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ConclusionsVery low rates of HIV-1 postnatal transmission were achieved by using infant prophylactic LPV/r or 3TC for the whole duration of breastfeeding, without a difference between the two drugs, which were both well tolerated. Infant Peri Exposure Prophylaxis is a feasible and effective strategy to reduce HIV transmission through breastfeeding. Further studies should evaluate the benefit of adding infant PEP to WHO option B/B+ in order to prevent residual breastfeeding transmission. References:1. www.who.int/child_adolescent_health/documents/9789241599535/en/ 2. McIntyre, J., Strategies to prevent mother-to-child transmission of HIV. Curr Opin Infect Dis, 2006. 19(1): p. 33-8. 3. Violari, A., et al., Early antiretroviral therapy and mortality among HIV-infected infants. N Engl J Med, 2008. 359(21): p. 2233-44. AVAILABILITY OF HUMAN RESOURCES AND INFRASTRUCTURE FOR EARLY INFANT DIAGNOSIS (EID): RESULTS FROM A NATIONAL SITUATION ASSESSMENT, 2010. Nobuntu Noveve, Selamawit Woldesenbet, Ameena Goga, Debra Jackson, Carl Lombard, Vundli Ramokolo, Gayle Sherman, Adrian Puren, Yogan Pillay. Introduction HIV/AIDS is the major cause of morbidity and mortality in developing countries. In 2008, HIV related deaths in under- five children in South Africa are accounted for more than a third of all deaths in under-five children. Vertical transmission from mother-to-child seems to be the main mode of transmission. The most affected children are those born to HIV positive mothers who do not get prevention of mother-to-child transmission of HIV (PMTCT) intervention. A situational assessment was conducted to establish the availability of human resources and infrastructure for Early Infant Diagnosis (EID). Methods: A cross-sectional study design was used to collect data from 680 facilities selected from all nine provinces. A multi stage probability proportional to size and simple random strata sampling was a method of choice. The facilities were stratified into three categories based on immunisation workload of less than 180 per year, between 180 and 300 per year and over 300 per year. These were further stratified into HIV prevalence greater than 29% or less than or equals to 29%. Thereafter, a simple random selection took place across all nine provinces. Structured questionnaires were used to collect data from clinic managers, nurses providing immunisation, PMTCT nurses, nurses providing sick child (including IMCI) services and district health information offices. Findings
Various cadres of staff are available in different proportions in sampled facilities nationwide. The number of professional nurses available in sampled facilities was 3657(59%), ranging from 42% to 87% in WC. The staff nurses account for 3% in NC to 100% in LP with overall 40% (n=350); ENAs 0% in LP/NC to 12% MP with overall 5%. According to our findings, lay counsellors generally outnumber the ENAs and Staff nurses. See table 1 below. Human Resource Available in Sampled Facilities- number (%) and * average number per facility
** Doctors provide onsite support to numerous clinics and are not necessarily based full-‐time in one clinic. This data item refers to the number of doctors that provide support to clinics in the sampled facilities ***Enrolled nurse assistants Facility managers highlighted skill gaps at primary health facilities. Our findings reveal that less than 60% of the staff available at sampled facilities is trained to perform heel prick for HIV testing. Table 2 shows the proportion of staff that is trained to perform heel prick for HIV testing versus the staff that performs heel prick without training. Table 2 Number (%) of staff performing heel prick vs. Number trained.
During our visit 20% of the sampled facilities in EC, MP and LP reported stock-outs of DBS kits in the past month. 10% Sampled facilities in LP and NC were out of stock during the visit. 17% facilities in LP and 28% in NC had expired DBS kits.
More than 60% facilities in KZN, EC and GP stored blood specimens in the consulting room where they were collected. The other sampled facilities in WC (44%), LP (52%) and MP (44%) used fridges, cooler boxes or special boxes to store specimens when collected Barriers to EID The health workers in sampled facilities reported barriers to the provision of early Infant Diagnosis. Some of these barriers are related to staff shortages, time and budget shortages for training, high volume of work at immunization service points. Others were personal factors like maternal fear of disclosure, maternal denial of HIV status and infant coming to the facilities with caregivers. 
