Preventing antenatal stillbirths : an innovative approach for primary health care

BACKGROUND : In South Africa (SA), approximately 16 000 stillbirths occur annually. Most are classified as unexplained and occur in district hospitals. Many of these deaths may be caused by undetected foetal growth restriction. Continuous wave Doppler ultrasound of the umbilical artery (CWDU-UmA) is a simple method for assessing placental function. This screening method may detect the foetus at risk of dying and growth-restricted foetuses, allowing for appropriate management. METHODS : A cohort study was conducted across South Africa. Pregnant women attending primary health care clinics at 28–34 weeks gestation were screened using CWDU-UmA. Women not screened at those antenatal clinics served as control group 1. Control group 2 consisted of the subset of control group 1 with women detected with antenatal complications excluded. Women with foetuses identified with an abnormal CWDU-UmA test were referred and managed according to a standardised protocol. A comparison between the study and control groups was performed. RESULTS : The study group consisted of 6536 pregnancies, and there were 66 stillbirths (stillbirth rate [SBR]: 10.1/1000 births). In control group 1, there were 193 stillbirths in 10 832 women (SBR: 17.8/1000 births), and in control group 2, 152 stillbirths in 9811 women (SBR: 15.5/1000 births) (risk ratio: 0.57, 95% confidence intervals: 0.29–0.85 and 0.65, 0.36–0.94, respectively). CONCLUSION : Screening a low-risk pregnant population identified the low-risk mother with a high-risk foetus, and acting on the information as described was associated with a significant reduction (35% – 43%) in stillbirths. This demonstrates a step-change reduction in stillbirths and warrants screening in SA.This study was part of the PhD thesis of T.M.H. "The effect of introducing Basic Antenatal Care Plus and Umbiflow on antenatal care and perinatal mortality" available at https://repository.up.ac.za/handle/2263/85609.The South African Medical Research Council (SAMRC) and the Council for Scientific and Industrial Research (CSIR).https://www.safpj.co.zaam2023Obstetrics and GynaecologyStatistic

Maternal near miss and maternal death in the Pretoria Academic Complex, South Africa : a population-based study

BACKGROUND. In order to reduce maternal mortality in South Africa (SA), it is important to understand the process of obstetric care, identify weaknesses within the system, and implement interventions for improving care. OBJECTIVE. To determine the spectrum of maternal morbidity and mortality in the Pretoria Academic Complex (PAC), SA. METHODS. A descriptive population-based study that included all women delivering in the PAC. The World Health Organization definition, criteria and indicators of near miss and maternal death were used to identify women with severe complications in pregnancy. RESULTS. Between 1 August 2013 and 31 July 2014, there were 26 614 deliveries in the PAC. The institutional maternal mortality ratio was 71.4/100 000 live births. The HIV infection rate was 19.9%, and 2.7% of women had unknown HIV status. Of the women, 1 120 (4.2%) developed potentially life-threatening conditions and 136 (0.5%) life-threatening conditions. The mortality index was 14.0% overall, 30.0% for non-pregnancy-related infections, 2.0% for obstetric haemorrhage and 13.6% for hypertension. Of the women with life-threatening conditions, 39.3% were referred from the primary level of care. Vascular, uterine and coagulation dysfunctions were the most frequent organ dysfunctions in women with life-threatening conditions. The perinatal mortality rate was 26.9/1 000 births overall, 23.1/1 000 for women with non-life-threatening conditions, and 198.0/1 000 for women with life-threatening conditions. CONCLUSION. About one in 20 pregnant women in the PAC had a potentially life-threatening condition; 39.3% of women presented to a primary level facility as an acute emergency and had to be transferred for tertiary care. All healthcare professionals involved in maternity care must have knowledge and skills that equip them to manage obstetric emergencies. Review of the basic antenatal care protocol may be necessary.http://www.samj.org.zaam201

The prevalence of abnormal Doppler’s of the umbilical artery in a low-risk pregnant population in South Africa

