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Discussion:

This is the first study to document congenital CMV prevalence amongst a large sample of HIV-exposed infants in sub-Saharan Africa, and the first report of congenital CMV in Southern Africa. Our study shows that despite universal

maternal ART, and the low rates of HIV of 2-3% currently reported, the prevalence of cCMV in HIV exposed newborns

is high, at 2,94% and significantly higher in mothers with CD4counts <200cells/μL at 6,3%.

Our study prevalence is high compared to the general population rates documented in screening studies in the U.S., Europe and South America 1, 15. In addition, the overall rate of cCMV in this study was consistent with that reported for HIV-EU infants in these countries 16,17,18 Even for mothers with CD4 cell counts >200 cells/uL the rate of cCMV infection in our study remained elevated in relation to populations with high CMV sero-immunity. In conclusion, whilst the HIV burden in women of childbearing age in SA is high, this will drive an excess risk of congenital CMV.
In summary, our study findings demonstrate a high rate of cCMV in the era of prenatal antiretroviral therapy in this

South African population of HIV exposed newborns, and an association of CMV transmission with advanced maternal immunosuppression.

Preventing congenital CMV should remain the ultimate goal and although fraught with complexity, work on a vaccine continue. A breakthrough for a HumanCMV vaccine came in 2009 with the publication of a Phase II study of a purified recombinant vaccine based on adjuvant glycoprotein B demonstrating 50% efficacy against acquisition of HCMV in young woman in the trial.19 More exciting for us in seroprevalent areas is a Meghan Eberhardt’s new approach targeting viral IL10, thereby altering the host innate immune response, decreasing local and systemic CMV replication.20

Minimizing severe maternal immunosupression with early, even pre-conception, anti-retroviral treatment will also impact on the CMV burden: In South Africa, intensification of the adult HIV program in recent years21 can be expected to continue to reduce the rates of immunosuppression among women prior to conception. In addition, recent implementation of WHO option B guidelines for prevention-of mother-to-child-transmission (PMTCT) will impact pregnant women across all CD4 count categories. Therefore, the birth prevalence of cCMV in HIV-exposed infants in this population may need re-evaluation and the transmission rate in HIV uninfected mothers should also be determined.

Studies have shown that cCMV results in a substantial and severe disease burden, particularly in terms of childhood hearing loss, with nearly 20% of bilateral moderate to profound sensorineural hearing loss being caused by cCMV infection. The burden of cCMV-induced hearing loss in this population, as well as the impact of cCMV infection

on morbidity, growth and development in HIV-exposed infants should be formally evaluated.


Author’s own conclusions regarding present and neonatal practice implications:

Universal newborn CMV screening may not be realistic, but selective screening may be warranted in high risk cases:

• clinical signs (microcephaly, HSM, rash, petechiae, conj bilirubinaemia etc) AND/OR
• 2/ more risk factors: - “high risk” HIV-exposure (maternal CD4 count <200?/ VL cut-off?),
- unexplained IUGR,
- unexplained thrombocytopaenia, petechiae

- failed hearing screening


Once the diagnosis is confirmed treatment with intravenous Gancyclovir and, or oral Valgancyclovir should be considered in all symptomatic and possibly asymptomatic cases with a very high CMV viral load. Treatment has unequivocally been shown to be of benefit in symptomatic cases and to overall reduce hearing loss if started in the first month of life4,22,23. The predominant obstacle to Rx is cost. Further collaborative studies on standardising viral load laboratory methods and interpretation may prove invaluable, especially in deciding who not to treat.

Ophthalmological, neurodevelopmental follow up is essential and repeated hearing screening up to 2- 4 years of age. Unlike many other congenital or early-onset disabilities, infants with hearing loss have the prospects of outcomes potentially matching those of their hearing peers provided the loss is identified early and intervention initiated by 6-9months of age24-26.



References:

  1. Kenneson A. Cannon MJ. Review and meta-analysis of the epidemiology of congenital cytomegalovirus (CMV) infection. Rev Med Virol. 2007 Jul-Aug;17(4):253-76.

  2. Dar L et al. P Congenital cytomegalovirus infection in a highly seropositive semi-urban population in India. Pediatr Infect Dis J. 2008 Sep;27(9):841-3.

  3. Van der Sande M.A. et al . Risk factors for and clinical outcome of congenital cytomegalovirus infection in a peri-urban West-African birth cohort PLoS One. 2007;2(6):e492.

  1. Ghandi RS et al. Management of congenital cytomegalovirus infection: an evidence-based approach. Acta Paediatrica 2010;99:509-515

  2. Dollard SC et al. New estimates of the prevalence of neurological and sensory sequelae and mortality associated with congenital cytomegalovirus infection. Rev. Med. Virol. 2007;17:355-363

  3. Swanepoel D. et al. Early hearing detection and intervention in South Africa. J of Ped Otorhinolaryngol. 2009, doi:10.1016/j.ijporl.2009.01.007

  4. Wonkam A. et al. Aetiology of childhood hearing loss in Cameroon (sub-Saharan Africa). Eur J of Med Genetics 56(2013): 20-25

  5. Grosse SD et al. cCMV infections a cause of perm bilat Hloss: A quant assesm .J of Clin Virol 41(2008)57-62

  1. Slyker JA, Lohman-Payne BL, John-Stewart GC, Maleche-Obimbo E, Emery S, Richardson B, et al. Acute cytomegalovirus infection in Kenyan HIV-infected infants. AIDS. 2009;23(16):2173-81.


  2. Mwaanza N, Chilukutu L, Tembo J, Kabwe M, Musonda K, Kapasa M, et al. High rates of congenital cytomegalovirus (CMV) infections linked with maternal HIV infection among neonatal admissions at a large referral center in sub-Saharan Africa. Clin Infect Dis. 2013.

  3. Lanari M, Lazzarotto T, Venturi V, Pap I, Gabrielli L, Guerra B, Landini MP, Faldella G. Pediatrics 2006;117;e76-83

  4. Boppana SB, Fowler KB, Pass RF, Rivera LB, Bradford RD, Lakeman FD, Britt WJ. J of Pediatrics 2005;146:817-823

  5. Luck S, Sharland M. cCMV: new progress in an old disease. Paed and Child Health(2008)19;4, 178-184

  6. Atkinson C, Emery VC. Cytomegalovirus quantification; Where to next in optimising patient management? J of Clin. Virol(2011), doi:10.1016/j.jcv.2011.04.007.

