Editor’s Note


Table 3: Reason and duration for admissions of newborns



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Table 3: Reason and duration for admissions of newborns

Mode of delivery

Reason for admission

Duration of admission

Caesarian section

(Elective - prior

obstetrical indication)

Transient tachypnea

of the newborn



48 hours

Caesarian section

(Breech)

Meconium aspiration

Syndrome


24 hours

Caesarian section

(Severe condylomata)

Hydronephrosis on antenatal scan, daily monitoring of renal function until mother was discharged

72 hours

Normal vertex delivery

Phototherapy

48 hours

Conclusions

Careful adherence to protocol and follow up at a high risk clinic identifies new or concealed maternal or fetal complications in 29% of patients with a previous IUD and no obvious maternal or fetal disease at booking. The main pathology necessitating earlier intervention was new onset of diabetes mellitus (47.62%) or preeclampsia (23.81%). Fifty-one percent of women went into spontaneous labour before their planned induction date. There was no difference in outcome whether induction was booked at 39 or 40 weeks – most went into spontaneous labour by 39 weeks. As expected, the emergency caesarean rate in the IOL group was higher. The complication rate for the entire cohort (maternal and fetal) was minimal. These pregnancies remain high risk, but with careful follow-up (and exclusion and management of complications), the fetus may be safely delivered at term.


A DECADE OF AVOIDABLE FACTORS; ARE WE TAKING SUFFICIENT HEED?
Monica Engelbrecht, Hannes Steinberg

DoH FS and UFS


Introduction:

The perinatal problem identification program (PPIP) is a package of a self-audit system that is used to monitor the perinatal services. The perinatal deaths occurring at a service are analysed and allocated a cause of death as well as an avoidable factor identified for each. These avoidable factors then should guide policy/practice change, hopefully leading to less avoidable deaths.

Certain health facilities in the Free State province have been active with PPIP since 2002. Avoidable factors have been entered into the program. The trends of these avoidable factors gather as part of the PPIP in the FS have not been analysed over time before.
Method:

The avoidable factors for the analysed perinatal deaths captured as part of the PPIP in the Free State have been analysed over a period of a decade (2002 – 2012). The analysis has been done on the available PPIP database for the Free State. The entire free state data as well as for individual institutions data that have contributed for a longer period was done. Trends were analysed to attempt to describe the changing of avoidable factors over time. It is assumed that as avoidable issue are addressed they slowly decrease in prominence and are replaced by others.


Results:

The total numbers of avoidable factors are reflected in Figure 1. Over time the number of avoidable factors has increased. The number of facilities contributing to the PPIP over the years is superimposed in red. In Figure 2 the numbers of avoidable factors are compared with the number of analysed deaths in the database per year. It can be seen that there was roughly one avoidable factor per analysed death.



Figure 1: Number of avoidable factors: FS PPIP and the number of facilities contributing to PPIP over the years.

Figure 2: FS PPIP audited deaths and avoidable factors

The avoidable factors are classified according to the patient associated factors, medical personnel associated factors and administrative factors. In only 3 out of the eleven years observed the medical personnel associated factors are more prominent than the patient associated factors.

There is a choice of classifying the avoidable factors into possible and probable, with probable being regarded as: should this factor have been corrected than the death would probably have been avoided. If only the “probable” avoidable factors in the database are considered, then the administrative factors become more prominent. The patient associated factors become less prominent. See Figure 3 and 4.


Figure 3: FS PPIP avoidable factors: all grades percentage

Figure 4: FS PPIP avoidable factors: probable; percentage
For the further analysis in this paper only probable avoidable factors were used.


  1. Patient associated factors: “Never initiated Antenatal-care” remained in number one spot (most common avoidable factor) ranged from 30-45% in the study period. “Inappropriate response to poor foetal movements” “Booked late in pregnancy” and “Delay in seeking medical attention during labour” all appear in the top 5 avoidable causes for the entire period observed, with slight changes in the ranking. District facilities tend to have more patient associated factors than the regional institutions.




