The Perinatal Conference are held under the auspices of the Department of Obstetrics and Gynaecology, University of Pretoria and sponsored by Abbott Laboratories SA (Pty) Ltd

Editor's note:

An editorial board was appointed to look at the papers in this year's Proceedings. Where there were marked errors in the papers these were referred back to the author for correction. If, however, these were not corrected the paper has been printed in its original form. The editors thus accept no responsibility for any mistakes found. if corrections were suggested by the editorial board and these did not in any way affect the meanings intended in the paper, these changes were made without contacting the author. We apologise if this causes offence but, in view of the amount of administrative work involved in contacting the relevant authors, it was felt this was the easiest course to follow.

Table of Contents

ECLAMPSIA AT HARARE MATERNITY HOSPITAL: DETERMINANTS OF MATERNAL OUTCOME. Majoko F..............................................1

MATERNAL MORTALITY AND SEVERE MORBIDITY ASSOCIATED WITH HYPERTENSION IN PREGNANCY. Buchmann EJ......................3

AUTOMATED BLOOD PRESSURE MEASUREMENT IN THE ASSESSMENT OF METHYLDOPA THERAPY IN SEVERE PRE-ECLAMPSIA. Steyn DW.................................................................6

HELLP SYNDROME IN TYGERBERG HOSPITAL. Du Preez JP..............9

AN HIV/AIDS SUPPLEMENT TO PEP. Woods D.............................12

DEVELOPING AND IMPLEMENTING KANGAROO MOTHER CARE (KMC) PRACTICE AT WITBANK HOSPITAL, MPUMALANGA (PHASE I). Onyari S..................................................................................14

PREGNANCY OUTCOME IN PATIENTS WITH CLINICALLY INCREASED MIDTRIMESTER DIASTOLIC BLOOD PRESSURE WHO RECEIVED ROUTINE ANTENATAL CARE. Carstens MH...................................15

COMPANIONSHIP DURING LABOUR (VIDEO). Huxtable L..............17

MOTHERS' INTENDED METHOD OF FEEDING OF BABIES UPON DISCHARGE FROM THE NEONATAL UNIT AND FACTORS ASSOCIATED WITH THE CHOICE. Hallbauer U..............................18

MATERNAL MORTALITY AND 'NEAR MISS' INTERVIEWS: HOW EASY IS THIS APPROACH? Mdeni T.....................................................22

NON-INSTITUTIONAL DEATHS. Motsemai D.................................24

MATERNAL DEATHS AND 'NEAR MISSES': HOW MUCH DO INTERVIEWS ADD TO CLINICAL AUDIT. Cebekhulu Q ...................25

KNOWLEDGE OF WOMEN, MORE THAN 34 YEARS OF AGE, ABOUT THEIR RISKS OF PREGNANCY. Davies R, Keti V............................29

CARDIACS AND PREGNANCY – A FATAL COMBINATION? Schoon MG...............................................................................................31

17 YEARS OF PERINATAL RESEARCH IN SOUTH AFRICA. Pattinson RC...........................................................................................32

DOES THE ADMINISTRATION OF OXYGEN BY NASAL CANNULAS TO LOW BIRTH WEIGHT INFANTS WITH RESPIRATORY DISTRESS DECREASE THEIR EFFORTS OF BREATHING? A PILOT STUDY. Frerich S...................................................................................33

PROBLEMS IN SEEKING SOLUTIONS IN MIDDELBURG DISTRICT. Muller M..................................................................................35

PARTNERSHIP IN SAFE MOTHERHOOD. Moosa EZ........................36

LOW PLATELET COUNTS AS MARKER OF HIV. Roux W..................37

MAGNESIUM SULPHATE FOR TREATMENT OF PRE-ECLAMPSIA: A TRIAL TO EVALUATE THE EFFECTS ON WOMEN AND THEIR BABIES. (THE MAGPIE TRIAL). RESULTS OF THE PILOT STUDY AT KALAFONG HOSPITAL. Pattinson RC...........................................38

ON-SITE SYPHILIS SCREENING AT PRIMARY HEALTH CARE CLINICS Chaane T.................................................................................39

A PILOT PROJECT TO IMPLEMENT IN GAUTENG THE PRINCIPLES AND PHILOSOPHY OF THE INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) – A WHO CHILD SURVIVAL STRATEGY. Rabosiwana M............................................................................41

AUDIT OF AN ANTENATAL CLINIC FOR WOMEN LIVING WITH HIV. Dinat N...................................................................................43

GASTROINTESTINAL DEVELOPMENT AND THE PREVENTION OF NECROTISING ENTEROCOLITIS. Newell SJ...................................44

THE USE OF GRANULOCYTE-COLONY STIMULATING FACTOR IN THE PREVENTION OF NOSOCOMIAL INFECTION IN NEUTROPAENIC INFANTS BORN TO WOMEN WITH SEVERE PRE-ECLMAPSIA. Kirsten GF...........................................................................................49

RANDOMISED CONTROLLED TRIAL OF RECOMBINANT GRANULOCYTE COLONY STIMULATING FACTOR (r-GCSF) IN NEONATES BORN TO WOMEN WITH PROTEINURIC HYPERTENSION TO PREVENT NOSOCOMIAL INFECTIONS. Price V........................51

SERIAL INTERLEUKIN 6 MEASUREMENTS IN THE EARLY DIAGNOSIS OF NEONATAL SEPSIS. Ballot DE................................................52

A REVIEW OF EARLY ONSET GROUP B STREPTOCOCCAL DISEASE. Bomela HN..............................................................................56

NEONATAL BACTERAEMIA AND PSEUDOBACTERAEMIA AT CHRIS HANI BARAGWANATH HOSPITAL. Saloojee H..............................57

SAVING MOTHERS. REPORT ON CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS IN SOUTH AFRICA 1998 . Moodley J……………………………………61

AUDIT OF PERINATAL MORTALITY IN NORTHERN KWAZULU NATAL – PROBLEMS AND ANSWERS. Gandhi M......................................80

SOCIODEMOGRAPHIC PROFILE OF WOMEN IN THE MATERNAL MORTALITY STUDY. Rees HR.....................................................84

MAKING SENSE AND GETTING DIRECTION FROM NEAR MISS AND MATERNAL MORTALITY AUDITS. Pattinson RC.............................86

DOES MATENAL “NEAR MISS” AUDIT MAKE A DIFFERENCE? Mantel GD...........................................................................................88

DEVELOPMENT AND VALIDATION OF A SCALE TO MEASURE PATIENT SATISFACTION WITH ANTENATAL CARE. Steyn PS.........91

DOES EPISIOTOMY BENEFIT THE LOW BIRTH WEIGHT BABY?. Buchmann E............................................................................95

ACTIVE BIRTH UNIT STATISTICS. De Jager M...............................96

BIRTH ASPHYXIA: AN UNAVOIDABLE EXPERIENCE? Ballot DE......97

ARE DEATHS DUE TO BIRTH ASPHYXIA PREVENTABLE? THE RELATIONSHIP BETWEEN INTRA PARTUM ASPHYXIA AND NURSING STAFF ALLOCATIONS AT WITBANK HOSPITAL. Chegwidden R.....100

REASONS FOR THE PROVEN INACCURACY OF THE PINARD STETHOSCOPE IN DETERMINING THE FETAL HEART RATE DURING LABOUR. v/d Westhuizen CE..................................................................103

INTRAUTERINE GROWTH RETARDATION AND THE FETAL GUT: IMPLICATIONS FOR FEEDING THE PRETERM INFANT. Newell SJ. .106

IMPROVING COMPLEMENTARY FEEDING PRACTICES IN CHILDREN AGED 3 TO 12 MONTHS IN THE HIGHVELD REGION, MPUMALANGA, SOUTH AFRICA. Malek E..........................................................109

RANDOMISED CONTROLLED TRIAL OF A BREAST MILK FORTIFIER TO SHORTEN HOSPITAL STAY IN LOW BIRTH WEIGHT INFANTS. Honey EM..............................................................................112

THE ADVANTAGES OF BREAST FEEDING. Newell SJ....................113

TIDAL VOLUME AND ON-LINE RESPIRATORY COMPLIANCE MEASUREMENTS AS PREDICTORS FOR SUCCESSFUL EXTUBATION OF NEONATES BEING VENTILATED FOR HYALINE MEMBRANE DISEASE. Pieper CH..............................................................................116

THE ROLE OF KININS AND CYTOKINES IN HYPOXIC ISCHAEMNIC ENCEPHALOPATHY OF THE TERM NEWBORN. Adhikari M...........118

THE LONG TERM NEURO-DEVELOPMENTAL OUTCOME OF INFANTS <1250G ELECTIVELY NOT ADMITTED TO THE NEONATAL INTENSIVE CARE UNIT. Kirsten GF.............................................................121

SHOULD WE VENTILATE THE NEWBORN EXTREMELY LOW BIRTHWEIGHT INFANT: OUTCOMES OVER THE LAST DECADE. Urban M..................................................................................123

THE ETHICS OF SELECTING INFANTS FOR NEONATAL INTENSIVE CARE.Cooper PA...............................................................................124

IMPLEMENTING A NATIONAL NEONATAL RESUSCITATION PROGRAMME. Saloojee H.............................................................................129

A NEW EDUCATIONAL STRATEGY TOWARDS IMPROVING MATERNAL AND NEONATAL CARE. Hay IT................................130

EVALUATION OF THE USE OF THE NEONATAL MANUAL OF THE PERINATAL EDUCATION PROGRAMME. Greenfield DH................132

THE POTENTIAL TO REDUCE PERINATAL DEATHS IN A RURAL REGION THROUGH STUDY OF THE MATERNAL CARE MANUAL OF THE PERINATAL EDUCATION PROGRAMME BY MIDWIVES. Theron GB.........................................................................................134

THE WHO REPRODUCTIVE HEALTH LIBRARY. Hofmeyr GJ...........137

OBSTETRICAL HAEMORRHAGE – PREVENTABLE KILLER? Schoon MG.............................................................................................138

MISOPROSTOL VERSUS METHYLERGOMETRINE FOR THE PREVENTION OF POSTPARTUM HAEMORRHAGE: A DOUBLE BLIND RANDOMISED TRIAL Amant F................................................................................139

MISOPROSTOL VERSUS SYNTOCINON: A RANDOMISED DOUBLE BLIND PLACEBO CONTROLLED PHYSIOLOGICAL STUDY OF INTRA-UTERINE PRESSURE DURING THE THIRD STAGE OF LABOUR.

Nikodem C...............................................................................142

TITRATED ORAL MISOPROSTOL SUSPENSION FOR INDUCTION OF LABOUR. A PILOT STUDY. Matonhodze BB................................143

INFLUENCE OF BACTERIAL VAGINOSIS ON THE ABSORPTION OF MISOPROSTOL. Jivkov BI.........................................................144

THE IMPACT OF THE PREGNANCY CONFIRMATION CLINIC ON ANTENATAL CARE. Tsuari M.....................................................145

ROUTINE EXTERNAL VERSION FOR ABNORMAL PRESENTATION – THE SUCCESS RATE AND OUTCOME WITHIN AN OBSTETRIC SERVICETheron AM...............................................................................146

DOES HIV SERO-POSITIVITY CHANGE THE POST-OPERATIVE MORBIDITY OF CAESAREAN SECTION PATIENTS? Urbani G, Goosen H...........................................................................................148

PRETORIA PASTEURISATION – A POTENTIAL METHOD FOR THE REDUCTION OF VERTICAL TRANSMISSION OF HUMAN IMMUNODEFICIENCY VIRUS VIA BREASTFEEDING. Jeffrey BS.....150

LESSONS LEARNED IN ESTABLISHING A RANDOMISED CONTROLLED TRIAL TO INVESTIGATE THE EFFECTS OF VITAMIN A ON VERTICAL TRANSMISSION OF HIV-1. Steinberg WJ...............151

INTERIM ANALYSIS OF EARLY EFFICACY OF VARIOUS SHORT-TERM ADV/3TC COMBINATION REGIMENS IN PREVENTING MOTHER-TO-CHILD TRANSMISSION OF HIV-1: THE PETRA TRIAL. McIntyre JA 154

ECLAMPSIA AT HARARE MATERNITY HOSPITAL: DETERMINANTS OF MATERNAL OUTCOME

Majoko FDepartment of Obstetrics and Gynaecology, University of Zimbabwe Medical School

IntroductionMaternal mortality for the Greater Harare Maternity Unit (GHMU) remains unacceptably high at 370/100 000 live births. Eclampsia is a major contributor to maternal mortality, responsible for 20% of deaths in 1997.

ObjectivesTo study the presentation, management and outcome of women with eclampsia at Harare Maternity Hospital (HMH) aiming at identifying factors which influenced outcome.

Methods and SubjectsPatients admitted with or developing eclampsia at HMH during an 18 month period were included in the audit. A comparison was made between the women who died and those who survived. The effects of age,

parity, booking status, gestational age, location of first seizure, number of fits prior to admission, seizure to delivery interval, ICU admission, maternal complications and the standard of care given on maternal outcome was examined.

ResultsThere were 25 425 women delivered at HMH during this period of whom 144 had a diagnosis of eclampsia (5.7 per 1000 births). The case fatality was 24.3%. The majority of fits (66.9%) occurred antenatally. The mothers who died were significantly older than the survivors, mean ages 26.1 vs 22.3 (p=0.007), and had a higher proportion of multiple seizures, 0.67 vs 0.39 (p=0.009) respectively. Fifty-five percent of eclamptics were in their first pregnancy (p=0.001). Delays in achieving delivery, inadequate clinical assessment and poor monitoring were common problems at the central level, with 26.8% of women still not delivered more than 12 hours

after onset of convulsions. The booking status, gestational age, seizure to delivery interval and location at time of first seizure did not affect maternal outcome.

ConclusionEclampsia remains a significant cause of maternal mortality and there is scope for reducing these maternal deaths. The management should be aggressive with early delivery and close monitoring of the mother.

MATERNAL MORTALITY ANDSEVERE MORBIDITY ASSOCIATED WITH HYPERTENSION IN PREGNANCY

Buchmann EJ and the Near Miss Study GroupDepartment of Obstetrics and Gynaecology, Baragwanath Hospital

Keywords: pre-eclampsia, maternal death, maternal near-miss

The multicentre Near Miss Study was undertaken in Pretoria, Soweto and the Free State to investigate whether primary obstetric causes, final causes, and avoidable factors were comparable between maternal deaths and near misses. Near misses are women who are pregnant or less than six weeks postpartum, and who suffer severe morbidity which, without intervention, would have resulted in death. The definition of a near miss has been published elsewhere and is based on an organ systems approach, using organ failure or severe dysfunction as a marker of near miss.During the Near Miss Study, which included 702 near misses

and 220 deaths, hypertension in pregnancy was found to be the most frequent primary obstetric cause, accounting for 226 (32%) of near misses and 54 (25%) ofdeaths. The objective of this part of the Near Miss Study was to determine whether near misses and deaths due to hypertension were comparable in patterns of organ dysfunction and in avoidable factors.

MethodsFrom the Near Miss Study data, all near misses and deaths which had hypertension as the primary obstetric cause were included. Cases where abruptio placentae was the primary obstetric cause, even in the presence of hypertension, were excluded. Audit teams from the three participating centres examined the case-notes of near misses and deaths and decided on the final causes (organ dysfunction) and avoidable factors (patient, administrative and medical) for each case.

Results

Patterns or organ system dysfunction are shown in Table 1. The conversion rate expresses the probability in this study of an organ system dysfunction progressing to maternal death (deaths/near misses + deaths). Thirty-eight percent of near-misses and 54% of deaths were avoidable in terms of patient-related factors (p=0.04). The most common patient-related avoidable factor was failure to book for antenatal care (19% and 19%).Administrative-related avoidable factors were present in 18% of near-misses and 35% of deaths (p=0.005). The most common administrative-related avoidable factor was a lack of

appropriate medical facilities (6% and 20%, p=0.001), most usually a shortage of intensive care units. Medical-related avoidable factors were present in 57% of near misses and 80% of deaths (p=0.001). The most common medical-related avoidable factor was inappropriate management (24% and 35%, not significant).

Table 1 Patterns of organ system dysfunction in maternal near misses and deaths

Dysfunction Near miss(n=226)

Death(n=54)

Conversion rate (%)

Cardiorespiratory 116 25 18Cerebral 44 36 45Renal 86 9 9Coagulation 35 4 10Hepatic 29 5 15Circulatory (shock) 8 7 47

DiscussionCerebral and cardiorespiratory

dysfunction predominated amongst deaths, with the highest effective conversion rates from

near miss to death. Renal and coagulation failure had the lowest conversion rates. This reflects the ability of the participating obstetric centres to treat these conditions. Cardiorespiratory failure in pre-eclampsia is potentially preventable and treatable, and should be given prominence in protocols of management

for severe pre-eclampsia. Avoidable factors were found more frequently in women who died than in near misses. This suggests that appropriate management of women with severe pre-eclampsia may reduce the conversion of near-misses to deaths. There is a possibility in this study that the observers may have been biased and tended to find more fault with death (a negative outcome) than with near miss (a positive outcome).Audit of near misses in hypertension in pregnancy does not give the same information as audit of maternal deaths. It gives supplementary data to that of deaths and allows us to identify problems in the management of

severely ill women with pre-eclampsia.

AUTOMATED BLOOD PRESSURE MEASUREMENT IN THE ASSESSMENT OF METHYLDOPA THERAPY IN SEVERE PRE-ECLAMPSIA

Steyn DW, Odendaal HJDepartment of Obstetrics and Gynaecology, Tygerberg Hospital and University of Stellenbosch and MRC Unit for Perinatal Mortality, Tygerberg, South Africa

Keywords: pre-eclampsia, alpha-methyldopa, ambulatory blood pressure monitors

Expectant management of carefully selected patients with severe pre-eclampsia (PE) before 34 weeks gestation may benefit the fetus without harming the mother. Precise control of maternal blood pressure (BP) is an integral part of this approach. Methyldopa (MD) is well established as anti-hypertensive drug of choice in pregnancy because of its safety for the fetus. The recommended dosage varies from 2000 to 4000 gram per os per day, but should be as low as possible due to potentially hazardous maternal side effects. Conventional blood pressure measurement has several limitations in pregnancy which may influence accuracy.

Ambulatory blood pressure measurements (ABPM) offer an alternative method of acquiring frequent

assessments in a way which may decrease the number of potential errors. We assessed the efficacy of MD to control BP in patients with severe PE using ABPM.

Patients and Methods38 patients with severe PE before 34 weeks gestation were managed expectantly if no indication for immediate delivery existed. Patients received MD, either as 500mg qid or 750mg tds with the aim of maintaining diastolic BP (DBP) between 90 and 109mm Hg as determined by sphygmomanometer assessment. BP was also monitored every 30 minutes with the pregnancy validated Spacelabs 90207 monitor. The main measures of comparison were DBP >109mm Hg, mean 24 hour DBP and day-night variability. All results were unavailable to the clinician.

ResultsTable 1 summarises the distribution of BP values obtained in 89 recordings (3870 measurements) in 38 patients. The mean diastolic blood pressure and the day-night

differences are depicted in Figures 1-3.