  7. Mussi-Pinhata M.M. et al Birth prevalence and natural history of congenital cytomegalovirus infection in a highly sero-immune population. Clin Infect Dis. 2009 Aug 15;49(4):522-8.

  8. Guibert G. et al. Decreased risk of cCMV infection in children born to HIV-1-infected mothers in the era of highly active antiretroviral therapy. Clin Infect Dis. 2009 Jun 1;48(11):1516-25.

  9. Duryea E.L. et al. Maternal human immunodeficiency virus infection and congenital transmission of cytomegalovirus. Pediatr Infect Dis J. 2010 Oct;29(10):915-8

  10. Frederick T et al. The effect of prenatal highly active antiretroviral therapy on the transmission of congenital and perinatal/early postnatal cytomegalovirus among HIV-infected and HIV-exposed infants. Clin Infect Dis. 2012;55:877-84.

  11. Pass RF, Zhang C, Evans A, et al. Vaccine prevention of maternal cytomegalovirus infection. NEJM 2009;360(12):1191-1199

  12. Eberhardt MK, Deshpande A, et al. Vaccination Against a Virally-Encoded Cytokine Significantly Restricts Viral Challenge. J of Virology Nov 2013;87 (21):11323-31

  13. Fox MP, Shearer K, Maskew M, Macleod W, Majuba P, Macphail P, et al. Treatment outcomes after 7 years of public-sector HIV treatment. AIDS. 2012;26(14):1823-8.

  14. Kimberlin DW et al. Effects of Gancyclovir therapy on hearing in symptomatic cCMV disease involving the central nervous system: a randomized controlled trial. J Pediatr 2003:143:16-35

  15. Smets K et al. Selecting neonates with cCMV infection for Gancyclovir therapy. Eur J Pediatr 2006 Dec;165(12):885-90

  16. Nelson HD, et al. Universal newborn hearing screening: systematic review. Pediatrics 122 (2008) e266-e276

  17. Watkin P et al. Language ability in children with permanent hearing impairment: influence of early management, family participation. Paed.120(2007) e694-701

  18. Yoshinago-Itano C, Levels of Evidence: universal newborn hearing screening and early detection and intervention systems. J. Commun. Disord.37(2004):451-465


FEATURES OF TUBERCULOSIS (TB) EXPOSED NEONATES AND EFFECTIVENESS OF TB CHEMOPROPHYLAXIS USING RIFAMPICIN AND ISONIAZID AT CHRIS HANI BARAGWANATH ACADEMIC HOSPITAL.
KT Mathivha, SC. Velaphi
Background:

South Africa has a high incidence of tuberculosis (TB) in excess of 500/100 000. Distribution of tuberculosis has changed from a peak in people over the age of 50 years to a median age of 30 years. This change makes women of child bearing age to be at risk of contracting TB. TB is a leading cause of morbidity and mortality in women of child bearing age. This is also the peak age during which women are infected with human immunodeficiency virus-1 (HIV-1).

The increase in incidence of TB infection has been associated with an increase in HIV-1 co-infection. Consequently TB is the commonest HIV-1 related illness and is a cause for mortality in women in impoverished regions of Africa where TB is endemic. TB and HIV-1 are independent risk factors for maternal mortality and adverse perinatal outcomes.

TB infection during pregnancy is associated with increased risk of preterm births, intrauterine growth retardation, maternal mortality and perinatal infant mortality when compared to healthy pregnant women. Women Infected with TB during pregnancy are likely to infect their offspring resulting in perinatal TB (a descriptive term encompassing TB acquired in utero, intra -partum and postpartum). The risk of developing disease after infection during the first five years is high.

The most effective way to prevent children from becoming infected with Mycobacterium tuberculosis is to diagnose and treat adult TB patients as early as possible. TB disease can be prevented by providing therapy to young and vulnerable children including newborn babies born to mothers with TB. There are two regimens that are used for chemoprophylaxis in infants, one using isoniazid (INH) monotherapy for at least six months and the other using INH and rifampicin (RIF) for three months.

The Essential Drugs List for South Africa (EDL) 2006, recommended three months of INH and RIF at a dosage of 5mg/kg/day and 1mg/kg/day respectively for chemoprophylaxis of congenital (perinatal) TB. Childhood TB guidelines of the South African Society for Paediatric Infectious Diseases (SASPID) 2009 as well as World Health Organization (WHO) recommend INH six months of INH at a dose of 8-12mg/kg/day.

Both regimens (INH monotherapy, INH and RIF chemotherapy) have been found to be equivalent in terms of efficacy, proportion of side effects and mortality. Adherence to three months chemoprophylaxis regimen of INH and RIF was significantly better than adherence to six months chemoprophylaxis of INH only. The recommendation was that shorter periods of chemoprophylaxis such as INH and RIF combination should be considered to improve adherence but further studies are required.

At Chris Hani Baragwanath Academic Hospital >30% of women attending antenatal clinic are HIV-1 infected and have co-infection with TB. In our hospital characteristics of mothers with TB and their infants have not been reported. We used three months of INH and RIF chemoprophylaxis for a period of three years (2007-2012), because of the benefits of adherence compared to six months of INH.


Objective:

To describe features of neonates exposed to maternal TB and; to assess effectiveness of TB chemoprophylaxis using three months of INH and RIF.


Methods:

The study was a retrospective observational descriptive study. Maternal and infant records were reviewed.

Data collected from maternal records were demographic characteristics, time of TB diagnosis in the mother, maternal health at delivery and maternal HIV status and CD4 counts. Data collected from infant records are demographic characteristics, clinical presentation at birth, laboratory findings and diagnosis of TB infection at birth and at three months of age.
Results:

Over a three year period, 86 pregnant mothers were diagnosed with TB and their infants investigated and followed up for TB. Maternal ages ranged between 16 to 41 years (median age 29 years). Diagnosis of TB was made antepartum and peri-partum in 64 (72.7%) and 24 (27.3%) respectively. At time of assessing the infants, 49 (55.7%) mothers were ill and hospitalized and 8 (9%) died in the peri-partum period. Eighty four (97.7%) mothers were HIV-1 positive. Among those with recorded CD4 counts 55 (65.5%) had counts < 200/mm3.

