The 32nd Conference on Priorities in Perinatal Care in South Africa was held under the auspices of the Priorities in Perinatal Care Association and sponsored by

Abbott Laboratories SA (Pty) Ltd.

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Editor’s Note:

The articles included in these Proceedings were, mostly, received electronically and have been included as submitted by the presenter/author. Faxed articles have been retyped.Some articles have been shortened.Abstracts were included where articles were not submitted.Articles have not been included for presentations, which were withdrawn and not presented at Priorities.Late submissions received after the Proceedings had been compiled and passwords allocated are included at the end of the Proceedings.

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INDEX

HOW LOW CAN WE GO? SUSTAINING IMPROVEMENTS IN PERINATAL MORTALITY AT A DEEPLY RURAL HOSPITAL. Dr CB Gaunt 1

A HAPPY STORY: HOW CHILD PIP ASSISTED A DEEPLY RURAL HOSPITAL IMPROVE ITS PAEDIATRIC SERVICE. Dr TL Gaunt

6

IMPROVING QUALITY OF CARE USING AUDIT IN A LOW RESOURCE LIMITED SETTING (Abstract). Nakibuuka V K

13

NEONATAL ASPECTS OF THE CHILD PROBLEM IDENTIFICATION PROGRAM – nCHIP: 2005-2011. Kim Harper

14

A STUDY OF NORMAL BIRTH WEIGHT FRESH STILLBIRTHS AT THREE ACADEMIC HOSPITALS. M Bothma 19

PERINATAL PROBLEM IDENTIFICATION PROGRAM V3. JD Coetzee 23

BIRTH REGISTER SURVEY FOR 12 CORE ESMOE-EOST DISTRICTS. E Etsane28

COVERAGE OF THE EMERGENCY OBSTETRIC SIGNAL FUNCTIONS IN THE 12 CORE DISTRICTS INVOLVED IN THE ESMOE-EOST SCALE-UP PROGRAMME. RC Pattinson

32

IMPACT OF INTER-FACILITY TRANSPORT ON MATERNAL MORTALITY IN THE FREE STATE PROVINCE. MG Schoon

33

MAKING THE VISION WORK – THE ROLE OF SUPPORTIVE SUPERVISION IN MATERNAL AND CHILD HEALTH. Anne-Marie Bergh

37

THE REFERRAL SYSTEM IN THE ESMOE – EOST 12 CORE DISTRICTS. KR Mokhondo 41

A PILOT OF ESMOE-EOST SATURATION TRAINING: FEZILE DABI HEALTH DISTRICT: FREE-STATE. DR KGOEBANE

47

INITIATING EMERGENCY OBSTETRIC SIMULATION TRAINING EXERCISES: SUCCESSES AND FAILURES. JD Makin

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NINTH INTERIM REPORT ON CONFIDENTIAL ENQUIRIES INTO MATERNAL DEATHS IN SOUTH AFRICA. Professor Sue Fawcus

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A SEMI-RURAL STORY OF DEATH AUDITING. Luzanne Grundling67

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TRENDS IN ARV THERAPY-RELATED MATERNAL DEATHS IN KWAZULU-NATAL FOLLOWING CHANGES IN ARV THERAPY GUIDELINES. NF MORAN

71

A REVIEW OF MATERNAL DEATH RECORDS OF HIV+ WOMEN IN SEDIBENG DISTRICT, GAUTENG. Senate Sejake

75

LOW DOSE CALCIUM SUPPLEMENTATION FOR PREVENTING PRE-ECLAMPSIA: A SYSTEMATIC REVIEW AND COMMENTARY. Hofmeyr GJ

79

MATERNAL TACHYCARDIA AT 34 – 38 WEEKS’ GESTATION (abstract). Nel N83

ASSOCIATION OF MATERNAL TACHYCARDIA, AS OBSERVED DURING ROUTINE MONITORING AT 34-38 WEEKS’ GESTATION AND BIRTH WEIGHT. Hein Odendaal

85

WOMEN REFERRED TO CHRIS HANI BARAGWANATH ACADEMIC HOSPITAL FOR PROLONGED PREGNANCY (abstract). Bandile Masuku

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HOW SAFELY CAN WE FOLLOW UP POST-TERM PREGNANCY WITH UNCERTAIN GESTATION USING AMNIOTIC FLUID INDEX MEASUREMENT? Amenah Mohamed

90

THE OBSTETRIC OUTCOME OF WOMEN WHO HAD SUCCESSFUL EXTERNAL CEPHALIC VERSION FOR BREECH PRESENTATION AT TERM. GB THERON

93

UNDERGRADUATE STUDENTS’ RESEARCH ON INFANT FEEDING IN MPUMALANGA. Anne-Marie Bergh

96

FONEASTRA MOBILE MILK PASTEURISER: IMPROVING SAFETY AND MONITORING SYSTEMS FOR LOW-TECH HUMAN MILK BANKS. Penny Reimers

100

SOCIAL CIRCUMSTANCES THAT DRIVE EARLY INTRODUCTION OF FORMULA MILK AND PERCEPTIONS ON ITS DISCONTINUATION IN THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION PROGRAMME: VOICES OF A PERI-URBAN COMMUNITY IN SOUTH AFRICA. Petrida Ijumba

103

NECROTISING ENTEROCOLITIS IN PREMATURE INFANTS AT CHRIS HANI BARAGWANATH HOSPITAL. WHAT ARE THE ASSOCIATED FACTORS? Peter Angura 111

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REQUIREMENTS FOR ROLL-OUT OF BEST PRACTICES ACCORDING TO KEY INFORMANTS INVOLVED IN KANGAROO MOTHER CARE IN SOUTH AFRICA: A GUIDE FOR AN OPERATIONAL PLAN. Dr WH ten Ham

117

THE BABY SKIN CARE RESEARCH PROGRAMME (abstract). Bedwell C121

UTERINE RUPTURE AND MATERNAL MORTALITY IN SOUTH – AFRICA 2008-2010. Sue Fawcus

122

MATERNAL AND NEONATAL OUTCOME OF PLACENTA PRAEVIA (abstract). Simpiwe Mose

126A COMPARISON OF TECHNIQUES FOR DELIVERY OF THE IMPACTED FETAL HEAD AT CAESAREAN SECTION FOR CEPHALOPELVIC DISPROPORTION: A RANDOMISED CONTROLLED TRIAL (abstract). E Buga

127

THE INFLUENCE OF SKIN INCISION TO DELIVERY TIME AT CAESAREAN SECTION. Jana Nicolene Rossouw

128

VACUUM DELIVERY: A DYING SKILL (abstract). RC Pattinson131

OPTIONS FOR DIFFICULT SECOND STAGE. Hofmeyr, GJ132

AN AUDIT OF DECISION TO DELIVERY TIMES FOR EMERGENCY CAESAREAN SECTIONS IN A BUSY URBAN OBSTETRIC UNIT IN SOUTH AFRICA (poster). Sue Fawcus 136

MONITORING IN LABOUR – THE CLOCK IS TICKING. Sheila E Clow137

FETAL HEART RATE MONITORING; DOES IT COUNT? A Jagau142

THE EVALUATION OF A TABULAR APPLICATION OF THE NICE GUIDELINES FOR UNIVERSAL INTERPRETATION OF NON-STRESS TEST(NST) AND CARDIOTOCOGRAPHY(CTG) (abstract). Noxolo Jack

148

COMPARABILITY OF AN INNOVATIVE DOPPLER ULTRASOUND FETAL HEART RATE MONITOR TO A PINARD FETAL STETHOSCOPE USING CARDIOTOCOGRAPHY AS A STANDARD TO ASSESS THE FETAL HEART RATE IN SINGLETON PREGNANCIES DURING LABOUR AT MOWBRAY MATERNITY HOSPITAL (abstract). Chinula L

149

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THE EPIDEMIOLOGY OF MECONIUM ASPIRATION SYNDROME: INCIDENCE, RISK FACTORS, THERAPIES AND OUTCOME AT A SEMI RURAL HOSPITAL. N Kapongo

150

DEVELOPMENTAL TRAJECTORIES OF EEG ACTIVITY AND FUNCTIONAL CONNECTIVITY IN LATE PRETERM INFANTS (abstract). Fifer WP

161

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SESSION 1: PAPER 1

HOW LOW CAN WE GO? SUSTAINING IMPROVEMENTS IN PERINATAL MORTALITY AT A DEEPLY RURAL HOSPITAL

Dr CB GauntZithulele Hospital, Eastern Cape, South Africaben@zithulele.org

IntroductionIn 2005, the deeply rural Zithulele Hospital in the Eastern Cape was something of a backwater. The maternity service was beset by problems including poor standards and out of date practices. Initial efforts to improve this bore satisfying fruit including, by 2008, a substantial increase in deliveries and a markedly reduced perinatal mortality rate. The next step was to sustain these improvements and build on them. This paper outlines the continued development of the service and reflects on factors that have enabled a continued decrease in perinatal mortality rate and a change in the causes of mortality, while acknowledging remaining challenges.

Initial challenges When new senior staff arrived in 2005, the maternity service faced multiple problems. These included inexperienced poorly supervised staff, poor protocols, infrequent use of the partogram, inappropriate medication use (such as unrefrigerated ergometrine for third stage management), inadequate resuscitation equipment (a single laryngoscope in the whole hospital) and only two delivery packs with doubtful sterilisation in between cases.

Initial successes 2005-2008In addition to daily on the ground efforts, a monthly audit was established immediately, using the Perinatal Problem Identification Programme. By addressing the challenges in a structured manner, significant improvements were made over the first three years. These included a rise in deliveries as the community started to trust the service more, and a significant reduction in the 6 monthly corrected perinatal mortality rate (PNMR). (See Figures 1 & 2).

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Figure 1 Total deliveries 2005-2008 Figure 2 6-monthly PNMR <1000g

Continued progress 2009-2012Despite these successes, however, the hospital team was well aware that the real challenge lay in sustaining them over time. The foundation for success had been laid by paying attention to staffing and commitment, training and audit, basic rules for safe practice, improving paperwork and protocols and by improving the working environment. By building on this foundation we were able to achieve continued improvements in the following areas.

Continued improvement in service utilisationThe total number of deliveries increased again by 68.5% in the second four year period, for a total increase of 158% since 2005. (See Figure 3)

2005 2006 2007 2008 2009 2010 2011 2012

745 912 996 1143 1159 13161613

1908

Figure 3 Total deliveries 2005-2012

Continued reduction in corrected perinatal mortality rateWe recognised that the PNMR is likely to vary slightly over time. We therefore started to focus on the annual PNMR and in 2012 set ourselves the ambitious target of reducing it to under 20 per 1000.

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745.0912.0

996.01,143.0

0.0

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49.1

36.744.3

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38.1

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2005 2006 2007 2008 2009 2010 2011 20120

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60Chart TitleJan-Jun Jul-Dec

2006 2007 2008 2009 2010 2011 2012

40.80 41.70

24.60

33.90

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27.50

19.50

Figure 4 6-monthly PNMR >1000g Figure 5 Annual PNMR >1000g

Changing the profile of causes of perinatal deathIn addition to the reduction in mortality, another success was in reducing intra-partum asphyxia in particular. This is the leading cause of perinatal death countrywide, but is often avoidable. Figure 6 shows the steady reduction in the proportion of cases in which intrapartum asphyxia was the primary cause of death for infants over 1000g. In 2012, for the first time, intrapartum asphyxia was displaced as the leading cause of death (by unexplained MSB).

2005 2006 2007 2008 2009 2010 2011 2012

38.1 35.1

53.7

35.739.5

33.330

25.7

Figure 6 Primary cause of death IPA (%) in neonates >1000g

Success factorsIn addition to building on the success factors already mentioned, key elements in sustaining our gains in perinatal mortality have been:

Continuously returning to the basics of safe practiceAlthough it can seem repetitive at times, staff turnover amongst both doctors and midwives necessitates continued repetition of basic principles. The use of the partogram in every labour, encouraging midwives to call doctors early in

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cases of prolonged second stage of labour and continued revision of CTG interpretation principles are the mainstays of this.

Emphasising skills and knowledge transferSharing institutional knowledge is a major challenge for all organisations, particularly those like our public sector institutions where staff turnover is high. New doctors are extensively orientated when they arrive at the hospital. While we are wary of overdoing this – and especially aware that many well-intentioned protocols go unread or unconsulted, we have also collected protocols for the most important and frequently seen conditions across the hospital into a Handbook which is revised regularly. Another critical element that can’t be emphasised enough is that we ensure that senior assistance is available. Knowing there is someone to call in the midst of trouble empowers junior staff to use their own skills more confidently.

Continued non-negotiablesWe have maintained unbroken 24 hour caesarean section cover at the hospital since early 2006 (despite the public sector strikes and autoclaves breaking down). In addition, we have held monthly perinatal mortality meetings without fail since inception. There is a daily full doctor round in maternity, including on weekends, despite the fact that calls have become increasingly busy over the years. We have also continued and expanded our outreach to the 10 local clinics we serve. While this is of necessity often a bit too focussed on providing HAART services, it provides ongoing positive contact and builds relationships with the clinic nurses nonetheless. Lastly, we have a regular weekly journal club which helps us stay up to date with latest practice in a variety of disciplines.

A culture of caringMuch of this is underpinned by good relationships between clinical and nursing staff at all levels, including management. Of course we have our challenges, but this helps to foster a team approach and has helped us develop and maintain a culture of caring for patients. What is interesting is how this has slowly started to mature into expecting good outcomes too. The old cliché about women with live foetuses leaving with live babies is actually starting to become something people really do expect – and likewise in the paediatric ward.

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Addressing past challengesIn the analysis of our first four years’ effort we noticed that critical challenges that needed addressing included improving access in labour, improving neonatal care and following this up by encouraging mothers to have better infant feeding practices.

Although we do not have hard data to correlate our efforts with outcome, a waiting mothers centre that is very well utilised has undoubtedly played a role in stabilising our BBA (born before arrival) rate and reducing this avoidable factor in mortality. A new tar road has certainly helped as well!

In neonatal care we have worked with neonatologist colleagues to develop locally appropriate protocols. Despite the continued lack of some basics including CPAP, a neonatal trained nurse has played a leading role in improving standards (all other neonatal care is provided by midwives). In early February we discharged our smallest baby yet – she was born weighing 900g.

Remaining challenges

HIV epidemicThe HIV epidemic is far from over. Our data shows a steady rise in HIV prevalence at delivery despite a plateauing in antenatal surveillance rates for our district. This poses a particular challenge as despite all the positive looking numbers we see about ARV programmes, the reality is that many exist relatively on a knife-edge. Ensuring ongoing quality within these programmes, while making them ever more accessible is an ongoing challenge.

2007 2008 2009 2010 2011 2012

20.8 21.5 23.6 25.2 26.230

Figure 7 Percentage of women HIV positive at delivery

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Maternal mortalityMaternal mortality is naturally a sensitive issue and remains a challenge. Out of 26 women who have died in nearly 8 years, however, only 5 have had obstetric causes. HIV, TB, together with suicide and MVA remain the significant contributors.

20052006

20072008

20092010

20112012

2013012345678

Obstetric haemorrhage

Puerperal sepsis

Hpt with pulm oedema

General medical condition

NPRI - HIV +ve OI

NPRI - HIV +ve TB

NPRI - HIV -ve TB

MVA

Suicide

Figure 8 Maternal mortality over time, by cause

SustainabilityThe audit process never ends. At one level this is what makes it exciting, stimulating and worthwhile. A recent example is that in 2012 we noticed an increase in perinatal deaths related to hypertension. It became clear that different doctors had different approaches to managing hypertension and that people had become confused as to basic principles. This was an opportunity to revisit the topic and establish a clear guideline again. However, there is also a danger that the process can become tedious. There is a need to maintain a balance between the slightly depressing nature of mortality audits and the ever beckoning goal of improving care for our patients. It is this that must ultimately drive us – not the need to report something to head office, not a quest to prove a point, not indeed the numbers themselves!

ConclusionWhen we first presented our data in 2009 we acknowledged that the real challenge lay in sustaining them. Happily, years of continuing effort by the maternity team has resulted in on-going improvements in the rate and nature of perinatal death. We hope that by sharing this update on our progress we can again inspire colleagues in both rural and urban settings to set goals and dream that they can achieve them despite resource limitations, thereby improving care for the communities they serve.

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SESSION 1: PAPER 2

A HAPPY STORY: HOW CHILD PIP ASSISTED A DEEPLY RURAL HOSPITAL IMPROVE ITS PAEDIATRIC SERVICE

Dr TL Gaunt, Dr CB Gaunt, Dr EM Gatley, Zithulele Hospital, Eastern Cape, South Africamamagaunt@gmail.com

IntroductionIn 2005, the deeply rural Zithulele Hospital was a relatively quiet institution – but the quietness hid a significant burden of paediatric disease. (A 2011 survey found that one third of women delivering their second child or more had had at least one of their children die). With new senior doctors and a growing multi-disciplinary team we set about addressing the challenge of improving paediatric care. In 2010 Philani, a Cape Town based NGO using mothers as HCW’s in the community was started with a strong relationship with the hospital. This paper outlines some of those successes using our Child PIP data, what factors contributed to them and how using Child PIP as a foundation for monthly audits helps drive continued improvement.

Monthly mortality meetingsIn 2006 we were able to start a monthly audit meeting of all paediatric deaths that had occurred in our institute the previous month. Although, not yet an official Child PIP site, we were able to use the Child PIP tool to assess the deaths and ward numbers. In 2007 we became an official Child PIP site thanks to the hard work of Dr Griffiths. We began looking at the modifiable factors with resultant actions that have had some long term effects.

The following graphs show how the paediatric service has got busier over the past 5 years, while in hospital mortality rate is on the decline, despite being busier.

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2007/8 2008/9 2009/10 2010/11 2011/12 Apr12-Feb13

565729

1002859 890 955

66 52 75 40 21 15

Admissions & deaths - by year

Admissions Death

Figure 1: Admissions & deaths by year

2007/8 2008/9 2009/10 2010/11 2011/12 Apr'12-Feb'13

11.68

7.13 7.494.66

2.36 1.57

Mortality rate

Figure 2: Mortality rate by year

Factors that contributed to these improvements

A child health championWith a team of 4 long term committed doctors, we could each choose one of 4 priority areas we had identified to focus on. With a champion behind the cause, paediatric care was constantly on the agenda of both clinical and policy meetings. An NGO was set up by the long term doctors to assist with hospital needs such as milk when there was none in our ward. Through the NGO a garden focused on teaching mom’s about door-size gardens was set up.

A paediatrics queueModifiable factor: Child not triaged at A&E (spent time in a queue) Until early 2007 all out patients waited to see the doctors in the same queue. After finding several critically ill children and especially infants waiting untriaged in the long line, the simple strategy of creating a paeds queue resulted in much better triage. The queue sits inside OPD instead of the waiting room and there is better overall surveillance and triage for very sick children. As a result the number of children accessing care rose significantly as the communities we serve saw how we value child health and that they wouldn’t have to wait all day to be seen.

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The following graph shows the increase in paediatrics admissions. The number seen in OPD is obviously much more. In 2006 we were seeing 7-10 children a day with up to 15 on a “busy day” whereas now we see between 25 and 30 children a day with up to 50 patients on a busy day. This increase in patient numbers accessing care has, we believe, resulted in a big decrease in out of hospital mortality. This is an unmeasurable but important part of improving child care in our area.

Apr-05

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120

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Figure 3: Total admissions by month

Paediatric ward oversightModifiable factors: Doctors in children's ward inadequately supervised Lack of standardised case management protocols in wardIn 2007 in a monthly mortality meeting it was noted that there were several different approaches being used in care of the sick children, some approaches not completely acceptable. Clinicians requested some easily accessible, locally relevant protocols for management of commonly seen and frequently fatal conditions. These protocols were drawn up using established protocols from other institutions, which were then adapted with our drug supply and referral environment in mind. Some of our paediatrian friends and colleagues were able to assist with proofing the protocols, which were then printed in a Zithulele handbook. Each new doctor is formally orientated and given their own copy of the handbook (which includes adult and paediatric care). The protocols are reviewed yearly.

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The doctor overseeing paediatric care at the hospital started doing a weekly supervision round with the paediatric ward doctor providing both senior oversight and continuity of care for the ward and its nursing staff.

Breastfeeding “campaign.”Modifiable factor: Child not provided with adequate (quality and/or quantity) food at homeThe vast majority of deaths in the <1yr category were noted to fall in the category “no breast, ever” or “mixed (feeding), since birth” on the death data form. In addition it became apparent on questioning each admission that very few of our admissions were breastfed at all. The feeding practices were very concerning with many moms introducing solids in the first month of life and formula given in dilute forms with most babies receiving less than half the calories needed a day. In a survey in our community water from the rivers and community taps was found to have coliform organisms in 100% of samples studied.

We drafted a formal breastfeeding policy with buy in from all hospital staff and more and more of our clinic staff. Every mom delivering at our institute is now engaged on feeding choices with many of the facts observed from research done in the community and paediatrics ward. Mothers are regularly asked to engage with the actual price of correctly formula feeding their babies over the first year. One of the best interventions to date is a visit to each mom 2 weeks after discharge from a mentor mother (HCW from the Philani NGO in our area.) In 2012 a group of breast feeding experts from Cape Town visited and did some intensive, practical teaching of all staff (incl the general assistants) and the CHW’s in our area.

A further success is the decline in children presenting with 40% reduction in admissions with weight less than 3rd centile and nearly 50% reduction in admissions with severe malnutrition. Both categories show a reducing in hospital mortality rate too.

Engagement of often fatal traditional practicesModifiable factors: 'Traditional remedy' given from traditional healer, with negative effect on child

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Caregiver delayed seeking careMany deaths in the ward were assessed as having “traditional remedy” and “delayed seeking care” as probable modifiable contributing factors. Those admitted with certain traditional medicines (e.g. for ipleyti and ibhala) frequently had severe renal and liver impairment on admission. By engaging better with the community we were able to better understand when such medicines might be used and try pre-empt their use as well as pick up children who may have received such medicine and treat them appropriately.

Every mother on discharge from maternity leaves with information on the deleterious effects of these specific medicines. Our therapy department set up a traditional leaders’ forum where information sharing allowed us to discuss our concerns about the effect of some traditional practices on the very young. Again the Mentor Mothers were able to engage the community at grass roots level, challenging these practices in the homes they visit. We have by no means won on this front and realise that we do not truly understand the tradition that surrounds these practices.

PMTCT and paediatric HAARTModifiable factors: No documentation of mother's antenatal HIV status No ART service provided at clinic/OPDIn 2005 there was no ARV service at all at our institution. Even by 2006 with some advocacy for PMTCT only 55% of women delivering at our institution knew their HIV status at delivery. Now in 2012 the number of women aware of their status and accessing PMTCT approaches 100%.

2006 2007 2008 2009 2010 2011 2012

54.7

93.7 99.8 99.8 99.8 99.9 99.9

Percent of women knowing HIV status at delivery

In October 2005 we placed the first child in our district on HAART (through Madwaleni’s programme) We currently have 270 children enrolled on HAART at our hospital. Several of the doctors have done the HIV diploma and we regularly

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consult with Paediatrics HIV experts in an attempt to keep our care on the cutting edge in the ever changing landscape of Paediatric HAART.

Closing the IMCI gapModifiable factors: Inadequate IMCI implementation at clinic/OPD We have 10 clinics in our district that we directly serve. By the end 2010 there were still NO IMCI trained nurses in these clinics. In conjunction with our LSA we were able to facilitate IMCI training to nurses from 6 of the clinics and some of our hospital nurses. A follow up IMCI course for the other 4 clinics unfortunately has not yet happened due to budgetary constraints and some red tape. It is our dream to have all nurses involved in paediatric care IMCI trained.

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Child PIP helps us fight an outbreakIn March 2011 we noticed an “out of the ordinary” spike in deaths in the ward. This was confirmed when analysing our Child PIP data. There were concerns that the clinical picture in these children was very similar. We were able to present both the clinical findings and the Child PIP data to both the NICD and management, and although we never isolated the causative organism we were able to significantly improve our infection control. Of note, the poor oxygen supply often forcing us to share oxygen between 2 children and the lack of many surgical items, including gloves, was addressed.

Intravenous fluid regulation addressedThe regulation of fluids to sick infants and children is a regular headache with recurrent stock outs of “dial-a-flows” and no supply of giving sets for the rate minders previously donated to the hospital. In a recent Paediatrics mortality meeting this was listed again as a probable modifiable factor contributing to a death. Two students attending the meeting were assigned the job of setting up 2 Swedish donated pumps with their expired giving sets to be used in cases where expired giving sets would be less risky than unregulated fluids. A few days later 2 infants were admitted with gastro and critically ill. Both received regulated fluid and made it to discharge. One infant was our smallest ever preemie who had been discharged from maternity just 2 weeks prior!

SummaryIn the past 5 years of data collection we have seen a 40% increase in admissions to paediatric ward with a paradoxical decrease in the paediatric ward mortality rate, from 11.68% in 2007/8 to 2.36% in 2011/12 and 1.57% in the first eleven months of 2012/13, an 86% drop in total.There has also been a 40% reduction in admissions with weight less than 3 rd

centile and nearly 50% reduction in admissions with severe malnutrition and reducing mortality rates in these categories too.This graph gives a reflection on when each of the discussed interventions took place in the time line of mortality rate decline.

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Apr-07

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0.0

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25.0Mortality rate by month

Paeds queue Monthly MMs

Weekly su-pervisory WR IMCI train-

ing

MMZ

Measles Ward outbreak

ConclusionImprovements in the quality of the paediatric service at Zithulele Hospital are due to many factors, not least the dedication of a committed team. The use of the Child PIP audit tool and the discipline of regular audit have enabled us to build on the commitment to quality by helping us to identify problems and challenges accurately, take measures to address them; and also to celebrate some successes. We hope that by sharing this data it will encourage colleagues in urban and rural settings alike to make this simple, ongoing audit a way of life.

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SESSION 1: PAPER 3

IMPROVING QUALITY OF CARE USING AUDIT IN A LOW RESOURCE LIMITED SETTING

Nakibuuka V K 1 , Okong P2, Byaruhanga R21Department of Paediatrics, Nsambya Hospital, Kampala, Uganda.2Department of obstretics and Gynaecology , Nsambya Hospital , Kampala, Uganda

IntroductionMaternal and neonatal conditions in Uganda contribute 20.4% of the total burden of ill health and avoidable deaths. Perinatal death audits significantly reduce Perinatal mortality.

Aim: To assess the quality of maternal and newborn care and the effect of perinatal death audit on perinatal mortality.

MethodsIn three and half years (March 2008 - June 2011), weekly perinatal death reviews were conducted by a team consisting of midwives, paediatricians, administrators and obstetricians for a total of 474 perinatal deaths. Each case was discussed in detail, identifying gaps in care and cause of death. The quality offered to the mother was classified into four categories: 1. Optimum 2. Probably acceptable 3. Probably suboptimal and 4. Suboptimal. Solutions were implemented according to the gaps identified. Descriptive analysis of data was made.

Results Of the 474 deaths, 170 (35.9%) were macerated stillbirths, fresh Still births 120 ( 25.3%)and Early neonatal deaths 184( 38.8%). A total of 268 ( 56.5%)of the mothers received optimal care, 98(20.7%) probably acceptable care, 56 (19.7%) probably suboptimal care, Suboptimal care 22 (4.6%).The major causes of death were: Intrapartum asphyxia 146 (30.8%) Unknown 142(30.0%), respiratory distress syndrome 51 (10.8%), Meconium aspiration sydromme 30 (6.3%), Hypoxic Ishaemic encepthalopathy 27 (5.7%). The Major gaps in care included: substandard use of partograph, poor neonatal resuscitation skills, delays in performing surgery and inadequate fetal heart monitoring. Local solutions implemented included: twelve sessions of neonatal resuscitation training, training and provision of CPAP, On Job training for Partograph use, provision of fetal heart monitoring charts for mothers in latent phase of labor and and 2nd stage of labour, Workshop annually on essential newborn care for midwives.Perinatal mortality rate was 50, 45, and 46 per 1000 live births in 2008 and 2009, 2010 respectively after introduction of the audits compared to 62.5 per 1000 total births in 2007.

Conclusion: Perinatal audits have potential to significantly contribute to maternal and newborn quality of care and to reduce health facility related perinatal mortality.

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SESSION 1: PAPER 4NEONATAL ASPECTS OF THE CHILD PROBLEM IDENTIFICATION PROGRAM – nCHIP: 2005-2011

Dr Kim Harper [MBChB (UCT), DCH (SA), FCPaed (SA)] Child PIP Eastern Cape Provincial Co-ordinator, Executive & Technical Task Team Representative. Principal Paediatrician, Department of Paediatrics & Child Health, East London Hospital Complex.

Background:The Child Problem Identification Program (Child PIP) is designed to collect quality of care information on the deaths of all children who are admitted to hospital paediatric wards. Neonates are often admitted to general hospital wards post discharge after birth and may die there. Child PIP also collects data about these neonates, and “makes them count.” Extensive and detailed data has been collected over the past 7 years (2005-2011) from 141 hospitals participating in the Child PIP project during this period. This report numerically details & characterises these deaths, provides evidence for mortality trends and looks at modifiable factors associated with their deaths.

Method: The National Child PIP Database was interrogated using the Child PIP, version 3.1, software tool. Data from the period 2005 (the start of Child PIP data collection) to 2011 was selected. All contributing hospitals’ data from all provinces was selected & reviewed.

Filters were then applied to limit the dataset to neonates (0-28 days). Audited death data was reviewed, i.e., data on deaths that were actually discussed at mortality audit meetings. Analysis of the data was performed by means of the Child PIP software program, as well as by means of data exported to Microsoft Excel© for statistical calculations.

Results (2005-2011):A total of 692 974 admissions and 29 222 tallied deaths (30 688 audited deaths) were recorded from 2005-2011, covering all age categories. The overall In-Hospital Mortality Rate (IHMR) was 4.2 deaths/100 admissions.

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There were 45 240 neonatal admissions (6.5% of all admissions) and 2290 tallied neonatal deaths (2020 audited deaths), resulting in a neonatal specific IHMR for the period under review of 5.1. Neonatal deaths formed 7.8% of all deaths captured. Trend data is summarized in the table below.

Audited deaths provide quality of care information and these deaths were used for further analyses.

Table 1: Core Data & Neonatal Death Data: 2005-2011.

Year 2005 2006 2007 2008 2009 2010 2011NN admissions 1362 2969 4534 8148 4270 9729 10185NN deaths 77 150 190 445 473 484 471Neonatal IHMR 5.7 5.4 4.2 5.5 5.6 5.0 4.6All admissions 23745 40665 63378 110779 14144

5 155283 156383All deaths 1557 2393 3199 5521 5915 5927 4692Paediatric IHMR 6.6 5.9 5.0 5.0 4.2 3.8 3.0NN proportion of all admissions 6% 7% 7% 7% 6% 6.3% 6.5%

The majority (56.6%) of ill neonates who subsequently died (1143/2020) were not referred but taken directly to hospital by caregivers. This may be a reflection of the acuteness of the illness or the late recognition of ill neonates.

A small percentage (6.2%; 162/2020) died after re-admission to a general ward. 6.4% (128/2020) of babies who died had lost their mother or their mother was ill. In 87.5% of neonatal deaths, the mother was listed as the primary caregiver, and the grandmother in 4.2%.

Nearly half (47.6%) of admitted neonates died within 24hrs, testifying to the severity of their illness amongst other factors; this compares to 29.8% for other age groups. An average of 4.2% were certified as dead on arrival.