  1. Medical personnel associated factors: “Delay in referring patient for secondary/tertiary treatment” remained in number one spot (most common avoidable factor in this category) ranging from 15-30% for the observation period. “No response to poor uterine fundal growth” appeared in the top 5, seven out of the eleven years, but seems to have decrease in importance in the last 3 years. FD not observed during labour reduced from 15% to less than 1% of cases during the observation period. There is a greater variety of medical personnel associated factors in only the “probable” factors are considered. In the central hospitals nasocomial infection has been identified more often as an avoidable factor in recent years.

As an institution starts off with the PPIP the medical personnel associated factors top the chart, by the third year in every institution the patient associated factors top the lists, but by the sixth seventh years the medical personnel associated factors are top of the lists again. This seems to hold true for district and regional hospitals.


  1. Administrative factors:” Inadequate facilities/equipment in neonatal unit/nursery” appears in the top 3 for the entire period of study. Replaced by “No accessible neonatal ICU bed with ventilator” in the last years as top avoidable factor. Administrative factors become more prominent if only the “probable” factors are considered.




  1. Insufficient notes to comment on avoidable factor: Is found in less than 5% of cases throughout most of the period observed.


Conclusions:

Patient related avoidable factors remain in a similar order throughout the study period in the Free State PPIP data. This may be a sign that the important messages are not being transmitted to the community. The Medical personnel associated factors are changing more frequently, which suggested that the personnel is reacting in part to the discussed factors. The distinction of “probable” and “possible” does have an effect on the ranking of the avoidable factors.

FS needs more community “buy-in” with service delivery to affect changes with the patient related avoidable factors.
EARLY INFANT FEEDING PRACTICES IN HIV EXPOSED AND UNEXPOSED INFANTS: RESULTS FROM THE SOUTH AFRICAN PMTCT EVALUATIONS, 2010 AND 2011
Dudu Nsibande1, Debra Jackson2, Ameena Goga1, Carl Lombard1, Vundli Ramokolo1, Selamawit Woldesenbet1, Gayle Sherman3, Adrian Puren3, Yogan Pillay4

1MRC, 2University of the Western Cape, 3NICD, 4NDOH
Background

Infant feeding pattern is a significant predictor of childhood morbidity and mortality1. Avoiding breastfeeding will expose infants to malnutrition, diarrhoea, pneumonia and lead to developmental delays2. In resource-limited settings or where the use of formula milk is not affordable and feasible and acceptable and sustainable and safe, use of infant formula is associated with significantly higher mortality 1. Breastfeeding has been identified as one of the key child survival strategies. Although HIV can be transmitted from mother to child through breast milk, evidence indicates that the risk of child death due to malnutrition, diarrhoea, pneumonia and other opportunistic illnesses exceeds the risk of HIV vertical transmission in resource poor settings. Vertical transmission can be reduced to as low as 1.1% with ARV treatment and exclusive breastfeeding for 6 months 3.

Between 2001 and August 2011 the South African Programme to prevent HIV transmission from mother to child provided free commercial infant formula for all non-breastfeeding HIV exposed infants. In August 2011, the South African NDoH adopted and championed the Tshwane Declaration in Support of Breastfeeding4. Subsequently the SA NDoH recommended exclusive breastfeeding for six months and continued breastfeeding thereafter regardless of HIV status. The provision of free commercial infant formula milk was phased out between August 2011 and April 2012.

In the light of the various changes that have taken place in the infant and young child feeding policies, we aimed to describe infant feeding practices among HIV exposed and unexposed infants attending primary health care facilities for their 6 week immunisation who participated in the South African National PMTCT Evaluation.5


Method

Study design

Two cross-sectional facility-based surveys were conducted among caregiver-infant pairs who presented at their local primary health care clinic/community health centre for their infant’s six-week immunization (1st DTP dose) visit. All consented infants aged 4-8 weeks, receiving their six week immunization.were included. Severely ill infants needing emergency medical care or urgent referral to the next level of care were excluded from the study.