BACKGROUND : The assessment of fetal blood flow using Doppler waveform can be used to identify placental insufficiency, and hence is a tool to identify fetuses at risk of stillbirth due to fetal growth restriction (FGR). In South Africa the largest category of perinatal deaths is ‘unexplained intrauterine death’. The majority of the mothers are clinically healthy women. This study was performed to determine the prevalence of abnormal umbilical resistance indices (abnormal RI) to see if screening a low-risk pregnant population is worthwhile. METHODS : A descriptive study across 9 sites in 8 provinces of South Africa was performed to determine the prevalence of abnormal RI of the umbilical artery in women classified as having a low-risk pregnancy. The study was conducted from 1st September 2017- February 2020.The pregnant women classified were screened using a continuous wave Doppler ultrasound apparatus (UmbiflowTM) between 28 and 34 weeks’ gestation. Women with fetuses with an abnormal RI were referred to a high-risk clinic and were managed according to standard protocol. The outcomes of all the deliveries were recorded. FINDINGS : UmbiflowTM screening of the umbilical artery was performed in 7088 women across nine sites; 919 (13¢0%) fetuses had an abnormal RI. Absent end diastolic flow (AEDF) was found in 87 (1¢2%) fetuses. The prevalence of small for gestational ages (SGA) babies was 23¢1% in the normal RI group and was significantly higher in the abnormal RI group 32¢1% (p<0¢0001). There was a statistical difference in the perinatal mortality rate between the normal RI (9.8/1000) and abnormal RI group (21.4/1000) [RR 0¢046; 95% CI -0¢06 0¢98]. INTERPRETATION : The prevalence of abnormal RI and AEDF in this screened low-risk population was about ten times higher than that previously recorded in high income countries. Continuous wave Doppler ultrasound screening detected previously undiagnosed growth restricted babies. The prevalence of AEDF warrants continuous wave Doppler ultrasound screening of the low-risk pregnant population in South Africa.The South African Medical Research Council (SAMRC) and the Council for Scientific and Industrial Research (CSIR).http://www.journals.elsevier.com/eclinicalmedicineam2022Obstetrics and GynaecologyStatistic

Maternal near miss and maternal death in the Pretoria Academic Complex, South Africa: A population-based study

BACKGROUND. In order to reduce maternal mortality in South Africa (SA), it is important to understand the process of obstetric care, identify weaknesses within the system, and implement interventions for improving care. OBJECTIVE. To determine the spectrum of maternal morbidity and mortality in the Pretoria Academic Complex (PAC), SA. METHODS. A descriptive population-based study that included all women delivering in the PAC. The World Health Organization definition, criteria and indicators of near miss and maternal death were used to identify women with severe complications in pregnancy. RESULTS. Between 1 August 2013 and 31 July 2014, there were 26 614 deliveries in the PAC. The institutional maternal mortality ratio was 71.4/100 000 live births. The HIV infection rate was 19.9%, and 2.7% of women had unknown HIV status. Of the women, 1 120 (4.2%) developed potentially life-threatening conditions and 136 (0.5%) life-threatening conditions. The mortality index was 14.0% overall, 30.0% for non-pregnancy-related infections, 2.0% for obstetric haemorrhage and 13.6% for hypertension. Of the women with life-threatening conditions, 39.3% were referred from the primary level of care. Vascular, uterine and coagulation dysfunctions were the most frequent organ dysfunctions in women with life-threatening conditions. The perinatal mortality rate was 26.9/1 000 births overall, 23.1/1 000 for women with non-life-threatening conditions, and 198.0/1 000 for women with life-threatening conditions. CONCLUSION. About one in 20 pregnant women in the PAC had a potentially life-threatening condition; 39.3% of women presented to a primary level facility as an acute emergency and had to be transferred for tertiary care. All healthcare professionals involved in maternity care must have knowledge and skills that equip them to manage obstetric emergencies. Review of the basic antenatal care protocol may be necessary.http://www.samj.org.zaam201