Editor’s Note


Hospital length of stay and average growth rate



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Hospital length of stay and average growth rate:

Variable

Mean

Median

Minimum

Maximum

Admission weight

(grams)

1558

1600

1020

1780

Discharge weight

(grams)

1831

1820

1720

2440

Weight difference

(grams)

273

200

40

800

Length of hospital stay (days)

11.6

10.0

5.0

33.0

Weight gain

(g/day)

23.3

23.1

4.1

45.0


















The MEANS procedure:

Variable

N

Mean

Std deviation

Median

Minimum

Maximum

Gain

GV

70

70


23.3

13.8


7.84

4.81


23.1

13.7


4.16

2.31


45.0

27.1


Literature review:

Study

Study population

Weight gain (g/day) KMC vs. Conventional care

Length of hospital stay (days)

Ali et al 2009

<1800g

19.3 vs. 10.4

13.7 vs. 15

Cutaneo et al 1998

1000-1990g

21.3 vs. 17.7

13.4 vs. 16.7

Ramanathan et al 2001

<1500g

15.9 vs. 10.6

27.2 vs. 34.6

Suman et al 2008

<2000g

23.9 vs. 15.5




Our study

<1800g

23.3

11.6


Discussion:

According to World Health organization, adequate weight gain from the second week of life is 15g/kg/day, approximate weight gain for different post-menstrual ages are 20g/day up to 32 weeks and 25g/day from 33 to 36 weeks. 1 This study showed an adequate weight gain of 23.3g/day during hospital stay. Mean hospital length of stay was 11.6 days which is lower as compared to other studies indicated above. The studies above were randomised control studies, comparing KMC to conventional neonatal care. They showed better weight gain and length of hospital stay in the KMC unit as compared to the Conventional group. Although our study was retrospective study it showed a comparable weight gain and length of hospital stay with the other studies. It should be taken in to account that the smaller the weight of the population group, the slower the rate of growth and the longer the length of hospital stay as seen in Ramanathan et al, where they included infants less than 1500g. The weight gain was less and the length of hospital stay longer as compared to other studies including our study. Our study had the same population group as Ali et al. The growth velocity in our study was slightly lower than that recommended by World health organisation. Mean growth velocity was 13.8, with standard deviation of 4.81.



Most of the infant included in the study were exclusively breast feeding (94.3%) at the time of discharge, supporting the fact that KMC does encourage breastfeeding. Retroviral disease contributes to burden of disease in preterm infants with 51.4% of the infants in the study being exposed. Pelonomi hospital caters for low socioeconomic population and therefore exclusive breastfeeding will reduce the risk of mother-to-child transmission and prevent risk of malnutrition.
Conclusion:

Limitation of the study:

  • Retrospective nature of the study

  • Study population: 70 participants

  • Short duration of the study

  • Poor documentation of admission registers.

Kangaroo mother care is safe and effective in under resourced settings. It allows adequate growth and encourages exclusive breastfeeding. It is less costly and can be implemented in small rural hospitals to reduce burden in the tertiary hospital. Infants can be stabilised in tertiary hospital, and transferred back to the referring hospital to continue KMC until they are able to feed and have gained adequate weight for discharge.
References:

  1. Department of Reproductive Health and research, World Health organisation.Geneva.2003.Kangaroo Mother Care-A practical guide

  2. Lawn EJ, Mwansa-Kambafwile J, Horta BL, Barrws FC, and Cousens S.2010.’Kanagaroo mother care ‘ to prevent neonatal death due to preterm complications. International Journal of Epidemiology.39(S1):i144-i154

  3. Escott –Stump S.2008. Nutrition and Diagnosis-Related Care.6thed.Philadelphia:Lippincott Williams and Wilkins

  4. Medical Research Council Unit for Maternal and Infant Health Care Strategies, Perinatal Problem Identification Program (PIPP) Users and Saving Babies Technical Task Team.2008.Saving Babies 2006-2007 Sixth report on Perinatal care in South Africa. www.pipp.co.za.

  5. Kadam S, Binoy S, Kambur N, Mondkar JA and Fernandez A.2005. Feasibility of Kangaroo Mother Care in Mumbai. Indian Journal of Paediatrics.72(1):35-38

  6. Ali SM, Sharma J, Sharma R, Alam S.2009.Kangaroo Mother Care as compared to conventional care for low birth weight babies. Dicle Med J,.36(30:155-160

  7. Cautaneo A, Davanzo A, Worku B, Sorjoro, Echeverria M, Bedri A, Harksari E, Orsono L, Gudetta B, Setyowereni D, Quintero S, Tamburine G.1998.Kangaroo Mother Care for Low Birth Weight infants: A randomised control trial in different setting. Acta Paediatrica. 87(9):976-985

  8. Ramanathan K, Paul VK, Deorari AK, Taneja U, George G.2001. Kangaroo Mother Care in very low birth weight infants. Indian J Paediatr.68(11)1019-23

  9. Suman RP, Udani R, Nanavati R.2008. Indian Paediatr.45(1):17-23.


ARE MATERNITY WAITING HOMES (MWH) RELEVANT AND COST EFFECTIVE IN THE DELIVERY OF PERINATAL HEALTHCARE SERVICES TO REDUCE PERINATAL MORBIDITY/ MORTALITY IN SOUTH AFRICA? A CRITICAL REVIEW (ABSTRACT)
Dr Donald HA Amoko, Clinical Head, Department of Obstetrics and Gynaecology Witbank Hospital Senior Lecturer Department of Obstetrics and Gynaecology, University of Pretoria and acting District Specialist Obstetrician and Gynaecologist, Nkangala District Mpumalanga Province

Ronel Taute MCYH District Coordinator, Nkangala District Mpumalanga Province


Introduction

One of the contributory factors to the high maternal mortality ratios in South Africa is delay in seeking help by high risk mothers due to either lack of transport or negligence on the part of the patients. Most of these delays have resulted in maternal deaths and stillbirths as complications from the risk conditions. One of the recommendations made by the WHO and endorsed by National Confidential Enquiry into Maternal Deaths Committee is the establishment of Maternity Waiting Homes to deal with such problems. These MWHs have been tried in a number of developing countries in Africa, India and South America. It was last evaluated by the WHO in the 1996s. This paper critically reviews the impact of MWHs as reported in the literature and make recommendations as to their relevance and cost-effectiveness in the south African context.


