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

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

Pelvimetry for fetal cephalic presentations at or near term for deciding on mode of delivery

BACKGROUND : Pelvimetry assesses the size of a woman's pelvis aiming to predict whether she will be able to give birth vaginally or not. This can be done by clinical examination, or by conventional X-rays, computerised tomography (CT) scanning, or magnetic resonance imaging (MRI). OBJECTIVES : To assess the effects of pelvimetry (performed antenatally or intrapartum) on the method of birth, on perinatal mortality and morbidity, and on maternal morbidity. This review concentrates exclusively on women whose fetuses have a cephalic presentation. SEARCH METHODS : We searched Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2017) and reference lists of retrieved studies. SELECTION CRITERIA : Randomised controlled trials (including quasi-randomised) assessing the use of pelvimetry versus no pelvimetry or assessing different types of pelvimetry in women with a cephalic presentation at or near term were included. Cluster trials were eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS : Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS : Five trials with a total of 1159 women were included. All used X-ray pelvimetry to assess the pelvis. X-ray pelvimetry versus no pelvimetry or clinical pelvimetry is the only comparison included in this review due to the lack of trials identified that examined other types of radiological pelvimetry or that compared clinical pelvimetry versus no pelvimetry. The included trials were generally at high risk of bias. There is an overall high risk of performance bias due to lack of blinding of women and staff. Two studies were also at high risk of selection bias. We used GRADEpro software to grade evidence for our selected outcomes; for caesarean section we rated the evidence low quality and all the other outcomes (perinatal mortality, wound sepsis, blood transfusion, scar dehiscence and admission to special care baby unit) as very low quality. Downgrading was due to risk of bias relating to lack of allocation concealment and blinding, and imprecision of effect estimates. Women undergoing X-ray pelvimetry were more likely to have a caesarean section (risk ratio (RR) 1.34, 95% confidence interval (CI) 1.19 to 1.52; 1159 women; 5 studies; low-quality evidence). There were no clear differences between groups for perinatal outcomes: perinatal mortality (RR 0.53, 95% CI 0.19 to 1.45; 1159 infants; 5 studies; very low-quality evidence), perinatal asphyxia (RR 0.66, 95% CI 0.39 to 1.10; 305 infants; 1 study), and admission to special care baby unit (RR 0.20, 95% CI 0.01 to 4.13; 288 infants; 1 study; very low-quality evidence). Other outcomes assessed were wound sepsis (RR 0.83, 95% CI 0.26 to 2.67; 288 women; 1 study; very low-quality evidence), blood transfusion (RR 1.00, 95% CI 0.39 to 2.59; 288 women; 1 study; very low-quality evidence), and scar dehiscence (RR 0.59, 95% CI 0.14 to 2.46; 390 women; 2 studies; very low-quality evidence). Again, no clear differences were found for these outcomes between the women who received X-ray pelvimetry and those who did not. Apgar score less than seven at five minutes was not reported in any study. AUTHORS' CONCLUSIONS : X-ray pelvimetry versus no pelvimetry or clinical pelvimetry is the only comparison included in this review due to the lack of trials identified that used other types or pelvimetry (other radiological examination or clinical pelvimetry versus no pelvimetry). There is not enough evidence to support the use of X-ray pelvimetry for deciding on mode of delivery in women whose fetuses have a cephalic presentation. Women who undergo an X-ray pelvimetry may be more likely to have a caesarean section. Further research should be directed towards defining whether there are specific clinical situations in which pelvimetry can be shown to be of value. Newer methods of pelvimetry (CT, MRI) should be subjected to randomised trials to assess their value. Further trials of X-ray pelvimetry in cephalic presentations would be of value if large enough to assess the effect on perinatal mortality.Department of Reproductive Health and Research, World Health Organization (WHO)http://www.cochranelibrary.com2018-03-30am2017Obstetrics and Gynaecolog

