H2_20160513Being friendly …with your patients, understanding, there was a woman who understood me, they asked me cos my blood pressure was high, there was a woman who asked me was there something wrong, they didn’t keep me here because it was high they wanted the reason from me why was I stressing what was wrong to find out why it was high. Line 8 p3 Tsh_PNM3_11_H1_20160509

Q-was your care provider able to spend time caring for you other than during a procedure?

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5. Verbal abuse is normalized. Women were very clear about how they wanted to be spoken to, however, even when midwives recognized this, they believed that it was an essential part of care in labour to speak firmly, or as women said, to shout. Women described not being shouted at and being spoken to kindly and gently.‘They don’t need to shout at you. The shouting part [hesitates] it’s not okay! ‘Tsh_PNM3_II_H2_20160512‘I say that cos, I received respect, cos when I entered the door the other sister was next to me and they helped me to the bed and then they dressed me and ‘Please can you just open the legs, nicely, and hold it and just relax. The baby is on its way. Don’t push, just open it nicely and they touch my hand. Just open it; just help me to push this out.’ They were so nice’. Line 17 p2 Tsh_PNM7_11_H1_20160509‘It means a lot you know like when you talk with a polite voice it makes you calm, even if you feeling pain you understand’ Tsh_PNM1_11_H3_20160513

Q-were you spoken to kindly in labour with no shouting.6. Dissonance between knowledge and Practice This theme relates more to barriers to care; it highlights that care providers can often describe what is required but due to structural or organizational barriers are unable to provide it. Therefore, if this was improved, women’s experience would improve. Midwives could describe a positive birth environment.I think it should not be so much different from home situation. I think if there is a kitchen, there is a dining room, there’s a bedroom, then she’s used to that kind of situation and she can easily go around. Then she is comfortable rather than if there is a bed that she has to stay in the bed the whole time. Tsh_N_FG5_H3_20160511Both women and midwives recognised that if there was enough equipment then they could stay in the room and women also observed this as a positive‘I think everybody should be in his or her own room, with someone with you. Private. Without everyone looking at you while you are screaming! You can’t hold it, and in a comfortable bed with your own toilet. You don’t have to go out when you can’t even walk! ‘Tsh_PNM3_II_H2_20160512

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Q- Did the labour ward environment let you have privacy and comfort?Q-Did the midwife have to leave you alone to collect equipment ?7. Professional hierarchy acting as a barrier to decision making and referralThis was more linked to barriers than to experience directly. It may impact on care experience due to delay in care and decision making but the woman would not directly see this first hand. If at organisational level the role of midwife led care was advocated for, it may reduce women being dissatisfied when turned away from hospitals that are providing obstetric led care. This also relates to clarifying rights of access described in the Batho peli principles.Q- Did you have explained to you before labour, which hospital you should attend and why?Discussion:This study demonstrated that women and care providers both know what women want from care. For the care provider; staffing, culture, systems and environment impacts on her ability to provide everything that she knows women want, however women are also understanding of some of these challenges. By supporting and advocating for companions in labour and working with communities to promote the role and responsibilities of the companion this could be addressed. Notably, the language that women use to describe what they want relates more to the limbic system therefore; emotions, fear, safety are important while midwives describe care fro a rationale language based neocortical level. Therefore, if women are to experience good quality care, it needs to be addressed not just through the language of respect and rights but also so that it has a positive effect through emotions and reducing fear on the autonomic nervous system within the limbic system. This has the potential to impact not only directly on her experience but on the promotion of normal birth as impacting on the limbic system also impacts on the regulation of oxytocin through the hypothalamus.

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Conclusion:Women want to feel welcomed, cared for and to have support from care providers and a companion when they want one. The attitude and way of talking is very important and was of greater significance than what was said. There is a need to clarify referral pathways and rationale in context of rights, actively promote midwife led care and midwifery identity in advocacy for positive birth experiences and active birth in the media, with communities and with antenatal care. If hospitals display the things they cannot currently meet; private rooms, companions and where they are with improving it it would take responsibility from the midwife/nurse as the face of the hospital and improve rapport. Use of feedback will improve women and midwives voice and ownership of service.

Figure 2:factors impacting on experience of care

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SIZE-FOR-GESTATIONAL-AGE AND TIMING OF STILLBIRTHS IN THREE SOUTH AFRICAN PROVINCES (Click on title to access article in .pdf format)

Tina Lavin 1 , David B. Preen1 & Robert Pattinson21 Centre for Health Services Research, School of Population Health, The University of Western Australia; 2 SAMRC Maternal and Infant Health Care Strategies Unit, University of Pretoria

Background Evidence in high-income countries suggests that size-for-gestational-age may a play a role in the timing of stillbirths, however there has been little research in low-and-middle-income countries (LMICs). In particular studies to date have indicated that there may be a critical period for increased mortality for small-for-gestational-age babies between 28-36 week gestation. This study explored the timing of and cause of stillbirth by size-for-gestational-age in three South African Provinces: Western Cape (antenatal care visits occurred at booking, 20, 26, 32, 34, 36, 38weeks ), Limpopo and Mpumalanga (booking, 20, 26, 32, 38 weeks).

In Limpopo and Mpumalanga antenatal care visits occurred at booking, 20, 26, 32, 38 weeks; in Western Cape visits occurred at booking, 20, 26, 32, 34, 36, 38weeks.

Methods Secondary analysis of the South African Perinatal Problems Identification Program (PPIP) database allowed for the analysis of timing and primary cause of stillbirths (>1000g and >28 weeks) between October 2013 to August 2015. Comparisons by province, size-for-gestational-age, gestational age groups, and maternal condition at death were performed.

ResultsThere were 8111 stillbirths during the study period and 528727 live births. The greatest proportion of deaths for small-for-gestational-age babies occurred between 33-37 weeks gestation in all three provinces (52.9%; p<0.05), while for appropriate-for-gestational-age and large-for-gestational-age babies there was no increase during this time. No increase was seen in poor maternal condition for small-for-gestational-age babies and 54.9% of deaths had a healthy mother.

Conclusion The peak in stillbirths for small-for-gestational-age babies seen in all provinces between 33-37 weeks suggests that the current detection of small-for-gestational-age is inadequate even in Western Cape where frequent antenatal care visits occur. Detecting small-for-gestational-age is further complicated as in most cases the mother is healthy.

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CAUSES SECOND TRIMESTER MISCARRIAGES AS DETERMINED BY PLACENTAL HISTOLOGY AND AUTOPSY

Coen Groenewald a , FRCOG, Colleen Wrightb,c, FRCPath, Lucy Brinka, MSc, Pawel Schubertb,d, MD, Elaine Geldenhuysa, Nat Dip Med Tech, Hein Odendaala, and the PASS Network aDepartment of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South AfricabDivision of Anatomical Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africac Lancet Laboratories, Johannesburg, South AfricadNational Health Laboratory Services, South Africa

Objectives: To describe the placental histology and autopsy findings in pregnancies where fetal demise occurred before a gestational age of 22 weeks. Study design: This study was a subset of a larger study where the effect of alcohol exposure during pregnancy on stillbirths was studied. In a prospective cohort, 7,010 singleton pregnancies were followed from the first antenatal visit until birth. Gestational age was assessed by ultrasound, preferably at the first antenatal visit. All pregnancy losses were identified and when the fetus delivered at or after a gestation of 20 weeks, the mother or parents were approached for consent for autopsy. For this study, losses before 22 weeks gestation (second trimester miscarriages) were available to describe the placental pathology and findings at autopsy.Results: Fourteen cases were identified in which 13 had an autopsy and 12 histological examination of the placenta. The most prevalent histological abnormality was placental abruption which was seen in 6 miscarriages, occasionally on its own, or in combination with acute chorioamnionitis or maternal vascular malperfusion. The second most frequent finding was maternal vascular malperfusion, as found in five placentas, also as a single finding or in combination with others. The third most frequent pathology was acute chorioamnionitis, found in four placentas, in combination or alone. Other causes were diffuse chronic villitis due to cytomegalovirus infection and early amnion rupture with anhydramnios and cord obstruction.Conclusions: Causes of late second trimester miscarriages differ little from causes of stillbirth. There is value in placental histology in late second trimester miscarriages as a means of identifying cause of demise.

Financial Support: This research was supported by grants U01HD055154, U01HD045935, U01HD055155, U01HD045991 and U01AA016501 issued by the National Institute on Alcohol Abuse and Alcoholism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute on Deafness and Other Communication Disorders.

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PREMATURE INFANT CARE IN THE CONTEXT OF KANGAROO MOTHER CARE IN SOUTH AFRICA: LESSONS FROM THE FIELD

Elise van Rooyen1, Anne-Marie Bergh2

Department of Paediatrics, Kalafong Hospital and University of Pretoria; SAMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria

BackgroundKangaroo mother care (KMC) is considered one of the high-impact, cost-effective interventions in the care of low birth weight (LBW) and premature infants and is also a strategic priority of the national Department of Health in reducing neonatal morbidity and mortality. The aim of this presentation is to summarise some of the main issues regarding the care of premature infants in South African hospitals related to kangaroo mother care.

MethodsOver a period of 15 years, 109 hospitals in four provinces were visited and assessed by means of a standard tool measuring progress with the implementation of KMC. The open-ended items of the tool covered some of the important issues related to the care of premature infants and most visits also included an informal discussion with health workers on enablers and challenges. The information from 26 implementation workshops conducted in South Africa over the same period also informed the interpretation.

ResultsThe following themes will be discussed: • Organisation of services (lack of management support and available

human resources and support services; parameters for referral resulting in too few neonatal admissions and leading to skills loss)

• Organisation of neonatal space (poor architectural planning for neonatal units in new structures; problems with lodger mother accommodation; inappropriate chairs/beds; duplication of spaces and services for in-born and out-born infants with unequal quality of care)

• Organisation of work flow (care of newborns divided between different departments; poor work allocation of health professionals resulting in no one taking responsibility for KMC; medical and nursing rotations resulting in loss of trained staff)

• Professional attitudes and supervision (resistance; fear of small neonates; distrust of mothers; lack of sufficient supervision of mothers and babies in KMC)

• Guidelines, documentation and record keeping (previously few or no protocols for small newborns; insufficient contextualisation of guidelines; using only a weight parameter for discharge; no consideration for the potential complications with late preterms)

• Infection control (archaic principles of infection control in some hospitals)

• Discharge and follow-up (insufficient follow-up arrangements at the hospital or in the community)

Conclusion

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Although South Africa has made great strides in the implementation of KMC, much still needs to be done. One way is to conduct more quality improvement projects related to neonatal care in general and the care of LBW and preterm infant in particular, including improving KMC practice and the provision of KMC services. SUCROSE AS PAIN RELIEF: A RANDOMIZED CONTROLLED STUDY OF TWO DIFFERENT DOSES OF SUCROSE DURING VENIPUNCTURE

Laila Kristoffersen a ,b, Moelo Malahlehac, Zama Duzec, Eva Tegnanderb, Ndaye Kapongo c,d, Ragnhild Støena,b, Turid Follestade, Sturla Eik-Nesb, Håkon Bergsenga,b

aDepartment of Neonatology, St. Olavs University Hospital, Trondheim, Norway, bDepartment of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, NTNU, Trondheim Norway, c Pediatric Department, Neonatal Unit, Lower Umfolozi, Regional War Memorial Hospital (LURWMH), dKwaZulu-Natal university medical school, eDepartment of Public Health and General Practice, NTNU, Trondheim, Norway

Objective: The purpose of this study was to compare the effect of two different doses of sucrose on pain score during venipuncture in preterm and term infants. Methods: A randomized, blinded crossover study. Infants with a birth weight more than 1000 grams admitted to the Neonatal Intensive Care Unit at Lower Umfolozi Regional War Memorial Hospital, Empangeni, South Africa and St. Olavs University Hospital, Trondheim, Norway were enrolled in the study. During two consecutive venipunctures, the infants received 0.2 milliliter (mL) or 0.5 mL sucrose 24% in a randomized order. The infant received half the dose two minutes prior to blood sampling, and the other half immediately before sampling. Pain scores were measured twice using Premature Infant Pain Profile-Revised (PIPP-R). The first pain score (PIPP-R1) was obtained for 30 seconds immediately after skin puncture, and the second (PIPP-R2) was obtained 30 seconds immediately after the needle was removed. Results: The study included 53 infants with 106 venipunctures. The mean PIPP-R1 score was significantly lower when 0.5 mL sucrose 24% was used compared to 0.2 mL (6.83 versus 5.30; p=0.008). There was also a trend towards a lower mean PIPP-R2 score with 0.5 mL compared to 0.2 mL sucrose, but this difference was not statistically significant (5.40 versus 4.70; p=0.291).Conclusion: Better pain relief during venipuncture was provided with 0.5 mL compared to 0.2 mL sucrose in newborn infants. Further research is needed to determine the optimal dosing of sucrose during painful interventions in neonates.

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MATERNAL AND FETAL OUTCOMES IN THE CONTEXT OF OPTION B+ STRATEGY IN EASTERN CAPE: FINDINGS FROM PROSPECTIVE COHORT STUDY

Nonkosi Selanto-Chairman, Oladele Vincent Adeniyi, Gerry Boon, Daniel Ter Goon, Anthony Idowu Ajayi, Yusimi Ordaz Fuentes, Justus Hofmeyr, Craig Carty and Jack Lambert on behalf of the East London Prospective Cohort Study (ELPCS) Group

Background: We investigated the HIV-RNA levels at delivery in women on the highly active anti-retroviral therapy and examined the determinants of probable virological failure PVF. We also report the rate of in-utero transmission of HIV.Methods: Plasma samples of 1709 pregnant women enrolled in the PMTCT Database of the East London Prospective Cohort Study across three large maternity services in Eastern Cape, South Africa were used. Participants who had been on HAART for at least 16 weeks were sampled within 24 hours of delivery. Primary outcome measure was the rate of peri-partum viral suppression categorised as full suppression (lower than limit of detection), low level viraemia (VL=20-999 RNA copies/ml) and probable virological failure (VL≥1000RNA copies/ml). Secondary outcome measure was the rate of intra-uterine transmission measured as positive birth PCR. Results: Among all the participants (N=1709), 57.2% achieved complete viral suppression at delivery, 25.3% had low level viraemia and 17.5% had probable virological failure. Age ≤ 25 years, unemployment, pre-conception awareness of HIV status, prior default of HAART, self-report of poor adherence, partner disclosure, and on-time pick up of HAART, alcohol consumption during pregnancy and cigarette smoking during pregnancy were significantly associated with peri-partum virological failure. In multivariate (LR) analysis, after adjusting for confounding factors, prior default of HAART, pre-conception awareness of HIV status, unemployment and self-reporting of poor adherence were the independent significant determinants of peri-partum virological failure. We found 20 cases of in-utero HIV transmission (1.05%). Conclusion: Our findings suggest that the goal of prevention of mother-to-child transmission could be undermined by lifestyle behaviours and poverty in the study setting. Programmatic re-engineering and community engagement would be crucial for strengthening the PMTCT programme in South Africa.

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COMPARING MATERNAL TRIPLE ANTIRETROVIAL AND INFANT NEVIRAPINE PROPHYLAXIS FOR THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV DURING BREASTFEEDING

Taha T, Flynn P, Cababasay M, Fowler MG, Mofenson L, Owor M, Shapiro D, Fiscus S, Stranix-Chibanda L, Coutsoudis A, Gnanashanmugam D, Chakhtora N, McCarthy K, Mukuzunga C, Kawalazira R, Moodley D, Nematadzira T, Kusakara B, Bhosale R, Vhembo T, Bobat R, Mmbaga B, Masenya M, Nyati M, Theron G*, Mulenga HB on and the PROMISE Study Team*Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital.

Sponsors:US National Institutes of Health. The study products were provided free of charge by Abbott, Gilead Sciences, Boehringer Ingelheim, and GlaxoSmithKline.

Introduction:The vast majority of mothers in high HIV prevalence countries in sub-Sahara Africa breast feed their infants. Breast feeding (BF) is crucial to reduce infant morbidity and mortality but may result in HIV transmission if the mother is HIV infected. If ARV prophylaxis was not used, 9% of infants born HIV negative became infected through breastfeeding when continued to 18 months.1 At that time measures to address transmission of HIV during breast feeding were desperately required. The relevant question was which ARV prophylaxis regimen should be used? The Breastfeeding, Antiretroviral and Nutrition (BAN) study was designed and conducted Malawi to address the first 6 months of breast feeding.2

Standard of care neonatal twice daily AZT and lamuvudine for 1 week in the control arm were compared to two study arms, initiating women on highly active antiretroviral treatment (HAART) (2nd arm) or administering daily NVP to the infants (3rd arm). The transmission rate at 28 weeks amongst infants who were HIV negative at two weeks was: 7.6% in the control arm, 4.7% in the maternal HAART arm and 2.9% in the infant NVP arm. Compared to the control arm the maternal HAART arm (p=0.01) and the infant NVP arm (p=0.001) had significantly less transmissions. Daily NVP for infants during breast feeding became standard of care and included in PMTCT protocols.Goga and co-workers showed that during 2012-13 in South Africa the most rapid increase in postnatal mother-to-child transmission (MTCT) occurred during the 1st

6 months postpartum, followed by a gradual increase thereafter.2 The cumulative incidence increases to 4.3% by 18 months. Postnatal MTCT accounted for 39% of perinatal MTCT.

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Both maternal HAART (mART) and infant nevirapine (iNVP) are effective in preventing postnatal HIV transmission. The breast feeding arm of the Efficacy and Safety of Antepartum Antiretroviral Strategies to Prevent Perinatal HIV Transmission study (PROMISE 1077BF) is the first randomised trial designed to compare the efficacy and safety of these two strategies during extended breast feeding through to the second year of life.

Methods:PROMISE 1077BF is an open-label, randomized trial conducted in sub-Saharan Africa (13 sites) and India (1 site) to assess efficacy and safety of different antepartum, intrapartum and postpartum antiretroviral strategies for preventing perinatal HIV transmission. In the postpartum component of 1077BF HIV infected women with CD4 counts of more than 350 cells/mm3 (or the country-specific threshold for commencing HAART) and their HIV uninfected infants were randomised at 6 to 14 days postpartum to mART or iNVP. These regimens was continued until 18 months post-delivery unless there was cessation of BF, infant HIV infection or toxicity. Kaplan-Meier (K-M) probabilities and incidence rates per 100 person years were determined in the primary analysis of efficacy and safety.

Results:2431 mother-infant pairs were enrolled between June 2011 and October 2014. Women were asymptomatic (median CD4 count 686, 97% WHO Clinical Stage 1) with a median age of 26 years. Infant’s median gestational age and birthweight were 39 weeks and 2.9 kg respectively. Baseline characteristics were comparable by study arm. Median duration of BF was 15 months and not significantly different by study arm (p=0.85). K-M estimates of MTCT of HIV at ages 6, 9 and 12 months were 0.3% (95% CI 0.1-0.6%), 0.5% (95% CI 0.2-0.8%) and 0.6% (95% CI 0.4-1.1%), respectively and not significantly different between the arms. Infants 12 months survival was 98.9% and not significantly different by treatment regimen. Maternal and infant safety outcomes did not differ significantly (Table I).

Conclusions:Both mART and iNVP were safe and were associated with very low MTCT rates during extended BF with high infant survival rates. The cumulative transmission rate through to 6 and 12 months of age was 0.3% and 06% respectively.

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Mothers who do not adhere or tolerate ART and if mART are stopped due to severe ART adverse effects iNVP throughout BF offers a safe and efficacious alternative to prevent MTCT during breast feeding.

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Table I. Maternal and infant safety outcomes

Outcome mARV(n=1220)

Rate (95% CI)

iNVP(n=1211)

Rate (95% CI)

p-value(K-M log rank test)

Composite maternal safety endpoint(Grade 3-4 sign/symptoms; Grade 2-4 lab events, maternal deaths)

14.8(12.7 – 17.3)

14.6(12.5 – 16.9)

0.99

Composite severe maternal safety endpoint(excludes Grade 2 lab events)

5.1(4.3 – 6.1)

5.6(4.8 – 6.6)

0.61

Composite infant safety endpoint(Grade 3-4 sign/symptoms; Grade 2-4 lab events, infant deaths)

44.1(39.2 – 49.5)

43.5(38.7 – 48.8)

0.95

[Safety outcome incidence rates (per 100 person years) by study arm]

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BENEFITS OF FEEDING HUMAN MILK EXCLUSIVELY TO VERY LOW BIRTH WEIGHT INFANTS ADMITTED TO THE NEONATAL UNIT AT KALAFONG HOSPITAL

S.D.Delport,* P.J.Becker#*Dept of Paediatrics, Kalafong Hospital and the University of Pretoria (Retired)#Research Office, Faculty of Health Sciences, University of Pretoria

IntroductionFeeding human milk to very low birth weight (VLBW) and extremely low birth weight (ELBW) infants should be standard of care because of its advantages to the wellbeing of these vulnerable infants.1 Infants fed preterm formula in combination with human milk or only preterm formula have a nine- and twelve fold greater risk respectively for necrotizing enterocolitis (NEC) compared with human milk.2 If mother’s own milk (MOM) comprises more than 50% of the feeding volume within the first two weeks, the risk for NEC is decreased significantly.3 When MOM is in short supply, the availability of donor human milk (DHM) facilitates an exclusive human milk diet. NEC is associated with an increased risk of death and neurodevelopmental impairment.4 Additional benefits of human milk are prevention of hospital-acquired infections, a shortened hospital stay and a decreased mortality.4

Aim To determine the effects of feeding human milk exclusively to very low birth (VLBW) infants (≤1500g) admitted to the neonatal unit at Kalafong Hospital.