Objectives

  1. Determine the critical success factors of maternity waiting homes in countries where it is reported to have had an impact on the MMR and BBA rates.

  2. Determine whether the critical success factors of maternity waiting homes can be applied in the South African socio-cultural context

  3. Make recommendations or adjustments.


Methodology: We reviewed all the literature related to the implementation and evaluation of MWH in countries where they have been tried. The authors then identified the critical success factors taking into account the socio-cultural environment in which MWHs have been implemented. These critical success factors (CSF) and the socio-cultural environment factors in these countries are compared to the South African context. Recommendations are then made.
Results: Apart from South American and Asian countries, MWHs have been tried in Eastern Nigeria, DRC, Zimbabwe, Mozambique and Ethiopia. The critical success factors (CSF) required for MWHs included socio-cultural belief systems, admission criteria, costs (material and human resources), type of building, stakeholder/community involvement, thorough needs assessment, ability and capacity of the nearby institution to deal promptly with emergencies that may arise and the specific objectives plus indicators for evaluation. There is not enough evidence in the literature to evaluate the effectiveness of MWHs since indicators for evaluation and objectives have not been specific enough to evaluate their impact.
Conclusion: While there may be beneficial effects on perinatal outcomes, there is insufficient evidence to quantify these effects and thus make policy decisions on countrywide establishment of MWHs. Africa.
Recommendations: MWHs should be piloted in the poorer provinces in South Africa before countrywide implementation.
BEST PRACTICE GUIDELINE DEVELOPMENT – WHAT DOES IT MEAN AND HOW IS IT DEVELOPED? (ABSTRACT)
Dr Welma Lubbe; Prof H Klopper, Prof C van der Walt

Senior lecturer – North-West University (Potchefstroom Campus)

Presenting author’s email: Welma.lubbe@nwu.ac.za

Oral presentation


Best practice guidelines (BPGs) are systematically developed statements, based on the best evidence available, to assist practitioner decisions about appropriate health or disability care for the preterm infant hospitals in South Africa. BPGs are based on results from an integrative literature review, which includes research and empirical results. The statements take into account evidence for effectiveness, which includes systematic reviews and primary empirical research to support statements and form a fundamental basis for planning. Teams of role players (researcher, reviewers and clinical practitioners) assists in the development of the guidelines (NZGG, 2001:5; RNAO, 2005:91; RNAO, 2006:18-47).

“Guidelines provide guidance in decision making at each level of interaction; between health professional and consumer, between purchaser and provider, and between ‘funder’ and ‘purchaser’” (NZGG, 2001:5). The development of BPGs may therefore further inform educational programs, measure staff knowledge on specific topics; assist in the development of tools to assess the level of operationalization identified clinical care practices in hospitals (Lubbe, et al., 2012: 252). Neurodevelopmental supportive care (NDSC) for preterm infants is used as sample BPG for this abstract.


The Scottish Intercollegiate Guidelines Network (SIGN, 2008) described a detailed process for BPG development that used as the process of BPG development as utilised in this study. The guiding principles for BPG development are (NZGG, 2001:7):


  • Processes for developing and evaluating guidelines focuses on outcomes valued by health care professionals (e.g. quality of life measures).

  • Guidelines are based on the best available evidence and include an indicator of success in the form of a statement about the strength of the recommendations (concluding statements), which is a critical element of a BPG.

  • The method used to synthesise the evidence is the strongest applicable. Best available evidence was identified during an integrative literature review (Lubbe et al, 2012).

  • The process of guideline development is multidisciplinary including the researcher, second reviewers, and statistician and expert panels.

  • Guidelines are flexible and adaptable so that individual circumstances can be taken into consideration.

  • Guidelines are developed with some consideration of limitations such as resource constraints and the setting that may influence implementation strategies (contextualising).


Following the above process resulted in a BPG document that is based on the best available evidence, conclusion statements and 18 formulated BPGs which were graded, and finally validated by a peer review process. The BPGs are now available in a print format that are user-friendly and can be used by both researchers and clinicians.


DOES TECHNOLOGY ONLY MEAN MACHINES AND EQUIPMENT? - BPG GUIDELINES TO DIRECT NDSC AS MODEL OF CARE IN THE SA CONTEXT (ABSTRACT)
Dr Welma Lubbe; Prof H Klopper, Prof C van der Walt

Senior lecturer – North-West University (Potchefstroom Campus)


Abstract

Neurodevelopmental supportive care (NDSC) for the preterm infant in the NICU has been defined as nursing and medical interventions that aims to lower the stress of the infant in the NICU, prevents developmental delays and improve both short- and long term outcomes of preterm infants. Als et al. (2003:405) and Goldberg-Hamblin et al. (2007:167) stated that ‘Developmental care will make the biggest difference and be most successful in the most challenged settings with little resources’. Although the South African context can benefit tremendously by implementing NDSC, this model of care is rarely seen as a comprehensive care modality in the NICU. NDSC is implemented in a fragmented manner, based on single interventions and not as a comprehensive modality of care.

Previously the building blocks for NDSC has been identified by Lubbe et al (2012), however to ensure that the theory can be used in practice best practice guidelines (BPGs) has been formulated to support the implementation process of NDSC as comprehensive care model in South Africa.

Best practice guidelines are systematically developed statements, based on the best evidence available, to assist practitioner decisions about appropriate health or disability care (NDSC) for the preterm infant in hospitals in South Africa. BPGs are based on results from an ILR, which included research and empirical results. The statements took into account evidence for effectiveness, which included systematic reviews and primary empirical research to support statements and form a fundamental basis for planning. Teams of role players (researcher, reviewers and clinical practitioners) assisted in the development of the guidelines (NZGG, 2001:5; RNAO, 2005:91; RNAO, 2006:18-47).

79 conclusion statements were formulated from the mentioned integrative literature review, followed by a situational analysis and these statements were grouped together into five categories, which included 18 comprehensively formulated BPGs for NDSC of the preterm infant in the South African context. The five categories with the BPGs that resort under each is provided in the following table?

CATEGORIES

Direct infant environment

Direct preterm infant care

Family unit

Staff

Systems

BPGs

Environment



Positioning

Handling

Individualised care

Self-regulation

Feeding

Pain management



Family centered care

Family education

Parent profile


Staff education

Multi-disciplinary team

Staff attitude


Communication

Protocols

Management support

Resources

Implementation time

Each guideline is descriptive in nature, e.g. in the category ‘Direct preterm infant environment’ the first guideline read as follow:



Guideline 1 – Environment: Environmental design implies creating an environment conducive for preterm infant development, similar to the intra-uterine environment.

