Midwife-led units in community settings

Cape Peninsula, South Africa

Associate Professor Sheila ClowMr Jason Marcus & Mrs Carol AdamsUniversity of Cape Town & Mowbray Maternity Hospital, Cape Town, SOUTH AFRICA

6 June 2010

Country-specific contextLarge countryRural-urban divide Inequitable health services, e.g.

◦public sector per capita expenditure ~$158

◦private sector per capita expenditure ~$942 (6x)

Health indicators◦ IMR 42.8/1000 (Health Systems Trust, 2007)

◦MMR 237/100 000 (Hogan et al, 2010)

High GINI co-efficientRedressing inequities

Specific challenges relative to midwifery skills

All midwives are trained as nursesProfile of nurses is most closely related

to the population profileNo distinction on the register for those

in current practiceNo requirement for relicensing Few posts designated for midwives Outreach programme to midwives ad

hocAccess to further training constrained by

shortage

Promising approaches – a promise that has delivered!

Free-standing midwife-run unitsfor “low risk” maternity care close to the people who require itand integrated in a defined referral system

◦8 midwife units◦2 secondary referral hospitals◦1 tertiary academic hospital

Initiated in the Cape Peninsula, South Africa in 1974 (prior to the Alma Ata Declaration)

Assumptions underpinning the Peninsula Maternal & Neonatal Service

Normal or low-risk pregnancies are well managed by suitably qualified midwives

Tertiary level hospitals focussed on ill patients ◦ inappropriate setting for a normal low-risk

pregnancy, and◦ inappropriate use of expensive resources and

infrastructureHealth services should be accessible,

acceptable and appropriate to the population, at a cost that is sustainable for the community

No poor options for poor people

Scope of Service

Full range from pregnancy diagnosis to 1st week post birth

Limited Emergency Obstetric Care (EmOC)

Advanced midwives are licensed to perform assisted deliveries – vacuum and forceps

Clinical guidelines are evidence based

Clinical guidelines are evidence based

Expectations are clear◦no inductions, continuous EFM, epidural

analgesiaBasic Antenatal Care (BANC) Better Birth Initiative – including doulas

Prevention of Mother-to-Child transmission (including HIV counselling and testing)

Kangaroo CarePhototherapyBaby-friendly Hospital InitiativePerinatal mental health

Total births in the Peninsula Maternal & Neonatal Service, 2008

Total births in PMNS

Total births at MOU's

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

38292

17515

Total Births in 2008

Mitchell’s Plain Midwives’ Unit – selected data

New b

ooking

s

Repea

t ant

enat

al a

ttend

ance

Admiss

ions

to M

OU

Tran

sfer

s fro

m la

bour

war

d

Tota

l del

iver

ies

0

5000

10000

15000

20000

25000

7195

21536

10403

1701

4193

5991794

866 141 349Total for yearMonthly average

Mitchell’s Plain staffing per shiftAntenatal clinic

◦2 registered midwives◦2 enrolled nurses◦1 enrolled nursing auxiliary

Labour ward & observation ward◦Day duty – 3 registered midwives◦Night duty – 2 registered midwives

Postnatal outpatients◦1 enrolled nurse

Maternal mortality rates for all 9 provinces

EC FS GP KZN LP MP NC NW WC0

50

100

150

200

250

81

234

114 118

78

143 147

102

70

MMR/100 000

MMR/100 000

Source : Health Systems Trust, 2003

PMNS data, 2008

38 292 deliveries22 Maternal deaths ~ MMR 57.5/100

000 ◦17 died in tertiary level care◦12 were postpartum◦5 = direct causes – 4 Hypertensive◦1 = co-incidental◦16 = indirect causes

12 Non-pregnancy related infections 11 known HIV+

8 with CD4 < 200Source : Fawcus, 2009

Before the advent of HIV and AIDS …

The PMNS MMR reached 31/100 000

The MMR for the midwife units was 20/100 000

Source : de Groot 1993

Lessons learntThe system worksHealth indicators are the best in the

countryCost effective and frees up higher

levels of the service to those requiring it

Some “medium risk” patients can be managed at this level

Creates a space for midwives to practice to their fullest potential

Cost effectiveness

13 years after the introduction of this initiative

the number of hospital births was the same

AND there were 9000 births occurring in the midwife units

The midwife units have 15% of the bed capacity of the entire service, yet account for 50% of all deliveries