It might be argued that ill neonates being admitted are those “high risk” neonates with many underlying risk factors. Of the neonatal deaths, 13.9% were Low Birth Weight or Ex-Preterm infants, and 13.6% had some other underlying problem. However, 72.5% of the deaths were thought to be initially otherwise healthy neonates when they were discharged.

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HIV: A third (35.8%) of neonates who died were HIV exposed. While HIV PCR testing is not routine in the neonatal period, 17% were confirmed HIV negative and 3.3% were proven to be HIV infected. The HIV status was not known in 25%. Of the HIV exposed neonates who died, only 60.4% (437/724) received PMTCT. Reviewing HIV seven year trend data, the proportion of HIV uninfected neonates who died is increasing; those known to be infected at the time of death decreasing, while the proportion of HIV exposed neonatal deaths remained similar year on year. Those whose HIV status was not known, is decreasing.

Cause of Death: Infection remains the principal cause of death. While often a non-specific diagnosis, masking other specific but difficult to diagnose illnesses, septicaemia (526) still reigns supreme, followed by respiratory illnesses (383), pneumonia (275), and diarrhoeal illness (207) in order, with “other diagnosis” (77), and meningitis (69) following. However, it should be noted that acute respiratory tract infections usurped the top spot in 2011 for the first time, concluding a steady rise of stature since 2007.

Feeding: Of the deaths, 26.2% were exclusively breastfed and 32.6% were never breastfed, while 9.2% received mixed feeding; 32.1% of feeding methods were unknown. There is a worrying trend in that the while health professionals are taking more interest in feeding practices, with the “unknown method of feeding practices” decreasing, the proportion of formula fed neonates over time is increasing. This issue needs to be the focus for the coming years in neonatology.

Comparing exclusive breastfed (BF) vs. non-breastfed (NBF) neonatal deaths, a striking difference was noted in deaths due to respiratory illness (137/658 BF vs. 241/658 NBF) and diarrhoea (29/207 BF vs. 84/207 NBF) but not in septicaemic deaths (166/526 BF vs. 156/526 NBF).

Modifiable factors assist us in determining where we can do better. A third of the modifiable factors occurred in the home & community setting and two thirds in the health system. For most deaths, there was at least one modifiable factor that occurred in the ward or during the acute stage of care in the emergency department.

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The most common modifiable factors, ranked, are listed in Table 2, below.

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Table 2 Top ranked modifiable factors associated with neonatal deaths.

Description PersonNumber

Percent

Caregiver delayed seeking care Caregiver 8122 8.3Caregiver did not recognise danger signs/severity of illness Caregiver 5758 5.9Child not provided with adequate (quality and/or quantity) food at home Caregiver 4248 4.3

Inadequate history taken at A&EClinical Personnel 2203 2.2

Inadequate investigations (blood, x-ray, other) at A&E

Clinical Personnel 1989 2

Inappropriate treatment given at home with negative effect on the child, e.g. enema Caregiver 1748 1.8`Traditional remedy` given from traditional healer, with negative effect on child Caregiver 1589 1.6Lack of High Care and/or ICU facilities for children in own and higher level facility Administrator 1552 1.6

Inadequate physical examination at A&EClinical Personnel 1495 1.5

Insufficient notes on home circumstances or child’s health history

Clinical Personnel 1412 1.4

Inadequate notes on clinical care (assessment, management, monitoring at A&E

Clinical Personnel 1342 1.4

Caregivers top the list. However, inadequate assessments, poor initial management and lack of suitable high care facilities are where clinicians and administrators need to focus.

Conclusion:By 2011, almost 10 000 neonates/year were recorded by Child PIP users as being having been admitted to general paediatric wards in South Africa.

Unlike the unequivocal downward trend of IHMR for other age groups (6.6 in 2005 to 3.0 in 2011), the neonatal IHMR remains fairly static around 5 deaths/100 admissions (range 5.7-4.2). This is seen in the graph below.

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Graph 1 Comparative IHMR Trends: Neonates vs Non-Neonates.

Globally, infants less than one month of age account for 40% of deaths of children younger than five years of age. While progress is being made in decreasing the childhood mortality rate, the same is not true for the neonatal mortality rate, which remains largely unchanged over a comparative period.Consequentially, neonates form a greater proportion of the childhood deaths.

Neonatal ward deaths must be reduced in order to further reduce the overall IHMR in South African Hospitals and crucially to reduce the U5MR. This can be achieved, as up to 25% of neonatal deaths were thought to be avoidable by Child PIP users.

Furthermore, analyses of modifiable factors show that action and resources should be focussed on two principal areas: At the community level, dealing with safe practices of caring for neonates and earlier recognition by caregivers when they become ill; and for clinicians, on the initial admission process, and on perfecting the fundamental aspects of caring for terribly ill newborn infants. Clear and practical guidelines as to where these babies should be admitted, need to be formulated.

It is hoped that this national overview of the lot of neonates (dying in general hospital wards) will spur health professionals to focus on appropriate life-saving interventions at an institutional level for admitted neonates.

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0

1

2

3

4

5

6

7

2005 2006 2007 2008 2009 2010 2011

NeonatesNon-Neonates

SESSION 1: PAPER 5

A STUDY OF NORMAL BIRTH WEIGHT FRESH STILLBIRTHS AT THREE ACADEMIC HOSPITALS

M Bothma, EJ BuchmannDepartment of Obstetrics and Gynaecology, University of the Witwatersrand

IntroductionGlobally an estimated 1.19 million stillbirths occur during labour, with almost all of these deaths occurring in low- and middle-income countries. In South Africa, intrapartum fetal death is still very common and frequently occurs in situations of entirely normal labour. The objectives of this study were: 1) To determine the incidence of fresh stillbirths weighing 2500 g or more at three academic hospitals; 2) To identify the direct cause, along with associated risk factors for these deaths; and 3) To identify avoidable factors relating to poor or substandard intrapartum care with specific emphasis on intrapartum fetal heart rate monitoring.

MethodsThis was a prospective, cross sectional, descriptive study conducted at three obstetric units in Johannesburg, Gauteng. The hospitals were Chris Hani Baragwanath Academic Hospital, Charlotte Maxeke Johannesburg Academic Hospital and Rahima Moosa Mother and Child Hospital. Three six-month periods were sampled at each of the three hospitals consecutively, for a total eighteen month data collection period from May 2011 until October 2012. The study population was all fresh stillbirths weighing 2500 g or more that were delivered either vaginally or by caesarean section at these institutions. Every morning the birth registers were inspected for deliveries in the hospital in all the areas where deliveries could take place (admissions area, labour ward, obstetric theatre etc). Records of fresh stillbirths and unspecified stillbirths weighing ≥ 2500 g were noted from the registers and then further investigated by finding the mothers and the clinical details of the stillborn babies in the postnatal wards. If the stillbirths were found to be eligible for inclusion, their mothers were approached to participate in the research. Once the women agreed, by signed informed consent, to participate in the study, the researcher recorded the relevant information on a data sheet. The information recorded was found in the antenatal card and the maternity case file wherein all clinical notes are

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documented by nursing staff and doctors. Any uncertainty about documented information was clarified by speaking to the stillborn baby’s mother, the nursing staff, the midwives, or the doctors involved in the management of the particular case. Antenatal maternal characteristics, intrapartum details (including progress of labour and delivery), and details regarding intrapartum fetal monitoring were all recorded.

ResultsA total of 52 women with fresh stillbirths eligible for inclusion were identified with a mean age of 25.6±5.5. Twenty-three (44.2%) were nulliparous. Sixteen women (30.8%) were HIV infected. Twelve women had a previous caesarean section. The mean gestational age was 38.4±2.3 weeks with a mean birth weight of 3052±460 g. Six women had prolonged active phase of labour, with the cervix dilating at a rate of less than 1cm/hour. None of the patients had augmentation of labour and meconium stained liquor was found in 23 (44.2%) of the cases. There were 24 (46.2%) vaginal deliveries, 24 (46.2%) caesarean sections, 3 (5.8%) vacuum deliveries and 1 (1.9%) forceps delivery. There were 30 women (57.7%) with identifiable catastrophic events relating to the intrapartum stillbirth which are shown in table 1. Twenty-two women (42.3%) had appropriate fetal monitoring and 15 (28.8%) had inadequate or no fetal monitoring. The remaining 15 (28.8%) of the 52 cases were diagnosed as intra-uterine fetal deaths on arrival at hospital. The mean time from recognition of emergency to delivery (n=25) was 107.8±92.3 minutes. The emergency was not recognised in 12 (23.1%) of the cases presenting with live babies on admission.

Table 1: Causes directly related to the fresh stillbirthIdentifiable catastrophic events Abruptio placentae Uterine rupture Cord prolapse Entrapment of aftercoming head of breech

16 (30.8%)4 (11.5%)7 (13.5%)3 (5.8%)_30 (57.7%)

No direct cause identified IUFD on arrival Fetal heart present on arrival

22 (42.3%)5 (22.7%)17 (77.3%)

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Table 2: Intrapartum fetal monitoring and interpretation, and recognition-to-delivery time interval (n=52)Monitoring Monitored Not monitored IUFD on arrival

22 (42.3%)15 (28.8%)15 (28.8%)

Fetal distress Yes No Unknown because not monitored IUFD on arrival

20 (38.5%)2 (1%)15 (28.8%)15 (28.8%)

Incorrectly interpreted tracings 5 (9.6%)Intrauterine resuscitation 5 (9.6%)Emergency recognisedEmergency not recognisedIUFD on arrival

Minutes taken from recognition of emergency to delivery median with range (n=25) mean±SD

25 (48.1%)12 (23.1%)15 (28.8%)

182 (13 – 360)107.8±92.3

Table 3: Summary of fresh stillbirths not associated with catastrophic events (abruptio placentae, entrapment of aftercoming head of breech, uterine rupture, cord prolapsed)(n=22)Monitoring Monitored Not monitored IUFD on arrivalFetal distress Yes No Unknown due to not monitored IUFD on arrivalIncorrectly interpreted tracings

12 (54.6%)5 (22.7%)5 (22.7%)

12 (54.6%)0 (0.0%)5 (22.7%)5 (22.7%)4 (18.2%)

Emergency recognisedEmergency not recognisedIUFD on arrival

Minutes taken from recognition of emergency to delivery (mean±SD)(n=11)

11 (50%)6 (27.3%)5 (22.7%)

131±114

ConclusionThirty seven (71.2%) out of the total number of 52 cases had a fetal heart beat present on arrival to hospital. Even when excluding the 30 cases with catastrophic intrapartum events directly relating to the stillbirth, there were 17 (77.3%) out of 22 cases who presented with a fetal heart beat on arrival to hospital. This is an unacceptable high percentage of babies that were initially alive on admission and subsequently died before delivery, indicating a clear opportunity for intervention. The problem seems to lie in the monitoring of patients in this study, along with consequent reactions to it. The fact that 15

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(28.8%) patients were not monitored in facilities with adequate intrapartum fetal heart rate monitoring available, is not acceptable. The emergency was not recognised in 12 (23.1%) of the patients even with skilled birth attendants available and even in the 25 cases where the emergency was recognised, the time taken from decision to delivery was too long with only 4 cases having had a decision to delivery interval of ≤ 30 min. The reasons for delay in decision to delivery interval is most likely due to avoidable administrative factors like shortages of immediately available theatres, other emergencies being prioritised and anaesthetic delays. This current study also echoes what has been found nationally in “Saving Babies” with the majority of fresh stillbirths presenting alive on arrival to hospital, indicating an opportunity for intervention and prevention of these deaths. There appears to be a failure to detect or respond to evidence of fetal distress even in facilities with skilled staff and proper equipment. An unacceptable number of babies is not benefitting from the available resources, which means that the health system is failing in one of their most basic functions: caring appropriately for a woman and her baby in labour.

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SESSION 1: PAPER 6PERINATAL PROBLEM IDENTIFICATION PROGRAM V3

JD CoetzeePPIP Developer

BackgroundThe current version of PPIP (2.2.3) has been in use since 2004. To date, 502 user licenses have been issued, 456 of which to users in South Africa, 25 to users in other African countries, and 21 outside Africa. The latest “Saving Babies” report1 states that “During the period 1st January 2010 to 31st December 2011, 1,324,320 births and 32,178 stillbirths and 14,587 early neonatal deaths were recorded on the national Perinatal Problem Identification Programme (PPIP) database from 588 PPIP sites. This represents 73.1% of all births in institutions using the District Health Information System (DHIS) for the denominator (July 2012).”This document will highlight the major changes made to PPIP with the release of version 3.0.

TechnicalPPIP is still a 32-bit Windows-based application, presented as a single installation file which can be downloaded from the PPIP web site. It still requires a unique user licence to remain functional, which will be different from the licence issued for version 2. It is still free of charge.PPIP requires a minimum screen resolution of 1,366 x 768. Some of its reporting functions depend on MS Office® being installed on the user’s computer.The installation system and Help file are compatible with the latest versions of Windows.

InterfaceThe user interface has been ‘modernized’ and updated. The two main functions of PPIP (data entry and data analysis) are now accessed separately. For the person only involved in data capture, therefore, the data entry functions are presented on its own, while the data analysis function becomes a completely separate functionality. Fig 1 displays the PPIP main window with the data entry function selected, while Fig 2 shows the data analysis function active.

1 Saving babies 2010-2011: Eighth report on perinatal care in South Africa. RC Pattinson, Tshepesa Press, Pretoria, 2013

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Figure 1 - Data Management

Figure 2 - Data AnalysisData pyramid managementPPIP makes use of a “data pyramid” structure to enable the combined analysis of data originating at different institutions and on different levels in the health system. Original data can enter the final pyramid on any level, and analysis can be done at any level in the pyramid.PPIP now allows the user to set up an unlimited number of pyramids, to allow for the analysis of data in more than one way. (The pyramid may represent actual geographical layout, or may represent tiers in the health care system, or level of care etc.) An unlimited number of data sets can be included in each pyramid, with up to 25 logical levels in each pyramid. No duplication of data occurs; the original data remains in a single data set, but it becomes part of the analysed data when this data set is included in the pyramid being analysed.Data pyramid management (creating / updating pyramids, setting up the structure of the pyramids) all happen on a single window, which gives the user an easy view of data pyramid structure. (Fig 3)

Figure 3 - Data Pyramid ManagementData fields

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A number of new data fields were added:The number of primiparae, multiparae and grand multiparae delivered during the monthThe number of women delivered during the month where syphilis and HIV serology were not determinedA new delivery method category “Other (Destructive etc.)”Antiretroviral treatment of women who delivered during the month was expanded to “Received PMTCT”, “Received HAART”, “Received no drugs” and “Unknown”.Maternal parity for each perinatal deathGestational age for each perinatal deathThe maternal obstetric condition for each perinatal death

Data analysisWhere possible, existing data analysis functions were expanded to offer the user more control over the exact subgroup of deliveries or deaths being analysed. Data filters have been expanded, but are easier to use and combine. The following new functions were added:Single cause analysis. This allows the user to select a single primary / final cause of death / avoidable factor / maternal obstetric condition, and then to analyse trends, weight distribution, weight / gestation distribution, maternal age distribution, maternal parity distribution, gestational age distribution, timing of death, syphilis serology and HIV serology of all deaths where the selected cause or factor was identified.Custom data reporting template. PPIP helps the user to design a MS Word® document which serves as a template for a data report. This template can be formatted in any way, and can include any of a wide range of data fields, tables or lists. The template alone determines the actual data analysis, independent from the copy of PPIP used to create it. It can therefore be used by any number of users to generate exactly the same report, using any data contained in the individual user’s data files. Fig 4 displays a report template, while Fig 5 displays the same template after execution of the report.

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Figure 4 - Report template

Figure 5 - Report template after executionReportingAll the results of data analyses can be printed, written to a Portable Document Format (.pdf) file, written to a MS Word® file, or transferred to a MS Excel® file. Graphs that display the result of data analyses can be copied to the Windows

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clipboard with a right-click to make it easy to include these in your own custom reports.

Data sharingAs in PPIP v2, the import- and export wizards still assist in transferring data from one user to the next. The functions of both wizards have been simplified. The import wizard can now import more than one data set at a time, and allows the user to select the data set which will contain the imported data. The export wizard allows the selection of individual data sets for export, not only branches of the data pyramid. Both the importing and exporting functions are significantly faster; even with very large files, the time it takes to import or export data is now measured in seconds, not minutes any more.

CodingThe coding system has been updated. A number of new codes, as requested by users, have been added, and the code lists have been reorganised to make the grouping of causes of death or avoidable factors more logical.Existing version 2 data must be imported (using the single Import Wizard), at which time the codes in this imported data is updated to reflect the changes in the code lists.PPIP still prints its own code lists.

A last wordI want to extend my gratitude to the MRC Unit for Maternal and Infant Health Care Strategies at Kalafong Hospital for support and encouragement during the development of PPIP.PPIP is nothing without its users. I salute the many individuals using this tool in an honest effort to improve our service to women and their babies.

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SESSION 1: POSTER 1BIRTH REGISTER SURVEY FOR 12 CORE ESMOE-EOST DISTRICTS

E Etsane; J Makin; RC Pattinson; M Mkhondo; R Kgoebane; J Tatane

Background The standard ESMOE-EOST programme has been introduced in 12 core

districts to improve the quality of emergency obstetric care provided by all health care providers involved in maternity and neonatal care.

The new Department of Health Birth Register (BR) was introduced for piloting at 11 of the 12 priority districts; during baseline visits. The specific birth register used, had both a labour and postnatal ward function.

AimsTo pilot the Birth Register at 12 priority ESMOE-EOST sites and receive comments from maternity care staff to Revise and update the register Ensure that the register that captures all indicators; including DHIS

indicators; necessary for effective evaluation and monitoring the quality of care provided

Align the data in register with the data collection system at facilities Promote buy-in and ownership create a user friendly registerThe final purpose would be to have a common register suitable for the whole

country

Methods (1) Birth Registers were provided to 11 core districts, for piloting Data was collected from a convenience sample of 80.1. Telephonic interviews2. Standardised questionnaire; open-ended questions3. Conducted with operational managers and midwives in labour wards

The questionnaire was used to collect the following information:1. Months of use of the birth register2. Births entered since introduction3. Scale rating their experience with use of the BR

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(0-4; 0= very poor; 4=excellent)4. Two open-ended questions regarding:i. What they likedii. What they did not like5. Specific questions regarding:i. Combined function (labour and postnatal) of BRii. Size of rows and columns and where exactly were there problemsiii. Whether the data included was sufficient for facility reporting

Method (2) Any columns that should be removed6. Recommendations on how to make the BR more user-friendly.

Results: (1)Table 1: Use of registerType of Facility NumberCHC’s

District hospitals

Regional hospitals

Tertiary hospitals

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41

9

2Months of Use (range) 0.5-4.5

No. Of deliveries during time (range) 4-3826

Score (mean; std)

0 – very poor

1

2

3

4 - Excellent

3.05 (0.9)

2 (2.5%)

3 (3.8%)

6 (7.5)

47 (58.8%)

22 (27.5%)

86.3% said it was very good or excellent

Results: (2)Table 2: Like about the register – Common themes identified

Themes NumberHas all information 47User FriendlyIn favour of Yes/No responses

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Statistics easily accessible 13

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Less books used 13Like everything 12Covers all HIV/PMTCT 7

Table 3: Not like about register – Common themes identifiedThemes Number New Birth RegisterSpace issues 51 √Extra columns needed 15 √Numbering on page 11 √Quality of cover 5 √√ = New Birth Register has addressed these specific issues

Results: (3)Table 4: Specific questions askedQuestion ResponsesCombined labour ward and postnatal function

Good (all on the same floor)

Bad (physical distance between labour and postnatal wards)

64 (81%)

15 (19%)

Space inadequate

Columns

Rows

63 (81%)

57 (76%)

Results: (4)Table 6: Type of Facility and combined function

Type facility CHC District Regional Provincial/TertiaryCombined function

Good 28 (100%) 34 (85%) 1 (50%) 1 (11.1%)Bad 0 6 (15%) 1 (50%) 8 (88.9%)

Table 7: Recommendations to improve User-friendlinessThemes Number New Birth RegisterIncrease size of columns and rows 22 √Additional columns 21 √Remove some data/ columns 13 √Separate registers – labour and postnatal 9 √Improve quality of cover 5 √

Conclusion: Overall, there has been a very positive response to the new birth register Issues of space have been mentioned as being of particular concern The data indicate majority of sites support use of only one register for

labour and postnatal units; but the need for separate registers has been highlighted by institutions for reasons of practicality

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Comments and recommendations relating to the National Birth Register have been taken into consideration as much as possible and are reflected in the new register

Indicators relating to maternal and neonatal care have been reviewed and updated according to participants’ comments

The revised Birth Register will strengthen the recording and data capturing systems which are crucial to monitor and evaluate the quality of care being provided

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SESSION 2: PAPER 1COVERAGE OF THE EMERGENCY OBSTETRIC SIGNAL FUNCTIONS IN THE 12 CORE DISTRICTS INVOLVED IN THE ESMOE-EOST SCALE-UP PROGRAMME

RC Pattinson, JD Makin, R Mkhondo, R Koebane, E Estane, CM BezuidenhoutMRC Maternal and Infant Health Care Strategies Unit, University of Pretoria, LSTM, Liverpool

Aim: To assess ability of the hospitals and community health centres in the 12 core districts to perform the basic and comprehensive emergency obstetric care signal functions.

Method: The 136 health institutions in the 12 core districts were visited (55 Community Health Centres (CHCs); 64 District Hospitals (DH), 13 Regional Hospitals (RH) and 4 Provincial Tertiary (PT) hospitals) between July and October 2011. The institution had been informed of the survey and given the forms to complete at an information meeting held in their province. During the visit the survey form was collected and a walk though of the institution held to verify the data.

Results: The UN has set some basic guidelines for providing emergency obstetric care; namely “for every 500,000 population, there should be at least one comprehensive and four basic emergency obstetric care facilities”. In every district the number facilities far exceeded these norms with respect to the population they served.

Almost all (82.1%) institutions had prescribed referral routes, 88.8% had prescribed referral criteria and 70.9% could produce the document stating the referral policies.

Table 1 gives the ability of each type of institution to perform the signal functions.

Table 1. Ability of facilities to provide basic and comprehensive emergency care.

Emergency care CHC DH RH PT

Number of facilities 55 64 13 4Basic Parenteral antibiotics 63.0 92.1 100.0 100.0

Uterotonics 98.1 96.8 100.0 100.0Anticonvulsants. 96.3 96.8 100.0 100.0Manual removal of the placenta 51.9 81.0 100.0 100.0Evacuation of the uterus 3.8 92.1 100.0 100.0Assisted delivery 5.6 57.1 76.9 75.0Bag & Mask ventilate neonate 80.0 92.2 100.0 100.0

Comprehensive

Perform a caesarean section 0.0 75.8 100.0 100.0Blood Transfusion 5.6 95.2 100.0 100.0

Conclusion: Assessing signal functions allow health care managers to determine what level of care a health facility provides. They are not all encompassing, but are clearly important in maternal and neonatal care at facility level.

1. There are more than enough health facilities to provide a comprehensive emergency obstetric and neonatal service.

2. The vast majority of CHCs cannot provide the complete set of BEmOC signal functions.

3. Almost a quarter of district hospitals cannot provide adequate CEmOC.4. The attitude to assisted deliveries needs to change.5. CEOs of CHCs and district hospitals need to ensure that they employ health care

providers that deliver the correct skills mix to ensure basic and comprehensive

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emergency care can be effectively run. This area is an area where task shifting can be fruitfully employed.

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SESSION 2: PAPER 2

IMPACT OF INTER-FACILITY TRANSPORT ON MATERNAL MORTALITY IN THE FREE STATE PROVINCE

MG SchoonProvincial specialist obstetrician, Free State Department of Health; Senior lecturer, faculty health sciences, Free State University

IntroductionMaternal mortality in the Free State province ranks among the highest in South Africa. Various strategies are implemented to reduce the mortality rates within the province. Adverse events reports within the province identified transport as a contributing factor and were previously presented at Priorities in Perinatal Care conferences.

In response to the observation, the Free State department of Health prioritised inter-facility transport as an intervention to reduce maternal mortality. This was however one of many interventions including focussed ESMOE training and primary care reengineering that included appointment of some key staff to assist in the fight against maternal deaths.

Since the introduction of the inter-facility vehicles in December 2011, a sustained reduction of deaths was observed. This prompted the question what intervention resulted in the reduced outcomes.The purpose of this study was to analyse the impact of inter-facility vehicles on the maternity outcomes.

MethodsThis was a retrospective analysis of data collected monthly through the standard information collection processes in the department of health. Maternity parameters was obtained from the district health information system. Maternal deaths was taken from the maternal deaths notification register and the Emergency services data was calls registered by the emergency and rescue services call center on their electronic call database. Data were analysed with logistic regression, chi square and simple descriptive statistics. The period of data collected was from 1 January 2011 until 30 October 2012. This is therefore a before-after intervention study.

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ResultsOf the 112901 inter-facility calls, 18754 logged calls were dedicated to maternity transfers and 17318 were dispatched. Table 1 summarises the maternal data and inter-facility calls. A total of 458 and 395 calls logged during the 2 period were logged, but not dispatched or patients were not transported. This includes those where vehicles were not dispatched or calls that were dispatched, but the patients were not transported.

2011(Jan-Dec)

2012(Jan-Oct)

Delivery in facility 46 979 40 462Live birth in facility 46 170 39 924Birth before arrival rate (BBA)# 9.29% 9.05%Maternal death in facility* 129 61MMR/100000 live births 279.4 152.8Inter-facility transfers registered 9 341 9 413Vehicles dispatched after call registered 9 186 8 966Inter-facility transfer rate* 19.6% 22.2%Vehicles dispatched within 1 hour 7 738 8 132% vehicles dispatched within 1 hour* 84.2% 90.7%Register-dispatch interval (Minutes) * Average 32.01 22.47 Standard deviation 75.56 77.67 Median 10.16 6.65

The calls requesting inter-hospital transfers reflect the referrals to another level of care. During 2011 the transfer rate was 19.6 % and during 2012 it was 22.2 %. This increase was statistically significant p<.001.The number of deliveries during 2011 was 46979 and during January to October 2012 it was 40462. The institutional maternal mortality decreased from 129 (279/100000 live births) in 2011 to 61 (152/100000 live births) in the period January to October 2012 (p=0.000076 RR 0.54 95% confidence interval 0.40-0.74) . During 2011 a total of 9186 vehicles were dispatched with an average call register dispatch time of 32.01 minutes. A total of 7738 (84.2%) vehicles were dispatched within 1 hour. In 2012 dispatched vehicles were 8966 (mean dispatch time 22.47 minutes) with 8132 (90.7%) dispatched within 1 hour. The proportion of transfers during dayshift did not significantly differ between the 2 periods (2011, 72.6%; 2012 72.5%, p=0.9). The distribution of the calls between urban and rural areas were also similar during the 2 periods (2011, 66.48% urban; 2012, 65.2% urban ; p=0.07).

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The maternal mortality, stillbirths and neonatal mortality timeline (Figure 1) demonstrate a profound change in the maternal mortality since December 2011 with a lesser trend to reduction in stillbirths. There was no change in the neonatal mortality over time.

The correlation between mean call register-dispatch time and maternal deaths (r2=0.5913; p=0.000034) and proportion of dispatched vehicles within 1 hour (r2=0.5729; p=0.000051) show a clear correlation with reduction in mortality associated with shorter dispatch times and higher proportion dispatched within 1 hour.

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When the inter-facility dispatch intervals are plotted against the maternal mortality then the clear relationships can be seen.

ConclusionsThis study evaluating the relationship between maternal mortality before and after introduction of dedicated inter-facility transport demonstrates how effective transport of pregnant women to an appropriate facility can save lives. This

40

Correlation between monthly maternal mortality rates and inter-facility vehicle dispatch

R² = 0.5913

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0

450.0

0.00 10.00 20.00 30.00 40.00 50.00

MM

R

Avg regsiter-dispatch time (min)

MMR

Linear (MMR)

Mean dispatch time (minutes) % vehicles dispatched within 1 hour

Relationship between mortality

and call dispatched within

1 hour

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0

450.0

74.0%

76.0%

78.0%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

Jan-

11

Feb-

11

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-

11

Sep-

11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr-1

2

May

-12

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

Oct

-12

Mon

thly

MM

R/10

0000

live

birt

hs

% t

rans

fers

with

in 1

hou

r be

twee

n fa

ciliti

es

4 per. Mov.Avg.(Proportiontransferred in1 hour %)4 per. Mov.Avg. (MMR)

0

5

10

15

20

25

30

35

40

45

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0

450.0

Jan-

11

Feb-

11

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-

11

Sep-

11

Oct-1

1

Nov-

11

Dec-

11

Jan-

12

Feb-

12

Mar

-12

Apr-1

2

May

-12

Jun-

12

Jul-1

2

Aug-

12

Sep-

12

Oct-1

2

Call

regi

ster

-disp

atch

tim

e (M

in)

Mat

erna

l mor

talit

y/10

0000

live

birt

hs

4 per. Mov. Avg.(MMR)

4 per. Mov. Avg.(Mean dispatchinterval(Minutes))

Relationship between mortality

and mean call dispatch time

intervention does not require skill, but ensure effective wheels to get the patient with complications to the right facility with the right skills as quickly as possible.

The EMS philosophy that a patient within a facility is better off than someone at home is not valid for pregnant women at facilities without the appropriate skills mix.

41

SESSION 2: PAPER 3

MAKING THE VISION WORK – THE ROLE OF SUPPORTIVE SUPERVISION IN MATERNAL AND CHILD HEALTH

Anne-Marie Bergh,1 Carolé Cilliers,2 Maria Belizán,3 Robert Pattinson11 MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria2 Department of Sociology, University of North West3 Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina

BackgroundThe development of the concept of supportive supervision and the importance thereof emerged from studies on health systems strengthening. During the past decade there has also been a proliferation of training manuals on the topic. Everywhere where scale-up programmes are implemented, supportive supervision seems to be included in the design. However, this kind of supervision also seems to be an activity included more informally in programmes and in everyday healthcare activities.In our previous research on completing the audit cycle it was found that people as agents of change are key role-players and that leadership and supervision was needed to complete the audit cycle. The literature also confirms the importance of supervision for improving health worker performance – “Specific supervision practices such as audit with feedback can increase health worker adherence to clinical guidelines.”Traditionally supervision was considered to be an organisational and management process. This approach was, however, not effective. In the past decade the term “supportive supervision” evolved as a concept promoting best-practice for health worker supervision in low-income countries. According to Marquez and Keen, supportive supervision is ”a process that promotes quality at all levels of the health system by strengthening relationships within the system, focusing on identification and resolution of problems and helping optimize the allocation of resources and promoting high standard, teamwork and better two-way communication.”In the context of the re-engineering of primary health care in South Africa supportive supervision is viewed as one the building blocks for health system strengthening. In the current scale-up of the Essential Steps in the Management of Obstetric Emergencies and the Emergency Obstetric Simulation Training (ESMOE-EOST) programme there have been challenges with regard to follow-up on emergency obstetric simulation exercises (“fire drills”). The question arose as

42

to the role that supportive supervision could play to assist health facilities to institute regular emergency drills.The aim of our study was to conduct a formative assessment of the understanding and experiences of key informants with regard to supportive supervision. The exploratory research questions were:

• What are current understandings of supervision?• What are health worker expectations of supervisors and their activities?• How do burning issues impact on supervisory activities?