Each of the 18 guidelines was graded, strength and sufficiency of evidence were indicated and supporting literature as well as clinical impact and supporting evidence were provided. Finally, implementation recommendations were also provided. All the guidelines were peer reviewed and validated using the Delphi process, adapted as needed and prepared for distribution to users.


WHERE AND WHY DO INFANTS DIE?
Dr M Kunneke

Dept of Paediatrics, Worcester Hospital, WC


Introduction

It is a well-known fact when any mortality review process is being used, mortality rates will drop. Below is a slide demonstrating the example of the power of a mortality audit using South African data as supplied by the Child PIP program.




In Worcester Hospital, a general specialist service hospital, Child PIP has been used for seven years. This resulted in the in hospital mortality rates dropping slowly but steadily.


What we saw through the process, is that most of the children who died, were in the <1year age group. We also know that most of the children are not dying in hospitals, but outside, deaths that are rarely discussed. The mortality in this group, remains unknown, not discussed and not addressed or modified. The aim of this pilot statistical analysis is to look at the deaths in this age group by using Child PIP, PPIP and the forensic pathologist’s data.


Specific question:

My specific question is, how many children actually die in Worcester and what is the cause of death. Secondly, if there are any modifiable factors that could be addressed or systems to be put in place to decrease infant deaths in the entire community.

In other words: “Do we have a problem” and “How big is the problem if it exists”.
Method:

Data from the Child PiP program, PPIP program, both used in Worcester Hospital were collected for the year 2013. Data from the region, forensic pathological services were sought to see what the number and cause of childhood deaths in the community was for 2013. Unfortunately regional data is only available three years down the line. The forensic pathologist refused to avail any data until an official study protocol has been handed in. Unfortunately it is thus impossible for me as a clinician to be aware of, discuss and try to modify behavior in cases where children die outside of the hospital practice. I could get a raw number of 40 for children over 1 month but less than 1 year who died in the community in 2013. Unfortunately no cause of death was known in most cases. The study as planned could not be done.


Discussion:

Abovementioned data is of utmost importance to give a full picture of infant deaths in Worcester. A full picture and data of infant deaths, regardless of where it happens, have never been done before. We are thus in the dark regarding the actual deaths and not planning services or specific interventions.

This study could not determine why children died and guide us as to where focus should be placed in the care of children under 1 year of age to decrease or prevent deaths in future.
Conclusions:

Using PPIP and Child PIP mortality rates in Worcester Hospital declined. BUT

90% of babies <1 year die in the community.

HOWEVER: No process is in place to review, audit, discuss and thus decrease community mortality in children.


Recommendations:

The regional paediatrician should be notified of every child death.

The district health team should discuss each of these deaths using the Child PIP method

A cause of death must be assigned and interventions planned.

Saving children reports on these deaths could be produced and printed.

District health AOP and interventions should be planned accordingly.

During this year connections will be built with all parties in the region and the process started to discuss community childhood deaths regularly in the appropriate forum.
REDUCING MATERNAL AND PERINATAL DEATHS: A RANDOMISED CONTROL TRIAL STUDYING EFFECTS OF THE COPPER INTRAUTERINE DEVICE AND INJECTABLE PROGESTOGEN CONTRACEPTIVE ON DEPRESSION AND SEXUAL FUNCTIONING OF POSTPARTUM WOMEN IN THE EASTERN CAPE
Mandisa Singata1&2, D Khalil1, GJ Hofmeyr 2
University of Cape Town 1, Fort Hare University/University of Witwatersrand2

Background

One of the most effective methods of reducing maternal and perinatal deaths is by reducing unintended pregnancies. A previous study from our unit presented at the Priorities in Perinatal Care conference, found that in the East London area about 1/3 of pregnancies are terminated, and of the remainder, about 2/3 are unintended. Many women had stopped using effective contraception because of perceived side-effects. Greater understanding of the side-effects of commonly used effective methods of contraception will contribute to the quality of counselling, enabling women to choose a method which is suitable for themselves.

There is an epidemic of unintended pregnancy globally, with profound consequences for women, their families, and their communities1. In 2012, it was estimated that over 222 million women have an unmet need for modern contraception 2. This need is greatest where the risks of maternal mortality are highest2.

Contraceptive non-use and method discontinuation are common causes of unintended pregnancy3. Several studies have reported that unacceptable side effects are a common reason for contraceptive method discontinuation 4,5,6,7. Berga and Smith (2012) theorise that depot medroxyprogesterone acetate (DMPA) suppresses endogenous ovarian function as well as producing progestin dominant hormonal exposure. These changes can potentially affect both libido and the functioning of the reproductive tract. The authors hypothesize that decreased oestrogen results in less vaginal lubrication, thereby leading to sexual dysfunction8

This study compares the relative effects of two long acting contraceptive methods (DMPA versus the non-hormonal copper intrauterine device (Copper T380a; Cu-IUD)), on depression and sexual dysfunction in women. Both depression and sexual dysfunction are given as potential side effects of hormonal contraceptive use 9; however, limited evidence exists to support this claim. The Cu-IUD is a non-hormonal method, with no proven or theoretical risk of depression or sexual dysfunction10; therefore, the Cu-IUD method provides a good ‘control’ comparison with the hormonal intervention (DMPA) evaluated in this study.
Methods

A Randomised control trial was conducted; women were randomized to one of two groups: the injectable DMPA or the Cu-IUD.


To be able to show a reduction in mean depression score from 11.5 to 6.9, 73 women were required in each group (alpha = 0.05, beta= 90%). To allow for 25% loss to follow-up, the sample size was increased to 200. The required sample size was increased to allow for some non-compliance, which might have reduced the power of the trial. Finally, a total of 242 women were included in this study.
Sample Population

Pregnant women were enrolled and invited to participate in the study immediately after childbirth. Whilst still in hospital and prior to discharge. The population for this study was recruited from women who gave birth between 06 December 2012 and 30 March 2013.


