Editor’s Note

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The Limpopo Initiative for Newborn Care (LINC) was started in 2003 as an initiative to improve newborn care in the Limpopo Province. A team was formed consisting of 2 advanced midwives, 2 retired neonatal care doctors, and the team was led by Dr Anne Robertson, the Child Health specialist at the University of Limpopo in Polokwane.

The progamme consisted of:

  1. Outreach visits by a team of a doctor and a midwife to the hospitals in the Province. The objective of these visits was to assess the facilities, equipment, support services, statistics and staffing, and to make recommendations on possible improvements to the senior management of the facility.

  2. The visits were usually about twice per year to each hospital, so that there was not a lot of continuity of support from the visiting teams.

  3. Training of the staff (Doctors, Midwives and Enrolled Nurses and Enrolled Nursing Assistants), who were working with the newborns in basic newborn care. The training was at the provincial tertiary hospital, because there was a clinical emphasis on this training, and there were usually sufficient numbers of patients in this hospital to be able to demonstate the clinical problems.

Sekhukune District is a “deep rural” district south and south-east of Polokwane. There are 5 district hospitals and 2 designated regional (level 2) hospitals in the district. There has only been 1 paediatrician at one of the regional hospitals in the distrct during the 10 year period of the evaluation, with an occasional paediatrician at the other regional hospital. There has not yet been the appointment of a paediatrican, paediatric nurse or midwife to the District Clinical Specialist Team.

The hospitals are really only able to function reasonably because of community service doctors, who unfortunately usually only stay for short periods. This gives problems with the level of knowledge of the doctors and also the continuity of care, which therefore has to be mainly nurse based.


Two outcomes were measured

  1. The availability of some items of functional equipment.

The items selected were: incubators, infant scales, the needs for administration of oxygen, intravenous lines, management of jaundice, blood glucose, infection control and resuscitation of the newborn in the labour ward.

Scores were allocated based on a scoring system which was developed during the initiative to be able to do an objective situation assessment of a newborn care facility. The clinical management of the patients was not assessed. The equipment availablity was extracted from the reports of visits made by the teams.

  1. The early neonatal mortality rates, using data from the Perinatal Problem Identification Programme (PPIP).


  1. Equipment

There was an overall improvement in the score from 55.4% to 77.1% for the availability of functional equipment in the categories assessed. The best improvements were in:

  • Oxygen therapy: 23.9% to 69.3%

  • Intravenous therapy: 46.4% to 83.6%

  • Infection control: 40.7% to 84.1%

The best improvement for an individual hospital was from 48.8% to 79.1%.

The poorest improvement for an individual hospital was from 48.4% to 59.3%

  1. Early neonatal mortality

The following were the changes in the mortality rates over the 10 year period:

  • Birth weight > 499g: Reduction from 16 / 1000 to < 10 / 1000

  • Birth weight > 999g Reduction from 14 / 1000 to < 8 / 1000

  • Birth weight 1000 – 1499g Reduction from 298 / 1000 to 232 / 1000

  • Birth weight 2500g + Reduction from 5.0 / 1000 to 3.5 / 1000

Table 1: Early neonatal mortality rates: Birth weight > 999g
Comment: Most of the reduction in the mortality rate has occurred in the first 5 years after the onset of the Initiative.
Table 2: Early Neonatal Mortality rates: Birth weight 1000 – 1499g
Comment: As with the over 1000g birth weight category, most of the reduction has occurred in the first 5 years of the initiative.

Table 3: Early Neonatal Mortality Rates: Birth weight 2500g or more
Comment: It is interesting to note that these rates have come down. It may be that resuscitation and basic care of the asphyxiated baby is better, or it may be that there is also a growing awareness of the neonatal mortality associated with fetal hypoxia occurring during labour, and action is being taken to improve the monitoring of the fetal condition in labour.

Only the mortality rate in the 1000 – 1499g birth weight category has not dropped below the national target rate for that birth weight category.


The LINC outreach in Sekhukune District has resulted in improvements in the availability of functional, important items of equipment needed for newborn care. There has also been a reduction in the early neonatal mortality rates in the district. Most of this reduction has been in the first 5 years of the initiative. The early neonatal mortality rate for the birth weight group 1000 – 1499g has still not come down to the national target of 150/1000. This may be an area where the use of CPAP will make a difference. Reducing mortality in these babies will further reduce the overall mortality rates.

There is still a need for ongoing assessments the quality of clinical care, as this will give an indication of where the problems lie.
V Booysen.