The median gestational age was 36 weeks (range, 28 – 38 weeks). Thirty eight (43.2%) were small for gestational age. Gastric aspirates for acid fast bacilli (AFB’s) were done in 88 infants and four (4.5%) had positive AFB’s. At three months follow up 16 (18.2%) defaulted. Of the remaining (72) non infected infants, 63 (87.5%) had PPD done and only 1 (1.4%) ha d a positive PPD. Among infants born to HIV-1 positive mothers who returned at three months of age 5 (7.2%) were HIV-1 PCR positive.

Of the 5 infants with positive HIV-1 PCR their birth weight ranged from 1600 to2700 grams and only one infant had positive AFB results. Four of the mothers were on highly active anti-retroviral therapy (HAART) and one did not receive anti-retroviral therapy. All the five mothers had CD4 counts < 200/mm3.


Conclusion:

The majority of mothers with TB during pregnancy are HIV-1 positive with significantly low CD4 counts. TB exposed infants are born preterm, small for gestational age and 5% are infected by time of delivery (in-utero infection). There is a high default rate at three months follow up, making it difficult to properly assess effectiveness of INH and RIF chemoprophylaxis at three months. Among those who attended follow up and had PPD done, 1.4% had TB infection. The high HIV-1 transmission in this cohort is of major concern, especially with the use of RIF as part of chemoprophylaxis. Studies looking at the role of RIF in reducing effect of ARV’s in reducing mother to child transmission need to be conducted.


NATIONAL BIRTH DEFECTS DATA: 2006-2012 (ABSTRACT)



Vuyiswa Mtyongwe, Dineo Tshikedi, Keshika Sivnannan, Colleen Aldous*

Sub-Directorate Human Genetics, National Department of Health

*School of Clinical Medicine, University of KwaZulu-Natal
The Birth Defects Notification tool (data collection tool) was introduced nationally by the National Department of Health (NDoH) in 2006 to standardise birth defects notification. It was required that all birth defects be reported to provincial Departments of Health and then forwarded to the Sub-directorate Human Genetics at the NDoH. This initiative has grown since its implementation and we are now able to reflect on the data collected. The dataset forms a valuable foundation for a way forward in birth defects surveillance albeit we recognise its shortcomings.
Birth defects notifications provided by all provinces from July 2006 to December 2012 were analysed critically.These notifications were received by fax, post or courier. On receipt, data was captured at the Sub-directorate in a database using Microsoft Access, exported into Microsoft Excel and descriptive statistics performed. Statistics for the scope of the birth defects and reporting compliance were gleaned.
Since the implementation of the tool, 12 754 birth defects have been reported across the country. There have been discrepancies regarding reporting leading to under-reporting of birth defects, as well as compliance in completing the notification tool.
Whilst the current Birth Defects Notification tool provides some valuable data, getting a comprehensive picture of true birth defects incidence is not being delivered. However, we believe that building on this data reporting foundation together with increased training in the provinces, will lead to an improvement in the reporting compliance and forwarding of birth defects notifications to the NDoH.
THE NUMBERS, CHARACTERISTICS AND OUTCOME OF TERM/NEAR-TERM INFANTS WITH INTRAPARTUM ASPHYXIA ADMITTED AT CHRIS HANI BARAGWANATH HOSPITAL
E Bruckmann
Introduction

Birth asphyxia is one of the common causes of mortality and morbidity in children. Globally, it is estimated that about 3.3 million neonates died in 2009. In South Africa (SA) there were 14 000 neonatal deaths in 2008. About a quarter of neonatal deaths are due to asphyxia. Although in South Africa, 5.6/1000 live births of neonatal deaths in bigger babies (birth weight >1000 grams) are due to asphyxia, the incidence of asphyxia, characteristics and predictors of poor outcome in neonates with asphyxia is not widely reported. Chris Hani Baragwanath Academic Hospital (CHBAH) is one of 9 national central hospitals in SA but has not been part of the national survey therefore figures from Saving Babies Report cannot be extrapolated to patients admitted at CHBAH. Knowing this information will assist in highlighting the burden of asphyxia with its associated morbidities in survivors, and in planning use of limited resources in management of neonates with intrapartum asphyxia.


Objectives

  • To determine the proportion of babies weighing >2000 grams at birth with a diagnosis of asphyxia.

  • To determine the characteristics of neonates with a diagnosis of asphyxia.

  • To compare characteristics of neonates with severe hypoxic ischaemic encephalopathy and/or died to those who survived to hospital discharge with no HIE and/or mild to moderate HIE.


Methods

A retrospective, descriptive study of neonates with birth weight of ≥ 2000g who required bag mask ventilation (BMV) at birth and were admitted with a primary diagnosis of asphyxia to a Level 2 or 3 nursery at Chris Hani Baragwanath Academic Hospital in the period 1 Jan. to 31 Dec. 2011. Exclusions to the study were those born before arrival to hospital, and infants with severe congenital abnormalities. The study was conducted after getting approval from the hospital protocol review committee and the University of the Witwatersrand Human Research Ethics Committee.


RESULTS

Incidence

There were 22 803 live births over this 12 month period, of which 21 086 had birth weight of ≥2000 grams. A total of 357 newborns were diagnosed with asphyxia of which 36 died in labour ward nursery and 321 were admitted to level 2 or 3 nursery.

Defining asphyxia as an Apgar Score of <7 at 5 minutes and/ or base deficit of >12 mmols/L, the incidence of asphyxia at CHBAH was 8.7 – 12.4/ 1000 live births, whereas using need for bag mask ventilation and admission the incidence increased to 16.9/1000 live births. (Table 1)
Table 1 Incidence of Asphyxia According to Different Criteria of Diagnosing Asphyxia

Definition

Number of babies weighing ≥ 2000 g diagnosed with asphyxia

Incidence of asphyxia (per 1000 live births)

All with Bag mask ventilation

357

16.7

Apgar <7 at 5min

254

12.1

BD > 12

297

14.1

Apgar <7 and BD >12

219

10.4

Apgar < 5 at 10min and BD>16

54

2.5

BD > 16 + HIE2/3

134

6.4

Two hundred and eighty one infants (55.7%) with asphyxia developed signs of hypoxic ischaemic encephalopathy, giving an incidence of 8.4/1000 live births among infants weighing more than 2000 grams. Among those who developed HIE, 53% had moderate to severe HIE. HIE 3 was associated with high mortality rate (Table 2).