Research Questions

This study posed the following research questions: Are there statistical differences in the effects of injectable DMPA on postpartum depression as compared with the Cu-IUD (Copper T 380A)? Are there statistical differences in the effects of injectable DMPA on sexual functioning as compared with the Cu-IUD?


To answer the first question, two depression scales were used: the BDI-II and the EPDS. Depression was expressed as continuous (means/medians) and categorical variables (number of events) for each test and the relative risk of depression in each group was calculated to determine whether there was any difference between the groups. A 95% CI which spans from <1 to >1 indicates no statistically significant difference between the groups at the 5% level.
Results

There were no statistical significant differences between groups for almost all baseline variables as measured by the Chi square test and Fisher’s exact test were appropriate. Only one variable (CD4 count), had a statistically significance difference p < 0.05.




DMPA IUD

Time

n

Median (IQR)

n

Median (IQR)

p- value

EPDS -Baseline

116

9(3 to 21)

118

8(2 to 20)

0.2

-1Month

110

4(1 to 18)

117

2(0 to 21)

0.04*

-∆ 1 month

110

-3 (-7 to 0.5)

117

-4(-8.5to 0.5)

0.3

-3 months

113

2 (0.5 to 19)

117

2(0 to 19)

0.1

-∆ 3 month

113

-4.5(-7.5to 11)

117

-4(-6.5 to 16)

0.4

BDI -Baseline

116

6(2.5to12.5)

118

5 (2.5 to 9.0)

0.1

-1Month

111

8(4.5 to 19.5)

117

7(4 to 12.5)

0.2

-∆ 1 month

111

2(-1.5 to 8.0)

117

1(-1.5 to 5.5 )

0.2

-3 months

113

9(4.5 to 14.5)

117

5 (2 to 11.5)

0.002*

-∆ 3 month

113

0(-3.5 to 4.5)

117

0(-3.5 to 4.5)

0.09

*P< 0.05 (Wilcoxon test)
ASEX was used to answer the second question on sexual functioning. There was no difference in the relative risk of sexual dysfunction when data from all 5-items of the ASEX (sex drive, arousal, vaginal lubrication, orgasm and satisfaction) were combined. The incidence of sexual dysfunction was not significantly different between the groups as well.
One month comparison of DMPA & IUD ASEX items and total events of no sexual intercourse

There was no statistically significant difference in ASEX scores. However, significantly more women in the DMPA group had not resumed intercourse at one month postpartum. The Yates corrected Chi-square gave us p=0.00 (P<0.05) showing the difference was statistically significant.



Conclusion and Recommendations

Postpartum women are particularly vulnerable to depression; therefore these results may not be generalizable to women at other times of their reproductive lives. However, it is important to bear these potential effects on mood in mind when offering contraception to postpartum women and women who may depressed, or at risk of depression, until more evidence becomes available.




  • Women using injectable progestogens should be screened for depression at their six week follow-up visit and, if found to be at risk of depression, an additional follow-up visit’s should be scheduled, with appropriate referral if indicated.

  • The IUD is a useful alternative contraceptive method for DMPA contraceptive users who cannot tolerate side effects if they occur. DMPA users can continue to use DMPA with confidence as a convenient and effective method of preventing unintended pregnancy.

  • Policy makers and governments can promote the use of long acting contraceptive methods with the knowledge that the risk of side effects outweighs the burden of unintended pregnancies

The findings of the study raised sufficient concerns to justify further research with a bigger sample size; randomised control trials to be conducted from a variety of social settings to determine whether the trend towards depression and sexual dysfunction found in this study could be validated or rejected.
A Cochrane systematic review and meta-analysis of available high-quality data for long-acting progestogen contraception compared to the IUDs methods should be conducted to provide women with the best possible information regarding relative benefits and risks of these two important reversible methods of contraception.
References

  1. Gipson, J.D., Koenig, M.A. & Hindin, M.J. 2008a. The effects of unintended pregnancy on infant, child, and parental health: a review of the literature. Studies in family planning. 39(1):18-38. (Singh S and Darroch JE, 2012)

  2. Paul, C., Skegg, D.C.G. & Williams, S. 1997. Depot medroxyprogesterone acetate: Patterns of use and reasons for discontinuation. Contraception. 56(4):209-214. DOI: 10.1016/S0010-7824(97)00140-6.

  3. Barden-O'Fallon, J., Speizer, I., Rodriguez, F. & Calix, J. 2009. Experience With Side Effects Among Users of Injectables, the IUD, and Oral Contraceptive Pills in Four Urban Areas of Honduras. Health care for women international. 30(6):475-483. DOI: 10.1080/07399330902801187.

  4. Brunner Huber, L.R., Hogue, C.J., Stein, A.D., Drews, C., Zieman, M., King, J. & Schayes, S. 2006. Contraceptive use and discontinuation: Findings from the contraceptive history, initiation, and choice study. American journal of obstetrics and gynecology. 194(5):1290-1295. DOI:http://dx.doi.org.ezproxy.uct.ac.za/10.1016/j.ajog.2005.11.039.

  5. Gilliam, M.L., Warden, M., Goldstein, C. & Tapia, B. 2004. Concerns about contraceptive side effects among young Latinas: a focus-group approach. Contraception. 70(4):299-305. Paul, Skegg & Williams, 1997)

  6. Berga, S.L. & Smith, Y.R. 2012. Chapter 25 - Hormones, Mood and Affect. In Handbook of Neuroendocrinology. George Fink A2Donald W. Pfaff and Jon LevineA2 George Fink, Donald W.Pfaff & Jon Levine, Eds. San Diego: Academic Press. 551-571..

  7. Westhoff, C., Wieland, D. & Tiezzi, L. 1995. Depression in users of depo-medroxyprogesterone acetate. Contraception. 51(6):351-354. DOI: 10.1016/0010-7824(95)00100-O..

  8. Gabalci, E. & Terzioglu, F. 2010. The Effect of Family Planning Methods Used by Women of Reproductive Age on Their Sexual Life. Sexuality & disability. 28(4):275-285. DOI: 10.1007/s11195-010-9161-9.