Patients and MethodsA cohort descriptive study was done with a retrospective analysis of data collected prospectively. VLBW infants admitted over a period of 11 years, divided into three consecutive epochs of 3.5, 4 and 4 years respectively were studied. The epochs were determined by the feeding strategy, i.e. mixed feeding (epoch 1) and feeding of human milk exclusively (epochs 2 and 3). During epoch 1, HIV-non-exposed infants received mixed feeding if MOM was inadequate while HIV-exposed infants received preterm formula. During epoch 2 human milk was administered exclusively. MOM was supplemented by DHM if indicated. In the absence of the mother, her infant received DHM for an arbitrary period of 14 days with the explicit objective to prevent NEC which peaks at 7-10 days after birth and because the supply of DHM was limited. After 14 days, preterm formula was administered if no MOM was available. The Kalafong

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Human Milk Bank (KHMB) was inaugurated in September 2016 (epoch 2) but with limited functional capacity due to inadequate staff. During epoch 3 improved proficiency of the KHMB facilitated on-site availability of an adequate supply of DHM. During the course of epoch 2, prevention of mother to child transmission (PMTCT) of HIV was rolled out which enabled the safe access of infants to MOM. The following maternal indicators were documented: pregnancy intention, maternal HIV infection, pregnancy-induced non-proteinurinc/proteinuric hypertension, HELLP syndrome, eclampsia, prolonged rupture of membranes (PROM), premature prelabour rupture of membranes (PPROM) and caesarean delivery. The indicators related to the infants were: birth weight (BW), admission to the neonatal intensive care unit (NICU), length of hospital stay, survival until discharge and death resulting from NEC and hospital-acquired septicaemia.

ResultsVLBW (≤1500g) infants (n=2016) admitted consecutively to the neonatal unit at Kalafong Hospital over a period of 11.5 years (1/1/2003-31/12/2014) were audited. Infants admitted between 1 July 2006 and 31 December 2016 were excluded to allow for a 6-month wash-out period during the initiation of exclusive human milk feeding. The study period was subcategorized into epoch 1 (1/1/2003-31/6/2006), epoch 2 (1/1/2007-31/12/2010), and epoch 3 (1/1/2011-31/12/2014) with 838, 871 and 907 admissions respectively. Of the mothers (throughout the study period) 60% reported the current pregnancy to be unintended, 30% were HIV-infected, 30% had pregnancy-induced hypertensive disease (PET, HELLP, eclampsia), 30% had PROM or PPROM and 65% had a caesarean delivery. Infants who died within 72 hours after birth were excluded from analysis because they would not have received a meaningful volume of human milk leaving 743, 778 and 801 infants in epoch 1, 2 and 3 respectively. ELBW infants comprised 18% (131/743), 20% (156/778) and 29% (232/801) of the infants in epoch 1, 2 and 3 respectively. The birth weight (BW) had a decreasing trend with more ELBW infants in epoch 3 vs epoch 1 (P < 0.001, 95% CI: 1.5 – 2.4). Admission to the NICU decreased from 47% during epoch 1 to 35% during epoch 3 for LBW infants and from 82% to 76% for ELBW infants during epoch 1 and 3 respectively. Survival of LBW infants (mean BW 1277g, SD 153) during epoch 1 was 93% vs 95% in epoch 3 (mean BW 1290g, SD 154)(P < 0.05). Survival of the ELBW infants was 64% during epoch 1 vs 75% during epoch 3 (P = 0.02).

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Of the total number of deaths during epochs 1 (N = 85) and 3 (N = 81), the preventable deaths (NEC and hospital-acquired septicaemia) comprised 44/85 (52%) and 30/81 (38%) (P = 0.02) respectively. Of the preventable deaths (N = 44) during epoch 1, NEC comprised 15/44 (34%) versus 3/30 (10%) during epoch 3 (OR = 0.02, 95% CI 0.52 - 0.88). The median length of hospital stay for all VLBW infants was 31 days (range 4 – 130 days) for epoch 1 versus 37 days (range 6 -122 days) for epoch 2. During epoch 3 the median length of hospital stay was 35 days (range 5-133 days). For the infants ≥1000g the median length of stay was 31 days (range 4 – 130 days) during epoch 1 versus 28 days (range 5 -121 days) during epoch 3. For ELBW infants the median length of hospital stay was 55 days (range 31 -130 days) during epoch 1, 67 days (range 31 – 122 days) during epoch 2 and 65 days (24 – 133 days) during epoch 3.

ConclusionsSurvival of VLBW infants improves after the introduction of an exclusive human milk diet. An improved survival is also demonstrated in ELBW infants. Fewer VLBW infants are admitted to a NICU. Deaths resulting from NEC and hospital-acquired infections are decreased due to a decrease in deaths resulting from NEC. ELBW infants have a decreased duration of hospital stay as well as infants with a BW between 1000g and 1500g.

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FACILITATING THE USE OF DONOR MILK IN RESOURCE LIMITED SETTINGS THROUGH THE DEVELOPMENT OF THE PIASTRA, SIMULATED FLASH HEATING, PASTEURISATION SYSTEM

Penny Reimers 1 , Brodie Daniels1, Anna Coutsoudis1, Philip Barlow2, Noel Powell11 Dept Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa.2 iThemba Lethu Breastmilk Bank, Durban, South Africa.

IntroductionSeveral less developed countries have large numbers of orphaned and abandoned infants unable to access breastmilk, thereby being deprived of these benefits, which are vital in vulnerable communities. Concerns about wet nursing and sharing unpasteurized breastmilk have made it difficult to meet these orphans’ needs since traditional pasteurisation processes used by Human Milk Banks (HMBs) are expensive. In addition, smaller hospitals in rural settings are also unable to access donor milk for low birth weight babies in NICU’s due to accessibility challenges and cost. Recently, PATH and University of Washington, Seattle, developed the FoneAstra, a cell-phone–based, simulated Flash Pasteurization system, in order to fill this gap [1].Given the costs and constraints of using android phones in resource-limited community settings and hospitals, the objective of this research and development (R&D) project was to modify the FoneAstra by replacing the android phone with cheaper, off-the-shelf, Raspberry Pi technology with an easy to use touch screen and to test the safety of this pasteurization device in its efficacy of destroying bacteria and its effect on IgA, an important immune factor present in breastmilk which is known to be affected by heat. Secretory IgA accounts for 90% of total immunoglobulins in milk, and plays an important role in passing on antibodies to the infant in response to specific antigens which the mother has been exposed to [2,3].

MethodologyStandard R&D procedures were used to develop the device. Two device temperature settings were tested for optimising the system (71.5°C and 72°C). Efficacy of the pasteurization was tested by the NHLS by culturing breastmilk samples (from 45 different donors) on 5% horse blood agar and incubating for 24 hours.

The procedure for microbiology testing is as follows:

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Thawed frozen breast milk samples are gently mixed before processing.

A sterile pipette is used to inoculate 100ul of breastmilk sample onto the surface of a blood agar plate.

Using a sterile spreader, the inoculum is spread over the entire surface area of each plate and allowed to dry on a level bench, facing upward.

Once dry, the plate is inverted and incubated at 37°C in a CO2 incubator aerobically, for 24 hours. The agar plate is then examined for growth.

If no growth is observed, it is reported as “No growth”. The donor milk is cleared for use.

If growth occurs, it is reported as “Bacterial growth detected”. The donor milk sample must be discarded [4, 5].

Retention of IgA was tested using an ELISA assay (Abcam) and reported as percentage of controls (medians with confidence intervals [CI]).

Results

Figure 1. The Pi Astra pasteuriserThe new device (PiAstra)

was successfully developed at a lower cost and installed in 2 community-based HMBs; and 3 rural hospital NICUs. The mobile nature of the device also made it possible to install in 3 NICUs in Ethiopia. The PiAstra pasteuriser proved effective in destroying all bacteria in the 45 samples of breastmilk. Retention of IgA was 47.1% (CI: 37.5 – 49.0) and 45.4 (CI: 33.6 – 57.9) for temperature settings of 71.5 and 72°C, respectively (See Figure 2).

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Figure 2. Effect of simulated FH on the retention of immune components expressed as percentage retention.

While the retention of IgA was not significantly different between the two temperatures, our data showed that pasteurising with the system set to remove the milk at 71.5°C resulted in the milk being heated to 72°C for a mean time of

30.7 seconds (sec), while setting the pasteurizer at 72°C resulted in the milk being at 72°C for a mean time of 40.2 sec. Since the lower temperature

was adequate for destroying all bacteria and provides better retention of IgA, this temperature setting will be used on all new devices (See Figure 3).

Figure 3. PiAstra temperature data

ConclusionThe availability of a simple, easy to use, low cost, bench top, mobile device, simulating flash pasteurisation, provides opportunities for communities and NICU’s to give safe breastmilk to orphaned/abandoned infants and low birthweight infants in low resourced settings and rural hospitals. Promoting the use of donor milk when breastmilk is not available promotes breastfeeding in the general population, improves outcomes for vulnerable infants and reduces the incidence of necrotising enterocolitis in low birth weight.

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OPPORTUNITIES AND IMPLICATIONS FOR PERINATAL SERVICES ARISING FROM RECENT SCIENTIFIC ADVANCES IN EARLY CHILDHOOD DEVELOPMENT (ECD) AND THE NATIONAL INTEGRATED ECD POLICY: MOVING FORWARD – EXPERIENCE FROM THE WESTERN CAPE FIRST 1000 DAYS INITIATIVE

E Malek*, H Goeiman**, T Naledi**, M Champion**, E Arends***Department of Paediatrics and Child Health, University of Stellenbosch ** Western Cape Provincial Department of Health

IntroductionRecent advances in neuroscience highlights the critical importance of the window of opportunity from conception to the 2nd year of life to protect and enhance infant early brain development and has clear implications for optimizing perinatal services. The Western Cape Province has embarked on a transversal First 1000 days Initiative (led by the Western Cape Health Department) which aims to ensure that every pregnant woman and child is nurtured and parents and care-givers are supported from conception onwards, especially the most vulnerable, through a whole of society approach, so that children can achieve their full potential throughout their life course. The new National Integrated ECD Policy of 2015, launched in 2016, provides an enabling context for strengthening such endeavors in South Africa, as has been done in other countries.

MethodsA review of current models of care was performed to advise reshaping current perinatal services in relation to two key Western Cape Provincial processes: (i) A transversal 1st 1000 days theory of change (TOC) process was embarked upon with provincial project leads and representatives and key partner stakeholders and articulates the complexity and critical elements of First 1000 Days project Manifesto that: “Relationships Matter Most” It unpacks interrelationships explicitly in relation to the ecological model as well as social determinants. (ii) A comprehensive 1st 1000 days situation analysis was undertaken by the Western Cape Provincial Department of Health using the Survive, Thrive and Transform framework. To improve outcomes of the 1st 1000 days an overall Survive, Thrive and Transform systematic intervention framework with accountability outline was developed and adopted for implementation of seven key priorities identified in the systematic review, which include the development and implementation of an appropriate First 1000 Days Package of Care (POC)

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across the care continuum, the improvement of maternal and child wellbeing by initiating inter-sectoral health promotion programmes and the implementation a clear communication and engagement strategy which engages all stakeholders. Three key strategies were identified, namely, provincial-wide clinical care interventions, community based interventions and advocacy and liaison to improve social determinants.

To inform the package of care redesign, a review of key documents was performed to identify key pointers with respect to optimizing perinatal services, which included the recently published Lancet Series on Early Childhood Development (4 Oct 2016), the National Integrated Early Childhood Development (ECD) Policy (2015), and the Healthy Child Programme (UK).

ResultsKey Practices arising from the review:

(i) Neuroscientific Advances (Advances in ECD, Lancet Series, October 2016):

Nurturing care: Three intervention packages are put forward, namely (i) Family support and strengthening package, encompassing the 3 main elements of Services (eg families’ access to quality health services), Skills building (eg responsive nurturing care and reduction of harsh discipline), and Support (eg social protection, safety networks and family support policies); (ii) Caring for the Caregiver package, which emphasizes care and protection of parents’ physical and mental health and wellbeing (starting before birth) while enhancing caregiver’s capacity to provide nurturing care to their child, and (iii) Early learning and protection package (for ECD centres and parents)

Enabling Conditions: National policies can expand enabling conditions for families to provide nurturing care by allowing (i) more parenting time (for example maternity and paternity leave, breastfeeding breaks at work and leave to look after sick children) and (ii) resources (such as cash transfers eg CSG/pregnancy grant, health insurance, minimum wage and free pre-primary education)

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Country examples: The Chile CCC model is a fully government funded program implemented since 2007 and guaranteed by law from 2009, which combines health services, community-based parenting support and preschool learning from gestation to 4 years of age in all 345 municipalities. The Ministries of Social Development coordinates with the Ministries of Health and Education. It uses prenatal care in public health facilities as its entry point, providing universal as well as targeted services to ensure that children younger than 4 years living in a family with risk factors for poor early development also have access to age-appropriate stimulation and education and that their families are referred to additional social protection services including cash transfers and home visits, and provides high quality information about CD to families and providers through media such as TV and a website.

Role of Health Sector The Global Strategy for Women’s Children’s and Adolescent’s Health provides the health sector with an approach to move beyond only the ending of preventable deaths (survive) towards ensuring health and wellbeing (thrive) and expanding enabling environments (transform) to realizing the right to health and wellbeing.

Rapid scale-up is possible The example of UNICEF/WHO Care for Development (CCD) is highlighted:Developed as a module of IMCI, it is compatible with health service delivery in LMIC’s and community workers are trained to help parents become aware of young children’s emotional and learning. They encourage, model, promptand praise mothers and caregivers to talk to and stimulate young children.

Galvanising political will for ECD in the Global STG’s The SDG Goal 10 aims to help children at risk to attain their developmental potential, thus reducing equality among and between countries.

(ii) National Integrated Early Childhood Development (ECD) Policy (NDSD, 2015):

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Key Policy Positions: - Age Coverage: the policy shifts the starting age for promoting child development to conception - Parental support starts before birth: Provision of parent support - material, psychosocial, health and educational - starting in the antenatal period - First 1000 days program to be led by Health: Health care and nutrition programs are mandated to take the lead role for ECD services from conception to 2 years- Risk screening and supportive services for pregnant women, mothers and young children with respect to mental ill-health, substance abuse, exposure to violence, developmental delays and disabilities and abuse/neglect of a child- Social protection, Parent Support, Early Learning and other measures

5 Key Programmatic Priorities: - Support for pregnant women, new mothers/fathers and children under 2 years of age to be led by Department of Health- Review and Strengthening of National Food and Nutrition Strategy for children under 5 years of age- Provide universal early learning opportunities for young children from birth- Inclusion of children with disabilities in all ECD- Public communication on the value of ECD and ways to improve children’s resourcefulness

(iii) UK Healthy Child Programme (HCP, 2009) (www.dh.gov.uk/publications)• A single Universal Pathway covering preconception to 5 years of age

that delivers the core elements of the HCP with a focus on parent support as well as health surveillance.

• Criteria based targeted Programmes (Universal Plus Pathways & Universal Partnership Plus Pathways): - Program 1: Antenatal (from Notification of pregnancy to New Birth)

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- Programmes 2-8: (from New Birth to 5 Years old): Nutritional Healthy Start, Parental Mental Health, Infant Mental Health, Parenting Support, Early Childhood Development, Vulnerable Families, Safeguarding

Key to the HCP is a home visiting programme with 5 scheduled parenting review visits (during antenatal care, within 2 weeks of birth, at 2-3 months of age, at one year of age and at 2-2.5 years of age), during which parental and family risk and resilience factors for child health and development are reviewed in the context of a trust relationship between a well-supported nurse home visitor and the parent/caregiver that in turn supports the relationship between the parent and the infant.

ConclusionA draft model template for reshaping perinatal package of care service in the context of the Western Cape Provincial First 1000 Days Initiative is being developed (Figure 1), informed by the findings of the review as follows:

Key Design Principles for a Perinatal Package of Care include: - Acceptance of “Relationships matter most”, respect and empathy- Understand that “Early means Early” means starting from conception- Starting with what we have: - eg: Momconnect, Road to Health Book- Optimise and mobilise support (referrals and partnerships) at key milestones: eg notifications of pregnancy and birth, key review visits- Ensure risk and protective factor review and referral - Develop universal AND targeted packages of care - Map intersectoral links to care and support (parenting, community, government & non-governmental services) and provide these to clients- Adopt a participatory learning approach- Develop new measures for Thrive and Transform (“Wellness Index”)

Priority Areas for Perinatal Services - Screening for maternal/parental psychosocial risk and protective factors: tools, capacity & referral pathways for psychosoclal care & support- Build Listening and Motivational Counselling skills (CHW, counsellors)

- Invest in and support CHW home visits to build relationships with parents - Provide quality postnatal and well baby care

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- Designate parent review visits and provide parenting resources and support

Core Elements of the Package of Care - within Health: - Prenatal: planned pregnancies, risk screening, support- Pregnancy confirmation: risk screening & support, CHW support- Antenatal (>28 weeks): antenatal parenting support (review visit or group), risk based CBS home visits/ info/preparedness /CSG access- Intrapartum: respectful delivery, birth companion, - Postnatal: breastfeeding & psychosocial support, risk based CBS home visits, mother-infant responsiveness, child care, transition to child services, birth notification & registration, CSG application, review visit (2 weeks) - 6weeks -6 months: breastfeeding protection, growth monitoring, early learning, parent support, risk based CBS home visits, review visit (2 months)- 6months-2 years: complementary feeding, care-giver/parent info & support, early learning, risk based CBS home visits, review visits (1 year, 2-2.5 year)

Core Elements of Package of Care – role of other sectors: - Pre-pregnancy: Dept of Education: school curriculum, adolescent agency- Pregnancy: Dept of Education: prevention of and support for teenage pregnancy and breastfeeding; Dept Social Development: family support, material support; Local Authority: eg mom & baby library /ECD groups- Birth: registration: Home Affairs, SASSA/DSD: CSG provision- 0-6months: social protection, parent services, skills & support, workplace breastfeeding support; mom/dad and baby library groups, water & sanitation, clean fresh air, safe spaces, quality day care- 6mnth-2 years: above plus quality early learning access, safe spaces, road and home safety

Figure 1 Model draft template for perinatal package of care redesign (incomplete)

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MODELLED EPIDEMIOLOGICAL DATA FOR CONGENITAL DISORDERS IN SOUTH AFRICA

H Malherbe

Congenital disorders (CDs) are a common, costly and critical health issue that are yet to be prioritised as a health care issue in South Africa. Defined as abnormalities in structure or function, including metabolism, present from birth, CDs include chromosomal disorders, congenital malformations, single gene disorders, teratogens and disorders with multifactorial causes. While some of these are obvious at birth, others only manifest later in life. Serious CDs may lead to death or lifelong disability.

Terminology ConfusionThe use of inequivalent terms and definitions related to CDs has caused global confusion (4-6). In 2006, international agreement was reached by the World Health Programme (WHO) and the March of Dimes on the use of the synonymous terms ‘birth defects’ and ‘congenital disorders’, as defined above. However, use of various inequivalent terms, such congenital anomalies (macroscopic structural abnormalities) continues, both home and abroad. In the 2015 Edition of the National Guidelines for Maternity Care, 14 different, non-equivalent terms were used to refer to CDs. Congenital anomalies are essentially equivalent to the International Classification of Diseases 10th Revision (ICD-10) Chapter XV11 Congenital Malformations, deformations and chromosomal abnormalities, which excludes approximately 40% of CDs - including single gene disorders and environmentally caused CDs which are covered elsewhere in the ICD-10 system. Congenital anomalies and other inequivalent terms are used interchangeably in the literature, incorrectly, to represent the totality of CDs. In addition to uncertainty, this contributes to underreporting of CDs and prevents comparison between datasets.

Congenital Disorders in South AfricaModelled estimates indicate that CDs affect 6.8% or one in 15 live births in South Africa. Of these, 80.5% are caused by genetic factors and 19.5% by teratogens. Many remain undiagnosed due to the lack of qualified clinicians and available infrastructure to identify, diagnose and treat CDs. Although 30% of those affected by serious CDS will not survive regardless of intervention, up to 70% of CDs can be prevented or treated. For 40% of those affected this includes

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lifesaving or curative treatment, mainly through surgery for conditions such as club foot, cleft lip and/or palate, congenital heart disorders etc, and for the remaining 30%, rehabilitative or long-term therapeutic treatment can mitigate disability enabling an improved quality of life. Health measures for the care and prevention of CDs, termed medical genetic services, aim to ‘help people with a genetic disadvantage to live and reproduce as normally as possible’ and include early and accurate diagnosis, long-term and anticipatory care, genetic counselling and psychosocial care. In South Africa (SA) these services have declined in the past 25 years due to competing health priorities, especially HIV/AIDS and concomitant TB, which have redirected funding and government commitment. Misdiagnosed and untreated CDs result in patients not receiving relevant and often lifesaving care, and resulting deaths may be misclassified, leading to underreporting. This leads to an inaccurate and underestimated assessment of the contribution of CDs to the disease burden, preventing CDs and the relevant services from being prioritised appropriately, see Figure 1.

UnderreportingEmpiric data obtained through surveillance and monitoring are lacking in SA and despite the use of a standardised tool since 2006, CDs are underreported by over 98%. Without these empirical data, prevalence rates for specific CDs in SA cannot be established and the true contribution of CDs to the disease burden cannot be accurately assessed. This further contributes to the lack of recognition for this health care issue (Figure 1).

Figure 1 The cycle caused by the underestimation of CDs (20)

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Observed empiric data are necessary to obtain political commitment and funding to develop targeted medical genetic services at a local, regional and national level. Improved surveillance of CDs has been urged internationally, including through World Health Resolution (WHA) 63.17 of 2010 which recognised the contribution of CDs to neonatal deaths.

Modelling: The Modell Global DatabaseModelling offers a viable option to provide estimated figures, until improved surveillance systems can make good this shortfall – enabling informed policy making and health needs assessment to proceed so that relevant services can be developed where empiric data are lacking. In 2006, the March of Dimes Global Report on Birth Defects included a summary of a database (now known as the Modell Global Database - MGDb) with the first global estimates of birth prevalence data for serious genetic/partially genetic birth defects. This used data from well-established surveillance systems and registries with stable data over an extended period verified with other sources to generate baseline estimates of country-specific birth prevalence. The 2006 MGDb report filled the gap due to inadequate birth prevalence data for CDs at a national and global level, particularly for middle and low income countries, and has recently been updated and the methodologies documented.

