The KwaZulu-Natal Initiative for Newborn Care (KINC) is a programme which is being implemented in all 38 district hospitals in KZN. It consists of a number of approaches to improve newborn care including training of different cadres of health workers in the KINC approach, ongoing mentoring and support at hospital level to implement new guidelines, as well as accreditation of hospitals who are able to reach the required standard of care.
As a component of ongoing mentoring, action learning, a process of reflecting on, and making sense of, past events and behaviours so as to identify new ways of behaving has been introduced for maternity unit managers.
Action learning groups will be set up in each of the 11 district in KZN. An initial meeting will be held with participants and facilitators to set out the action learning strategy and thereafter the groups will meet monthly for one year. Each action learning group will be convened by a trained action learning facilitator. Each participant will present a real life problem to the group, develop action plans to address the problem and then, with peer support, commit to solving the problem or changing the behaviour over the period of the action learning group. During the action learning monthly meetings, the participant will make a contract with the group for progress made on actions or behaviours that need to be undertaken.
Previous experience with action learning groups among public sector managers have shown that action learning has the potential to serve as a learning and development strategy for managers working in rural health settings. A strong supportive bond between group members was developed. It also provided participants with the tools to apply action learning principles to other challenges in their working lives.
Providing high quality newborn care is a priority in KZN. KINC has included action learning as one of the strategies to strengthen and support neonatal nursery managers to provide this high quality care.
QUALITY INTRAPARTAL CARE, AS PERCEIVED BY WOMEN Tsweleng Louisa Mmakwena
Satisfaction is one of the most frequently reported outcome measures for quality of care and enhanced satisfaction has been identified as a goal for improvement in health care. Women’s satisfaction with maternity services, especially care during labour and birth, has become increasingly important to healthcare providers, administrators, and policy makers. Research shows that women’s satisfaction with childbirth is partly related to the health and well-being of the mother and her baby. according to Sawyer, Ayers, Jane Abbott, Gyte, Rabe and Duley (2013). The quality of the care that has been provided can impact on the woman’s experience, which can have a profound influence on their lives as stated by McNeil’s (2013)It is imperative for the voices of women to be heard in this regard.
Childbirth is a highly significant emotional event for most women. Midwives play a key role in this context. However, as noted previously, there are also other person- and context-related determinants of the emotional reactions of women who give birth. The inter relationships between these factors are not yet fully understood. Increased knowledge could provide midwives and other health care professional groups with an increased ability to assist women who give birth in optimal way according to Wilde-Larsson, Sandin-Bojo, Starrin and Larsson (2010). Studies to achieve that domain i.e. to hear from women, how they perceive the care, not sufficient, especially in South Africa, hence the execution of this research
To explore and describe the meaning of quality intrapartal care as perceived by women and to suggest guidelines for care, should the need arise
A descriptive explorative qualitative research design used. Purposive sampling technique was utilised to select the women for the study. The data were collected through series of individual in-depth, semi-structured interviews. Interview notes included. Data collected until data saturation. The setting was a postnatal clinic, in a province in South Africa. Data analysis performed using coding to elicit themes and patterns. Audiotapes were transcribed, as indicated by Hadwiger and Hadwiger (2011) Ethical approval was granted by Department of Health, the institutional manager and the participants, on informed consent
The following themes emerged from responses of participants:
Communication, Support, pain management, physical environment, decision making, individualised care, baby care, and self-care
Communication-All participants mentioned that midwives communicated well and that reflect quality intrapartal care. Support-Most participants felt that, no form of support provided or suggested .Pain management-Most of the participants, raised the concern that, nothing was given for the pain. The midwives only told them to pant and avoid pushing before full cervical dilatation. They maintained that, that must be done and starts during ante-natal care, for the intrapartal care to be of quality. Physical environment-The labour room-cubicles were small, and that could not give them proper movement, or even allow significant others, to come and stay with them during that ordeal. Decision making-Participants maintained that, they were not involved in any decision, pertaining to the care that they received. That ranked very low, and they said for the care to be of quality during intrapartum, it must be really be considered and be done. Individualised care-Some participants maintained that, not much attention was given to them, as individuals, they would like to be given more attention and be treated, as individuals with unique needs. Baby care -Most participants also mentioned the fact that before they live the labour ward, midwives taught them, how to handle and take care of the baby, and that they appreciated very much. Self-care-Self-care education was emphasised, at the end of intrapartal care, and it was intended for the puerperium. .That was good according to them but they wished that the one for the intrapartal care should have been indicated, during itrapartum,
DISCUSSION AND CONCLUSION
The women in this study were healthy and well, with normal pregnancy, labour, deliveries and healthy full term babies, and as such the findings of this research would only be confined to them and their situation.