MATERNAL DEATHS AT CHRIS HANI BARAGWANATH, 1997-2012
EJ Buchmann, CN Mnyani, KA Frank, MF Chersich, JA McIntyre
Department of Obstetrics and Gynaecology, and Centre for Health Policy, University of the Witwatersrand, Anova Health Institute, and School of Public Health and Family Medicine, University of Cape Town, Cape Town.
Introduction

The maternal mortality ratio (MMR) in South Africa is unlikely to decrease sufficiently to achieve the millennium development goal of a 75% reduction in MMR between 1990 and 2015. Maternal mortality returns from health facilities are aggregated at provincial and then national level, meaning that the Saving Mothers reports provide no data on individual districts or facilities. The lumping of district data into provincial maternal mortality data may hide important district-specific maternal mortality profiles. Knowledge of maternal mortality patterns and trends in districts may offer lessons for planning in those and similar districts. A database of maternal deaths has been kept at Chris Hani Baragwanath Maternity Hospital (CHBMH), which serves the Greater Soweto area in south-western Johannesburg, and also provides referral services for hospitals in other districts and provinces. The database provides an opportunity for studying maternal mortality in the most populous district in South Africa. This study was done to estimate MMR and determine causes of maternal deaths in women from Greater Soweto, Johannesburg, from 1997 to 2012.


Methods

CHBMH is the only government hospital serving Sub-districts D and G in south-western Johannesburg in Gauteng Province. The two sub-districts comprise the Greater Soweto area, with a population of 1.4 million people in 2001, which increased to about 1.8 million by 2011. CHBMH provides district hospital referral services for seven community health centres (CHCs) in Greater Soweto, in which midwives conduct low-risk births. As a large teaching hospital, CHBMH is also the referral centre for more distant areas, including other sub-districts of Johannesburg, other districts of Gauteng Province, and parts of the neighbouring North West Province. About 5% of births at CHBMH occur in women referred from such areas (hospital data, 2012). Therefore, women from Greater Soweto make up about 95% of hospital births.

This was a cross-sectional study. The study population was maternal deaths at CHBMH, with all cases included from 1997 to 2012, in women whose case-notes provided an address in Greater Soweto as their place of residence. All case notes were retrieved and reviewed by one specialist obstetrician and gynaecologist. Allocation of cause of death was based on the classification used by the National Committee on Confidential Enquiries into Maternal Deaths for the 2008-2010 ‘Saving Mothers’ report. The decisions on causes of death were based on the clinical findings and opinions in the notes, interpreted by the specialist who entered the information onto the data sheet. Information from the paper data sheets was entered into Epi-Info software by a second specialist obstetrician and gynaecologist. Data queries identified by the second specialist were dealt with by re-examination of the case-notes and discussion with the colleague who had captured data onto the paper data sheets.
Supplementary information was collected to obtain denominators for calculation of MMRs for Greater Soweto. Data from the DHIS for Johannesburg Health District provided numbers of live births for Sub-districts D and G (Greater Soweto), at CHBMH and at the seven CHCs. Data gaps and conflicts were resolved, where possible, by information or statistics available from the Department of Obstetrics and Gynaecology at CHBMH. Hospital maternal death numbers were also obtained for the years 1993 to 1996 to show a pre-1997 trend. Data was analysed using Stata 11 software (StataCorp, College Station, Texas, USA), by descriptive statistical techniques, applying proportions, percentages and rates. Missing data were excluded from the calculations. MMRs were presented as deaths per 100 000 live births, with 95% confidence intervals (CIs), assuming a Poisson distribution. Comparisons of proportions were made using the Chi-squared test or Fisher’s exact test. The Chi-squared test for trend was used to assess significant trend in proportions over exposure categories. Where applicable, associations were tested using unadjusted odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was accepted at P<0.05.
Results

Five hundred and eighty-seven maternal deaths were recorded at CHBMH from 1997 to 2012, of which 479 were in women from Greater Soweto, giving an overall MMR of 105 per 100 000 live births (95% CI 96; 115). There was a significant trend to reduced MMR after the peak of 139 per 100 000 live births in 2004 (Chi-squared test for trend). The peak coincided with the peak of antenatal HIV seroprevalence in Gauteng (Figure 1).




Figure 1 Antenatal HIV seroprevalence rates in Gauteng Province, and maternal mortality ratio (MMR) in Greater Soweto, Johannesburg, 1997-2012
For women with known age (n=474), 6.8 % were teenagers and 26.4% were aged 35 years or older. High parity (≥5) was uncommon, at 4.4%. Among women with information on previous births (n=463), 89 (19.2%) had a previous caesarean section. Twenty (4.2%) of the pregnancies were recorded as multiple. Out of 443 deaths in whom antenatal care attendance was recorded, 343 (77.4%) had attended antenatal clinic. Antenatal haemoglobin results were available for 277 women, and 132 women (47.7%) were found to be anaemic (haemoglobin <11.0 g/dL). The number of antepartum (undelivered) deaths was 102 (21.3%). Thirty-four women (7.1%) died in early pregnancy (<22 weeks) or after an early pregnancy loss. HIV testing data is shown in Table 1. Causes of maternal mortality are shown in Tables 2 and 3.
HIV infection (where results were available; n=333) was found in 92.4% of deaths from non-pregnancy related infection. HIV infection rates were 61% for obstetric haemorrhage, 30% for hypertension, and 60% for other causes of death. Anaemia on starting antenatal care (n=277) was present in 67.6% of deaths from non-pregnancy related infections. In women who died from hypertensive disorders, 40.3% were aged 35 years or older. Previous caesarean section was noted in 38.6% of women who died from obstetric haemorrhage. Of 22 women with previous caesarean section who died from obstetric haemorrhage, 8 had severe haemorrhage at repeat operation, 6 had uterine rupture, and 5 had placenta accreta.
Table 1 HIV, CD4 count and antiretroviral (ARV) treatment, 1997-2012





1997-2000

(n=99)

2001-2004

(n=116)

2005-2008

(n=144)

2009-2012

(n=120)

HIV pos

HIV neg


33 (33%)

6 (6%)


56 (49%)

22 (19%)


79 (55%)

32 (22%)


76 (63%)

27 (23%)


CD4 tested

10 (33%)

25 (45%)

64 (81%)

65 (86%)

CD4 <200/mm3

10 (100%)

22 (88%)

48 (75%)

44 (68%)

Received ARVs

0

1 (2%)

9 (11%)

27 (36%)





Table 2 Main causes of maternal death for Greater Soweto, 1997-2012


Hypertensive disorders 79 (16.5%)

    • Eclampsia 47

Obstetric haemorrhage 60 (12.5%)

