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Conclusions

Very 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


  1. Human Resources

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




EC

FS

GP

KZN

LP

MP

NC

NW

WC

National

Number of facilities visited

87

73

76

71

56

87

42

74

59

625

Professional

518

321

695

546

268

422

181

375

331

3657

Nurses

(54%)

(58%)

(58%)

(53%)

(48%)

(45%)

(44%)

(45%)

(46%)

(51%)

*6.0

*4.4

9.1

*7.7

*4.8

*4.9

*4.3

*5.1

*5.6

*5.9

Staff nurses

60

19

98

168

109

118

13

37

94

716

(6%)

(3%)

(8%)

(16%)

(20%)

(13%)

(3%)

(4%)

(13%)

(10%)

*0.69

*0.26

*1.3

*2.4

*1.9

*1.4

*0.3

*0.5

*1.6

*1.1

ENAs***

187

73

131

86

101

172

56

223

114

1143

(19%)

(13%)

(11%)

(8%)

(18%)

(18%)

(14%)

(27%)

(16%)

(16%)

*2.1

*1.0

*1.7

*1.2

*1.8

*2.0

*1.3

*3.0

*1.9

*1.8

Lay

185

123

216

193

76

181

118

142

117

1351

counsellors

(19%)

(22%)

(18%)

(19%)

(14%)

(19%)

(29%)

(17%)

(16%)

(19%)

*2.1

*1.7

*2.8

*2.7

*1.4

2.1

*2.8

*1.9

*2

*2.2

Doctors**

18

22

61

41

2

50

39

48

68

349

(2%)

(4%)

(5%)

(4%)

(0.4%)

(5%)

(10%)

(6%)

(9%)

(5%)

*0.2

*0.3

*0.8

*0.6

*0.04

0.6

*0.9

*0.6

*1.2

*0.6

TOTAL

968

558

1201

1034

556

943

407

825

724

7216

Average # health care personnel per facility

11.1

7.6

15.8

14.6

9.9

10.8

9.7

11.1

12.3

11.5

** 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.




No.(%) formally trained

No. (%) performing heel prick- range

Professional

Nurses


2165 (59)

2414 (66) – 52% in EC to 95% in WC

Staff Nurses


141 (40)


50 (14) – 8% in NC to 31% in WC


ENAs


34 (5)


163 (23) – 0% in LP to 13 % in MP

Lay Counsellors


74 (6)

46 (4)- 0% EC/FS to 13% in KZN

Doctors


missing

64(5)



  1. Supply of DBS kits

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.


  1. Blood Specimens Storage

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:



  • Continue to promote strategies such as task shifting to address human resource shortages.

  • Capacity building especially on the lay counsellors to do post test counselling and providing HIV results.

  • Provide regulations enabling ENAs, nurse assistants and lay counsellors to draw blood (heel prick) for infant HIV testing.

  • Expand EID training to professional nurses, doctors and all other staff involved in the provision of child health care services at primary health care facilities. Managers need to ensure that facilities are well equipped (adequate supply of DBS kits) and adequately staffed. They also need to establish procedures for monitoring and evaluating the implementation of EID services.


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
Background

Saving mothers interim 2012 report:



  • Haemorrhage accounts for 230 out of 1426 maternal deaths in South Africa

  • 81 of 230 (35%) were due to bleeding during or after C/S

  • The NCCEMD has highlighted bleeding at or after C/S as a priority area for intervention


Area

Population: 2.5 Mio, 1 Regional Hospital, 16 District Hospitals, 3 fulltime Consultants, 1 DCST O+G







Deliveries

2013

C/S Rate

2013

PNMR

2013

MMR

(2008 – 2010)

Uthungulu

30795

33

37.5

266

(168 – 2013)



UMkhanyakude

15157

17.4

22.1

91.1

(39.5 – 2013)



Zululand

16411

16.4

25.8

150.1

(146.2-2013)



Zone 4










160.3

KZN










177.3

National










179.5



Aim

  • Audit Study: all cases of PPH at or post C/S referred to LUDWMH-Empangeni

  • Objective: identify deficiencies in care which contributed to these adverse events