Figure 1 Barriers to EID Discussion Our findings reveal that lay counsellors outnumber the ENAs and staff nurses in general. Proper utilisation of lay counsellors at primary care facilities does not only alleviate the workload from other cadres allowing timely early infant diagnosis but could also leverage their skills in terms of weighing babies, performing anthropometry, feeding practises, addressing mothers on issues relating to safer sex, disclosure, stigma reduction, HIV and how to prevent it. The shortages and expiration of DBS kits leads to interrupted service thereby denying HIV exposed babies an opportunity to access care on time. This can be overcome by establishing functional inventory control systems that are monitored regularly. DBS cards are designed in such a way that specimens can withstand temperature variation better than other specimens. However, the ideal storage temperature to maintain their optimum quality is at room temperature. Therefore specimen storage needs to be addressed by facilities to ensure optimum temperature is maintained. Recommendations Policies need to promote enabling environments by designing strategies that can alleviate the most crucial problems of the health system. These include:
Conclusion Provision of infant EID services require well-functioning health systems, hence addressing the broader health systems’ infrastructural, human resources and supply constraints is crucial. Reference: The South African Programme to prevent Mother-to-Child Transmission of HIV (PMTCT). Evaluation of the Early Infant Diagnosis services in Primary Health care facilities in South Africa: Report on Results of a Situational Assessment, 2010. HAEMORRHAGE AT OR FOLLOWING CAESAREAN SECTION Dr U Wessels Dr N Mayat Lower Umfolozi District War Memorial Hospital Empangeni KZN
Saving mothers interim 2012 report:
Area Population: 2.5 Mio, 1 Regional Hospital, 16 District Hospitals, 3 fulltime Consultants, 1 DCST O+G
Aim
Method
Results January 2013 to November 2013
Indication for C/S
Analysis of data Active phase
Management of tear
Elective C/S: 11
Abruptio Placentae:
Morbidity Blood 29 patients required transfusion (1 – 10 u) Total: 87 units Hb of 7g/dl accepted due to blood shortage Inadequate Resuscitation: 12 patients arrived in shock with coagulopathy (blood shortage in district hospitals) Failure to control haemorrhage Continuous bleeding in transit Ventilation: 13 patients ( 1- 7 days) - Total ventilator days : 40 Other: Renal Failure : 4 Pulmonary oedema : 1 Relaparotomy : 3 Septicaemia : 1 Cardiac arrest (resuscitated) : 1 Mortality
Conclusion
Recommendations
References
Tourniquet and ruptured bladder 
B-Lynch 
UNECESSARY CAESAREAN SECTION: A MAJOR FACTOR CONTRIBUTING TO MATERNAL DEATHS FROM OBSTETRIC HAEMORRHAGE IN KZN Neil F Moran. Head of Clinical Department: Obstetrics and Gynaecology, KZN Department of Health; NCCEMD KZN Facilitator. Neil.moran@kznhealth.gov.za INTRODUCTION The interim Saving Mothers report (2011-12)1 states: “Deaths due to bleeding during or after caesarean section are increasing rapidly. The vast majority of these deaths are avoidable. Haemorrhage during or after caesarean section has become the most urgent problem to address.” Caesarean section (CS) rates are increasing in South Africa. This trend is particularly concerning in KZN Province, which has the highest CS rates (29% in State facilities)2. With some of the less well-resourced Provinces, one could speculate that the lower CS rate is partly due to lack of access to essential CS services, but this argument does not hold for Western Cape (CS rate 20%) or Gauteng (CS rate 21%). Here the lower rates compared to KZN suggest different obstetric practices and thresholds for deciding to perform CS. Clearly, not all these CS have valid indications. One way to reduce CS–related mortality is to do fewer CS. This study aimed to assess the contribution of unnecessary CS to maternal deaths from obstetric haemorrhage in KZN.
