Safety versus accessibility in maternal and perinatal care

This article adds to the debate on appropriate staffing in maternity units. My starting point for assessing staffing norms is the staff required to provide a safe maternity unit. A survey in 12 districts showed that their health facilities were not adequately prepared to perform all the essential emergency services required. Lack of staff was often cited as a reason. To test this notion, two norms (World Health Organization (WHO) and Greenfield) giving the minimum staff required for the provision of safe maternity services were applied to the 12 districts. Assuming the appropriate equipment is available and the facility is open 24 hours a day 7 days a week, at a minimum there need to be ten professional nurses with midwifery/advanced midwives to ensure safety for mother and baby in every maternity unit. The norms indicate that the units should do a minimum of 500 - 1 200 deliveries per year to be cost-effective. All 12 districts had sufficient staff according to the WHO. When the numbers of facilities with maternity units were compared with Council for Scientific and Industrial Research and WHO norms for number of health facilities per population, a large excess of facilities was found. Per district there were sufficient personnel to perform the number of deliveries for that district using the WHO or Greenfield formulas, but per site there were insufficient personnel. In my view there are sufficient personnel to provide safe maternity services, but too many units are performing deliveries, leading to dilution of staff and unsafe services. A realignment of maternity units must be undertaken to provide safe services, even at the expense of accessibility

Safety versus accessibility in maternal and perinatal care

This article adds to the debate on appropriate staffing in maternity units. My starting point for assessing staffing norms is the staff required to provide a safe maternity unit. A survey in 12 districts showed that their health facilities were not adequately prepared to perform all the essential emergency services required. Lack of staff was often cited as a reason. To test this notion, two norms (World Health Organization (WHO) and Greenfield) giving the minimum staff required for the provision of safe maternity services were applied to the 12 districts. Assuming the appropriate equipment is available and the facility is open 24 hours a day 7 days a week, at a minimum there need to be ten professional nurses with midwifery/advanced midwives to ensure safety for mother and baby in every maternity unit. The norms indicate that the units should do a minimum of 500 - 1 200 deliveries per year to be cost-effective. All 12 districts had sufficient staff according to the WHO. When the numbers of facilities with maternity units were compared with Council for Scientific and Industrial Research and WHO norms for number of health facilities per population, a large excess of facilities was found. Per district there were sufficient personnel to perform the number of deliveries for that district using the WHO or Greenfield formulas, but per site there were insufficient personnel. In my view there are sufficient personnel to provide safe maternity services, but too many units are performing deliveries, leading to dilution of staff and unsafe services. A realignment of maternity units must be undertaken to provide safe services, even at the expense of accessibility.http://www.samj.org.zaam201

Improving survival rates of newborn infants in South Africa

BACKGROUND:The number, rates and causes of early neonatal deaths in South Africa were not known. Neither had modifiable factors associated with these deaths been previously documented. An audit of live born infants who died in the first week of life in the public service could help in planning strategies to reduce the early neonatal mortality rate. METHODS: The number of live born infants weighing 1000 g or more, the number of these infants who die in the first week of life, the primary and final causes of these deaths, and the modifiable factors associated with them were collected over four years from 102 sites in South Africa as part of the Perinatal Problem Identification Programme. RESULTS: The rate of death in the first week of life for infants weighing 1000 g or more was unacceptably high (8.7/1000), especially in rural areas (10.42/1000). Intrapartum hypoxia and preterm delivery are the main causes of death. Common modifiable factors included inadequate staffing and facilities, poor care in labour, poor neonatal resuscitation and basic care, and difficulties for patients in accessing health care. CONCLUSION: Practical, affordable and effective steps can be taken to reduce the number of infants who die in the first week of life in South Africa. These could also be implemented in other under resourced countries

Two-component Bose-Einstein condensates :equilibria and dynamics at zero temperature and beyond

PhD ThesisIn this Thesis we study steady state solutions and dynamical evolutions of two– component atomic Bose–Einstein Condensates. We initially investigate the equilibrium properties of condensate mixtures in harmonic trapping potentials at zero temperature. Subsequently we simulate the coupled growth of these condensates by inclusion of damping terms. Finally, we investigate the evolution of coupled Bose gases via the so-called classical–field method. A recent experiment [D. J. McCarron et al., Phys. Rev. A, 84, 011603(R) (2011)] achieved Bose–Einstein Condensation of a two–species 87Rb–133Cs phase segregated mixture in harmonic trapping potentials. Depending on relative atom numbers of the two species, three distinct regimes of density distributions were observed. For these experimental parameters, we investigate the corresponding time–independent ground state solutions through numerical simulations of the coupled Gross–Pitaevskii equations. By including experimentally relevant shifts between the traps, we observe a range of structures including ‘ball and shell’ formations and axially/radially separated states. These are found to be very sensitive to the trap shifts. For all three experimental regimes, our numerical simulations reveal good qualitative agreement. The observed experimental profiles cannot be guaranteed to be fully equilibrated. This, coupled with the rapid sympathetic cooling of the experimental system, leads to a situation where growth may play a determining factor in the density structures formed. To investigate this further, we introduce phenomenological damping to describe the associated condensate growth/decay, revealing a range of transient structures. However, such a model always predicts the predominance of one condensate species over longer evolution times. Work undertaken by collaborators with the more elaborate Stochastic Projected Gross–Pitaevskii equations, which can describe condensate formation by coupling to a heat bath, predicts the spontaneous formation of dark–bright solitons. Motivated by this, we show how the presence of solitons can affect the condensate distribution, thus highlighting the overall dynamical role in the emerging patterns. Finally, we use classical field methods to analyse the evolution of non trapped Bose gases from strongly nonequilibrium initial distributions. The contrast between miscible (overlapping) and immiscible (phase segregated) components gives rise to important distinctions for condensate fractions and the formation of domains and vortices. In addition, splitting the particles of a single component thermalised state into two components is investigated. We then study the effects of suddenly quenching the strength of the interspecies interactions. Under suitable conditions, this quench generates isotropic vortex tangles. While this tangle subsequently decays over time, we propose how a repeat sequence of quenches at regular intervals could be employed to drive the tangle, thereby potentially providing a novel route to the generation of quantum turbulence