The South African Modell Global Database

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Lack of prioritisation

Neglected services

Non-diagnosis & mis-

diagnosis

Inadequate data

Underreporting

Underestimate of CD burden

A long-term intention of the MGDb has been to expand the modelling method to develop sub-national estimates generated by individual countries using locally sources demographic data. This study used the MGDb modelling methods to quantify the CD burden of disease in SA for 2012. The MGDb, which uses birth prevalence data from well-established surveillance systems, was used with local demographic data to generate baseline country estimates for specific categories of endogenous CDs in the absence of care. The actual birth prevalence (factoring in available care) was then estimated using the MGDb approach to evaluate the effect of present interventions (in 2012) compared with baseline estimates. Access to relevant health services, and so the impact of interventions, was quantified using the infant mortality rate (IMR) as a proxy. Specific demographic data sources used are detailed in Table 1.

Conditions includedFour groups of early onset CDs (presenting before the age of 20) with mainly endogenous causes were included in the MGDb-ZA, including: Single gene disorders (autosomal dominant, autosomal recessive, sex-linked single gene disorders and consanguinity related disorders); chromosomal disorders (Down syndrome, other trisomies, rare autosomal chromosomal disorders and sex chromosomal disorders); non-syndromic, isolated congenital malformations (neural tube defects, congenital heart disease, oral facial clefts, potentially fatal other malformations and non-fatal other malformations); and additional conditions (congenital hypothyroidism, pyloric stenosis and prematurity associated persistent patent ductus arteriosis). CDs caused by post-conception causes, non-genetic CDs with a functional effect, later onset single gene disorders and disorders due to genetic risk factors were excluded.

Table 1. Details of South African demographic data indicators required and sourced in the South African MGDb (MGDb-ZA).

Indicator Data source Civil Division

National Total or Rate

Population (1 000s) CARe projection model1

Provincial 52 261

Annual (live) births (1 000s) CARe projection model1

Provincial 1 169

Infant mortality rate CARe projection Provincial 28/1 000 LB1 Professor Rob Dorrington, Centre for Actuarial Research, University of Cape Town, Personal Communication.

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model1

Under-5 mortality rate CARe projection model1

Provincial 46/1 000 LB

Mean life expectancy CARe projection model1

Provincial 62 (male & female)

Total fertility rate Dorrington & Moultrie 2015 (23)

Provincial 2.5

Sex ratio at birth CARe projection model1

Provincial 1.02

Stillbirth rate Cousens et al 2011 (24)

National 20.4 /1 000 births

Neonatal mortality rate 40% IMR5 Provincial 11.3/ 1 000 LB Crude birth rate CARe projection

model1Provincial 21.9

Percentage urbanized CARe projection model1

Provincial 63%

Percentage mothers aged 35+2

CARe projection model1

Provincial 13%

Coefficient of consanguinity (F)3

Modell et al 2016 (6) National 0.0007

IMR adjusted for HIV/AIDS 7 Johnson et al 2016 (25)

Provincial 25

IMR adjusted for HIV/AIDS and consanguinity

Modell et al 2016 (6) & Johnson et al 2016 (25)

Provincial/National

24

ResultsBaseline estimates (in the absence of care) for 2012 indicated a birth prevalence of 30.5 affected births per 1 000 live births. Half of the affected 35 675 births died under-5 years, with 25% (n=9 535) dying in the first month of life. The modelling was repeated applying the calculation with access to care, which was estimated at 30% based on the IMR. Of the 34 040 affected births, 10 320 received care and 23 585 received no care. Pre-conception and pre-natal interventions prevented 1 860 affected births and the birth prevalence was reduced by 1.1 per 1 000 live births to 29.4 per 1000 live births. Overall survival at five years increased by 12% (n=3 235), with 5 010 under-5 deaths prevented. Deaths from CDs during the neonatal period were reduced by 3 060. 2 Percentage of mothers aged 35+ is required for calculating estimates for chromosomal disorders.3 Coefficient of consanguinity and HIV/AIDS related mortality are required to adjust the IMR for use in the calculation of access to service.

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The MGDb-ZA estimates that 49% of neonatal deaths were due to CDs (with access to 30% services). This proportion is higher than the 10% recorded by the Perinatal Problem Identification Programme (26), which includes congenital anomalies only. The accuracy of the modelled data generated by the MGDb-ZA is dependent on the quantity of the available literature and the demographic data inputs and will be further refined along with the modelling methods.

Limitations

The MDGb-ZA modelled estimates for a sub-set of CDs only (early onset, endogenous CDs as specified).

Estimates cannot be compared with the 2006 database due to the changes in modelling methods and different sources of demographic data used.

The lack of available empiric data required the use of a uniform consanguinity adjustment to be applied to the IMR across all provinces, which may result in an overestimate of adverse outcomes for consanguinity associated disorders.

The MGDb-ZA uses demographic denominators for live births only as reliable stillbirth data is scarce – which leads to a modest underestimate of the affected births calculated (6).

Provincial estimates were used for neonatal, infant and under-5 mortality rates due to the incompleteness of vital registration data (see Table 1).

ConclusionThis study indicated that the number of lives affected by CDs – the disease burden - is much higher than the number documented through national surveillance. It has dispelled the myth that ‘little can be done’ to treat CDs by demonstrating the number of lives that can be saved through access to services and prevented through relevant interventions. With the increase in survival of those affected by CDs comes a greater proportion living with disability and requiring therapeutic treatments and rehabilitation. This highlights the need for increased commitment, capacity and resource allocation for the care and prevention of CDs through the provision of comprehensive medical genetic services, including improved surveillance.

With over 40% of under-5 deaths occurring during the neonatal period and CDs contributing a growing proportion of these deaths as both the infant mortality

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and neonatal mortality rates decrease, more needs to be done during this critical period of early life. Early diagnosis and appropriate care may help reduce CD-related deaths, many of which are preventable and contribute towards achieving the Sustainable Development Goal 3 target of an Under-5 mortality rate of 25 per 1000 live births by 2030.

This study highlighted the utility of modelled data in profiling the disease burden of CDs in SA, and the impact of medical genetic services in reducing mortality and improving the quality of life of those affected. Further study includes analyses of modelled estimates (a) for specific CDs, (b) in specific provinces of South Africa, and (c) costing of specific interventions.

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THE KNOWLEDGE OF BASIC NEONATAL RESUSCITATION AMONG MIDWIVES AT DISTRICT HOSPITALS

Fezeka Mafisa Nursing Service Manager: Mother & Child Cluster - Steve Biko Academic Hospital, Pretoria, Gauteng, South Africa

INTRODUCTIONGlobally there is an increase of neonatal deaths resulting in part from intra-partum asphyxia or hypoxia related to ineffective neonatal resuscitation at birth. Midwives can play a pivotal role in reducing neonatal deaths. The researcher was concerned about an increasing rate of early neonatal deaths, in the Chris Hani Health District, Eastern Cape.

Consequently, a multi-pronged approach was put into place by the district, to address neonatal mortality by means of training midwives in basic neonatal resuscitation. The resulting question was whether the Chris Hani Health District midwives have the ability to conduct deliveries with the required knowledge in neonatal resuscitation, which could improve neonatal outcomes.

RESEARCH METHODOLOGY

Research Design

In this study, a quantitative non-experimental and descriptive

approach was employed in order to realise the objectives of this

study. The study also established correlation between the level of

training, qualifications and experience of midwives and their

knowledge level regarding basic neonatal resuscitation.

Population and sampling

The target population of this study was all permanently employed

registered midwives, allocated in 13 maternity wards of the

district hospitals of the Chris Hani Health District (N=145 in March

2015); excluding community service practitioners as they were

rotated every 2 to 3 months in all wards. Due to the relatively

small population size, the researcher chose to select the total

population of all midwives working in maternity wards in the Chris

Hani Health District hospitals.

Data collection

Data was collected in the 12 district hospitals for three months

from the 4th of January to the 31st of March 2016; as the 13th one

was used for pilot study in December 2015. The accessible

population was only 124. The total number of midwives who

completed the questionnaires was 117, which excluded the seven

which were used in the pilot. The total number of captured

questionnaires for data analysis was 110. The response rate of the

participants in completion of the questionnaire was 94%.

Instrumentation

A structured self-administered questionnaire was developed

specifically to collect biographical data and determine the

knowledge of basic neonatal resuscitation. The researcher

designed appropriate question items which were intended to

measure midwives’ understanding of basic neonatal resuscitation

with regard to their knowledge as outlined in the WHO Guidelines

on Basic Newborn Resuscitation, Perinatal Education Programme

– Newborn Care, National Guidelines on basic neonatal

resuscitation and the HBB training manual.

- Section A: Biographical data included gender, age, race, marital

status, highest qualifications in midwifery, professional position in

the unit/area, service experience of the midwives, training as well

as participation in neonatal resuscitation.

- Section B: 22 multiple choice questions and one scenario

whereby participants were expected to sketch the sequence of 4

steps in the application of HBB. The knowledge questions were

used in evaluating knowledge on the preparation for birth and

identification of neonates requiring assistance; including

appropriate decisions and actions related to drying, warming,

airway clearance, stimulation and bag and mask ventilation

techniques during neonatal resuscitation.

A questionnaire was envisaged to be time-effective when dealing

with the bigger sample size of this study, easier to administer and

had minimal bias on the part of the researcher in the analysis and

interpretation of results.

Data analysis

The raw data was captured on an Excel worksheet by the

researcher and analysed with STATA (version 13) program by a

statistician at the Biostatistics Unit, Stellenbosch University.

Application of descriptive statistics was in the form of data

summarised with the use of frequencies and percentages for

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nominal and ordinal level data and means and standard deviations

or medians and interquartile ranges for interval and ratio level

data where appropriate.

ETHICAL CONSIDERATIONS

The participants were informed that participation was completely

voluntary and were free to withdraw from the study at any time

without penalty. Personal privacy, confidentiality of all

information obtained and anonymity ensured at all times. The

research adhered to all ethical principles as described in the

Declaration of Helsinki.

RESULTS

The biographical data presentation includes gender, race, age,

marital status, qualifications, professional position held, years of

experience of midwives, training in neonatal resuscitation as well

as participation in neonatal resuscitation.

Gender: The majority of midwives are females (n= 97; 88.2%) and

the minority (n=13; 11.8%) are males. This distribution shows the

dominance of females in the profession which is substantiated by

Keighley (2009:27), who has acknowledged the female dominance

in the nursing profession.

Race: The race group of midwives as consisting of African (n=95;

86.4%), Coloured (n=10; 9%), Indian (n=2; 1.8%) and White (n=3;

2.7%). As the district is more rural, the majority of nurses are

Africans, in keeping with the racial demography of the province

and the country since recruitment and equity policies are

implemented (SANC, 2016: 5)

Age: The mean age of midwives as 43 years with a standard

deviation (SD) of 11.1, the youngest being 23 years of age and the

oldest being 64 years of age. The age distribution shows maturity,

i.e. midwives are generally older.

Marital Status: Single (n=41; 37.3%), married (n=45; 40.9%),

divorced (n=8; 7.3%) and widowed (n=16; 14.5%). The larger

number of participants were married (n=45; 40.9%). This denotes

stability and support at home in a work that is exceedingly

demanding and exhausting.

The biographical data on the training, qualifications and

experience of midwives in neonatal resuscitation was analysed

with descriptive statistical analysis.

Identification of midwives’ training, qualifications

and experience in neonatal resuscitation

Training: was two-fold i.e. training in midwifery and in neonatal

resuscitation. All participants were trained in Midwifery in one

way or another. Neonatal resuscitation: Midwives were trained in

Helping Babies Breathe (HBB: n=78, 70.9%), followed by neonatal

resuscitation (n=65, 59.1%), Essential Steps in Management of

Obstetric and Emergencies (ESMOE: n=43, 39.1%), and least on

Paediatric Life Support (n=4, 3.7%) The other five participants

indicated that they did other training for example Mother and

Baby Friendly Hospital Initiative training (n=5, 4.5%). The higher

percentage (70.9%) of midwives trained in HBB could reflect that

priority is given to HBB training at a district hospital level.

Qualifications: 4yr Degree=15.5%; 4yr Diploma=24.5%; 1yr

Midwifery=30.9% and Post-basic / Advanced Midwifery=29.1%

The study reflects that almost one third is qualified in Post Basic /

Advanced Midwifery and Neonatal Nursing) which are the most

desired qualification for the midwives to function in a

knowledgeable capacity, especially at a district hospital level

(SANC,2014:2).

Midwifery Experience: 83.6% (n=92) of participants had more

than 3 years experience which means that the majority of the

midwives are well-experienced in midwifery.

Determining the knowledge of midwives on neonatal resuscitation at birth

Table 1: Preparation for birth and identification of neonates requiring assistance

Variable Correct Response n %Situation in which to anticipate that the neonate will need to be resuscitated at birth

Caesarean section under general anaesthesia Correct 72 65.5Incorrect 38 34.5

To prepare for a birth You identify a helper and make an emergency plan

Correct 108 98.2Incorrect 2 1.8

To prepare the area for delivery Make sure the area is clean, warm, and well-lighted

Correct 110 100Incorrect 0 0

What to do to keep the baby clean Wash your hands before touching the baby and help mother wash her hands before breastfeeding

Correct 110 100Incorrect 0 0

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The value of one minute Apgar Score It is used to assess the infant’s clinical condition at birth.

Correct 100 90.9Incorrect 10 9.1

What to do in the Golden Minute Help a baby breathe if necessary Correct 103 93.6Incorrect 7 6.4

What to do if a baby is quiet, limp and not crying Dry the baby thoroughly Correct 100 91Incorrect 10 9

What to do if the baby does not respond on to steps of stimulating breathing

Begin ventilation Correct 103 93.6Incorrect 7 8.4

Next step to do if an infant cannot be adequately ventilated with bag and mask

Be intubated and ventilated Correct 66 60Incorrect 44 40

Rates recommended for ventilating a newborn infant 40 breaths per minute Correct 62 56.4Incorrect 48 43.6

Table 2: Knowledge on bag and mask ventilation techniques during neonatal resuscitation

Variable Response Option Provided n %In order to have an effective ventilation with bag and mask

The mask should cover the eyes True 0 0False 110 100

In order to have an effective ventilation with bag and mask

Air should escape between the mask and the face True 1 1False 109 99

In order to have an effective ventilation with bag and mask

Squeeze the bag to produce gentle movement of the chest True 86 78.2False 24 21.8

In order to have an effective ventilation with bag and mask

Squeeze the bag to produce 80 to 100 breaths per minute True 59 53.6False 51 46

You can stop ventilation Baby is blue and limp True 5 5False 105 95.6

You can stop ventilation Baby's heart rate is 80 per minute True 11 10False 99 90

You can stop ventilation Baby's heart rate is 120 per minute and the chest is not moving True 10 9.1False 100 90.9

You can stop ventilation Baby's heart rate is 120 per minute and the baby is breathing or crying

True 107 97.3False 3 2.7

A newborn baby's heart rate should be Faster than your heart rate True 110 100False 0 0

A newborn baby's heart rate should be Slower than your heart rate True 3 2.7False 107 97.3

Clamping of the umbilical cord at birth In newborn babies who do not require positive-pressure ventilation, the cord should be clamped earlier than one minute after birth.

True 44 40False 66 60

Intrapartum suctioning in the presence of meconium-stained amniotic fluid

Suctioning of the mouth and nose at the delivery of the head is not recommended

True 47 43False 63 57

During ventilation with bag and mask It is important to select the mask that covers the chin, mouth and nose, but not the eyes.

True 106 96False 4 4

An effect of a good seal of the mask A good seal between the mask and the face allows you to move air into the baby’s lungs during ventilation.

True 108 98False 2 2

Positioning of the baby’s head To help open the baby’s airway, you should position the baby’s head hyper extended

True 52 47False 58 53

Initiation of positive-pressure ventilation within a minute

In newborn babies who do not start breathing despite thorough drying and additional stimulation, positive-pressure ventilation should be initiated within two minutes after birth.

True 65 59False 45 41

What to do with a baby who is gasping or not breathing at all

A baby who is not breathing well (gasping or not breathing at all) needs continued ventilation with bag and mask.

True 90 82False 20 18

When to stop ventilation during bag and mask ventilation

If the baby’s heart rate is 120 per minute and the baby is breathing or crying

True 109 99False 1 1

What should be done with newborn babies with no detectable heart rate after 10 minutes of effective ventilation

Resuscitation should not be stopped. True 61 55False 49 45

Table 3: Knowledge on 4 basic steps to follow on preparation for delivery

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Variable Correct Response n %Scenario: preparation for the birth and care for the baby in less than 10 minutes

Clean hands and maintain clean equipment throughout (Step 3)

Incorrect 74 67Correct 36 33

Scenario: preparation for the birth and care for the baby in less than 10 minutes

Prepares an area for ventilation and check equipment (Step 4 )

Incorrect 87 79Correct 23 21

Scenario: preparation for the birth and care for the baby in less than 10 minutes

Identifies a helper and makes an emergency plan (Step 1)

Incorrect 44 40Correct 66 60

Scenario: preparation for the birth and care for the baby in less than 10 minutes

Prepares the area for delivery(Step 2)

Incorrect 69 63Correct 41 37

Figure 1: Knowledge Scores

The total knowledge scores of participants were compared across the demographic variable categories. In general the participants’

knowledge of basic neonatal resuscitation does not show any significant differences regarding race, gender, marital status and

qualifications.

.

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Describing the relationships between midwives’ training, qualifications, experience and their

knowledge level in basic neonatal resuscitation.

It was important to do these comparisons based on the conceptual framework for this research study constructed on

literature of the grounded theory of knowledge management (Jennex, 2008:33) and the theory of Dr Patricia Benner on the

levels of nursing experience (Benner, 2013:402-7). It is assumed that as a midwife qualifies from novice, more experience

can be gained; as one is exposed to more training, one’s knowledge improves and one can become an expert.

The total knowledge scores of participants were compared across the demographic variable categories. In general the

participants’ knowledge of basic neonatal resuscitation did not show any significant differences regarding race, gender,

marital status and qualifications Though there were no relationships found between midwives’ training, qualifications and

their knowledge; years of experience as a midwife were found to be associated with knowledge of basic neonatal

resuscitation.

CONCLUSIONS

This research has highlighted the importance of knowledge in empowering the midwives to master their work in the way

they prepare the delivery room for the birth and helping neonates breathe at birth within ‘The Golden Minute’.

Furthermore, the study shows the importance of the relationships between knowledge, experience, training and

qualifications. While the focus of the study was not on training per se, on-going training of health workers forms the core

of WHO guidelines in dealing with health-related problems. Focus on training will need to be broadened to include

attitudes, competences and skills. Other studies such as the one outlined by Monebenimp et al. (2012, 8-14) prove in-

service training as having a direct effect in reducing neonatal mortality rate.

While the focus of the study was not on training per se, on-going training of health workers forms the core of WHO

guidelines in dealing with health-related problems. Focus on training will need to be broadened to include attitudes,

competences and skills. Other studies such as the one outlined by Monebenimp et al. (2012, 8-14) prove in-service training

as having a direct effect in reducing neonatal mortality rate.

The study findings implied that the midwives who were longer in midwifery services obtained higher knowledge scores as

they gained knowledge through experience. These midwives were more likely to have been afforded the opportunity for

further study in midwifery speciality. It could thus be necessary to identify nurses for specialisation in the various fields of

midwifery and neonatology. As this is a long-term strategy, mentoring of those midwives who join the service by the

experienced midwives will also empower them to gain more experience, thus leading to self-motivation and more

knowledge (Kim et al., 2013:4-5).

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NEONATAL BRAIN MR IMAGING IN NEONATAL ENCEPHALOPATHY.

Mary A RutherfordProfessor of Perinatal ImagingKings College London and University of Stellenbosch

South Africa has an incidence of neonatal encephalopathy of between 2.3 and 4.3 per 1000 live births. Many of these babies will have sustained clinically significant injury to the brain that will have life-long effects for the individual child, their family and society. Magnetic resonance brain imaging (MRI) is a safe technique for assessing the neonatal brain. It is complimentary to good quality serial ultrasound in the detection of perinatal brain injury and is becoming widely available in clinical settings. MRI is able to reliably detect acquired brain injury. Experienced interpretation of neonatal images allows the following;

Detection of congenital abnormalities Detection of antenatal injury Assessment of the site and extent of any injury acquired during labour and

delivery.

A good quality neonatal MRI, together with detailed information about the antenatal history, labour, delivery and the neonatal course enables a prediction of neurodevelopmental outcome to be made with confidence. Acute hypoxic ischaemic events are associated with injury to the basal ganglia and thalami, which usually result in cerebral palsy. Chronic hypoxic ischaemic injury is more often associated with white matter and cortical lesions. These are usually associated with cognitive and behavioural impairments although motor impairment in the form of cerebral palsy may occur if the lesions are severe. This presentation will illustrate the role of a well-timed neonatal MRI in detecting and assessing perinatally acquired injuries and how these relate to later outcome.

Neonatal MR imaging allows us to inform parents about the presence and nature of any injury and its likely impact on their child’s development. This may alleviate their own, often misplaced, guilt. Information from MRI allows a plan for therapy and rehabilitation and provision for the child as they grow. This information can be used in hospital adverse event proceedings to assess clinical practice and make appropriate changes when necessary. In addition, neonatal MRI can assist in identifying causation without recourse to later expensive lengthy medicolegal proceedings.

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PREVALENCE OF HYPOTHERMIA ON ADMISSION TO A NEONATAL UNIT AT A TERTIARY HOSPITAL: A PRELIMINARY REPORT

M Mayer 1 , L Bobotyana1, N Xhinti2, S Velaphi3

1Department of Paediatrics, Nelson Mandela Ac. Hospital & Walter Sisulu University2Helping Babies Breathe Programme, Resuscitation Council of Southern Africa3Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and the University of the Witwatersrand

BACKGROUND: Hypothermia is associated with morbidity and mortality during the neonatal period. Prevalence of hypothermia on admission to the neonatal units in developing countries, including in facilities from our own country is not well known. Since neonatal hypothermia is associated with mortality it is important to assess burden of this condition in settings where mortality rates are high, since its prevention might significantly reduce mortality in our institutions. OBJECTIVES: To determine prevalence of hypothermia (axillary body temperature <36.5 ⁰C) on admission to a neonatal unit and characteristics of neonates with hypothermia at a referral tertiary hospital. METHODS: Records of neonates who were admitted to a neonatal unit from September-November 2016 were reviewed for axillary temperature on admission, maternal and infant characteristics. Comparisons of maternal and infant characteristics were made between hypothermic and non-hypothermic neonates on admission. RESULTS: A total of 269 neonates were admitted to the neonatal unit over this 3 month period. Among the 248 (92.2%) who had axillary body temperature recorded on admission, 55 (22.2%) had hypothermia. Just over a third (38.2%) of those with hypothermia had moderate hypothermia (32-35.9⁰C). The only factor identified to be associated with hypothermia on admission was birth weight with hypothermic infants having birth weight lower than the non-hypothermic infants (2090 ±736 vs 2362±886 grams, p = 0.038). CONCLUSION: There is a high prevalence of hypothermia on admission to the neonatal unit. This requires a review and monitoring of implementation of practices and/ or interventions known to reduce neonatal hypothermia.

