Oxytocin – ensuring appropriate use and balancing efficacy with safety

Maternal deaths due to haemorrhage continue to increase in South Africa (SA). It appears that oxytocin and other uterotonics are not being used optimally, even though they are an essential part of managing maternal haemorrhage. Oxytocin should be administered to every mother delivering in SA. Awareness is required of the side-effects that can occur and the appropriate measures to avoid harm from these. Second-line uterotonics should also be available and utilised in conjunction with mechanical and surgical means to arrest haemorrhage in women who continue to bleed after the appropriate administration of oxytocin

Alerts for managing postpartum haemorrhage

A review of maternal deaths from postpartum haemorrhage (PPH) in 2014 - 2016 raises concern at the slow rate of reduction of mortality. Folder review showed that 87.8% of deaths were avoidable and identified ‘red flags’: common omissions (poor problem recognition), commissions (incorrect treatment) and areas of substandard care (inadequate monitoring and/or management). The lessons learnt have led to key practice points for managing PPH, which are presented in this article. These include: referral to an appropriate level of care for delivery, medications for prevention of PPH, and how facilities can be prepared for PPH to detect it timeously – before the onset of coagulopathy. Emergency management of severe obstetric haemorrhage includes resuscitation, identifying the cause/s of the bleeding, medical treatment of PPH, non-medical interventions for PPH in the labour ward, early recourse to theatre with ongoing bleeding and a description of effective surgical interventions. The problems associated with referral of patients with PPH are discussed. Updated management algorithms for PPH in South Africa are presented

Knowledge and expectations of labour among primigravid women in the public health sector

Objectives. We analysed knowledge and expectations of the process and pain of labour in primigravidas attending a local midwifery obstetric unit (MOU). It was anticipated that the results of this study could inform the development of interventions aimed at improving the analgesic care of women delivering at primary health care obstetric units. Design. Qualitative analysis of data obtained from in-depth semi-structured interviews. Setting. A Cape Town MOU. Subjects. 30 black African, Xhosa-speaking primigravidas. Outcome measures. An open-ended interview guide was developed. The themes explored included previous painful experiences, knowledge of labour, expectations of and attitudes towards labour pain, and knowledge of biomedical analgesia. Results. Patients were poorly informed about the process and pain of labour. Most women appeared highly motivated concerning their ability to cope with labour. Most expected pain, but had no concept of the severity or duration of the pain, and knew very little concerning methods available for pain relief in labour. Conclusion. Women at this MOU were poorly prepared for the experience of delivery. Antenatal programmes should incorporate sensitive education concerning the process and pain of labour and the methods available to alleviate pain

Caesarean section rates in South Africa: A case study of the health systems challenges for the proposed National Health Insurance

Broader policy research and debate on the issues related to the planning of National Health Insurance (NHI) in South Africa (SA) need to be complemented by case studies to examine and understand the issues that will have to be dealt with at micro and macro levels. The objective of this article is to use caesarean section (CS) as a case study to examine the health systems challenges that NHI would need to address in order to ensure sustainability. The specific objectives are to: (i) provide an overview of the key clinical considerations related to CS; (ii) assess the CS rates in the SA public and private sectors; and (iii) use a health systems framework to examine the drivers of the differences between the public and private sectors and to identify the challenges that the proposed NHI would need to address on the road to implementation