Some of the things in this study were excellently done and reflecting quality intrapartal care, according to the women and this discussion will leave them out and focus only on those things that were of concern to them
Most mothers remember childbirth as a period in which they experienced a high-intensity pain. However, this study showed that the mothers had resigned themselves to this. The women wanted to be accompanied through this critical period, yet, the physical structure, did not allow them and nobody encouraged them on this. During the process, the women had expectations, but they had a hard time expressing whether or not the expectation had been met This study showed that only limited pain management with no assessment to identify pain was found. High-intensity pain during childbirth was assumed to be a common occurrence by the care provider and the woman was left to cope with this by herself. Methods of alleviating pain were not offered by the midwife or physician, both of whom were more interested in labour progress and preventing complications. This study revealed that service direction has not been focused on the client. Therefore, to improve care and pain management for women in labour, the care providers should make radical changes in current service, particularly in considering the client’s needs, according to Rachmawati (2012)
GUIDELINES FOR PRACTICE
Women in labour should always be treated as individuals and their choices taken into account as much as possible. Evidence has shown that the use of non-pharmacological pain relief in the form of complementary medicine in labour, along with continuity of caregivers, is more likely to lead to physiological labour and spontaneous vaginal delivery as indicated by Rachmawati (2012) Personal and professional support during labour is critical. Women’s responses to childbirth pain may be modified by the support received from caregivers and companions women who are well supported and confident feel less pain. This idea was expressed in the images of child bearing women. Comforted by comfort measures, a safe and private environment, reassurance, information and guidance, strengthening of coping resources through encouragement, emotional support and human presence, they were able to transcend their pain experience with a sense of strength and profound psychological and spiritual comfort during labour as stated by Mosby’s Nursing Consult (2014) Pain relief is the way in which women feel that they have coped with pain during labour. This may involve the use of pharmacological or non-pharmacological techniques or a combination of these methods, according to McCrea and Wright (2011)
Sawyer, A., Ayers, S., Abott, J., Rabe, H.& Duley, L., 2013, ‘ Measures of satisfaction with care during labour and birth: A comparative review’, BMC pregnancy and childbirth,13,108
McNeil, A. & Jomeen, J., 2010, ‘Gazelling: A concept for managing pain during labour and birth’, British journal of midwifery, Vol, 18, No 8
Wilde- Larson, B., Sandin- Bojo, A., Starrin, B. & Larson, G., 2011,’Birthing women’s feeling of intrapartal care : A nationwide Swedish cross sectional study’, Journal of clinical nursing,Blacwell publishing Ltd, 20, 1168-1177
Hadwiger, M.C. & Hadwiger, S. C., ‘Filipina mothers’ perception about childbirth at home’, International nursing review.
McCrea, B. H. & Wright, M. E., 2011, ‘Satisfaction in childbirth and perceptions of personal control in pain relief during labour’,Journal of advanced nursing
Mosby’s nursing consult,2011,‘The pain of childbirth: perceptions of culturally diverse women’, Viewed 06 March2014,from www.nursingconsult.
THE PRETERM BIRTH SYNDROME: APPLYING THE PHENOTYPIC PROTOTYPIC CLASSIFICATION IN A MIDDLE INCOME PUBLIC URBAN TERTIARY HOSPITAL Mabuza KM, Molokoane F, Makin J, Pattinson RC
MRC Maternal and Infant Health Care Strategies unit, Department of Obstetrics and Gynaecology, University of Pretoria
Preterm birth is a complex syndrome with multiple etiological factors, which may require different preventive strategies. At the GAPPS conference proposed that preterm births should be divided into distinct phenotypes, based on the presence of severe maternal, fetal and placental conditions. This was called the prototype phenotypic classification system of preterm birth syndrome. They asked units to test classification system.