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

Too little, too late : the recurrent theme in maternal deaths due to sepsis

BACKGROUND : Maternal sepsis accounts for 11% of direct obstetric deaths, making it the third commonest cause of death, after obstetric hemorrhage and hypertensive disorders. OBJECTIVE : To evaluate the risk factors and quality of care for maternal deaths due to sepsis. METHODS : Detailed secondary file review for all maternal deaths classified as pregnancy-related sepsis in South Africa between 2014-2016 and comparison of management with the Surviving Sepsis guidelines. RESULTS : There were 158 maternal deaths from sepsis. The postpartum period carried the greatest risk (94% of deaths), especially after caesarean delivery (50%). Adequate fluid resuscitation was done in only 25 cases (16%) and initiation of empiric antibiotics was often delayed (48% of those receiving antibiotics). Only 28% of women with possible source of infection in the uterus had a hysterectomy (39 cases). CONCLUSION : Healthcare professionals often underestimate the severity of maternal sepsis and poorly adhere to treatment guidelines.http://www.journals.co.za/content/journal/medogam2019Obstetrics and Gynaecolog

Causes of perinatal mortality and associated maternal complications in a South African province : challenges in predicting poor outcomes

BACKGROUND: Reviews of perinatal deaths are mostly facility based. Given the number of women who, globally, deliver outside of facilities, this data may be biased against total population data. We aimed to analyse population based perinatal mortality data from a LMIC setting (Mpumalanga, South Africa) to determine the causes of perinatal death and the rate of maternal complications in the setting of a perinatal death. METHODS : A secondary analysis of the South African Perinatal Problems Identification Program (PPIP) database for the Province of Mpumalanga was undertaken for the period October 2013 to January 2014, inclusive. Data on each individual late perinatal death was reviewed. We examined the frequencies of maternal and fetal or neonatal characteristics in late fetal deaths and analysed the relationships between maternal condition and fetal and/or neonatal outcomes. IBM SPSS Statistics 22.0 was used for data analysis. RESULTS : There were 23503 births and 687 late perinatal deaths (stillbirths of ≥ 1000gr or ≥ 28 weeks gestation and early neonatal deaths up to day 7 of neonatal life) in the study period. The rate of maternal complication in macerated stillbirths, fresh stillbirths and early neonatal deaths was 50.4%, 50.7% and 25.8% respectively. Mothers in the other late perinatal deaths were healthy. Maternal hypertension and obstetric haemorrhage were more likely in stillbirths (p = <0.01 for both conditions), whereas ENNDs were more likely to have a healthy mother (p < 0.01). The main causes of neonatal death were related to immaturity (48.7%) and hypoxia (40.6%). 173 (25.2%) of all late perinatal deaths had a birth weight less than the 10th centile for gestational age. CONCLUSION : A significant proportion of women have no recognisable obstetric or medical condition at the time of a late perinatal death; we may be limited in our ability to predict poor perinatal outcome if emphasis is put on detecting maternal complications prior to a perinatal death. Intrapartum care and hypertensive disease remain high priority areas for addressing perinatal mortality. Consideration needs to be given to novel ways of detecting growth restriction in a LMIC setting.http://www.biomedcentral.com/bmcpregnancychildbirtham201

Changing priorities in maternal and perinatal health in Gert Sibande District, South Africa

Gert Sibande District is a predominantly rural district in Mpumalanga Province, South Africa (SA), with a population of just over 1.1 million. It has a high prevalence of HIV infection and pregnancy-related hypertensive disease. In 2010 the district was one of the worst-performing health districts in SA, with a maternal mortality ratio of 328.0 per 100 000 births. Various programmes were introduced between 2010 and 2017 to address major causes of maternal and perinatal morbidity and mortality in the district. The focus has been on HIV-related morbidity, the direct obstetric causes of maternal and perinatal morbidity and mortality, and health systems strengthening. During the period 2010 - 2017, there was a steady decline in institutional maternal mortality with a drop of 71% in maternal deaths over a period of 6 years, from 328.0 per 100 000 births to 95.0. However, the ratio levelled off in 2016 and 2017, mainly as a result of a changing disease profile. The stillbirth rate showed a decline of 24.4% over a period of 8 years. With perseverance, rapid response and evidence-based strategies it was possible to more than halve the institutional maternal mortality ratio within 6 years. However, with the changing disease profile, conditions such as hypertensive disease in pregnancy should be prioritised and new strategies developed to further reduce maternal and perinatal mortality and morbidity.http://www.samj.org.zaam2020Family MedicineObstetrics and Gynaecolog