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PREVALENCE AND CAPSULAR TYPE DISTRIBUTION OF GROUP B STREPTOCOCCUS (GBS) AMONG PREGNANT WOMEN IN WINDHOEK, NAMIBIA

M Mukesi, F Engelbrecht, S Khan and SR Moyo1* Faculty of Health and Applied Sciences, Department of Health Sciences, Namibia University of Science and Technology

Vertical transmission of Group B Streptococcus (GBS) from colonized mothers to their new born babies can result in early onset GBS infection which occurs in the first 7 days of life and is a leading cause of invasive bacterial infection in neonates. Mortality in early onset disease is estimated at 5% and is characterized by bacteraemia, pneumonia and meningitis, associated with severe shock. Capsular serotyping has been one of the mainstays in the descriptive epidemiology of GBS. Ten capsular serotypes 1a, 1b, 11-IX, have been described based on the antigenicity of their capsular polysaccharides. The capsule represents one of the major virulence factors of GBS. This study sought to determine the prevalence of GBS in pregnant women in Windhoek Namibia and establish the capsular type distribution of GBS isolated from the same pregnant women. Lower vaginal and rectal swabs were collected from women between 35 and 37 weeks gestation for isolation of GBS. Multiplex Polymerase Chain Reaction (PCR) was performed using One TaqR master mix for determination of capsular types. Electrophoresis was done using 2% agarose with ethidium bromide. A total of 860 pregnant women were screened for GBS. The prevalence of GBS among pregnant women in Windhoek was 13.6%. Out of a total of 117 GBS isolates, serotype distribution was as follows: II (59.4%), III (24.6%), V (10.1%), Ib (2.9%), Ia (1.5%) and IV (1.5). Capsular types Ia, Ib, II, III and V constituted 98.5%. These capsular types ( Ia, Ib, II, III and V) have been implicated as cause of early onset GBS diseases in several settings. Capsular type III which is widely regarded as the most invasive was the second most common among pregnant women in the current study. In Windhoek, Namibia the capsular types colonising pregnant women are those which have been implicated in early onset disease in new born babies. Although capsular type distribution of GBS in Namibia is similar to that of neighbouring countries like Zimbabwe and South Africa, the prevalence of GBS among pregnant women at gestational age between 35 and 37 weeks, was lower, compared to the neighbouring and other African countries.

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MATERNAL AND NEONATAL VITAMIN D STATUS AND ITS ASSOCIATION WITH EARLY-ONSET NEONATAL SEPSIS IN BLACK SOUTH AFRICANS

Sithembiso Velaphi 1 , Shabir Madhi2, Alane Izu2, John Pettifor3 1Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand; 2Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand; 3Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand

Background: In neonates, vitamin D deficiency (VDD) has been associated with increased risk for early-onset sepsis (EOS). Vitamin D status in pregnant women and their offspring and its association with EOS in black South Africans is not known. Serum 25-hydroxyvitamin D [25(OH)D is the biomarker measured to assess vitamin D status.

Objectives: To assess vitamin D status in pregnant black South African women and their offspring, and its association with EOS in neonates.

Methods: We prospectively enrolled pregnant women and their offspring, and measured 25(OH)D in maternal and cord blood at delivery. Neonates with suspected sepsis at birth had IL-6 and CRP measured in addition to blood culture to support diagnosis of sepsis. Predictors of VDD (levels <30 nmol/L) were assessed and comparison between neonates with laboratory confirmed EOS and well ones was performed.

Results: A total of 621 pregnant women, 360 well neonates and 293 with suspected EOS were enrolled over a 21-month period. Maternal and cord blood 25(OH)D levels were 54.7±30.1 and 39.0±21.3 nmol/L, and prevalence of VDD was 18.8% and 39.8% respectively. Predictors of VDD were being born by caesarean section (OR: 5.07, 95% CI 1.92-13.4), born in winter (OR: 4.76, 95% CI 2.73-8.29) and being of low birth weight (OR: 2.39, 95% CI 1.26-4.55). Deficit of 25(OH)D in cord blood was associated with EOS on univariate analysis.

Conclusion: About one in five pregnant women, and one in three neonates have VDD amongst black South Africans. Being born in winter and maternal 25(OH)D are major determinants of cord blood 25(OH)D. 25(OH)D appear to play a role in neonatal sepsis but further studies are required.

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RETINOPATHY OF PREMATURITY IN INFANTS <1250G AT KALAFONG HOSPITAL OVER FIFTEEN YEARS

S. Delport,* K.Masemola,* C.Carrim#Departments of Paediatrics* and Ophthalmology,# Kalafong Hospital and the University of Pretoria

IntroductionRetinopathy of prematurity (ROP) is defined as a vasculopathy of the developing retina and is the cause of blindness in approximately 50 000 of 1 500 000 blind children worldwide. Timeous screening is mandatory to facilitate an early diagnosis of disease progression and intervention. At Kalafong Hospital, infants with a birth weight (BW) ≤1300g are screened at a chronological age of six weeks by means of indirect ophthalmoscopy. The International Classification of ROP (ICROP) is used to define the disease by its relation to location (zone 1,2,3), severity (stage 1 to 5), extent in clock hours with specific reference to the presence of ‘plus disease’ (dilation and tortuosity of vessels). Severe disease is characterised by stages 3, 4 or 5 in more posterior zones and the presence of ‘plus disease’. Screening was initiated in 2000 after Kalafong Hospital was litigated for blindness in an unscreened infant.

AimTo determine the incidence of ROP in infants with a BW <1250g over two random time periods after 2000 and to determine whether this incidence is decreasing as compared with 2000.

Patients and MethodsScreening data of infants <1250g from two random time periods were audited and compared with data from a definitive study completed during 2000. Each time period comprised 2 years. Infants who were not screened or incompletely screened were excluded from the final audit. Screening was initiated at 6 weeks after birth and was by means of indirect ophthalmoscopy after pupil dilation with cyclopentolate hydrochloride 2mg/ml and phenylephrine 10mg/ml. Weekly or biweekly examinations took place until vascularisation had matured. ROP was classified as none, mild (stages 1 & 2) and severe (stages 3,4,5). Therapeutic intervention was in the form of laser therapy.

Results

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A total of 652 infants had a BW <1250g of whom 303/652 (46%) were audited because they were fully screened: 65/104 infants during time period 1 (2000), 104/271 infants during time period 2 (2008-2009) and 134/277 infants during time period 3 (2013-2014). Infants <1000g comprised 35% (37/104), 47% (128/271) and 60% (165/277) of infants <1250g during time periods 1, 2 and 3 respectively. Severe ROP was diagnosed in 11% of infants during time period 1 versus 3% during time periods 2 and 3. ROP did not develop in 58%, 95% and 93% of infants during time period 1, 2 and 3 respectively. The number of infants not screened or partially screened decreased from 88/271 (33%) during time period 2 to 67/277 (24%) during time period 3 (p = 0.01).

DiscussionThe incidence of severe ROP is decreasing at Kalafong Hospital since screening was initiated in 2000. This finding is in the face of a higher burden of extremely low birth weight (<1000g) infants and may due to a beneficial effect of the exclusive human milk diet administered to infants ≤1500g. More eligible infants are fully screened and may reflect an increased level of awareness amongst healthcare workers and mothers alike.

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TREND IN SURVIVAL AMONG VERY LOW - BIRTH WEIGHT INFANTS AT A SEMI-RURAL HOSPITAL. (LURWMH)

M. Malahleha, Z. Duze*, N. Kapongo*(*): Paediatric Department, Neonatal Unit, Lower Umfolozi, Regional War Memorial Hospital (LURWMH).

IntroductionPreterm birth is a significant risk factor for survival of the neonates and is associated with increased perinatal mortality and morbidity. Every year, an estimated 15 million babies are born preterm worldwide, and this number is rising (1). In South Africa, immaturity related complications are the leading cause (45%) of early neonatal deaths (2). Very low birth weight (VLBW) infants represent a vulnerable group of new-borns with high mortality rate. The success story of improving survival rates of VLBW infants in developed countries has been well documented (3, 4,5). This occurred on the background of improved antenatal care (high coverage of antenatal steroids), implementation of Neonatal Intensive Care programs and improved post-natal follow up services. These quality and levels of care are far to be a reality in developing countries where the survival of VLBW infants remains low (6,7, 8, 9). Low- cost interventions, including antenatal steroids provision, promotion of early and exclusive breastfeeding, resuscitation of new-borns, care for small babies according to standardized protocols, Kangaroo Mother Care (KMC), home post-natal visits and others, have been tested and suggested (10,11). We described an overall VLBW survival rate of 72.5% at LURWMH during the period 2011 to 2013 (12). In 2011 VLBW 800-999 g category became eligible for nasal CPAP and surfactant therapy and those infants 900-999 g without poor prognosis were considered for mechanical ventilation. Using eight year neonatal data base, we sought to analyze the evolution of VLBW survival rates between two chronologic periods 2006-2010 and 2011-2013 with the aim to identify differences in perinatal characteristics associated with better outcome at discharge level.

Material and MethodsClinical Facilities

Empangeni Neonatal unit is part of a child and Maternal Hospital, Lower Umfolozi Regional War Memorial Hospital (LURWMH) in North-East of Kwazulu-Natal, South

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Africa. This is the only maternity and neonatal regional referral centre for an area with a population estimated at 2.5 Million. According to census 2001, poverty rate and unemployment rates stand at 63.5% and 53.7% respectively. The proportion of households with access to safe water (32%) and sanitation (24%) are far below the national figures (79% and 62%, respectively). Fifty thousand (50 000) live births occur in the entire area annually including 10 000 at LURWMH .The neonatal service was introduced at the hospital in 1998 with a 15 unit beds without intensive care facilities. Between 1999 and 2008 the unit was expanded to 92 bed neonatal units: 16 NICU beds, 40 high care, 16 special care beds and a Kangaroo mother care (KMC) unit (20 beds). Nurse to patient ratio has been well below recommended figures (NICU: 1/3 to 1/4). During the study period the medical staff included 2 full time-paediatric consultants, fifteen medical officers and 2 interns. Because of the burden in neonatal admissions needing mechanical ventilation, our NICU unit is set up to allow only 2.8 meters square around every infant bed which is below the provincial norms of 5 meters squares. It is the Unit policy not to offer intermittent positive pressure ventilation (IPPV) to infants weighing less than 1000 g. VLBW infants 800-999 g are eligible to receive surfactant therapy and Nasal continuous positive airway pressure (NCPAP) with generally no back up option of intubation and ventilation for those infants for whom non-invasive ventilatory support failed. Depending on NICU bed availability infants weighing 900 -999 g without poor prognosis were considered for IPPV. Ethical approval for the study was obtained from the hospital Ethics Committee.

Data collectionThe Neonatal database at LURWMH is in place since 2000. Using the neonatal database, we evaluated survival rates until hospital discharge among infants weighing 500 to 1499 g admitted at LURWMH between 2 chronological periods: Jan 2006 to Dec 2010 and Jan 2011 to Dec 2013.The following determinants of VLBW infants survival were considered for comparison between the two periods: BW (mean), proportion of male gender, the referred status, the proportion of VLBW who received CPAP and surfactant, the proportion of VLBW delivered by C/S.

Neonatal Management at LURWHAll babies, irrespective of the birth weight, were provided with standard neonatal care (incubator, supplemental oxygen, IV fluid, antibiotics, blood transfusion,

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phototherapy as needed and KMC) it is Unit policy to offer IPPV for infants 1000 g or more. VLBW infants 800-999 g are eligible to receive surfactant (InSurE) and ncpap with generally no back up option of intubation and IPPV except for some selected infants 900 -999 g with no poor prognosis and depending on availability of beds. Babies were discharged home once they had established enteral feeds, were off supplemental oxygen, maintaining temperature and had achieved a weight of 1800 g (or at least 1700 g with no clinical concern). Some babies were discharged to their district hospital for weight gain once they had achieved at least 1500 g with

Statistical AnalysisThe primary outcome measures were deaths and survivors at hospital discharge level. Capturing and analysis were carried out using Epi-info-3-5-1 programme.This include simple frequency analysis, Stratified analysis to determine stratum specific odds ratio, Chi-square associations to determine odds ratios and confidence intervals, Summary odds ratio and parametric& non parametric one way analysis of variance test for comparing means, Analysis for linear Trend in proportions using the extended Mantel-Maenszel Chi-square. A 5% level of significance was used.

ResultsThere were 3827 VLBW infants admitted at LURWMH from January 2006 to December 2013. Fifty six per cent (2141) were from the 2006-2010 period and the rest 1686 (44%) were from the following period, 2011 -2013. The yearly admission means were 428.2 and 562, respectively in chronological order.The overall trend in VLBW admissions (as proportion of LBW) is shown in table 1. The chi-square linear trend was 3.608 (p value 0.05), indicating an increase in VLBW admission burden from January 2006 to December 2013.Comparison of the two periods of the keys determinants of VLBW infant’s survival is shown in table 2. There was no significant difference between the two periods with regards to the mean birth weight (1123 g vs 1127 g, p value 0.98) and the proportion of male gender proportion (48.5% vs 48.7%). There were more referred VLBW infants during the period 2006-2010(28%), compared to 23% during 2011-2013. More infants were delivered by C/section (51.1%) during the period 2011-2013 than the previous period 2006-2010 (42.6%). The

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proportion of VLBW infants who received Nasal CPAP and surfactant was higher during the 2011-2013 periods (51.4% vs 29%).Details of the infant’s survival rates are summarized in table 3. There was no significant difference in overall survival rates, 69.9 % and 72.5% (OR 1.13, CI 0.98-1.30), but significant difference in survival rates was observed between the two periods in the birthweight category 800-999 g. (OR 1.65; CI 1.18-2.31).

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DiscussionThe overall VLBW survival rate of 72.5% (2011-2013) is in keeping with developing setting figures and compare favorably with published rates from non- rural settings in South Africa ( CMJAH 2006/2007 : 70.5% (7); CH Baragwaneth (6) 2000-2002 : 72%). This represents an improvement if compared to 69.9% survival rate reported during the period 2006 to 2010 , prior to the introduction of Unit policy which expanded cpap and surfactant therapy to the BW group 800- 999 g. This could explain in part our better ELBW infant’s survival rate of 40.5% compared to 32% (CH Baragwaneth) and 35% (CMJAH). The expansion of nasal CPAP & InSurE (intubate, surfactant and extubate) technic to the BWt group 800-999 g, was introduced selectively in 2008 and it became routine and official policy in January 2011. The survival rate in this BW group is 57.7%. This is a significant improvement compared to 45.5% rate before the policy shift (OR =1.68, 95% CI: 1.18-2.31; P< 0.0028). This review joins the national debate as to whether it is appropriate to continue using a cut-off point of 1000 g, and whether BW is an appropriate variable to use in deciding neonatal intensive care provision. The big concern and argument has been that because of limited resources, attempt to expand NICU access to the ELBW infants may compromise the care and therefore the outcome not only for ELBW infants but for all neonates sharing these facilities.Deliveries by C/S were advantageous for survival. This has been reported elsewhere (12, 13, 14,). Indications of C/S were not recorded and information about the presenting part is unknown. Further studies are warranted to determine whether this may be a causal association or C/S is just a marker of quality care (good antenatal attendance, antenatal steroid provision, excellent Intrapartum monitoring, skilled paediatrician attending to the infant). Malloy MH (21) analysed the impact of C/S on VLBW infants’ mortality and concluded that the positive impact on mortality was independent from maternal risk factors for Caesarean section.

ConclusionThere was an increase in overall VLBW infant survival rate during the 2011-2013 periods, despite the increase burden of VLBW admissions. But this increase in was not statistically significant. Survival of ELBW is low but improving especially in the BW 800-999 g Survival of ELBW is low but this is improving especially in the BW category 800-999 g, most likely related to CPAP and surfactant policy change intervention. The following factors were associated with

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the improved survival rates: being born in hospital, provision of Nasal CPAP and C/S delivery.

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POSTNATAL AGE AT DEATH AMONG INFANTS WHO DIED DURING THE NEONATAL PERIOD

N. Xhinti 1 , L. Bobotyana2, M. Mayer2, , S. Velaphi31Helping Babies Breathe Programme Project, Resuscitation Council of South Africa2Department of Paediatrics, Nelson Mandela Ac. Hospital & Walter Sisulu University3Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and the University of the Witwatersrand

Background: The first 72 hours immediately following birth is the most critical period for newborn survival. It is reported that up to 50% and 75% of all neonatal deaths occur within the first 24 hours and first week respectively. Understanding when neonates die at a local level assists in identifying factors that might be contributing the neonatal deaths.

Objective: To determine the postnatal age of neonates at time of their death at Nelson Mandela Academic Hospital (NMAH).

Methods: Death register of all neonatal deaths from 1st January 2015 to 31st December 2016 at NMAH was reviewed. Deaths were grouped according to their postnatal age, and birth weight. Characteristics recorded in the death register were described and compared between those who died within the first 72 hours of life and those dying at 72 hours and beyond.

Results: A total of 747 deaths were recorded in the death register over a two year period. Of these 747 deaths, 357 (47.8%) were referrals and 461 (61.7%) were very low birth weight infants (VLBWI) (birth weight <1500 grams). Overall 13%, 55% and 72% occurred within the first 24, 72 and 96 hours of life respectively. There were less deaths occurring within the first 24 hours among the referrals (9% vs 17%). There was a greater number of deaths with normal birth weight in the first 24 hours compared to those who were VLBW (23% vs 15%). The significant differences between those who died within the first 72 hours and those dying at 72 hours and beyond was lower Apgar scores at 1 minute (p = 0.013) and 5 minutes (p<0.001) and higher number being inborn (56.3% vs 47.2%, p=0.031) in those who died within 72 hours of life.

Conclusion: Just over half of neonatal deaths occur within the first 72 hours of life and about three-quarters of deaths occur within the first 96 hours of life, suggesting that more emphasis should be placed on immediate care of neonates soon after birth. Majority of deaths being VLBW suggests that a further analysis is required to look at factors contributing to deaths of VLBW infants, and that deficiencies identified should be corrected. Babies dying within the first 72 hours are most likely dying from intrapartum related complications.

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PLACENTAL INSUFFICIENCY AMONG HIGH-RISK PREGNANCIES WITH NORMAL UMBILICAL ARTERY RESISTANCE INDEX AFTER 32 WEEKS GESTATION.

L Geerts, E Van der Merwe, A Theron, K Rademan. Department of Obstetrics and Gynaecology, Tygerberg Academic Hospital, University of Stellenbosch, South Africa

Objective: To determine the incidence of abnormal multi-vessel Doppler values among advanced pregnancies (32 weeks gestation or more) with recognized clinical risk factors for suboptimal placentation (fundal height < local 10th centile, no growth in 4-6 weeks or drop since the last visit, any hypertension, pre-existing diabetes, previous mid- or third trimester fetal loss, previous abruption or fetal growth restriction) but with a normal umbilical artery resistance index (RI), and to assess whether clinical and ultrasonography findings can identify them, as currently no further investigations are offered to these women.Methods: In a prospective cross-sectional study at Tygerberg Academic Hospital, South Africa, consecutive women with high-risk pregnancies but normal umbilical artery RI after 32 weeks underwent ultrasonography (fetal biometry, assessment of liquor volume and placenta maturation) and Doppler assessment (uterine, umbilical, and middle cerebral arteries) between February 11 and October 21, 2013. Study data were compared among two main groups and four sub-groups: fetuses with normal uterofetoplacental Doppler values and those with any abnormal pulsatility index, each subdivided into small for gestational age (SGA) and appropriate for gestational age (AGA) by estimated fetal weight.Results: Of 210 participants, 72 (36.2%) had abnormal Doppler results and 38 (50%) of these were not (yet) SGA. Sixty (28.6%) fetuses were SGA and 38 of these (63.3%) had abnormal Doppler results. Clinical characteristics did not differ between groups with normal or abnormal Doppler values; however, among normal Doppler results, SGA pregnancies demonstrated poorer fundal growth (P=0.006). Significant associations existed between abnormal Doppler results and asymmetric growth, inappropriately advanced placental maturation, and reduced liquor volume (all P ≤ 0.04), but sensitivities (3.9%, 4.8%, and 14.5%, respectively) were too low to be clinically useful.Conclusion: A normal umbilical artery RI after 32 weeks, in women with a valid indication for assessment of placental function, is falsely reassuring whether the fetus is small for gestation or not. Maternal and pregnancy characteristics and imaging variables did not reliably identify the more than one-third of pregnancies with evidence of suboptimal placentation. Identifying these women will require multivessel Doppler assessment to determine the appropriate level of care before or during labour and this should not be restricted to SGA fetuses in view of inaccurate dating practices in the region.

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SCREENING AND MANAGING LOW RISK PREGNANT POPULATION USING CONTINUOUS WAVE DOPPLER ULTRASOUND IN A MIDDLE-INCOME COUNTRY

Spencer Nkosi, Bob Pattinson and for the Umbiflow research groupSAMRC/UP Maternal and Infant Health Care Strategies unit

Aim: To determine the prevalence of raised resistance indices (RI) of the umbilical artery in a low risk middle income country; and to ascertain if the deaths of foetuses can be prevented by actively managing the group with raised RIs.

Setting: Mamelodi township on the eastern side of Pretoria, South Africa.