Table 2 Incidence and Mortality Rate to Hospital Discharge According to HIE Sarnat Staging




Total

N (%)

Incidence

/1000 live births

Died

N (%)

No HIE

357

-

0 (0)

HIE 1

254

6.2

2 (1.5)

HIE 2

297

5.8

7 (5.7)

HIE 3

219

1.3

16 (57.1)

All HIE

54

13.3

25 (7.8)


Table 3 Differences between Infants with Mild to Moderate HIE and Severe HIE or Death




No HIE or

HIE 1-2

(n=256)

HIE 3 or death

(n=37)

P- value*

P-value**

APGAR 5

5.8

3.9

<0.01

0.97

APGAR 10

7.5

5.0

<0.01

0.004

Time to spontaneous respiration

6.2

15.4

<0.01

0.79

pH

7.1

6.9

<0.01

0.97

Base Deficit(mmol/L)

17.5

22.8

<0.01

0.12

Glucose (mmol/l)

6.8

6.9

0.88

N/A

Bicarbonate

(mmol/L)

11.6

8.9

<0.01

0.02

Logarythmic regression analysis was performed on those results showing a statistical significance in predicting no/mild HIE and mod/severe HIE/death. Factors showing a significance using univariant analysis were APGAR at 5 and10 minutes, time to spontaneous respiration, mode of resuscitation, pH, base deficit and bicarb all with p<0.05. Multivariant analysis showed only two factors with significant predictive value for severe HIE or death namely APGAR at 10min with p-value of 0.004 and bicarb levels in the first hour after birth with p-value of 0.02. (Table 3).

The odds of having severe HIE or death were greater if Apgar score at 10 minutes were <5, Adrenalin required during resuscitation and time to spontaneous respiration was >20 minutes. (Table 4)
Table 4 Odds of Severe HIE or Death with Apgar Score, Extent of Resuscitation and Time to Spontaneous Respiration




OR (95% CI)

Apgar Score at 5 min.

> 7


5 to 7

<5

Reference

1.79 (0.50-7.01)

9.33 (2.83-34.03)



Apgar Score at 10 min.

> 7


5 to 7

<5

Reference

3.05 (1.08-8.62)

19.13 (5.66-66.89)



Extent of Resuscitation

BMV only


Chest Compressions

Drugs

Reference

4.51 (1.06-17.98)

81.2 (13.17-647.7)


Time to Spontaneous Respiration

< 5 minutes

5 to 10 minutes

10 to 20 minutes

>20 minutes


Reference

2.18 (0.55-9.24)

3.41 (0.74-16.20)

27.19 (6.89-117.38)



Conclusion

Incidence of asphyxia and HIE at CHBAH is high. A low Apgar score at 10 minutes is associated with poor outcome. An Apgar score <5 at 10 minutes and time to spontaneous respiration >20 minutes might assist in decision making where resources are limited. Asphyxia must be prevented and neuroprotection should be used in those with severe HIE as it is associated with high mortality and survivors are more likely to have neurologic impairment.



THE INFLUENCE OF BIRTH SITE ON SHORT-TERM OUTCOMES OF ENCEPHALOPATHIC NEWBORN INFANTS TREATED WITH THERAPEUTIC HYPOTHERMIA AT GROOTE SCHUUR HOSPITAL, CAPE TOWN, SOUTH AFRICA (ABSTRACT)
Victoria Nakibuuka, Kirabira,1,2 Natasha Rhoda1, Alan Horn1

  1. Division of Neonatal Medicine, department of Paediatrics, Groote Schuur Hospital , University of Cape Town, South Africa

  2. Department of Paeditarics, Nsambya Hospital, Uganda


Background

International consensus guidelines recommend that term or near-term newborns with moderate or severe hypoxic ischaemic encephalopathy (HIE) should be treated with hypothermia within six hours of birth, but many of the affected babies are born outside the treatment centers. There are few data describing the influence of birth-site on outcome after HIE in South Africa.


Objectives: i) To describe the demographic differences between inborn and outborn babies with HIE who are treated with hypothermia in a tertiary neonatal intensive care unit in South Africa; and ii) to compare the frequency of abnormal short-term outcome by discharge; including mortality, abnormal amplitude-integrated electroencephalogram (aEEG) at 48 hours, or failure to establish normal breast- or cup-feeding.
Methods: This was a retrospective, comparative and descriptive analysis of data extracted from a prospectively collated registry of babies with moderate or severe HIE, who were admitted to the neonatal intensive care unit and treated with hypothermia at Groote Schuur Hospital between 1 January 2011 and 31 December 2012.
Results: A total of 57 babies were treated with hypothermia of which 23 (40%) were inborn and 34 (60%) outborn. Cooling was initiated significantly earlier among the inborn babies (age 2.3 hours vs 4.3 hours, P=0.002 ). A non-reassuring cardiotocograph (CTG) and the occurence of pregnancy complications were significantly more common in inborn babies (P=0.001 and P=0.03 respectively). More outborn babies died or had an abnormal aEEG at 48 hours (22% vs 32%) and fewer outborn babies achieved normal feeding at discharge (22% vs 38%), but these differences were not significant.
Conclusion: This retrospective review quantifies the significant burden of HIE in outborn babies at this centre; it also quantifies the significant delays in initiating cooling in this group. Although short-term outcomes were not significantly increased in outborn babies, the apparent paucity of pregnancy and CTG abnormalities in referred infants may suggest opportunities for improved pregnancy and intrapartum monitoring; these findings should be used to inform a larger cohort study to adequately inform policy.

