Babies group, for the Saving

Pattinson, R C

English

South African Medical Journal (SAMJ)

June 2003, Vol. 93, No. 6  SAMJEDITORIALlight of new evidence or arguments. Fourth, there must be aprocess of enforcement that facilitates the implementation ofthe last three conditions. 3Ideally this process, which ensures fairness, transparencyand accountability, should be used by both public and privatehealth care providers who together administer the country’slimited medical resources.  Failing this, resource allocation willcontinue to be viewed by doctors, health care administratorsand the public as irrational and potentially subject to hiddenpolitical and interest group manipulation.  Neither will thisflawed type of allocation produce the greatest social benefitsfor the largest number of people who need care.   Instead it willonly exacerbate the twin burdens faced by both public andprivate health care providers — heightened expectations on thepart of patients unfairly denied benefits, and drastically risingcosts as advocacy groups mount challenges to irrationalmedical decision-making.  This outcome would be a formulafor widespread loss of confidence in both public and privatesector institutions, as taxpayers and medical aid members arecalled on to bear unsustainable costs for a chaoticallyadministered health system. Explicit, transparent and accountable rationing processes arenot yet being widely used — although there is a growingtendency to do so in some countries,4 and at least one recentexample has been documented in South Africa. 5 South Africa’sConstitutional Court has on one occasion approved a hospitalpolicy, forced by shortages of funding, equipment andpersonnel, to limit dialysis for chronically ill patients only tothose eligible for transplants.  All who failed medical criteriawere denied life-saving dialysis.6Until open, accountable, explicit priority-setting proceduresbased on sound scientific data (and a single trial seldomprovides this) and ethically principled criteria become morewidely used, scarce resources will continue to be channelledtowards those patient populations and drug companies whomake the loudest noises and to those medical disciplines mostvociferous about advancing practice in their domain. Noethical, medical or scientific rationale supports this type ofarbitrary and  unaccountable means of allocating scarce publicor private health care resources.S R BenatarProfessor of Medicine andDirector, Bioethics CentreUniversity of Cape TownT E FleischerDeputy Director, Bioethics CentreUniversity of Cape Town1. Smith J, Pieper CH, Kirsten GF. Born too soon, too small, to die — a plea for a fair innings. SAfr Med J 1999; 89: 1148-1151.2. Rothberg A, Cooper PA. Rationing versus equity — the South African dilemma. S Afr Med J1999; 89: 1151-1153.3. Daniels N, Sabin J. Limits to health care: fair procedures, democratic deliberation and thelegitimacy problem for insurers. Philosophy & Public Affairs 1997; 26(4); 303-350.4. Ham C. Priority setting in health care: learning from international experience. Health Policy1997; 42: 49-66.5. Benatar  SR. Fleischer TE,Peter JC, Pope A, Taylor A.Treatment of head injuries in the publicsector in South Africa. S Afr Med J 2000; 90: 790-793.6. Soobramoney v. Minister of Health, KwaZulu-Natal 1998 (1) SA765 (CC).T E Fleischer serves on Medscheme’s Drugs and Therapeutics Committee.434A third Perinatal Care Survey workshop was held at theHammanskraal campus of the University of Pretoria, 18 - 20November 2002. Like the previous two, this workshop broughttogether the users of the Perinatal Problem IdentificationProgramme (PPIP), the national and provincial Maternal, Childand Women’s Health (MCWH) units, the national andprovincial Health Information and Epidemiology units, and theMedical Research Council (MRC) Research Unit for Maternaland Infant Health Care Strategies to discuss perinatal carebased on an audit of perinatal deaths in South Africa.It is not possible at this stage for South Africa to haveconfidential enquiries into all perinatal deaths, like the one intomaternal deaths, because of the magnitude of the task. Asolution, however, has been developed whereby the nationalbasic perinatal data (i.e. data from every site where babies areborn) and data from sentinel sites around the country that haveconfidential enquiries into all the perinatal deaths in theirareas, are combined. The basic perinatal data is a minimumdataset that includes all births and deaths in weight categories.The data from the sentinel sites add descriptive data of causesand avoidable factors to the basic perinatal care indices. Thisgives a good reflection of the magnitude of the problem ofperinatal care in the country, and also provides information onwhy the infants are dying by including details on pathologyand health system failure. The combination of both sets of datagives a reliable picture of perinatal care in the country and candirect health workers to areas where the greatest improvementscan be made. The reports published under the ‘Saving Babies’banner are available for 2000 and 2001 from the NationalDepartment of Health.1,2 The third report, involving 73 sentinelReduction in perinatal mortality feasible without incurringmajor costsEDITORIALsites, represents every province and every geographical areaand combines the data for 2000 - 2002.  (Details of the processand findings are summarised in ‘Why babies die — a perinatalcare survey of South Africa’3 and ‘Challenges in saving babies— avoidable factors, missed opportunities and substandardcare in perinatal deaths in South Africa’,4 published in thisissue of the Journal (pp. 445 and 450).  Considerable discussion took place at the workshops withregard to prioritising interventions and deciding whichstrategies to implement. The recommendations of the group aregiven below. Subsequent reports by this group will concentrateon identifying what strategies are most effective, and onproviding case histories of how this was achieved. In this waythe group hopes it will play a significant role in improving thecare of pregnant women and their babies. Five key strategies were decided on and regarded asimplementable solutions. The strategies are described in such away that their implementation can be measured.Recommendations on improving the process were alsodiscussed. The group also recognised that it has extremelyvaluable information and that all groups of society need tohear it.  For this reason strategies were developed todisseminate the information. Finally, it was recognised thatsome of the findings need better investigation and researchneeds to be conducted in those priority areas. All theserecommendations are aimed at health workers, healthadministrators, medical schools and nursing colleges. Specificrecommendations for the public were not addressed in thereport. These suggestions come from the workshop and are notgovernment policy. They serve to initiate the process ofdiscussing ways of decreasing perinatal mortality in SouthAfrica.Five key strategies1. Ensure that each site conducting births has the necessaryequipment and protocols and that the health care providers areappropriately trained to manage labour and in particulartrained in the use of the partogram. Introduce a qualityassurance tool to assess the success of the training.Motivation: Intrapartum asphyxia and birth trauma is asignificant contributor to perinatal deaths throughout thecountry, but especially in the rural areas where in babies over 2 500 g it was responsible for more than 50% of deaths.2. Ensure that each site conducting births has the necessaryequipment, protocols and appropriately trained staff to manageasphyxiated neonates. See that training programmes inneonatal resuscitation are accessible to all staff involved withconducting childbirth.Motivation: The most common cause of neonatal death inbabies over 2 500 g is hypoxia. Adequate resuscitation of theseinfants could significantly reduce mortality and morbidity.3. Ensure that each site caring for premature infants has thenecessary equipment and protocols appropriate to the level ofcare and that the health care workers are appropriately trainedin care of the premature infant, including kangaroo mothercare. See that implementation programmes are available to thestaff.Motivation: The neonatal death rate for areas outside ofmetropolitan areas with functioning tertiary health careservices is almost twice as high as that for neonates inmetropolitan areas for birth weights 1 000 - 2 000 g. Little canbe done to prevent the births of these infants, and in order toreduce mortality, improvements in the care of prematureinfants in cities, towns and rural areas will have to occur.Kangaroo mother care as a step-down facility for neonatal careis a cost-effective intervention for caring for stable prematureinfants and allows for better utilisation of scarce intensive andhigh care neonatal resources. It has also been proved to reduceneonatal mortality in rural settings.  4. Ensure that each site providing antenatal care hasprotocols in place for where and when to refer patients andthat the health care providers are appropriately trained therein.Introduce a quality assurance tool to assess the success of thetraining.Motivation:A considerable number of missed opportunitiesoccurred in the antenatal clinics where the health care workersdid not take the appropriate actions.5. Move to a system where the time and point at which thewoman confirms she is pregnant also becomes the woman’sfirst antenatal visit where she can be classified according to riskand where her further antenatal care is specifically planned. Ifthis is not practice, establish what the barriers are andovercome them.Motivation: The most common patient-orientated avoidablefactor was no or infrequent attendance at antenatal care. Theproblem is not lack of knowledge about antenatal care, but thecomplication occurring before the woman intended startingantenatal care. If antenatal care could be initiated when thepregnancy was confirmed, then this problem would be greatlyreduced, allowing adequate time to intervene in the pregnancyif necessary.If implemented, these recommendations will also impact onmaternal mortality and are compatible with the ‘SavingMothers 1999 - 2001’5 recommendations.The Department of Health has produced Guidelines forMaternity Care in South Africa6 for clinics, community healthcentres and district hospitals. These guidelines are all that isneeded for these institutions to develop their own protocols.  