Method: A stepped wedge design was used starting with one community health centre (Stanza Bopape) and later expanding to other community health centres and clinics in Mamelodi township. Women attending Stanza Bopape clinic were screened using an Umbiflow apparatus by research sisters between 28 and 32 weeks’ gestation. Those women having a raised Umbiflow test were referred to a special high risk clinic at Mamelodi Hospital. The women at this clinic followed a standard protocol of management. The outcome of all the deliveries in Mamelodi township were recorded and the outcome of the Umbiflow group compared with women not having an Umbiflow.

Results: This analysis is an interim analysis of the first 14 months and includes only women recruited at Stanza Bopape clinic. There were 10703 births during the period of babies 1000g or more. 1121 women had an Umbiflow test; of these the outcome is available in 137 foetuses with high risk Umbiflow testing and 933 women with low risk Umbiflow testing (a further 3 had twins and 45 are missing). The prevalence of a raised RI was 12.8% with 14 women (1.2%) of Umbiflow population having absent end diastolic flow (AEDF). The high risk Umbiflow group had significantly more small for gestational age (SGA) babies than the low risk group, but Umbiflow had a poor sensitivity (25.9%) and poor positive predictive value for detecting SGA babies. There were 13 perinatal deaths in the Umbiflow group of which the mothers 5 of the 7 deaths in the high risk group were lost to follow-up.9052 women did not have an Umbiflow, but attended antenatal clinic and delivered a baby 1000g or more. The perinatal mortality rate was significantly lower (Risk Ratio 0.54, 95% Confidence Interval 0.31-0.94) in the Umbiflow group when compared with this group.

Conclusion: The prevalence of a raised RI in this low risk group of women undergoing a continuous wave Doppler ultrasound test of the umbilical artery was 12.8% and of AEDF was 1.2%. This is about ten times that recorded in low risk pregnant women in high income countries. The women with raised RIs were actively managed and the perinatal mortality rate in the Umbiflow group was significantly lower than the perinatal mortality rate of women who attended antenatal care and did not have an Umbiflow test.

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COST-EFFECTIVENESS OF THE UMBIFLOW DOPPLER TO SCREEN AND MANAGE A LOW-RISK PREGNANT POPULATION IN A MIDDLE-INCOME COUNTRY

Laura Rossouw*, Spencer Nkosi**, Bob Pattinson*** Research on Socio-Economic Policy, Economics Department, Stellenbosch University** SAMRC/UP Maternal and infant Health Care Strategies Unit

Aim: To assess the cost of preventing a stillbirth using Umbiflow.

Setting: Mamelodi township, eastern part of Tshwane district, an urban low and middle income area.

Method: Data from Nkosi et al.’s paper on Umbiflow was used to estimate the cost of preventing a stillbirth and a comparison made with other intervention to prevent perinatal death.

Results: The total implementation costs of the Umbiflow Doppler amounted to US $69534,12. The average cost per women screened is $64,99 ($37,83 programme cost and $27,16 utilization cost per screening). The total cost of saving a life by reducing stillbirths is $ 11679,14. When we focus solely on programme costs (or exclude the cost-generating activities of detecting high risk pregnancies) this cost declines to $6798,14 per life saved. The cost per life year gained is $133,30 per life year gained, or $81,35 if we only consider the programme costs.In this analysis, we choose to compare the Umbiflow’s cost-effectiveness to economic evaluations of similar neonatal life-saving interventions in order to say something about its’ relative cost effectiveness. Chola et al.1performed a projection analysis of the costs and effects of scaling up various existing interventions to prevent infant and child mortality. All cost-effectiveness estimates are presented as cost per life year gained in 2015 US$. In order to make our cost-effectiveness measure more comparable to that of Chola et al.1, we deflated our estimate of cost per life year gain in 2016 US$ to 2015 prices. In 2015 US$, the Umbiflow costs $183,17 per life year gained. Compared to these estimates, the Umbiflow is more cost-effective than scaling up clean-birth practices, immediate assessment and stimulation during childbirth, breastfeeding promotion, appropriate complementary feeding, the hygienic disposal of children’s stools, the DPT, Pneumococcal, Rotavirus or Measles vaccines, therapeutic feeding (for severe wasting), and antiretroviral treatment. However, the Umbiflow is less cost-effective than scaling up labour and delivery management, neonatal resuscitation, antenatal corticosteroids for preterm labour, antibiotics for preterm rupture of membranes, hand washing with soap, the Hib vaccines, Kangaroo mother care, oral rehydration solution, oral antibiotics, case management of pneumonia in children and PMTCT.

Conclusion: Chola et al cautiously apply the WHO recommendation to distinguish between non-cost-effective, cost-effective and highly cost-effective interventions. If we apply the same threshold, the Umbiflow is highly cost-effective.

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MATERNAL HEART RATE PATTERNS UNDER RESTING CONDITIONS IN LATE PREGNANCY

Hein Odendaal 1 , Coen Groenewald1, Michael M. Myers2-5, William P. Fifer2-5 PASS Network1 Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa2 Department of Psychiatry, Columbia University Medical Center, New York, NY3 Department of Pediatrics, Columbia University Medical Center, New York, NY4 Division of Developmental Neuroscience, New York State Psychiatric Institute, New York, NY5 Extraordinary Professor, Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa.ObjectivesTo describe maternal heart rate patterns observed during antenatal monitoring under resting conditions between the gestational ages of 34 to 38 weeks and to demonstrate associations with uterine activity.MethodsEach participant had five high quality ECG electrodes attached to their anterior abdominal wall which were attached to the Monica AN24 device to collect raw electrical signals from the maternal and fetal ECG and signals of uterine activity. A dedicated computer programme was then used to download the raw data and extract the maternal and fetal heart rate patterns and uterine activity. ResultsIn the visual review of several thousand recordings, several distinct maternal heart rate patterns were observed and further investigated. These included unusually high or low levels of variability, tachycardia, bradycardia regular and irregular periodic changes and sporadic changes where the heart rate suddenly decreased or increased. Some of the fluctuations, especially decelerations of maternal heart rate, seemed to be associated with uterine activity.

Figure 1. The vertical scale gives the heart rate in beats per minute and the horizontal scale time in minutes. The maternal heart rate and contraction patterns are indicated by red and black colours respectively. Recording speed is 1 cm/min. The MHR fluctuates rapidly between 90 and 130 bpm. It is difficult to detect the baseline. There seems to be an association between the MHR changes and uterine activity.ConclusionsThe clinical implications of the different patterns for both the mother and fetus needs further exploration. There is a need for computerized analyses of the different maternal patterns across gestation aged to determine their relevance.

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Financial Support: This research was supported by grants U01HD055154, U01HD045935, U01HD055155, U01HD045991 and U01AA016501 issued by the National Institute on Alcohol Abuse and Alcoholism, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Institute on Deafness and Other Communication Disorders.

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POSTERIOR AXILLA SLING TRACTION AND ROTATION FOR INTRACTABLE SHOULDER DYSTOCIA: DATA AND VIDEO

GJ Hofmeyr and C CluverEffective Care Research Unit, Universities of Witwatersrand, Fort Hare and Walter Sisulu and Eastern Cape Department of HealthDepartment of Obstetrics and Gynaecology, University of Stellenbosch

INTRODUCTION:Shoulder dystocia is an unpredictable obstetric emergency. Several techniques have been described for management and include Mc Roberts position, anterior shoulder delivery, techniques to deliver the posterior shoulder and arm, rotational procedures, and maternal position changes. Recently there has been a move towards favouring procedures that enable delivery of the posterior arm. These include delivery of the posterior arm, digital axillary traction and more recently the Posterior Axilla Sling Traction (PAST) procedure.

OBJECTIVE:To report on all cases reported to us where PAST has been used in cases of intractable shoulder dystocia and to present a video clip of the procedure.

STUDY DESIGN:A record of all published and known cases was collected including information on preliminary obstetric techniques used and how the PAST technique was performed. Maternal outcomes including maternal injury and length of hospital stay and fetal outcomes including birth weight, Apgar scores, nerve injuries, fractures hospital stay and outcome were documented.

RESULTS:We have recorded 22 cases. In 5 cases the babies had demised in utero. Twelve were assisted deliveries. PAST was successful in 21 cases. In one it was partially successful as it enabled delivered the posterior shoulder with digital axillary traction. The most commonly used material was a plastic suction catheter. Once the posterior shoulder was delivered the shoulder dystocia was resolved in all cases. Time from insertion to delivery was less than 3 minutes when recorded. The birth weights of the infants varied from 3200gm to 4800gm. Posterior arm humerus fractures occurred in 3 cases. There was 1 case of a permanent Erbs palsy and 4 cases of transient Erb’s palsies. All were of the anterior arm and are assumed to have occurred during prior attempts to deliver the anterior arm.

During this series we found that when direct delivery of the posterior shoulder was difficult due to very severe impaction, the sling could be used to easily rotate the shoulders through 180 degrees assisted by counter pressure on the back of the anterior shoulder. This new method may further reduce fetal trauma during difficult shoulder delivery. Sling rotation was used in 6 cases.

CONCLUSIONS:This series confirms that PAST can be a lifesaving technique when all other techniques fail. Advantages are that it is easy to use, even by someone who has not seen it used, the suction catheter used is readily available, it aids rotational manoeuvres and it is inserted quickly with 2 fingers. All obstetricians and midwives should be aware of this potentially lifesaving technique. A video clip will be presented. The full teaching video is available on the WHO Reproductive

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Health Librabry at http://www.youtube.com/watch?v=jsC9aUzx510&list=PL68EE6D503647EA2F&index=9

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THE ODON DEVICE

Valerie Vannevel – SAMRCRobert C Pattinson – SAMRC

BackgroundProlonged second stage of labour is associated with maternal complications such as haemorrhage, infections, vaginal and perineal tears and an increase in operative deliveries (forceps, vacuum, caesarean section); as well as stillbirths and neonatal morbidity and mortality (cephalhematoma, facial nerve palsy). Second stage caesarean sections can be medically indicated; many of them could however be avoided by obstetricians skilled in performing operative vaginal deliveries. The BD Odon Device is a new device, developed to assist the delivery of the fetus during the second stage of labour. It is a low cost and easy to use technological innovation which makes it a possible revolutionary development in obstetrics, especially in low resource settings. The device was invented by Mr Jorge Odón and developed and produced by Becton Dickinson and Company. Animal and mannequin studies have been conducted, as well as a preliminary clinical study in Argentina.

MethodsThe safety and feasibility study of the BD Odon Device is sponsored and coordinated by the Department of Reproductive Health and Research of the World Health Organisation. Sixty low-risk obstetric patients with a slightly delayed second stage of labour will be included and delivered with the Odon Device. Safety outcomes (maternal and infant) and feasibility outcomes (successful delivery) will be assessed at different time points: labour and delivery, immediate postpartum and 6 weeks postpartum.

ConclusionIf the BD Odon Device proves to be safe and feasible, a randomised clinical trial is planned to assess the device compared to vacuum extraction.

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TSHWANE MOTHERS’ EXPERIENCES OF CHILDBIRTH

Sarie Oosthuizen,1 Anne-Marie Bergh,2 Robert Pattinson21 Tshwane District Health Services and Department of Family Medicine, University of Pretoria 2 SAMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria

Background The labour experience of a woman is characterised by complex interactions related to the health system and healthcare provider behaviour. A challenged primary health care system can lead to incidents of mistreatment and other unacceptable practices in the labour ward. The aim of this presentation is to report on mothers’ childbirth experiences in midwife obstetric units (MOUs) in Tshwane District.

MethodsAn anonymous, semi-structured survey questionnaire related to client satisfaction, respectful care and clinical care practices was administered sequentially to 653 women during their postnatal follow-up visit 3 to 42 days after delivery. Mothers 17 years and older were eligible to participate and all 10 MOUs were included in the sample. Data was collected over a period of 10 weeks.

ResultsThe mean age of birthing mothers in the MOUs was 27 years, with 7.6% being adolescents and 10.1% mothers 35 years or older. Nearly half of the clients (46.6%) resided in Gauteng, with 23.1% originating from neighbouring Limpopo and Mpumalanga and 21.7% from Zimbabwe and Mozambique. Setswana was the predominant first language of South African participants and the educational level of 57% of all participants was grade 12 or higher.Mothers had spent a mean of 7.18 hours in the clinic before their babies were born. They rated their experiences as follows:Category of care n %Non-consented clinical care 311 47.6%Disrespectful care (rudeness, shouting at, bullying, degrading and judgemental language) 178 27.3%Withholding of clinical care (no reaction when calling for help, had to deliver alone, midwives slept on duty)

23 3.5%

Physical assault in the intrapartum period:Assault 4 0.6%PV done to hurt mother 118 18.1%

Twenty-eight (28) mothers called for a change of attitude and humanity and requested equal treatment: ”We are also human!”

ConclusionMidwife obstetric units do not meet the needs and expectations of birthing women. Interventions should address changes in the context of respectful relationships, cognitive care and attending to maternal needs. This should be linked with midwife competence and quality clinical care. The results of this

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survey informed the development of a quality improvement package for MOUs in Tshwane District.

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A QUALITY IMPROVEMENT INTERVENTION PACKAGE IN MIDWIFE OBSTETRIC UNITS IN TSHWANE DISTRICT, SOUTH AFRICA

Sarie Oosthuizen,1 Anne-Marie Bergh,2 Robert Pattinson21 Tshwane District Health Services and Department of Family Medicine, University of Pretoria 2 SAMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria

Background The mandate of the District Clinical Specialist Team is to find ways of improving clinical care, keeping track of their progress by using national and provincial indicators pertaining to mothers, newborns, children and women’s health (MNCWH). The purpose of this study was to develop a context-specific intervention package for improving the quality of clinical care and the level of respectful behaviour in midwife obstetric units (MOUs).

Methods• All 10 MOUs in Tshwane District were included in the study, 5 as intervention

MOUs and 5 as controls. • Baseline activities included a review of respectful nursing practices and

clinical care in all 10 MOUs by means of documented observations of practices and a questionnaire survey among 653 mothers 3 to 42 days postnatally.

• Preparations for conducting the intervention included in-depth and semi-structured interviews with facility managers and the advanced midwife team leaders of each of the 5 intervention MOUs as well as group discussions with pregnant women allocated to the intervention MOUs. The support of the MCWH program manager and the area managers was also solicited.

• The interventional phase of the study consisted of twelve narrative sessions in each of the 5 MOUs. All five facility managers, advanced midwife team leaders and the midwife teams gave written consent for participation.

• The intervention package in the 5 MOUs included the following components, individually adapted for the context in each MOU: obstetric triage and admission bed; handover rounds with risk assessment to advocate improved quality clinical care practices and adherence to protocols and maternity guidelines; effective communication practices; and improved labour ward routines. Health system gaps were addressed on micro, meso and macro levels.

• Outcome measures were changes in key maternity output indicators and client satisfaction with treatment received from midwives during childbirth.

ResultsA preliminary analysis of indicators yielded the following:

In-facility fresh stillbirths

n (rate per 1000 births)

TRANSFERSBirth asphyxia

n (rate per 1000 live births)

Meconium aspirationn (rate per 1000 live

births)

2015 2016 p 2015 2016 p 2015 2016 p

Intervention MOUs

38(8.50)

6*(1.42)

0.005 69(15.64)

25(5.95)

0.525 54(12.24)

19(4.52)

0.023

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Control MOUs

34(8.38)

22(5.67)

30 (7.53)

14(3.65)

15(3.77)

15(3.91)

*Unavoidable stillbirths due to prematurity < 700g and abruptio placenta

The MomConnect and in-facility recorded complaints from both intervention and control MOUs were minimal. In feedback sessions midwives expressed their satisfaction with the newly instituted risk-management routines in the labour wards. The analysis of change in client satisfaction is still underway.

ConclusionA context-specific, multi-component, clinically-focussed intervention package has the potential to improve morbidity and mortality rates in MOUs with improved patient satisfaction.

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UNDERSTANDING MATERNAL MORTALITY: ETHEKWINI METRO KZN

Dr T Ibrahim (DCST Obstetrician eThekwini)

IntroductionAccording to the 2011-2013 Saving Mothers Report, eThekwini Metro had 341 maternal deaths for the triennium, the highest number of deaths of all districts in the country. This number was higher than 4 Provinces total deaths. The iMMR for the triennium was 197.61. The iMMR for South Africa and KZN was 158.29 and 171.09 respectively. There were 172565 facility live births, 30.6% of all facility live births in KZN. KZN has 11 districts. eThekwini is a largely populated district with 2 tertiary, 4 regional, and 4 district level hospitals. There are over 100 PHC clinics with 16 MOUs within the district. Understanding the details of the maternal mortalities would be key to implementing effective plans to reduce the number of deaths. These details must be known to the facility (including senior management) and the district office (usually the DCST). In 2014 the maternal mortality data provided to the district office from regional and tertiary hospitals was incomplete and therefore a consolidated analysis of maternal mortality for the district was not possible. While, by and large the facility maternal death meetings at clinics and district were held within a short time (“72 hrs”), with key players and management, these meetings were lacking at regional and tertiary level hospitals. The regional and tertiary hospitals contribute the largest proportion of deaths. To implement Quality improvement plans and recommendations from the NCCEMD, an understanding of district problems related to maternal mortality was needed. Accountability and action was also required.

MethodThrough the DCST specialist and district management, notifying deaths to district office (DCST) from all facilities in the Metro was made obligatory. A meeting was convened in May 2015 by the District Manager and DCST with the CEOs, medical managers and O&G HODS of regional and tertiary hospitals, to emphasize the importance of conducting a MMM within 72 hrs of a death with the key role players and the presence of senior hospital management. These meetings were made mandatary. All deaths throughout the district are to be reported to DCST and they are to be invited to the “72 hr” meeting.

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All deaths in the district, including the community deaths are summarised. A comprehensive analysis of all deaths and avoidable factors, and of all referrals in or into the metro is done every quarter and a report generated.

Results 7 Maternal mortality reports have been generated since 2015 with causes of deaths, avoidable factors, number referred into the district and contribution of Level 1 to higher level mortality were summarized. District plans were developed by addressing the main problems identified.Summary of 2014 maternal mortality in eThekwiniIn 2014 facility MMM with management were being conducted at district level only. The number of deaths reported to district office was 101. These did not include the community deaths. The iMMR was 173.8 (58128 live births). The details of most deaths were not known with any certainty. Therefore the top causes of deaths, avoidable factors etc are not known.

Summary of 2016 maternal mortality in eThekwiniIn 2016 all the district level deaths and 5 of the 6 regional / tertiary hospitals conducted these meetings. In 2016 details of deaths are known to the DCST and comprehensive reports were generated. Because of better reporting to DCST, the notification of all deaths to Provincial NCCEMD co-ordinator could be tracked in 2016.

Total number of deaths = 71MMR = 131iMMR = 120 ( 114.5 if co-incidental deaths are excluded)Live births in facility = 54134Number of cases referred to regional / tertiary by Level 1 at the acute presentation or contributed greatly to their death : 11 (15%)Number of cases referred from a different district : 5Unbooked cases : 18 (25%)Deaths considered possibly or probably avoidable : 37 (52%)

HIV results : HIV positive : 31 (43.7%) Unknown : 9 ( 8 unbooked) CD4 results available : 22 ( 71%) Viral load results available : 11 Too early for VL : 6 (55%)

Level at which deaths occurred Tertiary Hospitals : 19 (29%)Regional hospitals: 33 (51%)District hospitals : 9 (14%)

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Clinics : 4 (6%)Community deaths (DOA) : 6 ( 8.5%)

Cause of deaths

1) Medical and surgical disorders : 17 ( 24%)2) Non pregnancy related infection : 13 (18.3%) 3) Hypertension : 13 ( 18.3%) All due to complications of pre-eclampsia a) eclampsia = 2 b) pulmonary oedema = 6 c) combination of factors = 2 (both included HELLP ) d) ICH = 34) Ectopic pregnancy : 5 ( 7%)5) Anaesthetic Complications : 3 ( 4.2%)6) Miscarriage : 2 ( 2.8%) Septic miscarriage due to illegal TOP and uterine trauma (PM in a DOA) 7) Co-incidental : 38) Obstetric haemorrhage : 1 Abruption with hypertension – final cause of death is pulmonary oedema due to acute kidney injury.9) Hyperemesis : 1 Wernickes encephalopathy10) Embolism : 1 Pulmonary embolism - diagnosed on PM11) Unknown : 12 ( 16.9%) No information = 1 PM done = 3

Main avoidable factors 1) NPRI : possibly or probably avoidable in 69% of cases. Diagnosis of TB and assessment of viral load suppression still an issue 2)Hypertension : Possibly or probably avoidable in 69% of Management of severe hypertension still an issue, fluid balance and pulmonary oedema Contribute to deaths as well as delays in delivering those with severe pre-eclampsia. 3) Medical and Surgical disorders : Possibly or probably avoidable in 35%. Examination and assessments incomplete and lack of good support by medical teams.4) Ectopic pregnancy : Possibly or probably avoidable in 80%. Delay in diagnosis and delay in taking to OT after diagnosis of ectopic pregnancy. 5) Anaesthetic complications : Possibly or probably preventable in 100%.

ConclusionKnowing the details and avoidable factors of the maternal deaths form the basis of developing appropriate and effective facility and district quality improvement plans for any given area. However, this does not guarantee improvement in maternal mortality. There are many challenges. Communicating avoidable factors to other disciplines involved in maternal care and receiving buy-in to

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improve care is a real issue. Developing and ensuring that appropriate action plans are actually implemented by facilities remain the biggest challenge. REDUCING MATERNAL AND PERINATAL DEATHS FROM HYPERTENSION USING FACILITY HELD TRACER FORM FOR DCST TO MONITOR COMPLIANCE TO CLINICAL GUIDELINES

Dr SD MandondoDCST O&G Amathole EC

Problem statement and purpose / rationale In 2013, Amathole experienced a high number of maternal deaths due to hypertension (7/12 i.e. 58% – three times the national of 14%. Hypertension is the third most common cause of maternal death in South Africa. These deaths in Amathole have been due to the following causes: Eclampsia, Abruption, Pulmonary Oedema, Intracerebral Haemorrhage, Renal Failure and HELLP Syndrome.On PPIP in 2014 Hypertension accounted for 16.4 of perinatal death and APH abruption 11.3. Amathole district has no regional or tertiary hospital so all pre-eclampsia cases are referred to Frere and Cecilia Makiwane Hospital in Buffalo city district.