Mid-upper arm circumference: A surrogate for body mass index in pregnant women

Background. Nutrition in pregnancy has implications for both mother and fetus, hence the importance of an accurate assessment at the booking visit during antenatal care. The body mass index (BMI, kg/m2) is currently the gold standard for measuring body fatness. However, pregnancy-associated weight gain and oedema, as well as late booking in our population setting, cause concern about the reliability of using the BMI to assess body fat or nutritional status in pregnancy. The mid-upper arm circumference (MUAC) has been used for many decades to assess malnutrition in children aged <5 years. Several studies have also shown a strong correlation between MUAC and BMI in both pregnant and non-pregnant adult populations.Objective. To assess the correlation between the MUAC and BMI in pregnant women booking for antenatal care in the Metro West area of Cape Town, South Africa.Methods. We conducted a cross-sectional study of women booking at four midwife obstetric units. Anthropometric measurements (height, weight and MUAC) were carried out on pregnant women at their first antenatal booking visit.Results. The results showed a strong correlation between MUAC and BMI in pregnant women up to 30 weeks’ gestation. The correlation was calculated at 0.92 for the entire group. The MUAC cut-offs for obesity (BMI >30) and malnutrition (BMI <18.5) were calculated as 30.57 cm and 22.8 cm, respectively.Conclusion. MUAC correlates strongly with BMI in pregnancy up to a gestation of 30 weeks in women attending Metro West maternity services. In low-resource settings, the simpler MUAC measurement could reliably be substituted for BMI to assess nutritional status

21 years of confidential enquiries into maternal deaths in South Africa : reflections on maternal death assessments

Since 1999, seven triennial reports have been submitted by the South African National Committee for the Confidential Enquires into Maternal Deaths (NCCEMD) to the Minister of Health along with recommendations on methods to reduce maternal mortality. The committee, via an extensive network of provincial assessors, has documented the rise and fall of maternal deaths with the institutional Maternal Mortality Ratio (iMMR) reaching a peak of 189/100000 live births in 2009 and dropping below 100/100000 live births in 2019 for the fi rst time since the start of the enquiry. All provinces have shown a decline in the iMMR, with the Free State, KwaZulu-Natal, Mpumalanga, North West and Northern Cape halving their iMMR from their peaks. The enquiry documented the dramatic rise in deaths due to non-pregnancy related infections until 2008-2010 and a sharp decline from 2011-2013 deaths due in deaths. Consistently more than 90% of the women who died in this category were HIV positive, and the sharp decline is associated with the widespread availability and use of antiretroviral therapy. A decline in hypertensive disorders of pregnancy deaths from 2005-2007 after an early rise in 2002-2004 was observed and an increase obstetric haemorrhage deaths mostly due to bleeding during and after caesarean delivery, followed by a decrease from 2014-2016 once the problem had been identifi ed and addressed. Unfortunately, there has been a steady rise in early pregnancy deaths and deaths due to pre-existing medical and surgical conditions. Interventions contributing to the downward trends include the introduction of safe antiretroviral therapy regimens, the district clinical specialist teams (DCST), the scale-up of Essential Steps in Managing Obstetric Emergencies (ESMOE) training, BANC plus, the Safe Caesarean delivery programme, and the Hypertensive disorders of pregnancy (HDP) guidelines. The proportion of all deaths that were potentially preventable has declined steadily indicating a steady continual improvement in the quality of care, but the types of missed opportunities and sub-standard care have remained constant. The confidential enquiry into maternal deaths (CEMD) system in South Africa has been very useful in describing the causes of maternal death, both pathological and health system failures, and for suggesting effective interventions which were adopted in the National Department of Health’s Strategic Plans.https://journals.co.za/journal/medogam2021Obstetrics and Gynaecolog

Maternal near-miss audit in the Metro West maternity service, Cape Town, South Africa: A retrospective observational study