MethodsKey informants were purposively sampled to cover a broader field than obstetrics and gynaecology. They included specialists and general practitioners working in Internal Medicine, Paediatrics and Family Medicine, nurses and midwives with a wide range of experience in the public, private and non-governmental sectors, and an education management specialist. Data saturation was reached after 10 interviews. The interviews elicited descriptions of the following: informants’ own experiences in the role of supervisee and supervisor; their views on the characteristics and competencies of supervisors, and on supervision, leadership and management; different types of supervisory activities; training of supervisors; challenges to supportive supervision; and the supervisory role of district clinical specialist teams. Interviews were audio-recorded. A manual analysis of the data from the transcribed interviews was conducted, using a grounded theory approach.

FindingsWithin the “big picture” one finds multiple constructions of the notion of supportive supervision, demonstrating the complexities of teamwork within the health system. Leaders, managers and mentors all have a supervisory function, which can be found on a spectrum between formal and informal arrangements and actions. The supervisor is also a teacher, coach and team facilitator, with the responsibility for promoting the learning and doing of supervisees. Four functions or responsibilities of supportive supervision were conceptualised from the data: (1) Formulating a vision or goals based on evidence

43

• At the higher levels of the health system: “We need the leaders that really know what they want to achieve, what do they see as outcomes … We have a Minister of Health that really has got vision … leading by example.”

• At the lower levels of the health system (vision/goals/objectives/focus): “Vision for the supervisor … says what can be achieved … and then secondly it is being able to imagine myself as part of that and it is where I will be, what I will become and what I can do.”

(2) Communicating the vision and getting buy-in“Share with the people as well to say this is our vision, we would like to go this route so that they are buying in … Because once they buy in and share their vision, they are starting to do the work much better and also from the experiences of other health providers you have your own support.”

(3) Implementing or operationalising the vision• The basis of supervision it to know yourself and be true to yourself.• Provide support in a professional relationship of trust. The supervisor is

neither a buddy, nor a policeman. Consistency, integrity, flexibility, and truthfulness are essential requirements.

• Supervision has two faces: the content or task (clear guidelines, skills, resources) and the person (“the human part” of building people).

• There are different styles of supervision and learning facilitation, including being a role model (“Get out of your chair and out of your office”) and finding the correct balance between support and challenge.

(4) Being accountable to the vision“I think if we stop this blaming everybody and saying we were all part of it, we all are accountable. It is not just the Minister of Finance who is accountable for what goes on on the financial side. Each one of us are accountable and we need to look at our responsibilities there.” • Monitoring and evaluation: “We need data that is current, that is reliable,

that you can use to take decisions on, that you can trust to take decisions on.”

• Constructive feedback (more strongly established in the nursing profession than among doctors): “It is strangely enough … the thing that people find the most difficult.”

• Knowing what is going on in the community.

44

In terms of the role of district clinical specialist teams should play in supportive supervision participants indicated that role clarification was very important. They expected these teams to play the following roles: agents of change; public health specialists; clinical governors; auditors; team players using a multidisciplinary, holistic, interdependent approach; persons of authority to direct, reprimand and take decisions; teachers and trainers understanding the big picture and the protocols on how policy fits into the management of patients; and communicators with an ability to give feedbackMaking the vision work is also confronted with many challenges. There may be great ideas and good programmes, but there are problems of practicalities, the financing of programmes and the integration of services. Human resource challenges include: the unavailability of the right people to act as supervisors; staff shortages (”They cannot supervise. They have to do the work themselves”); resistance and lack of discipline (“disappearing doctors”); and inherited incompetence or destructive managers. There is also lack of standardisation and double standards for different people. The focus is still very much on curative services and there are time and quality challenges. This is further complicated by managerialism – “the trend to control … people are just controlled and … checked and that is it.”

ConclusionDespite the high prominence of supportive supervision in maternal and child health projects, it remains a challenge to implement it in a complex health system – “I think one must have a long term view. If you look at countries that caused change to happen, it has been with a vision of 20 years or so.” Further investigation is needed in the field to observe how supportive supervision comes to life in practice and how it can be strengthened within the current initiatives – “There are quite a lot of good things happening in the health system and we need to identify those and make sure they do not die a silent death.”

45

SESSION 2: POSTER 1

THE REFERRAL SYSTEM IN THE ESMOE – EOST 12 CORE DISTRICTS.

KR Mokhondo, JD Makin, ME Etsane, DR Kgoebane, C Bezuidenhout, RC PattinsonMRC unit for Maternal and Infant Health Care Strategies, University of Pretoria and LSTM, Liverpool

Introduction: The ESMOE – Essential Steps in Managing Obstetric Emergencies and EOST - Emergency Obstetric Simulation Training programme is a National Department of Health initiative and MRC Unit in Pretoria has been tasked with the scale –up which initially targeted the Districts which are most in need of this programme. As part of Phase 1 of this scale up, a baseline survey of the health facilities was performed by members of the EOMOE-EOST team. This facility-based audit covered the total population served, total number of beds, functionality of referral system, availability of emergency obstetric care and neonatal care, availability of drugs and equipment, number of staff providing emergency obstetric care and newborn care, signal functions that include basic emergency obstetric care and comprehensive emergency care, all registers in use and auditing processes done within the institution. This presentation looks only at the functionality of the referral system in the 12 core Districts.

Method:

Baseline survey was done together with training of doctors and Midwives at the 12 core facilities. Questions asked on referrals included:

Patients receive from / transfers from other facilities Patients referre to / transfers to other facilities Distances in kilometres between the facilities. Transport available at the facility for example:

1. Patient’s own transport2. Dedicated ambulance.3. General ambulance service.4. Others.

Availability of prescribed referral routes Availability of prescribed criteria for referrals

46

Whether official documentation for referral routes and referral criteria were in place.

Personnel comments on functioning of their referral system.

Results: 1. Number of Health Institutions- 134:

Community Health Centres=53 District Hospitals= 64 Regional hospitals= 13 Provincial hospital=4.

Table 1 shows the type of transport used between facilities

Table 1: Ambulance Services that are available and made use of.

CHC District Hospital Regional/tertiary /Provincial

Dedicated obstetric ambulance

3(5.7%) 12(19%) 3(23%)

Ambulance general 53(100%) 59(93%) 17(100%)

2. Distances between referral and referring institutions were categorised as tables and figures:

Shown in Table 2

Table 2 : Distances between referring and referral sites.

Distance (Km) CHC DH<21 23 621-50 15 751-75 8 1276-100 12101-150 12>150 12

Shown in Figures 1 & 2. :

47

48

Table 3: Prescribed referral routes per district District Yes Tota

l %Amathole 19 22 86.4Fezile Dabi 5 5 100.0Lejweleputswa 6 6 100.0Thabo Mofuntsanyane 11 12 91.7Ekurhuleni 11 13 84.6Ugu 7 7 100.0Umgungundlovu 7 8 87.5Uthungulu 8 10 80.0Waterberg 7 10 70.0Gert Sibande 9 14 64.3Francis Baard 3 7 42.9Bojanala 17 20 85.0Total 110 134 82.1

Table 4: Prescribed referral criteria per district District Yes Total %Amathole 20 22 90.9Fezile Dabi 5 5 100.0Lejweleputswa 6 6 100.0Thabo Mofuntsanyane 11 12 91.7Ekurhuleni 12 13 92.3Ugu 7 7 100.0Umgungundlovu 8 8 100.0Uthungulu 9 10 90.0Waterberg 7 10 70.0Gert Sibande 10 14 71.4Francis Baard 6 7 85.7Bojanala 18 20 90.0Total 119 134 88.8

Table 5. Documented referral policies per district.District Yes Total %Amathole 14 22 63.6Fezile Dabi 5 5 100.0Lejweleputswa 5 6 83.3Thabo Mofuntsanyane 10 12 83.3Ekurhuleni 6 13 46.2Ugu 7 7 100.0Umgungundlovu 6 8 75.0Uthungulu 9 10 90.0Waterberg 4 10 40.0Gert Sibande 8 14 57.1Francis Baard 6 7 85.7Bojanala 15 20 75.0Total 95 134 70.9

2. The comments regarding the referral system were analysed by means of a thematic approach. Two major themes emerged:-1. Delays in getting the patient to the referral institution (up to 6 hours at

some facilities) -Ambulance delays

49

-Call centre delays -Difficulties in contacting the referral hospital. Twenty-five of the CHCs and 25 of district hospitals mentioned at least one of the above problems.

2. Getting the patient into the referral hospital -The referral hospital refusing to take the patient,- Referral hospital capacity in terms of beds or staff being insufficient, -Unsatisfactory communication between health care workers because of poor perceptions at each facility level of each other’s level of functioning. Ten of CHCs and 14 DH’s mentioned at least one of these problems

ConclusionThe major means of transport from CHC’s and district hospitals remains a general ambulanceMany of the above facilities are more than 20 kilometres from their referral facility. The distance issue is further compounded by delays in the system. A woman who has delay in second stage will thus not be able to reach this facility within 1 hour and thus the facility needs to provide a full basic emergency care service including assisted delivery. The majority of facilities have prescribed referral criteria and routes and these are for the most part documented. More attention however needs to be focused on these areas. From the comments it appears that communication between facilities remains a problem and a source of deep unhappiness amongst the staff both at the referral facility and at the referring facility. Clearly this affects patient care. IT NEEDS TO BE ADDRESSED! Communication could be facilitated and standardised by making use of the SBAR Clinical report on Maternity situation.

50

SBAR Clinical report on Maternity situation

SITUATION

The problem I am calling about is __________________________________________________________________________I just made an assessment of the patient:Vital signs:- BP _____/_____ Pulse ______ resp rate _______ Oxygen saturation _____% Oxygen at ____l/min Temperature _____ CI am concerned about:Blood pressure because :- Urine output:- systolic pressure greater than 160 mm Hg Output less than 100 ml over last 4 hours Diastolic pressure more than 100 mm Hg Signifficant protein uria (+++/++++) Systolic pressure less than 90 HaemorrhagePulse because:- Antepartum Pulse rate more than 120 Postpartum Pulse rate less than 40 Fetal well ebing Pulse rate greater than systolic BP CTG pathologyRespiration rate because:- Rate less than 10/min Rate more than 30/min Early obstetric warning scores BACKGROUND (tick relevant sections) The woman is:- Parity [primiparous / multiparous/ granmultiparous] with gestation _______weeks and a [ singleton/ multiple] pregnancy She had _____ previous caesarean sections or episodes of uterine surgery The present fetal assessment is : Fundal height ________cm Presentation ________ with _____fiths above brim: Fetal heart rate __________bpm CTG : Not done / normal/ suspicious/ pathological Antenatal risks Risks identified on antenatal card ________________________________________________________________________________ Labour Not in labour / spontanious onset of labour/ induced labour IUGR / Pre-eclampsia/ reduced fetal movements/ Diabetes/ Antepartum haemorrhage On syntocinon infusion (_____IU/_______ml fluid given at ______ml/hour) Most recent vaginal examination done at _______h Dilated ______cm with ______above brim and position ___________ Membranes : Intact/ rupured at _______h with currnetly Clear / meconium stained liquor/ Blood stained liquor Delivered ________________at _____h with 3rd stage complete/ retained placenta Post Natal Delivery date __________at ___________h____ Type of delivery ______________ With/ without perineal trauma Blood loss ___________ ml Syntocinon infusion ______IU/ _________ml at ________ml/hour Fundal height: High / Atonic/ Tender/ Abdominal- perineal wound oozing Treatment given/ in progress Rx __________________________________________________________________________________________________ASSESSMENT I think the problem is ________________________________________________________________________________ The problem may be related to: Cardiac/infection/ respiratory/haemorrhage/PET/HELLP/Embolism/ Pulm oedema/Fetal distress I am not sure what the problem is, but the woman is deteriorating and we need to do somethingRECOMMENDATIONRequest Please come and see the woman immediately I think delivery need to be expidited I think the patient need to be transferred I would like advice on management of the patientResponse____________________________________________________________________________________________________________

Person completing form: (name) _____________________________________Rank__________________Date_______ Time_______PERSON REPORTED TO (Name) _______________________________Rank)____________________Inst_______________________

NB! After completing and consultation, place this form in the patient file as proof of communication and response

S I am calling about (name of woman) __________________________Ward:____________Hosp. No __________________

B

AR

51

SESSION 2: POSTER 2

A PILOT OF ESMOE-EOST SATURATION TRAINING: FEZILE DABI HEALTH DISTRICT: FREE-STATE

DR KGOEBANE, JD MAKIN, KR MOKHONDO, ME ETSANE, C BEZUIDENHOUT, RC PATTINSON.

IntroductionA trial run saturation training for the 12 core health districts of the scale-up programme in South Africa as an initiative of the National Department of health was conducted in Fezile Dabi district from 8th October to 2th November 2012. The MRC Unit for Maternal and infant Healthcare strategies has been requested to implement the scale-up with the assistance of 4 UK Master trainers who were present during the training. It was divided into two phases of two weeks each at the following health centres namely; Boitumelo Regional Hospital (Training College), Kroonstad and Metsimaholo District Hospital, Sasolburg. The training was divided into a 3 day workshop (Doctors, adv .midwives, professional nurses) from Regional and District Hospitals, and a 2 day workshop (Medical doctors, Professional nurses) from District Hospitals, Community Health Centres providing Obstetric and Newborn care as well as from Casualty of other areas where pregnant woman might present. 135 participants (48 Doctors, 85 adv. midwives and professional nurses and 1 advanced paramedic) were trained. Eleven Free-state master trainers and four trainers from the Liverpool School of Tropical Medicine conducted the programme over the 4 week period. The training was composed of lectures and skills sessions training. At the beginning of each of the workshop a MCQ test was written, this was repeated at the end of each workshop. Consent was requested and obtained from each participant prior to starting the first test. Each participant was given a number to keep and as well as indicate rank/category on the pre and post-test answer sheet. Participants were given 5 multiple choice questions for 10 topics. The assessment was self-administered before and after training to evaluate personnel improvement in knowledge and skills through the Esmoe/Eost saturation training. The mean pre-test score of all participants was 64.1% and the post-test 77.4% (p<0.000). There was a 13% improvement in knowledge for professional nurses and 11% for doctors immediately after training. There was also an improvement in each phase (59.5% to 76.2% for phase 1 and 67.7% to 76.6% for phase 2). At the end of each 2-day and 3-day workshop participants completed a questioner to

52

evaluate the training and was also asked to suggest improvements or make general comments. An analysis/results of each module is given below.Table 1: Results of Knowledge Assessment.Component Assessed Mean Pre

n = 136

Mean Post n=136

Difference

P value

1. Eclampsia 4.41 4.71 0.302. Haemorrhage 3.84 4.12 0.263. Obstructed labour: 3.09 3.80 0.714. Sepsis: 3.01 3.31 0.305. Assisted deliveries 3.36 3.89 0.526. Obstetric complications 3.25 4.14 0.887. Surgical skills 3.06 3.56 0.058. Post-abortion sepsis 2.73 3.09 0.369. CPR 2.68 3.38 0.6910. Neonatal resuscitation 3.40 4.21 0.81Total 64.1% 77.4% 13.3% <0.00

0.

Aims of the pilot1. To assess whether there was an improvement in the knowledge of the

participants.2. To assess how the participants felt about the workshop.3. To assess logistical issues that might have an impact on further rollout of

this programme to the other core district (coverage, cost etc.)

TABLE 1 COSTING OF THE PROGRAMMEExpense CostAccommodation for delegates and presenters R82814.90Transport delegates and presenters R37140.08Catering R84303.18 TOTAL R204,257.34

53

Table 2 Participants’ assessment of lectures.

ODULES N MINIMUM

MAXIMUM

MEAN STD. DEVIATIO

PERCENTAGE

HIV PREG REL 90 1 3 2.62 .6452.543HIV PREG CONT 90 1 3 2.43 .671

HIV PREG PRES 90 1 3 2.58 .599FOET MON REL 133 1 3 2.87 .417

2.81FOET MON CONT 133 1 3 2.76 .446FOET MON PRES 133 2 3 2.80 .404PARTO REL 133 0 3 2.91 .379

2.89PARTO CONT 133 0 3 2.86 .440PARTO PRES 133 1 3 2.96 .323MART REL 131 2 3 2.95 .226

2.886MART CONT 133 2 3 2.83 .373MART PRES 133 2 3 2.88 .327SHOCK REL 133 2 3 2.92 .276

2.876SHOCK CONT 134 2 3 2.85 .358SHOCK PRES 134 2 3 2.86 .350ECLAMP REL 134 2 3 2.96 .223

2.896ECLAMP CONT 134 2 3 2.87 .334ECLAMP PRES 134 1 3 2.87 .364OBST HAEM REL 134 2 3 2.93 .251

2.926OBST HAEM CONT

134 2 3 2.87 .334

OBST HAEM PRES

134 2 3 2.93 .251

NEO REL 132 0 3 2.88 .4102.846NEON CONT 133 0 3 2.84 .474

NEON PRES 133 0 3 2.82 .490OBST EMRG REL 134 1 3 2.93 .280

2.893OBST EMRG CONT

133 2 3 2.88 .327

OBST EMRG PRES

134 2 3 2.87 .334

MISC REL 133 1 3 2.89 .3412.866MISC CONT 134 1 3 2.84 .392

MISC PRES 133 2 3 2.87 .335ASSIST DEL REL 132 1 3 2.90 .324

2.866ASSIST DEL CONT

134 1 3 2.83 .416

ASSIST DEL PRES 133 1 3 2.87 .357SURG SKILLS REL 86 1 3 2.76 .484

2.646SURG SKILLS CONT

86 1 3 2.58 .603

SURG SKILLS PRES

86 1 3 2.60 .619

REL= RelevanceCONT=ContentPRES=Presentation

54

TABLE 3:Participants comments on workshop in general.ATTITUDE ORGANIZATION PRESENTATIONS

82 Positive: Informative. Relevant. Educative.

37 Positive: Well organised. Good learning

process. Goal directed. Reinforcing of

previous teachings.

Boosted confidence.

25 Positive: Partogram session

excellent.

13 Negative: Improve quality of

presentation. Align with Mat. Case

record. To be presented by

experienced Midwife.12 Negative:

Hiv programme Should apply new Regimen on Hiv.

Guidelines used outdated. CTG was difficult to

understand needs real life situation.

55

PRESENTERS DURATION AND VENUE PRACTICAL SKILLS EXERCISE

25 Positive: Knowledgeable. Valuable

contribution.

5 Negative: Hiv not

knowledgeable need a person on PMTCT programme.

Assisted delivery especially forceps not clear.

5 Negative: Clarity on

miscarriage, abortion and Top to include ethical and cultural/religious aspects.

21 Negative: Time between sessions

insufficient. Training period too short

at least 3& 5 days

4 Positive: Indicated relevant, useful

3days.

10 Positive: Venue at Kroonstad

excellent and conducive for training.

3 Negative: Venue at Sasolburg

lecture rooms too small ventilation poor.Moving from point A to B was time consuming.

25 Positive: Skills exercises were well

organised.

Facilitators very knowledgeable.

Facilitators approachable had patience with each participant.

20 Negative: More focus on skills less on

theory. Possibly more time to

achieve competence.

Conclusion1. There was a significant improvement in knowledge of midwives and doctors attending all courses.2. Comments from the participants were on the whole positive.

Attention needs to be paid to: Certain modules especially HIV to make sure that what is presented is in

line with the HIV treatment guidelines. Possibly cutting down on the theory and concentrating more on the skills

demonstrations.3. This is a very expensive undertaking-a more cost effective method of providing saturation training should possibly be sought.4. Of concern is the fact that according to official figures only 69% of all staff needing training did attend the courses-11% short of the 80% target. This could be possibly due to:

Inaccuracies in the Persal system, The fact that staff may rotate through the different departments of facility, People being unable to attend because of work pressures and not being

released by institutions.

56

These are all issues that need to be addressed in the other core districts.Acknowledgements:Our grateful thanks for assisting the ESMOE team in this pilot project in Fezile Dabi Health district must go to Professor Martiens Schoon and his team.

57

SESSION 2: POSTER 3

INITIATING EMERGENCY OBSTETRIC SIMULATION TRAINING EXERCISES: SUCCESSES AND FAILURES

JD Makin, R Mokhondo, R Kgoebane, E Etsane, J Tatane, A Modise, RC Pattinson.MRC Unit for Maternal and Infant Health Care Strategies

Aims1. Assess whether Emergency Obstetric Simulation Training (EOST) exercises

are taking place in hospitals and community health centres (CHC’s) that received EOST training workshops.

2. Identify facilitating/inhibiting factors affecting their introduction.SettingThis involved CHC’s (53) & Hospitals(District -64, Regional-13, Provincial/Tertiary-4) in 12 core health districts. It was part of Phase 1 of the scale-up of Essential Steps in Managing Obstetric Emergencies (ESMOE) and EOST in South Africa. The hospital sites received mannequins the EOST training manual and a CD The CHC’s were invited to attend the training workshop at the referring hospital, no mannequins were given to the CHC’s but they received the EOST manual and CD’s. It must be noted that not all EOST exercises require mannequins

Method A convenience sample of CHC’s (28) and hospitals (69) was taken. A telephonic interview with a senior health care worker from labour ward was conducted. A structured questionnaire-was used. The questionnaire for the hospitals covered the following:-

1. attendance at EOST training workshop.2. whether the importance of EOST was apparent3. whether EOST exercises were taking place at their facility.4. what type of EOST exercises were being done.5. the reasons for not doing exercises.6. how useful they found the EOST manual.7. whether the mannequins were being used. 8. the reasons for not using the manneqins9. how useful they found the EOST exercises.10.any comments around implementation.

58

The questionnaire for the CHC’s covered all of the above points but also asked about the type of model the particular CHC had implemented to ensure that the staff at the CHC was exposed to EOST exercises See Table 1.

Results: Table 1: Models for CHC’s

1.Attending EOST exercises at referral site 11 (39.2%)2 Borrowing mannequins from district hospital/province –running their own EOST

5 (17.9%)

3 Asking member of district/provincial team to bring mannequins and assist

5 (17.9%)

4. Undecided 7 (25%)

It appears that the majority of CHC’s were involved in some form of EOST exercises , the largest percentage attending EOST exercises at their referral centre

Table 2: Attendance and importance of EOSTHospitals (69) CHC’s (28)

Interviewee had attended the EOST training workshop

48 (69.5%) 21 (75%)

Importance of EOST appreciated 60 (87%) 21 (75%)

Most of the interviewees had attended the EOST workshop given at their facility orf at the referral hospital in both the hospital and CHC group The majority felt that EOST exercises were important

Table 3: EOST started & reasons for not startingHospitals CHC’s

Started running EOSTUncertain

53 (77%)4 (6%)

17(61%)

Reasons for no EOST1. Staff shortage/ no time2. High staff turnover3. Waiting for trained person/institution4. Does not know anything about it5. Equipment issues6. Too short a time from workshop to interview/still

planning7. No reason given8. No transport to referral site

51311

23

2

312

111

59

Table 4: Types of EOST done, manuals and mannequins

Hospitals CHC’sDrills1. PPH & retained placenta +manual removal2. Eclampsia3. Shoulder dystocia4. Cord prolapse5. Partogram6. Breech delivery7. Neonatal resuscitation8. Maternal resuscitation9. APH10.Twin delivery11.CTG interpretation

342913131212136641

8552141110

EOST manual easy to use (those doing exercises) 53 (100%) 14(82.3%)

Mannequins used in EOST 41(77.4%) 5(17.8%)

Reasons for not using mannequins1. Kept locked up2. None of drills done needed mannequins3. Shortage of staff4. Waiting for doctor to borrow them5. Only done the theory

11100

11111

Drills performed, are in line with areas of management where most maternal and neonatal deaths occur. The majority found the EOST manual easy to use. At the hospitals the mannequins are being used In contrast the CHC’s who did not receive mannequins –the majority are not using them

Table 5: Usefulness of EOSTHospital CHC’s

EOST exercises helpful 53(100%) 14(82.3%)

Reasons why helpful1. Improve skills and knowledge

e.g. obstetric emergencies in eclampsia partogram2. Feel like real midwives3. Do things correctly without panicking.4. Applicable to what is happening in real life.5. Teaching junior staff and refresher for older staff.6. Communication

Within team Sharing experiences Enthusiasm Involving referral clinics.

7. On site so don’t have to travel.

23

4

23

21111

7

24

1

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Table 6: Problems mentionedProblems Hospitals CHC’s1.Shortage of staff and involving those on night duty –

impact sustainability1. Unsupportive doctors –don’t attend2. Rotation of doctors difficult to attend and then to keep

going3. Transport to site

Need to get district specialist involved4. Need own mannequins / problems with borrowing

mannequins5. All members of staff should receive training materials6. Should have more EOST training workshops7. Involve midwives from clinics doing deliveries10. Communication about EOST workshop poor

√

√√

√

√

√

√√√√

Conclusions:a) The majority of institutions were doing EOST exercises at the time of

the survey.b) Facilitating factors were:-

Majority of healthcare workers see the need for these exercises. This is reflected in the numbers of exercises done involving the mismanagement of emergencies where most women are dying e.g. PPH, Eclampsia.

The very positive response from those doing the exercises namely skills improvement, communication and the feeling of empowerment.

c) Inhibiting factors were:- The lack of initiative to start EOST at some facilities (waiting for

others, not contacting referral centre, no mannequins) Doctors not participating Shortage and rotation of staff impacting on sustainability, Communication with all staff involved about the initiative Transport issues, equipment and support from other levels of

care for CHC’s

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SESSION 3: PAPER 1

NINTH INTERIM REPORT ON CONFIDENTIAL ENQUIRIES INTO MATERNAL DEATHS IN SOUTH AFRICA

Professor Sue Fawcus, Department of Obstetrics and Gynaecology, University of Cape TownOn behalf of the NCCEMD

Aim: This interim report summarises the finding on confidential enquiries into maternal deaths in South Africa for 2011, and presents new data trends in maternal deaths.

Method: The report covers the maternal deaths that were reported to the NCCEMD secretariat by 22nd August 2012, and that occurred in 2011. The same definitions used in the Saving Mothers report were used in this report.

Results: Data was entered on 1466 maternal deaths.

The institutional MMR (iMMR) decreased from 176.22/100000 live births in 2008-2010 to 153.23/100000 live births in 2011 (a 13% reduction).

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All provinces showed a reduction in their iMMR except Mpumalanga Province which showed a slight increase. All provinces showed a reduction in the iMMR due to non-pregnancy related infections when compared with 2008-2010. The iMMR decrease at all levels of care except in Community Health Centres which showed no real change.

63

64

This reduction was mainly due to the reduction in deaths due to non-pregnancy related infections (71.29/100000 live births in 2008-2010 to 55.53/100000 live births in 2011 – a 22% reduction). Non-pregnancy related infections were the most common category of death in all provinces with obstetric haemorrhage and hypertension being the next most common conditions. Pregnancy related sepsis following a viable pregnancy was the third most common direct cause of maternal death, however complications of miscarriage was the third most common cause of direct deaths in three provinces (Gauteng, KwaZulu-Natal and Limpopo). Medical and surgical conditions have continued to show an increase. Of major concern is the continuing high numbers of death from obstetric haemorrhage of which bleeding associated with Caesarean section is the most frequent causal subcategory accounting for 27.6% of haemorrhage deaths.

65

66

In only 4.6% of maternal deaths due to non-pregnancy related infection was the HIV status unknown, and of those tested 93% were HIV positive. Every province showed an increase in the number of maternal deaths that were tested for HIV infection. Overall 85.3% of maternal deaths were tested, a 6.1% increase from 2008-2010. The iMMR for HIV positive women decreased from 430.35/100000 live births to 354.134/100000 live births and all provinces showed a reduction. The iMMR for HIV negative women decreased slightly from 75.46/100000 live births in 2008-2010 to 71.05/100000 live births in 2011. Two provinces the Free State and Mpumalanga provinces showed an increase.

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The iMMR for non-pregnancy related infections in HIV positive women fell from 267.3/100000 live births in 2008-2010 to 191.6 in 2011, a 28% reduction. PCP pneumonia (13.3%), other pneumonias (22.9%) and tuberculosis (25.6%), complications of antiretroviral therapy (11.5%) and meningitis (10.2%) were the most common underlying causes in the non-pregnancy related infections category.

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The pattern of avoidable deaths was the same as the 2008-2010 report, with non-pregnancy related infections, obstetric haemorrhage and hypertension contributing to 25.3%, 23.3% and 16.4% of the avoidable deaths respectively. This is 75% of all avoidable deaths.

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Discussion and Conclusions• Caution must be used in interpreting the data, since it is only for one year.• The iMMR has decreased and this is very encouraging!• The decrease is due to declining deaths in NPRI

– 95% of which are HIV positive women– PMTCT plus is working!

• The direct causes of death have not declined• A campaign is needed to reduce deaths from CS bleeding• There is no need to change 2008-2010 recommendations which

emphasise the 5Hs.

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SESSION 3: PAPER 2

A SEMI-RURAL STORY OF DEATH AUDITING

Luzanne GrundlingBarberton Hospital

BackgroundBarberton Hospital is situated in the Lowveldt of Mpumalanga, 30km from the Swaziland border and + 100km from Mozambique. Mining, forestry and agriculture are the main activities in the area. The majority of our patients stay within 10km of the hospital and have easy access to medical care, with the 4 clinics located within less than 5km of the hospital, but in contrast a large number of patients stay in very remote areas with scares assess to facilities. The furthest referring clinic is more than 50km away from the hospital. We also have quite a number of patients from nearby Swaziland and Mozambique that come for deliveries or bring their sick children to our facility.

Perinatal death auditingThe Obstetric Department started collecting PPIP data in 2002 and the most obvious problem that was identified was the high Neonatal mortality rate in neonates weighting less than 2kg.

PPIP: 2002- 2012

050

100150200250300350400450500550

Neonatal mortality rate'

2002 2004 2006 2008 2010 2012>2.5kg

>2.5kg 2-2.499kg

1.5-1.999kg 1-1.499kg

After acquiring a bubble CPAP machine and surfactant, a 44% reduction in neonatal mortality rate was noticed in the weight group 1-1,999kg. This translates into 44 neonates more surviving in the past 10years.

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PPIP: Neonatal mortality

153127.3

142.9

98

12.9 9 6.4 00255075

100125150

Neonatal mortality rate'

2002-2004 2005-2007 2008-2010 2011-2012

2-2,499kg1-1.999kg

2-2,499kg 1-1.999kg

2012 84:1000

Child death Auditing:ChildPIP data was collected since 2005. In Hospital Mortality Rate (IHMR) has steadily reduced from 4.4% in 2005 to 0.9% in 2012, while the total number of admissions slightly reduced in 2012. A possible cause for the reduced admissions is the opening of a dedicated paediatric OPD as of February 2012. Careful follow-up by doctors dedicated to paediatrics, seems to reduce the number of admissions for minor complaints.

Child PIP data IHMR 2005- 2012

45 51 45 4432 29 25

84.4 5 4.6 5.1 3.6 3.6 2 0.90

10

20

30

40

2005 2006 2007 2008 2009 2010 2011 2012IHMR %

IHMR %

Number ofdeaths

1333

1354

1347

1131

1221

1089

1235

1118

0100200300400500600700800900

1000110012001300

Number

2005 2006 2007 2008 2009 2010 2011 2012

IHMR

Since commencing death auditing in 2005, the following problems were identified: 1. Too many "Unknowns", especially no information regarding PMTCT and maternal wellbeing; 2. Too many avoidable deaths (especially due to gastroenteritis and dehydration; and 3. inadequate assessment and management of HIV care.

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The main causes of death have change of the past 7 years with an obvious reduction in suspected PCP deaths.