As there are no national guidelines for neonatal care, thismust be a priority. Information, for example on implementingkangaroo mother care, is not readily available. Training courseson neonatal resuscitation are commercially available but are435June 2003, Vol. 93, No. 6  SAMJJune 2003, Vol. 93, No. 6  SAMJEDITORIALinaccessible to the majority of those caring for neonates. A newPerinatal Education Programme on basic neonatal care hasbeen produced, but has not been widely publicised as yet.   Methods of assessing the quality of care of women in theantenatal period and intrapartum were discussed. Workableexamples for auditing antenatal and intrapartum care areavailable. These tools could be very influential in changingpractice.  (Examples of these tools are given in Saving Babies2001. Second Perinatal Care Survey of South Africa.7 Thesereports1,2 are available for the National Department of Health,Private Bag X828, Pretoria, 0001, or at www.ppip.co.za).The Better Births Initiative is available on the Internet8 and isa programme aimed at directly improving the standard andquality of care during labour.A number of crucial questions crystallised during theworkshop; the group felt it was necessary to answer theseurgently. They were:• What is the primary pathology related to unexplained intra-uterine deaths (IUDs)?• What are the barriers to implementing on-site screening forsyphilis?• What are the barriers to implementation of initiation ofantenatal care on confirmation of pregnancy?• What is the feasibility of introducing nasal continuouspositive airway pressure (nCPAP) for the care of prematureinfants in cities, towns and rural areas? ConclusionThere are a few essential ingredients necessary to effectchange.9 The first phase is to identify the magnitude of theproblem and to realise that it is feasible to improvesignificantly on the current state of affairs. The second phase isto have the knowledge available to improve the situation, topersuade the health workers to use that knowledge, and tomake the knowledge and facilities available to the vastmajority of the population. For this, a political will must existto push through the necessary changes.South Africa is at the point where it can give a reliableestimate of its perinatal mortality rate, prioritise the commoncauses of perinatal death, and list the major avoidable factors,missed opportunities and areas of substandard care that existsurrounding these perinatal deaths. Most importantly, SouthAfrica now knows that these common causes and factors areremediable, and remediable without a massive increase inhealth spending.  Medical knowledge is available to prevent these deaths andthe health system is in place to make that knowledge availableto the vast majority of pregnant women. There is a strongpolitical will to improve the care of pregnant women and theirinfants. Therefore all the ingredients are available, except thatof persuading health care providers to use the knowledgeavailable and to direct their energies in the most appropriateway. Should that occur, South Africa should see a sudden andmajor improvement in perinatal care.R C Pattinson, for the Saving Babies GroupDirector: MRC Maternal and Infant Health Care Strategies Research UnitPrivate Bag X396Pretoria1. Pattinson RC, ed. Saving Babies: APerinatal Care Survey of South Africa, 2000. Pretoria:Government Printer, 2001.2. Pattinson RC, ed. Saving Babies 2001: Second Perinatal Care Survey of South Africa. Pretoria:Government Printer, 2002.3. Pattinson RC. Why babies die. A perinatal care survey of South Africa. S Afr Med J 2003; 93:445-450 (this issue).4. Pattinson RC. Challenges in saving babies. Avoidable factors, missed opportunities andsubstandard care in perinatal deaths in South Africa. S Afr Med J 2003; 93: 450-455 (this issue).5. National Committee for Confidential Enquiries into Maternal Deaths. Saving Mothers 1999 -2001: Confidential Enquiries into Maternal Deaths In South Africa. Cape Town: GovernmentPrinter, 2003.6. Buchmann EJ, Nyathikazi N. Guidelines for Maternity Care in South Africa. AManual for Clinics,Community Health Centres and District Hospitals . Pretoria: Government Printer, 2003.7. Philpott H. Quality assurance. In: Pattinson RC, ed. Saving Babies 2001. Second Perinatal Car eSurvey of South Africa. Pretoria: Government Printer, 2002: 68-86.8. The Better Birth Initiative. In: Effective Health Car e Alliance Programme(http://www.liv.ac.uk/lstm/ehcap/bbimainpage.html, accessed 30 Apr 2003).9. De Brouwere V, Tonglet R, Van Lerberghe W. Strategies for reducing maternal mortality indeveloping countries: what can we learn from the history of the industrialised West? Trop MedInt Health 1998; 3: 771-782.436

Reduction in perinatal mortality feasible without incurring major costs

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Reduction in perinatal mortality feasible without incurring major costs

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South African Medical Journal (SAMJ)