Background. A maternal near-miss is defined as a life-threatening pregnancy-related complication where the woman survives. The World Health Organization (WHO) has produced a tool for identifying near-misses according to criteria that include the occurrence of a severe maternal complication together with organ dysfunction and/or specified critical interventions. Maternal deaths have been audited in the public sector Metro West maternity service in Cape Town, South Africa, for many years, but there has been no monitoring of near-misses.Objectives. To measure the near-miss ratio (NMR), maternal mortality ratio (MMR) and mortality index (MI), and to investigate the near-miss cases.Methods. A retrospective observational study conducted during 6 months in 2014 identified and analysed all near-miss cases and maternal deaths in Metro West, using the WHO criteria.Results. From a total of 19 222 live births, 112 near-misses and 13 maternal deaths were identified. The MMR was 67.6 per 100 000 live births and the NMR 5.83 per 1 000 live births. The maternal near-miss/maternal death ratio was 8.6:1 and the MI 10.4%. The major causes of near-miss were hypertension (n=50, 44.6%), haemorrhage (n=38, 33.9%) and puerperal sepsis (n=13, 11.6%). The first two conditions both had very low MIs (1.9% and 0%, respectively), whereas the figure for puerperal sepsis was 18.9%. Less common near-miss causes were medical/surgical conditions (n=7, 6.3%), non-pregnancy-related infections (n=2, 1.8%) and acute collapse (n=2, 1.8%), with higher MIs (33.3%, 66.7% and 33.3%, respectively). Critical interventions included massive blood transfusion (34.8%), ventilation (40.2%) and hysterectomy (30.4%). Considering health system factors, 63 near-misses (56.3%) initially occurred at a primary care facility, and the patients were all referred to the tertiary hospital; 38 (33.9%) occurred at a secondary hospital, and 11 (9.8%) at the tertiary hospital. Analysis of avoidable factors identified lack of antenatal clinic attendance (11.6%), inter-facility transport problems (6.3%) and health provider-related factors (25.9% at the primary level of care, 38.2% at secondary level and 7.1% at tertiary level).Conclusions. The NMR and MMR for Metro West were lower than in other developing countries, but higher than in high-income countries. The MI was low for direct obstetric conditions (hypertension, haemorrhage and puerperal sepsis), reflecting good quality of care and referral mechanisms for these conditions. The MIs for non-pregnancy-related infections, medical/surgical conditions and acute collapse were higher, suggesting that medical problems need more focused attention.

Management of incomplete abortions at South African public hospitals

Objective. The objective of this report was to review and describe the management of incomplete abortion by public sector hospitals.Design. A descriptive study in which data were collected prospectively from routine hospital records on all women admitted with incomplete abortion to a stratified random sample of hospitals between 14 and 28 September 1994.Setting. Public sector hospitals in South Africa.Patients. Women with incomplete abortions.Main outcome measures. Length of hospital stay, details of medical management, details of surgical management, determinants of the above.Main results. Data were collected on 803 patients from the 56 participating hospitals. Of these, 767 (95.9%) were in hospital for 1 day or more, and 753 (95.3%) women underwent evacuation of the uterus. Sharp curettage wasthe method employed in 726 (96.9%) and general anaesthesia was used for 601 (88%) of the women requiring uterine evacuation. Antibiotics were prescribed for 396 (49.5%) and blood transfusions were administered to 125 (17%) women. Statistical analysis showed length of stay to be longer in small hospitals (under 500 beds) and when the medical condition was more severe. Antibiotic  usage and blood transfusion were more common with increasing severity and a low haemoglobin level on admission. However, some inappropriate management was identified with regard to both.Main conclusions. It is suggested that uncomplicated incomplete abortion can be more effectively and safely managed using the manual vacuum aspiration technique with sedation/analgesia as an outpatient procedure. Attention should be directed at the introduction of this management routine at all types of hospital and to the ensuring of appropriate management of women with complicated abortion

Knowledge and expectations of labour among primigravid women in the public health sector

Objectives. We analysed knowledge and expectations of the process and pain of labour in primigravidas attending a local midwifery obstetric unit (MOU). It was anticipated that the results of this study could inform the development of interventions aimed at improving the analgesic care of women delivering at primary health care obstetric units. Design. Qualitative analysis of data obtained from in-depth semi-structured interviews. Setting. A Cape Town MOU. Subjects. 30 black African, Xhosa-speaking primigravidas. Outcome measures. An open-ended interview guide was developed. The themes explored included previous painful experiences, knowledge of labour, expectations of and attitudes towards labour pain, and knowledge of biomedical analgesia. Results. Patients were poorly informed about the process and pain of labour. Most women appeared highly motivated concerning their ability to cope with labour. Most expected pain, but had no concept of the severity or duration of the pain, and knew very little concerning methods available for pain relief in labour. Conclusion. Women at this MOU were poorly prepared for the experience of delivery. Antenatal programmes should incorporate sensitive education concerning the process and pain of labour and the methods available to alleviate pain. South African Medical Journal Vol. 97 (6) 2007: pp. 461-46