    • Uterine atony 12

    • Uterine rupture 12

    • Placental abruption 11

    • Caesarean section 10

    • Placenta praevia/accreta 5

Acute collapse 40 (8.4%)

Pregnancy-related infection 30 (6.3%)

Miscarriage 15 (3.1%)

Ectopic pregnancy 11 (2.3%)

Non-pregnancy related infections (NPRI)* 191 (39.9%)

    • Pneumonia 50

    • Pulmonary TB 35

    • Extrapulmonary TB 21

    • PCP 20

    • Wasting syndrome 16

    • Malaria 6

Medical and surgical disorders 31 (6.5%)

    • Cardiac disease 16





Discussion

The results show a significant reduction in maternal mortality ratio since 2004, probably related to the introduction of antiretroviral treatment for pregnant women. However, HIV remains the dominant underlying risk factor for maternal deaths. Advanced maternal age, anaemia and previous caesarean section play a role in maternal mortality from hypertension, non-pregnancy related infection and obstetric haemorrhage respectively.


THE IMPACT ON THE MATERNAL AND FETAL OUTCOMES OF LOWER RESPIRATORY TRACT INFECTIONS IN PREGNANCY (ABSTRACT)
Dr Machetela, Dr Frank, Dr Hull, Dr Omar

University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital


Background:

Although the incidence of lower respiratory tract infection (LRTI) in pregnancy has been reported to be the same as in non-pregnancy, the risk factors associated with developing LRTI influence the outcome of the pregnancy.

The recent Saving Mothers report (2008-2010) indicated that HIV- related complications such as LRTI are the leading cause of maternal and neonatal mortality and morbidity in South Africa. This is an indicator that the health system is struggling to manage this condition effectively.
Methods:

This was an observational prospective study of eight-four pregnant patients admitted with clinical diagnosis of LRTI. The clinical profile of these women and the causative organisms were determined. The X-Rays findings were analysed to confirm the diagnosis. The impact of HIV on these patients was also evaluated.


Results: Fifty eight per cent (n=49) had Pneumonia, 21% (n=18) had Tuberculosis and 17% (n=14) had Pneumocystis Jiroveci (Carinii) Pneumonia respectively. The most common organisms isolated on sputum were: Haemophilus Influenza, Streptococcus Pneumonia, Candida species, Staphylococcus Aureus and Enterococci species respectively.

There was one maternal death due to community acquired pneumonia associated with obstetric comorbidity (hypertension). LRTI was associated with seventeen preterm deliveries with a mean birth weight of 1985g, a mean gestational age of 30.5 weeks, three stillbirths and one early neonatal death.

Women who were HIV positive presented with more severe disease as compared to their HIV negative counterparts. Further, HIV was associated with a statistically significant number of preterm and still- births.
Conclusion: LRTI with concurrent HIV in pregnancy has a negative impact on the maternal and neonatal outcome and this condition needs aggressive management.
A CLINICAL AUDIT OF PROVIDER INITIATED HIV COUNSELLING AND TESTING IN A GYNAECOLOGICAL WARD OF A DISTRICT HOSPITAL,IN KWAZULU-NATAL, SOUTH AFRICA
Moodley J, #Bryan M, #Tunkyi K, Khedun S.

Women’s Health and HIV Research Group, Department of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban; #Department of Obstetrics and Gynaecology, Addington Hospital, Durban.


Introduction

The HIV pandemic is in its 4th decade, yet only one third of the population in countries with the greatest burden of this disease are reported to have been tested1. Expansion of HIV testing to the total population of a country is pivotal to overcoming the HIV pandemic as it has been reported that early initiation of highly active antiretroviral therapy (HAART) not only reduces transmission but also prolongs life2,3. Furthermore, the reduction of perinatal mother to child transmission (PMTCT) to <3% in South Africa is mainly due to increasing numbers of antenatal attendees agreeing to provider initiated counselling and testing (PICT), dual therapy for PMTCT and HAART if required4.


A recent systematic review and a number of observational studies report that PICT in low and middle income countries (LMIC) has increased HIV testing rates. Most of these studies on increased HIV testing have been carried out in antenatal clinics, TB centres and sexually transmitted disease clinics5-7. There is scant data on whether PICT has been integrated into routine care provided by health facilities catering for the general population.
Our impression is that PICT is patchy at best in a gynaecological ward in a district hospital in South Africa. We therefore carried out a clinical audit of PICT to women admitted to a gynaecological ward.
Methodology

A retrospective chart review of all patients admitted to the gynaecological ward and stayed for a period of < 4 days over a 8 month period. The charts of individual patients were reviewed immediately after hospital discharge and relevant data such as demographic information and whether the patient was offered HIV testing was recorded in a structured format. Institutional Ethics (BREC 196/12) and hospital regulatory permissions were obtained .The data was analysed using simple descriptive statistics.


The general policy at the study site was to offer PICT to all women admitted to the gynaecology ward. In this model of HIV testing, all health care workers are encouraged to initiate the testing process, by suggesting the need for a test. The patient can opt out, if so desired. Detailed counselling is provided once the HIV result is known and referral to dedicated HIV clinics is arranged. Patients who have been tested previously and state that they have tested negative are offered re-testing. Patients who state that they have tested positive have a CD4 done or provided with advice and referred to a dedicated HIV Clinic for further management.
The rapid HIV test used was the First Response (Premier Medical Corp Ltd, India). If the patient tests positive, a second HIV rapid test, the Determine (Alere Medical, Co. Ltd, Japan) is used as a confirmatory test. If both rapid tests are positive, the result is regarded as confirmation of the presence of HIV infection. If the second test is negative a laboratory ELISA is performed to confirm the result.
The district hospital is in an urban setting in the Durban Metropolitan area and is predominantly attended by lower socio-economic population groups. The overall HIV prevalence among antenatal women aged 15 -49years in KwaZulu-Natal is estimated at 39.5%8. All patients who stayed in the ward for more than 4 days were excluded from this audit because we believed that the longer the duration of hospital stay the greater the chances of PICT being initiated. Patients who were confused and in an unstable clinical state were also excluded. All other admissions were included in the study.
Results

Over the study period of 8 months there were 1019 patients admitted and who stayed for < 4 days. 1014 case files were evaluated (5 files were missing). Table 1 describes the characteristics of all patients .The mean age was 23.4 ± 6.3 (18-54) years. The majority (65%) were in the 18-29 years age group. The mean parity was 1.08 ± 1.05 (range: 0-4). The mean hospital stay was 2.35 ± 0.48 (range 2-3). Four hundred and eighty seven (48%) had a previous pregnancy.