Table 1 The distribution of blood pressure values obtained in the two treatment groups

Dosage Patients 24 hour Records Recordin

gs

<90mm Hg

90-109mm

Hg

> 109mm

Hg

500mg qid

25 50 1733 1289(60%)

793(37%)

55(2.6%)

750mg tds

13 39 2137 1392(80%)

336(19%)

5(0.2%)

Figure 1 The mean diastolic blood pressure over the 24 hour period in the two treatment groups

Figure 2 The distribution of individual diastolic blood pressure values in the two treatment groups

Figure 3 The distribution of day-night differences in diastolic blood

pressure in the two treatment groups. (Mean diastolic blood pressure during the day minus mean diastolic pressure during the night for each recording)

Mean DBP was significantly lower at night in both groups. The mean DBP was higher at night time in 41% of recordings in both groups.

ConclusionsThe use of alpha-methyldopa is associated with 1.5% diastolic blood pressure values >110mm Hg. Two thirds of mean 24 hour values <90mm Hg. DBP values above 109mm Hg occurred significantly more often in patients receiving MD 6 hourly. There were some patients with a reversed diurnal pattern of blood pressure, but this was not

influenced by the dosage of MD. However, the therapeutic goal may have to be redefined when using ABPM.

HELLP SYNDROME IN TYGERBERG HOSPITAL

Du Preez JP, Steyn DW, Kirsten GFDepartment of Obstetrics and Gynaecology, Tygerberg Hospital and the University of Stellenbosch and the MRC Unit for Perinatal Mortality, Tygerberg

Keywords: HELLP Syndrome, perinatal mortality, prematurity

Pre-eclampsia is a major cause of maternal and perinatal mortality and morbidity in South Africa. The HELLP syndrome was described as a combination of haemolysis, increased liver enzymes and thrombocytopaenia in patients with severe pre-eclampsia. The initial opinion was that this was a particularly severe form of the disease which almost always requires prompt delivery. We usually follow these guidelines locally, irrespective of gestational age. While this approach should be beneficial to the mother, it will not necessarily improve perinatal outcome and may indeed be harmful to the neonate. Some authors have indeed questioned the need for immediate delivery recently. Expectant management of

carefully selected patients with severe pre-eclampsia maybenefit the fetus without harming the mother. This may also be true for some patients with HELLP syndrome. We report the results of a descriptive study which we undertook to assess the clinical impact of HELLP syndrome in Tygerberg Hospital.

Patients and MethodsWe prospectively collected the names of 90 consecutive patients who presented to the labour ward in Tygerberg Hospital with HELLP syndrome. The folders of these patients were reviewed, the relevant data collected and entered onto a data sheet. All patients were initially admitted to the labour ward for assessment of both mother and fetus. The obstetric firm on call attended tothe patients. The gestational age at presentation as well as the fetal condition determined the approach to management. In the absence of fetal distress, patients presenting after 34 weeks gestation were stabilised and delivered as soon as possible.

Between 28 and 34 weeks gestation, we administered betamethasone and attempted to gain 48 hours before delivery. Patients presenting after 28

weeks gestation with fetal distress were delivered. Termination of pregnancy was recommended to mothers with non-viable fetuses. Obstetric considerations determined the route of delivery.Pre-eclampsia was defined according to the guidelines of the ISSHP. To make the diagnosis of HELLP syndrome, we required confirmation of increased liver enzymes, thrombocytopaenia and haemolysis. (Serum aspartate aminotransferase > 70E/L, platelet count <100 000/mm, lactate dehydrogenase >600 E/L or a peripheral smear indicative of haemolysis). Neonatal deaths were defined as deaths during the first 28 days of life and were considered early when occurring during the first 7 days. Any one of the following complications was consideredas neeonatal morbidity. Intracranial haemorrhage, convulsions, intraven-tricular haemorrhage, intubation and ventilation, pneumonia, pulmonary haemorrhage, pulmonary hypertension, pneumothorax, patent ductus

arteriosus, congestive cardiac failure, sepsis or necrotising enterocolitis.The main measurements of outcome were the development of maternal and perinatal morbidity and mortality.

ResultsThree of the ninety mothers died, while morbidity occurred in a further 26 (29%) patients. Two of the maternal deaths were associated with septic shock and multiple organ failure, while the third was due to a massive intracerebral haemorrhage.Ninety two babies, including three sets of twins were delivered. One stillbirth was not delivered as it was still in utero when its mother died. Another was born in the peripheral hospital before referral and its outcome is unknown. Only 22 babies (24%), including three stillbirths, were born at 34 weeks gestation or later. Fifty-nine (78%) of 76 viable (>28 weeks gestation or >1000 grams) neonates survived.There were nine late abortions associated with termination of pregnancy, while four more patients presented with intrauterine deaths after 28 weeks gestation. Seventy four babies were born alive. The eight early neonatal deaths and the seven late neonatal deaths all occurred in patients who

delivered at 31 weeks gestation or earlier. Serious neonatal morbidity occurred in 17 (29%) of the 59 survivors.ConclusionsHELLP syndrome is a serious complication of pre-eclampsia with a high rate of maternal and perinatal mortality and morbidity. Prematurity is a major contributing factor to poor neonatal outcome. There may therefore be a small subgroup where expectant management may benefit the fetus without harming the mother. This subgroup will not be easily defined, but warrants further investigation.

AN HIV/AIDS SUPPLEMENT TO PEP

Woods DDepartment of Paediatrics and Child Health, University of Cape Town

Keywords: HIV, education, perinatal

The Perinatal Education Programme continues to provide distance learning opportunities for midwives throughout Southern Africa. Currently 20 000 PEP manuals have been distributed and 5000 PEP certificates awarded. Doctors, students at nursing colleges, and medical students at most South African universities use PEP manuals as resource material. Two prospective, controlled studies have documented the success of PEP in providing continuing perinatal education to midwives. Therefore, PEP meets an important training need for perinatal health care workers in South Africa.Together, the Maternal Care and Newborn Care manuals provide a two year course on the management of most perinatal problems. Using the educational

principles of self-study, problem solving, peer tuition, self-assessment and co-operative learning, midwives can improve their knowledge, clinical skills, attitudes, and standard of patient care. A formal tutor is notneeded, and students are not required to leave their place of employment to join a PEP course. Small groups of midwives manage their own training courses. PEP protocols and documentation are widely used in clinics and hospitals.South Africa is facing a crisis in health care as the rate of HIV infection in pregnant women reaches 20%. The mother-to-infant transmission rate in most communities is 35%. As a result, AIDS is rapidly becoming the major cause of both maternal and infant death. The correct management of pregnancy, labour, delivery and the newborn infant offers a means of reducing the spiraling infant mortality rate due to HIV infection. An extensive training campaign among midwives is urgently needed if they are to

provide this service.A third PEP manual has been written which addresses the training needs of midwives and doctors who care for women and infants in communities where HIV infection is a problem. The manual provides a training opportunity for health workers to acquire the knowledge to care for both mother and infant. The style and format is the same as the first two PEP manuals. Seventeen doctors, midwives and social workers, experienced in the field of perinatal HIV, contributed to the manual. An examination, with a certificate for successful candidates, will be offered on completion of the manual. It is hoped that the Perinatal HIV/AIDS manual will improve the standard of maternal and infant care in all South African communities.The Perinatal HIV/AIDS manual consists of 5 units:Unit 31 Introduction fo

perinatal HIV/AIDSUnit 32 HIV/AIDS in

pregnancyUnit 33 HIV/AIDS in labour

and deliveryUnit 34 HIV/AIDS in the

newborn infantUnit 35 HIV/AIDS and counselling

Perinatal HIV/AIDS manuals are available, in English, from the Perinatal Education Trust. The price, inclusive of postage and tax, is R50 per manual.

Enquiries should be addressed to:The Distribution ManagerPerinatal Education TrustP O Box 34502GROOTE SCHUUR, 7937Tel/Fax: (021) 618030

DEVELOPING AND IMPLEMENTING KANGAROO MOTHER CARE (KMC) PRACTICE AT WITBANK HOSPITAL, MPUMALANGA (PHASE I)

Onyari S, Malek E, Ncapai NG, Makanga O, van de Wal E*Department of Paediatrics, Witbank Hospital and University of Pretoria* Speech Therapy, University of Pretoria

IntroductionThe study was done in two phases.Phase 1: Preparatory StageMotivation to carry out study Small baby room. Growing number of LBW/

premature deliveries. Shortage of staff. Financial constraints. Bonding - Baby-friendly

hospital.

ObjectivesPhase 1:1. Train staff, create

awareness, motivate organisational changes necessary to implement KMC.

2. Develop practice guidelines for testing and implementing KMC.

3. Prepare a suitable physical environment.

Results1. Staff prepared - labour

ward, antenatal clinics, baby room, paediatric department.

2. Mothers informed of KMC: are now practising part time KMC in the baby room. (Flyer) (Talks)

3. Environment obtained for full time KMC.

4. Practice guidelines provided.* Selection criteria* Kangaroo protocol* Nursing duties* Mothers duties and

activities* Data collection sheet* Staff questionnaire* Parent questionnaire* Follow-up

ConclusionPhase 1: Objectives 1, 2, 3

achieved. A six bed KMC unit is ready.

Phase 2: Study in progress

PREGNANCY OUTCOME IN PATIENTS WITH CLINICALLY INCREASED MIDTRIMESTER DIASTOLIC BLOOD PRESSURE WHO RECEIVED ROUTINE ANTENATAL CARE

Carstens MH, Steyn DWDepartment of Obstetrics and Gynaecology, Tygerberg Hospital and the University of Stellenbosch and the MRC Unit for Perinatal Mortality, Tygerberg

Keywords: mild hypertension, pre-eclampsia

IntroductionWe recently reported an association between the addition of Ketanserin to Aspirin and improved pregnancy outcome among patients with mild to moderate midtrimester hypertension. Some patients with clinically increased diastolic blood pressure (DBP) did not eventually participate in the Ketanserin study due to one or more exclusion criteria.

AimTo assess pregnancy outcome in patients with initial midtrimester DBP above 80mm Hg, as measured by sphygmomanometer, but who did not participate in the Ketanserin

randomisedcontrolled trial (RCT).

Patients and MethodsPatients with clinical DBP of more than 80mm Hg were excluded from a RCT to investigate the role of Ketanserin in lowering the rate of pre-eclampsia if the increase in DBP was not sustained when measured on three occasions with a Dinamap Vital signs monitor. The patients who did not meet the inclusion criteria for the Ketanserin RCT, were managed according to existing departmental policies by the firm which initially referred the patient. After delivery, these patients' data were analysed.Inclusion criteria for Ketanserin study:- gestation between 12 and

20 weeks.- clinical DBP of 80mm Hg at

the antenatal clinic.- DBP repeatedly above

80mm Hg when measured with a Dinamap Vital Signs monitor.

- singleton pregnancy without fetal abnormalities.

- patient consent.

Exclusion criteria for Ketanserin study:- abnormal

electrocardiograph.- underlying medical

condition.

ResultsOne hundred and ninety seven patients for the RCT. Fifty nine patients did not qualify for the RCT. Of the 59 patients, the majority (79.6%) were excluded because the DBP was lower than 80mmHg when measured with a Dinamap Vital Signs monitor. The records of 51 patients were available for analysis. Eight mothers developed pre-eclampsia, while 8 required anti-hypertensive treatment. Six patients required Dihydralazine

for severe hypertension. The mean gestation at delivery was 37 weeks, but 6 patients delivered before 34 weeks gestation. Forty six babies survived of whom 1 was admitted to the neonatal intensive care unit. Neonatal morbidity occurred in 5 of the survivors.

ConclusionPatients with midtrimester DBP >80mm Hg probably represent a high risk group who should be carefully observed during the antenatal period.

Table 1 Maternal characteristics at entryAge 28.8 + 6.6 yearsGravidity 2 (1-8)Parity 1 (0-7)Primigravida 11 (21%)First blood pressure 135.5 + 14.3 / 76.2 + 9.2 mm Hg Second blood pressure 130.1 + 16.5 / 72.3 + 9.1 mm HgThird blood pressure 129.0 + 17.2 / 73.0 + 9.3 mm Hg

Table 2 Neonatal outcomeGestation 37.1 + 4.9 weeksBirthweight 2850.6 + 951.5 gramsBirthweight (viable babies) 3049.0 + 691.9 gramsApgar 5 minutes 10 (0-10)5 minutes Apgar <7/10 1Intensive care unit 1 baby for 19 daysVentilation 1 baby for 15 daysStill births 1Miscarriages 4

Survivors 46

COMPANIONSHIP DURING LABOUR (VIDEO)

Hofmeyr J, Nikodem C, Huxtable L, Brown HUniversity of the Witwatersrand and Coronation Maternal and Child Hospital

This video is part of a large project.This project aims to highlight the experiences of women using maternity services, document the care they receive, and document the views of health workers about what type of care should be provided, as well as obstacles to change. The project will focus on labour support because this is the aspect of care during labour for which probably the greatest discrepancy exists between evidence of effectiveness and lack of implementation in developing countries. An educational programme to facilitate the introduction of labour support programmes will be developed and tested.The primary objective of this trial is to evaluate the change in health care service providers through a motivational educational programme containing information on how to

overcome obstacles in introducing interventions in their service that have proved to be helpful in childbearing women.The visual educational programme will be designed to alter attitudes and behaviour of medical, nursing and administrative staff with respect to the implementation of evidence-based interventions with the focus on the introduction of a community-based labour support programme in their institutions.The visual education programme will be made in consultation with experts from relevant fields such as adult education and change management. The programme will address the research findings of phase 1, as well as giving clear guidance on how to go about introducing a labour support programme. Structured workshops will be used to implement the programme.

MOTHERS' INTENDED METHOD OF FEEDING OF BABIES UPON DISCHARGE FROM THE NEONATAL UNIT AND FACTORS ASSOCIATED WITH THE CHOICE

Hallbauer U, Grobler J, Niemand I*Department of Paediatrics*Department of Obstetrics and Gynaecology, University of the Orange Free State

Keywords: Breastfeeding, neonatal unit

BackgroundOnly a minority of babies followed up after discharge from the neonatal unit seemed to be exclusively breastfed. All these babies had been ill or premature and there was an interruption of the normal breastfeeding process. It has been reported from other countries and from rural areas in South Africa that at least a 75% exclusive breastfeeding rate is possible in this situation.

ObjectiveThe aim of the study was to determine how many mothers planned to exclusively breastfeed their babies after discharge and to investigate factors that

contributed to this decision.

DesignA descriptive study was used. The day the mother left the unit with the baby, she was interviewed by the authors (UH & JG) sometimes with assistance from other doctors in the unit. The mother gave verbal consent. Basic medical data about the mother and baby was obtained from the hospital notes. Frequently misconceptions or mis-understandings of the mother about feeding of her baby were noticed during the interview. These were corrected at the end of the interview and advice was given.

SettingNeonatal Unit, Pelonomi Hospital, Bloemfontein. May 1996 - May 1998.

SubjectsMothers (n=81) of babies that were admitted to the neonatal unit within 24 hours of birth were interviewed. Exclusions: HIV+ mothers, babies with congenital anomalies affecting feeding, any other situation where breastfeeding is contra-indicated.

Information from the interviews with the mothersMost mothers (74%, n=60) replied they had decided during pregnancy to exclusively breastfeed their babies. There were no significant associations with parity, age, level of education, previous breastfeeding experience or whether she would return to schoolor work. The reply to the

question "How will you feed your baby tomorrow" is however significantly associated with that decision (p<0.05).In total, 60% of mothers intended to breastfeed exclusively "tomorrow", but this dropped to 50% in reply to the question "How will you feed your baby in a week's time?" 'Other' feeding methods were breast- and bottle-feeds, bottle-feeding only, or bottle-feeds and porridges.

Decided to breastfeed only during pregnancy

Yes60 (74.1%)

No (bottle, other,undecided)

21 (25.9%)How will you feed your baby tomorrow?

BF only 41Other 19

BF only 7 (=60%)Other 14 (=40%)

The mother's decision to exclusively breastfeed on discharge was also significantly associated with the birthweight of the baby (p<0.0008) and the gestational age at birth (p<0.0005).

Will breastfeed only – average birth weight 2411g.Other feeding – average birth weight 1823g.

Gestational age of Birth (weeks)

< 34 > 34 weeks

Will BF tomorrow 17 (42.5%) 31 (75.6%)Other feeds tomorrow 2310

Birth weight < 2000g > 2000gBF only 47.7% 73%Other 52.3% 27%p=0.0378 <0.05Discharge weight < 2000g > 2000gBF only 46.7% 75%Other 53.3% 25%p=0.0187 <0.05

There were no significant associations between the choice of feeding method and age, parity or education of the mother, or any feeding practices during the hospital stay or any assistance given to the mother by hospital staff. It would, however, appear that though not statistically significant, the average stay of babies whose mothers did not intend to breastfeed only, was longer.

A significantly greater proportion of mothers who intended to exclusively breastfeed, saw their babies daily (p=0.0220). More mothers living in and around Bloemfontein saw their baby daily compared to those living farther away. The latter group was also much less involved in the feeding process (breastfeeding or feeding by bottle or nasogastric tube).

Chosen feeding method vs mother-baby contact

Many mothers felt it would be difficult to breastfeed after the interruption. They said milk would have dried up, milk would be sour, or one just cannot feed after a non-breastfeeding period. While the baby was in the unit, many mothers (70%, n=54)

expressed their milk, however only 31 of these expressed more than once a day (maximum mentioned was 5 times a day) and many only started after 3 days. Mothers staying further away expressed milk to a lesser degree.

The main reasons for not expressing were: no milk, not knowing how to express, did know it was important to express. There was no association between expressing milk and any demographic data of the mother or baby or whether the mother participated in the feeding process in any way.Only 37% of mothers stated they were shown how to express milk and 42% were shown how to breastfeed. This did not influence their feeding decision at discharge."Do you know how to increase your breastmilk supply?" Only one mother had the correct knowledge, though 58% of mothers thought they knew and explained how. Most stated that drinking a lot of tea, eating a lot of food especially porridge or meat would help.Mothers were asked where they would seek help if they had problems breastfeeding at home. Two thirds of the mothers replied that they would get help at a clinic, hospital or doctor.

Conclusions

The decision to breastfeed is mainly made during pregnancy and this helps to motivate the mother to do so even in often unexpectedly difficult circum-stances. Overall, only 50-60% of mothers thought they would exclusively breastfeed their babies at home. Except for frequent mother-baby contact, unfortunately no hospital practices in this study influenced mothers to decide to breastfeed only when they took their baby home. The birth weight, discharge weight and gestational ages of the babies has an important influence, as can be expected. The expressing of milk and actual breastfeeding of the baby during the hospital stay was not at a level that would sustain lactation adequately in most mothers. Virtually no mother had the correct knowledge on how to increase her breastmilk supply.

RecommendationsBreastfeeding motivation and teaching of the process must be an essential part of antenatal care.Lodger-care or re-admission of

the mother-baby pair for 2-3 days before going home to increase milk supply.Kangaroo care would improve breastfeeding rates.Certain staff members in the neonatal ward should have skills in managing lactation under difficult circumstances.The "insufficient milk syndrome" in SA should warrant further studies.

MATERNAL MORTALITY AND 'NEAR MISS' INTERVIEWS: HOW EASY IS THIS APPROACH?

Mdeni T and the Near Miss Study GroupMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria

ObjectivesTo assess whether the barriers experienced when interviewing women classified as 'Near Miss' or when interviewing the relatives of women who have had a maternal death, prevent this approach from being adopted as part of the routine audit of maternal death and 'Near Miss' in public sector services. A 'Near Miss' is defined as a woman suffering severe acute morbidity which if not treated appropriately could result in her death.