Maternal deaths in South Africa are notifiable by law. The notification process includes filling a purpose-designed maternal death notification form and submitting this together with a copy of the case notes of the deceased to the provincial office of the Department of Health. In KZN, all notified maternal deaths are assessed by a group of provincially appointed expert assessors. The details of the assessments are entered into a computerised database (MaMMAS database) and then forwarded to the National Department of Health, so that the Saving Mothers report can be compiled. Confidentiality is maintained throughout this process. With permission from the National Committee for the Confidential Enquiries into Maternal Deaths (NCCEMD), the MaMMAS database for KZN was used to identify all notified 2013 cases which had been assessed as deaths due to obstetric haemorrhage. The case notes of these cases were reviewed to extract any additional relevant data. Where the patient had been delivered by CS, the indication for the CS was reviewed by the investigator, and categorised as valid, debatable, or not valid. Elective CS for previous CS was accepted as a valid indication. In addition, all haemorrhage deaths were analysed to see if failure to perform CS or delay in performing CS was a factor in the death Permission was granted by the NCCEMD for a summary of this data to be presented at the Priorities in Perinatal Care Conference, without breaking confidentiality with regard to any specific case. RESULTS At the time of presentation at the Priorities Conference, the KZN MaMMAS database for 2013 deaths is estimated to be only 75% complete. These results are therefore preliminary, and are included in table 1, together with the complete MaMMAS data from 2012 for comparison. Table 1 Details from MaMMAS database regarding maternal deaths due to obstetric haemorrhage in KZN 2012-2103
*The final number of maternal deaths that will be entered into MaMMAS for 2013 is predicted to be about 275. This estimate is based on notified cases received by the KZN Provincial Office by the time of the 2014 Priorities Conference (including cases not yet assessed or entered in to the MaMMAS database). While the total number of maternal deaths is predicted to decline by about 15% in 2013 compared to 2012, the number of haemorrhage deaths does not appear to be declining. The causes of the 31 obstetric haemorrhage deaths in 2013 were sub-classified as follows: Uterine atony 2, Abruptio placentae 3, ruptured uterus 7 (with previous CS 2, without 5), Morbidly adherent placenta 2, Retained placenta 1, Bleeding during CS 1, Bleeding after CS 10, Other PPH 5. In twenty of the 31 cases (65%) death followed delivery by CS. In 30 out of the 31 cases, a copy of the cases notes was available for review by the investigator, including all 20 cases where a CS was performed. The indication for CS was assessed as valid in 12/20 cases (60%), debatable in 3/20 (15%) and not valid in 5/20 (20%). In 4/31 cases (13%) not performing a CS or delay in CS contributed to the death. Some of the case details are summarised below: Cases of haemorrhage death (2013) where the indication for CS was assessed as not valid: 1. Stated indication: twins and fetal distress
Assessment: Before any decision for CS, intrapartum resuscitation should have been done. Artificial rupture of the membranes should have been considered as this would have most likely led to vaginal delivery within a short period of time given her parity 2. Stated indication: poor progress with fetal distress (failed VBAC)
Assessment: Once a decision had been made to attempt a VBAC, and there was poor progress in the active phase of labour, then membranes should have been ruptured before deciding that the VBAC had failed. HIV is not a contraindication to AROM in such circumstances. She might have progressed well after AROM. There was misinterpretation of the CTG, leading to a mistaken diagnosis of fetal distress. 3. Stated indication: Abruptio grade 3
Assessment: Once the diagnosis of abruption with IUD had been made, the patient should have been resuscitated and transferred to the regional hospital, and the plan should have been to aim for vaginal delivery 4. Stated indication: Abruptio grade 2
Assessment: The prognosis for the baby was extremely poor. Even though born alive, the likely outcome was neonatal death. A decision to aim for vaginal delivery should have been taken. 5. Stated indication: Fetal head high in advanced labour
Assessment: There was no indication for CS. In the African parturient, the head often does not engage until the second stage of labour. The fact that the head was so low at CS shows that this patient would have delivered vaginally. Cases of haemorrhage death (2013) where the indication for CS was assessed as debatable: In two of these cases, the CS was performed in the second stage of labour, the first for poor progress, the second for fetal distress. In both cases the investigator felt that a vacuum extraction could have been attempted, but this was not considered. The indication was classified as debatable because there was inadequate information in the case notes to be sure about whether all the obstetric criteria for safe vacuum extraction were in place (level of head above brim etc). The third case occurred at a District hospital where the CS was done for a footling breech at 35 weeks’ gestation in early labour (2cm dilated) in an obese para 4 with previous normal vaginal deliveries. She bled to death at CS. At post-mortem it was found that half of the uterine incision had not been sutured. The reason the indication was felt to be debatable is because the diagnosis of footling breech was made on the basis that a foot was felt at the level of the cervix, on per vaginal exam. This could well have been a complete breech, where feet are often felt on vaginal exam. If it was a complete breech, then allowing a vaginal breech delivery would have been a sensible decision rather than CS. There were factors making the CS high risk in this case, including maternal obesity, and the apparent lack of skill of the CS surgeon.