There was lack of early recognition, appropriate classification of hypertension and inappropriate referral to district hospitals versus tertiary level care and treatment to prevent complications. There was prolonged 2 weeks follow. Protocols were a poorly understood by the health workers. There was lack of skills in management of hypertension and fluid balance amongst doctors and nurses. DCST experienced challenges in mentoring clinicians using maternity case records as these records were hand held by patients hence DCST could only identify gaps in clinical care during perinatal audit reviews or during routine ANC audits post-delivery. Clinicians were not doing prompt follow up on baseline blood results at the high-risk clinics.

At referral hospital Frere and CMH a near miss audit of perinatal outcomes from 213 cases of severe hypertension showed that there was a 48% of babies born to Mothers with severe pre- eclampsia were early neonatal deaths .

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NEAR MISS INDICATOR Total cases Neonatal Deaths Stillbirths

Number Near Miss cases ( NM) 213 57 24Eclampsia Near Miss cases 100 9

Severe Pre eclampsia Near Miss cases 94 42Help Syndrome NM 20 6

Table 1. Perinatal outcomes of maternal near miss cases from severe pre- eclampsia and eclampsia

Brief outline of activities, time lines DCST Developed a facility held tracer card to follow up and monitor compliance to clinical guidelines on management of hypertension in pregnancy. The form is kept at district hospital high risk clinic to allow the nurse champion to follow up clients , blood results and track any defaulters .All blood results are entered on form and visiting specialist can review all forms to assess care and call clients who may be inappropriately managed , needing induction or referral .To strengthen implementation DCST

Conducted road shows to orientate clinic nurses, hospital maternity staff and doctors on pathophysiology of hypertension and protocol on the management of hypertension in pregnancy.

Reviewed the referral system for patient with preeclampsia to fast track their access to level three hospital care bypassing district level one and two hospital care.

Each hospital and CHC to identify a doctor and nurse to champion the high risk ANC clinic.

Impact and results Reduction from to 33 % maternal deaths from hypertension (7/12 to 2/6) when compared to the previous year .Deaths at tertiary hospital reduced Frere 19 to 10 in 2015 and 9 in 2016 .The were reduced number of deaths from Amathole district due to hypertension . There were deaths from hypertension referred from other districts .

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Cause of death Amathole

2013 2014 2015 2016 Jan -Dec

TOTAL 12 6 5 6HIV 3 1 2 1Hypertension 7 (58%) 2( 33%) 1 ( 20%) 1Haemorrhage 2 3 2Miscarraige 2 2HPT deaths CMH from Amathole District

1/19 Bworth 1/17 Stutterheim

?/18 Stutt

HPT deaths FRERE from Amathole

1/18 Bworth 2/10 Idutywa 1/9 Komga

Table 2 Maternal deaths by cause in Amathole and referral to tertiary

PPIP review findings indicate that due to hypertension has reduce from 16.4% to 6.9 % in and APH from 11 to 6.6 in 2014 . The stillbirth rates improved from 17 to 13 .3 .The improvements have been sustained in 2015 however slight increase in stillbirth in Mnquma where adhere to BANC+ will be strengthened .

Causes of neonatal deaths from PPIP

2013 2014 2015 2016

Spontaneous Preterm

23.9 38.2 32.9 36

Intrapartum Asphyxia

19.4 20.4 19.3 29

HPT complications

16.4 6.9 9.9 9.2

Infections 11.6 3.1 4.2APH 11.3 6.6 6.1 6.1Unexplained IUD 9.1 15.1 21.1 17Stillbirth rate 17 13.3 14.1 14.2MMR 83 58 44 76

Table 3 PPIP audit results . Primary obstetric causes of deaths 2013-2016 Possibility for scale up beyond current practice and suggested implementation strategies

With introduction of Banc plus the will be 2 forms ,1 at the local clinic to ensure all patients with hypertension or at risk are linked to Community health worker and feedback obtained from them 2 weekly. Delivery outcomes and status of mother and baby pair will be done till 6 weeks post-partum .

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District hospitals will continue to retain form at facility and track defaulters .At tertiary all maternal near misses from hypertension will be clerked using the tool to assess compliance of clinics to Banc + and identify both patient and health-worker gaps in management .

HYPERTENSION IN PREGNANCY BANC PLUS TRACER SHEET example

Patient Name:

Nono Mama Know HPT Y/N Treatment

Yes HCTZ /Enalapril

Address: Ntselamanzi Location no

Known Chronic Renal Failure

No

Phone No.: Previous GPH less 28 weeks

Alive* ENND IUFD

Referring ClinicName of Sr

Mbutho Previous GPH >34 weeks

Alive ENND IUFD*

Supporter Phone No and Name

Zama065 690 4444

Previous Abruption Alive ENND IUFD*

Referring Hosp

Victoria Sr Boy Other Risk Factor BO H/obese/Pr C/S /Diabetes i

AGE 38 HIV status /CD4 /VL Pos / CD4 438/VL less 50

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To be completed for each ANC visit and circle current visitVisits: 1

booking

2 3 4 5 6 7 8

Date: 6/8 19/9 31.10 3/11 5.12Parity 3GA 20 wks. 26 wks. 32 wks 36 wks 36

wksBP 140/10

0160/120 160/120 116/112 140/8

0DIPSTIX NAD NAD NAD Prot +

Alb3+Methyldopa dosage Nil 250mg/

dy250mg/dy

250mg/tds

Lab Tests Ranges

Urine ACR <0.0324hr Urine protein

<300

HB 12 – 15

13.48 9.2 15.7

PLATELETS 150 – 400

109

UREA 1.8 – 6.7

1.6

CREATININE 40 – 100

45

Uric acid 0.15–0.35

0.39

AST 5 – 40 36ALT 5 – 40 23LDH 266 –

500 -

Defaulter tracedDate referred

ASS IGNED COMMUNITY HEALTH WORKER NAME AND PHONE .S IBONGILE MANDONDO 060 560 2474FEEDBACK 2 WEEKLY FROM CHWDEL IVERY HOSP ITAL ,METHOD , OUTCOME AND BIRTHWEIGHT ; CMH CS ST ILLB IRTH 2.10 KG

CONTRACEPT ION .PEUPERAL IUCD

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6 WEEK MATERNAL AND BABY CONDIT ION :MOTHER STABLE ON HCTZ AND PERINDOPRIL BABY 2.5 KG

BANC+ protocol: generic

13. Hypertension- chronic or pregnancy induced

Systolic BP ≥140-159 mmHg AND/OR Diastolic BP ≥ 90-109 mmHg On two readings, at least one hour apart.

NO proteinuriaNO threatening signs

Initial resuscitation/ treatmentPut the patient on an examination couch/bed (left side)Check the Respiratory rate and saturation Check for oedema and proteinuria, as well as for threating signsAsk again about family history of hypertension, history of hypertension in previous

pregnancy, previous stillbirths, and neonatal deaths, bleeding in previous pregnancyAsk for contact number of person supporting them during pregnancy and link CHW Link patient to community health worker to follow up .Complete the Hypertension in

pregnancy form and retain it in facility ,update and track patient till 6 weeks post delivery

Further management and monitoring:

1. Check BP 1 hour after initial measurement:2. If still diastolic value 90 -109 mmHg, or still systolic 140-159 mmHg, start with alpha

methyl dopa 500 mg 8 hourly and refer as below (within 2 days). 3. If the second reading is normal (<90 mmHg diastolic and <140 mmHg Systolic) referral is

not necessary, but repeat the blood pressure measurement two days later. Any subsequent high reading then classifies the patient as hypertensive and treatment is needed.

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Advice to pregnant woman:

1. Reason for referral to doctor’s clinic and appointment date

2. Reduce workload and to rest3. Danger signs and to report to clinic

immediately if the following occur:Any headacheBlurred visionAbdominal pain

4. Take medication as prescribed5. CHC will visit her and ensure adherence 6. Councel to take Calcium and asprin

Referral process:

1. Fill in the MCR with all the relevant information, including specifically the dose of alpha methyl dopa.

2. Phone the District Hospital Doctor’s Clinic to make an appointment for the client within 2 days.

Signed by: Signature: Date:

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THE TRAIN-THE-TRAINER MODEL FOR SCALING-UP ESSENTIAL STEPS IN THE MANAGEMENT OF OBSTETRIC EMERGENCIES (ESMOE) IN KWAZULU-NATAL PROVINCE, SOUTH AFRICA: FEASIBILITY AND PERCEIVED IMPACT

Neil F. Moran, Moise Muzigaba, Jagidesa Moodley

BackgroundSouth Africa regularly publishes and disseminates national recommendations, in the form of “Saving Mothers” reports, on how to reduce maternal mortality, based on a national confidential enquiry into maternal deaths1. The Saving Mothers reports have consistently found that inadequate knowledge and skills of the midwives and doctors providing maternity care, especially emergency obstetric care, is one of the main problems contributing to maternal deaths. In response to this deficiency, a training programme, called Essential Steps in the Management of Obstetric Emergencies (ESMOE), has been developed in South Africa for improving skills in managing obstetric emergencies.The ESMOE programme consists of twelve modules. Each module is designed to be conducted with a small group of participants, and consists of a short lecture followed by skills demonstrations and skills practice. Examples of the modules include use of the partogram, management of obstetric haemorrhage, and surgical skills. The ESMOE programme also includes an emergency obstetric simulation training (EOST) component relevant to each module (also referred to as the obstetric “fire drills”) which can be incorporated into the various modules, or conducted separately in the clinical setting.One of the key recommendations of the last two Saving Mothers’ reports is to “Improve health worker training”, with the recommendation further specifying that all health care practitioners involved in maternity care in South Africa be trained in the ESMOE-EOST programme.Although KwaZulu-Natal (KZN) is the third smallest province in South Africa, it is the country’s second most highly populated province. In all the Saving Mothers reports, KZN has been the province which has recorded the highest number of maternal deaths. This article describes the (KZN) model for scaling up ESMOE training in the province in order to achieve the recommendation that ESMOE training be available to all maternity-care workers at all maternity facilities on an ongoing basis.This article presents the results from a survey which sought to determine a) whether the health care workers who had completed the KZN ESMOE master trainer course were still employed by the Department of Health, b) whether they

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were active in conducting ESMOE training, specifically ESMOE fire drills, and c) the factors which facilitate or hinder the successful implementation of the ESMOE programme in the master trainer’s workplace.The findings would guide the Province regarding whether to maintain the current KZN strategy for scaling-up ESMOE training or whether changes to the strategy are required.

KZN model for scaling-up ESMOE trainingThe KZN strategy involves the train-the-trainer principle. Regular provincial three or four day ESMOE “master trainer” courses are conducted in collaboration with the University of KwaZulu-Natal. These courses, held approximately three times a year, at a central university venue, train about 30 participants each time. Those completing the course are certified as ESMOE master trainers. The course focusses particularly on training the participants in how to conduct skills demonstrations and fire drills. One of the key principles of the KZN master trainer course is that both midwives and doctors should be trained together, so as to instil in them the value of team training, as different categories of health worker need to be able to function as a team when confronting real emergencies.The KZN Department of Health took on the role of identifying suitable participants for the course by liaising with the district health management teams and with the health facilities themselves. It was important for any prospective participant from a facility to understand that attending the course came with a responsibility to conduct regular ESMOE training at that facility after completing the course. Thus it was important for enthusiasts with passion for teaching to be chosen. It was also important for the managers of the facilities who sent participants to the course to understand that they should ensure that the master trainer, having returned from the course, does actually conduct ESMOE training at their facility.KZN set a target that there should be ESMOE master trainers at every hospital running an obstetric service in the province. This would mean that every hospital would be self-sufficient, in that regular ESMOE training could be conducted at every hospital without the need for external trainers. By the end of 2013, at least one midwife and one doctor from each hospital had been trained. Each district health management team includes a District Clinical Specialist Team (DCST) which includes at least one of an advanced midwife, a family physician or an

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obstetrician. The KZN ESMOE master trainer course had trained at least one member of each DCST, so that the DCST could oversee the implementation of ESMOE training at the facilities within the District, and lend support and offer mentorship to the facility-based ESMOE master trainers.Taking participants through a three-day train-the-trainer course, however, does not guarantee that the participants will initiate ESMOE training once they return to their workplace. The potential benefit of the train-the-trainer strategy in reducing maternal mortality can only be realised if the majority of these master trainers do indeed start training their colleagues once they have completed the course.

Methods This study was approved by the UKZN Biomedical Research Ethics Committee and the Health Research Committee of the KZN Department of HealthThe study involved a cross-sectional survey design and targeted 51 government-sector hospitals spread across all the districts in KZN province. These hospitals were identified as ESMOE sites as they are the hospitals in the province which provide maternal care and delivery services and have sent at least one health care worker to be trained as an ESMOE master trainer. The study comprised a convenient sample of 143 ESMOE master trainers who were working at any of the target hospitals. This sample was drawn from a population of 406 master trainers who had completed the ESMOE master trainer programme during the 2011 to mid-2015 period. By May 2015, fourteen master trainer courses had been conducted. The master trainers included consultants in obstetrics and gynaecology, medical officers, clinical managers, community service medical officers, midwives, advanced midwives, a few emergency care practitioners, family physicians, and district clinical specialist team members. For practical reasons, the study targeted hospitals rather than smaller facilities such as clinics and community health centres, as hospitals were more likely to have larger numbers of master trainers per site.

Data collection A structured quantitative questionnaire was developed specifically for this study. The questionnaire included questions about the demographic and professional profile of the respondents, factors which promote or hinder the implementation of the ESMOE programme in their workplaces, the perceived impact of the

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ESMOE training in their workplace, and whether they had started implementing ESMOE fire drills and were still doing so at the time of the survey. Information was also collected on the categories of health care workers with whom fire drills were conducted, and the types and frequency of fire drills that the respondents had facilitated since completing the ESMOE master trainer course. Before data collection, a letter requesting to conduct the study was sent to the chief executive officer (CEO) of each eligible hospital. Hospitals that authorised the study were then physically visited with prior arrangement with the hospital CEO to request all ESMOE master trainers at that hospital make themselves available for the survey. All available master trainers completed the questionnaire after reading the participant information sheets and signing the consent forms.All the data were analysed using Stata 13 software.

ResultsOf the 51 hospitals approached, only 42 participated in the study. Two hospitals were not eligible: one because it was found that the hospital no longer had any ESMOE master trainer working there, and the other because at the time of the survey, the hospital had temporarily closed its maternity service due to infrastructural renovations, and the master trainers from that hospital were working at a different hospital. Seven other hospitals did not respond with the required authorisation for the study to be conducted there, despite repeated requests. From the 42 facilities which participated, 150 ESMOE master trainers were contacted and consent obtained from them. Of these, 143 responded to the survey (95.3% response rate). This represents 35% of the entire population of master trainers (406) who had completed the master trainer course at the time of the study. Not all of the 143 respondents responded to every question. The percentages listed below represent the percentage out of those who responded to that particular question. A selection of the results are listed below:Of those who responded to the field in question:

42% were doctors, and 57% were midwives

25% had moved to a post with a different job description since completing the master trainer course

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Despite this, 89% were still in a job where they could perform the role of a master trainer

92% of the master trainers had started implementing ESMOE fire-drills (emergency obstetric simulation training) and at the time of the survey and 83% (109 of 132 respondents) were still running the fire-drills. 75% were conducting fire-drills one a month or more frequently

The most frequently covered topics in these fire drills were obstetric haemorrhage and pre-eclampsia/eclampsia. Over 70% of respondents had conducted these drills.

92% of the respondents reported the participation of midwives in the fire drills they were running, while only 51% reported that medical officers participated.

44% of respondents felt that ESMOE training had a positive impact on the clinical skills of doctors at their facility, while 67% felt that it had a positive impact on midwife skills

56% felt that the ESMOE training had a positive impact on teamwork between different categories of staff, while 57% reported a positive impact on staff morale at their facility

The main reported barriers to implementation were shortage of staff, time constraints due to clinical workload, and shortage of equipment.

Good professional relations with junior peers, line managers and between different categories of staff, as well as supportive workplace policies, and support from outside the facility were reported as factors that enabled the implementation of ESMOE training at a facility

DiscussionDue to difficulties in accessing all workers who had completed the ESMOE master trainer course, only a minority of them (35%) were surveyed. In particular, those based at community health centres or primary health clinics were excluded as the survey only focused on those working at hospitals. Those who had left the Department of Health, for example because of retirement, were also excluded. Several hospitals did not authorise access to their master trainers for the survey.

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At other hospitals not all of the master trainers made themselves available for the survey. These factors mean that the responses received are not necessarily representative of all the health workers who have completed the master trainer course. Furthermore, the questionnaire format can lead to inaccurate or subjective responses, as the accuracy of the responses was not verified.Despite these limitations, there were encouraging findings. The survey was able to track down 143 master trainers across 42 of the 51 hospitals in KZN. Of these 109 reported that they were currently conducting fire drill training at their facilities, which suggests that significant coverage has been achieved for ESMOE training within a few years of the introduction of the programme, although there are obviously still gaps. Of those conducting fire drills, the majority are running drills on obstetric haemorrhage and hypertension, which are the two areas that the National Committee for Confidential Enquiries into Maternal Deaths had identified as being priority areas for training.

ConclusionThe survey suggests that the KZN model of running central ESMOE train-the-trainer workshops has resulted in successful implementation of ESMOE training by the master trainers at the hospital level and has improved clinical competencies, teamwork and staff morale. While this model for scaling-up ESMOE training has the potential for giving access to ESMOE training for all maternity health workers in KZN, it requires sustained resources for running regular master trainer workshops as well as external support and oversight at District level for the facility-based master trainers. Further research is required to assess the impact of the programme on clinical outcomes.

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IMPROVING PERINATAL OUTCOMES AND QUALITY OF NEONATAL CARE AT BUTTERWORTH HOSPITAL: A QUALITY IMPROVEMENT PROJECT

Yose-Xasa B¹, Mandondo S², Didiza N²¹Clinical Manager – Butterworth Hospital²DCST O & G & Advanced Midwive – Amathole Health District

Introduction: Butterworth Hospital is a medium to large district hospital located in Amathole Health District, Eastern Cape, with 260 beds. The hospital services a population of approximately 300 000 people, conducts an average of 3500 deliveries per annum & 20 000 emergency headcount per annum. Its location along N2 and being the only hospital between East London & Mthatha provides easy access for all motorists travelling along the national road. Butterworth Hospital is a referral hospital for 3 Community Health Centres (CHCs) namely, Nqamakwe, Dutywa and Willowvale and a centre for 24-hour Comprehensive Emergency Obstetric Care receiving patients from Tafalofefe Hospital together with the mentioned CHCs and a 24-hour Casualty department. The hospital experiences a challenge of inadequacy of human resources for health with a number of fulltime Medical Officers ranging from 7 – 9 at any given time and balancing with 2 – 4 Community Service Medical Officers. There is approximately 24 – 36 nurses running a 60-bed maternity unit inclusive of labour ward & labour ward theatre. High number of hypoxic babies delivered resulting in litigations; Absence of standardised guidelines on neonatal care, training on MSSN, proper stationery for admitted newborn babies, and lack of standardised audit tools to assess the quality of care provided were some of the critical challenges experienced at patient care level. A need to act was identified and presented to management.

Aim: Improve perinatal outcomes and neonatal outcomes to meet national targets and improve the quality of neonatal care for low birth weight and low Apgar babies to more than 80% in 2016.

Intervention / Method: 1. Shifted the task of assisting for the surgeon to professional nurses and advanced midwives during Caesarian deliveries in July 2014 in order to have 2 doctors (Surgeon & Anaesthetist) to preside during a Caesarian Section instead of 3 doctors. 2. Introduction of neonatal guidelines – The MSSN Chartbook, proper stationery for newborn admission, medical

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equipment for improved quality of care for all sick neonates, introduction of audit tools through the LINC Toolkit.

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Results1. Shifting assisting to the surgeon to professional nurses which resulted in

dramatic reduction in emergency referrals and fresh stillborn babies.Process measures: An Increase in number of C/S done & reduction in emergency referrals observed

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Overview of total deliveries, c/s, transfers out & transfers in

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Outcome measures : Perinatal Mortality Rate not yet stabilised as there are many other variables involved mainly MSB. Marked reduction in Neonatal Death Rate

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Comparison of C/S rate with ENNDR

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Chart 3: showing an Inverse proportion between C/S rate and ENNDR

2. Introduction of proper tools to improve quality of neonatal care

These tools include neonatal guidelines in the form of a chartbook – Guidelines for the care of all newborns in District Hospitals, Health Centres and Midwife Obstetric Units in South Africa;

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The Newborn Admission Record compiled in the form of a booklet; Procurement of proper medical equipmentAudit tools for Low Birth Weight, Low Apgar.

Process Measures: First set of 150 Newborn Admission record were purchased by Clinical Manager & Nursing Manager in 2015. Amathole Health district procured 300 records for the 2016/2017 Financial Year.

Outcome Measures: Clinical Audits were conducted to measure quality of care for neonates born with low Apgar scores and those with low birth weight.

CA LBW

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Clinical Audit for Low Birth Weight & Low Apgar babies compared to ENNDR in 2014 & 2016

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DiscussionImprovement of neonatal outcomes require commitment at all levels of care. The management level will create an enabling environment for operational staff to operate in the form of availability of appropriate medical equipment, appropriate infrastructure, distribution and training of the health workforce and a patient centred environment where each and every member of the improvement team buys in into the aim and objectives of the improvement project. In the case of Butterworth hospital, the district management team committed funds for equipment purchase, the hospital management team provided 3 more rooms to accommodate the neonatal unit. Training of health workers was done facilitated by DCSTs together with in-reach at Frere Hospital Nursery. Members of the

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management team started purchasing the newborn admission record neatly bound and later on the DCST team facilitated purchase of such stationery. All the above were based on a newborn care toolkit that was provided for by health partners of this initiative, the Limpopo Initiative for Newborn Care (LINC team). The MSSN guidelines were received within one year of publication.This common goal for improvement of health outcomes was also experienced when professional nurses committed to provide the service of being surgeon’s assistant in the light of limited number of medical personnel. As the numbers of professional nurses, advanced midwives in particular decrease, the gains made during the period of study will be reversed. One of the highlighted reasons is the fact that translation from an ordinary professional nurse (PNA2) to a professional nurse with a speciality (PNB1) takes many years. It would be ideal for hospitals like Butterworth to adopt a strategy where professional nurses working in maternity unit with advanced midwifery and neonatology get translated within a year of attaining a post basic course.