Sampling

All public health clinics and community health centres were stratified according to the number of immunizations per year, based on 2007 South African DHIS.Specifying relative precisions of 30% to 50% for the expected MTCT rate across provinces plus a design effect of 2 a total sample size of 12 200 infant DBS specimens were needed for valid national and provincial HIV transmission. Stratified two-stage sampling was used. In the first stage, facilities (Primary sampling units - PSUs) were randomly sampled proportional to size (PPS) within each stratum. At the second stage a fixed number of infants per a facility were sampled. Within each stratum, the sampling window of three weeks across the population of facilities was used5,6.



Ethical considerations

Written, signed, informed consent for all procedures in the study was obtained from each eligible caregiver for the interview and DBS sampling (separately). A confidential Study ID used to link consent forms, lab forms and questionnaire and to provide the infants’ blood test results to mothers or legal guardians. Ethical approval was obtained from the Medical Research Council and from each of the nine provincial research ethics committees. Ethical approval was also granted from the United States Centers for Disease Control and Prevention Atlanta.



Data collection

Data collection for the 2010 survey occurred between June-December 2010 and for the 2011 evaluation between 15 August 2011 and 16 March 2012. The study questionnaire was adapted from several validated tools5. Primary caregivers (98% mothers) of enrolled infants were asked about their infants intake of 8 groups of fluid and food items during the previous 24 hours and 7 days prior to that (i.e. recall over the previous 8 days).

Electronic questionnaires were loaded on low-cost mobile phones using the Mobile Researcher software management solution. Infant HIV exposure was measured using DBS specimens collected from infants. Specimens were tested for HIV by means of a laboratory HIV ELISA test (Genscreen HIV antibody assay) and HIV exposed infants were defined as those cases where this was reactive. Testing of specimens was done at the National Institute for Communicable Diseases, a division of the South African National Health Laboratory Service (NHLS), conducted the testing.

Data management and analysis

Questionnaire data was maintained by Mobile Researcher and exported to Excel for data analysis. Anonymised laboratory data were exported to Excel and merged with questionnaire data. Analysis was weighted for sample ascertainment and population live births and was done in SAS version 9.2. Feeding patterns use WHO definitions for exclusive breastfeeding, no breastmilk or mixed breastfeeding. We present our analysis according to infant HIV exposure status.


Results

Data on 10154 and 10106 mother-infant pairs were collected in 2010 and 2011 respectively. Of these 3107 and 3024 infants were HIV exposed in 2010 and 2011 respectively.


Characteristics of participants
Table 1 Characteristics of participants


HIV-exposed infants

Prevalence of exclusive breastfeeding over the past 8 days

Amongst mothers of HIV-exposed infants, there was a significant increase in exclusive breastfeeding over the past 8 days nationally from 20.4% (95% CI 18.5-22.3%) in 2010 to 35.5% (33.12-38.0%) in 2011. Only Limpopo and Northern Cape did not report significant increases in EBF (20.3% in 2010 and 28.3% in 2011; 43.7% in 2010 and 43.5% in 2011 respectively). In both periods, Northern Cape province reported the highest EBF (43.7%; 43.5%) in both periods and the Western Cape reported the lowest EBF (7.9%;18,8%). In 2011, KwaZulu-Natal measured the second highest in EBF (42.5%) - a significant increase from 26.1% measured in 2010.