There were two cases of rupture of the uterus, where a CS performed earlier would have prevented the rupture. In the first case, there was a failure to make a decision for CS when there was evidence of fetal distress. Subsequently the fetus became an intra-uterine death. The rupture followed induction of labour with excessive doses of misoprostol. In the second case, there was delay in the second stage of labour. After the decision for CS was made, there was a 90 minute delay before the CS could be done, by which time rupture of the uterus had occurred. There were two other cases where there was delay in responding to poor progress in advanced labour. The CS should have been done earlier. When the CS was eventually done, there was subsequent uterine atony, which could have been contributed to by the delay in doing the CS LIMITATIONS OF THE STUDY The cases of obstetric haemorrhage were reviewed by a single investigator. The investigator is a specialist obstetrician/gynaecologist with twelve years’ experience of being an assessor of maternal deaths in KZN. Nonetheless the assessment of the validity of the indications for caesarean section represents the investigator’s own opinion and is therefore subjective and open to debate. CONCLUSIONS The majority of Obstetric haemorrhage deaths in KZN follow CS. Avoiding unnecessary CS would significantly reduce the number of these deaths. In the longer term, it would also reduce the number of pregnant women with previous CS, which would reduce the risk of death in future pregnancies. Delays in performing caesarean sections also contribute to maternal deaths. Avoiding unnecessary CS would reduce the workload of CS and therefore reduce delays in performing CS with valid indications. Maternity units in KZN need to implement measures to improve decision-making for CS. REFERENCES 1. Tenth Interim Report on Confidential Enquiries into Maternal Deaths in South Africa 2011-2012. Compiled by Robert Pattinson, Sue Fawcus and Jack Moodley for the National Committee on Confidential Enquiries into Maternal Deaths. Department of Health. Republic of South Africa. 2. National Perinatal Mortality and Morbidity Committee Triennial Report (2008-10). www.doh.gov.za. Accessed 1st April 2014.
MRC Maternal and Infant Health Care Strategies unit, Obstetrics and Gynaecology Department, University of Pretoria. * Liverpool School of Tropical Medicine Aim: To assess the maternity staff available in maternity units in 12 health care districts in South Africa and compare the staff to the health care facilities available and the population served Method: The 133 health institutions in the 12 core districts were visited (53 Community Health Centres (CHCs); 63 District Hospitals (DH), 13 Regional Hospitals (RH) and 4 Provincial Tertiary (PT) hospitals) between July and October 2011. The institutions had been informed of the survey and given the forms to complete at an information meeting held in their province. During the visit the survey form was collected which included the staffing of that unit at that time. Where uncertainty was detected the units were contacted telephonically to clarify the situation. The WHO norms of 1 DH and 4 CHCs should serve a population of 500,000 people and 1 midwife should deliver 175 babies per year were taken for comparison purposes. For 1 professional nurse to be available 24 hours a day, 7 days a week 5 professional nurses should be employed. To ensure safety 2 professional nurses (ideally one an advanced midwife) should be available 24 hours a day. This implies that 10 professional nurses provide a minimum critical mass of staff to provide a safe maternity service. Further a maternity unit should thus perform a minimum of 1200 births per year (taking into consideration the number of referral into and out of the unit). Results: In all 12 districts there was an excess of maternity units for the population served. The total professional nurse personnel per district allocated to maternity care was also in excess of 175 deliveries per midwife per year in all districts. With respect to having a critical mass of staff per institution 54 (41%) had theoretically too few staff (22 (42%) of CHCs, 31 (49%) of DH’s, 1 (8%) of RH’s and none of the TH’s had less than the minimum critical mass of professional nurses in the maternity units). These units are theoretically unsafe. However, 70 (53%) institutions consisting of 42 (79%) of CHCs and 26 (41%) of DHs and 1 RH did not perform the minimum number of deliveries. Only 11 (21%) of CHCs, 37 (59%) of DH, 12 (92%) of RH and all TH performed more than minimum number of 1200 births per year. All 11 (21%) of CHCs had both the minimum critical mass of staff and minimum number of deliveries; of the 31 remaining 22 CHCs had both too few staff and too few deliveries and 11 had a critical mass of staff, but too few births. In DH 22 (34%) had the minimum critical mass of staff and minimum number of births; 4 (6%) had more deliveries and less than the critical mass of staff, 10 (16%) had more than the critical mass of staff but less than minimum number for births and 27 (43%) had less than the critical mass of staff and minimum number of births. Conclusion: There were