MEDICO-LEGAL ISSUES WITH RESPECT TO INTRAUTERINE HYPOXIA (BIRTH ASPHYXIA)
Peter Cooper; Department of Paediatrics and Child Health, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital

E mail: peter.cooper@wits.ac.za


Introduction

Litigation in South Africa against hospitals, doctors and nurses has become very common in recent years. This is occurring in both the private and the public sector. Not only is it extremely distressing for the individuals involved, but it is resulting in a significant increase in health costs. Many claims in relation to long term brain damage from intrauterine hypoxia are being made and average amounts claimed per case are in the region of R10-15 million. This has resulted in a marked escalation in the costs of insurance against litigation for doctors.


Methods & Results

This paper reflects my own experience from having given an opinion in a number of such cases and, in some instances, evidence in court.


Neonatal encephalopathy is a term that is used to describe a neonate who manifests with an abnormal neurological state. Although hypoxia/ischaemia is an important cause of neonatal encephalopathy (referred to as hypoxic ischaemic encephalopathy or HIE), it is not the only cause. Others include neonatal stroke, infections, insults occurring earlier in pregnancy, congenital abnormalities of the brain etc. Thus the term neonatal encephalopathy is preferred until a definitive diagnosis can be made.
Encephalopathy can be classified as mild, moderate or severe defined briefly as follows:

Mild – jittery, increased tone, usually able to feed orally, usually settles by 24-48 hrs

Moderate – depressed level of consciousness, abnormal tone, frequently convulsions, unable to feed orally initially, will not settle within 72hrs

Severe – severe neurological depression, apnoea, uncontrolled convulsions, coma etc
Mild encephalopathy seldom if ever results in significant brain damage, but moderate and severe encephalopathy can result in severe long term neurological sequelae.
Studies from developed countries indicate that only 8-10% of cases of childhood cerebral palsy are a result of intrapartum hypoxia. However, while accurate figures from developing countries are not usually available, the proportion is almost certainly substantially higher. Thus for any handicapped child the question that arises is whether the handicap of the child can be attributed to intrauterine hypoxia.

A consensus statement was published by the International Cerebral Palsy Task Force with MacLennan as first author in the British Medical Journal in 1999 and was supported by national obstetric, paediatric and nursing societies from the United States, Britain, Ireland, Australia, New Zealand and Canada.  These criteria were modified by the American College of Obstetricians and Gynecologists and are still the most widely accepted set of criteria linking acute intrapartum events with subsequent handicap – these are shown below:



Essential Criteria

  1. Evidence of a metabolic acidosis in intrapartum fetal, umbilical arterial cord, or very early (taken within an hour of birth) neonatal blood samples (pH < 7.00 and base deficit > 12 mmol/l)

  2. Early onset of severe or moderate neonatal encephalopathy in infants of > 34 weeks’ gestation

  3. Cerebral palsy of the spastic quadriplegic or dyskinetic type

  4. Exclusion of other causes for the handicap.

Criteria that together suggest an intrapartum timing but by themselves are non-specific

  1. A sentinel (signal) hypoxic event occurring immediately before or during labour

  2. A sudden, rapid and sustained deterioration of the fetal heart rate pattern usually after the hypoxic sentinel event where the pattern was previously normal

  3. Apgar scores of 0-6 for longer than 5 minutes

  4. Early evidence of multisystem involvement

  5. Early imaging evidence of acute cerebral abnormality

In recent years, MRI scanning has proved to be very helpful. Years after the insult, specific patterns of injury can be seen e.g. changes in the cortical and sub-cortical structures following a partial and prolonged episode of hypoxia/ischaemia and changes in the basal ganglia following a sudden and severe episode e.g. ruptured uterus.

If these criteria are met, the question becomes whether the intrauterine hypoxia was avoidable. In most of the cases that I have been involved in, the avoidable factors were clear cut e.g. lack of fetal monitoring or misinterpretation of the CTG, inappropriate use of uterine stimulants and inadequate resuscitation at birth. In addition postnatal management is being scrutinized more closely looking at aspects such as hypoglycaemia, hypocarbia, hyperoxia and hyponatraemia.


A further serious problem is inadequate records being made at the time of these events. When these cases enter the legal system it is usually a number of years after the event and the legal system takes the view that if something was not documented it did not happen. Since doctors and nurses cannot remember the details of events that took place a number of years ago, this makes the defence of many of these cases extremely difficult.
The availability of postnatal hypothermia for the management of HIE has not yet entered the legal debates but is likely to do so. While hypothermia is relatively simple to initiate, as with any other therapy, is should not be used where the facilities are not adequate for its use.
Discussion

In most cases where awards are made against hospitals, doctors and nurses they are on the basis of basic errors or omissions that have been committed, compounded often by a lack of clinical records of the events that took place. Communication with parents is extremely important as the resentment that parents feel about the lack of communication may be one of the reasons why they initiate litigation.


LEADERSHIP EFFECTIVENESS FOR MATERNAL, NEWBORN AND CHILD HEALTH (ABSTRACT)
Voce AS, Public Health Medicine, University of KwaZulu-Natal

Taylor R, Graduate School of Business and Leadership, University of KwaZulu-Natal


Introduction

Improving the quality of maternal, newborn and child care is a major challenge currently facing South Africa towards achieving the Millennium Development Goals. Varying quality of care has been achieved within comparable contexts, with similar resource constraints, reportedly attributable to leadership effectiveness. In re-engineering primary health care, District Clinical Specialist Teams (DCSTs) have been appointed to each health district in South Africa, primarily to provide clinical leadership and governance towards improving quality of care.



Methods

An exploratory qualitative study design located within the constructivist grounded theory paradigm was implemented in KwaZulu-Natal to describe, for DCSTs: (1) what comprises leadership; (2) what comprises leadership effectiveness; (3) how leadership effectiveness is measured; and (4) how leadership effectiveness develops. Purposive sampling was used to elicit the perspectives of (1) DCSTs in the Province, through focus group discussions, and of (2) District Managers, through key informant interviews. Data was collected until saturation and redundancy had been attained. Data was analysed using an inductive and iterative approach, following the stages of grounded theory data analysis. Criteria for ensuring the trustworthiness of the study were adhered to. The study received the ethical approval of the Health and Social Sciences Ethics Committee at the University of KwaZulu-Natal.