Cause of death(% )

PCP, 3

Chronic Diarrhoea, 9.1

Meningitis, 6

Slice 12, Slice 13, Slice 15, Slice 16, Slice 17, Slice 18, Slice 19, Slice 20, Slice 21, Slice 26, Slice 28, Slice 29, Slice 30, Slice 31, Slice 32, Slice 33, Slice 34, Slice 39, Slice 41, Slice 42, Slice 43, Slice 44, Slice 45, Slice 46, Slice 47, Slice 52, Slice 54, Slice 55, Slice 56, Slice 57, Slice 58, Slice 59, Slice 60, Slice 65, Slice 67, Slice 68, Slice 69, Slice 70, Slice 71, Slice 72, Slice 73, Slice 78, Slice 80, Slice 81, Slice 82, Slice 83, Slice 84, Slice 85, Slice 86, Slice 91, Slice 93, Slice 94, Slice 95, Slice 96, Slice 97, Slice 98, Slice 99, Slice 104, Slice 106, Slice 107, Slice 108, Slice 109, Slice 110, Slice 111, Slice 112, Slice 117, Slice 119, Slice 120, Slice 121, Slice 122, Slice 123, Slice 124, Slice 125, Slice 130, Slice 132, Slice 133, Slice 134, Slice 135, Slice 136, Slice 137, Slice 138, Slice 143, Slice 145, Slice 146, Slice 147, Slice 148, Slice 149, Slice 150, Slice 151, Slice 156, Slice 158, Slice 159, Slice 160, Slice 161, Slice 162, Slice 163, Slice 164, Slice 169, Slice 171, Slice 172, Slice 173, Slice 174, Slice 175, Slice 176, Slice 177, Slice 182, Slice 184, Slice 185, Slice 186, Slice 187, Slice 188, Slice 189, Slice 190, Slice 195, Slice 197, Slice 198, Slice 199, Slice 200, Slice 201, Slice 202, Slice 203, Slice 208, Slice 210, Slice 211, Slice 212, Slice 213, Slice 214, Slice 215, Slice 216, Slice 221, Slice 223, Slice 224, Slice 225, Slice 226, Slice 227, Slice 228, Slice 229, Slice 234, Slice 236, Slice 237, Slice 238, Slice 239, Slice 240, Slice 241, Slice 242, Slice 247, Slice 249, Slice 250, Slice 251, Slice 252, Slice 253, Slice 254, Slice 255, Slice 260,

Septecaemia, 15.2

PTB, 9.1

Pneumonnia, 18.2

Acute diarrhoea with shock,

12.1

Others, 27.3

Pneumonia, 19

PCP, 19PTB, 11.1Acute diarrhoea

with shock, 9.5

Meningitis, 4.8other, 19.2

Chronic Diarrhoea, 11.1

Septecaemia, 6.3

Pneumonia PCPPTB SeptecaemiaAcute diarrhoea with shock Chronic DiarrhoeaMeningitis other

2005

2011-2012

Evaluating of PMTCT protocol:From the PPIP statistics it is clear that remarkable improvement has been made in the assessment of pregnant mother's HIV status. In 2002-03 no HIV pregnant women's HIV status was known, while only 1.9% of women had unknown statuses in 2012.

PPIP: Maternal HI V status

0%10%20%30%40%50%60%70%80%90%

100%

NegativePositiveNot tested36.5%

1.9%

Although more is known of the HIV status of mothers, children and the use of Perinatal ARV's, follow-up of the exposed children remains a challenge. It is difficult to assess how many HIV PCR's were done, especially due to the fact that several clinics refer the specimens to another NHLS laboratory, several children don't stay in the drainage area and children who were breastfeeding often had more than 1 PCR done in one year.

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Children commencing HAART

<1y, 15

1-5y, 48

5-10y, 22

10-15y, 15

<1y

1-5y

5-10y

10-15y

<1y, 29.4

1-5y, 35.3

5-10y, 21.6

10-15y, 13.7

2011 – 60 childrens

2012 - 51 children

From the Paediatric Out Patients statistics in 2011 and 2012, it seems that 1,6% and 2,83% of exposed infants respectively were started on ARV's. This does seem to be well within the target range of expected HIV transmission for the current PMTCT program, but the reality is, that we might be missing a large number of children who are actually HIV Positive.

It seems that the only reason to truly follow the HIV exposed children; would be to have a way to link the mother giving birth, with the exposed child. This kind of register, would have implications for confidentiality and would potentially be extremely labour intensive for medical staff.

We therefore still do not have a solution for the problem of PMTCT follow-up, but at Barberton Hospital we would continue to strive to identify every women and child exposed to HIV and ensure prompt treatment for those in need.

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SESSION 3: PAPER 3

TRENDS IN ARV THERAPY-RELATED MATERNAL DEATHS IN KWAZULU-NATAL FOLLOWING CHANGES IN ARV THERAPY GUIDELINES

NF MORAN, KZN Department of Health, on behalf of NCCEMD and KZN Maternal Mortality Assessors

Introduction The findings of the the confidential enquiry into maternal deaths, including the most recent Saving Mothers report (2008-10)1, clearly indicate that in South Africa today HIV-infection is the most important condition contributing to maternal deaths. There will be little progress in reducing maternal deaths unless intensive management of HIV infection in pregnancy is prioritised. Early antenatal care booking, with testing for HIV and initiation of HAART (highly active antiretroviral therapy) according to set criteria are therefore appropriately included amongst the Key Recommendations of the latest Saving Mothers report1. It is however essential to maintain vigilance with regard to any adverse drug reactions to HAART therapy, and to ensure that safe and effective drug regimens are used.In KwaZulu-Natal (KZN), the province in South Africa with the highest numbers of HIV positive pregnant women, roll-out of highly active anti-retroviral therapy (HAART) for eligible HIV +ve patients started state facilities in 2004. With the initial roll-out, the recommended first-line regimen for pregnant women included nevirapine (NVP) rather than efavirenz (EFV) as the non-nucleoside reverse transcriptase inhibitor, as there were concerns about the risk of teratogenicity with EFV. This was despite the available evidence that severe adverse drug reactions (hepatitis and severe skin reactions) were more likely with NVP than with EFV. The numbers of pregnant women initiated on HAART greatly increased following the introduction of new national ARV guidelines in 2010, as the criteria for starting HAART were widened. In KZN the new guidelines were widely implemented by mid-2010. Approximately 20,000 pregnant women were initiated on HAART during 2011 in KZN alone.From 2010, through 2011, clinicians in South Africa raised concerns regarding the high incidence of adverse drug reactions to NVP in women who had recently initiated HAART. The main reactions noted were severe skin lesions (Stevens-Johnson syndrome) and hepatitis. This was confirmed by the 2008-10 Saving Mothers report1 which reported an increase in maternal deaths due these

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reactions in 2010, compared to 2008 and 2009. The increase was most notable in KZN.In response to these concerns, the National Department of Health amended the national ARV guidelines in April 2012, recommending that EFV rather than NVP be routinely used for HAART even in pregnant women. In KZN, this amendment to the guidelines was promptly disseminated and widely implemented within one or two months (by mid 2012). This paper uses KZN data, from the confidential enquiry into maternal deaths, to analyse trends in maternal deaths due to complications of ARV therapy, as the national ARV guidelines have changed from 2010 to 2012.

Methods.Maternal deaths in South Africa are notifiable by law. The notification process includes filling a purpose-designed maternal death notification form and submitting this together with a copy of the case notes of the deceased to the provincial office of the Department of Health. In KZN, all notified maternal deaths are assessed by a group of provincially appointed expert assessors. The details of the assessment are entered into a computerised database (MaMMAS database) and then forwarded to the National Department of Health, so that the Saving Mothers report can be compiled. Confidentiality is maintained throughout this process. The KZN MaMMAS database was used to retrieve statistics on the numbers and causes of maternal deaths in KZN from 2008-2012, and a more detailed review of the case notes of KZN maternal deaths due to complications of ARV therapy was conducted for 2011 as the majority of the case files were still accessible. The data was analysed in three blocks: 1.July 2008-June 2010 (2-year period before the new 2010 guidelines were implemented); 2.July 2010-June 2012 (2-year period after the new 2010 guidelines were implemented); 3.July-Dec 2012 (first 6 months after implementation of amendment to 2010 guidelines (EFV replacing NVP)). Permission was granted by the National Committee for the Confidential Enquiries into Maternal Deaths for a summary of this data to be presented at the Priorities in Perinatal Care Conference, without breaking confidentiality with regard to any specific case.

Results

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KZN 2011 data: In 2011, there were 30 maternal deaths assessed as being due to ARV complications which was 9% of all maternal deaths in KZN. In 28 of these 30 cases, the adverse drug reaction was assessed to be due to NVP (21 hepatitis, 6 Stevens-Johnson Syndrome, and one both). Of the 23 with documented CD4 counts, 10 had a CD4 count below 250 cells/mm3, and 13 above 250 cells/mm3. Out of these 28 cases of maternal death, there were 23 cases of associated fetal loss (stillbirths, miscarriages and intra-uterine deaths, including cases where the woman remained undelivered at death).

TrendsNote: the 2012 data presented in the table below is preliminary. At the time of the presentation (March 13th 2012), a total of 295 maternal deaths had been notified in KZN for 2012, of which only 235 had been entered to the KZN MaMMAS database. Of the entered cases, 133 cases were from January to June 2012, while 102 were from July to December. The 2012 data in the table is based only on these entered cases. It is expected that the final number of reported cases for 2012 will still rise modestly, and all cases will need to be entered in order to provide definitive data about trends from 2008-2012. The data up to and including 2011 is unlikely to change significantly.

Trends in maternal deaths due to non-pregnancy-related infections (NPRI) and adverse drug reactions to antiretroviral drugs (ADRs to ARVs)

July 2008 –Jun 2010 (2 years)

July 2010- Jun 2012 (2 years)

July 2012-Dec 2012 (6 months)

Total maternal deaths 750 680 102 (not final)

NPRI (including ADRs to ARVs)

367 (48.9%) 303 (44.6%) 41 (40.2%)

ADRs to ARVs 16 (2.1%) 47 (6.9%) 3 (2.9%)

NPRI (excluding ADRs to ARVs)

351 (46.8%) 256 (37.6%) 38 (37.3%)

Liver failure final cause

13 (1.7%) 46 (6.8%) 3 (2.9%)

Points to note: The total numbers of maternal deaths declined by 9% in the two year

period after the implementation of the 2010 ARV guidelines, compared to the previous two year period.

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This decline was almost entirely due to a decrease in the deaths due to NPRI (the NPRI category includes deaths due to ADRs to ARVs).

This decline in deaths due to NPRI would have been greater if not for a tripling of the numbers of deaths due to ADRs to ARVs.

The numbers of women who died with liver failure being the final cause also tripled over the same period, indicating that many of the women who died from ADRs to ARVs died from liver failure.

Following the implementation of the amendment to the ARV guidelines in 2012, replacing NVP with EFV for HAART, the proportion of deaths due to ADRs to ARVs has reduced by over 50%, as has the proportion of deaths with liver failure as the final cause

Of the three maternal deaths due to ADRs to ARVs in the period July-December 2012, one was a reaction to NVP in a patient who had been started on a NVP regimen despite the new guideline, and the other two cases were cases of lactic acidosis in women who were on a stavudine-based regimen.

Conclusions. The implementation of new ARV guidelines in 2010 resulted in a decrease in maternal deaths due to NPRI. This was, however, accompanied by an unacceptably high incidence of maternal deaths due to complications of ARVs (mainly NVP-related). NVP reactions were not confined to women with CD4 count above 250, and often resulted in fetal loss as well as maternal death.Preliminary data from the second half of 2012 suggest that the switch in the guidelines from NVP to EFV has resulted in a major decrease in deaths due to ARV complications. This decrease is likely to further contribute to a fall in the numbers of maternal deaths in the NPRI category, and therefore to a fall in the total number of maternal deaths in South Africa.

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SESSION 3: PAPER 3

A REVIEW OF MATERNAL DEATH RECORDS OF HIV+ WOMEN IN SEDIBENG DISTRICT, GAUTENG

Senate Sejake

IntroductionThe maternal mortality ratio in Sedibeng District, Gauteng Province, from 2002 – 2004 was 220/100 000. For the past decade HIV has been identified as a factor that has slowed the decline in maternal deaths in South Africa. The purpose of this study was to describe personal and service level factors contributing to maternal mortality of HIV positive women. It is hoped that the results of this study will be useful in developing interventions that will assist to curb the maternal mortality ratio.

Objectives of the studyThe overall aim of this study was to describe personal and service level factors contributing to maternal mortality of HIV positive women in Sedibeng District so as to curb the maternal mortality ratio. The specific objectives of the study are as follows:

1. To describe personal and facility level factors among HIV positive pregnant women including: age, relationship status, employment status, household income, parity, gravidity, level of facility and professional category of attending health care provider.

2. To describe the antenatal care of HIV positive pregnant women who died.

3. To describe the hospital care received by HIV positive pregnant women who were admitted to hospital.

4. To describe co-morbid conditions with HIV/AIDS and causes of death among women who died

5. To compare the antenatal care that was received by the HIV positive women who died maternal deaths with the National Department of Health guidelines.

Literature reviewIn the triennium 2005 – 2007 the leading causes of maternal deaths in South Africa, referred to as the “big five” were:

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Non-pregnancy related infections (43.7%) Complications of hypertension (15.7%) Obstetric haemorrhage (12.4%) Pregnancy related sepsis (9.0%) Pre-existing maternal disease (6.0%)3

South Africa needs to address the “Big 5” in order to meet the Millennium Development Goals for maternal survival by 2015. The main challenge for maternal mortality is HIV/AIDS. Poverty has been identified as an important underlying cause of death that is related to each of the big five challenges.29 A high maternal mortality rate results in low economic development.28 The main risk factors for maternal mortality include illiteracy, poverty, poor nutrition, low weight in pregnancy, minimal weight gain in pregnancy, first pregnancy or higher than the fourth (excessive fertility), maternal age younger than twenty or older than thirty four years, poor outcome of previous pregnancies, infections and illnesses during pregnancy, unintended pregnancies and unsafe abortions, smoking and inadequate health care during pregnancy and delivery.28

A high percentage of avoidable factors for maternal mortality occurs within the community.31 These community-based modifiable factors are predominantly delays in recognizing the danger signs in pregnancy, and seeking health care timeously, even though antenatal care coverage is generally high in South Africa.27 It is recommended that to save mothers in South Africa requires everyone to have a role to play in providing every woman with essential care: government officials and policy makers, health managers, health care providers and communities.28 The inequity and socio-economic factors that exist for women need to be addressed urgently. Better care for the women requires improvement in both coverage and quality of care. Highly effective interventions that address the big five health challenges already exist as health care packages in policy in the country.29

MethodologyA cross-sectional, descriptive study was carried out. Data was collected on antenatal care, hospital care and access to HIV services. Data were analysed using Stata 10. The results were compared with the national guidelines for the care of HIV positive pregnant women to identify discrepancies between the two.

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Pilot studyA pilot study was conducted with the research supervisor, on five maternal death records from Thembisa Hospital to test the face validity of the data collection tool.

Data analysisOne hundred and twenty five (125) maternal death records from three hospitals in Sedibeng were reviewed for the period 2004-2009. The data were primarily analysed in Excel and some additional analysis was conducted using Stata 10.

Ethical considerationsThe Research Ethics Committee of the Gauteng Department of Health was asked to provide permission for the study to continue. The CEOs of Sebokeng, Kopanong and Heidelberg Hospitals gave permission to review the maternal death records for the identified period. No identifying information about the patient was captured on the data coding sheet.

ResultsTable 1: HIV statusHIV status N Percentage

(%)Negative 27 21.6Positive 76 60.8Unknown 22 17.6TOTAL 125 100

Table 2: Age group by HIV status Age group HIV- HIV+ Unknown Total

N % N % N % N %18 years and below

0 0 2 2.6 1 4.5 3 2.4

19 – 34 years 14 51.9 56 73.7 14 63.7 84 67.235 years and older

13 48.1 18 23.7 7 31.8 38 30.4

TOTAL 27 21.6 76 60.8 22 17.6 125 100

Table 3: Antenatal clinic attendance by HIV statusAntenatal clinic attendance

HIV- HIV+ Unknown Total

N % N % N % N %Did not attend 4 14.8 21 28.0 20 90.0 45 36.0

Attended 23 85.2 55 72.0 2 2.5 80 64.0

TOTAL 27 100 76 100 22 100 125 100

Table 4: Gestational age at first antenatal booking

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Trimester when ANC booking was made

HIV- HIV+ Unknown Total

N % N % N % N %

First trimester 0 0 0 0 0 0 0 0

Second trimester 15 65.2 29 52.7 1 50 45 65.3

Third trimester 8 34.8 26 47.3 1 50 35 34.7

Table 5: Access to antiretrovirals (ARVs) for women who were eligibleAccess N %

Women already on ARVs 2 7.7

Started on ARVs 14

Never started the ARVs 10 38.5

Table 6: Condition on admission to hospital

Condition HIV- HIV+ Unknown TOTALN % N % N % N %

Stable 10 37.0 7 9.2 1 4.5 18 14.4Critically ill 17 62.9 69 90.8 19 86.4 105 84.0DOA 0 0 0 0 2 9.1 2 1.6TOTAL 27 100 76 100 22 100 125 100

1. Recommendations Integration of services for pregnant women Implementation of health policy and monitoring thereof Training of health care workers in the care of all pregnant women Community mobilization for contraception, HIV testing and antiretroviral

therapy Strengthening of postnatal care for HIV positive women

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SESSION 4: PAPER 1

LOW DOSE CALCIUM SUPPLEMENTATION FOR PREVENTING PRE-ECLAMPSIA: A SYSTEMATIC REVIEW AND COMMENTARY

Hofmeyr GJ on behalf of the Calcium and Pre-eclampsia Trial working group (Justus Hofmeyr, Sue Fawcus, Stephen Munjanja, Adegboyega Oyebajo, Mandisa Singata, Natalia Novikova, David Hall, Jose M Belizan, Gabriela Cormick, Ana Pilar Lazaga Betran, Tina Purnat, Eduardo Bergel, Jim Roberts?, Dianne Sawchuck, France Donnay, Kate Teela and Peter von Dadelszen)

BackgroundPre-eclampsia is disproportionately prevalent in poor communities. The epidemiological, clinical and laboratory studies linking pre-eclampsia to dietary calcium deficiency have been outlined in a previous systematic review of high dose calcium supplementation.

Evidence from previous randomized trialsWe previously conducted a systematic review of randomized trials of calcium supplementation of at least 1g daily during pregnancy. The risk ratio (RR) for pre-eclampsia for trials with fewer than 400 participants was 0.21 (95% confidence interval (CI) 0.12 to 0.36). The WHO trial of calcium supplementation among low calcium intake pregnant women showed that although 1.5-g calcium/day in the second half of pregnancy did not prevent preeclampsia (RR 0.92, 0.75 to 1.13), there was a significant reduction in the outcome maternal death or severe morbidity (RR 0.80, 0.65 to 0.97), including a trend to fewer deaths with calcium supplementation (1/4151 vs 6/4161 women).

World Health Organization GuidelinesIn 2011 the World Health Organization published guidelines recommending calcium supplementation with 1.5 to 2 g elemental calcium daily for pregnant women in areas where dietary calcium is low (whqlibdoc.who.int/publications/2011/9789241548335_eng.pdf). This recommendation has raised discussion regarding the dosage of calcium recommended.1. The dosage of 1.5 to 2 g calcium daily is well above the daily recommended dietary calcium of 1 to 1.2 g.2. Calcium decreases iron absorption at doses of calcium >800 mg/day.

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3. Recent reports have raised the possibility of harmful effects of excessive calcium supplementation. None of these associations is particularly robust. Nevertheless, the possibility of adverse effects is reason enough to justify efforts to determine the lowest effective dose of calcium supplementation (perhaps better considered to be calcium replacement up to the recommended daily allowance) to reduce the effects of pre-eclampsia.

For these reasons there was a need to review systematically the evidence for lower dosages of calcium supplementation in pregnancy, which has not, to our knowledge, been done previously.

Methods of the reviewWe searched the Cochrane pregnancy and childbirth database for randomized trials of low-dose (<1g/day) calcium supplementation during pregnancy which included pre-eclampsia as an outcome, as well as searching PubMed. Two authors extracted data from the original papers or translations of papers other than those in English using a purpose-designed data extraction form.

ResultsOne trial included a comparison which met our primary inclusion criteria (low risk of bias, low dose calcium compared with no calcium). Both groups from this trial included in the review received low dose aspirin as a co-intervention. Six trials did not report adequate allocation concealment strategies (high risk of bias), of which 3 used calcium alone two used calcium plus Vitamin D and one used calcium plus antioxidants. Two trials with low risk of bias used calcium plus linoleic acid.

The effects of the interventions are shown in Figure 1. There was consistency of effect between the trials for all outcomes except caesarean section and preterm birth, for which a random effects model was used for meta-analysis.

There was a consistent reduction in pre-eclampsia across all 9 trials (2234 women, relative risk (RR) 0.38, 95% confidence interval 0.28 to 0.52). The overall results were also consistent with those of the one trial of low dose calcium supplementation alone with low risk of bias (171 women, RR0.30, 95% CI 0.06 to 1.38).

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An unexpected finding in one trial of calcium plus antioxidants commencing at 8-12 weeks of pregnancy was a trend to reduced miscarriage (60 women, RR 0.06, 0.00 to 1.04).

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DiscussionTrials of low-dose calcium supplementation, without or with vitamin D, linoleic acid or antioxidants, report a reduction in pre-eclampsia similar to that shown in the smaller trials of high dose calcium supplementation. Due to the limitations of the studies included, these findings should not be regarded as conclusive. However, they are consistent with the possibility of a beneficial effect of low-dose calcium supplementation during pregnancy, and therefore highlight the need for methodologically sound, sufficiently powered trials to either confirm or refute this effect.

Currently, we are conducting a trial of low-dose calcium supplementation (500mg per day) in women with previous pre-eclampsia, commencing before pregnancy and continuing up to 20 weeks of pregnancy. The findings of this review, though studying calcium supplementation in late rather than before and early pregnancy, support our principle of studying lower-dose calcium supplementation in relation to the hypertensive disorders of pregnancy.

AcknowledgementsWe thank Lelia Duley, Tess Lawrie, Alvaro Atallah and Maria Regina Torloni, for contributions to the Cochrane review which served as a framework for this review.This work was supported by a grant to Effective Care Research unit from the University of British Columbia, a grantee of the Bill & Melinda Gates Foundation.

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Figure 1. The effect of low-dose calcium supplementation in the second half of pregnancy with or without vitamin D, linoleic acid or antioxidants, on pre-eclampsia

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SESSION 4: PAPER 2

MATERNAL TACHYCARDIA AT 34 – 38 WEEKS’ GESTATION

Nel N¹, Nel DG2, Myers MM3, Fifer WP3, Groenewald CA¹, Odendaal HJ1, for the PASS Network1. Department of Obstetrics and Gynaecology, Stellenbosch University2. Department of Statistics and Actuarial Science, Stellenbosch University 3. Departments of Psychiatry and Pediatrics, Columbia University, New York City

IntroductionMaternal heart rate (MHR) is not routinely recorded during routine antenatal visits. Recording of the raw data of the maternal and fetal ECG with the Monica AN24TM device is part of the physiological assessment for the Safe Passage Study (www.safepassagestudy.org). Heart rates are not displayed during the recordings. Post-acquisition processing for quality control purposes several days later revealed that maternal heart rates (MHR) above 100 bpm were not uncommon. No publication could be found on the significance of an increase in MHR beyond the expected pregnancy-related physiological increase of 12 to 14 bpm. As the physiological and pathological consequences of maternal tachycardia (MT) as observed during routine antenatal care are uncertain, this cohort study was done to compare MT with participants who did not demonstrate MT (NMT). MethodsMaternal tachycardia (MT) was defined as a continuous rate above 100 bpm for at least 10 minutes of the recording. Filed raw data of each of the first 1 431 Monica AN24TM recordings, done during 34 to 38 weeks’ gestation, were examined using the DK1.5b programme supplied by Monica Health CareTM for MT. The recording of the participant who was seen immediately after the one with tachycardia, was selected to the comparison group. If this recording also demonstrated MT, or was of poor quality, data of the next participant was selected. Medical charts of the MT and NMT groups were then compared regarding anthropometric data, number of antenatal care visits, number of recordings of the MHR during pregnancy and labour, haemoglobin values, underlying cardiac disease and infective complications defined as an increase in maternal temperature above 38°C. The hypothesis was that MT could be associated with anaemia, underlying cardiac disease, and infective complications in later pregnancy. STATISTICA version 9 was used for the statistical analyses and to compare the two groups. Ethical approval was obtained from the Health Research Ethics Committee of the Faculty of Medicine and Health Sciences of Stellenbosch University.ResultsMT was found in 102 of the 1 431 participants (7.1%), continuous throughout the recording in 86.2%. The MT and NMT groups (median values) were comparable regarding maternal age (22.0 yrs vs 23.5 yrs), height (1.6 m vs 1.6 m), weight (59.5 kg vs. 60.0 kg), success rate of MHR recording (100% vs 100%), duration of MHR recording (53.7 min vs. 55.2 min), number of antenatal visits (6 vs 5) and number of MHR recordings at antenatal clinic visits (0.0 vs 0.0). The gravidity was significantly lower in the MT than in the NMT group (median 1 vs. 2) and also the parity (0 vs 1)(Mann-Whitney U test 0.01 and 0.00 respectively). Haemoglobin value at booking (12.0 g/100 ml vs 11.9 g/100 ml), haemoglobin value at 28-38 weeks (10.5 g/100 ml vs 11.0 g/100 ml) and haemoglobin value at delivery (10.4 g/100 ml vs 11.1 g/100 ml) also did not differ significantly. Very low haemoglobin values were never found; the lowest was 7.0 g/100ml in the MT

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group and 8 g/100 ml in the NMT group. No pre-existing cardiac conditions were found in either group. Infective morbidity at any stage after the prenatal recording was observed in 7 cases in the MT group and 2 in the NMT group. Most of these cases were related to an increased temperature after caesarean section. In only 3 cases did the increase in temperature precede delivery. The earliest temperature increase was noted 2 weeks after the recording.

ConclusionsNo cases of underlying maternal cardiac disease or severe anaemia were found in 204 low risk pregnant women. The presence of MT also did not indicate possible maternal infection at time of the recording. At present, the standard antenatal care practice of not routinely recording the maternal pulse rate in low risk pregnancies is acceptable but since this study is small, it’s findings needs to be confirmed in larger studies where the effects of other confounders are also examined.This research was funded by the following grants from the National Institute on Alcohol Abuse and Alcoholism and the Eunice Kennedy Shriver National Institute of Child Health and Human Development: U01 HD055154, U01 HD045935, U01 HD055155, U01 HD045991, and U01 AA016501.

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SESSION 4: PAPER 3

ASSOCIATION OF MATERNAL TACHYCARDIA, AS OBSERVED DURING ROUTINE MONITORING AT 34-38 WEEKS’ GESTATION AND BIRTH WEIGHT

Hein Odendaal1, Nicola Nel1, Daan Nel1, Michael M Myers1, 2, William P Fifer 1, 2, Coen Groenewald1 1Stellenbosch University, 1,2Columbia University

Electronic fetal heart rate (FHR) monitoring is widely used to evaluate fetal well-being, before and during labour. However, very little is known about the quantification of FHR patterns before 26 weeks. Trans-abdominal acquisition of the fetal ECG provides a non-invasive and inexpensive opportunity to record the FHR from as early as 20 week’s gestation. The technique is superior to Doppler ultrasound in evaluating fetal cardiac rhythms during epochs of fetal movement and it affords the accurate recording of true beat-to-beat variation. In this ancillary study of the Safe Passage Study (www.safepassagestudy.org) we report on the fetal associations of maternal tachycardia (heart rate > 100 bpm, continuously for at least 10 minutes), as compared to a comparison group of cases without tachycardia, as very little is known about the clinical implications of tachycardia during pregnancy without any apparent cause and as such cases were regularly encountered in our study.

MethodsAs part of the Safe Passage Study, the AN24 Monica device is used to record the maternal and fetal heart rates between gestations of 34 and 38 weeks. All recordings are done under resting conditions with a 15°left or right lateral tilt of the mother to prevent supine hypotension. After the raw maternal and fetal ECG data have been collected, it is downloaded and stored in a laptop from where it could be imported for analysis of the heart rates with specially designed software by the manufacturers. The heart rate patterns are not known to the people who are doing the recordings. The first 1431 consecutive Monica AN24 recordings were examined for maternal tachycardia. The recording immediately following the one with tachycardia was selected for the comparison group to ensure that cases were selected from the same season and often, the same dat. Univariate analysis was undertaken to establish whether association exists between cases and comparisons. Where the factor was a continuous variable, a t-test was used. Contingency tables were used where factors in objectives were considered

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categorical. Multiple logistic regressions were used to determine the association of the factors with demographic variables. ResultsMaternal tachycardia was found in 102 cases, giving a prevalence rate of 7.1 %. The mean success rate of the recordings was 99.9% in each group. The mean birth weight in the tachycardia group was 3226 g in contrast to 3032 g in the comparison group (p<0.01). General conditions that could affect birth weight such as maternal age gravidity, parity and maternal height and weight did not differ between the two groups (Table I).

Table I Comparison between the groups regarding maternal factors.Variable Group Mean SD Median Qi-Q3 p-valueMaternal age (yrs) Tachycardia 22.9 5.7 22 18.0-25.0

Comparison 24.4 5.8 23.5 20.0-28.0 <0.05*Gravidity Tachycardia 1.8 1.0 1 1.0-2.0

Comparison 2.2 1.2 2 1.0-3.0 <0.02*Parity Tachycardia 0.7 0.9 0 0.0-1.0

Comparison 1.1 1.2 1 0.0-2.0 <0.001*

Maternal height (m)

Tachycardia 1.6 0.1 1.6 1.54-1.63

Comparison 1.6 0.1 1.6 1.54-1.63 >0.05#Maternal weight (kg)

Tachycardia 62.2 13.7 59.5 52.35-68.0

Comparison 62.3 14.8 60 51.0-72.1 >0.05#Success rate (%) Tachycardia 99.9 0.4 100 99.9-100

Comparison 99.9 0,3 100 99.9-100 >0.05*Mann –Whitney U test# ANOVA test

The mean gestational age in the tachycardia group was 39.2 weeks and 38.9 weeks in the comparison group (ANOVA p>0.05). There were 46 (45.1%) males in the tachycardia group and 52 (50.9%) in the comparison group but the difference was not significant (Fisher exact, one-tailed p=0.2418). Birth weights were lower in females but the difference was not influenced by the group (Figure 1).

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Figure 1 Effect of sex on birth weight in the two (19.6%)

In the tachycardia group 29 (28.4%) of mothers reported smoking during pregnancy in contrast to 40 (39.2%) in the comparison group; the difference was not significant (Fisher exact test, one tailed p> 0.05). No significant interaction was found between the smoking status and the group (Figure 2).

Figure 2 No significant interaction between smoking and group.

Six (5.9%) newborns in the tachycardia group were small for gestational age in contrast to 20 (19.6%) in the comparison group (Fisher exact test, one tailed p< 0.005).

ConclusionTo our knowledge this is the first study to suggest there is a positive correlation between maternal heart rate during pregnancy and fetal weight. After exclusion of common variables associated with increased birth weight, maternal heart

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remained as an independent fact. Higher maternal heart rate is probably a function of better placentation in early pregnancy leading to an increase of the normal physiological changes during pregnancy which also leads to an increase in maternal cardiac output followed by better placental perfusion. An attenuation of this effect is probably less often seen in the cases where the mother smoked cigarettes as there were fewer smokers in the tachycardia group. It is difficult to explain the high prevalence rate of growth restriction in the comparison group. Although the possibility of selection bias, such as in favour of cigarette smoking, was considered, as there were more smokers in the comparison group, no specific condition could be identified. The possibility of small numbers should also be considered. These findings warrant further investigation as the study numbers are small. One should also examine the association of a low maternal heart rate with birth weight.