A paradoxical reduction in upper genital tract infection despite the massive HIV epidemic

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An approach to hypertensive disorders in pregnancy for the primary care physician

Hypertensive disorders in pregnancy (HDP) are a leading obstetric cause for maternal morbidity and mortality nationally as well as globally. The Saving Mothers is a report published every three years by the National Committee for Confidential Enquiry, which reports the trends in maternal deaths in South Africa. The last three Saving Mothers reports identified many gaps in the management of HDP and interventions to address these gaps were recommended. The recently published national guidelines on the management of HDP have highlighted approaches for the diagnosis, assessment and management of HDP. This article synthesises the national guidelines and provides approaches for the primary care physician working at the primary healthcare or the district hospital level. The algorithms provide easy clinical pathways once the correct assessment has been made.http://www.safpj.co.zaam2021Obstetrics and Gynaecolog

Challenges to improve antenatal and intrapartum care in South Africa

The major causes of maternal and perinatal deaths have been well described in South Africa. These causes are related to HIV infection, placental insufficiency and intrapartum asphyxia. The health system failures that most commonly lead to preventable mortality are related to managing hypertensive disorders in pregnancy (HDP), detecting fetal growth restriction antenatally and managing labour effectively by providing caesarean delivery to those who need it and avoiding it in those who do not. Improving antenatal and intrapartum care are vital aspects in efforts to improve survival, but to achieve this the following challenges need to be overcome: managing the increased antenatal care contacts needed to detect HDP creating a next level of expertise, and access for women to high-risk care creating the environment for respectful care and companionship in labour managing labour as physiologically as possible detecting and managing placental insufficiency. This article provides some exciting solutions to these health system barriers.http://www.samj.org.zapm2020MusicObstetrics and Gynaecolog

Barriers to obstetric care among maternal near-misses

BACKGROUND. There are several factors in the healthcare system that may influence a woman’s ability to access appropriate obstetric care. OBJECTIVE. To determine the delays/barriers in providing obstetric care to women who classified as a maternal near-miss. METHODS. This was a descriptive observational study at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. One hundred maternal near-misses were prospectively identified using the World Health Organization criteria. The ‘three-delays model’ was used to identify the phases of delay in the health system and recorded by the doctor caring for the patient. RESULTS. One or more factors causing a delay in accessing care were identified in 83% of near-miss cases. Phase I and III delays were the most important causes of barriers. Lack of knowledge of the problem (40%) and inadequate antenatal care (37%) were important first-phase delays. Delay in patient admission, referral and treatment (37%) and substandard care (36%) were problems encountered within the health system. The above causes were also the most important factors causing delays for the leading causes of maternal near-misses – obstetric haemorrhage, hypertension/pre-eclampsia, and medical and surgical conditions. CONCLUSIONS. Maternal morbidity and mortality rates may be reduced by educating the community about symptoms and complications related to pregnancy. Training healthcare workers to identify and manage obstetric emergencies is also important. The frequency of antenatal visits should be revised, with additional visits in the third trimester allowing more opportunities for blood pressure to be checked and for identifying hypertension.http://www.samj.org.zaam2016Obstetrics and Gynaecolog

Scaling up kangaroo mother care in South Africa: 'on-site' versus 'off-site' educational facilitation

Background Scaling up the implementation of new health care interventions can be challenging and demand intensive training or retraining of health workers. This paper reports on the results of testing the effectiveness of two different kinds of face-to-face facilitation used in conjunction with a well-designed educational package in the scaling up of kangaroo mother care. Methods : Thirty-six hospitals in the Provinces of Gauteng and Mpumalanga in South Africa were targeted to implement kangaroo mother care and participated in the trial. The hospitals were paired with respect to their geographical location and annual number of births. One hospital in each pair was randomly allocated to receive either 'on-site' facilitation (Group A) or 'off-site' facilitation (Group B). Hospitals in Group A received two on-site visits, whereas delegates from hospitals in Group B attended one off-site, 'hands-on' workshop at a training hospital. All hospitals were evaluated during a site visit six to eight months after attending an introductory workshop and were scored by means of an existing progress-monitoring tool with a scoring scale of 0-30. Successful implementation was regarded as demonstrating evidence of practice (score >10) during the site visit. Results : There was no significant difference between the scores of Groups A and B (p = 0.633). Fifteen hospitals in Group A and 16 in Group B demonstrated evidence of practice. The median score for Group A was 16.52 (range 00.00-23.79) and that for Group B 14.76 (range 07.50-23.29). Conclusion : A previous trial illustrated that the implementation of a new health care intervention could be scaled up by using a carefully designed educational package, combined with face-to-face facilitation by respected resource persons. This study demonstrated that the site of facilitation, either on site or at a centre of excellence, did not influence the ability of a hospital to implement KMC. The choice of outreach strategy should be guided by local circumstances, cost and the availability of skilled facilitators