Results

Respondents distinguished conceptualisations of ‘effective leader’ vs ‘effective leadership’, spanning individual, relational and systemic dimensions. The unique role and contribution of DCSTs towards leadership effectiveness in the health system was elucidated. Conceptualisations of authority, power and influence contrasted currently prevailing organisational culture with a changing organisational culture, providing a context for the sustainable attainment of quality of care and improved maternal and perinatal outcomes. Respondents shared insights with regard to factors facilitating and hindering DCST leadership effectiveness, and the measurement of the unique contribution of DCSTs towards leadership effectiveness. Respondents provided tentative reflections on the progression/development of DCST leadership effectiveness.


Discussion

The complex web of inter-related factors associated with quality of care and improved maternal, newborn and child health outcomes pose particular leadership challenges. DCSTs are uniquely positioned in the health system, providing leadership leverage in the clinical, programmatic and systemic spheres.


IS THERE A NEED FOR DEBRIEFING FOLLOWING CATASTROPHIC LABOUR WARD EVENTS?
K Frank
Introduction

Given that non-pregnancy related infections are the leading cause of maternal death in South Africa and the HIV positivity rate amongst our pregnant women is around 29.4%2 it is highly likely that junior doctors working in obstetrics and gynaecology will be exposed to a maternal death during their training. The fresh stillbirth rate of 25.2 per 10004 at our institution along with the high number of deliveries occurring here further increases the probability of exposure to a catastrophic labour ward event. The loss of a patient can be distressing for the doctors involved and can have far reaching emotional effects. This study was undertaken to assess the support, in the form of debriefing, offered by the department and whether there is a need to increase the availability of debriefing.


Methods

The study is a prospective, cross sectional, hospital based study. It was conducted by questionnaire from July 2011 to June 2012. The questionnaires were completed anonymously by interns, medical officers and registrars working in the department of Obstetrics and Gynaecology. A total of 146 questionnaires were distributed and 56 were returned resulting in a response rate of 38%.


Results

Thirty-one interns, seven medical officers and eighteen registrars responded to the questionnaire. Nineteen respondents found exposure to a maternal death more distressing than exposure to a fresh stillbirth. Eleven found the fresh stillbirth to be the more distressing event. Poor or late healthcare seeking was cited as the most common reason that the patient was responsible for the outcome (93%). Resuscitation and patient management problems were felt to be the leading cause (22%) of how healthcare workers were responsible for the outcome. Lack of equipment and hospital bed status was the leading cause (30%) of administrative factors responsible for the outcome. There was a range of negative emotions experienced by the doctors following exposure to a maternal death or fresh stillbirth in both the short (<48 hours) and long (>48 hours) term time periods. These included anger (73%), guilt (50%) and self-blame (24%) in the short term. In the long term the most common emotions experienced were anger (56%), helplessness (50%), anxiety (41%), hopelessness (38%) and inadequacy (38%). Eighty five percent of cases were discussed at the departmental morbidity and mortality meeting (M and M) and 52% of respondents felt that this was helpful in terms of resolving negative emotions related to the case. Twenty-seven percent felt that the morbidity and mortality meeting affected them negatively. Despite the majority of the cases being discussed at the morbidity and mortality meeting and the majority of respondents finding this helpful 67% of respondents felt that departmental support was inadequate. Eighty-seven percent felt that formal debriefing should be offered by the department. In 60% of cases respondents hoped to gain personal relief from debriefing and 86% would feel comfortable debriefing to a senior staff member. Twenty-eight percent of respondents sought debriefing themselves and 87% of these felt that it was helpful. Sixty-five percent of respondents were expected to counsel the patient or her family following the event. Forty-eight percent did not feel equipped to counsel the patient or her family in terms of their own emotions or their counselling skills. Eighty percent of respondents felt that there should be more training at medical school or upon entering the department on how to counsel the family of a deceased patient and how to support colleagues following catastrophic labour ward events.


Conclusion

Maternal deaths and fresh stillbirths are sources of emotional distress for doctors involved with them. Careful discussion of the case at the morbidity and mortality meeting may provide some emotional relief but it also has the potential to be harmful. The M&M meeting is not considered adequate departmental support following catastrophic events. Debriefing with senior staff members or colleagues following such an event may be an effective way of providing departmental support. One of the forms of debriefing that may be appropriate in this situation is critical incident stress debriefing although there is a role for further research into exactly how these debriefing sessions should be structured. There is a controversy surrounding debriefing which, at this point, remains unresolved. Until there is resolution on this matter the department should proceed with offering debriefing with caution. An additional way in which doctors could be equipped to deal with the death of a patient is by improving their counselling skills, either at medical school or through a program run by the department.



PSYCHOSOCIAL IMPLICATIONS OF STILLBIRTH FOR THE MOTHER AND HER FAMILY: A CRISIS-SUPPORT APPROACH
Melanie Human, MA SW, ¹ Coen Groenewald, MD, ¹ Sulina Green, PhD, ² Richard Goldstein, MD, ³ Hannah C. Kinney, MD, 4 and Hein Odendaal, MD, 1

1 Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Science, Stellenbosch University, Tygerberg, South Africa; 2 Department of Social Work, Stellenbosch University, South Africa; 3 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA,; 4 Department of Pathology, Boston Children’s Hospital and Harvard Medical School, in collaboration with the PASS Network.


Introduction

Stillbirth is a major problem in South Africa. During 1 January 2010 till 31 December 2011, 32,178 stillbirths were tracked by the National Perinatal Identification Programme at 588 sites in South Africa. The National Department of Health is aware of the high stillbirth rate and several issues are addressed at different levels by several organizations to try to reduce stillbirths and support bereaved mothers. An event that should have been a joyous birth ends in a tragic death, forcing the mother to deal with the emotions of birth and death simultaneously. The bereaved mother needs to receive specialised care and support as soon as possible and the crisis intervention approach, as a social work method, is seen as being helpful to regain a sense of equilibrium in her, and the family’s life.