MethodsIn three centres (Chris Hani Baragwanath Hospital, Kalafong and Bloemfontein), questionnaires were administered to women classified as 'Near Miss' and to the relatives of women who have had a maternal death. These questionnaires explored

the socio-demographic background of the women, the history of the pregnancy and the women's response to that pregnancy, the response of partners to the pregnancy, the contraceptive history of the woman and access to services including transport. Women who had experienced a 'Near Miss' were interviewed in the hospital wards, whilst the relatives of women who had a maternal death were interviewed in their homes. Questionnaires were modified to the different circumstances.

ResultsIdentifying women who were classified as 'Near Miss' was found to be easy, as they were by definition recovering in the wards of the tertiary hospitals involved in this study. Identifying and locating the relatives of women who had a maternal death proved to be much more difficult. Many families did not have telephone contact numbers and the primary contact had to be made by home visits which required the use of a

car. Relatives were often not at home necessitating repeat visits, and when located the response of relatives ranged from co-operation to hostility and resistance to being interviewed. In some cases relatives had expectations that the interviewers could offer them social and financial support, while in others they requested the interviewers to assist them in pursuing complaints against the hospitals or clinics involved. Interviewers often had to go back on repeated visits to obtain information, and sometimes found it hard to identify a relative with intimate knowledge of the woman and the circumstances of her pregnancy.It was particularly difficult to locate the relatives of women living outside the catchment area of the hospital. In the three centres there were different proportions of women with maternal deaths who lived within the catchment areas of the respective hospitals. The Bloemfontein and Kalafong sites had more women with maternal deaths who had lived outside the

catchment area of the hospital, making access to relatives particularly difficult.

DiscussionMany of the documented approaches to maternal death audit involve interviewing the relatives of women who have died. This study showed that this approach to the collection of data is very difficult. While it is easy to identify and locate women on the ward who are classified as 'Near Misses' it is much more difficult, time consuming and expensive to identify the relatives of women who have died. Having identified them, the information obtained is often incomplete. The presence of an interviewer from the health services also raises expectations for social and financial support which are difficult to address.

From this study it appears that the identification of relatives of maternal deaths, and the added value of information obtained, makes this an unrealistic way to collect data on maternal deaths for routine service audit. While it

is easier to identify women who are 'Near Misses' and to interview them while still in hospital, the additional value obtained from these interviews must be weighed up against the costs involved in employing interviewers for this purpose.The value of 'Near Miss' and maternal death interviewing is reviewed in a separate paper.

NON-INSTITUTIONAL DEATHS

Motsemai D and the Near Miss Study GroupDepartment of Obstetrics and Gynaecology, Free State University

ObjectiveTo evaluate deaths outside health care institutions in the Free State Province.

Study PopulationAll women that died during pregnancy in the Free State Province.

Study sampleAll cases that died outside a Health Care Institution during the period 1 January 1997 - 31 December 1998.

MethodsAll deaths were evaluated by a clinical researcher using a structured clinical form. Primary cause of death and final organ dysfunction were established in all cases. Avoidable factors were determined by the researcher and an interview was conducted with relatives in the case of death.

ResultsDuring this period 180 deaths were reported in the Free State Province. In 18 (10%) of cases the death occurred outside institutions. In 9 (50%) the primary cause of death did not relate to pregnancy and in a further 5 (28%) the primary cause could not be determined. The remaining cases were obstetric related. In these cases family members were of the opinion that the deceased did not attend the institutions because of lack of trust in health care workers.

ConclusionsThe majority of non-institutional deaths in the Free State Province were not obstetric related deaths. Relatives of the deceased had negative impressions of the health care institutions.

MATERNAL DEATHS AND 'NEAR MISSES': HOW MUCH DO INTERVIEWS ADD TO CLINICAL AUDIT

Cebekhulu Q and the Near Miss Study GroupReproductive Health Research UnitChris Hani Baragwanath Hospital

ObjectiveTo assess whether information gained from interviewing women with the diagnosis of near miss or interviewing relatives of women who have experienced a maternal death, contributes significantly to clinical audit based on medical records.

DefinitionA near miss: In this study a near miss is defined as a pregnant woman with an acute organ dysfunction, which if not treated appropriately, could result in death.Maternal death: Is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or

incidental causes (ICD-9).Added information: Is the information that was mentioned by the clients to the interviewer using a structured interview questionnaire and did not appear on clinical records, and if client interviews had not been conducted the information would have been missed.

MethodThree centres (Chris Hani Baragwanath, Kalafong and Bloemfontein Hospitals) collected clinical data on women presenting with the clinical diagnosis of 'Near Miss' and on women who had experienced maternal deaths. In addition, interviewers based at each site, conducted in depth interviews with the women themselves in the case of the ‘Near Miss’ or with the relatives of women who were maternal deaths. The interview recorded socio-demographic information, contraceptive use, responses to the pregnancy and to its complications, the response of partners to the pregnancy, and access to services. The information derived from these

questionnaires was then compared to that taken from the clinical records, and the additional information gained from the interview was recorded. The paper reviews data from Chris Hani Baragwanath site only.

ResultsThe total number of near misses and maternal deaths reported during the 2 year period of the study were 236 (Table 1). Of these 160 (67.8%) were near misses and 76 (32.2%) were maternal deaths.

Table 1 Information categoriesInformation categories Near misses

n=160 (%)Maternal deathsn=76 (%)

Interviews without added information

124 (77.5) 41 (54)

Interviews with added information

20 (12.5) 14 (18.4)

Subtotal 144 55Interviews not done 16 (10) 21 (27.6)Total 160 (100) 76 (100)

Interviews were conducted on 84.3% (199) of the total number of patients that were reported during the study. Of the 144 near misses and 55 maternal deaths interviewed, added information

was received from 20 (13.9%) and 14 (25.5%) respectively (Table 2). The findings clearly show that there was no difference between the two groups.

Table 2 Added information received from interviewing the near misses and the relatives of maternal deaths

Added information Near missesn=144 (%) n=160 (%)

Maternal deathsn=55 (%) n=76 (%)

ANC attendance 11 (7.6) 11 (6.9) 2 (3.6) 2 (2.6)Induced abortion 7 (4.9) 7 (4.4) 7 (12.7) 7 (9.2)Transport 1 (0.7) 4 (2.5) 1 (1.8) 3 (3.9)Family problems 0 (0) 0 (0) 1 (1.8) 1 (1.3)Delays 4 (2.8) 1 (0.6) 3 (5.5) 1 (1.3)Administration 0 (0) 0 (0) 4 (7.3) 4 (5.3)Interviews 20 (13.9) 20 (12.5) 14 (25.5) 14 (18.4)* Some interviews gave added information in more than one category

In a minority of cases, the additional information obtained

from the interviews changed the understanding of factors which, had contributed to a ‘near miss’

or a maternal death . This applied to additional information obtained on induced abortion practices,

booking, barriers to access to services and to transport problems. In the ‘Near Miss’ and maternal deaths group, additional information from interviews was found in 20 (12.5%) and 14 (18.4%) of cases respectively. There was no statistical difference between the type of information gained in the two groups.Interviews with the relatives of the deceased shed light mostly on the patient factors that could have been avoided. Whether these could actually have been avoided is highly questionable. A small number of maternal deaths (9.25%) and near misses (4.4%) yielded information on induced abortion which was missed during the clinical examination/ procedures. In this case patients had not informed the clinicians of how they had tried to terminate the pregnancy. One of the strong and important points of the questionnaires for all these cases,

is the admission by the relatives and the near-misses, that the pregnancies were not planned, and both the pregnant women and their partners were not happy about them. In addition, there was no support from their partners as well. A small number of maternal deaths (3.9%) and near misses (2.5%) showed that the patients delayed seeking treatment, but the difference between the two proportions was not significant.The questionnaires provided valuable information on whether the women had planned the pregnancy and issues relating to partner support. Two patients were delayed because of the unavailability of an ambulance. This was also recorded in the clinical records and was also reported during the interviews. It is through conducting the interviews that one is able to link the delays in seeking treatment or attending ANC with the aim to terminate the pregnancy and its only when they do not succeed that they end up at the clinic or hospital. The important medical factor that the interviews

highlighted is inadequate treatment and negligence by providers at the health facilities.

ConclusionWhile there is clearly some value for individual patient assessment by interviewing women diagnosed as ‘Near Misses’ and in interviewing relatives of women who are maternal deaths, the cost effectiveness of this approach should be considered. On the basis of data from one site, it would appear that the ‘Near Miss’ interviews produce additional information, which is similar to that obtained from maternal death interviews. If a similar finding is made at all sites, it would be hard to justify maternal death interviews, which are expensive and labour intensive, when compared to the simpler approach of ‘near miss’ interviews. Further work needs to be done to compare the information gained from the clinical records with that of the interviews before final recommendations can be made on the value of interviews for audit.

KNOWLEDGE OF WOMEN, MORE THAN 34 YEARS OF AGE, ABOUT THEIR RISKS OF PREGNANCY

Davies R, Keti V, Pattinson RCMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria

ObjectiveTo ascertain whether women more than 34 years of age are aware of their risks of pregnancy. To ascertain the main reasons why women more than 34 years of age become pregnant.

MethodsFifty pregnant and 30 non-pregnant women, more than 34 years of age, were interviewed about their knowledge of the risks of pregnancy and where applicable why they were pregnant. A structured questionnaire

was used and the women were interviewed in their own language. The women were from Pretoria and surrounding areas and were interviewed at Kalafong and Pretoria Academic Hospitals. Contraceptive failure was defined as failure to use a contraceptive or failure of the contraceptive method.

ResultsSeven (14%) of the pregnant women and 6 (20%) of the non-pregnant women were aware of any risk to themselves of pregnancy (Table 2). Fifteen (30%) of the pregnant women and 12 (40%) of the non-pregnant women thought that the health of their infants could be compromised (Table 2). Thirty-eight (72%) of the pregnant women were pregnant because of contraceptive failure (Table 1).

Table 1 Contraceptive usePregnant women (n=50):

Planned pregnancyNever usedUsed but failed

12 (24%)23 (46%)15 (30%)

pill: 8 (16%)injection: 5 (10%)IUCD: 1 (2%)vasectomy: 1 (2%)

Non-pregnant women (n=30):Not on contraceptionContraception used

10 (33%)20 (67%)

pill: 9 (30%)injection: 11 (37%)

Table 2 Awareness of the risks of falling pregnant over 34 years of age

Pregnant Non-pregnantN 50 30UnawareAssociate risks with: Mother Foetus/baby BothAware but don’t know what the risks are

29 (58%)2 (4%)10 (20%)5 (10%)4 (8%)

15 (30%)1 (3%)7 (23%)5 (17%)2 (7%)

DiscussionThere is a significantly increased risk of hypertension, antenatal admission and Caesarean section for pregnant women over the age of 34 (Larbi RTK, Buchmann EJ). This is disturbing because women of this age are not aware of these risks. Combined with the high rate of contraceptive failure in this group, there are many unplanned high-risk pregnancies in women over the age of 35. These pregnancies are avoidable with proper education and contraceptive counselling.

ConclusionWomen, more than 34 years of age, using the public health system in Pretoria are largely unaware of the risks of pregnancy to themselves or their infants. Contraceptive failure is the main

reason why women more than 34 years of age become pregnant. These findings point to the urgent need for a

public health education programme aimed at women over 34 and at health workers in the contraceptive services.

CARDIACS AND PREGNANCY – A FATAL COMBINATION?

Schoon MG and the Near Miss Study GroupDepartment of Obstetrics and Gynaecology, Free State University

ObjectiveTo evaluate serious morbidity and mortality relating to cardiac disease in 3 defined populations in South Africa.

Study PopulationAll women classified as near-miss at the referral hospitals, and all deaths of pregnant women residing in (a) Free State Regions A and B, (b) Pretoria/Mamelodi, and (c) Soweto.

Study SampleAll cases with cardiac disease as primary cause of death or near-miss during a 24 month period.

MethodsAll cases classified as a near-miss (organ dysfunction) and deaths were evaluated by a clinical researcher using a structured clinical form. Near-miss markers, primary causes of death and final organ dysfunction were

established in all cases. Avoidable factors were determined by the researcher and an interview was conducted with each survivor, or relatives in case of death.

ResultsThere were 55 cases with medical disease in pregnancy during the study period. In 35 (64%) it was because of cardiac disease. The conversion of near-misses to deaths was 8.6%, 33.3%, and 86.3% respectively for the Free State, Pretoria and Soweto.

ConclusionsThe percentage of deaths in all cardiac cases with serious morbidity/mortality is 25%. Only 6 cases were reported from Soweto, although Baragwanath hosts a cardiac clinic but with a 86% mortality rate. This could indicate good results from the cardiac clinic but failure to identify the cases at risk for death. In the Free State the morbidity is higher but with fewer deaths. Twenty five (71%) of the 35 cases in this province were near-misses on admission –

probably reflecting late referral to the referring institution.

17 YEARS OF PERINATAL RESEARCH IN SOUTH AFRICA

Pattinson RC, Tsuari MV, Prinsloo RVMRC Research Unit for Maternal and Infant Health Care Strategies

ObjectiveTo analyse all perinatal research included in the Proceedings of the Conference on Priorities in Perinatal Care in South Africa from 1982 to 1997.

MethodKeywords were allocated to each article. The keywords were entered onto a computer in Excel and counted in UNIX.

Results686 articles have been published in the Proceedings of Priorities in Perinatal Care in South Africa since 1983.

Top ten articles as defined by keywords were:

Keyword No of articles

1. Antenatal care 1022. Perinatal mortality 943. Education 704. Fetal monitoring 595. Hypertension 506. Neonatal ICUs 507. Low birthweight infant 438. Premature infant 40

9. Asphyxia neonatorum 3510. Syphilis 33

HIV/AIDS articles first appeared in 1986. Until 1990 there were 3 articles, from 1991-95 there were 8 articles and 6 from 1996-98. It is clear that HIV/AIDS research is not receiving the attention it deserves.Randomised control trials. In the first 5 years there were 12 randomised control trials, in the second five years 20 and in the third 28.

Neonatal articles. A total of 118 purely neonatal articles were published. It is worrying that in the last 2 years only 8 articles were published, possibly indicating the severe stress under which neonatal research has been placed in the new health services.

ConclusionThe database in MS Access 97 which includes the keywords, subject title, authors and references is available on disk on request for R5-00 or can be copied if a disk is supplied.

DOES THE ADMINISTRATION OF OXYGEN BY NASAL CANNULAS TO LOW BIRTH WEIGHT INFANTS WITH RESPIRATORY DISTRESS DECREASE THEIR EFFORTS OF BREATHING? A PILOT STUDY

Delport SD*, Cilliers PJ+, Frerich S** Department of Paediatrics, Kalafong Hospital and University of Pretoria+ Department of Electrical and Electronic Engineering, University of PretoriaMRC Unit for Maternal and Infant Health Care Strategies

IntroductionOxygen administered by nasal cannulas to low birthweight (LBW) infants can generate continuous positive airway pressure (CPAP), depending on the size of the cannulas relative to the nose and the flowrate of oxygen. This observation creates a possibility for the management of respiratory distress in LBW infants in peripheral settings in a non-invasive manner and at low cost.

ObjectiveTo determine the effort of breathing (EOB) in LBW infants with respiratory distress while receiving oxygen by headbox and

by nasal cannulas at a flow rate of 0.5 and 1.5 litres respectively.

Patients and MethodsLBW infants with respiratory distress needing supplemental oxygen were enrolled. They were studied for 15 minutes while in a quiet awake state and receiving oxygen by headbox, and by nasal cannula flow of 0.5 and 1.5 litres in succession and while maintaining a stable oxygen saturation acceptable for their gestational age. The sequence of the mode of oxygen administration was randomised in each patient. EOB was defined as the product of the respiratory rate (RR) and the means of the oesophageal pressure changes (OPC) per breath. Oesophageal pressure was measured by means of a pressure transducer (Telos) attached to a water-filled nasogastric tube (5F) placed in the distal oesophagus. The pressure waveform was sampled at 5 samples per second and recorded by means of a personal computer equipped with a custom made amplifier and analog to digital conversion

system. The RR, OPC and EOB were computed offline using software developed for the purpose of the study to facilitate interactive artefact rejection and statistical analysis. The RR, OPC and EOB were calculated per patient for each mode of oxygen administration and averaged over 15 minutes of recording.

ResultsThree patients with a median birthweight of 1.2kg have been studied. The EOB was unchanged when oxygen was administered by headbox and nasal cannulas at 0.5 litre flow. The EOB was on average 20% lower when the flow rate of oxygen was 1.5 litres by nasal cannulas because the infants were breathing slower.

ConclusionA decrease of EOB occurred at a high oxygen flow rate administered by nasal cannulas in 2 infants because the RR decreased. More infants will be studied to confirm this observation.

PROBLEMS IN SEEKING SOLUTIONS IN MIDDELBURG DISTRICT

Muller M, Ngeleka MT, Pattinson RCMiddelburg Hospital and MRC Research Unit for Maternal and Infant Health Care Strategies

IntroductionThe Perinatal Problem Identification Programme (PPIP) has been running in Middelburg District for 3 years. Feedback to the District was by monthly meetings for the first 30 months. In the last seven months, a Perinatal Mortality Committee was established in the hospital and was responsible for the feedback. The committee consists of doctors working in the maternity ward and nursing personnel from all wards involved in maternal and neonatal care. The committee meets weekly and discusses all perinatal deaths in the preceding week and all 'near misses’.

ObjectiveTo assess the effect of the new feedback system on maternal and neonatal care.

MethodA comparison of PPIP data from 1 June 1997 to 31 December 1997 and 1 June 1998 to 31 December 1998 was performed. Final control of allocation of avoidable factors and primary and final causes was performed by RCP.

ResultsThe perinatal mortality has remained constant 34.3 and 35.6/1000 deliveries for the two periods. The pattern of primary causes has however changed. The neonatal deaths have reamined high. Avoidable deaths due to intrapartum asphyxia have been halved.

The changes in the avoidable factors are shown below:Avoidable factor 1997 1998Patient orientated 8 23Medical Personnel

Antenatal CareIntrapartum Care

Neonatal CareDelays

285

1355

188622

Administration 3 4Lack of information 9 1

ConclusionThe feedback only affects the personnel in the hospital, and in this group, has made a big impact. However, the committee

is unable to affect the quality of care in clinics and in the community. A method of effective feedback to these groups is urgently required.

PARTNERSHIP IN SAFE MOTHERHOOD

Moosa EZAddington College of Nursing, Durban

IntroductionSafe motherhood is the primary goal of Maternal and Child Health services throughout the world. This can only be achieved through partnership between the mother, family, community, health care workers and all those involved in the care of the mother and child.

What it meansPartnership means working together, supporting and encouraging one another, monitoring and supervising activities towards achievement of a goal. Safe motherhood means ensuring physical and psychological safety of the mother through the pre-pregnancy stage, pregnancy, labour and puerperium so that the baby is conceived and born healthy and mature and into a healthy environment. Safe motherhood is about human rights – the right to quality

services and information and the incorporation of the WHO reproductive health strategy for the African Region. Must be based on the following: Family Planning Antenatal Care Safe delivery and Postnatal

Care Essential Obstetric Care Efficient monitoring,

supervision, communication and transportation.