  • Interventions: preventing PPH or improving the management of PPH


Method

  • A prospective observational audit

  • All cases of PPH at or after C/S were included, including those who had the C/S at LUDWMH

  • Cases which were not referred or who died before transfer were not included

  • All cases were routinely discussed at daily audit meeting

  • Standard template was filled (HUMMET form) to capture details


Results

January 2013 to November 2013



  • 42 cases of PPH at or post C/S

  • 6 maternal deaths


Indication for C/S

Prev. C/S

11 ( 4 scar dehiscence or ruptured uterus discovered at surgery)

Fetal distress

9

CPD

7

Abruptio placentae

7

Placenta praevia

2

PIH / Eclampsia

3

Miscellaneous (failed induction, morbid obesity, twins-breech)

3


Analysis of data
Active phase

  • Cx >7 cm: - lower segment tear sustained : 8

  • Cx < 7 cm: - lower segment tear sustained : 3

Management of tear

  • Not recognized : 2

  • Recognized and successful repair : 2

  • Failed haemostasis : 4

Elective C/S: 11

  • Uterine atony : 6

  • Adhesions with difficult access : 4

Abruptio Placentae:

  • 5 patients failed IOL

  • 1 previous C/S x 2

  • In 1 patient the indication seems to be abruptio placentae per se. (maternal death).


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

  • Referrals from district/clinic to Regional Hospital : 4.

  • Regional Hospital : 2.

  1. Abruptio placenta arrived in hypovolaemic shock, arrested on arrival.

  2. Diagnosed as abruptio, delayed laparotomy for ruptured uterus - died post op.

  3. C/S for CPD, PPH in post op ward, taken back to OT 6 hrs later in irreversible shock, B Lynch done.

  1. C/S for FD in twin pregnancy, difficult haemostasis, Balloon tamponade, arrived in irreversible shock.

  2. resp. distress at 25 weeks, diagnosed PCP, APH – ruptured uterus with hysterectomy, died 7 days later.

  3. sec. PPH, suture line dehiscence, delayed hysterectomy.


Conclusion

  1. uterine atony – balloon tamponade.

  2. Prolonged labour and lower segment tears: inadequate skills.

  3. Tourniquet: damage control for referral.


Recommendations

  • Continue improving skills in the management of PPH.

  • High care area to monitor PPH, use of early warning charts.

  • Improve inter-facility transfer.


References


  • 10th interim report on confidential enquiries into maternal deaths in SA (R. Pattinson, S. Fawcus, J Moodley)2011 and 2012- DOH

  • A Monograph of the Management of postpartum Haemorrhage (J. Moodley) DOH 2010, Pretoria

  • Use of a uterine tourniquet as a temporising measure during transfer of patients with obstetric haemorrhage – O+G forum August 2013; 23:29-31 U. Wessels, N. Mayat

  • C/S monograph DOH 2013, Pretoria (J. Moodley)


Tourniquet and ruptured bladder



B-Lynch
c:\users\wesselsu\desktop\pph photos\img_0484.jpg
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.
METHODS

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




2012

2013 (preliminary data)*

Total maternal deaths entered

321

200

Haemorrhage deaths

42 (13.1% of all deaths)

31 (15.5%)

Number (%) of haemorrhage deaths with previous CS

14 (33%)

11 (35%)

Number (%) of haemorrhage deaths delivered by CS

30 (71%)

20 (65%)

*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



  • Para 3, previous normal vaginal deliveries. Had been booked for elective CS (indication not stated)

  • Went into labour. On presentation was 7cm dilated with intact membranes. First twin was a cephalic presentation

  • Decelerations were noted on the CTG

  • No intrapartum resuscitation was done

  • There was no attempt made to rupture the membranes and attempt vaginal delivery

  • Patient was sent straight to theatre for CS

  • She bled to death post CS

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)



  • HIV positive, on HAART

  • Previous CS x1 attempting VBAC , poor progress at 4cm dilated

  • CTG reactive (no evidence of fetal distress)

  • Bulging membranes never ruptured (?HIV issue)