Stillbirth defies the modern expectation of a healthy outcome for pregnancy and has been demonstrated to be as profound and significant as any other type of bereavement. Grief experienced during this time is complex and individualistic. Main reasons contributing to the fact that this specific type of grief is so complex are: 1) lack of memories surrounding the baby, 2) sense of biological failure, especially felt by the mother of the baby, 3) minimization by others as well as lack of validation from others and 4) uncertainty regarding further pregnancies or parental future hopes. Grief following miscarriage and stillbirth is particularly susceptible to being disenfranchised, as only parents may have known the baby, felt it move, or observed it by ultrasound.
Method

This study explores and describes the emotions of 25 mothers who experienced a stillbirth within the Safe Passage Study (www.safepassagestudy.org) in South Africa. The mothers’ feelings about the stillbirth at least 6 months, but no later than 18 months, after the event were examined, as well as its impact on relationships with partners and other children. Participants were seen within five days of their loss. During this session the social worker rendered intervention based on the crisis-intervention approach. The crisis intervention model is used to address the special needs and concerns of a client in an acute, psychological crisis. Crisis intervention can be defined as follows: “It is a process for actively influencing psychosocial functioning during a period of disequilibrium in order to alleviate the immediate impact of disruptive stressful events and to help mobilize the psychological capabilities and social resources of persons directly affected by the crisis”. Interventive efforts have two principal aims: (1) to cushion the stressful event by immediate or emergency emotional and environmental first aid and (2) to strengthen the person in his or her coping through immediate therapeutic clarification and guidance during the crisis period (Sheafor, et.al.1994:68-69). Participants were then seen more than six months or longer after the loss, to provide further support to the participant and to evaluate the crisis-intervention approach shortly after the loss.

This study used a combination of quantitative and qualitative research approaches and assumed an exploratory and descriptive research design to provide a detailed description of the phenomenon being studied, i.e. the psychosocial implications of stillbirth. A questionnaire was used to obtain demographic (quantitative) data and a semi-structured questionnaire – the design based on information from literature - was administered during individual interviews. Different types of coping mechanisms were explored with special focus on seeing, holding and taking photographs of the baby. Lastly, attention was given to feelings regarding medical care, autopsy and support from the community.
Results

Participants were asked about the length of their current relationship or marriage. This was asked in order to establish at what stage of the relationship participants are.





Figure 1.1: Length of current relationship or years married

Figure 1.1 illustrates the distribution of the duration of the current relationship of the participants. Eighteen (72%) of the participants are in their relationship for between one and five years. This correlates with Erikson’s’ stage theory where he identified starting and establishing a relationship as an important task of early adulthood (Weiten, 1995:458). Therefore one would expect the duration of the relationship to be not longer than five years. None of the participants was involved with each other for less than one year. One (4%) of the participants was in a relationship for between six and ten years while within the categories of 11 to 15 years together, and the 16 and more years, there were both two (8%) participants in each. Two (8%) of the participants indicated that the question was not applicable to them because they were not in a new relationship yet.


Crisis intervention evaluation

Participants were asked about their perception of crisis intervention. This was important, in order to obtain the following objective of the research: “To develop pilot data about potential mechanisms concerning how social work intervention from a crisis intervention approach can be used to assist patients who have experienced a stillbirth and assist the family to adjust constructively.” Figure 1.2 illustrates the severity of the crisis as seen by participants.





Figure 1.2: Severity of crisis as seen by participants

Findings revealed that mothers still longed for their stillborn babies after a period of six or more months had passed. It also indicated that the father or partner of the baby and other children were affected by a stillbirth. Eighteen mothers (72%) saw the loss of their baby as a crisis and needed help from somebody. Two (8%) mothers experienced the stillbirth as a severe crisis, while 4 (16%) perceived the stillbirth as a slight crisis and 1 (4%) did not perceive the loss as a crisis. This experience was not affected by gestational age. Mothers felt crisis-intervention was beneficial, but preferred that it should be followed by on-going therapy, for at least 4 months, depending from mother to mother.



Comparing thoughts experienced directly after the loss and current thoughts.
Participants were asked to share their thoughts regarding the following statements directly after the loss and more than six months later.
Table 1.1: Comparing thoughts experienced directly after the loss and current thoughts

Twenty-one (84%) of the respondents indicated that they were afraid of falling pregnant again and twelve (48%) participants mentioned that they are still feeling afraid of falling pregnant even though it was more than six months ago. Twenty-one (84%) participants indicated that they feared another loss soon after the stillbirth and 19 (76%) mentioned that they still felt this way. Table 1.1 illustrates furthermore that 12 (48%) participants had nightmares of their babies shortly after the loss, with seven (28%) of the participants still experiencing this. Seven (28%) participants had thoughts of committing suicide while three (12%) participants still had these thoughts. This correlates with Hughes and Riches (2003) opinion on pathological grief. They identified two types of pathological grief: prolonged grief and absent grief. Thoughts of suicide fall under prolonged grief, with no improvement after six months.


Fifteen (60%) of the participants felt that nobody understood them after the loss, with eight (32%) participants indicating that they still felt this way. According to table 1.1 only one (4%) participant had thoughts of stealing a baby soon after the loss but no (0%) participants still felt like doing this. The majority of participants, 24 (96%), never felt like stealing another baby at any stage after the stillbirth. Thirteen (52%) of the participants avoided babies soon after the loss. Five (20%) participants still avoided other babies. Table 1.1 shows that 18 (72%) of the participants were unable to pack away the baby clothes, while eight (32%) participants mentioned that they were still unable to pack away the clothes, six months or more after the loss. Finally 20 (80%) of the participants reported that they tried to be strong and not show any hurt. Seventeen (68%) participants reported still doing this.
The stillbirth also resulted in feelings of alienation from community, friends and family - who did not know how to approach them.
Table 1.2: Community’s reaction on giving support

Seven (28%) mothers experienced support from people in the community while 3 (12%) explained that they were teased. Five (20%) mentioned that most people avoided them. Generally, mothers were satisfied with medical care received.


Conclusions

Key conclusions from the study indicate that crisis intervention directly after the stillbirth, as a method in social work, is effective when rendering service for bereaved mothers and families. This is clear as 18 (72%) mothers indicated that their loss was a crisis and they needed help from a professional. The support helped them to regain a sense of equilibrium. The study emphasizes the importance of social workers being aware that the stillbirth causes tension in partner- and family relationships. Receiving support from a social worker is essential, and allows bereaved mothers to feel empowered and encouraged them to openly grieve for their stillborn babies - much needed in an environment where a stillbirth is seen as a silent birth.