This advantages of this classification are:
It does not force any preterm birth into a predefined phenotype
Allows all relevant conditions to become part of the phenotype
Will improve understanding of the factors associated with preterm birth
Will improve surveillance of preterm birth across all populations, the same principles will be applied to the LBW.6,7
To test the phenotypic preterm birth classification in a public urban tertiary hospital.
The classification system was applied to all low birth weight (LBW) babies born at Kalafong Hospital in the west of Tshwane Metropolitan area in 555 mother and 598 LBW babies 1st Jan -30th Jun 2013
The files of 594 babies born with a birth weight of less than 2500g between January 2013 and June 2013 were collected. There were 450 (75.8%) were preterm and 144 were term, i.e. a gestational age of 38 weeks or more. In only 132 cases (22%) was the placenta sent for histology making the placental pathologic conditions unreliable. The demographic detail is shown in Table 1, the outcome of the low birth weight babies in Table 2 and the Pheontypic Preterm Classification is shown in table 3.
Table 1: Demographic features of LBW population
Number 555 (%)
27.7 yrs (6.19)
Antenatal care: Yes
Rhesus result: Negative
On dual therapy
Table 2: Neonatal outcome of LBW population
number 594 (%)
PNMR = 119.5/1000
SBR = 72.4/1000
ENNDR = 29.5/1000
Table 3. Phenotypic classification of preterm births at Kalafong Hospital
Term growth restricted babies accounted for 24% of all low birth weight babies. This is within the range for global term estimates for SGA rates; 5.3-41.5% (Lee ACC, Katz J, Blencowe H. National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010. Lancet Glob Health 2013;1: e26–36).
Given that determining the gestational age is poor using the last normal menstrual period and extrapolation of the symphysis fundus height is very unreliable. (Geerts L, Poggenpoel E, Thern G. A comparison of pregnancy dating methods commonly used in South Africa: A prospective study. S Afr Med J 2013;103(8):552-556.) The phenotypic classification should therefore be expanded to include all low birth weight babies.
The placental pathology category of the phenotypic classification was not useful as very few placentas were sent for histology.
Consideration should be given to expanding the “significant maternal condition” to include the clinical conditions in the placental pathology category, namely abruption placenta and placenta praevia into the maternal conditions group and excluding the placenta category altogether.
SURVIVAL OF VERY LOW – BIRTH- WEIGHT INFANTS ACCORDING TO BIRTH WEIGHT AND GESTATIONAL AGE AT A SEMI-RURAL HOSPITAL. (LURWMH) N. Kapongo*, Z. Duze* M. Samjowan*, S. Singh*, I. Gasarasi, T. Kalala*, D. Mngoma, CN Phili*, SR.Shazi*, NT.Mzolo*, R Hashmi*
(*): Paediatric Department, Neonatal Unit, Lower Umfolozi, District War Memorial Hospital (LUDWMH).
United Nation Millennium Development Goal 4 is to reduce child mortality by two-third between 1990 and 2015. Neonatal mortality and especially very low- birth –weight (VLBW) infant’s mortality are among the six factors to which over 90% of under-5 deaths are attributed. Data from rural areas are scares and, if available, they compare unfavorably with bigger centers.
We sought to determine the survival rate for infants weighing 500-1499 g according to birth weight (BW) and gestational (GA) at a semi-rural regional hospital, Northern Kwazulu Natal Province, South Africa.
This is a 3 year (Jan 2011 to Dec. 2013) review of the Epi-Info data base for neonatal admissions.
The data base is developed from a special neonatal register completed daily as neonates are admitted to the admission section of the Unit. Capturing and analysis of data were carried out using EPI-INFO 2000. Maternity data were retrieved from hospital PPIP data and from the Excel data summary compiled monthly using maternity clerk data forms.
The Neonatal Unit has 92 beds capacity (16 NICU beds; 37 high care beds; 16 special care beds; 20 KMC Beds and 3 beds admission section). This is the only referral center in Northern Kwazulu –Natal for 16 District rural hospitals with a population estimated at 2.5 Million.
Live births weighing between 500 g and 1499 g delivered or admitted at LURWMH from January 2011 to December 2013.