Table 2. Infant feeding practices amongst HIV-exposed infants over the past 8 days by province

Province

Mother reportedly received infant feeding counseling during ANC

% (95% CI)

At Risk/ Mixed Feeding

% (95% CI)


Exclusive Breastfeeding




2010

2011

2010

2011

2010

2011

Eastern Cape

82.4 (76.1-88.8)

94.2 (91.3-97.3)

20.3 (16.6-23.9)

9.9 (6.7-13.0)

14.8 (11.3-18.2)

23.2 (17.8-28.6)

Free State

91.6 (88.7-94.6)

95.5 (93.7-97.4)

22.9 (19.1-26.8)

19.2 (14.9-23.5)

18.0 (14.5-21.5)

35.1 (30.1-40.1)

Gauteng

92.4 (89.7-95.1)

91.8 (87.9-95.6)

14.8 (11.4-18.1)

9.6 (6.2-13.0)

19.6 (15.9-23.2)

37.6 (32.2-43.0)

KwaZulu-Natal

92.4 (90.0-94.8)

97.2 (95.2-99.2)

14.0 (10.5-17.5)

10.4 (6.9-13.9)

26.1 (21.2-31.1)

42.5 (37.1-47.9)

Limpopo

77.9 (72.0-83.7)

82.2 (76.2-88.2)

32.8 (27.0-38.7)

33.0 (25.9-40.1

20.3 (15.5-25.1)

28.3 (21.5-35.0)

Mpumalanga

91.5 (88.4-94.6)

93.5 (91.5-95.4)

29.7 (26.0-33.4)

20.6 (15.5-25.6)

13.9 (11.01-16.8)

34.5 (28.6-40.5)

Northern Cape

81.0 (73.3-88.6)

94.2 (90.3-98.2)

23.9 (16.1-31.8)

21.7 (13.8-29.7)

43.7 (37.0-50.3)

43.5 (35.9-51.1)

North West

81.5 (76.1-86.8)

90.6 (87.3-94.0)

21.3 (17.5-25.1)

23.2 (16.7-29.7)

25.7 (21.3-30.0)

38.9 (33.0-44.8)

Western Cape

85.3 (80.5-90.1)

95.0 (92.6-97.3)

7.0 (4.3-9.6)

11.4 (7.3-15.4)

7.9 (5.3-10.4)

18.8 (13.9)

South Africa

89.2 (87.8-90.6)

93.3 (92.0-94.7)

18.1 (16.5-19.7)

14.0 (12.3-15.7)

20.4 (18.5-22.3)

35.5 (33.1-38.0)


Avoidance of Breast milk

Nationally there was a reduction in breast milk avoidance amongst HIV exposed infants between 2010 and 2011 reduction was measured among HIV exposed infants reporting the avoidance of breast milk from 61.5% (59.2-63.8%) in 2010 to 47.1% (44.9-49.3%) in 2011. Three provinces had more than 50% of mothers reporting avoidance of breast milk in 2011- (Western Cape (68.5%), the Eastern Cape (58. 6%) and Gauteng (50.11%). Northern Cape, North West and Limpopo provinces had the lowest percentage of mothers reporting avoidance of breast milk (27, 5%, 34.9% and 35.5% respectively).



Infant feeding counseling

A significant increase was reported in infant feeding counseling from 89.2% (77.9-92.4) to 93.3% (92.0%-94.7%) in 2011. Although Limpopo reported the lowest in 2011, there was an improvement in reported infant feeding counseling from 77.9% to 82.2%. KZN reported the highest infant feeding counseling in both periods (92.4% and 97.2%).



Mixed Feeding

We categorized HIV-exposed infants who received breast milk plus any other milk or food (not including prescribed medicines) over the past eight days as being at-risk as they were practicing mixed breastfeeding. Nationally, a decline in reported mixed feeding was measured from 18.1% (7.0% -32.8%) in 2010 to 14.0% (12.3-15.7%) in 2011. However, 5 provinces exceeded the national average. Of all provinces, Limpopo, a rural province reported the highest prevalence of mixed feeding in both periods (32.8% to 33.0%). The lowest prevalence of mixed feeding was reported in Gauteng in 2011(9.6 %) compared to 14.8% in 2010). It is interesting to note that the province with the lowest rate of infant feeding counselling (82% in Limpopo province) had high rates of at risk infant feeding in HIV-exposed infants (33%).