  • She bled to death post CS

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



  • Para 0 at 34 weeks’ gestation presented to District Hospital with ante-partum haemorrhage

  • Abruptio with intra-uterine death was diagnosed

  • Doctor on duty ordered the patient to be taken to theatre for CS, without resuscitating the patient

  • She bled to death post CS

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



  • Para 3, with previous normal vaginal deliveries, presented to the regional hospital at 27 weeks’ gestation with severe antepartum haemorrhage. There was fetal bradycardia

  • The specialist on duty made a decision for CS, but was not present at the CS. The baby was born alive, 850g. Final outcome for the baby is not known

  • She required hysterectomy for bleeding at CS but bled further post op and died

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



  • Grav 6 para 5 with previous normal vaginal deliveries, presented at term to the District Hospital in active labour.

  • She was 8cm dilated, the fetal head was 4/5 above the pelvic brim; there were decelerations with contractions

  • The doctor was informed and ordered a CS without assessing the patient

  • At CS there was difficulty extracting the baby because the head was very low in the pelvis.

  • She bled to death post CS

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.

Cases where failure to perform CS or delay in performing CS was a factor in the death:

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.
SAFETY VERSUS ACCESSIBILITY: A DILEMMA IN MATERNITY CARE IN SOUTH AFRICA (ABSTRACT)
RC Pattinson, JD Makin, R Mkhondo, R Koebane, E Estane, C Bezuidenhout, *N van den Broek

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:

  1. Complications during labour commonly arise unexpectedly in apparently low-risk women. Experience in South Africa is similar to that reported from India: about 30% of apparently low-risk women require referral to hospital during labouri. In England the figure is >20%ii, in Denmark 15%iii, in Australia 7-29%iv, in Norway 29%v and in Japan 42%vi.

  2. Complications which arise in labour are frequently very urgent problems requiring immediate intervention (for example, cord prolapse, placental abruption, fetal distress, undiagnosed breech or twin pregnancy, shoulder dystocia, or postpartum haemorrhage). Even if the health center is only a few kilometers from the hospital, referral involves at best a very uncomfortable ambulance transfer for a women suffering the pain of labour, and at worst loss of life due to the seriousness of the condition or delays in availability of transport. Labour is a time of extreme anxiety and vulnerability, and for women the experience of an emergency transfer to hospital during labour may be devastatingvii.

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:

  1. This is a midwife-led unit similar to that conventionally situated in a community health centre.

  2. It is staffed, administered and funded by the Primary care services

  3. The care provided follows the primary care model – short-stay labour care with discharge 6 hours after birth if well.

  4. The Unit is situated within a hospital, in close proximity to the labour ward.

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:



  1. Women who arrive in the hospital in labour can be triaged directly to the appropriate level of care (primary vs secondary/tertiary)

  2. Women in labour do not have to fear being sent away from the hospital to a primary care health center.

  3. Maternal or neonatal complications in the OMBU can be managed by immediate transfer to the hospital service, or consultation from a hospital staff member.

  4. Because of the larger number of women delivered in the on-site OMBU compared with most health center-based OMBU’s where a 24-hour a day staff complement is needed even if only one or two births take place a day, the care is more cost-efficient.

  5. Traditional models of allocating women giving birth in large hospitals as ‘Low-risk’ (midwives’) clients, sometimes in a separate section of the labour ward, do not achieve the same levels of cost-efficiency, as these low-risk women still incur the expense of admission to a hospital, and the principle of low-risk care by the Primary Care services is undermined.

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.




Frere 2011

Frere 2012/3

MOU 2012/3

Frere + MOU 2012/3

2012/3 vs 2011 Risk Ratio

95% Confidence interval

Mothers giving birth

6352

5764

1611

7375







Babies born

6470

5875

1613

7488







Perinatal deaths

268

250

2

252

0.81

0.69 to 0.96

Perinatal mortality/1000

41.4

42.6

1.2

33.6







Maternal deaths

14

6

0

6

0.37

0.14 to 0.96

Maternal mortality/100000

220

104

0

81







Caesarean sections

2412

2574

0

2574







Caesarean sections (%)

38%

45%




35%

0.92

0.88 to 0.96



 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


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