All EMS Stations throughout the FS Province

BACKGROUND The transport of a neonate is always a very stressful situation because of a Neonates Physiological Instability. The mode of transport by ambulance has always been in a Transport Incubator. Despite being in a pre-warmed transport incubator....neonates often complicate on route, and especially HYPOTHERMIA is life threatening for a neonate METHOD The Saving Babies Report and NaPeMMCo Triennial Reports recommend and insist that the Bogota Declaration of 1989 be adopted.
"Kangaroo Mother Care is a Basic Right of the newborn, and should be an integral part of the management of low birth weight and full term newborns, in all settings and at all levels of care, in all Countries." KMC has been widely accepted and adopted IN HOSPITAL Institutions... but very little has been researched or documented on implementing KMC during a Neonatal Transfer by Ambulance.
RESULTS The Free State Province has adopted Inter facility KMC AS THE PREFERRED MODE OF TRANSPORT FOR ALL NEONATES. By road, helicopter and fixed wing airplane.

A SUMMARIZED PRESENTATION on Staff experiences of "before KMC...AND after KMC" with be shared with the delegates. Personal experiences, mother's stories and vital signs of the Neonate during transport and at the referral hospital.

CONCLUSION KMC not only humanizes neonatology, it makes better use of the human resources available, even in an Ambulance. Resulting in less stressed staff, mothers, and babies, thus improving Neonatal

Outcomes, not only on route, but increases the long term outcome for the Neonate.

E Brierley

In 2008 the South African Health Minister declared a statement of support for the promotion, support and protection of breastfeeding which also included the support for human milk banks (HMB’s). Due to this recent statement of support and the escalating recognition of the medical importance of donor breastmilk, is has become more of a priority for hospitals throughout South Africa to launch their own in-house human milk bank and therefore recruit breastmilk donors. Awareness of the concept of donating breastmilk in South Africa is limited. With an exclusive breastfeeding rate of only 8% this reduces the pool of potential breastmilk donors and increases the challenges faced by HMB’s in terms of recruiting donors.1 It is therefore imperative to gain a better understanding about women’s salient beliefs surrounding donating breastmilk in order to identify obstacles, barriers and therefore address these in future promotional interventions.

The theory of planned behaviour, illustrated in figure 12, has the ability to identify underlying beliefs that distinguish between those who will perform and those who will not perform a behaviour. It has the ability to generate an understanding of behaviour by tracking back to fundamental beliefs, and exploring whether the intervention, such as the educational documentaries (promos), has an influence on these beliefs and whether they increase the intention to donate breastmilk.

Figure 1: Theory of Planned Behaviour

Behavioral beliefs – focuses on personal experiences & information inferences relating to a behavior.

Attitude towards the act – positive or negative view of the behaviour.



Normative beliefs - expectations of significant referents/others.

Control beliefs - presence of factors which can facilitate a behavior or create a barrier

Perceived behavioral control - each facilitator or barrier act independently & contributes to a person’s subjective probability that they can overcome the barrier

Subjective norms - perceived pressure from society as to whether or not perform a behavior


Mothers within a Kangaroo Mother Care Unit at a maternity hospital in Cape Town were interviewed using a semi-structured interview schedule. Purposive sampling was used in order to include mothers from different cultures, religions and socioeconomic backgrounds. The inclusion criteria included mothers of premature babies in the KMC unit who consented in writing.

Semi-structured face-to-face interviews with mothers and nurses within a KMC unit were scheduled between July 2013 and September 2014. Direct contact with the respondents was important to explore the salient responses and circumstances that shape the belief structures underlying the intention to donate breastmilk. The interview consisted of six open-ended questions using the TPB as a guide. After the initial interview the 3 educational promos were shown after which the respondents were interviewed for the second time, using the same interview outline, with the aim to establish if the educational promos had altered their responses.

The data collected was transcribed and subjected to content and thematic analyses. Content analysis of the responses to the open ended questions were ranked to order the beliefs, and to select the 5 to 10 most frequently mentioned items as the salient set. The frequency of answers was calculated to establish modal responses for each belief and in order to make a comparison between pre and post viewing of the educational documentaries.


A total of 18 mothers were purposively sampled and recruited. The findings will be organised according to the TPB: behavioural beliefs, normative beliefs and control beliefs.