The Solution/ConclusionEmpowering one another – being connected to one another at all levels, identifying the missing links and linking the women, communities, health care workers as well as all other available resources to the different levels of the health care system. Asibambisane siphile!

LOW PLATELET COUNTS AS MARKER OF HIV

Roux WDepartment of Paediatrics, Tygerberg Hospital

Aim of the StudyTo evaluate thrombocytopaenia as possible marker for HIV exposure.

Background HIV is a worldwide epidemic. Rising numbers in the Western

Cape. Currently no screening for HIV. No neonatal signs or

symptoms described.

MethodDescriptive study done at Tygerberg Hospital on all HIV positive children over an eighteen month period (1997-1998). All children with a HIV marker were examined retrospectively for possible low platelet counts.

ResultsThirty patients were examined who were HIV Elisa positive. Of these, 10 patients had been admitted to Tygerberg Hospital during the neonatal period. Of

these 10 babies, 7 were ultimately HIV negative and 3 were HIV positive. Six of the 10 babies had unexplained thrombocytopaenia on full blood count during their neonatal stay (PI< 150000/mm3). Of the 20 patients with late (>28 days of life) admissions, 80% had thrombocytopaenia on at least one occasion. In total, 73% of all babies who were HIV Elisa positive had at least one low platelet count.

ConclusionUnexplained thrombocytopaenia during the newborn period should lead to a suspicion of a HIV positive mother. It does not necessarily seem to be a marker of HIV disease in the newborn. An epidemiological survey is needed to define the relationship between thrombocytopaenia in the mother and the baby and HIV disease as well as a sensitivity and specificity of the marker.

MAGNESIUM SULPHATE FOR TREATMENT OF PRE-ECLAMPSIA: A TRIAL TO EVALUATE THE EFFECTS ON WOMEN AND THEIR BABIES. (THE MAGPIE TRIAL). RESULTS OF THE PILOT STUDY AT KALAFONG HOSPITAL

Pattinson RC for the MAGPIE Study GroupMRC Unit for Maternal and Infant Health Care Strategies, and Department of Obstetrics and Gynaecology, University of Pretoria

ObjectiveThe Magpie Trial is designed to test the hypothesis that magnesium sulphate, when administered to women with pre-eclampsia, reduces the risk of maternal morbidity and of neonatal morbidity and mortality.

MethodA world-wide randomised controlled trial is being performed. Magnesium sulphate or placebo is administered to women who are not delivered (or delivered within the last 24 hours) and the blood pressure on trial entry is >90mmHg or >140mmHg, on at least two occasions and have proteinuria of at least 1+ and there is clinical

uncertainty about whether magnesium sulphate would be beneficial. Randomisation is controlled from Oxford.ResultsA pilot study was undertaken at Kalafong Hospital, Pretoria to test the forms and mechanisms of the trial. One hundred and one patients were entered in the pilot study over a period of 4 months. No adverse effects of magnesium sulphate were recorded. Two women developed eclampsia, and in these women there was no problem in giving adequate magnesium sulphate as part of the treatment of eclampsia. Samples of how the final tables will look are shown on the poster.

DiscussionThe Magpie Trial is now running worldwide.

ON-SITE SYPHILIS SCREENING AT PRIMARY HEALTH CARE CLINICS

Chaane T*, Pattinson RCChild & Nutrition Directorate, Gauteng Health DepartmentMRC Research Unit for Maternal and Infant Health Care Strategies, University of Pretoria

IntroductionSyphilis is a major preventable cause of perinatal mortality and morbidity in South Africa. There are effective, simple tests available that will detect all cases, where the fetus is at risk of dying due to syphilis. The test can easily be performed on site and is inexpensive, and requires no sophisticated apparatus.

MethodFive Antenatal Care Clinic/CHCs were selected as the pilot sites and every pregnant woman presenting at the clinic for their first visit was tested for syphilis routinely. Centrifuge, rotator and test kits were used for on-site RPR screening.

ResultsThe total number of patients tested over 5 months were:

- Mofolo 903 first visits – 139 patients tested positive and treated.

- Mogale Clinic 108 first visits – 22 tested positive and treated.

- Empilisweni Clinic 68 first visits – 11 tested positive.

- Soshanguve – 427 first visits, 77 tested positive.

Soshanguve CHC had a problem with utilising the equipment daily as there was contruction work done around the clinic, this resulted in electricity breakdowns, eventually blood was sent to the laboratory again.

ConclusionThese results indicated that:1. On-site syphilis testing

provides an opportunity for the health personnel to provide the results for the patients on the first visit.

2. Clients can be treated on the same day as they receive their results.

3. It is cost-effective and efficient to use on-site testing.

The savings for Mofolo CHC was R6433.48 x 5 months. Regions

and hospitals are responsible for extending this test within their budget. On-site RPR testing should be the standard procedure for syphilis screening. This life-saving, simple, effective test should be implemented throughout South Africa.Congenital syphilis is preventable, let us unite in fighting this condition.

A PILOT PROJECT TO IMPLEMENT IN GAUTENG THE PRINCIPLES AND PHILOSOPHY OF THE INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) – A WHO CHILD SURVIVAL STRATEGY

Rabosiwana MPre-School Health Services, Gauteng

Background The IMCI programme requires

specially trained and accredited trainers/facilitators.

Inequities of health care resources in Gauteng necessitate a range of modified interventions.

Relatively unprepared nurses have urgent learning needs to be able to care adequately for sick children.

Objectives1. To develop an adapted

interim training programme: Paediatric Introductory Module (PIM) based on IMCI principles and philosophy.

2. To orientate all health professionals in IMCI thus facilitating its eventual integration into the health service.

MethodsTwo Gauteng PHC nurses attended the 11 day National IMCI training in Mpumalanga Province. They planned and implemented at Lillian Ngoyi Clinic and Chris Hani Baragwanath Hospital a modified 10 day pilot course for 5 professional Gauteng nurses. Workshops are being arranged for regional health services’ doctors and nurses to promote IMCI approached.

ResultsObjective measures are difficult. Subjective measures showed that trainees were enthusiastic and felt they had benefited from the training. Their self confidence was increased. Senior nursing colleagues in the work situations appreciate and support the enhanced functioning of the course participants. Other health service providers appear to be developing a better understanding of IMCI and are therefore more supportive.Students were tested in the clinical situation and proved able to recognise and appropriately

manage potentially life-threatening illnesses in under six year olds. (Detailed results available). They were competent in monitoring growth and counselling mothers on child care including nutrition and immunisation. Students also evaluated the course (details available). Their feedback was positive but the need to further modify teaching methods was identified.

Conclusions and RecommendationsProgress has been made but there is a considerable challenge to expand such initiatives in the interim period prior to IMCI becoming generally available. Further evaluation should continue.

AUDIT OF AN ANTENATAL CLINIC FOR WOMEN LIVING WITH HIV

Rose L, Dinat N, Doedens LDepartment of Obstetrics and Gynaecology, Coronation Maternal and Child Hospital and the University of the Witwatersrand

BackgroundWorldwide, approximately 500 000 infants are perinatally infected with human immunodeficiency virus (HIV) each year, most of whom are born in developing countries. In 1996, the Ministry of Public Health of Thailand and Mahidol University, in collaboration with CDC, initiated a randomised, placebo-controlled trial of a short-term antenatal regimen of ZDV to prevent perinatal HIV transmission and indicated a reduced risk for perinatal transmission by approximately half. At Coronation Maternal and Child Hospital this regime from Thailand was introduced in the Antenatal clinic in April 1998 with education, and peer support for the women who tested HIV positive.

ObjectivesTo audit a dedicated clinic which has been running for one year. The clinic’s main goals have been to reduce perinatal transmission of HIV using interventions such as AZT and education. It also aims to provide peer support for HIV positive pregnant women.

MethodsA retrospective audit.

ResultsUptake of HIV testing, incidence of HIV amongst our antenatal bookers, use of zidovudine, problems of implementation of the programme as well as perinatal outcomes shall be presented.

ConclusionsThis type of clinic is possible to run and can reduce perinatal transmissions of HIV as well as successfully teach methods of safe formula feeding and provide support for those living with HIV/AIDS.

GASTROINTESTINAL DEVELOP-MENT AND THE PREVENTION OF NECROTISING ENTEROCOLITIS

Newell SJNeonatal Medicine and Paediatrics, St James University Hospital, Leeds, U.K.

This short paper aims to give a brief account of some aspects of fetal development which are important for gastrointestinal function and to explore methods of prevention of NEC which are supportable by the current literature.In the early embryo, the gut is one of the first discernible structures. It is the subject of massive growth during fetal development. The small intestine increases 6 fold in length during the second half of pregnancy. At the same time, gastrointestinal motility is established. Swallowing and gastric emptying begin in the second trimester. The volumes of liquor swallowed are initially small and gradually increase to around 500mls a day by term. This swallowing of liquor is important in regulation of liquor volume: polyhydramnios follows in oesophageal atresia.

We have been interested in the biological importance of the swallowed liquor in gut development. Liquor contains carbohydrates, lipid and proteins and a number of growth factors. Epidermal growth factor (EGF) is found in increasing concentrations in liquor with gestation and is present in high concentrations in breast milk. We have shown that EGF in liquor is produced in the amniotic membranes. The histological appearance of the fetal stomach is remarkably mature as early as 13 weeks. Using a monoclonal antibody, we were not able to find EGF produced by the gastric cells, but the receptor for the EGF was present on rapidly duplicating cells from 13 weeks gestation. It is important that the fetus swallows EGF for normal gastric development. In the rabbit fetus, if the oesophagus is ligated, gastric hypoplasia occurs. If however, saline containing EGF is instilled into the stomach, development is normal.The overall ontogenic timetable suggests that the structure of the gut, its anatomy, and the

presence of the digestive enzymes, is relatively mature by the time the fetus reaches 25-28 weeks gestation, the limits of viability. In contrast, gut function with normal patterns of motility are not seen until later. Indeed, gastrointestinal motility does not become mature until around 34 weeks when coincidentally normal swallowing, normal oesophageal motility, normal gastric emptying and a mature pattern of small intestinal activity are seen.The delivery of a preterm infant gives us the opportunity to watch ontogeny but at the same time presents us with the difficulties of immaturity. Problems of gastrointestinal motility are common. The anti-reflux barrier provided by the lower oesophageal sphincter is small in the least mature infants. Manometric

studies have shown that the pressure within the sphincter rises with gestation. Gastric emptying is also important if feeds are to be tolerated well. To study gastric emptying in the preterm infant a technique must be capable of measuring emptying of small amounts of milk. Serial ultrasound images of the gastric antrum allow measurement of gastric antral transit, a proxy for gastric emptying. Studies of gastric emptying lead to a better understanding of the factors affecting gastric emptying.

Factors affecting gastric emptyingIncreased gastric emptying

Slower gastric emptying No effect

breast milk prematurity phototherapyglucose polymers formula milk feed temperaturestarch caloric density non nutritive suckingmedium chain triglycerides fatty acidsprone position dextrose concentration

long chain triglycerides

osmolalityillness

Poor gastrointestinal motility leads to poor feed tolerance which may be exhibited through vomiting, increased gastric residue, bile stained gastric aspirate, abdominal distension, constipation and, in severe cases, is associated with necrotising enterocolitis. The symptoms, with the exception of NEC are common in the neonatal unit and are those which most frequently lead to difficulty in feeding.NEC is a severe condition and the commonest cause of surgical morbidity in the newborn. Its incidence is between 3 and 8 per 1000 live born infants affecting between 4% and 20% of low birth weight infants in various series.The British Paediatric Surveillance Unit collected data in NEC in infants in the UK over a period of 12 months. 295 cases were reported, although some under reporting is likely. The overall mortality was 22%. The mean age of onset was 14 days and 90% of these infants had been enterally fed prior to the onset of NEC. In order to prevent NEC one

must better understand its pathogenesis. Central to the causation of NEC is mucosal damage secondary to invasion of the mucosa by bacteria or macro molecules. This is more likely in the immature in whom the gut is a less good barrier. Equally, the barrier may be disrupted by factors including ischemia, milk feeds, toxins, bacterial overgrowth, viruses and pathogenic bacteria. Any one of these factors may in itself be sufficient in extreme cases but in most infants NEC has a multifactorial origin. The figures from the BPSU show that 13% of NEC occurs in term infants. In these patients, NEC almost invariably follows gut ischaemia usually due to birth asphyxia and occasionally associated with the need to perform transfusion. In contrast, in infants below 28 weeks gestation, risk factors other than prematurity are often absent, implying that gut immaturity is the major factor. For the infants in between these two gestation groups, other risks

factors such as intrauterine growth retardation, abnormal doppler studies, rapid enteral feeding, the use of formula feeds are often present.The prevention of NEC in the term infant therefore, may include the avoidance of birth asphyxia and rapid resuscitation. In the preterm, antenatal steroids and surfactant treatment which ameliorate lung disease reduce the chance of NEC. Infection control may be particularly important in epidemics. Indeed, in epidemics where there is a high incidence within a neonatal unit of NEC, the use or oral antibiotics to provide gut sterilisation is recommended. Drugs such as vancomycin, gentamycin or any of the aminoglycosides, may be given orally and are not absorbed systemically in large amounts. These are usually given over a period of a week or three, initially prior to the introduction of milk feeds and in situations of epidemic NEC (an increased clustering of NEC cases in a single unit). This can be effective in reducing the incidence of NEC.

A number of strategies are available in feeding to reduce NEC. First and foremost is the use of expressed breast milk. There is clear evidence, which accords with all our own experience, that the infant fed expressed breast milk is many times less likely to suffer NEC than a similar infant given formula feeds. Hyperosmolar feeds should be avoided. The timing of introduction of milk feeds and NEC is contentious. Studies have failed to demonstrate that withholding of milk prevents NEC. The more compelling evidence suggests that the rate of increase of milk feeds is important and that we should avoid increasing feeds in the at risk infant more rapidly than 20-30mls/kg/day.Trophic feeding (TF) probably prevents NEC. TF involves the administration of nutritionally insignificant volumes of milk during parenteral nutrition. For example, an infant of 1kg will be given 0.5ml/hour and the volume is not increased. In our randomised study of TF 100 infants were enrolled. There was

no difference in the incidence of NEC between the 2 groups.In the same study TF led to a 60% reduction of episodes of septicaemia. TF alters bacterial flora in the gut: stool culture showed an excess of lactobacilli in the infants who received TF, and a reduction in enterococci, an organism which has been positively associated with NEC. How might TF reduce the risk of septicaemia and NEC? Possibly, further light is thrown on this in a study where glutamate was given as a feed supplement. In the adult, glutamate is known to be very important for gut growth and development and its administration prevents small intestinal villous hypoplasia during enteral starvation during intensive care. In the study in infants, the addition of glutamate, 80-300mg/kg/day, was associated with over 60% reduction in the incidence of septicaemia.The benefits of altering the gut flora have been demonstrated in a French study in which infants were given bifidobacter as supplement during the first 28

days of life. These infants showed better feed tolerance and better growth. It is therefore, possible that trophic feeding, altered gut flora or the use of glutamate may reduce NEC by improving mucosal barrier function. This highlights one of the great difficulties in this area. Prospective randomised control trials with an outcome which is NEC are most difficult to conduct due to the sporadic nature of this disease and its generally relatively low incidence.In conclusion, therefore, the development of the gut is something which is well established during early fetal life. When the preterm infant delivers it is likely that the gut is structurally mature but problems with gastrointestinal motility frequently lead to feeding problems. Better knowledge of this process of development and the factors which influence it are likely to lead to more rational strategies in the appropriate use of enteral feeds and the avoidance of necrotising enterocololitis.

THE USE OF GRANULOCYTE-COLONY STIMULATING FACTOR IN THE PREVENTION OF NOSOCOMIAL INFECTION IN NEUTROPAENIC INFANTS BORN TO WOMEN WITH SEVERE PRE-ECLAMPSIA

Kirsten GF, Rickman R, Kirsten CL, Steyn W, Mansveld EDepartments of Paediatrics, Immunology, Obstetrics and Haemotology, Tygerberg Hospital and the University of Stellenbosch

Nosocomial infection occurs in 25-30% of very low birth weight infants and is due to deficiencies in humoral, cellular and phagocytic immunity compared to term infants or adults. Phagocytic abnormalities include decreased adherence, chemotaxis and phagocytosis as well as impaired transendothelial migration due to abnormalities of the CD 11b/CD 18 complex. In addition, infants born to women with severe pre-eclampsia are neutropaenic at birth in 17% of cases which makes them much more prone to acquiring nosocomial bacterial infections during the first 18 days of life. Granulocyte colony stimulating factor (G-CSF) influences the

survival, proliferation and maturation of haemopoietic progenitor cells.

Study Aim1. To determine whether

within 72 hours, recombinant human (rh) G-CSF administration will result in an increase in the neutrophil count.

2. To determine if, after stimulation with G-CSF, the neutrophils express the adhesion molecules required for chemotaxis, immune adherence and phagocytosis.

Study DesignDouble-blind, placebo controlled, randomised clinical trial.

Study SettingNeonatal wards, Tygerberg Hospital.

Patients and MethodsOver a period of 32 months, 253 infants of women with severe pre-eclampsia before 34 weeks gestation were prospectively screened for neutropaenia during

the first 72 hours of life. Twenty one infants diagnosed as neutropaenic were randomised to receive either 10/kg rh G-CSF or a placebo intravenously once daily for 3 days. Neutrophil counts, serum G-CSF levels and the adhesion molecules (CD 11a, b, c) were measured before and 3, 7 and 21 days after administration of rh G-CSF. Neutropaenia was defined as a total neutrophil count less than the 5th centile for postnatal age on the reference curves of Mouzinho et al.

Results42 (16.5%) were neutropaenic of whom 21 could be randomised between Monday and Friday to receive either rh G-CSF (Group A) or a placebo (Group B). The total neutrophil counts (Fig 1), the number of neutrophils expressing CD 11a, b, c (Fig 2) and the serum G-CSF levels (Fig 3) were significantly higher (p<0.05) 3 days after treatment in the G-CSF treated infants compared to the placebo group . However, the values on day 7 and 21 were similar for both groups. Four

(40%) of the infants who received rhG-CSF compared to 2 (20%) of the placebo group developed a definite bacterial infection. None of the infants in either of the two groups died.

Conclusions1. Baseline studies showed

that 99% of the neutrophils expressed the adhesion molecules.

2. On stimulation with G-CSF, the neutrophil count increased at day 3.

3. On day 3 and therafter, 99% of the neutrophils still expressed the adhesion molecules. This shows that there were no abnormal or early neutrophils being released from the bone marrow.

4. Neutrophil counts as well as their expression levels remained normal after day 3, therefore it appears the initial course of G-CSF was adequate.

RecommendationsA large randomised control trial is indicated to determine whether

the effects of rh G-CSF administration will in fact reduce the prevalence of nosocomial infection in neutropaenic infants of pre-eclamptic women.

RANDOMISED CONTROLLED TRIAL OF RECOMBINANT GRANULOCYTE COLONY STIMULATING FACTOR (r-GCSF) IN NEONATES BORN TO WOMEN WITH PROTEINURIC HYPERTENSION TO PREVENT NOSOCOMIAL INFECTIONS

Delport SD*, Price V*, Pattinson RC+, Makin JD*Department of Paediatrics, Kalafong Hospital+ Department of Obstetrics and Gynaecology, Kalafong HospitalMRC Research Unit for Maternal and Infant Health Care Strategies

IntroductionNeonatal neutropaenia is associated with pregnancy induced proteinuric hypertension and is a risk factor for nosocomial infections (NIs). Antenatal administration of steroids to induce lung maturity may mask neonatal neutropaenia at birth. These infants remain at a greater risk of Nis. r-GCSF increases the absolute neutrophil count and may decrease the risk of NIs.