Conclusion: Improvement of health outcomes is possible when the right people operating in a right environment utilising appropriate tools commit and cooperate.

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RESPONDING TO PROBLEMS IN LONG TERM REVERSIBLE CONTRACEPTION UPTAKE AMONG TEENAGERS AT MADWALENI HOSPITAL EC USING AN IUCD VIDEO IN XHOSA AS AN INNOVATIVE COUNSELLING TOOL

Dr A Miller, Dr SD Mandondo, S du Plessis, Dr M Allen, N Dangazele

Problem statement and purpose: Madwaleni Hospital is a 180-bed rural district hospital in the Amatole District. In 2013 the hospital had a high number of maternal deaths (5) and a high teenage pregnancy rate, with poor teamwork, lack of leadership in maternity and few, mainly non-South African trained doctors. However, once the maternity management was changed and recruited new committed doctors and a new clinical manager were recruited, this, together with in-service and district lead training, resulted in increased staff motivation. The iMMR WAS 0 in 2014/15 with an inpatient NNDR of 3.5 per 1000.In order to improve MMR and MNCWH indicators, the team, in conjunction with DCST, embarked on a strategy to improve long term reversible contraception. This coincided with the national roll out of Implanon which was launched at Madwaleni.Method: The entire facility was educated about the benefits of contraception and it was offered in all medical and surgical wards. From security at gate there was advocacy for contraception and uptake of Implanon was very high. Staff was trained on Implanon insertion with onsite mentorship. Results: About 80% of teenagers opted for Implanon on discharge, and it was the method of choice in 2015. Deliveries under 18 years reduced from 213 to 102 (16 to 10%).

Year Delivery in facility total

Delivery in facility under 18 years

% Delivery in facility under 18 years

Delivery by CS

Inpatient neonatal death Total

2011 1277 213 16 161 112012 1242 184 14.8 67 92013 1437 206 14.3 231 162014 1413 174 12.3 289 82015 1394 156 11.19 318 62016 1032 102 9.98 214 4

However, revised guidelines to exclude clients on ART and TB drugs reduced the uptake. Misinformation in the local community regarding side-effects also resulted in decreasing popularity of Implanon with insertions down to less than 5 a month. Despite retraining on managing side effects, the demand for removal increased. IUCD uptake was low during this period, largely because of lack of knowledge regarding the method amongst patients.Intervention: In 2015, the hospital recruited a family physician as clinical manager and in 2016 was accredited as a family medicine registrar training site; with 12 doctors, mostly permanent employees, and a large allied team. The need for increased appropriate long term reversible contraception uptake was identified by the staff as an improvement project. A video aiming at IUCD education and increased uptake was championed by Ms M du Plessis, a volunteer social worker in November 2016, in conjunction with the nursing and medical team. The video, which is narrated in Xhosa, is currently used extensively for patients who are considering IUCDs, as well as being shown regularly in the

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hospital wards and OPD. IUCD at CS is offered with increasing uptake of IUCD to 10-15 a month envisaged. All medical staff are now trained for IUCD insertion and removal.The link to video is attached and will be shown Full Resolution version: https://drive.google.com/uc?export=download&id=0B3WI_ngMPi2gVmoyRXVNU19ZbjQHIGH INCIDENCES OF IMPLANON SUB DERMAL IMPLANT PREMATURE REMOVALS IN FAMILY PLANNING CLIENTS: A CONCERN IN EKURHULENI DISTRICT

Nomvula MasekoEkurhuleni Health District, Gauteng Province

BackgroundImplanon sub-dermal implant is a new long term reversible contraceptive method which was launched by the department of health in February 2014. It is a progesterone only contraception and consists of a single rod and is about 4mm in diameter. It is inserted sub dermally on the inner part of the non-dominant upper arm. Once inserted is effective for three years.

Problem Statement & study objectives:In 2014, immediately after this new Implanon implant contraception method was initiated, a huge number of clients came back within a period of six months to get it removed.

To determine the rate of unwarranted premature removals of Implanon implant in the district.

To explore factors associated with unwarranted premature removal of this contraception method.

Methodology: Study design: Pre and Post Intervention. Study period: May 2014 to November 2015. Study sites: Six clinics in Ekurhuleni district (2 clinics per sub-district). Sampling: Convenient sampling based on clinic size. Target Population: Family Planning (FP) clients and health workers. Data analysis: Descriptive statistics (frequencies).

Results:Pre Intervention: May-Oct 2014Post Intervention: March-September 2015

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Intervention: November 2014-February 2015 Comprehensive training of nurses on Implanon insertion.

Training of other cadres such as Health Promoters and Ward Based PHC Outreach teams.

Health Education to FP clients on possible side effects of Implanon.

Six reasons for removals were: Breakthrough bleeding, on Anti-Retroviral Treatment (ART), pregnant,

weight gain, loss of weight, removal because others did so.

Comparison of insertions/removals

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Limitations and conclusion Lack of dedicated clinic registers to capture insertions or removals may

have affected actual numbers. Indicator not included in DHIS. The effect of the training was not measured and could have contributed to

the removal rate remaining the same.

Conclusion:

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• Premature Implanon removal was still a concern in the district.• The number of Implanon removals was not improved by the intervention.• The side effects of the Implanon implant are a bigger issue than

anticipated and will continue to contribute to increased premature removals.

Recommendations• It is important to look at long term effect of Implanon Implant for the

client. • Consider retraining health providers on proper counselling skills before it

is offered to the community.

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FACTORS ASSOCIATED WITH TB SCREENING FOR PREGNANT WOMEN LIVING WITH HIV IN UTHUNGULU DISTRICT IN 2012

Miss Sthandwa Mngayi , King Cetshwayo Health District OfficeDr Anna Voce, University of KZN

IntroductionTuberculosis (TB) and Human Immunodeficiency Virus (HIV) in pregnancy are risk factors for both maternal and perinatal outcomes . TB is both preventable and treatable in pregnancy. TB is preventable in pregnancy by initiating Isoniazid (INH) prophylactic therapy (IPT) after TB has been excluded . Prevention and treatment of TB in pregnancy is dependent on early detection through screening . This study explored factors associated with TB screening in the antenatal care services in the province of KwaZulu-Natal in uThungulu District in 2011/2012 .

MethodsAn observational study design with descriptive and analytic cross-sectional compone nts was carried out in uThungulu District health facilities for pregnant women living with HIV at first antenatal care visit. Multi-stage sampling was used. A structured interview and data extraction tools were used to collect data. Data was analysed using descriptive and doer/non-doer analytic statistics .

ResultsThe study found that Clinics were more likely to screen pregnant women for TB if visited by PHC supervisor , with personnel training on TB management , leadership and governance . Presence of enrolled nurses focusing on TB screening and trained in TB management was associated with higher TB screening coverage at clinics.

ConclusionsBased on the findings, conclusions made was that PHC supervisors should provide leadership in Basic Antenatal care service and that all midwives rendering antenatal care should be trained in TB management , in ART for pregnant women and in PMTCT to improve TB screening and management of pregnant women living with HIV.

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BARRIERS TO PROVIDING QUALITY MATERNITY CARE IN AN URBAN SETTING IN SOUTH AFRICA; A QUALITATIVE DESCRIPTIVE STUDY.

Jaki Lambert,1 Elsie Etsane,2 Nynke van den Broek,1 Anne-Marie Bergh,2 Robert Pattinson2 1 Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine2 SAMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoriae-mail address of author: jaki.lambert@gmail.com

BackgroundWith the focus on respectful maternity care there is an increasing awareness of the need to ensure person centred care as an aspect of Quality care. However, for that care to be truly patient centred, it is important to identify the barriers to achieving quality care and to understand if they are common to facilities or specific to each context. The explanation for improvement in maternal outcomes not being proportionate to attendance by a skilled birth attendant has been attributed, through the obstetric transition model, proposed by de Souza et la (2014), as a stage in the process to improving outcomes, wherein the progress has been made to ensure that women are attending facilities, but due to the quality of care, outcomes are not greatly improved.

A systematic approach to improvement is described by the World Health Organisation Quality of Care model (Tuncalp et al 2015), with quality being defined as: safe, effective, efficient, timely, equitable and person centred care. This requires the ability to measure all aspects of care quality. The challenge is often in monitoring the more qualitative aspects of care, from confidence to practice and skill level, to the interpersonal aspects of care. Both the landscape analysis by Bowser and Hill (2010) into respectful care and the systematic review by Bohren et al (2015) have increased the attention and progressed the discussion into acceptable care but recognised that more work is required to identify how to monitor this. Unfortunately, the ‘easy’ response in many instances has been to attribute responsibility to the care provider rather than taking a broader approach. It is clear that there is a complex interrelationship of contributing factors underpinning why a woman may receive care that is not acceptable to her. The social, economic and health system barriers health care providers experience in their daily working lives are equally attributable. (WHO 2016). While removing mistreatment and abuse does not equate to care of good

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quality, a first step must be to identify the barriers to improvement in order to be able to address them.Therefore, this study will facilitate quality improvement that is situated within the local and country context.

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METHODS

AimThe aim of the study is to identify if the barriers to providing good quality of care are consistent between facilities in Tshwane and whether they are context specific. Objectives

To identify barriers to good quality of care that can help inform how the quality of care can be improved.

To find out if a mobile platform (or alternatives) is an acceptable way of assessing quality of care.

DesignA qualitative descriptive study was carried out in Tshwane District, utilizing semi-structured interviews and focus group discussions (n=26). Participants included women of all risk levels and mode of delivery (n=18) who had given birth in the preceding 12 weeks in 4 hospitals in Tshwane Excluded from the study were women under 18, women who either did not wish to, or were unable to consent or who appeared too ill or unwell. A second group of participants included care providers of all cadres in the labour wards (n=16). Key informant interviews were conducted with (n=5) participants with an influential role regarding the care provided within health facilities. The sampling method was purposive and opportunistic to ensure that the sample chosen was representative of the chosen population. (Robson 2002)EthicsEthics approval was first gained from both the Liverpool School of Tropical Medicine (16-003RS) and the University of Pretoria (ref:81/2016). Individual permissions were then sought from all facilities identified for the study and from the Tshwane research committee(ref:09/2016)Data CollectionData collection methods included semi-structured individual or focus group interviews. The choice of method was determined by availability and by convenience to the identified participants, one to one interview was the preferred method as it elicited a richer level of data and reduced interruption. Women were invited to take part while they were waiting for appointments. Interviews took place in offices and consulting rooms off the main clinical area in order to preserve privacy, minimise disruption and allow for free discussion. Key informant interviews were prearranged at convenient times for the interviewees

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at one of the sites. An interview schedule was utilised for all interviews with the questions having similar content but with the questions appropriate to the participant group. An explanation of the purpose of the interview was given either in English or their preferred language and the patient information leaflet was reviewed and a copy offered to the woman. Consent was sought only after it was clear that the participant had understood the explanation and was happy to proceed, all interviews were audio taped. Interviews with the different participant groups continued until saturation was reached.Data AnalysisTranscriptions were independently reviewed by a second researcher and consensus reached over codes for analysis. The interviews were uploaded and coded in NVIVO 11 (mac version). The data was analysed using a framework thematic analysis, this methodology is used when analysing data from the perspective of informing health policy as opposed to from a more psychosocial perspective. The purpose was to deduce whether certain categories of acceptable care are confirmed and to use an inductive approach to identifying further categories (Gale et al 2013, Ritchie et al 2003). 5 interviews were open coded. Thirty-three codes were identified at this stage and categorised into seven categories. All interviewees were coded together as all participate in maternity services, separation into health care provider and recipient was carried out at the thematic analysis stage. An analytical framework of the seven categories: beliefs and attitudes; rapport/communication; human rights; organizational structures; leadership; professional issues; and use of mHealth (e.g. Momconnect/cell phone) was developed in excel. This facilitated analysis within and across categories to identify emerging themes: these were then examined to explore if they could be categorised according to existing frameworks and models (Freedman 2014, Bohren 2015).ResultsOnce analysis was complete the data was collected into the modified model (fig 1) allowing for classification of context specific barriers to good quality treatment. seven themes were described.1. Alone, exposed and unsupported. This theme crossed all seven categories and was described by women, students and midwives. This was the most important theme identified by women, not wanting to be alone, feeling cut off from family, most would have wanted a companion to be present and while they would have liked it, they did not expect the midwife to stay with them. Most were

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not offered a companion and if they were it was only for second stage. This is made worse by the ‘working definitions’ of labour. so women can always have a companion in labour? P: yes, they can always bring one person I: all the way through labour? P: Yes, from when they are in active phase. I: when is the active phase? P; when they are about to deliver, Tsh_StMW_11_H2_20160513It was evident across facilities that the first stage was often not being counted as labour but as the latent phase, with labour and the need for a companion being around the second rather than the first stage. While this may be a staffing issue and due to structure of labour rooms it also appears deep-seated in practice as it was brought up by various levels of staff and patients. Its supposed to be when they are in the active phase from 8 cm but due to the workload we only have time to go sit with the women on that side we usually take the woman when they are fully dilated to that side. Tsh_N1_11_H2_20160513Staff and students also felt exposed in their practice and unsupported. Leaders were identified by staff however their presence was transient, there was a lack of consistent leading by example. Key informants and staff all valued clinical leadership and recognised that when respected people: professor, lecturers, were there then the behaviour was’ the best it could be’. There was no description of visible leadership on a day to day basis.Nor did staff perceive that they had the support of leaders who were often only visible when something goes wrong and not to listen to the staff. The impact of this was clearly described;‘I also feel, if we don’t consult when we get old, we become these angry midwife. Because I’ve seen all those old angry midwives, they don’t smile any more, even when you greet them. You can’t differentiate if they are happy or sad any more. I feel like they are traumatised or something. They don’t get to talk about their experiences. They don’t get therapy. So I think we should do that more often and become happy midwives, giving adequate nursing care up until we go to pension.’Tsh_FG1_H1_20160509

‘Yes, you know patients complain always but they tend to be on the patients side they don’t hear the side of the midwives what really happened yes? Tsh_N1_11_H2_20160513

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This theme was evident across all facilities2.Mutual Distrust due to Negative Perceptions. Media has influence. Evident across all seven categories‘We are not bad and often women come with the mentality that we are going to get treated bad. And then after they get this care, they are like, ‘Wow, I expected to be treated bad. ’line 22 p8 nm 4 Tsh_FG5_N_H3_20160511Mutual distrust was evident, impacting on rapport building. Nursing staff were threatened by perceived high expectations, which they felt companions exacerbated, making them unwelcome. While negative beliefs about maternity services acted as a barrier to care as women were scared and Midwives felt undermined by the negative perceptions, and both groups felt that the media had some responsibility for this. Key informants expected caring behaviors but did not express them and some appeared judgmental, those that were supportive were better able to identify where changes could be made

3. Paternalistic attitude to women in labour impacting on consent and choice. This was evident in five categories; beliefs and attitudes, communication, human rights, professional issues and leadership This was expressed as a common view that women in labour are unable to make the right decisions, and need to be told what to do. With this belief comes the negation of the need for consent and choice. This lack of choice and control was apparent for both midwives and women. this links to compliance being valued compounded by a belief that, in a training institution, for skilled care, you barter choice. This gave an indication that choice and decision making is fundamental but that the midwives and nurses are not able to offer choice. Nor is there any evidence that they truly believe women can refuse or have alternative choices. Therefore, while midwives had the knowledge that choice and consent was important there was dissonance with their description of an ability to offer this care. This was evident to different degrees across facilities however H1 appeared to be better able to offer consent if not choice.Keep on reminding them what they have to do, even when they have had a baby they make mistakes. ‘Remember what I showed you on the chart, don’t do this or you will hurt the child.’ Tsh_N_FG5_H3_201605114. Procedure rather than patient centred, advocacy role of midwife not evident. This was evident across six categories; all other than momconnect. Clinical skills were valued above caring skills. Care in labour was primarily described in relation to interventions or tasks. Explanation and, consent is

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described, more as a means of achieving a clinical procedure, rather than a caring behavior or for building rapport. Skills and procedures were valued but there was no mention of the role of the midwife in advocacy or being with women. This was reflected from care providers and women. There was little evidence of who was the advocate for the care providers other than in one facility. Again staffing challenges is a contributory factor.Exemplary care was admired but not the norm, clear examples of good patient centred care was given but as an outsider looking in not as part of practice.Best care, l like during major ward rounds with the prof[essor], because you see something different, what they don’t usually do. I’m also not doing that because when they are taking rounds with the prof, they greet the patient and introduce themselves [laughter]. Tsh_FG1_H1_201605095. Verbal abuse is normalized; this was evidenced across six categories other than momconnect. There was no woman that thought the shouting was justified and described how it made them feel. Many of the women could clearly articulate how they wanted to be talked to.‘No, they just shout at you. No, ‘Do like this. Don’t push. You don’t have to push ‘cause the baby will be hurt’ and all that. They were just shouting, so I think the pain was getting worse when they do that! Just shouting at you, ‘Do like this. Open your legs!’ No, they were not nice! Tsh_PNM3_II_H2_20160512 It was normalised and justified in terms of pressure from being busy and staffing and as a necessary part of the labour process. There is an acceptance of being impersonal and distancing yourself from the woman’s experience. ‘after delivery, they are going to start to give you a different attitude because you were shouting at them, because you were trying to save the baby. You were not necessarily shouting at her but just trying to get her to do the right thing. ‘Tsh_FG1_H1_20160509 This often appeared to link to fear and not feeling supported, the time of birth appears tense and fraught from descriptions.6. Dissonance between knowledge and Practice. This was another cross cutting theme evident across all categories.In relation to the application of known human rights; where there was widespread understanding from women and their care providers around the importance of; privacy, food and cleanliness, both women and Midwives described not always able to access basic needs, for example when clothing is contaminated with no access to barrier aprons or when clean linen is not

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available. Therefore, system and environmental factors were often a barrier to practice causing a direct impact on women’s care in terms of safety, pain, dignity, privacy and mobility. The systemic impact on human rights was also seen relating to supplies and equipment, midwives knew what equipment was required but were unable to access this. Women experiencing pain and discomfort as a direct result of the wrong catheter size only being available and lack of pads causing embarrassment and shame for women. This appeared to be a barrier in one hospital in particular. However, while staff knew it was a supply or an environmental problem, women just perceive the lack and relate it to the care.… some are coming from the poor people. They don’t have pads and they don’t supply. So they are dirty, blood down legs. They are dirty because they don’t have them, no money. Poor people should have pads available. Tsh_PNM7_11_H1_20160509Most of the time we ask them if happy with care they tell us. But we can only offer a certain amount of care Tsh_N_FG5_H3_20160511However, another form of physical mistreatment, withholding pain medication or not addressing pain was experienced by some of the interviewees in this study. Not just that pain medication was not offered, but that if requested they were ignored or it was denied as an option. This is highlighted by women and key informants as an issue more than by midwives.‘It’s terrible. They don’t take good care; they shout you when you got them pain. They shout you to lie down; you don’t want to lost your baby. And when you got the pain, they just go way. They lock the door and sit in front of the reception. They were laughing Tsh_PNM5_11_H1_20160509Mobility was described in theory, however in terms of practice due to both environmental and the culture of the facility was not described in practice.Their position during delivery, although we tend to tell them what position they should be in, to be in for delivery for our own comfort or the visuals. Tsh_N1_11_H3_20160511However, the organisational and rights aspects become a problem where; Patients want to see a doctor therefore often come to the wrong level of hospital, as the nurse led service is valued less. This relates to the is human right approach of a perceived right to see a doctor? Recurring theme of scarce resource (obstetrician) seeing women that should be under midwife led care. Therefore, while the midwife knows that the woman does not require to see a

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doctor in practice there is a belief that she has this right, this is shared by the women.On of the greatest knowledge practice gaps relates to monitoring in labour. Due to staffing, existing culture and structure, women are attending late at the facility in order to spend time with family until ready to deliver. The lack of monitoring, for low risk women in labour underpins why women make this decision. However staffing is impacting on this not just numbers but skill mix so that even when midwives try to give care it is not to the level they wantSo because of that timeframe you know what you must do and you do it you say I am here to do 1, 2 3 and you do it and you leave you don’t explain why you want to do it because there is no time for that you need to attend to someone else so I feel I am not giving what I need to or what I would wish [emphasis] to be giving. Tsh_N2_11_H2_201605137. Professional Hierarchy acting as a barrier to decision making and referral.I think that this need to be in their training that makes use of the midwives but at the moment the doctors are the high and mighty and you can’t say a word .Tsh_KI3_II_H3_20160511Again evident across all categories, however there were distinct differences across facilities. In H1 where there were dedicated obstetric doctors there appeared to be better working relationship and respect and midwives were happier in their role. Those with advanced midwife qualification seemed more proud and enthusiastic about the job, perhaps due to more knowledge and skills resulting in them having less fear. Communication is often not supported when it is from a midwife to an obstetrician, for advice or referral, the general medical input appears to be more hierarchical than a benefit to patients and may be causing delay as they are not based in maternity and may not ‘like maternity ‘. Therefore, beyond numbers of staff there appears a lack of value or advocacy for midwife led services both from women and from medical colleagues that acts as a barrier to care.8. Momconnect/mobile phone this was used by the majority of women and was known to most care providers, the majority of women said they would be happy to feedback though this platform but it was also suggested that groups at clinics may be an effective way of collecting feedback also. Health care providers felt that if anonymised this would be an effective way of giving feedback regarding their ability to give the care they wanted to give.