Whether a mother donates breastmilk, or intents to donate, is not only driven by behavioural beliefs (advantages/disadvantages), but of facilitators (control beliefs) and social influences (normative beliefs). Although the respondents were not followed up to establish whether they became a breastmilk donor, reviews of various studies have illustrated that attitudes towards certain health-related behaviours, have shown considerable contributions towards the prediction of intentions.3 The current study found that a number of the respondents initiated the screening procedure following the final interview. Although this is not a definitive proof of donor recruitment it is an important finding since it implies that the potential to increase the breastmilk donor base in South Africa is considerable

One of the main findings of the current study was the altruism and empathy theme identified. This suggests that the respondents were both motivated and willing to put effort into donating breastmilk even before the viewing of the promos.

Behavioural beliefs citing the health benefits of breastmilk and donating rose considerably after the viewing of the promos, suggesting an improvement in positive attitudes towards donating and the value of donating. This confirms previous work on the impact of media campaigns, which have shown to increase mother’s knowledge surrounding breastfeeding and breastfeeding rates. A mass media campaign in Brazil illustrating simple messages about the benefits of breastfeeding dramatically increased the intention to breastfeed and ultimately breastfeeding rates.4

Previous studies surrounding breastfeeding and HMB’s have highlighted mothers concerns over not enough breastmilk. Perceived milk insufficiency is a well-documented issue and has been correlated to self-efficacy. According to a social cognition model by Bandura, self-efficacy can be used as a predictor for health behaviour and for instigating health promotion behaviour.5 Previous studies have demonstrated how breastfeeding workshops, along with the above mentioned elements can increase maternal self-efficacy and exclusive breastfeeding. In the current study the concerns over not enough milk reduced after the viewing of the promos. Thus suggesting that the promos were successful in building the respondents confidence, aptitude and therefore self-efficacy surrounding donating breastmilk.

It was optimistic to find a positive response about donating, and any concerns or barriers that respondents had were negated or minimised after the viewing of the promos. This demonstrates that the documentaries are addressing the preconceived fears that respondents have about donating breastmilk. HMBs generally relies upon mothers to transport the milk they are donating to their nearest drop off point. Transport was a consistent theme reported when ascertaining the obstacles to donating. Over half of the respondents rely upon public transport, consequently making the sustainability of donating challenging. Although the concern over transport had diminished after viewing the promos, it is important for milk banks to be aware of this barrier. A study using discourse analysis to evaluate the behaviours of regular blood donors revealed that the number of repetitive donations was not highly attributed to a positive attitude of the act but rather by convenience or control over the act.6 This implies how important it is to create a donor recruitment service that is convenient. Furthermore with self-efficacy emerging as a more important addition to the TPB due to the ability to predict both intention and perceived internal control (control derived from an individual’s personal resources), it is also imperative for this to be explored in future studies evaluating donor breastmilk recruitment.

It is evident from this study that there are gaps in both nurses and mothers knowledge surrounding donating, particularly surrounding breastmilk supply and the process of donating. Therefore providing more education via educational promos is necessary in order to increase the recruitment of donors. A study evaluating the role of an educational breastfeeding intervention on paediatrician’s knowledge of breastfeeding found that the paediatricians interviewed had significantly improved their knowledge and confidence on breastfeeding management.7 In the current study the nurses who were interviewed reported the importance of providing information to mothers after the viewing of the promos, implying that the documentaries were successful in escalating the nurse’s volitional control relating to the promotion and support of breastmilk donors. This does not infer that nurses will be more motivated and confident in recruiting potential donors; it does however suggest that there is a demand for donor recruitment aids within maternity hospitals.
According to the TPB subjective norm is an individual’s perceived social pressure to engage or not engage in a behaviour and who would approve or disapprove of the behaviour.8 It has been argued as the weakest predictor of the TPB due to the idea that social pressures do not affect a minority of people. However it is clear that in the field of breastfeeding, social pressure can have a major impact on the intention and continuation of breastfeeding and donating. A comprehensive literature review has shown that fathers in particular play a significant role in the maternal choice surrounding infant feeding and can not only increase mothers satisfaction with breastfeeding but also the duration of breastfeeding.9 The existing literature focusing on breastmilk donors and fathers is minimal. The current study has shown that although some of the respondents believed their husbands would disapprove if they were to donate, they also believed that their husbands and partners would be more approving if they had watched the promos and had access to more information about HMB’s.