ObjectiveTo determine by means of a double blind placebo controlled trial whether r-GCSF (30ug subcutaneously) decreases the incidence of NIs in neonates born

to women with pregnancy induced proteinuric hypertension.Patients and MethodsNeonates <1.8kg were randomised after birth to receive a placebo or r-GCSF either of which was administered subcutaneously for 5 days. NIs were documented prospectively if predetermined indicators of infection were met.

ResultsTwenty neonates were enrolled of whom 18 were analysed. NIs occurred in 3 of 10 neonates who had received r-GCSF and in 5 of 8 who did not (p=0.18).

ConclusionThere may be a trend to a lower incidence of NIs in neonates who had received r-GCSF. To decrease the current incidence by 50% with a power of 80% at 95% confidence, 86 neonates will have to be randomised and studied.

SERIAL INTERLEUKIN 6 MEASUREMENTS IN THE EARLY DIAGNOSIS OF NEONATAL SEPSIS

Magudumana MO, Ballot DE, Cooper PA, Trusler J, Cory BJohannesburg Hospital, University of the Witwatersrand

IntroductionInfection in the neonate presents a diagnostic dilemma as the clinical presentation is non-specific and there is no single reliable test for the early confirmation of definite sepsis. This results in the over treatment of large numbers of neonates who present with clinical suspicion of sepsis with associated increased costs and prolonged hospital stay. Early confirmation of definite infection would have a significant impact on reducing health care costs by allowing shorter duration of treatment and hospitalisation. C reactive protein (CRP) is an acute phase reactant, which has been used in the diagnosis of bacterial infection in the neonate. Interleukin 6 (IL6) is a pro-inflammatory cytokine produced by monocytes and macrophages activated by bacterial infection.

CRP is secondarily synthesised by the liver, mainly under the stimulus of IL6. The purpose of this study was to evaluate serial measurements of IL6 in the early diagnosis of neonatal infection in our patient population.

Subjects and MethodsThis study was conducted in the neonatal unit of the Johannesburg Hospital between February and May 1998. Subjects included all neonates who were investigated for suspected sepsis. Babies presenting with the signs suggestive of sepsis during the first 48 hours after birth were routinely treated with penicillin G and amikacin intravenously. A small number of infants were evaluated for sepsis due to an offensive smell, maternal chorioamnionitis or prolonged rupture of membranes. These infants did not routinely receive antibiotic therapy. Neonates who developed signs or symptoms of sepsis after 48 hours of age were regarded as potentially having nosocomially acquired infection and were treated with antibiotics according to the unit protocol at

the time. Initial blood specimens included full blood count (FBC), (including differential white cell count and platelet count), CRP, blood cultures and IL6 (referred to as CRP1 and IL61). Full blood count, IL6 and CRP measurements were repeated after 24 hours (referred to as CRP2 and IL62). The infants were categorised into groups ranging from no infection to definite infection by two observers (D.E.B. and M.O.M.) on the basis of their clinical presentation, FBC, CRP and blood culture results. This was done prior to the analysis of IL6 specimens. There was also a small group of babies with contamination and a further group of those who could not be classified. Standard statistical analysis was performed on a mainframe computer using Statistical Analysis (SAS) version 6.12.

ResultsThere were 255 infants included in the final analysis, 46.7% female and 53.3% male. The mean gestational age was 34.01 weeks (SD 4.77) and birth weight

was 2000 grams (SD 930). The maternal Rapid Plasma Reagin (RPR) positivity rate was 16.8%. Nosocomial infection was diagnosed in 24.9%. The number of neonates in the various categories of infection is shown in Table 1. Study categories 1 to 6 were comparable at baseline, apart from a lower Apgar score in those with probable infection and more babies with nosocomial infection in the study categories of definite and probable infection (Chi square p=0.001). There were significant differences between study categories 1 through 6 for IL6 and CRP (see graphs 1 & 2) measured after 24 hours (Pearson’s correlation coefficient 0.752). Logistic regression analysis showed that the combination of IL6 and CRP2 gave the best prediction of infection with a goodness of fit of 97.9%. Positive and negative predictive values and sensitivity and specificity at previously published cut-off value are shown for CRP and IL6 in Table 2.

Discussion and ConclusionThe management of suspected

neonatal sepsis would be greatly simplified if there were a single reliable marker of infection with results available soon after the onset of signs and symptoms. Our results suggest that IL6 is useful in the early diagnosis of neonatal infection, especially soon after the onset of signs and symptoms. There is no benefit in repeating an IL6 after 24 hours, as the levels are no longer increased in the infants with infection. Most infants evaluated and treated for suspected sepsis are not infected. A reliable prediction of the absence of infection would be most useful in the clinical setting as antibiotics could be withheld in more of these infants than is the current practice. The IL6 done at the presentation of signs and symptoms in our study showed that there was a negative predictive value of 90.18% at a cutoff value of 20pg/ml. There was also a good correlation between the early IL6 level and the late CRP level in those infants without infection. An early negative IL6 could therefore allow antibiotics to be withheld in a

substantial number of infants evaluated for suspected sepsis. We suggest that a possible approach to the evaluation of

an infant with suspected sepsis would be to do an IL6 at presentation and either serial CRP or a CRP level after 24 hours. Antibiotics could be withheld in those infants with an initial IL6 value <20 pg/ml. These babies must be closely observed for a further 24 hours prior to discharge and antibiotic therapy started if there is any suggestion

of sepsis. These babies could remain with their mothers and would not require admission to a level 2 neonatal ward. These issues are of great relevance in a developing country with limited health resources and hospital facilities. It is suggested that IL6 would be a useful addition to the battery of investigations offered as a 24 hour service.

Table 1 Classification of infants into categories of infectionStudy category NumberNo infection 124 (48.6%)Possible infection 68 (26.6%)Probable infection 25 (9.8%)Definite infection 20 (7.8%)Contamination 9 (3.5%)Unclassified 9 (3.5%)

Table 2 Sensitivity and specificityDiagnostic test and cutoff value

Sensitivity Specificity Positive predictive

value

Negative predictive

valueInitial IL620pg/ml 73.81% 56.11% 28.18% 90.18%50pg/ml 59.52% 72.22% 33.33% 88.44%IL6 after 24 hours20pg/ml 52.78% 80.42% 40.43% 87.12%50pg/ml 33.33% 88.81% 42.86% 84.11%Initial CRP 10mg/l

47.73% 81.38% 37.5% 86.93%

CRP after 24 hours 10mg/l

55.17% 81.12% 37.21% 89.92%

A REVIEW OF EARLY ONSET GROUP B STREPTOCOCCAL DISEASE

Bomela HN, Ballot DEUniversity of the Witwatersrand

Objectives of the Study To evaluate the incidence and

mortality associated with early onset GBS disease.

To determine whether the American Academy of Paediatrics and American College of Obstetricians and Gynaecologists recommendations are appropriate for South Africa.

Study DesignRetrospective, descriptive study at Johannesburg General Hospital. Lab records were reviewed from January 1995 to October 1998.

ResultsThe incidence in 1998 of GBS disease increased from 0.8 per 1000 live births in previous years to 2.7 per 1000. There was 60% mortality rate and 60% were admitted in the Intensive Care Unit: 70% were premature babies. There were no risk

factors in 27% of the pregnancies. 33% of the mothers were unbooked, 21% had prolonged rupture of membranes, 6% with urinary tract infection.

ConclusionGBS disease is associated with increased mortality and increased number of Intensive Care Unit admissions. Also there is an increased incidence of the GBS disease. Culture-based chemoprophylaxis would be too expensive for South Africa and an alternative would be to screen mothers who are at risk i.e. unbooked mothers, prematurity, prolonged rupture of membranes, urinary tract infection and maternal pyrexia and to provide colonised mothers with intrapartum chemoprophylaxis.

NEONATAL BACTERAEMIA AND PSEUDOBACTERAEMIA AT CHRIS HANI BARAGWANATH HOSPITAL

Saloojee H, van Wersmeskerken AChris Hani Baragwanath Hospital and the University of the Witwatersrand

IntroductionInfections are an important contributor to neonatal morbidity and mortality in most developing countries. At Chris Hani Baragwanath Hospital (CHBH) infections account for 20% of all neonatal deaths. The predominant organisms causing infections change in most neonatal units with time. The last major audit of blood culture patterns at CHBH was undertaken in 1990.The aims of this study were to identify organisms causing bacteraemia, evaluate antibiotic susceptibility patterns, rationalise antibiotic usage in the unit and to propose strategies to combat nosocomial infections.

MethodThis was a retrospective, descriptive survey.

All blood cultures collected over a 18-month period (January 1997 to June 1998) from infants in the neonatal unit at CHBH were analysed. The computerised database of the local hospital laboratory (South African Institute of Medical Research) was used to identify positive cultures. No correlation was made between positive cultures and the infant’s clinical condition or outcome. An assessment of “psuedobacteraemia” was made by the researchers based on known contaminant patterns at the laboratory, knowledge of vaginal commensals and the timing of the culture, ie. at birth or later. Anaerobic cultures were not routinely done on sick infants in the unit and are not reported. Ethical clearance was obtained from the University of the Witwatersrand Committee for Research in Human Subjects. Statistical analysis was done using Statistica 5.0 (Statsoft, USA).

ResultsIncidenceThere were 597 positive blood

cultures during the study period. During the same period there were approximately 16 135 births at the hospital. The incidence of positive cultures was therefore 37/1000 births. Overall, gram positive organisms accounted for 43% of the positive cultures and gram negative organisms for the remaining 57%. About half (48%) of positive cultures were taken within 72 hours of birth (early-onset).

Pseudobacteraemia (contamination)Pseudobacteraemia accounted 50% of early onset bacteraemias. Of the late-onset bacteraemias, 63% were classified as being probable infections (klebsiella,

pseudomonas, E coli, enterococcus), 28% as possible infections (S. epidermis) and 9% as unlikely infections.Table 1 reflects the eight most common organisms identified and their contribution to early and late onset bacteraemia.

Table 1 Commonest organisms causing bacteraemiaOrganism Positive cultures

(n=597)No %

Early-onset (n=287)

No %

Late-onset (n=310)

No %

Klebsiella 150 25 40 15 110 35Staph epidermidis 145 24 65 24 80 26Grp B Strep 66 11 67 23E coli 35 6 18 7 17 5Pseudomonas 32 5 12 4 20 6Staph aureus 17 3 8 3Enterobacter 17 3Other 135 23 60 24

Resistance to antibioticsTable 2 outlines the resistance patterns

of organisms to some of the antibiotics used in the unit.

Table 2 Percentage resistance to antibioticsOrganism Amikacin Gentamyci

nCefotaxime Piptaz Imipenem

Klebsiella 73 73 85 25 2Acinobacter 86 86 84 50 0Pseudomonas

9 10 91 0 -

Enterobacter 0 0 33 0 -E coli 11 22 0 0 -

DiscussionThe principle epidemiological facts presented in this study are:1. A 1.5-2 times higher

bacteraemia rate in our unit compared to other middle-income countries.

2. The emergence of multi-antibiotic-resistant Klebsiella as the main pathogen in the unit.

3. The high number of pseudobacteremias identified.

4. The need for epidemiological surveillance in the neonatal unit to allow for periodic changes in the antibiotic policy.

IncidenceThe incidence of bacteraemia at

Baragwanath (37/1000 births) is disturbingly high. It is higher than most reported figures. Comparative incidence figures are Spain (16/1000), Argentina (20/1000 patient days), Ghana (20/1000), Mexico (25/1000), and Malaysia (57/1000 in “high risk” neonates). The predominance of gram negative organisms reflects what is now a global phenomenon.

Patterns of organismsKlebsiella emerged as the major pathogen in neonatal units in recent years. The reasons for this happening are complex and multifactorial. Overcrowding and understaffing set the scenario for breaches in infection control procedures. Inadequate training, limited resources, extensive use of broad-spectrum antibiotics and poor compliance with established

guidelines all contribute to sustaining its presence and encouraging its proliferation.Group B Streptococcus (GBS) was the commonest gram positive organism identified in this study. Although GBS continues to be the most important bacterial pathogen associated with early-onset neonatal sepsis in many developed countries, it is remarkably uncommon in Asia, the Middle East and West Africa. Staphylococci predominate in these countries.

PseudobacteraemiaThe finding that half of all early-onset bacteraemias were probably due to contamination is alarming. This probably reflects poor blood culture collection techniques in the unit, particularly the cleansing of skin venepuncture sites. It is a costly error, since besides the added costs of repeat laboratory investigations, unnecessary antibiotics are often commenced which prolong hospital stay. There is little data on the incidence of pseudobacteraemia in the literature. Researchers in

Missouri also categorised half of their positive cultures to be contaminants. Identified sources of contamination include use of non-sterile blood collection tubes, cross contamination of a radiometric blood culture analyser, contamination of samples from a blood gas analyser and the use of contaminated alcohol swabs.

Resistance patterns and policy change in unitThe emergence of multiple-antibiotic-resistant Klebsiella organisms caused us to change our antibiotic policy during the study period. Piperacillin/ tazobactam (TazocinR), prescribed as monotherapy, replaced cefotaxime as the “second-line” antibiotic, while imipenem, and more recently meropenem, was introduced as a “third-line” antibiotic, particularly where Klebsiella septicaemia was suspected or proved. The routine use of Vancomycin as a “second-line” antibiotic has been dropped in view of the small number of resistant gram positive organisms causing nosocomial infections in

the unit.

Strategies to combat infectionOvercrowding and understaffing of the neonatal unit is a persistent problem at Baragwanath. Limited availability of disposable devices, suboptimal care of central and peripheral venous catheters and poor compliance with infection control measures all contribute to the alarming sepsis rate. While high nursery census and elevated patient staff ratios are unlikely to change, redesigning of infection control strategies to adapt to existing circumstances may reduce nosocomially-acquired infections. Our focus has been on improving handwashing and infant handling practices, on more diligent care of intravenous lines and on better endotracheal tube suctioning practices.

ConclusionThe incidence of bacteraemias at CHBH is amongst the highest reported in the world. Pseudobacteraemia is common and results in unnecessary costs. Klebsiella is the commonest

pathogen at CHBH and poses a major ongoing threat. There is significant resistance to “conventional” first-line antibiotics. PiptazR offers a cheap, broad-spectrum alternative, but resistance to it is developing rapidly. The need for ongoing surveillance and regular review of antibiotic policies is highlighted.

SAVING MOTHERS: REPORT ON CONFIDENTIAL ENQUIRIES INTO MATERNAL DEATHS IN SOUTH AFRICA 1998 – EXECUTIVE SUMMARY

Moodley J

In recognition of the need to reduce maternal mortality in South Africa, deaths during pregnancy, childbirth and the puerperium were made notifiable events on 1 October 1997, in terms of the National Policy Health Act, Number 116 of 1990. The Minister of Health appointed a National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). The establishing of the Confidential Enquiry allowed for the determination of where there is a breakdown in the health system and in turn this will allow for remedial action. The NCCEMD is tasked with “making recommendations, based on the confidential study of maternal deaths to the Department of Health such that the implementation of the recommendations will result in a decrease in the maternal

mortality”.The Confidential Enquiries into Maternal Deaths officially began on the 1st December 1997. It has been a considerable achievement by all involved to set the process in motion, report and analyse the maternal deaths for 1998. A very large sample of deaths was obtained from all levels of care. This large sample size gives validity to the description of the disease pattern resulting in maternal deaths and the identification of the problems in the health system. Unfortunately, the poor reporting in some provinces did not allow for a reliable estimate of the Maternal Mortality Ratio (MMR). The data obtained by NCCEMD agrees with the estimated MMR of 150/100 000 live births obtained by the Demographic and Health Survey. The women 30 and older were at greater risk of dying than younger women, and women in their first pregnancy or with 5 or more were also at

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greater risk.The “big five” causes of death are complications of hypertensive conditions in pregnancy, AIDS, obstetric haemorrhage, pregnancy-related sepsis and pre-existing medical conditions. The proportion of the various causes of maternal deaths varied between the levels of care. Obstetric haemorrhage was the most common cause of death at level 1 hospitals, whereas AIDS was at level 2 hospitals and hypertensive diseases at level 3 hospitals. The vast majority of anaesthetic deaths occurred at level 1 hospitals. Non attendance and delayed attendance at the health institutions were the most common patient orientated problems. Poor transport facilities and a lack of intensive care facilities were the major administrative problems. Problems in the care of women occurred in more than half the cases of maternal deaths, the majority occurring at the

primary level of care. Poor initial assessment and diagnosis of cases especially at secondary level of care, failure to follow standard protocols at primary and secondary levels and poor monitoring of patients at all levels of care were the common health worker related problems.Key Recommendations1. Guidelines on managing

conditions which commonly result in maternal death must be developed, distributed and implemented throughout the country by 2002.

2. Referral routes and criteria for referral must be established and implemented by 2001.

3. Establishing staffing and equipment norms per level of care must be performed in every health institution concerned with the care of pregnant women by 2001.

4. The distribution of the Termination of Pregnancy (TOP) services (especially with respect to second

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trimester TOP’s) must be expanded and the sites must be advertised to the public.

5. The partogram must be used for monitoring labour in every pregnant woman and problems detected on the partogram must be managed accordingly.

6. Blood must be available at every institution where caesarean sections are performed.

7. Medical Obstetric Clinics must be established to ensure the optimal management of women with pre-existing medical conditions, especially women with heart disease and diabetes mellitus.

8. Regional anaesthesia should be promoted in all sites performing caesarean sections.

9. Family Planning services must intensively educate women 30 years and older or with 5 or more children about the dangers of pregnancy. Contraceptive

use should be actively promoted in this group of women.

10. A National HIV/AIDS policy geared towards managing these women and dealing with the ethical considerations must be available by 2001.

Overview of data and motivation for the recommendations

In 1952 the Maternal Mortality Ratio (MMR), excluding early pregnancy deaths, was 54/100 000 births for England and Wales. This was the first year of the Confidential Enquiry in Maternal Deaths in England and Wales. In the triennium, 1994-1996 the MMR for the United Kingdom was 12.2/100 000 maternities. It is estimated that the MMR for South Africa is about 150/100 000 live births. Clearly the approximately twelve times higher MMR in South Africa is not due to a global lack of knowledge on how to manage severely ill pregnant women, but due to maternity

77

services in South Africa not implementing available knowledge.

MethodInformation for “Saving Mothers” comes from an analyses of data on women who died in South Africa during pregnancy, labour or the puerperium during 1998 and were reported to the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). A maternal death was defined as “the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes”.The maternal death notification process requires that all deaths of women that occur in pregnancy or within 42 days of being pregnant be reported. These deaths are then subdivided into direct, indirect and fortuitous deaths. The

maternal death notification form plus a copy of the case notes is sent to the Provincial Maternal Child and Women’s Health co-ordinator. This NCCEMD is notified and a Provincial Assessor assesses the case and the information is forwarded to the NCCEMD, where it is collated and analysed.During 1998, a total of 676 maternal deaths were reported. On the 15th May 1999, 74 maternal death notification forms had still not been received, but the primary (underlying) cause of death was given in 17 of these. Data was entered on 585 cases of the 619 cases received by 15th May. The 15th May was set as the cut-off date for data collection and entry to allow for data analysis and production of the “Saving Mothers” report during 1999.