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

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SESSION 4: PAPER 4

WOMEN REFERRED TO CHRIS HANI BARAGWANATH ACADEMIC HOSPITAL FOR PROLONGED PREGNANCY

Dr Bandile Masuku, Prof Eckhart BuchmannChris Hani Baragwanath Academic Hospital, University of Witwatersrand

ABSTRACT Background Pregnancy is considered to be prolonged when it extends beyond 41 completed gestational weeks. The diagnosis of prolonged pregnancy can be incorrect if the pregnant woman is not sure of her last menstrual period and if an early pregnancy ultrasound scan has not been done. Prolonged pregnancy poses a challenge as it is associated with increased perinatal risks. Chris Hani Baragwanath Academic Hospital (CHBAH) is a hospital that receives referrals of pregnant women who are considered to have prolonged pregnancy.

ObjectivesThe aim of this study was to determine the appropriateness of referral, the clinical management, and the pregnancy outcomes of pregnant women referred to CHBAH for prolonged pregnancy.

MethodsThis was a secondary analysis of data from a cross sectional study on “predictive ability of clinical palpation for estimating amniotic fluid volume in suspected prolonged pregnancy”, using a sample of women from those referred to CHBAH antenatal clinic for prolonged pregnancy. The sample was taken on days that the researcher was available to collect data. The researcher recalculated a best estimate of gestational age based on last menstrual period, ultrasound scan or early pregnancy palpation. After an obstetric clinical assessment, an ultrasound scan was done to estimate amniotic fluid volume. A decision was then made on admission for induction of labour according to the CHBAH obstetric protocol. All women were followed up to delivery. The secondary analysis considered data on gestational age at the time of referral, and defined a referral for prolonged pregnancy at a gestational age of less than 41 completed weeks as ‘inappropriate’.

ResultsOne hundred women were recruited. Forty-four were nulliparous, 20 were HIV-infected, and 10 were coincidentally hypertensive. The mean ‘best estimate’ of gestational age incorporating ultrasound scan results, when available, was 39.9 ± 1.5 weeks. Forty-five women were 41 or more weeks pregnant. For the best estimation of gestational age, early pregnancy ultrasound scan results (done at 24 weeks of gestation or less) were available for 26 women, and the LMP was used for 52 women. The majority of early ultrasound scans (22/26) were done by private medical practitioners, and most women with early ultrasound scans (16/26) were less than 41 weeks pregnant. Forty-four women were admitted for delivery on the day of referral, 10 because of coincident hypertension, and 34 for suspected prolonged pregnancy alone or in association with other findings such as poor obstetric history or reduced AFI. Eighty-five women gave birth at CHBAH and 15 gave birth at midwife obstetric units. There were 35 caesarean births, 24 of them for fetal distress. The mean birth weight was 3305 ± 414 g. Five newborns were admitted for observation of mild respiratory distress or asphyxia, but there were no cases of neonatal encephalopathy or confirmed meconium aspiration syndrome, and no neonatal deaths.

ConclusionThe majority of referrals for prolonged pregnancy were inappropriate because of a failure by referring antenatal clinic staff to assess gestational age accurately. This failure involves the use of both early antenatal ultrasound results, and evidence of gestational

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age based on the LMP. The most appropriate response would be tightening of the protocol, to ensure systematic and careful recalculation of gestational age before referral, and re-education of midwives at clinic level on gestational age estimation and referral for prolonged pregnancy.

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SESSION 4: PAPER 5

HOW SAFELY CAN WE FOLLOW UP POST-TERM PREGNANCY WITH UNCERTAIN GESTATION USING AMNIOTIC FLUID INDEX MEASUREMENT?

Amenah Mohamed, Gerhard Theron, Anneke TheronDepartment of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital

Background: Studies about management of prolonged pregnancy dealt with pregnancy with certain gestational age, confirmed with early ultrasound scans.

Objective: The primary aim for the study is to review the current management of

uncertain gestational age (GA) post term pregnancy in Tygerberg Hospital.

Women at 42 weeks with an uncertain GA and an amniotic fluid index (AFI) of ≥ 10 and reassuring cardiotocographs (CTG) would be assessed to determine whether follow up over one week or two weeks are required.

Method: A retrospective descriptive study included all patients with an uncertain gestation of 42 weeks referred to Tygerberg Hospital (TBH).

Result: A total of 135 pregnant women were studied. Booking fundal height (BFH) was used to determine GA in 99% and last menstrual period (LMP) in 1% of patients. All the patients included in this series had reactive CTGs and AFIs ≥ 10 at their first presentation to FEC (Fig. 1). One patient was included in this study with nonreactive CTG at entry, found while reviewing the data.

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Figure 1: AFI measurements in centimeters at the first visit to the FEC

A total number 118 (89.6%) woman went into spontaneous labour, 22 (18.6%) of whom had caesarean sections. Of the 22 women, 13 patients had pathological CTG of which, 7 within the first 14 days of first presentation to FEC. Two, had caesarean sections for fetal distress after 41 and 23 days of first entry respectively. Both of them missed their follow up after the 2nd AFI measurements which were 10 and 10.2 respectively. Seven women had cephalopelvic disproportion (CPD) or poor progress during the course of labour and delivered by caesarean sections. Induction of labour was offered to 17 (9.6%) women of whom 12 had pregnancy related complications or had an AFI of less than 5 (5 patients). Of the 5 that had IOL for diminished AFI, 4 patients had caesarean section deliveries for nonreactive CTG within 2 weeks of entry. Of the 135 women included, 104 (77%) had normal vaginal deliveries, of whom 8 following successful IOL. The remaining 31 (23%) were delivered by caesarean section. The indications were: 18 for fetal distress, 5 for failed IOL, 4 for CPD and 3 for poor progress and 1 elective delivery for fetal macrosomia.Time intervals between the first visit to the FEC and delivery varies between 0 and 46 days (median 10 days). Within the first 2 weeks of presentation to FEC at TBH, 11 (8%) patients had caesarean sections for fetal distress. 4 of the women

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10 12 14 16 18 20 22 24 26 28 300

5

10

15

20

25

30

35

40

45

AFI 1N

r of o

bs

had AFIs that reduced to less than 5 with CTGs indicating fetal distress following IOL. The remaining 7 women went into spontaneous labour 3 to 5 days after the last AFI measurement of whom, 3 had meconium in the liquor. Postpartum maternal complications were reported in 14 (10%) women with one maternal death secondary to septic shock four weeks postpartum, did not respond to resuscitation. This patient was HIV positive with an unknown CD4 count, though she was on HAART according to her fileMean Apgar scores for all babies at 1 min were 9 and at 5 min were 10. No neonatal morbidity or mortality was noted in this study

Discussion: The study is one of very few studies reporting on the management of patients reaching an uncertain gestation age of 42 weeks. The scientific based policy of IOL in or on completion of the 41st week does not apply to this group. A study conducted in Nigeria reported routine IOL for prolonged pregnancy (by sure LMP and early scan) is safe without a significant raise in fetal complications or caesarean section rate.1 The current Tygerberg Hospital protocol to manage this category of patients, depends on results of weekly follow up with a modified BPP that start at uncertain 42 weeks., This protocol is based on a to study done at the hospital.2 A review of more than 10,000 women with longitudinal AFIs done at a single institution, reported that AFI measurements at a confirmed gestational age of 41 weeks and measuring more than 8 were related to 0.5% chance to develop oligohydraminos within 4 days.3 The result of this study is that weekly surveillance must to be continued until AFI < 5.

Conclusion:Weekly monitoring with AFI and CTG for women at 42 weeks with unsure gestation is safe. A follow-up following 2 weeks cannot be recommended as 8% of women required caesarean sections within less than 2 weeks due to fetal distress.

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SESSION 4: PAPER 6

THE OBSTETRIC OUTCOME OF WOMEN WHO HAD SUCCESSFUL EXTERNAL CEPHALIC VERSION FOR BREECH PRESENTATION AT TERM

Rahel Kader, Gerhard and Anneke TheronDepartment of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital

Aim: To review outcome of pregnancies following successful external cephalic version (ECV) for breech presentation at term, particularly the caesarian section (CS) rate after successful ECV.

Introduction: ECV is a safe procedure with a minimal cost implication that can reduce non-cephalic presentation at onset of labour at term. Quantifying the effectiveness of ECV for breech presentation is complicated because ECV does not always result in cephalic presentation and subsequent vaginal delivery. Whilst the probability of successful CS is 53% at Tygerberg Hospital, the fetus may spontaneously revert back to breech before delivery.1 Despite population differences in ECV success rates, the ratio of successful ECV to spontaneous version in reported randomized controlled trials is consistent at about 3:1.2 Also cephalic presentation at term does not automatically translate to vaginal delivery and CS may still be performed for other reasons.3,4 The outcome of pregnancies following successful ECV is of interest.

Studies done between 1997 and 2004, found that pregnancies after successful ECV at term are not the same as those with cephalic presentations and was associated with a CS rate twice that in pregnancies with spontaneous cephalic presentations.4 In a matched retrospective analysis of CS risk after successful ECV, in USA, it was concluded that CS and operative vaginal delivery rates following successful ECV, were not increased.5 To date there were no similar studies reported from South Africa.

Methods: A retrospective descriptive study was done to audit all successful ECVs done at the Fetal Evaluation Clinic (FEC) at Tygerberg Hospital. The electronic data from the FEC was searched for successful ECV patients. The facilities where these patients delivered were identified. The outcome of the pregnancies was determined from patient files and/or the labour registers. The relevant information of each patient was captured.

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Results: Data was collected over a 7 year period, (April 2005 – April 2012). 106 successful ECV were extracted from the electronic data. Only 90 files could be located, 12 of which had insufficient information. The study was confined to the 78 files with sufficient information.

The median age of patients was 28.7 years with a range from 17 to 40 years, the median parity 1 and the range 0 to 6 and the median body mass index 27.2 and the range 18.2 to 45.0. The method of determining gestational age is known in 71 (91.0%) patients of whom 37 (52.1%) had an early ultrasound examination. The median gestational age at ECV as 37 weeks with the inter quartile range 36 to 38 weeks. The median ECV to delivery time was 2 weeks with the inter quartile range 1 to 4 weeks. Levels 2 and 3 care was required at time of delivery by 47 (60.3%) patients. Vaginal deliveries occurred in 49 patients and 29 (37.2%) had caesarean sections. The most common indications for caesarean sections were cephalo pelvic disproportion 8, fetal distress 6, reversion back to breech presentations 4 and other abnormal presentations 4 (2 face presentations, 1 shoulder presentation and 1 transverse lie). The mean birth weight of the babies was 3360g and the range 2100 to 4655g. On comparing the group that had vaginal deliveries to C/S, only nulliparous patients had a significantly (p=0.02) higher risk for C/S. Six out of the 9 patients with previous CS had a repeat CS. Excluding the patients with previous CS from the analysis resulted in a significant difference (p=0.02) between nulli- and multiparous patients (Table I). Two patients had abruptio placentae 8 days and 5 weeks following ECV, both babies were delivered alive by emergency caesarean sections. One intra-uterine death occurred 6 days following the ECV with acute chorio-amnionitis diagnosed on placental histology. There were no neonatal deaths. Four patients reverted back to breech presentation, 2 to transverse lies and 2 found to have a face presentations intrapartum.

Conclusions: Following successful ECV all patients need to be carefully followed up for possible reversion to breech presentation or transverse lie. Nulliparous and gravida 2 with previous CS patients need to be delivered in hospitals with CS facilities. Further studies are required to assess the outcome of ECV with previous CS and whether successful ECV results in more face presentations.

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Table I A comparison of nulli- to multiparious patients excluding previous CS

Para 0 (%) > Para 1 (%)NVD 13 33C/S 13 (50.0) 10

(23.3)

Total 26 (37.7) 43 (62.3)Chi2 p = 0.02

RR 0.50 (95% CI 0.28 – 0.90)

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SESSION 5: PAPER 1

UNDERGRADUATE STUDENTS’ RESEARCH ON INFANT FEEDING IN MPUMALANGA

Anne-Marie Bergh,1 Elsie Etsane,1 Martin Bac,2 Robert Pattinson,1 Jannie Hugo,2 medical students and mentors21 MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria2 Department of Family Medicine, University of Pretoria

BackgroundThe University of Pretoria medical students rotate in certain sub-districts in Mpumalanga for their 7-week district health and community obstetrics rotation. As part of their rotation they have to do a quality improvement (QI) project. For the past few years a specific focus area in maternal and child health was selected for their projects. In 2012 the focus was the promotion of the Mother- and Baby-friendly Initiative (MBFI) as a response to the 2011 Tshwane Declaration for the Support of Breastfeeding and the change in the national PMTCT feeding policy in April 2012.

MethodIn addition to negotiating their activities and inputs in the QI project with the team at the local hospital, students also collected data for a larger study and gave feedback to their sub-district at the end of their rotation. The MRC Unit then collated the results of the individual projects for feedback to Province. A total of 148 students collected data: 143 medical students and 5 BCMP (clinical associate) students.Two anonymous structured questionnaires were administered to a convenient sample of mothers in postnatal wards (n=479; 9 sites) and to mothers of infants between 6 weeks and 6 months of age (n=193; 13 sites). Information was solicited on demographics and current or intended feeding practices. Mothers in the postnatal ward were also questioned on breastfeeding practices immediately after birth. The postnatal ward sample included community health centres, district, regional, provincial and tertiary hospitals.

Preliminary resultsAn extract of preliminary result is presented. Some of the limitations of the study include the sampling method (convenience sampling), the self-report by mothers

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on their own practices without any further verification mechanisms, and the availability of the questionnaires in English only. The tables below give a summary of some of the main results. Table 1 describes the demographic characteristics of the two survey groups. The figures from the postnatal ward survey are probably a more accurate reflection of the real situation than the figures from the clinic survey. Table 2 gives information on feeding-related practices. In the postnatal ward the responses could be considered as how the respondents intended or expected to feed their infants and at the clinic mothers reported on their actual feeding practices. Whereas only 19% of the respondents in the postnatal ward reported that they intended to not breastfeed at 3 months, 27% of mothers visiting the clinic between 6 weeks and 6 months after the birth indicated that they had stopped breastfeeding before 3 months. The main reasons given were HIV status, school and work. Thirty-eight percent of the formula-feeding respondents indicated that they did not always have enough money to buy formula. The open-ended responses on what they do in such a case included borrowing money from somewhere (e.g. credit bureau) or someone (especially family) and changing feeding pattern (stretching formula, giving other solids and liquids, giving more breastfeeding).

Table 1 Demographic details of respondents

Indicator Postnatal ward

6 weeks – 6 months

First baby 42% 34%Average age 24.5 years 26.1 yearsTeenage pregnancy 24% 11%Married (traditional &/or civic) 21% 27%Education > Grade 10 61% 80%Employed 23% 32%Monthly income R2086 R1918Brick dwelling 80% 88%Electricity 87% 90%Fridge 80% 85%Water inside house / yard 85% 85%Flush toilet 49% 65%

Table 2 Infant-feeding related practices

Postnatal ward(intended/

6 weeks – 6 months

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expected) (actual)Not breastfeeding at birth 18% 19%Not breastfeeding 3 months 19% 27%Main reasons for introducing formula:

• HIV status 28% 15%• Back to school 14% 14%• Back to work 25% 14%

Formula from hospital/clinic 16% 1%Estimated cost formula / month R204 R295Not always enough money for formula - 38%

Both survey groups gave similar feedback in terms of their sources of information and also with regard to being informed about the dangers of formula and mixed feeding (Table 3). Mothers’ main sources of information are their own mothers and the clinic sister. The role of the clinic sister increases after the birth of the baby.

Table 3 Infant feeding education

Postnatal ward

6 weeks – 6 months

Major sources of general infant feeding advice:• Clinic sister 68% 77%• Own mother 35% 33%Information received on risks of formula feeding:• Total 65% 68%• Hospital sister 24% 25%• Clinic sister 47% 50%• Dietician 6% <1%• Community health worker 3% 1%• Own mother 6% 4%Dangers of mixed feeding 73% 74%

Respondents recalled that the main infant feeding messages they received from health workers in a group situation in the antenatal period were the “breast is best” message and a focus on specific advantages (Table 4). In individual consultations with nurses or doctors the “breast if best message” was also the one recalled most. Individual consultations lent themselves for mentioning that mothers had a choice in the method of feeding, whereas the HIV counsellors were reported as having focused more on promoting exclusive breastfeeding, talking on the dangers of mixed feeding, and giving a particular period in months (often 6 months) when breastfeeding should be discontinued.

Table 4 Recall of main feeding messages (postnatal ward respondents)

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MessageGroup education (antenatal care)

HIV counsellors

Individual consultations

Breast is best 30% 14% 32%Specific advantages 29% 3% 3%Mother has feeding method choice 1% 6% 8%Exclusive breastfeeding 7% 10% 5%Mixed feeding 5% 11% 9%Length/period of breastfeeding 2% 11% 9%Advice in favour of formula - 5% 2%

With regard to mothers’ self-report on birth practices promoting mother- and baby-friendly care, giving the baby for immediate skin to skin holding after birth is the practice least observed by health workers (Table 5). Just over half of mothers received support with breastfeeding and manual expression of breast milk.

Table 5 Birth practices promoting mother- and baby-friendly care (postnatal ward respondents)

Practice n %Walk & move during labour 376 83%Normal vaginal delivery 345 79%Baby held immediately 95 20%First holding skin to skin 167 36%Holding lasted <30 minutes 171 39%Staff offered help with feeding 240 52%Demonstration / Information on milk expression by hand 239 52%Baby always with mother 394 85%Dummy used 17 7%Promotion formula milk 18 4%Info help with feeding problems after discharge 284 62%

ConclusionSouth Africa has come a long way since the introduction to the 10 steps to successful breastfeeding as official policy. However, despite the evidence about certain infant feeding practices to be followed, there are still areas where new approaches are needed to address gaps with regard to both caregiver and health worker behaviour. Key areas for future improvement are health promotion and health education, skin-to-skin holding of the infant in the first hour after birth, and support with breastfeeding and milk expression in hospital.

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SESSION 5: PAPER 2

FONEASTRA MOBILE MILK PASTEURISER: IMPROVING SAFETY AND MONITORING SYSTEMS FOR LOW-TECH HUMAN MILK BANKS

Penny Reimers 1 ,2Anna Coutsoudis1,2, Mageshree Naicker1, Rohit Chaudri3, Kiersten Israel-Ballard4

1.University of KwaZulu Natal, 2. Human Milk Banking Association of South Africa, 3. University of Washington, 4. Programme for Appropriate Technologies in Health.

FoneAstra, a smart phone–based monitoring device, has been adapted to guide the user through the pasteurization process and record and transmit pasteurization temperatures. The goal of this project was to evaluate the FoneAstra system as a mobile milk pasteurizer (MMP) for a resource-limited milk bank.

BackgroundBreast Milk is known to reduce morbidity and mortality of vulnerable infants, especially of low birth weight infants in Neonatal Intensive Care Units. Breast milk lowers the incidence of hospital-acquired infections such as necrotizing enterocolitis (NEC) among preterm infants by 79% (Wight, 2002). Feeding breast milk to these infants could not only save lives, but also results in considerable cost savings.

In 2008 the World Health Organisation urged countries: “To investigate, as a risk-reduction strategy…the safe use of donor milk through

human milk banks (HMB) for vulnerable infants, in particular premature, low birth weight and immunocompromised infants, and to promote appropriate hygienic measure for storage, conservation and use of human milk.” (World Health Assembly, 2008)

At the Tshwane Declaration in 2011, the Minister of Health called for” Human milk banks

to be promoted and supported as an effective approach, especially in post natal wards and

neonatal intensive care units, to reduce early neonatal and postnatal morbidity and

mortality for babies who cannot breastfeed.” The Department of Health now investigating a

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roll-out plan for scaling up milk banking.

HMB provides an innovative opportunity for improving newborn health in low resource settings. PATH (Programme for Appropriate Technologies in Health) has been working to build advocacy and awareness around milk banking. Country assessments in Brazil, India and South Africa have identified best practices. They have identified operational, programmatic, and technology gaps and they have worked with milk banking experts to develop a global implementation framework to standardize quality control principles. This has been done with the view to to help facilitate governments wanting to implement safe and appropriate HMB which are specific for their local needs. Testing low-tech HMB systems is part of this approach.The goal of this project was to help expand the availability of safe, simplified and low-cost HMB systems for resource-poor settings. Milk bank processes include donor screening, safe pasteurization of breast milk to ensure pathogens are eliminated, screening of donor milk and safe storage, transport and tracking.Although several models for HMB exist, strengthening low cost de-centralized HMB is advantageous since it allows small hospitals to establish their own systems. This could complement existing larger centralized systems where the processing of donor milk is in one central location. Importantly, small localized milk banks are used as a mechanism for supporting and promoting breastfeeding – existence of a HMB attached to a NICU has have been shown to significantly increase breastfeeding rates .Flash-heat pasteurization, a low-cost, simple method originally designed for women to use in the home, has also been used to treat donor milk in a neonatal intensive care units but its lack of temperature monitoring has prevented scale-up.

Objectives:1. To field test implementation of MMP system at HMB in Durban, South

Africa.2. To evaluate the safety of the MMP process.

Methods:We collected data on the implementation of the new MMP system in order to assess the feasibility of using it in resource limited settings. In order to

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determine the safety of the new system 100 samples were collected and assayed for bacterial growth on pre- and post-pasteurisation samples to assess whether the MMP system did in fact destroy all bacteria during pasteurisation. Each sample was divided into two, one sample was pasteurised using flash heating with no temperature control and the other was pasteurised using the MMP system.

Results:The new system resulted in significant improvements over the traditional flash heating previously employed. These were:

Temperature monitoring provided with the MMP system gave staff confidence that they had reached temperature of pasteurisation and that they were not under-heating or over-heating the milk.

Donor milk volumes that could be pasteurised were tripled and time for heating was reduced through the introduction of an induction stove.

Data management was improved as temperature data could be uploaded and archived.

The new system allowed donor tracking and capability to print pasteurisation reports and bottle labels via blue-tooth enabled printer.

0% with growth post pasteurisation with FoneAstra MMP 86% with growth pre-pasteurisation (n= 100) 1% with growth post-conventional flash heating (n=100)

Conclusion:MMP provides safe pasteurisation through temperature monitoring and data tracking capability. Implementation of MMP to ensure quality assurance is feasible in a low-resource HMB.

Funding:Private foundations and individual donors to PATH and Health Innovation PortfolioBill and Melinda Gates Foundation Grand Challenges Explorations initiative.

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SESSION 5: PAPER 3

SOCIAL CIRCUMSTANCES THAT DRIVE EARLY INTRODUCTION OF FORMULA MILK AND PERCEPTIONS ON ITS DISCONTINUATION IN THE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION PROGRAMME: VOICES OF A PERI-URBAN COMMUNITY IN SOUTH AFRICA. Petrida Ijumba, 1,4* Tanya Doherty, 1, 2 Debra Jackson, 2 Mark Tomlinson, 3 David Sanders, 2 Lars-Åke Persson41 Health Systems Research Unit, Medical Research Council, South Africa 2 School of Public Health, University of the Western Cape, South Africa3 Department of Psychology, Stellenbosch University, South Africa4 International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Sweden.

Background: Breastfeeding is widely endorsed as the optimal strategy for feeding newborns and young infants, as well as improving child survival and achieving Millennium Development Goal 4. Exclusive breastfeeding for the first six months of life is rarely practised in South Africa. Following the 2010 World Health Organization infant feeding recommendations (exclusive breastfeeding for HIV positive mothers with maternal or infant antiretroviral treatment), South Africa adopted breastfeeding promotion as a National Infant Feeding Strategy and removed free formula milk from the Prevention of Mother-to-child Transmission of HIV programme. Aim: This study aimed to explore the perceptions of mothers and households members at community level regarding the value they placed on formula feeding, circumstances that drive the practice and the community’s assessment of free formula policy change in a peri-urban community. Methods: This qualitative study was a sub-study of a randomized controlled trial known as Good Start III, (ISRCTN41046462), which was implemented in Umlazi Township on the periphery of Durban, KwaZulu-Natal province between 2008 and 2011. The township has an estimated population of 1 million people. HIV prevalence is estimated at 41% amongst women attending antenatal public health facilities. The goal of the trial was to develop, evaluate, and cost an integrated and scaleable package delivered in households by community health workers, targeting pregnant and postnatal women and their newborns to provide essential maternal/newborn care, as well as, support for access to PMTCT. Design: We used a qualitative study design, including focus group discussions (FGDs) and in-depth interviews. The interview guide and FGDs sought responses to the following key questions: a) What motivates mothers to use formula milk? b) How does formula get into the households? c) What are your views of mothers who

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formula feed? d) What have you heard about formula milk given through clinics? e) What views do you have about what you have heard? f) How should this information have been communicated to you and the community? Two data collection methods were used because while infant feeding is personal, it is also embedded in the culture and social norms of the community, and hence group discussions were deemed a suitable forum to explore these norms. The FGDs and in-depth interviews were conducted by two experienced interviewers/FGD facilitators, fluent in isiZulu and English. Participants: We purposively selected 11 HIV-positive mothers and 9 HIV-negative mothers from the larger trial, who indicated that they were formula feeding their infants under-six months of age. Interviewers telephonically contacted 20 grandmothers and 20 fathers related to the above HIV-negative and HIV-positive mothers. Out of these 20 grandmothers and 20 fathers, we selected the first 14 of each group, who agreed to participate in focus group discussions (i.e. seven for HIV-exposed, seven for non HIV-exposed grandchildren and babies respectively). The majority of mothers (19 out of 20), who participated in the in-depth interviews, were 20 years old or above. However, 842 out of 3653 (23%) women who participated in the Good Start III trial were aged between 16 and 19 years and 3194 (87%) were single. To address this difference we purposively selected 14 teenage mothers aged between 16 and 19 years, who reported formula feeding their infants less than six months of age. Data collection: All interviews and FGDs were carried out at Prince Mshiyeni Memorial Hospital, from March to May 2011. Interviews lasted from 50 to 90 minutes and FGDs lasted from 90 to 180 minutes.Ethical considerations: We obtained Ethical approval (10/09/29) from the University of the Western Cape Research and Ethics Committee and acquired signed informed consent from all participants. Codes were used to preserve anonymity of participants.Data analysis: Thematic analysis as described by Braun and Clarke was used to analyse the data. The transcripts were coded, collated and grouped into themes. Data analysis was a continuous process. After each interview or FGD, the interviewers met with the first author to reflect on the findings. Gaps and new emerging questions were included in subsequent interviews and FGDs. The voice recorded interviews and FGDs were transcribed verbatim and translated into English. Both the isiZulu and English versions were read several times by the interviewers/FGD facilitators and PI to ensure that the content was retained after

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translation. TD also read several of the transcripts to confirm the identified themes.Trustworthiness: Multiple strategies were used to ensure trustworthiness of the research findings. Firstly, triangulation of the results from in-depth interviews and FGDs were used to compare findings across data collection methods. In addition, four different groups of participants were included (mothers, fathers, grandmothers, and teenage mothers) and information was compared across these four groups. Finally, the first author and TD identified themes independently.Results: The majority of the mothers in the in-depth interviews were aged 20-25 years and 35% had a high school education. Five (38%) had completed high school, four (30%) were in tertiary institutions, three (23%) were still in high school and one had dropped out. The majority of the fathers were aged between 24-30 years, 61% had a high school education and 60% were employed. The majority of grandmothers were aged between 50 and 59 and 77% had completed some high school. The majority of the mothers lived with their mothers and/or grandmothers. In addition, some of the teenage mothers had mothers who had been teenage mothers as well. The following themes were identified; inadequate involvement of teenage mothers; grandmothers who become replacement mothers; fear of failing to practice exclusive breastfeeding for six months; partners as formula providers; costly formula milk leading to risky feeding practices; variations in awareness and lack of understanding of the basis for the policy change; abuse of and dysfunctional policy as perceived reasons for policy change and proposed strategies for communicating the policy change. Social circumstances that drive early introduction of formula milkInadequate involvement among teenage mothersTeenage mothers’ uneasiness to take on a mothers’ role was identified across all groups: “I agree with other grandmothers, they do not want to breastfeed because they do not have love for their babies, although they continue having them when they are not ready to have them.” (GMFF59) “….formula feeding is a good thing….., I was going to be stuck with my baby … I am studying I managed to continue with my school….” (TFG-F19)

Teenage mothers perceived breastfeeding as a constraint to their freedom. They associated breastfeeding with losing weight, sagging or shrinking breasts. As a consequence they transferred the motherhood role to their own mothers or

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grandmothers: “… the second week after delivery the mother does not want to breastfeed, once she is visited by her friends they go to night clubs and you can see that the mother does not have time to breastfeed her baby the baby is yours.” (GMFG1B48)

Grandmothers becoming replacement mothersGrandmothers described facing a triple burden. They struggled with accepting the pregnancies of their young daughters, they used their meagre pension grants to buy formula for their grandchildren, and, they took on the role of raising their grandchildren to adulthood: “A grandchild becomes your own baby, therefore everything that concerns him becomes your responsibility and you cannot run away from this, no matter how annoyed you were about your daughter. When the baby arrives you forget all the negative issues…..the person who is always there ensures that the milk is there …….we as grandmothers we buy the milk ….” (GMFG1D57) “Oh she plays a role of being a mother because she is the one who bathes her and formula feeds her … she sleeps with my mother …..in most cases she is like a mother to her” (ZK+31)

Fear of failing to practice exclusive breastfeeding for six monthsMothers were aware of the risk of HIV infection if they were unable to breastfeed their babies exclusively. However, many of them had not disclosed their HIV status to their boyfriends or mothers. HIV- negative mothers were constantly worried that they may actually be HIV-positive due to their powerlessness to negotiate condom use and or having multiple sexual partners: “Some get tested at the clinic and they are told that they are infected (HIV positive) but they do not disclose their status at home. Then they prefer formula because even if the baby can be given water or other things, it will not be infected if it is formula fed.” (GMFG1G58)

Partners as formula providersMothers as well as the grandmothers expected the fathers to provide formula for their babies. Some fathers indicated that they were coerced to buy formula milk even though they would have preferred their babies to be breastfed:

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“... We are really suffering from buying formula …… they know that if they breastfeed they have to spend more time at home… they can prepare the formula, leave the baby… and visit another boyfriend….” (FFG2A40)“He asked me what I will feed our baby and I said formula milk. He said if it was up to him he would have breastfed our baby, I asked why, he said breastfed baby do not get sick easily. I said a person who is breastfeeding becomes thin ….. so it is better to formula feed. (TFG-D19)

Mothers who felt neglected by their partners indicated that formula feeding was better than breastfeeding because they could send the babies to their partners’ thus trying to make the fathers accountable: “….. it is better to formula feed so that if the baby’s father is giving you problems you can ‘dump’ the baby on him. ...... fathers send their babies to rural areas to stay with their mothers.” (TM+24)

Costly formula milk leads to risky feeding practicesFormula milk was expensive for most households. In an attempt to reduce the costs, grandmothers prepared diluted formula milk, so that a tin of formula lasted longer: “…. we do not put the correct amounts …those struggling to make ends meet … try to save the milk by reducing the quantities instead of putting the correct measurements…… babies get diarrhoea. All these formula rationing, causes the baby to be weak.” (GMF1G250)