There were 802 (79%)emergency admissions. Miscarriages (n =599; 59%) were the commonest indication for admission. Thirty six (29%) of the 124 patients with pelvic inflammatory disease had not been tested for HIV previously. Twenty six (72%) of the 36 patients were offered HIV testing. Eighteen (69%) of the 26 patients who were offered testing accepted and 8 (31%) declined testing. Figure1 shows the outcomes of the PICT process.
HIV counselling and testing

1014patients were available for HIVtesting.The HIV status of 451 (44%) wasknown on admission. One hundred and fifty seven of the 563 patients with unknown HIV status were offered PITC and 116(74%) accepted HIV testing. Forty five(39%) of the 116tested positive (Fig. 1).


Discussion

In our study, a high percentage of patients (n = 406: 72%: Fig 1) were not offered PICT. This confirms our observation that PICT is not being properly implemented in settings in which women present with acute gynaecological disorders and there is a rapid “turn over “of patients. This may be due the shortage of hospital beds and possibly lack of trained staff and counsellors. Further because the regular change of medical staff there may be a lack of on -going training on standard operating procedures.


These operational issues concerning PICT should be taken into account if we are to increase the numbers of individuals who are tested for HIV and started on treatment as early as possible. The numbers not offered testing might be higher because the opportunity to establish the date when the previous HIV test was done in those who stated that they had been tested previously was not taken. This could be regarded has missed opportunities for re testing especially for those who were at risk such as patients with a diagnosis of pelvic inflammatory disease, Bartholin’s abscesses and cervical cancer. More, importantly, it would seem that health care workers do not understand the PICT model. In this model, doctors or nurses can suggest to the patient that he/she has a test and instead of detailed consent form being worked through for and signed, a note in the file indicating that that HIV testing has been suggested and agreed to is sufficient. The healthcare worker then does the test and the detailed counselling is arranged. The counsellor can then do this time consuming but important part of the PICT process. It would appear that health care workers are not fully informed of this process and are distancing themselves from this responsibility and placing an overemphasis on counsellors. Integration of the process into routine health care and disseminating information to all health care workers is essential to increase the numbers of people involved in HIV screening and testing.
The average stay of patients in hospital was 2 days and most patients were young and had uncomplicated miscarriages. Only 19% of the incomplete miscarriages and 13% of the ectopic pregnancies were offered testing (Table 1). It is our impression that in an urban setting this group of patients with a diagnosis of miscarriage request to be discharged from hospital as soon as possible. Delays in counselling and testing prior to discharge from hospital may have been a reason why so few were offered PICT, although it is possible PICT was offered but not recorded in the hospital notes. This is one of the limitations of this retrospective audit. We only included women who stayed in hospital for less than 4 days (an arbitrary figure) because we wanted to overcome any biases that patients who stay in hospital for longer periods may have greater chances of being offered HIV testing.
Other operational issues such as privacy and confidentiality may have played a role in health workers not offering PICT. Obermeyer and Osborn (2007) reported that nurses noted a lack of private space as a major constraint to pre/post HIV discussions9. Other reports have also indicated the lack of private rooms for maintaining privacy and confidentiality as probable obstacles to PICT10,11. These resources were certainly lacking at the study site.
Wanyenzeet al., (2008) in a study done in Uganda, reported that prior to the implementation of PICT, only 20% of the patients discharged from a medical ward had received a HIV testing but after the initiation of PICT, 98% agreed to have a test and 81% were tested for the first time and HIV prevalence was 25%12. We did not have baseline data, but prior to the recommendation of PICT, an audit on HIV testing on women seeking termination of pregnancy at our study site showed low rates of HIV testing13.The need for monitoring and evaluation of PICT in general wards and continuing training of all health workers and counsellors, the provision of staff and sufficient privacy are essential if the number of people tested at point of health care contact is going to be increased.
In our study 74% of those who were offered PICT accepted testing. This is a reasonably high figure in such a setting of acute gynaecological emergencies. More importantly, 39% were HIV infected. Although, this is a ‘select group”, and the figure higher than that in the general population (17.8 %), it strengthens the need for PICT at all clinical contacts in public sector health facilities8.
Defaulting return visits is common in LMIC. Painter et al., (2004) reported that 72% of their patients accepted HIV testing but only 45% returned to collect their results14. The introduction of rapid HIV testing in the ward would overcome this problem. It could be argued that additional staff would probably be required for this. However, it ought to be realized that doctors and nurses have the knowledge and skills to assist in the initial counselling and testing. Much of the in-depth time consuming counselling can be done by the trained counsellors. These operational issues need urgent attention.
Although as stated above the response rate to PICT in our study was 74% and suggests a high level of acceptability. Other studies revealed that patients may feel “compelled to agree” or “forced” into HIV testing,15,16. Our study did not take these factors into account and this requires further investigation in general wards with “rapid turn-over” of patients. They may feel compelled to agree if they feel that they need to be discharged from hospital as soon as possible.
If the operational issues mentioned above are attended to, then wide spread implementation of PICT may be able to deliver the large-scale increase in HIV testing and counselling that is required to initiate early treatment and decrease HIV transmission at a population level.
References


  1. WHO, UNAIDS and UNICEF. Towards universal access: Scaling up priority HIV/AIDS intervention in the health sector: progress report 2010. Geneva WHO 2010

  2. Hammer SM, Antiretroviral Treatment as Prevention. N Engl J Med 2011;365(6):561-2. doi. 10 1056/NEJM 01107487.nejm.org accessed 09/09/2012.

  3. CohenMS, Chen YQ, McCauley J et al.Prevention of HIV-1 infection with early antiretroviral treatment. N Engl J Med 2011; 365:493 -505. doi 101056/nejm02110523.nejm.org accessed 09/09/2012

  4. Dinh TH, Goga A, Jackson D, Lombard S, Woldesenbet S, Puren A, et al. Impact of South Africa’s PMTCT programs on perinatal HIV transmission: results of the 1st year implementing the 2010 WHO recommended guidelines. Abstract book, 4th International Workshop on HIV Pediatrics 20-21 July 2012, Washington DC, USA. Rev Antiviral TherInfDism 2012; 8: 14.