Demographic FeaturesUnfortunately, the poor reporting in some provinces does not allow for a reliable estimation of the Maternal

78

Mortality Ratio (MMR) for the whole country. However, reliable estimates can be obtained for Free State, Gauteng, and the Western Cape. The MMR for these Provinces were 135, 67.4 and 49.8 per 100 000 live births respectively. The South African Demographic and Health Survey estimates a MMR of 150/100 000 live births for the whole country. Taking into the account that Gauteng and Western Cape are the most developed provinces and the MMR of 135/100 000 live births for the Free State Provinces, this estimate is in keeping with the findings of the Confidential Enquiry. This figure is low for a developing country and is close to the target of 124/100 000 live births by 2015 set by the Safe Motherhood Initiative of the WHO for developing countries.The older woman especially the woman 30 years and older was demonstrated to be at significantly higher risk than the

women under 30 years of age. Women during their first pregnancy or who had 5 or more pregnancies were also a greater risk of maternal death. Most deaths occurred in African women (92.6%). The remainder 4.4%, 0.9% and 0.7% occurred in Coloured, Whites and Indian races. In 1.4% the race was not recorded.The average gestational age at delivery or time of death of the women was 32.6 weeks (7.1 weeks). The gestational age was not recorded in 23.9% of cases. Death occurred before 24 completed weeks in 8.5% of cases, in 19.5% in the antenatal period, in 8.7% in labour and in 61.5% in the postpartum period.

Primary causes of deathThe “big five” causes of maternal death were complications of hypertensive conditions in pregnancy (23.2%), AIDS (14.5%), obstetric haemorrhage (13.3%), pregnancy-related sepsis (11,9), and pre-existing medical

79

conditions, mainly pre-existing cardiac disease (10.4%). The “big five” accounted for 73.3% of all the deaths. Obstetric haemorrhage includes antepartum and postpartum haemorrhage. Pregnancy-related sepsis includes cases of septic abortion and puerperal sepsis. Early pregnancy deaths due to complications of miscarriage (abortions) and ectopic pregnancies accounted for 7.5% of deaths. The deaths resulting from AIDS were probably significantly under-reported. The HIV status was unknown in 75.8% of maternal deaths. There were

32 cases of tuberculosis, pneumonia and meningitis and in 25 the HIV status was unknown. It is possible that some of could have been reclassified to AIDS if the HIV status had been known. The number of death due to AIDS is likely to dramatically increase in the following years.Other significant causes of death were acute collapse and embolism (7.3%) and anaesthetic complications (4.8%). No cause of death could be allocated to 3.2% of cases and there were 20 fortuitous deaths.

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Table 1. Primary causes of Maternal Deaths 1998

Primary cause of maternal death

N %

Direct deaths (n=358)Hypertension in pregnancy 131 23.2

Postpartum haemorrhage 48 8.5Antepartum haemorrhage 27 4.8

Abortion 32 5.7Ectopic pregnancies 11 1.9

Pregnancy-related sepsis 41 7.3Anaesthetic accidents 27 4.8

Acute collapse and embolism 41 7.3Indirect deaths (n=190)

Non-pregnancy-related infections 130 23.0AIDS 82 14.5

Pre-existing maternal disease 59 10.4Cardiacs 28 5.0

Not classifiable 18 3.2Total maternal deaths 565 100Fortuitous deaths 20

Direct causes of maternal death were responsible for 63.3% of deaths and indirect causes responsible for 33.6%. When considering direct causes of maternal death alone (see Appendix Table A.3), hypertensive conditions were responsible for more than 1 in 3 cases, haemorrhage more than 1 in 5, and pregnancy related sepsis (including septic abortions) just under 1 in 5 cases. In 138 maternal deaths, hypertension was present, (24.4% of all deaths), haemorrhage was involved in 93 cases (16.5% of all deaths) and

sepsis was involved in 67 (11.9% of all deaths). Obstructed labour contributed directly to 20 (3.5%) deaths, either by being a predisposing factor for haemorrhage or puerperal sepsis. Almost of a third of women (32.4%) who died had an anaesthetic at some point in the process.The deaths that could not be classified, were mainly deaths that occurred at home and where insufficient information was available to allow for an allocation of cause. There were 20 fortuitous deaths, with motor vehicle accidents being the

major contributor.

Levels of careThe majority of maternal deaths occurred in the Level 2 hospitals (35.0%), Level 3 having the second highest number (29.6%), followed by Level 1 hospitals (27.3%), home deaths (2.8%), community health centres (2.3%), private hospitals (1.8%) and unknown (2.7%).

Table 2. Levels of care and primary cause of all maternal deaths

Primary cause of death Level 1 Level 2 Level 3

N % N % N %Direct Deaths (110

)(116

)(103

)Hypertension in pregnancy 30 19.5 40 20.2 49 29.3Postpartum Haemorrhage 19 12.3 16 8.1 7 4.2Antepartum Haemorrhage 12 7.8 10 5.1 3 1.8

Abortion 7 4.5 10 5.1 14 8.4Ectopic Pregnancies 5 3.2 4 2.0 2 1.2

Pregnancy-related sepsis 10 6.5 14 7.1 17 10.2Anaesthetic related 15 9.7 9 4.5 1 0.6

Acute collapse and embolism 12 7.8 13 6.6 10 6.0Indirect Deaths (36) (79) (62)

Non-pregnancy-related infections 27 17.5 55 27.8 40 24.0AIDS 15 9.7 36 18.2 27 16.2

Pre-existing Maternal disease 9 5.8 24 12.1 22 13.2Cardiacs 5 3.2 11 5.6 12 7.2

Not ClassifiableUnknown 8 5.2 3 1.5 2 1.2

Total 154 100 198 100 167 100Fortuitous Deaths 2 4 6

Considerable differences in pattern of disease occurred at the various levels (Table 2). Obstetric haemorrhage was the

commonest cause of death in the Level 1 hospitals whereas non-pregnancy related infections was most common in

Level 2 hospitals and complications of hypertension in Level 3. Sixty percent of all

anaesthetic related deaths occurred at Level 1 hospitals (Table 3).

Table 3. Proportions of Primary Causes of Death per Level of Care

Primary cause of death Level 1 Level 2 Level 3

N % N % N % Tot. %Hypertension in pregnancy 30 25.2 40 33.6 49 41.2 119 100

Obstetric Haemorrhage 31 46.3 26 38.8 10 14.9 67 100Early Pregnancy Deaths 12 28.6 14 33.3 16 38.1 42 100

Pregnancy-related sepsis 10 24.4 14 34.1 17 41.5 41 100Acute collapse and embolism 12 34.3 13 37.1 10 28.6 35 100

Anaesthetic related 15 60.0 9 36.0 1 4.0 25 100Non-pregnancy-related sepsis 27 22.1 55 45.1 40 32.8 112 100

AIDS 15 19.2 36 46.2 27 34.6 78 100Pre-existing Medical disease 9 16.4 24 43.6 22 40 55 100

Cardiacs 5 17.9 11 39.3 12 42.9 28 100

Referral PatternsThe referral patterns within and outside the Provinces are shown in Tables 4. A total of 40% of maternal deaths were transferred between health institutions. Thirty-eight percent of cases were referred between health institutions within Provinces, with a range of

16% in Mpumalanga to 68% in the Western Cape. Two percent of maternal deaths were referred across Provincial boundaries. Most of these came from Mpumalanga and all these were referrals to Gauteng Province. North West Province also referred to Gauteng Province.

Table 4. Referral patterns within and between Provinces

Province Not referred

Referred within Province (%)

Referred from outside Province (%)

Total

Eastern Cape 30 24 (44%) - 54Free State 47 34 (42%) 1 (NC) 82Gauteng 69 44 (35%) 13 (10%) – 9 M;4 NW 126

KZN 101 64 (39%) - 165Mpumalanga 42 8 (16%) - 50North West 21 12 (36%) - 33

Northern Cape 10 11 (52%) - 21Northern

Prov.11 5 (31%) - 16

Western Cape 9 19 (68%) - 28Total 340 221 (38%) 14 (2%) 575

NC – Northern Cape, M – Mpumalanga, NW – North West

Avoidable factors, missed opportunities and substandard careTable 5 summarises the magnitude of the problems in care experienced. Patient orientated avoidable factors could not be assessed in 27% of cases, administrative factors in 13% of cases and in the medical personnel care of the emergency event in 17% of cases. This was due to inadequate information, mainly due to poor note keeping. In almost half of the maternal deaths there was a missed opportunity for preventing

death related to the behaviour of the woman herself or within her community. The most common factors were not attending antenatal care and delay in seeking help. It is not known what the specific reasons for non-attendance at antenatal clinics or the reason for delay in seeking help were. More attention will need to be placed on establishing these reasons so interventions can be introduced. Self-induced termination of pregnancy occurred in 30% of women dying from complications of abortion.

Table 6. Avoidable factors, missed opportunities and substandard care for 1998

Category %Patient orientated problems (n=410)

48.8

Administrative factors (n=485)Level 1Level 2Level 3

33.237.230.533.1

Medical Personnel OrientatedEmergency event (n=463) All 56.8

Level 1

Level 2

Level 3

74.256.843.6

Resuscitation (n=295) 28.8

Anaesthetic care (n=170) 25.3

Unprofessional conduct (n=559) 12.5

559 maternal deaths were analysed as some data was available

Problems with the administration were evenly distributed throughout the levels of care. However, delay in transporting patients between institutions was seen in 13.6% of cases requiring transport (Table 7). The problem varied considerably between Provinces with the lowest being 5% in Gauteng Province and the Western Cape to the highest of 38% in Mpumalanga Province, followed by the Eastern Cape at 33%. The problem of transport is

probably even greater than this because the delays in transporting women from their homes to health institutions could not be estimated due to lack of information. A correlation has been found between delay in the transfer of women with acute severe morbidity and their conversion to maternal deaths (Mantel, Pattinson, Macdonald – Maternal mortality and severe acute morbidity in the Pretoria Region (1/2/97-31/1/99). Report to Gauteng Health Department).

Table 7. Patient orientated and administrative avoidable factors, missed opportunities and substandard care for 1998

Category Major Problems %Patient orientated problems (n=349)

Non attendance antenatal careInfrequent attendanceDelay in seeking help

Self-induced TOP$

Discharged herself from hospital

21.28.9

18.630.02.9

Administrative factors (n=485)

Delay in transport from home to institution

Delay in transport between institutions*

Delay in admissions areaInsufficient ICU beds#

Lack laboratory facilitiesLack of availability of blood

4.113.61.9

15.62.2

11.72.93.7

transfusion@

Lack of appropriately trained medical officers

Lack of communication between health workers

* Denominator 235 (total number of maternal deaths who were transported within the health services) # Denominator 273 (total number of maternal deaths who died in tertiary institutions)$ Denominator for self-induced termination of pregnancy is 30.@ Denominator for lack of availability of blood transfusion is 94.

A lack of intensive care facilities, beds, equipment and personnel was found to be a factor in 15.6% of cases where mothers died in tertiary institutions. This is also probably an underestimate of the magnitude of the problem because it is not known in how many cases doctors from Level 1 and 2 hospitals wanted to refer patients but were informed that there was no ICU bed available and to try other hospitals. Mantel et al., found an association between the availability of ICU beds and the conversion from severe

maternal morbidity to mortality (Mantel, Pattinson, Macdonald – Maternal mortality and severe acute morbidity in the Pretoria Region (1/2/97-31/1/99). Report to Gauteng Health Department). A lack of availability of blood transfusion facilities was found in 11.7% of cases that required urgent blood transfusions.Management by the medical personnel of the emergency event revealed problems in the care in more than half the cases (Table 8). Medical personnel was defined as any health worker involved in the care of the patient.

Table 8. Medical Personnel Orientated ProblemsEmergency Event and Resuscitation

Emergency event

(n=462)

Major problems %

Initial Assessment

No notesDone incompletely at any level

4.528.4

Problem Recognition

No notesDone incompletely at any level

4.830.7

Management plan/

Protocol followed

More senior assistance not calledMore senior assistance not

availableDelay referral to

secondary/tertiary centrePatient managed at inappropriate

institutionWrong diagnosis

Standard protocol not followed Delays in getting treatment

performedTechnical skill not adequate or

available

8.03.59.19.3

13.039.05.2

2.2

Continued monitoring

Not done/no notesFailure to get special investigation results

Observations done infrequently/incompletely

Prolonged abnormal observations without action

6.54.5

19.55.8

The medical management problems were especially prominent in level 1 hospitals with there being problems in almost three quarters of patients who died and were managed for some part of their care at a primary care (Table 6). More than half the cases managed at the level 2 care for some part of their care also had problems. Assessing the patient was done poorly in level 1 (53 cases) and level 2 (60 cases) and better at level 3 care (13 cases). Similar data emerged for making a diagnosis or a problem list (52, 64 and 15 cases respectively). The wrong diagnosis was made in 22 cases at level 1, 38 cases at level 2 and 8 cases at level 3. The standard protocol was not followed in 84 cases at level 1, 50 cases at level 2 and 20 cases at level 3. Unfortunately, a reliable denominator could not be established for the levels of care because of the referrals between levels and patients entering level 2 or 3 without passing through level 1 or 2. Problems in the initial assessment of the case i.e. taking a history

and examining a case and in problem identification i.e. making a diagnosis or making a list of problems was especially poor at the secondary level of care. The major problems in the management related to not following the standard protocols for the management of the conditions (39% of cases) and wrong diagnosis (13% of cases). It is not known whether this is due to ignorance or “laziness” and a non-caring attitude on the part of the staff. There was a delay in referring patients or they were managed at an inappropriate level of care in 18.4% of cases. This may represent problems in transport, problems in appreciating the severity of the condition or not having an identified referral hospital that will accept the patient. In more than a quarter of cases, observations after the emergency event were done infrequently or incompletely, or there were prolonged abnormal observations without any action (25.3% of cases). It is not known what the reason for this is. It could be due to the lack of staff,

or due to laziness and a non-caring attitude on the part of the staff. The importance of being able to provide safe anaesthesia is vital, especially when considering almost a third of women who died had had an anaesthetic at some point in the process. In 25.3% of cases having an anaesthetic, it was assessed that there was some form of substandard care. The standard of anaesthesia is of concern especially in level 1 hospitals. Deaths related to anaesthesia are a major preventable cause of maternal death. The use of regional anaesthetic techniques has lead to a dramatic drop in deaths related to anaesthesia in the United Kingdom. Emphasis will need to be placed on this aspect in training doctors and anaesthetists in the future.Unprofessional conduct occurred in 12.5% of cases. The most common problems were not attending patients when called or seeing patients daily (26 cases) and not performing observations when prescribed (24 cases).

Key Recommendations

1. Guidelines on managing conditions which commonly result in maternal death must be developed, distributed and implemented throughout the country by 2002. The College of Obstetrics and Gynaecology (a faculty of the Colleges of Medicine) will be asked to facilitate the drawing up of guidelines on the management of hypertension in pregnancy, incomplete abortions, puerperal sepsis, labour in women with previous caesarean sections, and the operative management of obstetric haemorrhage. The College will be asked to ensure the involvement of nursing personnel and administrators. The guidelines must include the antenatal, intrapartum and postpartum monitoring of the conditions. The first guideline on the management of hypertension should be ready by January 2000. Workshops should be held in each Province to develop protocols

out of the guidelines. After acceptance of the protocols, each Province should ensure the promotion of the protocols, that every site that manages pregnant women are familiar with the protocols and that regular “fire drills” are carried out at the sites. This should be completed by December 2002.Motivation. In 39% of cases the medical personnel deviated from accepted protocols in the emergency management of pregnant women who subsequently died. It is not known whether this deviation from accepted protocols is due to ignorance or laziness. By ensuring protocols are available and promoted, ignorance should no longer be a factor.

2. Referral routes and criteria for referral must be established and implemented by 2001. Every health institution should have clear instructions on where it should refer its’ patients. There should be a

clear agreement between the referring and receiving institutions on the criteria required for referral. Once the criteria have been met the receiving hospital should accept the patient. Regular feedback between the institutions should occur. Care will need to be taken in developing the criteria to ensure the receiving institutions are not overloaded with unnecessary referrals. The College of Obstetrics and Gynaecology will be asked to provide criteria for the referral between levels of care as part of the guidelines developed in point 1. A similar process should occur as for the development of the protocols. Provincial Maternal, Child and Women’s Health departments should ensure each health institution in their province knows where it should refer and has the contact telephone numbers. This should be complete by January 2000.Motivation. Delay in referral or managing patients at inappropriate institutions

occurred in 18.4% of pregnant women who subsequently died. Lack of clear referral criteria, sites where to refer and resistance by the receiving hospital to accept patients are possibly responsible for these avoidable factors.

3. Establishing staffing and equipment norms per level of care must be performed in every health institution concerned with the care of pregnant women by 2001. The care of pregnant women requires both personnel and equipment. More personnel and more sophisticated equipment are required the higher the level of care required by the patient. The Maternal, Child and Women’s Health Directorate in the National Department of Health will be asked to provide a set of norms for staffing and equipment for each level of care by January 2000. Thereafter it will be requested to engage each Province to survey each site where pregnant women are

cared for and to match the staffing and equipment available to that which the norms specify. Disparities should be identified and corrected.Motivation. Poor monitoring of women occurred in 25.3% of pregnant women who subsequently died. It is not known whether this is due to inadequate staffing and equipment or due to laziness and a non-caring attitude on the part of the staff. Without clear norms it will not be possible to assess where the problem lies.

4. The distribution of the Termination of Pregnancy (TOP) services (especially with respect to second trimester TOP’s) must be expanded and the sites must be advertised to the public. The Maternal, Child and Women’s Health Directorate in the National Department of Health will be asked to audit the distribution of TOP services throughout the country, and to encourage the Provinces to establish TOP

services where there are none. Special attention must be given to the provision of services for the termination of second trimester pregnancies.Motivation. The majority of deaths due to abortions occur in the second trimester and were the result of interference by the woman herself or a non registered person in 30% of cases.

5. The partogram must be used for monitoring labour in every pregnant woman and problems detected on the partogram must be managed accordingly. The Provincial MCWH units will be approached to ensure that every institution in their Province where labour occurs, is using the partogram and knows how it should be used. Training institutions (Nursing colleges and medical schools) will be contacted by the NCCEMD to promote the teaching of the partogram to all health workers involved in the management of labour.Motivation. Lack of use of the partogram was clearly

illustrated as a major avoidable factor in women dying as a result of puerperal sepsis and postpartum haemorrhage. The use of the partogram allows for early identification of prolonged labour and timely intervention.

6. Blood must be available at every institution where caesarean sections are performed. The Provincial MCWH units will be asked to audit the availability of blood at these institutions and where it is not available, ensure that it becomes available. This should be done by January 2000.Motivation. The availability of emergency blood for women with obstetric haemorrhage is life saving. In 11.7% of maternal deaths where a blood transfusion was urgently required, it was not available. The excess of deaths at level 1 hospitals due to obstetric haemorrhage is in part due to the lack of blood.