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DiscussionIt is clear that both the themes described by Bohren et al (2015) and similarly the levels of attribution described by Freedman et al (2014) Fig 2. both align with the broad findings of the study and the development of the model of Barriers to Quality of Care (fig 1). However, what is added by this study is that it demonstrated providers have the knowledge regarding quality of care but that organisational and structural challenges along with certain beliefs and attitudes, staffing and culture within the labour wards are inhibiting implementation. There is a risk that workshops can make people more eloquent in their use of respectful care language but not change practice if the wider issues are not addressed. It is also clear that the working environment need to become a caring environment which cares for the staff as well as women. Respected clinical leadership, mentoring and role models support must be a constant to bring real change. The role of the midwife as carer and advocate need to be promoted as much ad the clinical role.The views of the women would appear to be an effective measure of care received but not of identifying the reasons why. This is the responsibility of the organisation.Skills drills and ESMOE were valued by all care providers as a way of maintaining skills but their value in promoting mutual respect, team working and referral is equally important in challenging thinking and behaviours. With the drive to improve skills there is a risk that technical skills can be valued above caring behaviours. These leaders need to supported to use candour in identifying what the hospital can and cannot meet in terms of structure, staffing, equipment and supplies. The public can then separate the care provider’s responsibility from that of the management and government. The media is clearly a tangible influence in Tshwane and could be utilised to better support rapport.The model in Figure one clearly shows level of accountability and identifies where improvement can be made to address the identified themes.ConclusionsThis study demonstrated that while there were variations between the facilities, the categories identified were applicable across all four facilities and the themes were consistent across all categories and facilities. The model of barriers could therefore be applied across Tshwane to help implement a model of quality improvement.

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While addressed separately, within Tshwane, mobile phone was overwhelmingly an acceptable way to gain feedback from both women and care providers.

**It is important to look at this study in the context of the wider study as it has focused on the negatives in order to identify barriers. This has meant that the many areas of good practice identified by both women and care providers have not been the focus and will be shared in another paper. Also that there were no instances of direct physical abuse described in the four hospitals. there were differences within the facilities however this would not mean that all facilities should not have these themes monitored as when there were problems they had significant impact on care.

Annex 1 : models

Figure 3: Modified model of barriers to quality of care in Tswhwane

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Figure 4:Freedman 2014

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MOMCONNECT AND NURSECONNECT: POSSIBILITIES FOR PERINATAL IMPROVEMENT.

L Bamford

MomConnect, a ministerial flagship programme was launched in August 2014. It is a mHealth programme aimed at improving the health of pregnant women and their infants as well as improving the quality of care that they receive from the public health system. It does this by sending SMS messages to pregnant and postpartum women based on their stage of pregnancy or the age of their infant. MomConnect allows these women to interact with the health system via a central helpdesk in the national Department of Health in Pretoria. Women can ask questions, they can rate the services they receive and they can submit complaints or compliments about the services they receive. These questions are answered by trained professionals staffing the helpdesk and the ratings and complaints are directed to the relevant managers in the health system thus providing them with valuable feedback and allowing for some improvement in service delivery.NurseConnect is the sister programme to MomConnect. It was started in May, 2016 and formally launched by the Minister of Health on World Prematurity Day 17 November 2016. It aims to support nurses and midwives in their daily work and specifically improve maternal and newborn clinical knowledge and provide professional and psycho-social support for nurses.

The content of NurseConnect is currently sent to them via SMS. There are three kinds of messages. The first group are informational with clinical content and are largely based on the NDOH protocols for nurses and midwives. These messages have all been reviewed by members of the NDOH content review committee, and edited by a medical professional for content and flow. Examples of clinical messages include:● “Remember the Golden Minute. If a newborn baby is not crying or breathing well after drying, you will need to help the baby breathe.”● “Take care not to perform a digital vaginal examination if antepartum bleeding is present." You must first rule out placenta praevia.”● “Remember: check mom's HIV status. Make sure that she and her baby are getting the care they need as outlined in the latest PMTCT guidelines.”The second group are motivational SMSs were developed by a medical professional and a writer, in close collaboration with nurses. They were designed

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to help support nurses and midwives in their daily work, and provide them with motivation and encouragement.Examples of motivational messages include:● “De-stress Tip: Laughter & tears are natural stress-busters! Have some fun after work. Treat yourself: go see a movie or have a massage.”● “Learning Tip: A midwife who works hard and puts her patients' needs first, will usually be respected & appreciated by the people she serves.”● “Did you know that your patients are 76% satisfied with the service they get at SA'smaternity wards? Hats off to all midwives, nurses & CHWs!”

There is also a NurseConnect mobisite (a website designed for mobile phones). Currently the content of the articles on the website are largely similar to the messages sent to the nurses but with much more technical stuff. Nurses can download articles about specific themes that may interest them. These articles were written by specialists and reviewed by the NDOH. Nurses are also encouraged to tell their stories or ask questions. The address of the mobisite is www.nurseconnect.org . By end of February 2017 over 1,2 million pregnant women had registered on MomConnect and received messages. This represents approximately 50% of all pregnant women in the public sector. These women on average ask about 1000 questions a day of the help desk; they have made nearly 8000 compliments and made over 1000 complaints.During the nine months that NurseConnect has been operational over 16000 nurses have registered and have received weekly maternal and neonatal health messages. Plans for the future include moving from SMS messaging to Whats App, which has already approved in principle for MomConnect and NurseConnect to use this format. The advantages of Whats APP are numerous. These include an easier registration proves; being able to convey much more information as well as pictures and other content; being able to have two way communication; and much lower cost of data transfer. The helpdesk for nurses will be operational from May 2017. This will allow nurses to ask questions about patient-related issues and get responses from professionals; it will allow nurses to make observations about the environment in which they work and make suggestions for improvement and it will also serve as a means for nurses to make complaints about their work situation.

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The current messaging is aimed at pregnancy and the neonatal period and this will be extended to child health messaging as well. It is also envisaged that a set of messages aimed at nurses working with TB patients will also come on line in the first six months of 2017 and that ultimately there will be messaging covering all aspects of nursing related practice in South Africa. Individual nurses will then be able to choose which sets of messages they want to receive. It is also envisaged that 80% plus of all nurses in the public sector will register on NurseConnect. This will make it easy for nurses as a whole to air their voices and better communicate their concerns, satisfactions, frustrations and successes. In short to tell their stories. In all of these the aim is to improve the quality of care received by their patients, especially those most vulnerable including babies in the perinatal period.

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LISTENING TO MIDWIVES

Barbara Hanrahan, Sue Armstrong : Witwatersrand University

Study title : Developing an intervention / complex intervention to enhance respectful maternity care in labour by midwives in the public

Midwives Obstetric Units in Gauteng. Listening to Midwives

Abusive and disrespectful care towards some women in labour and birth occurs in countries and facilities where women are most vulnerable. Women birthing at the public health sector Midwives Obstetric Units (MOU) in Johannesburg, Gauteng come from a wide variety of backgrounds. Johannesburg particularly attracts migrant families and short stay women from other areas such as Limpopo province and countries in Central and Southern Africa.

This means that mothers and midwives may face ethnicity, language, nationality, culture and financial challenges during maternity care at these community health clinics. (CHC) Midwives are often perceived to wield a lot of power and authority, whilst women may feel particularly vulnerable during pregnancy, labour and postpartum.

Early in the new millennium Penny Simkin – an obstetric physiotherapist published two papers on “Just another day in a woman’s life.” These were on the long term effects of a positive birth experience on the woman in her role as a mother and parent. Women experiencing traumatic births suffered from many more postnatal and beyond problems than women who perceived that their birth was a positive experience (not necessarily based only on the outcome). This impacted significantly on the quality of parenting and care for babies and young children. Especially the early bonding process between baby and mother. Which in turn influence the child’s early development.

Using Fraser’s 5 step approach, the exploratory phase (step1) of this study consists of an integrated literature review, interviews with postpartum mothers, midwives narrative sketches and midwives nominal groups.

For the purposes of this presentation I am focusing on what midwives had to say (slide) about respectful maternity care.

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Midwives at the 10 MOUs were asked to write a narrative sketch on how they perceived respectful maternity care, including opportunities and constraints. These sketches were anonymous so midwives could write honestly about their experiences

Then nominal group discussions were held following the morbidity and mortality meetings which each MOU held monthly together with midwives from the feeder clinics.(the midwives from feeder clinics usually worked on their own providing antenatal and postnatal care)

This preliminary analysis was done using codes and developing core themes. This will be used to work towards a thematic map that integrates the literature and the outcomes of the mother interviews.

Note : in the narrative sketches midwives wrote about respectful and non-respectful attributes of midwives. Whereas the main focus in the nominal group interaction was on the challenges in the work environment.

Themes which arose from the midwives input are :

Supportive behaviours identified by the midwives included : reassurance, welcoming, greeting woman by her name : M11 “listening and responding in an appropriate manner,”

Using appropriate body language, therapeutic touch, cultural sensitivity, consensual care, alleviating pain e.g. rubbing a woman’s back: M10 “Showing motherly love.”

Respecting women’s wishes : M8 “ treat the patient as an individual with respect and good care”.

Over 24 supportive behaviours were identified by the midwives.

Midwives working environment : challenges included :Lack of consumable shortages – no ID bands, linen savers’ aprons, sanitary pads – shortage of linen: M6 “ beds are not changed between patients”; “ The

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midwives absorb the costs of buy batteries and airtime (e.g. to get lab reports). (There is a system being put in place to assist midwives in getting lab reports – but not fully rolled out yet.) shortages of suturing materials.Overcrowding of the labour ward – reduced privacy; language barriers with foreigners interpreters often not available – no control over what the person used to interpret actually says. M33 “ respectful care is lost when there are factors like language barriers and we are overflowing with patients.”

Need heaters in winter, fans and mosquito control in summer.

Working with the community perception that M6 “ community perceives the midwives as cruel and inhuman. This causes a barrier between the midwife and patients. Patients have an attitude towards the midwives."

A lot of the midwives commented on the lack support from their immediate and facility managers, especially when something goes wrong. This leaves midwives feeling demoralised and unmotivated. Ultimately this leads to poor care.M23 “ If you do well you are not praised which is discouraging.” Low morale makes for absenteeism and resignations.

No debriefing occurred after adverse events. M24 “ so sad when you have to deal with a stillbirth. “ This was referred to often in both the narratives and nominal groups.

Staff shortages :There were often only 2 midwives per shift; midwives feel that this leads to compromised care : M13 “2 midwives per shift is not safe”. M15 “ I fear for the midwives (risk of litigation).”

The strenuous work load – midwives are exhausted, high staff turnover, absenteeism:. M23 “ We work extra hours that we are not paid for. M23 “The women come in with serious maternal conditions – which stretches the work load.”

Some midwives favour internal rotation as a way of recovering from the stress of labour ward – Although not all MOUs / CHC do internal rotation.

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Midwives also commented on the need for all the midwives in the labour ward to be experienced and up to date – often lacked confidence in their colleagues. A midwife cannot be sent out for in-service training – leaves the shift short of staff. Staff are expected to attend the M&M, staff meetings and in-service on the days off.

Health system failures:Equipment not maintained M12 “ the dynamap is not working and you want to check a BP manually and there is no baumanometer working “.

Intervals when there are stock outages of ARVs and oxytocin.

Time ambulances take to get to the MOU and then to transport high risk women and newborns to the referral hospital.

Client related factors:A lot of midwives wrote / commented on the women’s lack of birth preparedness – not knowing what to expect in labour, poor preparation of a bag for labour, post birth and baby. Many women had no money for food or transport.

M21 : “Unbooked women and BBA’s put midwives at risk”.

Women were very reluctant to be referred or transferred. High risk women arrive at the MOU in advanced labour may lead to an adverse event e.g. Stillbirth.

M20 : “women come in in advanced labour having taken traditional muti and present with hyperstimulation of the uterus and foetal distress.”

Conclusion :Many passionate midwives choose to work within a community at an MOU or doing antenatal and postnatal care at a feeder clinic. In these areas midwives work independently which is stimulating but often challenging. Midwives embracing these options need support and recognition of the constraints within which they work. Fast track problem solving will reduce work place stress and

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free midwives to concentrate on providing quality of care to women using these facilities.

Midwives need to be aware of the developing power relationships with their clients and not to abuse this inherent authority. This leads in to the realm of workplace bullying and misuse of power relationships in the MOU team.

Midwives in this study have shown that respectful care is on the agenda and can be promoted. Burnt out, exhausted and frustrated midwives, constantly working in understaffed shifts, are less likely to work on being respectful and are more likely to be verbally and physically abusive, especially towards women who appear to be unresponsive to the midwife’s instructions during labour and birth.

It is important that midwives be able to prioritise and utilize all 24 supportive behaviours they have identified as respectful care.

M24 “ My experience in maternity care is awesome. I love that each day is unpredictable. Each woman is an individual requiring individualised care.”

M31 “ Most of the women delivered at our clinic are happy to be delivered by midwives and they trust us.”

M16 “Respectful maternity care starts as soon as the woman walks into the facility”

Respectful maternity care can be achieved with very few facility based resources if midwives work lives are conducive to patient centred care. The greatest impact is made by the caregiver – the midwives. Thus the need to listen to what the midwives are saying.

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MATERNITY WAITING HOMES (MWH) IN THE FREE STATE PROVINCE: A REVIEW OF EXPERIENCES (2006-2016)

Shisana Baloyi 1 , Victor Moyo2, Victor Akeke3, Martin Schoon4.1Head of Department O&G, University of Free State and Universitas Hospital,2DCST Family Physician Mangaung district, Free State, DoH 3DCST Family Physician Thabo Mofutsanyane District, Physicisn Free State DoH, 4Provincial DCST Obstetrician Free State, DoH.

Introduction.Maternal mortality remains one of the major public health challenges globally. Access to professionally trained birth attendant during labour has been identified and accepted as one of the intervention strategies for reducing maternal and child deaths. With the aim of promoting institutional births to reduce the high maternal and child mortality rates for women living in remote areas or those who lack adequate transportation options in rural and poor zones, the government of South Africa has introduced dedicated obstetric ambulances identified the establishment of maternity waiting homes as a priority intervention. Maternity waiting homes take many forms, but are typically residential facilities located near emergency obstetric care facilities where women, often with high‐risk pregnancies, can await their delivery in close proximity to care. Some are simple shelters where women must provide their own supplies, while others have antenatal care services and medical staff available. Some hospitals in rural areas allocate a dedicated area at the antenatal ward for use as maternity waiting areas. Despite a lack of available good data supporting the impact of maternity waiting homes on maternal health outcomes, experience indicates that maternity waiting homes may improve access to obstetric care. A Zimbabwe study found that when MWHs were available, nearly 60% of women used them, concluding that MWHs can improve access to obstetric care. As long as access to emergency obstetric services is limited due to poor transportation systems, challenging terrain, and substantial distances, MWHs are a promising option for expectant families. We therefore use the access to emergency obstetric care as a proxy for good use of maternity waiting homes.

AimThis study analyzes that strategy and examines the benefit from and factors associated with the use of maternity waiting homes in those facilities which made them available.

Method We apply a quantitative approach and analysised the data extracted from surveys conducted from 2006 to 2016 on all the hospitals which created maternity waiting homes as well as a qualitative approach based on interviews with key informants who utilized the services.

ResultsThere were variable results with evidence of benefit to the patients(maternal and fetal). The results which dependent on the level of training of the birth attendance and the readiness of the facility to manage the prevailing obstetric emergency. The operation of the maternity waiting homes was usually satisfactory,

Conclusion.

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There is some benefit in MWH, this practice should be extended to other areas where women experience difficulties and delays in accessing care once labour has begun. Although the operation of the maternity waiting homes was usually satisfactory, there is still room for improvement with incorporating MWH to the WBOTs activities in popularizing the MWH to the society at large and strengthening the postpartum care. MWH associated with some adverse events were those established in institutions without caeserian section facilities and also located at a very far distance (> 150km) from the referring facility. In addition, in order to maximize the benefit, the institution with a maternity waiting home should have access to emergency C/S within an hour. A dedicated obstetric EMS has to be stationed in an institution with a MWH or there must be access to alternative emergency services like helicopter.

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CORRELATION BETWEEN NUMBERS OF EOST DRILLS REPORTED FOR CPD POINTS AND CHANGE IN IMMR PER DISTRICT

RC PattinsonSAMRC/UP Maternal and Infant Health Care Strategies Unit

Background: The 2016 Annual Saving Mothers report has made the observation that the actual emergency events that lead to a maternal death are rare in district hospitals. Table 1 gives the average number of deaths per institution over a two-year period. An average district hospital will only see one woman per two years that will subsequently die due to non-pregnancy related infections, obstetric haemorrhage and hypertension. A way to prevent deaths in rare events is to practice emergency drills.

Table 1. Estimated number of women that subsequently died seen per facility

No. facilit

ies (DHIS

)

Cases seen at the level that

subsequently died 2014&2015

Births 2014&2

015

Ave. births/faci

lity 2014&201

5

Ave. cases seen that

subsequently died /facility 2014&2015

NPRI OH HT NPRI OH HTCHCs 249 190 223 345968DH 256 332 231 221 785721 3069 1 1 1RH 48 277 162 174 478538 9970 6 3 4PT 16 140 84 122 148132 9258 9 5 8NC 8 46 28 40 116995 14624 6 4 5CHC – community health centres; DH – district hospitals; RH – regional hospitals; PT – provincial tertiary hospitals; NC – national central hospitals; NPRI – non-pregnancy related infections; OH – obstetric haemorrhage; HT – hypertensive diseases in pregnancy

Aim: To determine if the there is a correlation between performing emergency obstetric simulation training (EOST) exercises and change in institutional maternal mortality ratio (iMMR).

Method: EOST exercises are reported to the SAMRC/UP Maternal and Infant Health Care Strategies Unit for continuing professional development (CPD) points. These are recorded per site, district and province. The role of EOST exercises has been emphasised since 2014. The change in iMMR was calculated by taking the district iMMR for 2011-2013 and subtracting it from 2014 and 2015. Pearson’s test for correlation was used.

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Results: There was a significant association (Pearson coefficient 0.3; p<0.05) with the number of EOST exercises and drills performed (Figure 1, Table 2).

0 50 100 150 200 250 300 350 400 450 500

-150.00

-100.00

-50.00

0.00

50.00

100.00

Figure 1. Correlation between number of drills performed per district and change in iMMR per district: Pearson coefficient 0.3, p<0.05

Number of EOST exercises per district 2014 & 2015

Chan

ge in

iMM

R

Table 2. Association between emergency drills submitted for CPD points and iMMR per district.

Submitted Data for CPD (proxy for FireDrills)

Count of Districts

Average iMMR 2011-3 (Before)

Average No. of Drills (intervention)

Average iMMR 2014-5 (After)

Average Difference

% Decrease

NO 25 134,8 0 127,8 -7,0 -5,2YES 20 174,3 145 142,3 -32,1 -18,4Grand Total 45 152,4 64 134,3 -18,1 -11,9

P<0.004

Conclusion: There is a significant correlation between the number of EOST exercises reported for CPD points and a reduction in iMMR.

Recommendation: Emergency drills should be performed at least monthly in all maternity units.

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A STANDARDS-BASED APPROACH TO IMPLEMENTING PERINATAL PROBLEM IDENTIFICATION PROGRAM IN SEVEN PUBLIC HOSPITALS IN DAR ES SALAAM, TANZANIA IN 2016

Magembe G, Mwaitenda E & SequeiraD’mello BRegion Administrative Office for Health, Dar es Salaam Region and Comprehensive Community Based Rehabilitation Services in Tanzania (CCBRT)

Introduction Dar Es Salaam in Tanzania has a population of 4.3million (2012), and a stillbirth rate of 26/1000 births. Since 2010, in collaboration with CCBRT, the Dar Es Salaam Regional Health Management Team has been systematically strengthening the quality of maternity services to reduce maternal and newborn deaths at 22 public maternity units where 80,000 of the annual 120,000 births occur. While the maternal death rate was reduced significantly, the perinatal death rate remained almost constant. In 2013, stillbirths and neonatal deaths were not being reviewed. There were no standards in place for data collection and review. With technical assistance and training by the PPIP team in South Africa in 2014, the PPIP initiative was introduced into 3 health facilities in 2015 and scaled up to 7 high volume sites in 2016. The supported facilities include Amana, Temeke and Mwananyamala Regional Referral hospitals, Mnazi Mmoja and Buguruni Health Centers, Mbagala Rangi Tatu and Sinza Hospitals, that collectively average 62,000 deliveries per year. The initiative is led by the regional administration through a facility task force. Technical and logistical support was provided by CCBRT’s Maternal & Newborn Capacity Building programme with technical assistance from the South African PPIP team.MethodsA stakeholder task force was established, comprising members from the Region, municipal government and facilities to lead the startup of the initiative at the 3 regional hospitals and subsequently cascade to additional 4 health facilities. Training on PPIP was conducted in October 2014 in South Africa by Dr. Coetzee, followed by a training of facility PPIP teams on conducting stillbirth reviews, data entry and analysis. The task force agreed on a ten point standard for the perinatal audit process. Weekly coaching and database support provided to strengthen data and information keeping. Monthly and quarterly review meetings conducted under supervision of the municipal and regional administration to develop and follow up action plans, progress towards implementation of process standards, sharing best practices and encouraging progressResultsThe program has been implemented at the seven selected facilities, with active facility task forces and complete data entry. Standards improved from the average of 42% at the beginning of 2016 to 88% in December 2016.Improvement in data collection and storage documented. The perinatal data improved understanding on cause specific deaths and avoidable factors and utilization of data for improvement planning. Unexplained deaths decreased from 14 % to 9%.Providers trained on management of hypertension and prolonged labour which were leading causes of deaths, care for Primigravida was strengthened and fetal kick chart monitoring at RCH clinic reemphasized to decrease third trimester intrauterine deaths. The average drop in perinatal mortality rate is slight and reduced from 46.5/1000 to 41.0/1000 over the year. Discussion of results and conclusions:Implementing PPIP requires persistent pressure and a change in behavior. The regional leadership and standards based approach have helped harmonize

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practice, initiative clinical improvement initiatives, bring attention to the issue of perinatal death and helped advocacy among key stakeholders for strengthening care. Shortage of staff and essential supplies contribute to substandard care. Continued follow up on the action plans will yield better results in 2017. Scale up to additional public facilities planned.

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