  5. Kennedy CE, Fonner VA, Sweat MD, Okero FA, Baggaley R, O’Reilly KR. Provider initiated HIV testing and counsellingin low and middle income countries: A systematic review. AIDS Behav 2012 July3 [ Epub ahead of print: accessed 19th Sept. 2012 ]

6 Dalal S, Chung-won Lee, Farirai T, SchilskyA,Goldman T, MooreJ et al.,Provider-Initiated HIV Testing and Counseling: Increased Uptake in Two Public Community Health Centers in South Africa and Implications for Scale-Up.PLoS One. 2011; 6(11): e27293 (accessed 09.09.2012.)

  1. Leon N, Naidoo P, Mathews C, Lewin S, Lombard C. The impact of provider-initiated (opt-out) HIV testing and counselling of patients with sexually transmitted infections in Cape Town, South Africa: a controlled trial. Implement Sci. 2010; 5: 8.

  2. National Department of Health. Antenatal prevalence in South Africa. Department of Health, 2010. National Antenatal Sentinel HIV and Syphilis prevalence survey in South Africa.

  3. Obermeyer C, Osborn M. The utilisation of testing and counselling for HIV: a review of the social and behavioural evidence. Am J Pub Hlth 2007;97:1762–1774

  4. Bell E, Mthembu P, O’Sullivan S, Moody K. Sexual and reproductive health services and HIV testing: perspectives and experiences of women and men living with HIV/AIDS. Reproductive Health Matters. 2007;15(S:29 ):113–135.

  5. Greeff M, Phetlhu R, Makoae L, Dlamini P, Holzemer W, Naidoo J, et al. Disclosure of HIV status: experiences and perceptions of persons living with HIV/AIDS and nurses involved in their care. QualHlth Res. 2008; 18(3):311–324

  6. Wanyenze R, Nawavvu C, Namale A, Mayanja B, Bunnell R, Abang B, et al. Acceptability of routine HIV counselling and testing, and HIV seroprevalence in Ugandan hospitals. Bull WHO. 2008;86:302–309

  7. Devjee J, Khedun S, Moodley J. A study of surgical termination of pregnancy at a level 1 health facility in South Africa. S Afr J FamPrac 2012; 54(1): 72-76.

  8. Painter T, Diaby K, Matia D, Lin L, Sibailly T, Kouassi M, et al. Women's reasons for not participating in follow up visits before starting short course antiretroviral prophylaxis for prevention of mother to child transmission of HIV: a qualitative interview study. BMJ 2004;329:543–546

  9. Karim Q, Karim S, Coovadia H, Susser M. Informed consent for HIV testing in a South African Hospital: is it truly informed and truly voluntary?Am J Pub Hlth 1998;88(4):637–640

  10. Medley A, Maman S, Kass N. The complexities of the opt out approach to HIV testing within the ante-natal setting: an experience from Uganda. In: Int AIDS Conference, 2006. Abstract I.D No. 2199453, Toronto.


THE INCIDENCE OF HIV SEROCONVERSION DURING PREGNANCY AT PELONOMI HOSPITAL ANTENATAL CLINIC (ABSTRACT)
Kgasane T 1, Mohosho MM1.

  1. University of the Free State.

Introduction/Background: According to the recent survey (Global AIDS response progress – 2012), the prevalence of HIV in South Africa antenatal clinics is reported to be 30.2%1. Prevention of new HIV infections is critically imperative for South Africa. The prevention of mother to child transmission (PMTCT) is one of the most effective HIV prevention interventions.

Aim/ Objectives: The aim of this study is to determine the incidence of HIV during pregnancy as defined by seroconversion using the ELIZA HIV retesting strategy during the third trimester.

Design/Methods: Prospective descriptive cohort study in which mothers who had initially tested HIV negative during the current pregnancy where retested for HIV. The assessment was done from July 2010 till December 2012. The 500 HIV negative women who were firstly tested before 24 weeks were recruited, and they were HIV ELIZA retested after 24 weeks of gestation, provided that they had tested HIV negative at least six weeks prior.

Results/ Findings: Among 500 women who were recruited, 416 of them met the inclusion criteria. 61 women (14,7%) retested HIV positive. The teenage and advanced maternal age women constituted 13,2% and 15,1% of the study group, respectively. Condom use during the last 12 months till the index pregnancy was reported by participants as always (0,48%); sometimes (60%0 and never (39%). Marital status in the study group showed 41%( married), 57% (single) and 2% (divorced). Only 7% of the women reported to have more than one sexual partner since the last 12 months till the current pregnancy. 58% of the women reported that their pregnancies were unplanned.

Conclusion/Recommendations: The high incidence of HIV during pregnancy is a compelling reason for HIV retesting. This study shows the incidence of HIV seroconversion during pregnancy to have most likely quadrupled over the last four years. The public health programmes need to fully reinforce prevention of mother to child transmission strategies by absolute implementation of HIV retesting during pregnancy.
Reference:

  1. Joint United Nations programme on HIV/AIDS (UNIAIDS) 2012. Global AIDS Response progress reporting.

Monitoring the 2011 political declaration on HIV/AIDS: guidelines on construction of core indicators: 2012 reporting. Available at:

http://www.uniaids.org/en/media/uniaids/contentassets/documents/document/2011/JC2215 Global AIDS Response Progress Reporting en.pdf.



A RANDOMISED COMPARATIVE TRIAL COMPARING THE EFFICACY OF INFANT PERI-EXPOSURE PROPHYLAXIS WITH LOPINAVIR/RITONAVIR (LPV/R) VERSUS LAMIVUDINE TO PREVENT HIV-1 TRANSMISSION BY BREASTFEEDING.

THE ANRS 12174 PROMISE PEP TRIAL.
Kim Harper¹, Mandisa Madliki Singata¹, Amwe Aku¹, G Justus Hofmeyr¹, Debra Jackson², Thorkild Tylleskar³, Philippe Van de Perre4. ANRS 12174 Trial Group,
¹University of Western Cape/Fort Hare/Eastern Cape Department of Health, SOUTH AFRICA, ²University of Western Cape, School of Public Health, Cape Town, SOUTH AFRICA, ³University of Bergen, Centre for International Health, Bergen, NORWAY, 4INSERM U1058, CHU Montpellier, Montpellier, FRANCE.


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