7. Medical Obstetric Clinics must be established to ensure the optimal

management of women with pre-existing medical conditions, especially women with heart disease and diabetes mellitus. The Provincial MCWH units will be requested to ensure every level 2 and 3 hospital in their province has medical obstetric antenatal clinic.Motivation. Cardiac disease in pregnancy is a major cause of maternal deaths. The woman with a heart lesion has often been mismanaged by the health workers managing the pregnancy. By establishing these clinics, these women should not slip through, and their management could be more expertly performed.

8. Regional anaesthesia should be promoted in all sites performing caesarean sections. An audit should be conducted of the staffing, level of training of the health personnel and anaesthetic facilities at each site performing caesarean sections. The Department of Anaesthesia at the University

of Natal, will design a simple audit form for distribution throughout the country. The Provincial MCWH units will perform the audit. The College of Anaesthesia (a faculty of the Colleges of Medicine) will be approached to establish an outreach programme to rectify the problems identified by the audit. Regulations requiring the filling in of a standard anaesthetic form for each anaesthetic will be promoted.Motivation. Anaesthetic accidents are an important preventable cause of maternal deaths, and occur most commonly in the Level 1 hospitals. Lack of training and infrequent use of regional anaesthesia probably contribute to these deaths.

9. Family Planning services must intensively educate women 30 years and older or with 5 or more children about the dangers of pregnancy. Contraceptive use should be actively promoted in this group of women. Provincial MCWH

units should advise their family planning services of this and ensure there are sufficient facilities for women requesting tubal ligations.Motivation. Women 30 and over and with 5 or more children are at significantly greater risk of dying during pregnancy, labour and the puerperium.

10. A National HIV/AIDS policy geared towards managing these women and dealing with the ethical considerations must be available by 2001. Ethical and clinical guidelines are urgently required for managing AIDS. This should include the level of care at which a woman with AIDS should be managed and advice on the admission criteria for women with AIDS to intensive care units. The NCCEMD suggests that there should be an “opt out” policy for the screening of women with HIV. This means women should be informed that HIV testing will be routinely performed unless the woman

requests that the HIV test not be performed. Counselling of the all women should still take place but this can be done in groups. Knowledge of the HIV status of a pregnant woman will allow the pregnancy to be managed in a way that will decrease the risks for the woman and also allow for prevention of vertical transfer of the virus to the fetus/neonate.Motivation. AIDS is the second most common cause of maternal deaths in South Africa. A clear policy needs to be established on managing AIDS as this has enormous implications for the allocation of scarce resources. Many women with AIDS are managed at tertiary institutions using resources that might be better used on women with a better prognosis. Medical personnel are very reluctant to take such positions and the debate needs to be opened to allow for consensus to be established.

Other issuesThe NCCEMD wishes to emphasise the following points: Public health education can

play a major role in preventing maternal deaths. Antenatal education should be part of every health education programme that deals with reproductive health issues.

The reporting of every death that occurs during pregnancy, labour and the puerperium is essential so that an accurate MMR can be obtained and progress in preventing maternal deaths can be ascertained. All health workers are encouraged to report all these deaths. They are reminded that failure to report a maternal death is regarded as professional misconduct by the Health Professions Council.

The Health Professions Council will be requested to give additional Continuing Profession Development (CPD) points to medical practitioners who attend training programmes designed to reduce maternal mortality.

Using this positive encouragement it is hoped that the standard of care of all doctors dealing with pregnant women can be improved.

AcknowledgementsThe NCCEMD would like to thank all the health workers and administrators who have made the Confidential Enquiries into Maternal Deaths work and the Provincial Assessors and their Maternal, Child and Women’s Health counterparts in the Province for their hard work.

Note: The full report of “Saving Mothers. Report on Confidential Enquiries into Maternal Deaths into South Africa 1998” is available from the Maternal, Child and Women’s Health Directorate, National Department of Health, Hallmark Building, Pretoria

AUDIT OF PERINATAL MORTALITY IN NORTHERN KWAZULU NATAL – PROBLEMS AND ANSWERS

Gandhi M, Barnard A, Martineau A, Siderfin C, Welz T, West P, Wilkinson D, Pattinson RC

Keywords: Audit, perinatal, mortality

Very little is known about perinatal mortality in the remote coastal area of Northern KwaZulu Natal, encompassing the tribal authorities of Ubombo and Ingwavuma, known as Maputoland. The region is isolated with poor communications and the perinatal mortality rate (PNMR) is relatively high. The four primary hospitals in the area, Bethesda, Manguzi, Mosveld and Mseleni, are collaborating in an audit of perinatal mortality thus facilitating additional comparative analysis of results. The hospitals are 200-280 bedded and each support 8-10 outlying residential community clinics. Manguzi and Mseleni have new maternity departments built in the early 1990s and only

Mseleni and Mosveld have functional waiting mothers’ areas. Data collection began on 1st

September 1998.

AimTo analyse and reduce the PNMR in Maputoland.

MethodEach perinatal death is investigated by the co-ordinating medical officer or a midwife and the underlying cause and any avoidable factors are identified. Data is collated using the Perinatal Problem Identification Programme (PPIP), installed at each hospital. The results and interventions are discussed with the staff in each hospital at monthly perinatal mortality meetings. The PNMR is thus monitored as a continuous process.

ResultsSix months data was available at the time of writing. The total number of deliveries in hospital for the area was 3097. Most deliveries occurred at Mosveld Hospital (844), least occurred at

Mseleni (696). The total number of deliveries in the clinics was 564 and a large proportion of these were in the Manguzi Health District (213). The overall hospital PNMR for the area was 36.8/1000. Individual PNMRs for the collaborating hospitals were: Bethesda 49.2/1000, Manguzi 36.9/1000, Mosveld 27.4/1000, Mseleni 28.9/1000. The total PNMR for the area, including 12 perinatal deaths in the clinics, was 33.8/1000. 8% of all babies delivered weighed between 1500g and 2499g. 1.4% of all babies weighed less than 1500g. Most very low birth weight babies were delivered in Bethesda and Mseleni. The low birth weight PNMRs varied from 216.2/1000 at Bethesda to 162.5/1000 at Mosveld. The Perinatal Care Index (percentage of low birth weight babies over the overall PNMR), was highest at Mseleni (0.39) and lowest at Bestesda (0.19). A high perinatal care index (PCI) suggests that most mortality is associated with higher risk, low birth weight babies and so, is good. The three commonest primary obstetric

causes of perinatal death were macerated stillbirths (33.3%), intrapartum asphyxia (29.8%) and preterm labour (14.9%). Of the 33.3%, 22.8% of the macerated stillbirths were unexplained. Other less common causes included placental abruption, maternal disease and infection. 51% of neonatal deaths were due to asphyxia. The number of deaths where the mother was WR positive was 8.7% but data on this was incomplete with no results on 36% of the deaths at Mosveld.The major avoidable factors identified were:Medical Management Related: Problems with the management of labour: 24.6%, physical examination of the patient at antenatal clinic incomplete: 8.8% and inadequate neonatal resuscitation: 7%.Patient Related: Patient not responding to poor fetal movements: 14.9% and delay in seeking medical attention during labour: 7.6%.Administration Related: Lack of transport between patients, clinics and hospitals: 7% and

inadequate neonatal resuscitation facilities: 7%.Principle Interventions1. Monthly perinatal mortality

meetings and teaching sessions for doctors, hospital midwives and clinic midwives. This continuous monitoring also serves to raise awareness of hospital management of patients.

2. Better patient education, concentrating on important issues for an expectant mother.

3. Better neonatal resuscitation equipment and formal training on neonatal resuscitation.

4. Making existing waiting mothers’ areas more successful where they are not and encouraging the development of waiting mothers’ areas where they do not exist.

ConclusionJon Larsen recommends that rural areas with poor communication should be aiming for a PNMR of 25/1000 or less. There is, therefore, room for improvement

in Maputoland. Interestingly, even with numerous environmental problems in the area, the major avoidable factors are concerned with the basic management of labour once the patient is in hospital. These factors are wholly avoidable with consistent training and feedback. There are a large number of unexplained stillbirths and a question unanswered is how many of these are related to the high rate of HIV infection in the area (35-40%). At present all antenatal women are not tested for HIV and to suggest a test just after a woman has had a perinatal death is often not suitable. Not many of the patients were unbooked which suggests that the problems do not lie with their willingness to come to hospital when in labour, but their awareness of when they should seek medical attention and also with their actual ability to get to hospital. This begs the last question – how many women never come to hospital at all and deliver at home?Looking at the data comparatively, there is a marked

difference in PNMR and PCI between the hospitals. Comparing the hospital with the highest PCI, Mseleni, with the hospital with the lowest PCI, Bethesda, there are some clear differences. Mseleni has a new maternity department, with 70 beds and roughly 6 incubators. The hospital has had long term obstetric and paediatric medical officers working in the department and they have carried out regular perinatal mortality meetings for the last ten years. Finally, the hospital has a 30 bed waiting mothers’ area which is well-liked by the women in the area. Bethesda, on the other hand, has a much smaller, poorly equipped department with a small room for waiting mothers, which cannot comfortably house more than four women. There is a relatively fast turnover of medical officers and no regular perinatal mortality audit was being carried out until the beginning of this study. It would seem the factors mentioned in this comparison are some of the most important when running a successful maternity

department in an isolated rural area.Finally, when cumulative avoidable PNMRs are calculated, its seems that the rates in all four hospitals are beginning to go down over the six months since the study began. It is too early to see a definite trend as yet. This research has already led to the introduction of simple, sustainable monitoring systems which can be easily continued, providing useful information and further reducing the PNMR.

SOCIODEMOGRAPHIC PROFILE OF WOMEN IN THE MATERNAL MORTALITY STUDY

Rees HR, Beksinska M, and the Near Miss Study GroupReproductive Health Research Unit, Department of Obstetrics and Gynaecology

ObjectiveTo describe the sociodemographic circumstances of women who were defined as “near misses” (defined as women who because of pregnancy and/or childbirth are/were very ill and could have died if it were not for the medical treatment or intervention they had) or maternal deaths.

DesignAll maternal deaths and “near misses” identified at the Chris Hani Baragwanath Hospital between January 1997 and December 1998 were documented. Women identified as “near miss cases” were interviewed and information was collected by an interviewer-administered questionnaire. In the case of maternal deaths, a relative was contacted and interviewed using the same

questionnaire.

ResultsIn total 164 “near miss” cases were identified of which 159 women were interviewed. During the same period 74 maternal deaths were identified and relatives of 51 of these women agreed to be interviewed. Mean age of “near miss” cases was 29.7 years compared to 28.4 in the maternal death group. Highest educational level attained in both groups was identical (mean Std 7.4). Employment status was similar with 29% of the “near miss” cases and 33% of maternal death cases employed in a full or part-time capacity. Almost two thirds (65%) of “near miss” patients and 61% of maternal deaths were either married or co-habiting. A third (33%) of both groups lived in informal housing such as a shack or “zozo”. Less than one third (29%) of maternal death cases had access to tap water inside their dwelling compared to 40% of “near miss” cases. Similar figures are found for sanitation with only 28% of maternal death cases having access to an inside toilet

compared to 37% of “near miss” cases.

ConclusionPreliminary analysis shows little difference in the sociodemographic profiles of the two groups of women. The majority of the women lived in low-income households with limited facilities and access to services such as water and sanitation.

MAKING SENSE AND GETTING DIRECTION FROM NEAR MISS AND MATERNAL MORTALITY AUDITS

Pattinson RC* for the Near Miss Study Group* MRC Unit for Maternal and Infant Health Care Strategies and Department of Obstetrics and Gynaecology, University of Pretoria

ObjectiveTo assess whether “near misses” can be used as a surrogate of an analysis of maternal deaths to describe the pattern of maternal deaths and avoidable factors.

MethodA “near miss” and maternal mortality audit was conducted in 3 clearly defined geographical areas, mainly Free State Provincial Regions A and B, and the

Pretoria and greater Soweto areas of Gauteng. Regions A and B in Free State Province surround Bloemfontein and consist of a mixture of urban and rural residents, and the areas of Pretoria and greater Soweto are mainly urban. Near miss and maternal deaths were collected in the areas and a comparison was made of the disease profiles.

ResultsA total of 405 near misses and 139 deaths were collected over 2 years. Demographic factors did not differ between the near misses and maternal deaths.

The primary obstetric cause of near miss and maternal deaths are shown below.

Primary cause Near Miss Maternal Death Conversion rate

N % N % %DirectAbortion 45 11.1 14 10.1 23.7Ectopic pregnancy 28 6.9 4 2.9 12.5Antepartum haemorrhage 52 12.8 3 2.2 5.5Postpartum haemorrhage 74 18.3 7 5.0 8.6Hypertension 108 26.7 31 22.3 22.3Pregnancy related sepsis 19 4.7 6 4.3 24Embolism 1 0.2 7 5.0 87.5Anaesthetic related 14 3.4 5 3.6 26.3IndirectNon-pregnancy related infections

20 4.9 34 24.4 62.9

Pre-existing medical disease 39 9.6 16 11.5 29.1

Fortuitous 3 0.7 8 5.8Unclassified 0 4 2.9

The types of avoidable factors are similar between both groups.

DiscussionAudits of near misses and maternal deaths give different information. A population has a basic disease profile which is modified by the reponse of the health system to the profile. The “Conversion Rate” (i.e. maternal deaths/ near misses + maternal deaths) gives a measure of how good or bad the health service is with respect to managing the disease process. For example, the conversion rate for obstetric haemorrhage is 22.3% which indicates haemorrhage is managed well in these health services, whereas for hypertension it is 7.3% which indicates there is a problem. By use of the conversion rate for areas and disease processes, the areas of poor management can be identified.

DOES MATENAL “NEAR MISS” AUDIT MAKE A DIFFERENCE?

Mantel GDMRC Unit for Maternal and Infant Health Care Strategiesand the Near Miss Study Group

ObjectiveTo assess whether audit with passive feedback improves the quality of maternal care.

DesignDescriptive study before and after the intervention.

SettingKalafong and the Pretoria Academic Hospitals.

InterventionA maternal “near miss” describes a patient with an acute organ system dysfunction, which if not treated appropriately, could result in death. Audit of all cases of maternal near misses and mortality were performed

over 2 years. A program of passive feedback of the findings to the medical health care workers was introduced in the second year.

Outcome measureDetermine whether any change occurred between the first and the second year in the number of near misses or deaths, in the occurrence of severe organ complications, or in the number of missed opportunities amongst maternal near misses and deaths.

ResultsThere were 153 and 137 near misses in the first and second year respectively. 29 women died during each year. There was no change in the obstetric demographics noted. Postpartum haemorrhage as a primary obstetric cause of near miss decreased over the study period (29 to 13 cases, p=0.047, see Table 1).

Table 1 Primary obstetric factors in the 1st and 2nd years1st year 2nd year

Near miss (153)n (%)

Death (29)n (%)

Near miss (137)n (%)

Death (29)

n (%)

Direct causes:Hypertension 41

(26.8%)11

(37.9%)37 (27%) 8 (27.6%)

PPH 29 (19%) 1 (3.4%) 13 (9.5%) 1 (3.4%)APH 13 (8.5%) 0 (0%) 17 (12.4%) 1 (3.4%)Abortion 27

(17.6%)6 (20.7%) 28 (20.4%) 5 (17.2%)

Ectopic pregnancy 15 (9.8%) 0 (0%) 11 (8%) 0 (0%)Pregancy related sepsis 6 (3.9%) 4 (13.8%) 6 (4.4%) 0 (0%)Anaesthetic complications 2 (1.3%) 0 (0%) 3 (2.2%) 2 (6.9%)Acute collapse & embolism 0 (0%) 1 (3.4%) 0 (0%) 1 (3.4%)

Indirect causes:Non-pregnancy related infections

6 (3.9%) 4 (13.8%) 1 (0.7%) 3 (10.3%)

Pre-existing maternal disease

14 (9.2%) 1 (3.4%) 17 (12.4%) 5 (17.2%)

Fortuitous deaths: 0 (0%) 2 (6.8%) 4 (3%) 3 (10.3%)

Pulmonary oedema as a marker of near miss, in women resident in Pretoria, decreased from the first to the second year (9 to 1 case, p=0.03) but did not decrease significantly as a complication overall (28 to 25 cases, p=0.99) (see cardiac dysfunction in Table 2).

Hypovolaemia (see Table 2) as a complication did decrease overall (71 to 40 cases, p=0.043) and was contributed to mainly by a decrease amongst the women referred into Pretoria from outside the health region.

Table 2 Organ system dysfunction in the 1st and 2nd years1st year 2nd year

Near miss(153)n (%)

Death(29)n (%)

Near miss(137)n (%)

Death(29)

n (%)

Vascular 71 (46.4%)

3 (10.3%) 40 (29.2%) 3 (10.3%)

Cardiac 30 (19.6%)

6 (20.6%) 28 (20.4%) 19 (65.5%)

Immunological 19 (12.4%)

10 (34.5%)

26 (19%) 4 (13.8%)

Coagulation 30 (19.6%)

5 (17.2%) 29 (21.2%) 4 (13.8%)

Renal 31 (20.3%)

11 (37.9%)

25 (18.2%) 6 (20.7%)

Respiratory 18 (11.8%)

16 (55.2%)

26 (19%) 8 (27.6%)

Cerebral 14 (9.2%) 8 (27.6%) 16 (11.7%) 8 (27.6%)Liver 21

(13.7%)3 (10.3%) 9 (6.6%) 2 (6.9%)

Metabolic 3 (2%) 0 3 (2.2%) 2 (6.9%)

There was no discernible decrease in the occurrence of avoidable factors

associated with medical care between the 2 years.ConclusionsPassive feedback, in the form of case discussion with the medical staff, of the information gathered during the near miss audit has not made any difference to the overall incidence of maternal near misses or mortality. Near miss caused by postpartum haemorrhage and the complications of hypovolaemia did decrease, but was mainly amongst the referrals from outside the health region, an area not targeted with audit feedback and therefore caused by some other factor. There has been no discernible change in the occurrence of avoidable factors associated with medical care in

our region between the two years. Feedback, the final loop of the audit cycle, needs to be directed more widely and more actively, before any improvement in maternal care is going to take place.

DEVELOPMENT AND VALIDATION OF A SCALE TO MEASURE PATIENT SATISFACTION WITH ANTENATAL CARE

Steyn PS, Mouton J*Department of Obstetrics and Gynaecology and *Centre for Interdisciplinary Studies, University of Stellenbosch

Keywords: antenatal care, patient satisfaction

IntroductionRecent ethnographic studies done at antenatal clinics in the Western Cape Province showed that patients were not satisfied with the service. A main finding was that services were overloaded. Although some women were satisfied with their antenatal care, for many the experience was that of an early rise and a long wait before being subjected to a number of investigations performed on them without adequate explanation, being intimidated and shouted at by the staff and being forced to listen to an educational talk that focused mainly on the danger signs. The experience was unpleasant and they did not receive the reassurance and information on their pregnancy

that they desired.Although these studies are extremely important and useful in identifying areas for improvement in service, and to highlight areas for further inquiry, perceptions and incidents do not always give an objective view of the global situation in antenatal services. Problems have been identified, but the extent of the problem is unknown.

Aim of the StudyThe purpose of this study was to develop a new scale, or adapt an existing scale, and validate this to measure patient satisfaction with antenatal care at the Tygerberg Hospital (TBH) clinics. This standardised instrument may then be used to evaluate the extent of satisfaction.