Source : de Groot 1993

RequirementsSuitably qualified midwivesA tiered referral system to higher levels

of careClear and agreed referral criteriaCorrect use of evidence based clinical

guidelinesStandardised documentationGood communication systemsRegular clinical auditReliable transport

Suitably qualified midwives EducationRegulation

◦Professional◦Prescribing

Continuous professional development◦Perinatal update - referral hospital◦Total shutdown for staff training – 1 day

p.a.◦PEP (Perinatal Education Programme)

Clinical leadership

Added value!

A teaching and learning facility for undergraduate and postgraduate students in :

MidwiferyMedicineDentistryPhysiotherapyOccupational heathOccupational therapy

Future possibilitiesIncorporate into district health

serviceUltrasound scanning and

screeningPostnatal careTele-medicine / -midwifery

AcknowledgementsEmeritus Professor Herman De Groot, Dr John

Smith and the visionaries for decentralised primary health care, including maternity care

Miss Squires and the nurse managers who supported the initiative

The registered midwives, enrolled nurses and enrolled nursing auxiliaries which make this work

The mothers who have trusted our careThe medical teams at the Universities of

Cape Town & Stellenbosch and the referral hospitals who support this work

Programmes leading to registration as a midwife

Diploma course (1 year for RN or RPN, or 2 years for EN) (Reg. 254)

Comprehensive diploma / bachelor’s degree leading to registration as a nurse and midwife (Reg. 425)

Clinical requirements1 year diploma 4 year

diploma

960 hours 960 1000

ANC 60 hours Not specified

Antenatal women 30 30

Witness deliveries 5 5

Deliveries 15 15

Local Anaesthetic excluding pudendal block

excluding pudendal block + epidural

Episiotomy Performance 15

Perineal suturing suturing of 1 & 2 degree tears

Night duty at least 1/12 and no more than ¼ hours

Not specified

Clinical requirements1 year diploma

4 year diploma

pelvic assessments Not specified 5

conducting deliveries Not required 5

care of women in labour

Not required 25 (at least 3 through all 4 stages of labour)

internal examinations 15 sufficient number (no more than 5 rectal)

postnatal care Not specified 5 mothers & babies x 2 days5 mothers & babies x 5 days

exam at the routine postnatal visit

Not specified 3

Legal status of midwifery practice

Nursing Act No.50 of 1978 as amended

◦R1469 Scope of practice◦R2488 (26 October 1990) Conditions

under which registered midwives and enrolled midwives may carry on their profession

◦R387 15 February 1985 (as amended) Acts and omissions

Nursing Bill 2005 (31 August 2005)◦SANC Charter of Nursing Practice

R1469 as amended Scope of Practice

“The scope of practice will entail the following scientifically based acts or

procedures which apply to the practice of Midwifery and which relate to the mother

and child in the course of pregnancy, labour and the puerperium”

R1469 Scope of Practice Determine health needs

of mother and child Refer where necessary Prevention & promotion Monitoring progress of

labour, vital signs of mother & child, reaction to situations

Episiotomy, suturing of tears, local anaesthetic

Promote activities of daily living, e.g. exercise & sleep, oxygenation, hygiene, nutrition, elimination

Promote wound healing

Administration of medicine

Promote & facilitate breastfeeding

Establish a health promoting environment

Communication with parents

Assist with operative, diagnostic & therapeutic procedures

Co-ordination of health care

Provide effective advocacy

Care of the dying patient

Implications to considerStatus of regulation vis-a-vis protocol /

guidelinesChanges requiredNeeds to be evidence based, responsive to

changing evidenceNeeds to be responsive to changing health

care needs, yet maintaining safetyClarify who may do whatSkills trainingManagement of emergencies, e.g.

resuscitation, shoulder dystocia, prolapsed cordGuidelines required

Different models◦Free-standing birth unit (original

model)◦Unit linked to a comprehensive

health centre (primary level) (geographically close, but operationally still developing the relationships)

◦Unit on a secondary or tertiary hospital campus but operated separately