HIV-unexposed infants

Reported exclusive breastfeeding over the past 8 days

Among mothers of HIV-unexposed infants, a significant increase in exclusive breastfeeding was measured in 2011, 43.6% (41.6%-45.7%) compared to 31.3% (31.3% (29.-33.0%) in 2010, Limpopo, Northern Cape and North West were the only three provinces not reporting significant increases in exclusive breastfeeding. The lowest prevalence of EBF was reported in Eastern Cape and Limpopo. This is especially worrying as these are both rural provinces. The prevalence of exclusive breastfeeding was highest in the KwaZulu-Natal and Mpumalanga provinces.



Mixed feeding among HIV–unexposed infants

Data showed a reduction in mixed feeding amongst HIV-unexposed infants from 57.4% (55.5-59.2%) in 2010 to 46.2% (44.2-48.3) in 2011.


Discussion

Infant feeding per caregiver recall for the past 8 days suggests a substantial increase in infant feeding counseling, increase in exclusive breastfeeding and reduction in mixed breastfeeding amongst HIV exposed and unexposed infants. The Tshwane Declaration of Support for Breastfeeding was adopted in August 2011 just as the survey started. Its effects are likely to have been measured over the duration of the survey. This survey also provides data on uptake of the PMTCT programme and infant feeding.




Limitations

Infant feeding practices were documented from recall over the previous 24 hours and seven days prior to these 24 hours; infant feeding counseling data also relied on recall from the antenatal period; thus information bias was likely. The survey excluded infants who do not come for immunization, those seen in mobile facilities, sick infants seen in hospital and infants who have already died


Conclusions

Following the adoption of The Tshwane Declaration of Support for Breastfeeding data show that reported infant feeding counseling and infant feeding practices improved between 2010 and 2011.


Recommendations

More work is needed to provide appropriate infant feeding counseling and improve feeding practices. Also more research needs to be done assessed late infant feeding practices among HIV exposed and unexposed infants.


Acknowledgements:This project has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of Collaborative agreement 1U2GPS001137-02 and 1U2GPS001137-03 Its contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of CDC.
REFERENCES

  1. Goga A, Doherty T, Jackson D, Sanders D,Colvin M, Chopra M and Kuhn L . Infant feeding practices at routine PMTCT sites, South Africa: results of a prospective observational study amongst HIV exposed and unexposed infants - birth to 9 months. International Breastfeeding Journal 2012, 7:4  doi:10.1186/1746-4358-7-4

  2. National Department of Health SA. National Department of Health. Infant and Young Child Feeding Policy. 2007. Available from www.doh.gov.za

  3. Kuhn, L. Maternal and Infant Health is Protected by Antiretroviral Drug Strategies that Preserve Breastfeeding by HIV-Positive Women. Southern African Journal of HIV Medicine. 2012; 13(1).

  4. National Department of Health Breastfeeding Summit. The Tshwane Declaration of Support for breastfeeding in South Africa. South African Journal of Clinical Nutrition 2011; 24(4): 214-6.

  5. Goga A, Dinh T, Jackson D, for the SAPMTCTE Study Group. Evaluation of the Effectiveness of the National Prevention of Mother-to-Child Transmission (PMTCT) Programme Measured at Six Weeks Postpartum in South Africa, 2010. Published 2012 by South African Medical Research Council. Available from http://www.mrc.ac.za/healthsystems/reports.htm. Accessed 6 January 2014.

  6. Lehtonen R, Pahkinen E. Practical Methods for Design and Analysis of Complex Surveys 2004 New York: John-Wiley & Sons.


Increased CONGENITAL CYTOMEGALOVIRUS Co-Infection with In Utero-Acquired HIV-Infection
The NICHD HPTN 040 Study Team, presenting author Gerhard Theron, Department of Obstetrics and Gynaecology, University of Stellenbosch and Tygerberg Hospital.

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