When households completely ran out of formula milk and other commercial baby foods they fed their babies porridge (mahewu), water, sugar water, rooibos tea or ijuba (local brew) until they could afford to buy more formula milk: “Others resort to black tea with only sugar added. Some use ‘mahewu’ and those who drink alcohol feed ‘ijuba’ to the babies...” (GMF2GF58)

Free formula policy change Variations in awareness and lack of understanding of reasons for the policy change Some participants from all groups except the grandmothers confirmed that they had heard that free formula milk was being phased out, mainly from the radio or their local clinics: “Yes, there is something I heard from the radio that the

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Government is now suspending this formula milk because mothers fail to feed (breastfeed) their babies.” (FFG2F41)

“I heard that government will no longer give Pelargon because government wants everybody to breast feed.” (TFGC–19)

Even those who were aware of the phasing out of the free formula milk policy did not know why it was being phased out. Consequently, many had their own interpretation: “……. government is failing to provide this milk because of the increasing number of mothers who have to be given this milk … then decided to stop issuing it from January.”(NG-21) “Government wants them to get back to breastfeeding; they will be discharged without formula milk and when they get home they won’t get it because as the grandmother I will not buy it either.” (GMF1G58)

Some participants felt that certain unintended negative consequences of the free formula policy such as enticing teenage girls to fall pregnant early and have many babies, were reasons for the policy change: “…. government decided to suspend the free formula milk because…. it was contributing to people’s indulgence to unsafe sex,…. they know that if they get pregnant and eventually bear children, they will be provided with free formula milk.” (FFG2E28)

Abuse of and dysfunctional policy as perceived reasons for change Inappropriate use of free formula milk by both health care personnel and HIV-positive mothers was identified as a major concern. Fathers narrated how they know the people who have stolen not only formula milk but other foods meant to be given to malnourished children, HIV &TB patients: “It is the nurses themselves who steal the food….. They steal the food and sell it outside of the clinic to boost their pocket money, transport money and it becomes a trend.”(FFG2A40)

A HIV-positive mother regarding her friend’s experience in accessing formula milk and a grandmother had this to say about some recipients of free formula milk, who sold it to make some cash for personal needs: “My friend was getting it from the clinic but now she has changed it because she was saying they buy it from the clinic for R70.” (SN+20)

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“Some who get this free formula milk are not getting it for their babies …. but they sell it to their neighbours and use the money to make ends meet or buy alcohol and drugs , some mothers are not mothers…… then they will feed their babies tea or porridge.” (GMF1A58)

HIV-positive mothers expressed disappointment at the lack of clear and transparent procedures in distributing free formula milk which was viewed as being ‘personalised’ by some of the nurses and they treated it as their own commodity rather than a public service. “….. you do not collect it without bringing the baby, they give you when they see your baby or they turn you away.” (PN +34)“Soon after giving birth they gave me six tins once, refused to give me more. I have rights, government says when something has been given to people they must get it.” (TFGA+19). “I do not collect it but the nurses pretend as if it is the money that comes from their pockets” (TFG B+18). “I have seen that they do not treat us well…they do as if they have bought it.” (TFGD+16)The challenges faced by these mothers were confirmed by a grandmother working as a community health worker at one of the local clinics: “I would say they give those that they know or like a lot like a monthly supply and they give others one tin or not give them at all when they see that is not going to be enough for those that they like. It becomes painful because people go to the clinic to seek assistance.” (GMF1C67)

Some HIV-positive mothers viewed the clinic as an unreliable supplier of free formula milk and this forced them to make contingency plans for feeding their babies: “You do not have to trust too much on the supply from the clinic because at times you do not get it when it is finished. Therefore, you must have something on the side beside the milk you get from the clinic.” (ZK+31)Proposed strategies for communicating the policy changeParticipants made recommendations for how the information regarding phasing out the free formula milk policy could be communicated to them: “… the clinics and the hospital doctors should issue pamphlets to be distributed to tuck shops and public places. They should also use newspapers, TV and radio…” (GMF2F58)“There must also be people at transport stations (taxi ranks) to issue pamphlets because stations are always crowded.” (TFGC+ 19)

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“… announced on the radio…... Most of the time you find mothers at the clinic… can be informed at the clinic…. and churches that the free formula milk has been suspended, because these are the most used institutions, and the schools can also be used because most people use schools, meetings can … be asked to inform people.” (FFG1A35)

Conclusion: There is an urgent need to develop a multifaceted communication strategy clearly articulating the reasons for the infant feeding policy change and promoting the new breastfeeding strategy. The communication strategy should take into account inputs from the community. Similarly, the South African Infant Feeding Strategy needs to address the gaps in key health messages and develop community-orientated programmes with a focus on teenage mothers. These should encourage the involvement of grandmothers and fathers in decision making about infant feeding so that they can support exclusive breastfeeding for optimal child survival. With a supportive environment and one national infant feeding strategy, South Africa has an opportunity to reverse years of poor infant feeding practices and to improve the health of all children in the country.

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SESSION 5: PAPER 4

NECROTISING ENTEROCOLITIS IN PREMATURE INFANTS AT CHRIS HANI BARAGWANATH HOSPITAL. WHAT ARE THE ASSOCIATED FACTORS?

Peter Angura 1 , Sithembiso Velaphi21Department of Public Health, 2Department of PaediatricsUniversity of Witwatersrand

INTRODUCTIONNecrotising enterocolitis is an acquired inflammatory disease of the intestine that causes necrosis and gangrene of the intestinal tissues.1

A number of risk factors have been implicated in the development of NEC. They include prematurity, hypoxic-ischaemic injury to the intestine, enteral feeding and alteration in the normal microbiological flora of the intestine.2-4

Over 90% of cases of NEC occur in premature infants and there is an inverse relationship in the risk of developing NEC to birth weight and gestational age of the infant, making prematurity the single most independent risk factor for NEC.4-5

BACKGROUNDIn 2005, a study in France found seven out 79 preterm infants diagnosed with NEC compared to two out of 158 controls were born to mothers who were HIV infected, suggesting that HIV infection in mothers might be a risk for NEC in the infants (OR 6.63, 95%CI 1.26-34.8, P= 0.025).6 In South Africa, about 30% of pregnant mothers attending antenatal care are HIV positive,7 therefore a large number of babies were exposed to the virus. This study looked at the maternal and neonatal factors that are associated with NEC at CHBAH during the era of HIV infection.

METHODSObjectivesTo determine maternal and infant characteristics associated with the development of necrotising enterocolitis in infants born preterm and admitted at Chris Hani Baragwanath Academic Hospital neonatal unit. To determine factors associated with severe disease and/ or mortality in preterm infants diagnosed with NEC.

Study design The study was a case control, retrospective record review. Medical records of infants diagnosed with NEC and those of controls who were admitted at CHBAH neonatal unit between January 1, 2005 and December 31, 2008 (4 year period) were retrieved and reviewed. Maternal records of these infants were also reviewed.

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Study populationInclusion criteria: cases were infants of gestation ≤36 weeks who were diagnosed with NEC stage 2 and 3 according to what was recorded in the infants’ files. The diagnosis of NEC was based on Modified Bell’s staging criteria.8

Controls were preterm infants who were admitted with a diagnosis other than NEC during the same period. They were matched with cases and had to be within two weeks for gestational age, one week for postnatal age and 100 grams for birth weight.Exclusion criteria: Infants admitted at CHBAH from another hospital beyond age of 48 hours of life. Data analysis and EthicsSummary statistics was used to describe the baseline characteristics of participants. Chi Square and Fischer’s exact test were used to compare categorical data while continuous variables were compared using Student’s t test. Logistic regression analysis was used to determine independent factors associated with NEC. Odds ratios were reported with 95% confidence intervals. A significant difference and/ or association was taken as a p-value <0.05 and a confidence interval not including one. Permission to perform the study was obtained from the Human Research Ethics Committee of the University of the Witwatersrand and from the Protocol Review Committee of the CHBAH.

RESULTSA total of 110 preterm infants were diagnosed with NEC over the four year period, 220 controls were selected for comparison.

Stages of NEC according to birth weight and gestational age

Nearly 64% of infants who were diagnosed with necrotising enterocolitis were of birth weight <1500g and 71% of them were less than 33 weeks gestation. Less than 5% of the infants were ELBW or were of gestational age ≤27 weeks. About two thirds of infants (64.6%) were diagnosed with necrotising enterocolitis stage 2a. The remaining proportion were diagnosed with stage 2b (18.2%), stage 3b (14.5%) and stage 3a (2.7%). Severe necrotising enterocolitis (stages 3a and 3b) was diagnosed in infants of all birth weight and gestational age categories except in those infants of birth weight categories <1000g and 1650-1799g and gestational age category 25-27 weeks.

Comparison of infants’ and maternal characteristics between cases and controls

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The median birth weight and gestational age were similar in cases and controls (1370g (900-1760) versus 1380g (800-1795), p= 0.926 and 31 weeks (25-35) versus 31 weeks (25-35), p= 0.895 respectively). More controls (32%) were ventilated as compared to cases (11%), p< 0.0001. Infants who developed NEC were more likely to be born to mothers who did not receive antenatal steroids (36.8% versus 22.3%, p= 0.007), and who developed chorioamnionitis (16.8% versus 2%, p< 0.0001). There were no differences in other maternal and infants’ factors in cases compared to controls (Table 1).

Comparison of infants’ feeding between cases and controlsMore infants received the first feeds on or before day two of life in cases compared to controls (84.6% and 66.4% respectively, p= 0.001). More infants in cases (41%) than in controls (24%) had their feeds increased at volume ≥25mls/kg/day (p= 0.001). The mean rate of increase of feeds was greater in cases than in controls (29.3ml/kg/day and 25.2mls/kg/day respectively, p= 0.032). The types of milk feeds were similar in cases and controls, p= 0.634.

Factors associated with necrotising enterocolitisUnivariate logistic regression showed the following maternal and infants’ factors were associated with NEC: non-exposure of infants to maternal antenatal steroids (OR 2.0, 95% CI 1.21-3.38, p= 0.007), chorioamnionitis (OR 9.91, 95% CI 3.26-30.13, p< 0.0001), Apgar score <4 at first minute (OR 2.48, 95% CI 1.06-5.75, p= 0.034), not ventilated at birth (OR 3.81, 95% CI 1.96-7.40, p< 0.0001), postnatal age at first feeds ≤2 days (OR 2.77, 95% CI 1.54-5.00, p= 0.001) and increase of feeds at a volume ≥24.5mls/kg/day (OR 2.24, 95% CI 1.36-3.68, p= 0.001). Exposure to HIV infection in the mother and other factors were not associated with NEC in infants. See table1.

However, on multivariate logistic regression of the above factors, non-exposure of infants to maternal antenatal steroids (OR 2.35, 95% CI 1.25-4.42, p= 0.008), chorioamnionitis (OR 8.73, 95% CI 2.59-29.5, p< 0.0001), Apgar score <4 at 1st minute (OR 2.92, 95% CI 1.05-8.01, p= 0.038) and not ventilated at birth (OR 3.20, 95% CI 1.18- 8.69, p< 0.023) were the only factors that remained significantly associated with necrotising enterocolitis (Table 2).

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Table 1 Univariate analysis of maternal and infants’ factorsMaternal factors

Odds ratio

95% CI Infants’ factors

Odds ratio

95% CI

Age(yrs)Caeserian mode of deliveryMothers’ HIV statusMother did not attend ANCMother did not receive ANSMultiple gestationPIHAPHPROMChorioamnionitis

1.051.20

1.12

0.88

2.03

1.640.721.272.06

9.91

0.85-1.290.76-1.90

0.70-1.79

0.49-1.56

1.21-3.38*

0.91-2.950.41-1.250.57-2.820.89-4.773.26-30.13¶

1st min Apgar score <45th min Apgar score <7GenderSGANot ventilated at birthFormula milk feedsFeeds initiated ≤2 days of life¥Feeds increased ≥24.5mls/kg/day¥Use of antibiotics

2.48

2.26

0.850.943.81

1.12

2.77

2.24

0.90

1.06-5.75ǂ

0.96-5.32

0.54-1.340.53-1.681.96-7.40¶

0.70-1.78

1.54-5.00¥

1.36-3.68¥

0.53-1.55

* P= 0.007, ¶ P <0.0001, ǂ P= 0.034, ¥ P= 0.001

Table 2 Multivariate analysis of maternal and infants factors

Mothers’ and infants’ factor

Odds ratio

95% CI p- value

Mother did not receive ANSChorioamnionitis Apgar score <4 in 1st minuteNot ventilated at birthIncrease of feeds ≥24.5mls/kg/dayPostnatal age at first feeds ≤2 days

2.358.732.923.201.09

1.43

1.25-4.422.59-29.51.06-8.011.18-8.690.60-2.02

0.58-3.50

0.008<0.0001

0.0380.0230.759

0.435

Outcome in infants with NECNineteen percent of infants with NEC died. Seventy four percent (14/19) of those with stage 3 died compared to about 8% (7/91) among those with stage 2. Twelve (11%) of infants had surgery. Two thirds (67%) of infants who had surgery died compared to 13% among those who did not have surgery (Table 3).

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Factors associated with severe necrotising enterocolitis and with mortality in infants with NEC was lack of antenatal care, OR 4.31, 95% C1 1.46-12.73, p= 0.008 and OR 4.75, 95% CI 1.65-13.67, p= 0.004, respectively. HIV infection in the mother was not associated with severe NEC or with mortality. All other factors were not associated with severe NEC or with mortality.

Table 3 Outcome in infants with NECOutcome No; n(%) Yes; n(%)SurgeryDeath

98(89)89(81)

12(11)21(19)

Death according to NEC stage:Stage 2a (n=71)Stage 2b (n=20)Stage 3a (n=3)Stage 3b (n=16)

69(97)15(75)1(33)4(25)

2(3)5(25)2(67)

12(75)

Death among those who had surgeryDeath among those who had no surgery

4(33)85(87)

8(67)13(13)

Summary of findingsThe study showed multiple factors were associated with NEC. Ventilation and antenatal steroids were protective against NEC, consistent with previous findings.9-11

There was no difference between maternal HIV status between cases and controls. Non-attendance of antenatal care increased the odds for severe NEC and mortality. The reason is not known but possibly because these mothers missed opportunity for management of high risk conditions.12,13 Mortality was directly related to the severity of NEC.

Limitations and strength of the studyThe limitation was that estimations of gestational ages and Apgar scores, diagnosis of maternal conditions such as antepartum haemorrhage and chorioamnionitis, may have been inconsistent since they were performed by several attending clinicians or nurses (for Apgar scores) with varying degrees of experience. This may have resulted in presumably inaccurate estimation of association of NEC with these factors.

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The strength was that we studied 129 infants who were born to HIV infected mothers, a substantially larger number compared to nine infants previously studied.

Recommendations Pregnant mothers should be encouraged to attend antenatal clinics. All mothers presenting in preterm labour should be given antenatal

steroids in order to prevent the risk of developing NEC. Strategies or interventions that have been shown to reduce NEC, namely

breast milk feeding should be implemented, as NEC is associated with high mortality.

LIST OF ABBREVIATIONS

ANC- antenatal careANS- antenatal steroidsAPH- antepartum haemorrhageCHBAH- Chris Hani Baragwanath Academic HospitalCI- confidence intervalELBW- extremely low birth weightHIV- human immunodeficiency virus

LBW- low birth weightNEC- necrotising enterocolitisOR- odds ratioPDA- patent ductus arteriosusPIH- pregnancy induced hypertensionPROM- premature rupture of membranesSGA- small for gestationVLBW- very low birth weight

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SESSION 5: PAPER 5

REQUIREMENTS FOR ROLL-OUT OF BEST PRACTICES ACCORDING TO KEY INFORMANTS INVOLVED IN KANGAROO MOTHER CARE IN SOUTH AFRICA: A GUIDE FOR AN OPERATIONAL PLAN

Dr WH ten Ham Promotor: Dr CS Minnie Co-promotor: Prof SJC van der Walt

BackgroundHigh-quality evidence-informed products are part of best practices. Although there is no universal definition of best practice, according to Grol and Grimshaw (2003), best practices are related to nursing practice, methods, procedures and techniques based on high-quality evidence in order to obtain improved patient/health outcomes. However, Harrison, Legare, Graham, et al. (2010) argue that although evidence and evidence-informed products may be necessary, evidence alone is not sufficient to ensure evidence-informed decision making. They also indicate that the uptake and implementation of evidence do not occur with simple decision-making, as a variety of interrelating factors influence the uptake, implementation and roll-out of evidence into practice. Further, globally evidence-informed products are developed and made available, but the challenge remains to get evidence implemented and then rolled-out into practice (Grol, 2001). Roll-out of best practices is crucial as this can help to provide more patients with evidence-informed care (Edwards & Grinspun, 2011). Roll-out refers to “a way of closing the gap between best practice and common practice” (Massoud et al., 2006).

Roll-out of bet practices requires a point when evidence is accepted by most individuals and cannot be turned back and therefore change is inevitable: the so-called tipping point (Bodenheimer, 2007). To create that tipping point towards successful adoption, implementation and roll-out of evidence and to ensure that innovations (such as best practices) in the healthcare system are rolled-out, certain requirements are needed. Edwards and Grinspun (2011) in their “Evidence Informed Model of Care”, identified the following four requirements for roll-out (the so-called benefit levers): alignment, permeation plans (plans for roll-out), leadership for change and reinforcing and supporting structures.

In the South African context, best practices are often identified and evidence-informed products developed, but not optimally implemented and rolled out to lead to improved health outcomes. A case of ineffective roll-out involves the roll-

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out of the Kangaroo Mother Care (KMC) method. Although KMC as best practice is translated into practice and implemented on a limited scale, roll-out to the whole system seems to be problematic (Bergh, Van Rooyen & Pattinson, 2008).

Problem statement The background stated the importance of evidence-informed practice to improve the quality of care. However, there is a low uptake and roll-out of evidence-informed practices. Various factors can be used to facilitate the roll-out of best practices. Edwards and Grinspun identified four benefit levers which create the tipping point towards successful adoption, implementation and roll-out of evidence: alignment, permeation plans, leadership for change, and supporting and reinforcing structures. However, little is known about these benefit levers and it remains unclear what the use of benefit levers for system-wide roll-out would entail (Edwards & Grinspun, 2011).

Further, the use of benefit levers in developing a guide for an operational plan for the roll-out of best practices has not been investigated yet. An operational plan could be helpful to guide the roll-out of best practices in a certain context (e.g. South Africa) and improve health outcomes as currently best practices (such as KMC) are often not rolled-out on a system-wide basis to improve practice.

Aim and objectivesTo address these issues, the aim of the study was the following: to develop a guide for an operational plan for the use of requirements to facilitate successful roll-out of best practices in South Africa.To achieve this aim, the following objectives were set:

1. To explore and describe characteristics of requirements to facilitate roll-out of best practices.

2. To develop a guide for an operational plan to use requirements for the roll-out of best practices.

Design and MethodsA qualitative design was used which is exploratory and descriptive in nature.The following table will outline the steps and methods which addresses the objectives of the study.

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Table 1: Steps and methods addressing the steps and methodsObjective Steps and MethodsObjective 1: To explore and describe characteristics of requirements to facilitate roll-out of best practices.

Step 1: An integrative literature review for concept clarification of the requirements for roll-out of best practice using a systematic search strategy based on the systematic review methodologyStep 2: Retrospective analysis of the realization of requirements for the roll-out of KMC in South Africa

Objective 2: To develop a guide for an operational plan to use requirements for the roll-out of best practices.

Step 1: Formulating a guide for the operational plan (end-product) based on findings of objective 1Step 2: Refining the end-product using the input of panel experts

FindingsFindings per requirement were the following: AlignmentThe following is needed in terms of alignment to ensure the successful roll-out of the best practice: Buy-in/agreement of the stakeholders at all levels is required, the policies and guidelines supporting the roll-out of best practices should be aligned at all the levels, and the supporting structures should be aligned with the best practice.Plans for roll-outIn terms of plans for roll-out, the following was found: No general plan for roll-out was found. However for a succesful roll-out of best practices a well-structured plan for roll-out is required. This plan is driven by national/provincial level and aligned with and supported by all levels.Leadership for changeLeadership is needed for roll-out of best practices at all levels as a lack of leadership was found. Leadership requires certain characteristics: the ability to teach, good communication skills, being trained, etc., as well as the following roles: encouraging, convincing, advisory role etc. Leadership roles have to be understood by stakeholders involved in the roll-out of the best practice.Supporting and reinforcing structuresSupporting structures were found at a variety of levels, including: Resources, such as budget, human resources, policies and guidelines; Education & Development, such as sharing knowledge about the best practice, conferences, etc.; Communication (e.g. meetings regarding the roll-out of the best practice); Timing of rolling-out the best practice (too speedy roll-out may cause harm); The best practice itself, such as the clarity, complexity and benefits of the best practice.

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Recommendations The following recommendations were given:

Further research regarding: The requirements for the roll-out of best practices The costs and cost-effectiveness of best practices to be implemented and

rolled-out The complex health system of South Africa to enhance understanding of the

roll-out process and the effect of the system on the roll-out of best practices. Pilot-testing and validating the guide for an operational plan

Nursing education: Include the concept and practice of the best practice and the importance of

evidence-based practice in the curriculum of nursing and all other professions Provide formal training regarding the best practice at individual level Provide training of the health system and the use of requirements in the roll-

out of best practices at all levels

Nursing practice: Nationally, best practices should be rolled out Evaluation of the roll-out of best practices should be done

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SESSION 5: PAPER 6

THE BABY SKIN CARE RESEARCH PROGRAMME

Bedwell C, Lavender T.

Newborn skin is immature and damage to the skin barrier in the period following birth is thought to contribute to the development of atopic eczema in children. In the UK, women are advised to bathe infants in water alone for the first few weeks of life; however, many women choose to use skin care products on their newborn infants. In addition, there is a lack of robust evidence to support clinical practice, leading to wide variation in practice and the advice given to parents. Hence a programme of research was designed to address areas of newborn skin care, particularly in relation to skin cleansing and diaper area care.

The programme commenced initially with a qualitative exploration of the views of women and clinicians in the North West of England, revealing confusion and an illusion of evidence based practice; along with a willingness amongst parents and health professionals to use skin cleansing products, despite advice to the contrary. A subsequent pilot study (n=100) confirmed the feasibility of a trial designed to compare bathing in water only versus a specifically formulated newborn bathing product, from birth to four weeks of age. This led to completion of two adequately powered main trials; one comparing water only with a wash product for bathing (wash trial) (n=307) and a second comparing water only versus an optimally formulated cleaning wipe for diaper area care (wipes trial) (n=280). Sensitive clinical measurements were used to determine water loss, hydration and pH, along with clinical observations and maternal views. Results indicated that the products tested in these trials were equivalent (wipes 95 % CI -2.5 to 4.2) or not inferior (wash 95% C.I. -1.24 to 1.07) to water alone for newborn skin cleansing, in the four weeks following birth.

This programme provides robust evidence to inform both women and health professionals, enabling them to make an informed decision regarding skin care practices.

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SESSION 6: PAPER 1

UTERINE RUPTURE AND MATERNAL MORTALITY IN SOUTH – AFRICA 2008-2010

Prof Sue FawcusNCCEMD, UCT

Introduction. The fifth Saving Mothers report of South Africa reveals 108 maternal deaths due to ruptured uterus, giving a maternal mortality ratio of 3.9 per 100,000 for this cause, and accounting for 15.8% of the 688 deaths due to obstetric haemorrhage. Methods. Data on the108 maternal due to uterine rupture entered into the MAMMAs database were analysed. A detailed folder analysis of the case notes, death notification and assessor forms was performed for 88 of the cases.Results The number of deaths from obstetric haemorrhage and for uterine rupture have increased when compared to previous triennia.

The 108 maternal deaths included 47 women with Previous Caesarean Section (PCS) and 61 women with unscarred uteri (USC).

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Numbers of Maternal Deaths from Obstetric Haemorrhageand Uterine Rupture 1999 - 2010

Mat

erna

l Dea

ths -

num

bers

134

Previous Caesarean Section and Uterine Rupture 1999 - 2010

Previous Caesarean Section Unscarred Uterus

Level of Care and Uterine Rupture 2008 - 2010

Mat

erna

l Dea

ths

-num

bers

The MMR from ruptured uterus was highest in Free state, Mpumalanga, Limpopo and Eastern Cape. 80% of the women were para 1 – 4, 86% had had antenatal care, and 37% were HIV positive. Prolonged labour was documented in 46%, and a live baby delivered in only 24% (32.4% were undelivered and 41.7 % had a stillbirth). The detailed analysis of 88 folders included 41 women with PCS and 47 with USC. The 41 women with PCS included 68.3% with one PCS, 27 % with 2 PCS and 4.9% with 3 PCS. All went into labour. Onset of labour was spontaneous in 39 women with PCS, with 2 being induced. 31 of the 47 women with USC had spontaneous labour, and 15 (32.6%) were induced. One in the PCS group and 5 in the USC group had labour augmented. Uterine Rupture was confirmed by laparotomy/Caesarean Section in 56 (63.6%), postmortem 14 (15.9%) EUA 1 (1.1%), clinically in 17 (19.3%); and in 9 women (10.2%), the diagnosis was not suspected before death. Hysterectomy was performed in 28 (31.8%), uterine repair in 22 (25%) but there was no definitive surgical procedure for 37 cases (42%).The cause of the uterine rupture was assessed as being due to intrapartum rupture of a previous scar in the 41 PCS group. In the 47 USC group it was due to obstructed labour in 19 (40.4%) and incorrrect use of uterotonics in 16 (34%). This included 12 where misoprostol was

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Maternal Mortality Rate (MMR) from Uterine Ruptureper Provinces

MM

R: M

ater

nal D

eath

s per

100

,000

Liv

e Bi

rths

administered in excessive doses for induction, or given inappropriately with contractions. The cause of uterine rupture was unknown in 9 women.

88% of all the deaths were assessed to be probably avoidable. Avoidable factors were as follows:No delivery plan for women with previous CSLate presentation in labour by patient (15 %)Health worker delays in intervening with prolonged labour (delay in decision making (28%) and delay because referral needed, or theatres busy (7%) Incorrect usage of uterotonics (18%) esp IUDsDelays in considering laparotomy despite evidence of haemorrhagic shock (31%)

Details of incorrect uterotonic therapy for induction of labour or augmentation were as follows:Induction of labour

• IOL with misoprostol - 7 cases (pv doses 100- 600mcgms)• IOL with prostin – 2 cases (pv 2mgms 2hrly)• Repeat misoprostol given when contracting – 3 cases

Augmentation• With misoprostol - 2 cases (20mcgms po 2hrly) • With oxytocin -2 cases (10iu infusion in second stage)

(20iu infusion in first stage)

Discussion. The total number of deaths from uterine rupture in 2008-2010 could be higher. There may have been some undiagnosed uterine ruptures in those deaths classified as ‘APH or PPH unspecified’ and also in 7 deaths in the ‘acute collapse’ category that occurred after uterotonic medication was administered for induction of labour.The results indicate that earlier intervention for prolonged labour, and adhering to strict dosage protocols for induction of labour are essential. In addition delivery plans need to be made during the antenatal period for women with previous CS Health workers need training to recognize early signs of uterine rupture and perform laparotomy urgently.

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SESSION 6: PAPER 2

MATERNAL AND NEONATAL OUTCOME OF PLACENTA PRAEVIA

Simpiwe Mose, KA Frank

Background Obstetric haemorrhage as a result of placenta praevia is associated with adverse maternal and neonatal outcomes. The rising incidence of caesarean sections suggests that we are more likely to encounter increasing incidence and complications of placenta praevia. Knowledge of the risk factors and complications of placenta praevia is important to reduce the maternal and perinatal morbidity and mortality associated with this condition.

Method This was a descriptive prospective study of the maternal and perinatal outcomes of placenta praevia in patients seen at Chris Hani Baragwanath Hospital (CHBH). Patients with placenta praevia who gave informed consent to participate in the study were interviewed using a structured questionnaire. The study was conducted in Chris Hani Baragwanath Hospital. The information collected in the questionnaire was entered into a data base and analysed using Stata 11 statistical package. The study was carried out over a 6-month period and 50 subjects were recruited.

Results A total of 50 women with placenta praevia who were admitted to Chris Hani Baragwanath Hospital were studied. All were singleton pregnancies, and all were delivered by caesarean section. The youngest participant was 16 years and the oldest was 40 years of age. The mean gestational age at admission was 31.9±SD4.3. Patients who had no previous uterine operations constituted 76% of the total. Postpartum haemorrhage occurred in 24% of the cases; hysterectomies were carried out in 8% of the cases, mainly as a result of intractable haemorrhage. Twenty four per cent of the neonates required ICU admission and 10 % of babies were early neonatal deaths. There were no maternal deaths.

Conclusion Placenta praevia is associated with adverse maternal and neonatal outcomes. In our setting we require a high index of suspicion based on history and ultrasonographic findings so that patients at risk of placenta praevia are not overlooked. This will afford us an opportunity to detect early patients at risk and to provide appropriate management aimed at reducing maternal and neonatal morbidity.

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SESSION 6: PAPER 3

A COMPARISON OF TECHNIQUES FOR DELIVERY OF THE IMPACTED FETAL HEAD AT CAESAREAN SECTION FOR CEPHALOPELVIC DISPROPORTION: A RANDOMISED CONTROLLED TRIAL.

E Buga

BackgroundCaesarean section for cephalopelvic disproportion (CPD) is associated with considerable maternal and perinatal morbidity worldwide. The results of several trials have suggested that the reverse breech method of delivery of the impacted head had better outcomes than when the impacted head is pushed up by an assistant. The push method of delivery of the impacted head is aided by an assistant who inserts a hand into the vagina to push the head upwards, while the surgeon inserts his hand anteriorly to get below the head and deliver it. An alternative method of delivery of the impacted head would be for the surgeon to insert the hand posteriorly, instead of anteriorly, as there is more room in the pelvis posterioly. This method has not been evaluated and there are hardly any published reports describing it. The posterior method of delivery of the impacted head is practiced at my institution and the skill is passed on from one generation to the next.

MethodsThis study was a randomised controlled trial designed to compare the anterior and posterior methods of delivery of the impacted head at Caesarean section. Women were enrolled at Chris Hani Baragwanath and Charlotte Maxeke Academic Hospital at term and randomly assigned to either the posterior method of delivery or the anterior method of delivery. All the enrolled women were augmented with syntocinon for a duration of at least 6 hours before a diagnosis of CPD was made, after which they were then booked for caesarean section. In theatre, after the uterine incision had been made, the patients were randomised to either the anterior or posterior method of delivery. The primary outcome was the time taken to disimpact the fetal head. The secondary outcomes were, intraoperative blood loss, the duration of the caesarean section, tears to the lower segment and fetal outcomes which included the 5 minute apgar score and the fetal weight.

Results30 women were randomly assigned to the delivery of the impacted head with the surgeon’s hand introduced anteriorly (n=14) or posteriorly (n=16) into the uterus. There was no difference in the time taken to disimpact the fetal head where the hand was introduced posteriorly or anteriorly (p value = 1.0).The median blood loss in the anterior method was 700mLs (IQR 500-800) vs. the posterior method 675 mls (IQR500-800) but this did not reach statistical significance (p value = 1.0). The inter-quartile ranges were used because the statistical analysis revealed the results did not have a normal distribution. The mean time in minutes, taken to do the caesarean section, was similar between the two groups: posterior method (44±9.4) vs. anterior (44±9.6). The posterior method had three lower segment tears vs. the anterior method which had two lower segment tears (p value 1.0).This difference also didn’t reach statistical significance. Both randomization arms had good neonatal outcomes with no neonates born with 5 minute Apgar scores less than 7.