This research was funded by the following grants from the National Institute on Alcohol Abuse and Alcoholism and the Eunice Kennedy Shriver National Institute of Child Health and Human Development: U01 HD055154, U01 HD045935, U01 HD055155, U01 HD045991, and U01 AA016501.
Bibliography

Hughes, P. & Riches, S. 2003. Psychological aspects of perinatal loss. Current Opinion in Obstetrics & Gynecology, 15(2): 107-111.

Sheafor, B.W., Horejsi, C.R. & Horejsi, G.A. 1994. Techniques and guidelines for social work practice. United States of America: Allyn and Bacon.

Weiten, W. 1995. Psychology: Themes & variations. United States of America: Brooks/Cole Publishing.



PATIENT CENTRED MATERNITY CARE.
S Fawcus, J Rucell. with acknowledgements Professor Denny, dept O&G,UCT; Cape Metro task team
Introduction

There are two components of quality of care in maternity services: firstly evidence based effective care to reduce adverse maternal and perinatal outcomes; and secondly patient centred care in which women are treated with respect and dignity. In South Africa, publications such as the Jewkes report in Cape Town and the Human Rights Watch report in Eastern Cape report on abuse of women in labour and also suggest that harsh attitudes and behaviours of health professionals in maternity services can deter women from seeking care. Such behaviour constitutes abuse of women and is described in other low and middle income countries (Mozambique, Kenya, and Brazil); and in some high income countries. Review articles suggest the causes are multifactorial and include lack of professional support for health workers, hierarchical work relationships, excessive workload, inadequate staffing levels and poor infrastructure.



Global and National Initiatives to address abuse of women in labour.

In South Africa; the Better Births initiative introduced in early 2000s aimed to promote more evidence based maternity care and to promote dignity and respect in the treatment of women in maternity services. The tools of this initiative assisted with the first objective more than the second. At a global level and in S Africa, the Rights based approach provides an alternative framework and seeks to ensure accountability of health professionals and managers for poor quality of care. A new initiative coordinated by K4Health (USAID, MCHIP) called “Respectful Maternity Care” has been launched in Brazil, Kenya and Mozambique and has developed training and monitoring tools.



Cape Town Metro: Patient centred maternity care.

Based on the above literature, complaints from women about their experience of care and wide-spread observations by fourth year medical students of disrespectful behaviour by health staff, a Metro meeting was convened by the Head of the Metro district health service and Senior academics from the departments of Public Health and Obstetrics / Gynaecology. The W Cape has a strategy for 2014 of patient centred care, the core values of which are Caring, Competence, Accountability, Integrity, Responsiveness , and Respect (C2 A I R2 ). This was adapted to maternity care and a Code for patient centred Maternity care devised which includes zero tolerance for abusive or disrespectful behaviour but also tries to address health system problems which may contribute to such behaviours and negative attitudes.

The Code has four components:

1. Every woman, every couple seeking maternity care have the right to effective health care and the right to be treated with respect and dignity .

2. Every woman, every couple has the right to information about pregnancy and the necessary obstetric care .

3. Every woman to have a chosen personal and/or facility provided companion in labour. 4. Maternity facilities to be responsive to communities they serve.

The code has been adopted as W Cape policy and is currently being piloted in four MOUS. It has been supplemented by the development of monitoring tools which are both guides to implementation and tools to monitor progress. The process of implementation is being evaluated by a PHD student



Details of THE CODE for PATIENT CENTRED MATERNITY CARE

The code is structured with three columns:



  • CODE: the principles/end points/desired out comes

  • IMPLEMENTATION: necessary activities to achieve outcomes eg. clinical governance/training/infrastructure/budget

  • MONITORING : how do check implementation is occurring/how to evaluate and measure impact.


1. Every woman, every couple seeking maternity care have the right to effective health care and the right to be treated with respect and dignity .

  • Friendly reception by security personnel, receptionists, clerks and health personnel

  • Zero tolerance for acts of verbal and physical abuse by health personnel towards women in labour

  • Evidence based and effective obstetric care

  • Debriefing and support for health professionals working in labour wards on day and night shifts

  • Clean, adequately equipped facility with sufficient linen, consumables, equipment and essential medications

  • Infrastructure and space should be sufficient to enable privacy , comfort, and companions

2. Every woman, every couple has the right to information about pregnancy and the necessary obstetric care .

  • Women to be provided with ongoing information about their pregnancy and labour; and permission sought before any procedure including vaginal examination

  • Antenatal education and preparation for Labour


3. Every woman to have a chosen personal and/or facility provided companion in labour.

  • Each women to have chosen personal companion in Labour (latent and active phase of labour) and at antenatal clinic visits.

  • Each women to have doula/ward care assistant in Labour


4. Maternity facilities to be responsive to communities they serve.

Facilitate Community involvement and dialogue around maternity service provision


PROGRESS IN IMPLEMENTATION

  • Metro task team established

  • Produced code; endorsed and circulated by Head of Health

  • Identified 4 pilot sites / team building / dissemination

  • Each pilot site identified ‘champions’ with external Obstetrician assistance and Substructure involvement

  • Developed monitoring tools:

1. Patient exit questionnaire (daily)

2. Staff questionnaire (before/after)

3. Unit manager narrative report (monthly)


  • Evaluation of process ( PHD student)


CHALLENGES IN IMPLEMENTATION

  • ‘Champions’ found it difficult to get ‘buy-in ‘ from all staff

  • Fear of disciplinary action / suspension

  • Antagonism to adverse criticism eg from students

  • Non implementation of proper debriefing mechanisms

  • Differences of opinions on doulas

  • Infrastructural constraints

  • Monitoring tools too complex

  • Lack of attention to developing (a) the Logic and strategy informing the intervention and (b) How, and who is needed to implement a systems and behavioral reform approach to prevent abuse.


CONCLUSIONS

Implementing patient centred care is an important component of maternity care. Successful implementation requires attitudinal changes by staff, staff support mechanisms, appropriate infrastructural and functioning procurement processes as well as effective clinical governance. A more considered and consultative approach to behaviour change needs to be developed.






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