sufficient maternity personnel per district to manage the births for the population of each district and there was an excess of facilities per population that provided maternity services. However, in 41% of institutions there were too few staff to manage maternity care safely, and 53% of institutions did not deliver sufficient babies to warrant a critical mass of maternity staff. To provide a safer maternity service, maternity units will need to be consolidated to get a critical mass of staff. This will reduce the accessibility of maternity care to the population. A compromise needs to be sought. ON-SITE PRIMARY CARE MIDWIFE BIRTH UNIT: A NEW MODEL FOR SAFE PRIMARY CARE CHILDBIRTH G Justus Hofmeyr ¹,², Thozeka Mancotywa², Nomvula Silwana-Kwadjo², Batembu Mgudlwa², ¹Effective Care Research Unit, University of the Witwatersrand/Fort Hare, and ²Eastern Cape Department of Health Introduction: The South African national health system is based on the primary care model. This works well for non-emergency care such as antenatal care, which can be provided safely in a community setting. However, for care during labour, the theory that women can be triaged to low-risk labour care in a community health center is confounded by two fundamental flaws:
We have proposed an alternative strategy in metropolitan areas with high population density. This is the “On-site Primary Care Midwife Birth Unit (OMBU), with the following features:
For many years some large hospitals have divided labour ward care into ‘low-risk’ (midwives’) clients and ‘high-risk’ (doctors’) patients. However, in this system, low-risk women are admitted to the hospital, cared for by hospital staff, use the expensive hospital resources, and undermine the principle of Primary Care for low-risk pregnancy. There is also a tendency for obstetric interventions which are not appropriate for low-risk women to be utilized because of the hospital setting, leading to a cascade of unnecessary interventions. A study in New Zealand found that low-risk women receiving midwife care in a secondary care setting compared with a primary care setting had higher rates of caesarean section and admission of their babies to the neonatal intensive care unit. In England, Midwife-led units attached to a hospital are referred to as “alongside midwifery units” (AMU) as opposed to “freestanding midwifery units” (FMU)5. What is unique about the model described in the paper is that the principle of a midwife-led birth unit within a hospital has been adapted to the South African setting of separation of primary from secondary/tertiary services. The first OMBU in the Eastern Cape was established at Dora Nginza Hospital on the recommendation of two of the authors (GJH and N S-K) as a solution to excessive overcrowding in the labour ward. This paper documents experience with the subsequent establishment of an OMBU at Frere Maternity Hospital, East London. Prior to the establishment of the unit, a patient survey was carried out by one of the authors to assess women’s attitudes and access to such a unit, with encouraging results (Mgudlwa B, unpublished FCOG research report). Methods: This was an audit using routinely collected data submitted to the Provincial Health Department. The OMBU opened in March 2012. Data from Frere Maternity hospital and the MBU were collected retrospectively for the 12 month period July 2012 to June 2013. These were compared with the Frere Hospital data for the 12 month period Jan to Dec 2011, prior to opening of the OMBU. Results: The number of women giving birth in the OMBU during the 12 months was 1611. This contributed to an overall 16% increase in the number of births in the institution from 6352 to 7375, and a 9.3% reduction in the number in the hospital labour ward from 6352 to 5764. There was a significant reduction in both perinatal and maternal mortality, though factors other than the OMBU may have contributed to this. Conclusion: The OMBU has proved to have several advantages both for staff and for patient care, as well as cost-efficiency:
The unique aspect of the OMBU is that it is staffed and administered and funded by the Primary Care services. The lower cost of the short-stay primary care model is made further cost-efficient by the economies of scale with large numbers giving birth in a single unit. We recommend that the principle of On-site Primary Care Midwife Birth Units be adopted for all hospitals providing secondary and/or tertiary obstetric services. Table 1 Data for Frere Maternity Hospital and the On-site Midwife Birth Unit (OMBU), over two 12-month periods, after and before opening of the OMBU. Statistical comparisons are by risk ratios with 95% confidence intervals.
David KV, Pricilla RA, Venkatesan S, Rahman SP, G S YK, Vijayaselvi R. Outcomes of deliveries in a midwife-run labour room located at an urban health centre: results of a 5-year retrospective study. Natl Med J India. 2012 Nov-Dec;25(6):323-6. 2 Rowe RE, Fitzpatrick R, Hollowell J, Kurinczuk JJ. Transfers of women planning birth in midwifery units: data from the birthplace prospective cohort study. BJOG. 2012 Aug;119(9):1081-90 Yüklə 1,08 Mb. Dostları ilə paylaş:
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