ConclusionThe posterior method of delivery is similar to the anterior method of delivery and can be used as an alternative for delivering an impacted fetal head at caesarean section for CPD.

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SESSION 6: PAPER 4

THE INFLUENCE OF SKIN INCISION TO DELIVERY TIME AT CAESAREAN SECTION

Jana Nicolene Rossouw1, David Hall1 and Justin Harvey2

1Department of Obstetrics and Gynecology, Tygerberg Hospital, Stellenbosch University, Bellville, South Africa 2Centre for Statistical Consultation, Stellenbosch University, Cape Town, South Africa Corresponding author: Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, PO Box 19063, Tygerberg, 7505. Tel: +2721 938 9059. Fax: +2721 932 2455. E-mail: jnrossouw@yahoo.com (JN Rossouw)

INTRODUCTIONCaesarean section is the most common major surgical intervention in obstetrics. Because this procedure can be performed at various levels of health care, most health systems categorise patients requiring the operation into levels I-III of care. The goal of such categorisation is to provide appropriate surgical expertise for patients where surgical complications are anticipated. The rising rate of Caesarean sections in many countries is a great cause for concern. Recurrent Caesarean sections are associated with more intra-abdominal adhesions, placenta praevia and morbidly adherent placentas. The latter two conditions increase the chances of intra-operative complications such as blood transfusion, bladder injuries, Caesarean hysterectomy and even death. Kwee et al, in a study performed in the Netherlands, showed that placenta accreta was the most common indication for peripartum hysterectomy and was significantly associated to Caesarean section in the current or previous pregnancy.Prior Caesarean sections increase the chance of adhesions in the operative field and prolong the delivery time. Certain authors have demonstrated that incision to delivery times (particularly myometrium to delivery time) influence the Apgar scores of the newborn. This supports the opinion that slow delivery may be to the detriment of the baby. However, these findings have not been confirmed in recent studies. Currently, there is uncertainty concerning the importance of the incision to delivery time. The aim of this study was to investigate the factors influencing the skin incision to delivery time (and sub-divisions thereof) as well as the impact of these intervals on the immediate neonatal outcome as reflected by the five-minute Apgar score.

Table 1 Time intervals to delivery of baby and Apgar scoresApgar scores < 7 at 5 minutes n (%)

p-value

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Skin to myometrium (S-M)> 2 minutes> 3 minutes> 4 minutes

27 (3.2)22 (2.6)20 (2.4)

0.290.670.74

Myometrium to delivery (M-D)> 1 minute> 2 minutes> 3 minutes

24 (2.9)11 (1.3) 8 (1.0)

0.650.910.71

Skin to delivery (S-D)> 5 minutes> 8 minutes>10 minutes

22 (2.6)8 (1.0)4 (0.5)

0.760.540.41

Statistical analysis was done by means of the Pearson Chi-squared test.

DISCUSSIONCaesarean section is a common major surgical intervention. There are several factors that influence the time taken to perform the operation and prolonged incision to delivery time may influence the outcome of the baby. These considerations need to be taken into account when choosing the level of care. This study was performed at a combined secondary and tertiary academic hospital. When compared to elective ones, emergency procedures were performed more quickly at all surgical planes (p<0.01). Adhesions in the surgical field were present in 7.4% of primary and 67.7% of third procedures (p<0.001). The skin incision to delivery time was significantly longer in repeat procedures (p<0.001) and increased progressively with categories of obesity (p<0.001). The type of skin incision also influenced the total delivery time with Joel-Cohen incision the fastest time, followed by Pfannenstiel and then midline incision (p=0.005) and this is in agreement with the publication by Stark and Finkel. Although “skin to myometrium”, “myometrium to delivery” and “skin to delivery times” were calculated individually, none of the median values correlated with Apgar scores of < 7 at five minutes for emergency deliveries.An older study investigating the safety of multiple Caesarean sections performed in Israel, found that 5-minute Apgar scores ≤7, were significantly related to multiple Caesarean sections even after controlling for the effect of gestational age [10]. Gestational age was not taken into account in the index study. More recently an important contribution on surgical delivery intervals was made by Maayan-Metzger et al, in 2010. This large study involving only elective Caesarean sections under regional anaesthesia, investigated skin incision to delivery and uterine incision to delivery times and assessed the influence thereof on the short-term outcomes of singleton, full term infants. The study found that the duration of these intervals had no significant impact on any measured

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neonatal parameters including the 5-minute Apgar score <7 and concluded that obstetricians have a relatively large safety margin from the time of the skin and uterine incisions. The index study covered all Caesarean sections over a defined time period. Because the number of elective deliveries with low 5-minute Apgar scores was very small, only emergency procedures were used to correlate the Apgar scores. Compared to the study by, a wider range of surgical delivery intervals was tested but none of the median values correlated with Apgar scores of < 7 at five minutes for the emergency deliveries. Although factors such as adhesions, obesity or surgical experience may influence the time taken to deliver a baby at Caesarean section, the circumstances influencing the immediate neonatal outcome are multifactorial. The need to deliver the baby swiftly is greater in certain emergency procedures e.g. in the presence of a pathological cardiotocogram. Although this study included all Caesarean sections, the working definition of emergency Caesarean section was too broad to interrogate the influence of the underlying maternal and/or fetal condition e.g. pre-eclampsia or growth restriction on the Apgar score. Given the general findings on the surgical delivery intervals, the maternal and fetal factors in specific cases may be the more important determinants of outcome. In addition, umbilical cord gas evaluation may have been considered as a marker of immediate outcome but this is not standard practice for all Caesarean sections at the study institution. Finally the type of anaesthetic (not investigated here) may be another determining factor.In conclusion, this study showed that apart from maternal and fetal considerations that necessitate a higher level of care, there are surgical considerations such as obesity and adhesions at repeat procedures that require an appropriate level of skill. The lack of association between incision to delivery times and the Apgar score provide general reassurance and surgeons should not sacrifice careful surgical technique for hasty delivery of the baby.

Declaration of interest The content and writing of this article is the sole work of the authors. There is no conflict of interest by the authors. This article is a condensed form of our article that was accepted for publication in The International Journal of Gynaecology & Obstetrics. The article is currently going to press.

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SESSION 6: PAPER 5

VACUUM DELIVERY: A DYING SKILL

RC PattinsonMRC Maternal and Infant Health Care Strategies Unit, University of Pretoria

Aim: To correlate the use of vacuum delivery and perinatal outcome in South Africa

Method: Data from PPIP sites were assigned into their health districts and analysed accordingly. Various indicators were correlated. The ability to perform a vacuum delivery was surveyed in 12 districts.

Results: In South Africa, the PNMR for babies 1000g or more was 25.6/1000 births for 2010-2011. Intrapartum asphyxia and birth trauma was the major underlying cause of perinatal death with a rate of 4.87/1000 births. The assisted delivery rate for vacuum delivery was 0.52% and for forceps delivery was 0.15%, whereas the caesarean section rate was 21%. When the intrapartum asphyxia and birth trauma death rates was correlated with the vacuum delivery rate there was a significant negative correlation of r=-0.307, p=0.036. This is illustrated in the scatter gram below. Each dot represents a district.

Figure 1. Correlation between intrapartum asphyxia and birth trauma rate (IPA+T) and vacuum delivery rate

The ability to perform an assisted delivery in the 12 districts is given in table 1.Table 1. Ability to perform assisted vaginal delivery

CHC DH RH PTTotal 54 63 13 4

Vacuum (by doctor or midwife)

Available

3 (5.6%)

36 (57.1%

)

10 (76.9%

)

3 (75.0%

)Forceps (by doctor or midwife)

Available

3 (5.6%)

38 (60.3%

)

9 (69.2%

)

2 (50.0%

)

Vacuum by midwife Available

2 (3.7%)

12 (19.0%

)

3 (23.1%

)

1 (25.0%

)

Forceps by midwife Available

1 (1.9%)

9 (14.3%

)

2 (15.4%

)

1 (25.0%

)

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Conclusion: Our assisted delivery rate of less than one percent is too low and is probably due to the loss of skill in performing assisted delivery. An increase in deaths of pregnant women and their infants is likely unless the skills in vacuum delivery are regained.

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SESSION 6: PAPER 6

OPTIONS FOR DIFFICULT SECOND STAGE

Hofmeyr, GJ, Effective Care Research Unit, University of Witwatersrand, Fort Hare and Eastern Cape Department of Health

IntroductionDifficult second stage of labour with normally formed babies and vertex presentation is usually due to cephalopelvic disproportion, pelvic soft tissue resistance, inadequate uterine contractions, inadequate maternal bearing down, or a combination of these.The trend in modern obstetric practice is to manage difficult second stage by caesarean section, if necessary with breech extraction if the head is deeply engaged in the pelvis. Caesarean section carries increased risk for the mother in the current and future pregnancies, particularly when surveillance in subsequent labours cannot be guaranteed.Globally many women give birth with no access to caesarean section, and for some women caesarean section is culturally unacceptable. This paper will outline alternative strategies.

1. Childbirth companions: There is good evidence from several randomized trials that labour companionship reduces the duration of labour and the rate of caesarean section. All women in labour should have companionship, either from a ‘Doula’ or from a member of their family or a friend.

2. Fliuds and caloric intake: There is limited evidence that good hydration and nutrition may improve outcomes of labour.

3. Posture: There is some evidence that upright postures may improve outcomes in the second stage of labour. Women should be free to adopt the position they find most comfortable, while the supine position should be avoided.

4. Delayed pushing: Has been advocated as a strategy to reduce assisted deliveries with epidural analgesia, and there is some evidence that this may be done safely in this situation.

5. Uterotonic therapy: Uterotonics in the second stage of labour are used both in the formal and the informal sector, with concomitant risk of uterine rupture.

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6. Fundal pressure: Fundal pressure is used extremely widely by midwives and in some countries by obstetricians. The practice is condemned by most obstetricians as being dangerous. There is however very little objective evidence to support either view. We have developed an alternative method, ‘gentle assisted pushing’. This has shown promising results in a small pilot study (unpublished)

7. Amniotomy: This may accelerate the 2nd stage of labour.8. Birth canal dilation: Promising results were reported from a small pilot

study of an inflatable dilator. More recently, a mechanical dilator has been developed and is undergoing testing in Australia.

9. Vacuum extraction: Vacuum extraction has benefits such as less trauma for mother, ease of use and greater safety and more easily taught than obstetric forceps. Its declining use in low-income countries is seen a major shortcoming.

10.Forceps delivery: Obstetric forceps require considerable skill and training, but are essential for overcoming prolonged second stage of labour in certain situations such as face presentation, preterm birth and the after-coming head of a breech presentation.

11.The Odon device: The Odon device is a double plastic sleeve to assist birth. The sleeve is inserted around the baby’s head using an instrument with 3 spatulas. A small cuff in the leading edge is inflated to assist with traction. Traction is applied to the inner sleeve. A lubricant between the two sleeves assists to reduce friction during delivery. The device is being tested in Argentina, and a multicentre trial is being planned by WHO at several centres including East London.

12.Symphysiotomy: Symphysiotomy is regardedas safe and life-saving by some; barbaric by others, yet very little robust evidence exists to support either view. Symphysiotomy is an operation in which fibres of the symphysis pubis are divided with a scalpel using local analgesic infiltration. This allows the pubic bones to separate, creating more space in the pelvis for the birth of the baby. Symphysiotomy has come to be regarded as an unacceptable operation because of perceptions that complications for the mother are prohibitive, and the view that it is a 'second-class' operation used only in women from poor communities. In the last 20 years it has virtually disappeared from practice in many low income countries.

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When caesarean section is not available or not safe, symphysiotomy may be life-saving for both mother and baby. Complications of the procedure have been reduced by improved operative techniques (such as partial rather than complete symphysiotomy) and postoperative care (early mobilisation).

The main indications for symphysiotomy are cephalo-pelvic disproportion with cephalic presentation and arrested aftercoming head of the breech. Symphysiotomy may be lifesaving for women too ill to survive caesarean section following neglected labour.

Apart from the use of symphysiotomy to overcome existing obstruction, the availability of symphysiotomy may influence obstetric choices. For example caesarean section may be chosen for breech delivery because of the possibility of difficult vaginal delivery in a small proportion of cases. If the mother and caregivers feel reassured that the problem of obstruction to the aftercoming head can if necessary be overcome with symphysiotomy, then routine caesarean section can be avoided in a large number of cases, whereas symphysiotomy will be required in only a very small number in which the problem actually occurs. Availability of symphysiotomy as an option in a health service may encourage attendance by women who avoid the service because of a wish to avoid caesarean section.

13.Craniotomy: This procedure is also seldom used today, but avoids the risks to the mother of Caesarean section for a dead baby.

14.Posterior axilla sling traction: We have developed a novel technique to overcome intractable shoulder dystocia. Fold a strong plastic tube such as a suction catheter over the tip of one index finger. Feed it posteriorly under the axilla of the baby’s posterior shoulder. Use the index finger of the other hand to hook the loop of tubing out, creating a sling around the baby’s axilla. Traction on the sling ‘tilts’ the baby’s shoulders so that first the posterior then the anterior shoulder delivers. If the posterior shoulder cannot be delivered directly, the sling can be us ed to rotate the posterior shoulder to the anterior position for delivery.

Conclusions• Easy access to caesarean section has distracted attention from alternative

methods of assisting difficult second stage. The concept that caesarean

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section is the ideal management has rendered alternatives such as symphysiotomy politically unacceptable, even when no alternative exists. There is a striking lack of robust research evidence to guide practice. As practical obstetric procedures are used less and less, opportunities for clinical teaching are reduced, leading to fewer clinicians being skilled in their use. Several teaching videos have been developed by our unit and are freely available online on the World Health Organization Reproductive Health Library. They can also be downloaded by googling youtube rhl, select RHL videos – You Tube, choose one of the 12 videos, insert ‘ss’ between www. and youtube in the site address to navigate to a download site, where one can choose a download format such as MP4. The videos include

• Shoulder dystocia• Vaginal breech delivery and symphysiotomy• Vacuum extraction• Caesarean section technique• Labour companionship

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SESSION 6: POSTER 1

AN AUDIT OF DECISION TO DELIVERY TIMES FOR EMERGENCY CAESAREAN SECTIONS IN A BUSY URBAN OBSTETRIC UNIT IN SOUTH AFRICA

Dr S O’Dwyer, London Speciality School of Obstetrics and Gynaecology, London Deanery, London, UK.Professor Sue Fawcus. Department of Obstets Gynecol, University Cape Town

Introduction Decisions to Delivery Intervals (DDIs) for emergency Caesarean Sections (CS) are an auditable standard used often in maternity units as a marker of unit efficiency. In addition there are accepted guidelines for categorisation of emergency CS by degree of urgency

Aims Primary – to establish decision to delivery intervals for caesarean section in emergency cases at Mowbray Maternity Hospital (MMH).

Methods An audit of 110 emergency CSs, was conducted at MMH in Cape Town. The CSs were retrospectively categorized into Category 1 (immediate threat to the life of the mother or fetus) and Category 2 (maternal or fetal compromise that is not immediately life threatening) CSs. The targets set were 30 minutes DDI for Category 1 CS, and 75 minutes DDI for Category 2 CS, in line with American and British guidelines for intrapartum and perinatal care. DDIs were determined for each case.

ResultsThe 110 cases of emergency CS included 59 which were category 1 and 51 which were category 2. Seven cases did not have the Decision to deliver time clearly documented. Three of these were Category 1 and four were Category 2. They were excluded from analysis and 103 cases were audited.The majority of Category 1 Caesareans were done because of “Fetal Distress”, and the majority of Category 2 Caesareans were due to “Failure to progress”For the Category 1 CSs, only 8.9% of cases were accomplished within 30 minutes DDI. Of Category 2 CSs, 57.4% of cases were accomplished within the 75 minute DDI target. In most cases, there was no documentation as to why there was a delayed DDI (74.6%). Median DDI for Category 1 CSs was 64 minutes, and mean DDI was 67.5 minutes. Median DDI for Category 2 CSs was 73 minutes, and mean DDI was 88.7%. When both Category 1 and 2 CSs were considered together, 35.0% had a DDI of >75 minutes, and 12.6% of cases had a DDI of >120 minutes.

DiscussionPossible reasons for not achieving these targets include excessive work load of the obstetric theatre, and inadequacies in medical staff’s appreciation of the most urgent cases The results indicate a need to implement staff education sessions to emphasize the importance of achieving shorter DDIs to help reduce adverse maternal and fetal outcomes. Categorisation of the urgency at the time of the decision to perform emergency CS would be useful for Theatre to help prioritise cases. It would be useful to implement such a system with colour coded stickers for the different categories of emergency CS and then to do a re-audit after 3 months to see if any improvements have occurred.

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SESSION 7: PAPER 1

MONITORING IN LABOUR – THE CLOCK IS TICKING

Sheila E ClowDivision of Nursing & Midwifery, University of Cape Town

BackgroundPoor monitoring of labour has been identified in the Saving Mothers and Saving Babies reports as contributing to maternal and perinatal deaths.

Problem statementInadequate monitoring in labour and lack of insight into the importance of labour observations results in poor clinical decision making and management.

AimDetermine the effect of a focussed in-service training and mentorship package on the quality of clinical management in labour by registered midwives in two rural regions of the Western Cape

ObjectivesConduct a document audit of individual partographs with respect to

completeness of the documenting of intrapartum observations evidence of adherence to the management of labour guideline

Evaluate and compare the performance of the individual registered midwives with respect to

knowledge, clinical judgment, clinical assessment the ability to use and interpret the partograph, and adherence to the management of labour guidelines

Methods A pragmatic cluster randomised controlled trial, utilising 17 sites / clusters stratified by region and number of births per annum, and randomly allocated within strata.

Partograph audit1020 labour records of women in labour with normal singleton pregnancies and cervical dilatation less than or equal to 6 cm. Data collection over 12 months

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using a partograph evaluation instrument (presented at Priorities in Perinatal Care congress, 2012).

Midwife tests154 registered midwives working in maternity settings during the study period. Data was collected at two time points using matched tests to measure knowledge and clinical skills (using simulation).

The sampling was successful in that it yielded two comparable arms in respect of the profiles of records and midwives.The Intervention package consisted of

1. A 2-day focussed in-service training programme for registered midwives on monitoring in labour. The content was guided by

Saving Mothers & Saving Babies findings & recommendations Scope of Practice of Registered midwives ICM Competencies for basic Midwifery practice Guidelines for the use of the partograph (Western Cape 2004) Maternal & fetal monitoring

2. A 4-day mentor development training programme incorporating the monitoring in labour PLUS change strategies including

Practice Improvement model Health service level change Audit & feedback Clinical guidelines

The process / approach used was based on Adult learning approach Learner directed agenda Multiple teaching strategies Multiple engagement Application of theory to practice Motivational interviewing for behaviour change

The control sites received all standard communication (e.g. policies, clinical guidelines) and all routine activities continued (e.g. perinatal review meetings).

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The regional MCWH co-ordinators were asked to not include labour monitoring in the in-service training during the data collection period. This request was accommodated.

ResultsPartograph audit

30% of records had no partograph. Partograph scores were generally low with median scores below 50%. The difference in the completion of the partograph between two arms was

not statistically significant (Intervention effect 1.55 (95% CI : -1.18 to 4.28), -value = 0.267)

Partographs with higher scores (>27 points ~57%) were more likely to be in the intervention arm. The estimated difference was 13.6% (95% CI : 0.16 to 0.25), -value = 0.026.

Intervention sites with more than 500 births per annum had an intervention effect of 6.4 points higher than control sites. This was statistically significant (CI : 0.7-12.1), ρ-value = 0.029

Specific innovations Fetal heart recording before-and-after a contraction showed higher

adoption rates but this was not statistically significant (OR 2.0, ρ=0.237). 4 hourly comprehensive assessment showed statistically significant

improvement (OR 12.6, p<0.001)

Midwife tests Due to changes in the population, both intention-to-treat and per-protocol analyses were done using general estimating questions and mixed effects statistical models (to accommodate the relatively small number of clusters). There are was stability across analysis and models.

Mean scores were below 50%. There was a statistically significant difference in the test score of the

midwives at month 12, with those in the control arm 6% lower than those in the intervention arm (=0.006 (95% CI 2.1 to 12.3)).

Sub-scores of the midwife tests showed that the differences between the two arms for types and cognitive levels of questions were all statistically significant

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Discussion pointsSize of sitesIn the larger sites there would be more opportunities for the midwives to implement what had been learnt, and the mentor role was likely to be more effectively implemented in the larger services where one of the mentors was likely to be on duty with another registered midwife.

Barriers to use of partographFeedback in the intervention workshops identified lack of knowledge and confidence in using the partograph, and operational issues. 49 partographs included operational reasons for lack of observations.

Figure 1 Operational reasons for lack of observations recorded on partograph

In another department15%

Observations done by doctor & not recorded /

incomplete6%

Shift handover / doctors' rounds

8%With other patients / doing a delivery

36%

Ward busy33%

Lunch or tea break2%

Clinical skills deficitClinical skills and interpretation of observations were lacking, and some clinical findings were not believable, e.g.

where there was rapid cervical dilatation where moulding and caput were recorded apparently without a vaginal

examination being recordedIn some instances there was a significant change in the quality of the observations and recording after the change of shift

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Lack of understanding of labour / clinical relevance of observations Labour process e.g. recording the presenting part ascending as labour

progressed Clinical relevance of the observations e.g. “toilet”, “CTG”, yield no clinically

useful information Inexplicable clinical management decisions made in terms of what

observations were recorded

Climate for practice changePenn-Kekana, McPake et al (2007) found that 73.4% of hospitals regularly rotated nurses through maternity services and that some policies have discouraged midwives staying in Midwifery. The sense of feeling unsupported by management meant that the environment was not conducive to implementing policy interventions.

Conclusions & RecommendationsThe current levels of knowledge, clinical skills and monitoring are not consistent with the required standard for intrapartum care, neither does the current ad hoc approach to in-service training serve the needs of the health service in respect to intrapartum care. Unless there is a concerted effort to address learning needs and enhance clinical skills, deterioration is likely to continue, to the detriment of the pregnant & perinatal population.

Educational outreach is necessary and feasible. It is critical that midwives should have regular in-service training addressing the health challenges in their community

Barriers to use and completion of partograph need to be determined It is necessary to consolidate & strengthen the experience of registered

midwives working in maternity settings. Operational management and service level supports in maternity settings need to be addressed vigorously for improvement initiatives to be effective

There is considerable scope for the Advanced Midwife and other clinicians in the District Clinical Specialist team to provide the necessary clinical leadership in maternity settings.

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SESSION 7: PAPER 2

FETAL HEART RATE MONITORING; DOES IT COUNT?

A Jagau*, S Fawcus**, S Crede*, DL Woods*, J Wyatt*, JE Lawn*,****Powerfree Education and Technology** Head of Obstetrics MMH, Associate/ Professor UCT Faculty of Health Science*** Save the Children

Introduction The fourth Millennium Development Goal (MDG) aims to reduce the number of children who die under the age of 5. Currently 43% (n=3.1 million) of all child deaths worldwide consist of neonatal deaths (deaths under 28 days of age). The commonest cause of neonatal death is preterm birth complications. Intrapartum related events (“birth asphyxia”) in term infants is ranked second. In addition, 1.2 million intrapartum stillbirths occur each year but are not counted in the MDGs. However, they do count for the mothers and families who have to deal with the loss of an expected baby. These numbers suggest that there is space for improved intrapartum monitoring during labour which could help in reducing these perinatal deaths. A tool that is considered to improve intrapartum monitoring is the partogram (also referred to as the partograph). The first version of the partogram was developed by Philpot which later was adapted and adopted by the World Health Organisation (WHO) in 1987. A revised WHO version was published in 2000.

The partogram is an elaborate form on which observations during labour can be documented. It has been used as a screening tool in settings where people have to deal with a shortage of (experienced) staff. The tool includes three sections of information namely: the fetal condition, maternal condition and labour progress. Health care workers plot a curve with time on the horizontal axis and cervical dilatation on the vertical axis. This helps to monitor the progression of labour and alerts when labour is deviating from the norm in which case labour should be monitored more carefully (alert line identifies the slowest 10% of labours).7 Time for intervention is indicated when the curve of cervical dilatation crosses the action line. Amongst the observations are recording of the maternal heart rate, blood pressure, the frequency and duration of contractions as well as the fetal heart rate. These observations are supposed to be recorded at regular intervals.

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The value of the partogram has however been questioned. Lavender and Malcolms have argued that the partogram could reduce the midwives’ autonomy, limit her flexibility to treat each woman as an individual and it may restrict clinical practise. Even though the partogram is designed for under-resourced settings, most evidence regarding reliability of the tool has been evaluated in well-resourced settings where deaths are a rare outcome and practice is closer to the ideal of one midwife per woman in labour.13 Lavender et al published a Cochrane review of 6 studies involving 7706 women. They concluded that use of partogram should be locally determined as the studies they reviewed did not show a difference in outcomes between labour monitored with or without a partogram. Thus, the partogram is a standard of care, but does it make enough difference to outcomes to justify the extra work it puts on the health care workers? Or is the partogram not the problem. Does the solution rather lie in providing health care workers with better training and more appropriate monitoring devices. Besides questioning the use of the partogram as a recording tool, health care workers are also uncertain of the best way to monitor a fetus during labour. They question whether methods for counting the fetal heart rate, the device used and the time interval between monitoring make a difference to the outcome. Hence we set out to review the existing evidence, with a focus on high burden, low resource settings. The aim was to develop a systematic scoring system to assess partogram use in varying settings and to quantify the use of the tool with a particular focus on fetal heart rate monitoring (FHRM) as this has received limited focus to date and potentially provides the highest impact from the tool.

Review of existing evidence for the effect and use of the partogramIn a systematic review looking at the distribution and use of partograms globally, 8 papers were reviewed. The numbers of partograms that were assessed ranged from 234-1200. Most studies focus on general use without specific attention for fetal heart rate monitoring. The studies that were carried out show minimal utilization of partograms. When the partogram is used, few people use it correctly. All authors conclude that distribution and use of the partogram may be acceptable but the quality of use is below the standard required. Health care professionals in all different levels of care need to be trained and motivated to use the partogram consistently and according to the

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standard. Studies also show that, if monitoring with the partogram is done correctly, both maternal and neonatal outcomes are better. MethodsPartogram Assessment Tool

Based on the literature review and consideration of published partogram audits, we developed a partogram assessment tool (PAT) with a standardized scoring system to assess the partograms for completion and quality. The following principles were applied while designing the PAT: the tool must be easy and quick to fill out, fit on one page to reduce printing costs and the data must be easily transferable to a digital format so that a database can be created. The PAT assesses the partograms with the South African national guidelines as the gold standard. To get the full marks, a partogram has to be filled out according to these guidelines. The scoring system provides two scores, one general score and one specific scoring regarding fetal heart rate monitoring.

Study design and setting

The study was a retrospective audit of the quality of partograms, with a specific focus on monitoring the fetal heart rate. The study was conducted at Mowbray Maternity Hospital (MMH), which is situated in the urban boundaries of Cape Town, South Africa. MMH is a referral hospital providing maternal and neonatal services to a designated drainage region. Each month there are over 800 births at MMH of which 300 are by caesarean section. Data collection took place between January and May 2012.

Inclusion and exclusion criteriaFiles of mothers who were discharged during the period in which the research took place were obtained through the records department. Only partograms following labours of women with singleton pregnancies, and with at least 3 hours of monitoring were included. Partograms were excluded if it was impossible to determine which device was used for monitoring, if labour started with an antenatal stillbirth, if the fetus had non-viable anomalies, if the gestational age was below 28 weeks or if the woman was admitted with 7 centimeters or more vaginal dilatation.The study sample was divided into two groups based on the device that was used for FHRM; cardiotocograph (CTG) or non-cardiotocograph (not-CTG). Mothers in the not-CTG group were monitored with either a Doppler ultrasound

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fetal heart rate monitor (dFHRM) or a Pinard fetal stethoscope (PFS). In case a mother was in the non-CTG group, only the section up to the time they were transferred to the MMH was used for assessment. This was done because all mothers in MMH were monitored with a CTG. Data collection and analysis

Data were collected by one trained research midwife using the PAT form, for consistency in scoring Data were entered into Microsoft Excel and analysed using STATA 10. Summary statistics were estimated separately for CTG and non-CTG groups. Bivariate associations were calculated using chi-squared tests for all categorical variables. Ethical approvalThe study was approved by the ethics committees of the University of Cape Town and of MMH (approval number HREC 558/2011).

Results1306 files from mothers that were discharged from MMH after delivery were reviewed. After excluding 768 files that did not meet inclusion criteria, 538 eligible partograms were assessed and scored. In 6.7% (n=88) of all the screened patient files, a partogram should have been used but was not used without apparent reason. The study sample was divided in two groups, 50% (n=269) of the partograms were of mothers who were monitored with a CTG and 50% (n=269) of the partograms were of mothers monitored with a Pinard fetal stethoscope or dFHR. The labour of the CTG group started in a referral hospital because they were assessed to be at higher risk during the pregnancy. The women in the non-CTG group had normal pregnancies but were referred to the referral hospital during their labour because complications, like prolonged labour or an abnormal fetal heart rate, were diagnosed. There was no significant difference between the two groups in average age, gravidity, history of prenatal death, time of presentation and the total duration of monitoring. Outcomes of labourThe types of delivery are not significantly different for the two groups. The non-CTG group had more spontaneous vaginal deliveries than the CTG group (65.4% vs. 59.4%) but this was not significant (p=0.141). The Apgar scores were a bit lower for the non-CTG group but the difference with the CTG-group was not significant either for Apgar after 1 minute (p=0.0857) and for the Apgar after 5 minutes( p=0.4299). 7.1% of the babies born in the CTG-group were admitted to

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the neonatal special care unit (NSCU) and 17.5% needed resuscitation. 11.9% of the babies born in the non CTG group were admitted to the NSCU unit and 21.2% needed resuscitation.Partogram quality scoresAll the partograms were assessed and given a score, based on the quality of the recordings.. The group monitored with a CTG scored significantly better on the quality of fetal heart rate monitoring (p=0.0004) while the non-CTG group scored better on the monitoring of the mother and the progress of labour (p=<0.0001). 26 partograms had a break of at least 2 hours somewhere in the monitoring period where no observations were recorded. This happened 13 times in both the CTG and non-CTG groups.

DiscussionThis is the first study we are aware of using a standard way of scoring partograms that focuses on FHRM. Our data clearly showed that even in an academic hospital, the majority of partograms were poorly completed. The worst part was the FHRM section, even though this potentially has the highest impact on perinatal deaths given 1.2 million intrapartum stillbirths and 720,000 neonatal deaths in term babies annually from intrapartum complications. The results of this study do not evaluate how much a high PAT-score predicts better outcomes. In the study sample, there was only one stillbirth in the non-CTG group and Apgar scores were not significantly different in the two groups (p=0.0857). Further studies to review the relation between completion of partogram and outcomes of birth are recommended. These results show that the current approach to monitoring mothers during labour may not be feasible even in this relatively high resource setting and raises questions about the number and frequency of measurements required on the partogram, and the quality of fetal monitoring. Training alone will not solve these challenges, especially in the realities of under staffed, busy labour wards in most of Africa and South Asia. The data in this study depends on what was recorded on the partogram and not what midwives actually observed. Therefore it was not known whether many observations were not done or just not recorded. It was assumed that observations not recorded were not done. This study was not designed to link the PAT score to mortality outcomes. In the study sample there was only one stillbirth in the non-CTG group and the Apgar

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scores were not significantly different in the two groups (p=0.0857). Further studies using the scoring tool in high mortality settings to review the relation between completion of the partogram and outcomes of birth are planned.