BW and GA-specific survival rate for all live infants born or admitted for neonatal care at LURWMH
A total of 1686 neonates (500 g – 1499 g) were included in this review. Seventy-two per cent of infants survived until discharge (95% CI 70.2%-74.5%). The survival to discharge was 40.6% (95% CI 37.2%-45.2%) for infants weighing < 1000 g, and 85.1% (95% CI 82.9%-87%) for those weighing 1000-1499 g. Overall , 45.8% and 37.7% of VLBW 1000g+ and below 1000g, received mechanical ventilation , respectively. Survival rates at 26, 28, 30, and 32 weeks gestation were 40.5%, 74.0%, 84.5% and 92.7%, respectively. The main determinants of survival were BW (odds ratio (OR) 8.3 (95% CI: 6.53-10.59) and GA (OR= 0.1810 (95% CI: 0.1392-0.2346).Overall the rate of ventilation (NCPAP or IPPV) use, was 43.5% and ventilation was not associated with improved survival (OR =0.8497 (95% CI, 0.6809-1.0593).
Survival of ELBW infants is low. BW and GA were the strongest predictors of survival. Despite the rural status challenges, survival rates compare favorably with published data from non-rural settings.
Preterm birth is a significant risk factor for survival of the neonates and is associated with increased perinatal mortality and morbidity. Every year, an estimated 15 million babies are born preterm worldwide, and this number is rising (1). Preterm is defined as babies born alive before 37 weeks of pregnancy are completed. There are sub-categories of preterm birth, based on gestational age (1): extremely preterm (< 28 weeks; < 1000g); very preterm (28 to <32 weeks; < 1500 g) and moderate to late preterm (32 to < 37 weeks). Over 1 million babies die annually from complications due to prematurity (1). Preterm birth is the leading cause of neonatal deaths and the second leading cause of death after pneumonia in children under five years (1). In South Africa, immaturity related complications are the leading cause (45%) of early neonatal deaths (2). The fourth Millennium Development Goal is to reduce the mortality of children under 5 ears by two-third before the year 2015. Neonatal deaths account for 40% of deaths below 5 years. Neonatal mortality rate has been static in South Africa since year 2000 (3). With post neonatal mortality rate in decline, improving neonatal and maternal care is highly strategic in addressing the challenges of under 5 years mortality. Very low birth weight (VLBW) infants represent a vulnerable group of newborns with high mortality rate. The success story of improving survival rates of VLBW infants in developed countries has been well documented (4, 5,6). This occurred on the background of improved antenatal care (high coverage of antenatal steroids), implementation of Neonatal Intensive Care programs and improved post natal follow up services. These quality and levels of care are far to be a reality in developing countries where the survival of VLBW infants remains low (7, 8, 9, 10). Low- cost interventions, including antenatal steroids provision, promotion of early and exclusive breastfeeding, resuscitation of newborns, care for small babies according to standardized protocols, Kangaroo Mother Care (KMC), home post-natal visits and others, have been tested and suggested (11, 12). Carlo WA et al.(13) showed that , for infants ( 1500 g or more) born in rural communities, training of birth attendants in Essential newborn care (ENC) course , improved midwifes’ skills and knowledge and reduced early neonatal mortality rates among low-risk women who delivered in Zambian clinics. In another similar study (14), neither ENC nor Neonatal Resuscitation Program (NRP) training of birth attendants’ decreased early neonatal mortality, stillbirth, or perinatal mortality rates for VLBW babies born at home or primary clinic facilities. The recommendation is therefore, encouragement of delivery in a facility where a higher level of neonatal care is available when delivery of a VLBW infant is expected. Compounding the situation in developing countries is the transportation, accessibility, and inequity challenges within the health system. In South Africa, Pattisson et al.(15) documented that immaturity related rates as final cause of death were lowest in metropolitan areas (1.61) and higher in city and town (4.37) and rural (3.88) areas. The survival of VLBW infants according to birth weight have been documented in the South African public sector context (7,8,16). The huge back log in capacity, infrastructures and technological advances between metropolitan, town and cities and rural areas is a reality expected to be within the system for a long time to come. The current trend of increasing burden of LBW reported in some rural areas in South Africa 17) exacerbates the uneven balance between available resource and demand for neonatal beds, especially in remote areas. Therefore continuing audit data related to survival rates stratified by birth weight and gestational age at local level have an important role in evaluating perinatal services, formulation of Unit policies on intensive care’s provision and in counseling parents on prognosis. In this routine neonatal database 3 years review, we sought to determine the survival rates among VLBW infants admitted at LRWMH according to BW and GA and to identify perinatal characteristics associated with better outcome at hospital discharge level.