Donating breastmilk is a process that most commonly occurs in the home environment. Previous studies have demonstrated that the family can have equal or greater decision making powers than the mother when it comes to infants.10 A qualitative, exploratory study conducted in Brazil found that family members are one of the most crucial social support networks but can also be a source of pressure on breastfeeding women. The majority of respondents believed that their family, including grandmothers, would be approving towards donating. A study exploring motives behind breastmilk donations in Brazil found that family members were more influential among first time donors. This was also found in a study examining the motives behind blood donors and the retention of donors.11 Therefore including family members in the education of donor breastmilk is significant.


The current study has shown that within a KMC unit due to an empathetic understanding between mothers, the willingness and eagerness to donate breastmilk is considerable. The mothers inherently had an altruistic disposition and were emotive towards donating breastmilk. Self-efficacy has emerged as an important element to support the perceived behavioural control item of TPB. Studying this further to measure the effectiveness of donor recruitment aids will add insights into the personal, underlying beliefs of potential donors.

There are barriers to donating breastmilk, mostly relating to access to the HMB and transport and thus must be addressed in donor recruitment models. The educational documentaries minimised these concerns and raised the respondent’s confidence and knowledge of the health benefits relating to donor breastmilk. The approach to recruiting donors must be multi-faceted with family members, in particular husbands and nurses, being targeted by educational interventions, to aid the scaling up of donor recruitment. It is the researchers belief that the findings can be generalised to most of the population served by public maternity hospitals in South Africa. It is clear that the educational documentaries by themselves are not enough to increase donor recruitment. However with optimistic commitment from the Department of Health and endorsement of national breastfeeding policies this is an encouraging environment to scale up the recruitment of breastmilk donors in South Africa.

Prematurity is the largest cause of neonatal morbidity and mortality.1,2 It is generally correlated with low birth weight. 3Extremely low birth weight (less than 1000g) and the very low birth weight (1000 to 1500g) represent a high risk group. Statistics from the Perinatal Problem Identification Programme (PIPP) of South Africa show that during the year 2006 to 2007, 21 082 infants were born with birth weights between 500 and 1499g.4

Kangaroo mother care (KMC) refers to care of infants carried skin-to-skin with the mother.1,2 It’s central component is the kangaroo position, which refers to securing the infant in an upright position against the mother‘s chest, secondly, exclusive breastfeeding is encouraged as the optimal choice of infant feeding whenever possible, the third component refers to ambulatory care, where the preterm infant is discharged from hospital in the kangaroo position earlier than in the case of neonatal conventional care.5 It was first introduced in 1978 in Bogota, Colombia by Dr Edgar Rey and Dr Hector Martinez in response to shortage of resources and a large number of preterm infants that required only to feed and grow.1,2 Advantages of KMC are thermoregulation, stabilisation of blood pressure, pulse and respiratory rate. It reduces incidence of severe infection, prolong breastfeeding, increase weight gain and lead to shorter length of hospital stay.
Pelonomi hospital is a tertiary hospital in Free State, catering for two health districts (Xhariep and Mangaung). It opened its KMC unit in May 2011. It started with eight beds, but has now increased to 20 beds due to increased demands.

To determine the profile of infants receiving KMC in Pelonomi Hospital and their rate of growth and length of hospital stay.


  • Effects of KMC to rate of weight gain

  • Incidence of breastfeeding

  • Assess average hospital length of stay

  • Compare all of the above with literature

Study population:

Inclusion criteria

Exclusion criteria

  • Admission weight less than 1800g

  • Admission between 1 July to 31 December 2012.

  • Duration of at least 5 days in the KMC unit

  • Serious medical conditions and genetic abnormalities

  • Admission weight >1800g

  • KMC discontinued ( mother returning to work or readmitted)

  • Files lacking appropriate information

  • Admission less than 5 days

  • Readmission of the infant to High care unit for > 24 hours

Study design:

A descriptive, retrospective study was used to address the above objectives. Records of infants admitted during the period specified were obtained from archives after receiving approval from the ethics committee, University of the Free State and consent from the clinical head , Pelonomi Hospital. Data sheet was completed by the researcher and statistical analysis was done by the department of Biostatistics, University of the Free State.


There were 203 total subjects. 68 files could not be traced from records, 65 were excluded and only 70 met the inclusion criteria and were therefore included in the study. Majority of the infants in the study were delivered by caesarean section (74%). There was slight male predominance (51.4%). 65.7% had gestational age between 32 to 36 weeks with only 34.2% below 32 weeks gestation. More than 80% of the infants had birth weights between 1250 to 1800g, with only 2% less than 1000g. 51.4% of the infants included were exposed to retroviral disease. 94 % were exclusively breastfed on admission and discharge from KMC.

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