ConclusionEven in a South African teaching hospital setting which is relatively well staffed, partogram completion according to guidelines is about half of expected. In many African and Asian facilities, where there is understaffing and overcrowding, partogram use is even more challenging. Additional assessments of partogram use with the PAT in different settings, especially without CTG use, will provide more insights into FHRM practises and guide strategies to reduce death and disability for mothers and their babies. These data underline the need for a fundamental rethink of the approach to intrapartum tracking and especially the frequency and methods for FHRM.

FundingWe thank the Laerdal Foundation for providing financial support for this study. The funding agency was independent from the study design, data collection, and data analysis.

Competing interestsNone declared

Author contributionsTo add

AcknowledgmentsWe thank the midwives and support staff of Mowbray for their helpfulness in the data collecting process.

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SESSION 7: PAPER 3

THE EVALUATION OF A TABULAR APPLICATION OF THE NICE GUIDELINES FOR UNIVERSAL INTERPRETATION OF NON-STRESS TEST(NST) AND CARDIOTOCOGRAPHY(CTG)

Noxolo JackChris Hani Baragwanath Academic hospital

Objective: To assess parity of interpretation of cardiotocographs(CTGs) and non-stress tests(NSTs) between different grades of obstetric clinical staff by comparing assessment of traces by non-systematic eyeballing with assessment of traces using a tabular approach suggested by the National Institute of Health and Clinical Excellence (NICE) guideline for interpretation of CTGs and NSTs, and to identify components of NSTs and CTGs with which medical personnel experience difficulty with interpretation.

Design: Prospective observational study.

Setting: Maternity units of the tertiary care hospitals for the teaching and training of the Witwatersrand University postgraduates, interns and midwives.

Participants: Midwives, advanced midwives, interns, medical officers, registrars and specialists working in the above-mentioned maternity units.

Method: Participants were recruited at the time of formal gatherings and departmental meetings in the various institutions. Each was given 5 traces which were a combination of NSTs and CTGs to interpret and assess in a non-systematic way using 3 categories; baby well, baby requires further surveillance, and baby needs immediate delivery. The same participants were then given the same set of traces in a different sequence for interpreting in a systematic way using the tabular approach from the NICE guideline on electronic fetal monitoring with a scoring modification. All participants received the same 5 traces.

Main outcome measure: Differences in interpretation of CTGs by different grades of staff, and degree of certainty between study participants in the different assessment systems.

Results: Twenty seven specialists, 25 registrars, 21 medical officers, 10 interns and 15 midwives participated. There were varying interpretations by different grades of medical staff in the non-systematic assessment, with statistically significant differences in the assessment of 3 out of the 5 traces. These differences disappeared when the traces were assessed using the tabular approach based on the NICE guidelines. Using the NICE guidelines, there was uncertainty (failure to agree on classification by 75% or more of the participants) with baseline variability, decelerations and overall assessment of the CTG in most of the traces.

Conclusion: There is no uniformity in the non-systematic assessment of traces. Uniformity and reduction in inter-observer variation was attained by the use of the NICE guideline tabular approach. However, baseline variability, decelerations and overall assessment remain a problem in the interpretation of NSTs and CTGs using the NICE guidelines.

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SESSION 7: PAPER 4

COMPARABILITY OF AN INNOVATIVE DOPPLER ULTRASOUND FETAL HEART RATE MONITOR TO A PINARD FETAL STETHOSCOPE USING CARDIOTOCOGRAPHY AS A STANDARD TO ASSESS THE FETAL HEART RATE IN SINGLETON PREGNANCIES DURING LABOUR AT MOWBRAY MATERNITY HOSPITAL

Chinula L 1 , Fawcus S², Woods D² Lawn J³1Ob/Gyn Registrar, University of Cape Town, 2University of Cape Town, 3Saving Newborn Lives/Save the Children South Africa

Introduction In South Africa, ‘intrapartum hypoxia and birth trauma’ are among the top three causes of perinatal deaths. Severe intrapartum hypoxia is often preventable with appropriate maternal and fetal monitoring in labour. However, this remains a challenge in under- resourced settings, due to challenges that accompany the use of Pinard Fetal Stethoscope (PFS) which include user-dependence and questionable accuracy in busy midwife obstetric units. Although intermittent fetal heart monitoring is as effective as continuous electronic monitoring in low risk labours, the challenge is for a reliable, robust and cheaper fetal monitoring devices. The innovative crank powered Doppler Ultrasound Fetal Heart Rate Monitor (DUFHRM) developed by Power-free Education and Technology is robust, cheaper and designed for use even in settings with no or erratic access to mains electricity and overcomes some challenges that come with the use PFS. We assessed the accuracy of Fetal Heart Rates (FHRs) taken with the DUFHRM compared to FHRs taken with a PFS using Cardiotocography (CTG) as a standard fetal heart rate monitoring device.MethodThis was a comparative diagnostic study conducted at a public sector maternity hospital during 2012. We enrolled women with singleton pregnancies who had consented to participation without undue pressure or coercion. Paired readings of FHRs were taken with DUFHRM and PFS, by two midwives and also with CTG during active phase of first stage of labour before and after two preferably consecutive uterine contractions. The midwives were blinded to the CTG measurements by silencing the CTG and turning it away from their view. The DUFHRM and CTG readings were made at the start and end of each 60 second period of PFS monitoring. The proportion agreement of FHRs taken with DUFHRM to FHRs taken with CTG, and proportion agreement of FHRs taken with PFS to FHRs taken with CTG were determine and compared using McNemar Exact Significance Probability test (mcc)Results: We enrolled seventy six pregnant women with singleton pregnancies in the active phase of first stage of labour. The mean age of women enrolled was 24 years. 39 women (51.3%) were multigravida. 54 women (71.1%) were in labour at term. 66 women (86.9%) went into spontaneous labour. Labour was augmented in 32 women. 72 women had no medical conditions. Thus the majority of enrolled women had relatively low risk pregnancies. Before the first contraction, proportion agreement to CTG was 0. 605 (CI 0.486 – 0.715) with the DUFHRM and 0.355 (95% CI 0.248 –0. 473) with a PFS (mcc =0.0034) and again 0.802 (95% CI 0.695 – 0.885) with the DUFHRM and 0.368 (95% CI 0.260 -0.486) with a PFS (mcc = 0.000). After the first contraction, proportion agreement to CTG was.0.657 (95% CI 0.540 –0.762) with the DUFHRM and 0.421 (95% CI 0. 308 – 0.539) with a PFS (mcc =0.0079) and again 0.789 (95% CI 0.680 – 0.874) with the DUFHRM and 0.381 (95% CI 0.272 – 0.500) with a PFS (mcc = 0.000). Before the second contraction, proportion agreement to CTG was 0.506 (95% CI 0.388 –0.624) with the DUFHRM and 0.440 (95% CI 0.325 – 0.559) with a PFS (mcc =0.511) and again 0.773 (95% CI 0.662 -0.862) with DUFHRM and 0.506 (95% CI 0.388 – 0.624) with a PFS (mcc = 0.001). After the second contraction, proportion agreement to CTG was 0.546 (95% CI 0.427 – 0.662) with the DUFHRM and 0.493 (95% CI 0.375 –0. 611) with a PFS (mcc =0.651)) and again 0.773 (95% CI 0.618 – 0.828) with the DUFHRM and 0.480 (95% CI 0.363 – 0.59.=8) with a PFS (mcc =0.01).

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Conclusion: The DUFHRM significantly compared with CTG in assessing FHRs both before and after uterine contraction in singleton pregnancies in labour more reliably than PFS. This study provides strong evidence for the routine use of the DUFHRM rather than a PFS for assessing FHRs before and after contraction in relatively low risk pregnancies. This finding promises to improve the quality of intrapartum fetal monitoring in low risk pregnancies.

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SESSION 7: PAPER 5

THE EPIDEMIOLOGY OF MECONIUM ASPIRATION SYNDROME: INCIDENCE, RISK FACTORS, THERAPIES AND OUTCOME AT A SEMI RURAL HOSPITAL.

N Kapongo*, Z Duze* M Samjowan*, S Singh*, T Kalala*, A Thalane, CN Phili*, SR Shazi*, NT Mzolo*, R Hashmi* I Gasarasi*(*): Paediatric Department, Neonatal Unit, Lower Umfolozi, District War Memorial Hospital (LUDWMH).

IntroductionApproximately 13% to 20% of live-born infants are delivered through meconium-stained liquor (MSL). In the vast majority of labours, MSL is not of concern. In some circumstances, the passage of meconium in utero is associated with significant increases in perinatal morbidity and mortality. The aspiration of meconium into the lungs during intrauterine gasping, or when the baby takes its first breath, can result in a life-threatening disorder known as meconium aspiration syndrome (MAS).

Meconium, the faecal material that accumulates in the fetal colon through gestation, is a term derived from the Greek “mekoni”, meaning poppy juice or opium. Commencing with Aristotle’s observation of the association between MSL and the sleepy state or neonatal depression, Obstetrician have been concerned about fetal well-being in the presence of meconium-stained amniotic fluid (MSAF). Meconium is a sterile, thick, black-green, odorless material first observed in the fetal intestine during the third month of gestation. Meconium results from the accumulation of debris, including desquamated cells from the intestine and skin, gastrointestinal mucin, lanugo hair, fatty material from the vernix caseosa, amniotic fluid and intestinal secretions. It comprises 72 to 80 % of water and contains cholesterol, lipids, and enzymes including pancreatic phospolipase A2, muchopolysacharides, proteins, bile acids and salts as well as drug metabolites. The black-green color result from bile pigments.

In the fetus, passage of meconium occurs physiologically early in gestation, when it contributes to alkaline phosphatase activity in the amniotic fluid. Abramovich et al. noted that fetal defecation diminishes after 16 weeks and ceases by 20 weeks, concurrent with enervation of the anal sphincter. At that time, the rectum appears to be filled with meconium. From approximately 20 to 34 weeks, fetal passage of meconium is infrequent. Most newborn infants who

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pass meconium are mature (term). The incidence of MSAF in preterm deliveries is relatively low (4.8%).

Fetal hypoxic stress may stimulate colonic activity, resulting in the passage of meconium, and also stimulate fetal gasping movements that result in meconium aspiration. When aspirated into the lung, meconium may stimulate the release of cytokines and other vasoactive substances that lead to cardiovascular and inflammatory responses. The pathophysiology of meconium-induced lung injury is complex and not completely understood. Current evidences suggest that meconium aspiration by a newborn besides causing airway obstruction causes local inflammation. The inflammatory reaction leads to cellular influx of neutrophils and macrophages. Both release inflammatory cytokines, which in turn cause inflammation and set up the process of apoptosis. The end result depends on the extent of inflammation and degree of apoptosis. Moderate apoptosis may leave no permanent damage. Severe apoptosis initiates fibrotic reaction. It is also to be noted that meconium can induce serpin (protease inhibitor) expression, which plays a protective role against injury and apoptosis which outcomes depends from the ratio of proteases and serpins. If this ratio is large, a large damage is observed; if small, the damage is minimal.

Prevention of MAS is paramount. Four main types of intervention were found in the literature that may influence outcomes of labour where there is MSAF, namely: use of a scoring system of MSL; amnioinfusion; prophylactic antibiotics; and suctioning of the baby at birth. The American Academy of Pediatric Neonatal Resuscitation Program Steering Committee and the American Heart Association have promulgated guidelines for management of baby exposed to meconium. The guidelines are under continuous review and are revised as new evidence-based research becomes available. Current recommendations no longer advise amnioinfusion or routine Intrapartum suctioning for infants born to mothers with MSAF.

MAS occur in 5% of MSL –exposed infants and at least a third of infants with MAS require intubation and mechanical ventilation, and newer neonatal therapies, such as high-frequency ventilation(HFV) ,inhaled nitric oxide, and surfactant administration are often brought into play(6). Peter A. Dargaville et al. examined in a large cohort of infants within the Australian and New Zealand Neonatal

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network. MAS needing intubation occurred in 1061 of 2 490 862 live births (0, 43 per 1000), with a decreased incidence from 1995 to 2002. This reduction in incidence has been reported in many centers, at least in developed world. The apparent reduction in the risk of MAS has been attributed to better obstetric practices, in particular, avoidance of posmaturity and expeditious delivery where fetal distress has been noted.

A complete understanding of the epidemiology of MAS, even in developed world, has been hampered by the lack of population –based studies and difficulties in assembling large cohorts of infants with confirmed disease. A majority of researchers have sought to remedy this situation using information from database from large neonatal network (6). In developing countries, the limitations to assess the outcome of MAS is related to limited resources resulting in difficulties in making a diagnosis of MAS, which requires the presence of X-rays changes. Patients with possible MAS might die before a chest-X-ray (CXR) is done or might significantly improve and be discharge without having had a CXR unless they are admitted to Neonatal intensive care Unit (NICU) for mechanical ventilation. At LUDWMH, since 2011, following unexplained deaths of 3 infants MSAF exposed in the post-natal ward, infants delivered through MSAF, are systematically referred to Nursery admission section for routine 3 to 6 hours observation. We sought to examine, the incidence, risk factors, treatments and outcomes of MSAF and MAS within a definable 2012 population of live births delivered or seen at LUDWMH.

Material & Methods

Physical FacilitiesEmpangeni Neonatal unit is part of a child and Maternal Hospital, Lower Umfolozi District War Memorial Hospital (LUDWMH) in North-East of Kwazulu-Natal, South Africa. This is the only maternity and neonatal regional referral centre for an area with a population estimated at 2 Millions. According to census 2011, poverty rate and unemployment rates stand at 63.5% and 53.7% respectively. The proportion of households with access to safe to census water (32%) and sanitation (24%) are far below the national figures (79% and 62%, respectively). Fifty thousand (50 000) live births occur in the entire area annually including 10 000 at LUDWMH .The neonatal service was introduced at the hospital in 1998

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with a 15 unit beds without intensive care facilities. Between 1999 and 2008 the unit was expanded to 92 bed neonatal units: 16 NICU beds, 40 high care, 16 special care beds and a Kangaroo mother care (KMC) unit (20 beds). The post- natal ward has 86 capacity beds but daily patients average one hundred. This overcrowded post- natal ward combined to the nursing shortage has made inefficient newborn monitoring in the post- natal setting. Three full time Paediatric and four Obstetric consultants run the neonatal and maternity services, respectively.

Data collectionThis is a Review of Routine neonatal database (2012 neonatal admissions). The database has been in place since 2000 and has been revised and update over the years. In 2007, a dedicated Neonatal intensive care (NICU) database was added as linked page to the neonatal database. The process of routine daily build up of the NICU database is similar to that of the general Neonatal database and is described below. On admission, at discharge and during the weekly neonatal morbidity and mortality review, standardized clinical and laboratory data of NICU patients are collected in a monthly edited NICU admission book template compatible with CDC Epi-Info. 2000 locally designed data set. This includes demographic details, referral status, admission and discharge diagnosis, NICU admission criteria, ventilation details, downe’s score, obstetric risk factors, outcome and date of outcome, laboratory results. Only neonates admitted to NICU needing IPPV or nasal CPAP are enrolled in the NICU register. A team Unit secretarial support helps to update the information on a daily basis. A weekly and monthly data clean up and update is done before to run the monthly and yearly analysis program. The maternal and neonatal clinical files of all MSAF infants in the database for the period of study, were retrieved and reviewed to validate critical database information on MAS. Additional maternal details: age, parity, hypertensive disease, antenatal attendance; and fetal& neonatal information: fetal distress, resuscitation at birth, post maturity, cord problems, CTG, Intrauterine growth restriction, respiratory distress on nursery admission were retrieved. The infant’s chest radiographs were reviewed from the hospital electronic system (PACS system) to validate the diagnosis of MAS.

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For this review, the Empangeni Neonatal data set for the period of January 2012 to December 2012 was search for infants with MSAF and MAS. We defines MAS in a meconium –stained infant as respiratory distress displaying symptoms such as hypoxia, tachypnea, gasping respirations, and signs of underlying asphyxia, with a chest radiograph showing overexpansion of lungs with lung infiltrates (6). Perinatal asphyxia was defined by the association of 3 indicators: Fetal distress, depression at birth and significant metabolic acidosis, base excess < -12 millimols per liter. The grading of meconium in grade I, II and III reflects midwifes routine practice in the labour ward at LUDWMH. MSAF grade I: light staining is when there is a small amount of meconium diluted in a plentiful amount of amniotic fluid, MSAF grade II: moderate staining, in this case the waters looks definitely khaki green or brownish, MSAF grade III: heavy meconium is when there is reduced amniotic fluid and a large amount of meconium, making staining quite thick, green, oozy discharge rather than a watery flow. Any justifiable change of line of antibiotics according to the unit check list infection control tool is recorded as Nosocomial infection in an infant with at hospital stay more than 48 hours. During the study period, the protocol on MAS treatment and management of infants was in line with revised guidelines of the International Liaison Committee on Resuscitation (7). It is in our routine protocol to commence antibiotics in all cases of MAS. Surfactant is available in the unit. We do not have Nitric oxide facility. Maternity data were retrieved from hospital PPIP data and from the Excel data summary compiled monthly using maternity clerk data forms.

Statistical AnalysisCapturing and analysis were carried out using CDC Epi-Info-3_5_1 programme. This include simple frequency analysis, Stratified analysis to determine stratum specific odds ratio, Chi-square associations to determine odds ratios and confidence intervals, Summary odds ratio and parametric & non parametric one way analysis of variance test for comparing means. Univariate and stepwise multivariate analysis were used to determine the relative strengths of associations. Our analytic approach to these data was descriptive in nature. Differences in the demographic and other characteristics of infants with and without MAS were analyzed by comparing the two populations with univariate analysis. Continuous variables (e.g., gestational age, birth weight, parity, Apgar score) were evaluated with two-tailed t-tests. Categorical variables (gender,

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maternal hypertension, fetal distress, respiratory distress on admission …) were evaluated with two –tailed Chi-square tests. Nonparametric data were assessed with Kruskal-Wallis analysis of variance. After bivariate analysis, multivariate logistic regression was used to calculate adjusted odds ratio (OR) for MAS by comparing the MSAF neonates with and without MAS. At analysis level, we recoded MSAF grade III to thick, grade I and II to light. A 5% level of significance was used.

ResultsPopulation sample and outcomeA total of 9975 live births neonates comprises the starting population and 3329(33%) were admitted to the LUDWMH neonatal unit from January to December 2012. Of the 3329 neonatal admissions, 526 (16%) were admitted to Neonatal Intensive care (NICU) for mechanical ventilation. The total number of neonates with MSAF was 505 (5% of all live births and 15% of Neonatal unit admissions). Of the 505 with MSAF neonates, 71(1% of live births; 13% of NICU admissions; and 14% of all MSAF) developed MAS. A higher risk of MAS was noted in the group with initial resuscitation at birth, with 33% of cases from the group needing initial resuscitation, compared to 1% in the other group. MAS neonate needing mechanical ventilation occurred in 41(58%) and 15(21% of MAS and 37% of MAS ventilated). Among the 299 neonates with the diagnosis of perinatal asphyxia, 57(19%) had MSAF and of these 27(47%) developed MAS .Comparing the two groups of MSAF with and without concurrent asphyxia diagnosis, it was noted that the proportion of MAS was higher in the asphyxia group (47%) than 10% in the non- asphyxia group (OR 8.6, CI 4.2-15.8, p<0.00000). Although the proportion of ventilated MAS was similar in the two groups (59% and 56%), the mortality rate was higher in the ventilated- MAS asphyxia group (60%) than the 23% rate in the non-asphyxia group (OR 5, CI 1.15-25.62, p < 0.0195319). This information on the population sample and outcome flow is summarized in the 3 figures (1, 2, and 3).

Maternal, fetal, peri-partum and neonatal characteristicsThis information is shown in the 3 tables (1, 2 and 3) 1Ninety-six percent of infants were born inside a healthcare facility and only 4% were referred. The maternal HIV status was positive in 32% of cases, which was in line with the institutional rate from antenatal clinic. Fifteen percent of infants were born at 41

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weeks or more gestation. Electronic monitoring was documented in 93% of all MSAF cases, of which 29% had abnormal tracing. It was noted that the likelihood to have an abnormal tracing was higher in the MAS group (OR 7.01, CI 3.90-12.69, p< 0.0000). Sixty-eight percent were born by caesarian section (C/S). The information about the indication nor the emergency nature of the C/S is not recorded in the database. However twenty six percent of infants had a peri-partum diagnosis of fetal distress. The proportion of fetal distress was higher in the MAS group (63% vs 20%, OR 7.00, CI 3.9-12.43, p<0.0000). The number of infants who required resuscitation at birth (204) is far greater than the low (< 5)1 minute apgar (43) suggesting over-reading of Apgar score. Infants exposed to grade III meconium were most likely to develop MAS if compared to those exposed to grade I and grade II ( OR 3.98, CI 2.08-7.22, p < 0.000033).Primigravida status and maternal hypertension were significantly associated with MAS (OR 3.35, CI 1.92-5.89, P<0.0000033) ; (OR 6.04, CI 3.44-10.10.63, p< 0.00000) respectively. Univariate analysis identified ten risk factors (table 4) for MAS (p<0.05): maternal age < 18 years, maternal age <18 and > 35 years, maternal hypertension, Primigravida status, Meconium grade III, fetal distress, need for resuscitation at birth, low Apgar score (<5) at 1 minute, respiratory distress on admission, intra uterine growth restriction.With MAS as a dependent variable , binary logistic regression analysis identified the best predictor model with six independent risk factors (table 5): maternal hypertension, resuscitation at birth, fetal distress, 1 minute Apgar<5, meconium grade III and respiratory distress on admission.

Characteristics of ventilated MASThis information is shown in table 6 and 7. Of the 71 neonates with MAS, 41 (58%) needed mechanical ventilation: 2 (5%), 36(88%), 3(7%) had CPAP, IPPV, HFV, respectively. The median NICU stay was 5 days (range 1- 16) and the overall hospital stay at discharge was 7 days (range 1-44). The mean highest FIO2 and mean maximum peak pressure used were 78.8 %( range 40-100) and 22.6 cm H2O (range 15-35), respectively. Common complications among patients with MAS were PPHN (54%), air leak (22%), Nosocomial Infection(51%). There was significant proportion of male infants (63.4%), infants who required resuscitation at birth (90.2%) and those born from Primigravida mothers (58.5%).

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DiscussionThe incidence of MSAF in the live birth population at LUDWMH is 5%. Fourteen per cent of MSAF (10 per 1000 live births) developed MAS, of which 58% needed mechanical ventilation (4.1 per 1000 live births). The incidence of MSAF varies in different reports and our observation of 5% falls within the reported range of 5 to 24.6 %( 10). Majority of observed MSAF was grade III (49.8%) and grade II (41%), possibly because grade I being more subjective, is under reported and more prone for variations in incidence. In India, N.Sankhyan et al. (11) reported 159 (15.7%) of MSAF of 1009 deliveries. In 1995, a retrospective study (12) by Adhikari & Gouwns (569 cases of MAS from 11 hospitals in South Africa) revealed a high incidence varying from 4 to 11 per 1000 live births. Our incidence of 10 per 1000 live births falls on the higher bracket of incidence among major South African hospitals. This is expected in the context of high incidence of perinatal asphyxia (30 per 1000 LB, encephalopathy rate of 15.6 per 1000LB). We report a high case fatality of 21% of all MAS, 37% among ventilated MAS. In the abovementioned study, Adhikari & Gouwns reported a mortality rate of 12% of MAS and 36% among ventilated MAS. More recently, Velaphi & Van Kwawegen (13) reported a mortality rate of 33% among 88 ventilated MAS at Chris Hani Baragwanath Hospital. These mortality rates are high if compared to developed countries reported rates. Data from the Australian and New Zealand Neonatal Network group shows mortality rate around 2.5% (6). The high mortality rate of 37% among ventilated MAS in this review and other reported studies in South Africa could be related to associated conditions such as PPHN, Nosocomial infections and low usage of adjunct respiratory therapy. Five out of six independent risk factors predictors for MAS in our logistic regression model are directly or indirectly associated with Intrapartum fetal compromise and asphyxia was the only significant(p<0.0195319) independent variable found while comparing the survivors and Nonsurvivors groups among ventilated MAS at LUDWMH. These findings in the context of higher rate of antenatal attendance 86% overall, 93% in the MAS group and acceptably higher rate of Intrapartum monitoring, 91% overall and 97% in the MAS group. The interpretation of these results suggests important quality assurance issues in antenatal, peripartum and postnatal care. MAS can be managed effectively by joint effort of the obstetrician and pediatrician. Prevention is paramount; obstetricians should closely monitor fetal status in an attempt to identify fetal stress. Current recommendations no longer advocate amnioinfusion, routine Intrapartum suctioning for infants with

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MSAF. The low mortality rate in developed countries has been associated with an increase in the use of exogenous surfactant, high- frequency ventilation and inhaled nitric oxide, with more than 50% of infants receiving one or more of these therapeutic modalities (6). This postnatal therapy success happened in a general context of improved and efficient obstetric practices which have reduced to a minimum the impact of perinatal asphyxia contribution to the incidence of MSAF, MAS ; the severity of the disease and its influence on mortality. The association between the occurrence of MSAF & MAS and fetal distress has been shown by several workers (11, 13). Most of our peripheral centers are without capacity for managing high risk deliveries or giving essential newborn care. If incorporated into basic training for health workers some of the MAS predictors described in this review can facilitate early referral and prompt labour management. Secondly, remediable or preventable causes like maternal hypertension provide opportunities for intervention and planning. Majority (80%) of MASF infants were well babies on admission without any risk factors for MAS. This review shows that only 1 in 100 of these well babies on admission, developed MAS. This group of neonates can be monitored in the post natal ward. In a very work load- sensitive unit like ours, this will allow the neonatal admission ward to focus on achieving priorities during the first “golden” hour in most vulnerable infants such as very low birth weight , MAS and asphyxia infants. During the one year review, infants with MAS represent 2% of the Unit admissions and deaths due to MAS contributed to 5% of neonatal deaths. Midwives should be asked to monitor these infants for color, temperature, and respiratory rate, signs of retraction, feeding intolerance and muscle tone. They should ring the alarm bell for the neonatal team if any concern. In a case of well infant with a history of thick MSAF, the NICE guideline recommends observation at 1 and 2 hours of age and then 2 hourly for 12 hours after delivery (15). In our Unit routine we discharge well MSAF babies within 3 to 6 hours provided that they tolerate feeding. Van Lerland Y and al. found it was safe to discharge home well MASF infants with Apgar score > 8 at 5 minutes (16). The mode of delivery was not associated to MAS in this review (p=0.681088, c/s vs NVD). Adhikari & Gouws review (12) had similar observation but Velaphi & van Kwawegen (13) observed that infants ventilated for MAS were more likely to have been born by cesarean section. Our database did not capture the details of emergency vs elective c/s section. Primiparity was found among other risk factors predictors of MAS in univariate analysis. Some workers (11, 12) have made this observation. It

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is not clear whether or not MSAF is associated with primiparity status. The duration of labour of a nulliparous woman is significantly longer than that of a multiparous woman especially the second stage of labour (17). KA Lee & al. have recently demonstrated that the frequency of MSAF in women not in labour is drastically lower than in women with labour and clarified the association between MASF and the duration of labour. The longer the duration of labour, first stage, second stage, or total, the higher the frequency of MSAF (17). Our Neonatal database does not capture this information. Using the unit Nosocomial infection surveillance check list system, 51% of the ventilated MAS had Nosocomial infection. This is common in the infants with prolonged ventilation in the unit and it is associated with mortality and long term morbidity. Because of lack of reliable quantitative C- reactive protein service at the hospital laboratory, we were unable to assess the status of inflammation on admission. Velaphi & van Kwawegen observed that among the MAS infants who had their CRP level assessed, 92% had > 10mg /L and 78% had CRP > 20 mg /L, suggesting the presence of inflammation or infection. Several investigators have suggested that MSAF is highly associated with chorioamnionitis (18).

ConclusionThe incidence of both MSAF and MAS is high at this semi-rural Hospital. Terms neonates admitted with MAS represent a high-risk population with significant morbidity and mortality. Meconium aspiration syndrome is associated with variables of intra uterine fetal compromise. This happened in a context of high antenatal attendance and acceptably high coverage of fetal monitoring, suggesting quality assurance issues in the antenatal and intra partum care. The uptake of adjunct respiratory therapies in the management of intubated MAS is very low at LUDWMH. Urgent review of the policy of systematic observation of asymptomatic MSAF infants in nursery admission section is needed.

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SESSION 7: PAPER 6

DEVELOPMENTAL TRAJECTORIES OF EEG ACTIVITY AND FUNCTIONAL CONNECTIVITY IN LATE PRETERM INFANTS

Fifer WP, Burtchen N, Myers MMDepartments of Psychiatry and Pediatrics, Columbia University, New York City

IntroductionLate preterm births (born at 34 0/7-36 6/7 postmenstrual age) account for more than 70% of all premature births in the United States. Late preterm births are associated with 3 to 7 times increased morbidity and mortality in the neonatal period as well as in later infancy and childhood, increased rates of neonatal re-hospitalization and suboptimal long-term development. The period between 34-37 weeks of gestation has been identified as a particularly important phase of brain development. New techniques allow for non-invasive, rapid and significantly less expensive ability (compared to traditional methods) to collect basal electroencephalogram (EEG) patterns during sleep. It is currently not known if and how trajectories in EEG power and coherence differ between late preterm and full-term infants. We carried out a comparative study of EEG measures in late preterm and full-term babies to facilitate a better understanding of early brain development and ultimately identify biological markers of early vulnerability.

Methods128-lead EEG during sleep in 42 late preterm infants (gestational age (GA) 35 0/7 - 36 6/7 weeks) and 48 full-term (GA 39 0/7 - 40 6/7 weeks) at two time points: at 18-72 hrs and at 4 weeks after delivery (39-40 weeks and 43-44 weeks postmenstrual age for late preterm and full-term, respectively). EEG power and coherence were measured in 30-s epochs in ten spectral bands (1-50 Hz) in ten brain regions for EEG activity, and nine region-to-region indices for functional EEG connectivity.

ResultsFor EEG power, at birth late preterm infants showed significantly lower EEG power at low frequencies, as compared to full-term Infants (p<.001). At four weeks after delivery late preterm EEG power reached levels comparable to full-terms at birth for low frequency bands (p<.001). For high frequency bands, however, late preterm infant EEG power at 4 weeks remained low and neither reached levels comparable to full-terms at birth nor levels comparable to full-terms at 4 weeks of age (p<.01 and p<.05, respectively).For EEG coherence, late preterm infants at birth showed significantly lower left to right temporal and parietal EEG coherence, compared to full-term, with most pronounced findings at higher frequencies (p<.001). At 4 weeks, full-term temporal and parietal EEG coherence decreased significantly across frequencies, (p<.001). Late preterm EEG coherence at 4 weeks remained at levels comparable seen at birth. This resulted, especially at higher frequencies, in significantly higher EEG coherence for late preterms at 4 weeks, a pattern opposite to differences between late preterm and full-term infants.Findings were independent of sleep state.

ConclusionsFuture studies need to determine if and when late preterm EEG activity reaches levels comparable to full-term EEGs and if these differences are predictive of specific neurodevelopmental outcomes. Developmental trajectories of EEG coherence might reflect establishment of long distance connectivity and/or synaptic pruning. Future studies will need to investigate if persistence of immature patterns in EEG power and coherence might be associated with adverse neurodevelopmental outcomes as is observed in other studies of late preterm infants. This research was funded by the following grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development: R37 HD32774

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