MethodsWe used a survey with an interview-administered questionnaire allowing for open-ended comments in a cross-sectional sample of 200 successive patients attending the antenatal clinics at Tygerberg Hospital. An adapted 16-item

Likert matrix scale as used by Perneger in Switzerland was used. Seven aspects of antenatal care appropriate to the TBH clinics were identified. The seven aspects that we used related to general satisfaction in the relationship with the patient, the time spent in consultation, the explanations given and the subjectively rated technical performance.Positive and negative value laden statements were classified as referring to care in general, to the physician, to access of care and to the organisation. Each statement was followed by five response options ranging from “strongly agree” to “strongly disagree”. The preliminary version of the questionnaire was administered by face-to-face interviews to a sample of 50 patients to clarify ambiguities in the wording of items, to confirm the appropriateness of the response scales and to determine acceptability and completion time.

Properties of the TBH instrument

Internal consistency of the items was tested with Cronbach’s alpha co-efficient. A value of 0.7 to 0.9 is considered acceptable. Internal consistency may be low when items in the dimensions do not measure the same concept, which was the problem in the case of access to care. Three items relating to access to care were dropped from further analysis. The one item on reception staff was also dropped, as its reliability could not be tested. The item to total correlation also demonstrated the low item-to-total correlation of the three items measuring access to care.Factor analysis is an important tool to establish construct validity of theoretical concepts when multiple indicators are used. It involved an analysis of the intercorrelations between indicators. The item loadings generated indicate how strongly each factor contributes to an underlying factor. In this study, factor analysis resulted in a single factor that accounted for 53.6% of the total variance. All the items had to do with the process

of antenatal care. There was no discrimination between the various aspects of provider behaviour.

ResultsThe socio-demographic results showed that the mean age was 28.4 years (SD 6.2) and the mean gravidity and parity was 3.1 (SD 1.7) and 1.6 (SD 1.4) respectively. The patients in the four different clinics differed significantly in their socio-demographic characteristics. The patients in the low risk clinic were significantly younger. The gravidity of the patients in the special care clinics was significantly higher than in the other clinics. Patients in the high risk level one clinic booked later than the other patients.

Satisfaction RatingThe satisfaction scores ranged from 48.3 to 100 (Figure 1). The mean is 86.4 with a standard deviation of 12.1. The distribution is negatively skewed to the left with a high mean rating. This is well-known and consistent finding amongst all

socio-economic groups with physician and medical care. If variation exists, it presents as ranging levels of positive attitudes rather than a truly negative sentiment. Patients tend to assume that whatever system of care is provided, was planned and is therefore the best. Socially desirable response sets can also account for these skewed satisfaction scores. People are known to be hesitant in expressing negative or socially unacceptable opinions.There was a significant difference in satisfaction rating between the clinics (Figure 2). The mean satisfaction rating for people attending the special care clinic was 98.4 with a standard deviation of 2.2. The mean scores for patients attending the low-risk clinics was 92.3 with a standard deviation of 11.2 and the mean total scores for the high-risk level one and two clinics were 83.3 and 86.1 respectively. There was a significant difference between the satisfaction scores in the special care and the high-risk clinics. There was no significant difference between the

satisfaction scores in the special care and low risk clinics. At the time of the survey only one medical officer saw the patients. This suggests that continuity of care can be an important determinant of satisfaction with care.When the differences in socio-demographic variables were adjusted for in an ANCOVA model, the setting of the clinic was still the main predictor for the satisfaction score. None of the other variables tested for showed any significant difference in the satisfaction score.

ConclusionsThe problem of cross-cultural issues must be kept in mind in the development or application of a scale in a local setting. Construct validity through factor analysis is an important way to test for this problem. The high mean satisfaction rates could be due to social desirability response sets and one should control for that in further questionnaires. Continuity of care may be an important determinant of patient satisfaction with antenatal care.

Satisfaction ratings seem to be more a measure of care than a measure of patients’ characteristics.Further research is necessary to refine a standardised instrument in South African antenatal clinics. These questionnaires should be tested in a more heterogeneous population. The items referring to access of care should be reviewed and expanded. Items exploring continuity of care provider

should be included. Items should include personal and general reference items to antenatal care with a measure of SDRS tendencies. Cross-cultural differences should be taken into account and one should validate each scoring instrument in its specific setting.It is important to take the patient’s subjective health assessment into consideration. If the patient’s perceptions and feelings are taken into account during health care decision making, patients become empowered by active engagement in maintenance and management of their own health.

DOES EPISIOTOMY BENEFIT THE LOW BIRTH WEIGHT BABY?

Buchmann E, Dinat N, Verhoeve HChris Hani Baragwanath Hospital, Soweto Community Health Centres, Coronation Hospital and University of the Witwatersrand, Johannesburg

IntroductionIt is thought that episiotomy for vaginal delivery of low birthweight (LBW) or preterm babies may prevent intracranial injury or neonatal death. No randomised controlled trials have evaluated this approach. The objective of this study was to measure neonatal morbidity and mortality following vaginal delivery of low birth weight infants, comparing outcomes with and without

episiotomy.

MethodsThree large community-based audits were combined into one database. Liveborn vaginally delivered infants of birth weight 1000-2499g were included. Subjects were used from the Chaiwelo (1995, n=189), Greater Soweto (1997, n=357) and Coronation (1998, n=614) studies of LBW infants. Outcomes were compared in accordance with the objective stated above.

ResultsCrude data from the entire data set are shown in the table.

Neonatal outcomes No episiotomy(n=900)

Episiotomy(n=260)

Statistical significance

Ventilation 91 9 NoneIntraventricular haemorrhage 68 11 NoneJaundice needing phototherapy 301 48 NoneNeonatal death 62 4 P<0.001Mean birth weight (g) 2007 2136 P<0.001

ConclusionEpisiotomy is associated with a more favourable neonatal outcome in vaginally delivered

low birth weight babies. The higher mean birth weight in the episiotomy group suggests, however, that larger infants (which always have higher

survival rates), by

stretching the perineum, are more likely to cause episiotomies to be cut. Observational studies of episiotomy are seriously confounded by birth weight and other factors. Only large randomised controlled trials will resolve this perinatal management dilemma.

ACTIVE BIRTH UNIT STATISTICS

De Jager M, Nolte AGW, Hofmeyr GJDepartment of Obstetrics and Gynaecology, Coronation Hospital, University of the Witwatersrand and Rand Afrikaans University

An Active Birth Unit (ABU) was established at the Garden City Clinic in 1995. Initially 5 private practicing midwives and 3 obstetricians for obstetrical back-up were involved. The unit was established not only to give the midwives the opportunity to do deliveries in a safe hospital environment, but also to give the patients the opportunity to be actively involved in any decision-making regarding their pregnancy, labour and post-natal period and to have the advantage of a one-to-one relationship with a caregiver they have known before.Midwives patients as well as high-risk patients are managed in the ABU which include hypertension, IUGR, inductions and previous C/S.The patients are managed with as little interventions as possible.

They have choices of delivering in or out of water, positions during labour and delivery and methods of pain relief, entonox, pethidine and mobile epidurals are available on request.Currently 9 midwives are making use of the unit with the back-up of 5 gynaecologists. C/S rate is less than 15% and minimal interventions are used. Detailed statistics will be presented.

BIRTH ASPHYXIA: AN UNAVOIDABLE EXPERIENCE?

Gregersen NE, Ballot DE, Guidozzi F, Cooper PAUniversity of the Witwatersrand

IntroductionRecent literature from developed countries suggests that most cases of birth asphyxia are unrelated to intrapartum management and that asphyxia is a relatively uncommon cause of cerebral palsy. Birth asphyxia rates appear to be considerably higher in developing countries, such as South Africa. It is our postulate that labour related problems remain an important cause of birth asphyxia in South Africa and that asphyxia is a more common cause of cerebral palsy than in a developed country.

Subjects and MethodsA retrospective review was conducted at the Johannesburg Hospital from 1/1/97 to 31/12/97. Babies were included if their birth weight was >1800g, the 5 minute Apgar was < 6 or if the birth and subsequent clinical course strongly suggested asphyxia.

Data regarding the peripartum and perinatal course of these neonates was obtained from maternal and neonatal records. Outcome was assessed from the follow-up notes of babies after discharge. Data collected included maternal demographic information, antenatal history, parity, gravidity, mode and complications of delivery. This information was reviewed by an obstetrician (FG) and a value judgement made as to whether the asphyxia was related to obstetric management or was unavoidable. If there was insufficient information available the case was termed unclassified. Neonatal information included demographics, Apgar score, birth weight, gestational age, need for ventilation, presence of seizures, grade of HIS, mortality, duration of ICU and hospital stay. The long-term neonatal outcome was assessed as normal or abnormal by the presence of microcephaly, hydro-cephalus, cerebral palsy, seizures, developmental delay and blindness.

Results

There were 48 inborn babies during the study period with a diagnosis of asphyxia. Maternal and neonatal data are shown in Tables 1 and 2. There were obstetric complications in 70% of pregnancies and 70% of babies were delivered vaginally. There was a C/S rate of 29% in the study group with an assisted delivery rate of 15% compared to 20.5% and 2.3% overall at the Johannesburg Hospital. The birth asphyxia was judged to be preventable in 22/48 (46%). A further 3 cases had asphyxia related to delay in transfer from outlying hospitals; 11 cases were unclassified and 12 had unavoidable causes of asphyxia e.g. abruptio placenta. The 25 potentially avoidable cases of asphyxia accounted for 5/6 (83%) neonatal deaths and 4/10 cases of cerebral palsy. The birth asphyxia rate was 6/1000 live births and the cerebral palsy rate 1.15/1000 live births. Neurological abnormality was present in 13/48 (27%) of babies at follow-up. Of these, 3 had minor development problems while the other 10 had evidence

of cerebral palsy. There were 5 patients with sepsis and a further 4 with suspected sepsis. Seven of these patients had HIE grade 1 and the other 2 HIE grade 2. 5/7 were normal at follow-up.

DiscussionIt is clear from the above audit that a significant number of cases of birth asphyxia (46%) are avoidable in a developing country such as South Africa. The cerebral palsy rate in this review is approximately 3 times that of the USA. The high birth asphyxia rate should be viewed in the context of an increasing workload at the Johannesburg Hospital. Delivery numbers have increased from <2000 per annum in 1989 to about 8000 in 1997. This increase in deliveries has not been accompanied by an increase in facilities. There is a lot of criticism levelled at high C/S rates but the cerebral palsy and birth asphyxia rates have not featured prominently in this argument. The C/S rate appears to be inappropriately low in this group of infants with unacceptably high rate of birth asphyxia and

cerebral palsy. A slightly higher C/S rate would seem to be justified if birth asphyxia can be prevented. Of particular concern are unsuccessful attempts at assisted vaginal deliveries where a timely C/S would seem to be better. The whole question of improved obstetric care, not only the C/S rate, must be addressed when attempting to prevent birth asphyxia. Proper regional care with improved antenatal assessment and labour monitoring with early transfer of

problematic cases to tertiary centres is needed.

Table 1 Maternal DataMean SD

Age 24.7 years 4.6Parity 0.84 1.04Gravidity 2 1.06

Number of Patients %Booked 37/48 77Pre-eclampsia 3/48 6PROM 7/48 14.5MSL 13/48 27Foetal distress 13/48 27APH 3/48 6Vaginal delivery 26/48 54C/S 14/48 29Vacuum 7/48 15Forceps 1/48 2

Table 2 Neonatal DataMean SD

Birth weight 3061 grams 658Gestational age 38.9 weeks 2.2Hospital stay 12.3 days 7.5Apgar score at 1 minute 2.4 1.4Apgar score at 5 minutes 4.7 1.8

Number of Patients %HIE grade 1 7/48 14.5 grade 2 16/48 33 grade 3 10/48 21

Seizures 24/48 50Ventilated 19/48 40Cranial sonar: Nil 29/48 60 Normal 10/48 21 Oedema 2/48 4Other abnormality 7/48 14Mortality 6/48 12.5Follow-up 28/48 67Abnormal outcome 13/48 27

ARE DEATHS DUE TO BIRTH ASPHYXIA PREVENTABLE? THE RELATIONSHIP BETWEEN INTRA PARTUM ASPHYXIA AND NURSING STAFF ALLOCATIONS AT WITBANK HOSPITAL

Pattinson RC, Kotze DC, van Vuuren HM, Fitzgerald T, Chegwidden RWitbank Hospital and MRC Unit for Maternal and Infant Health Care Strategies

IntroductionDuring the application of the Perinatal Problem Identification Programme in the Witbank district in 1998, a relationship between deaths due to intrapartum asphyxia, the number of registered staff on duty and bed occupancy came to light. As posts were frozen for the whole of 1998 it became apparent that staff shortages were in a direct relationship with the occurrence of perinatal deaths. Of the 22 perinatal deaths due to intrapartum asphyxia, 7 were not avoidable but the remaining 15 could all have been prevented.

MethodAll deaths classified by the Perinatal Problem Identification

Programme due to birth asphyxia for 1998 were traced and the time period during which labour occurred noted. This information was correlated with the nursing staff allocation and bed occupancy during labour. Duty rosters were audited and numbers of registered midwives, student and enrolled categories on duty during the labour were recorded. Registered midwives were counted as one unit and students and enrolled categories as 0.5 of a unit each as supervision was required.Duty times– Day duty 07h00-19h00- Night duty 19h00 – 07h00- Weekdays – Monday 07h00

– Friday 13h00- Weekends – Friday 13h00 –

Monday 07h00- Night duty, weekends and

public holidays were also considered as after hours.

Admissions and deliveries were also recorded as these increase the workload.Bed occupancy statistics were obtained from daily returns while the total number of deliveries for the year were retrieved from the

birth register.

Result3232 deliveries were conducted during 1998 and of these deliveries 22 resulted in birth asphyxia and death. 7 of the deaths could not be prevented (6 cord prolapse and 1 case where the patient delayed in seeking help). The 15 remaining were due to lack of foetal monitoring, misinterpretation of cardiotocographs and non compliance with protocols. Of the 15 deaths, 2 occurred on a weekday with 3 on a Friday afternoon. One occurred at change over (19h00) and 1 during the day. The remaining 10 occurred after hours i.e. at night or over weekends.On a weekday (07h00 – 19h00) there were on average 3 registered midwives and 2 students or enrolled categories on duty. After hours there were 2 midwives and 2 others on duty.The average bed occupancy was 86% over the days where deaths occurred and 66% over the entire year. (A high of 138% and a low of 38%). Averages of 5

admissions and 5 deliveries per shift, 10 patients in latent and active labour were recorded. All these required monitoring.On occasions some of these were not in labour but still required monitoring and care. Registered midwives also accompany Caesarean sections to theatre.Staffing was no different on days when a death due to birth asphyxia occurred to any other day.Nursing staff norms according to Booysens SW et al 1996 indicate that for the workload described above there should be 4.7 registered midwives on duty per shift therefore 9.4 rounded off to 10 for 24 hours, 6 on day duty and 4 on night duty.The formula used:1. daily average number of

patients x 365 = annual patient days (3610 antenatal admissions – 365 = 9.89 x 365 = 3610).

2. annual patient days x hours of direct care = annual hours of care (3610 x 5 = 18050).

3. hours of work of a RM = 40 hours per week x 48 weeks

(40 x 48 = 1920).annual hours of care = number of registered midwives hours of work of 1 RM per annum (18050 – 1920 = 9.4).

This would translate to 5 registered midwives and 2 students or other categories on day duty and 3 registered midwives and 2 students or other categories on night duty (students and other considered 0.5 units as supervision is required). If Booysens’ formula was applied to a bed occupancy of 13, 12 registered midwives would be required to cover a 24 hour period (7 on day duty and 5 at night).

ConclusionThe minimum staffing norm being 6 RM on day duty and 4 RM on night is not in place at the Witbank Hospital. On average, there are 3 midwives on duty per shift showing up at a 50% deficit. The PEP course has been introduced in an attempt to improve care. Even so, it would appear that deaths due to intrapartum asphyxia are not

preventable given the current staffing levels at the Witbank Hospital.

REASONS FOR THE PROVEN INACCURACY OF THE PINARD STETHOSCOPE IN DETERMINING THE FETAL HEART RATE DURING LABOUR

v/d Westhuizen CE, Howarth GR, Swanepoel M, Makin JMRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria

Keywords: intrapartum, fetal, monitoring

Electronic fetal heart rate monitoring (EFM) became traditional, and was accepted in the United States after its introduction into the clinical practices during the late 1960s. The use of EFM increased from 44.6% of live births in 1980 to 62.2% in 1988. By 1992, 73.7% of pregnancies were monitored electronically in the United States.By the end of the decade (1980s), the American College of Obstetricians and Gynaecologists stated that, although all women in labour needed some form of fetal monitoring, the choice of technique (EFM or intermittent auscultation) as based on a variety of factors, should be left to the judgement of the individual

physician.The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. There were an increased rate of Caesarean and operative deliveries in the group of patients monitored by continuous EFM. This finding was most striking in the low risk populations.The Cochrane Library – 1997 Issue 4 summarised the data from 9 randomised controlled trials and found that, with the exception of the reduction of neonatal seizures, the use of routine EFM has no measurable impact on fetal morbidity and mortality.Vintzileos did a randomised trial on intrapartum electronic fetal heart rate monitoring versus intermittent auscultation.It was concluded that intrapartum EFM was associated with decreased perinatal mortality due to fetal hypoxia, but also higher rates of surgical intervention for suspected fetal distress. He also did a meta-analysis on the same subject and came to the same conclusion.

In the African population the Doppler has been shown to be better in the monitoring of the fetal heart during labour then intermittent auscultation through a Pinard stethoscope.K Mahomed (University of Harare) did a randomised controlled trial on intrapartum heart rate monitoring. His results on detecting any abnormalities of the fetal heart rate were as follows: 54% of the abnormalities were detected by the CTG monitor, 32% were detected by the Doppler and only 15% of the abnormalities were detected by the Pinard stethoscope.Due to the above findings, a pilot study was done at Kalafong Hospital on 10 patients who were listened to by 23 different staff members and 45 readings were included in the study. These patients were all in labour and the fetal heart was auscultated by a Pinard stethoscope.It was found that 58% of the readings were interpreted incorrectly during labour and thus it was felt that a study should be done to try and find a possible reason for the inaccuracy of the

Pinard stethoscope to interpret the fetal heart rate during labour.

AimTo determine in this descriptive study the reason for the inaccuracy of the Pinard stethoscope.

ObjectivesThe objectives of the study were the following:1. Quantifying the loudness of

the fetal heart.2. Quantifying the loudness of

the background noise in the labour ward and during labour.

3. Testing the hearing capabilities of the labour ward staff.

MethodsWe included 15 patients with singleton pregnancies, with a gestational age of 36 weeks or more, fetus with a cephalic presentation, normal amniotic fluid index and a normal body mass index.To determine the loudness of the fetal heart, we took the 15 patients to the SABS (acoustic

department). The equipment used to determine the loudness of the fetal heart was as follows:microphone – BNK 0.25 inches type 4136analyser – BNK digital frequency analyser type 2131acoustic calibrator BNK type 4230.All patients were put in a sound proof room on a bed and the loudness determined through a Pinard stethoscope by connecting the microphone to the Pinard as if auscultating the fetal heart. To determine the background noise in the labour ward, a spectrum analyser microphone was used. Readings were taken during labour and during quieter times.The hearing capabilities of 23 staff members were tested by the Acoustic department of the University of Pretoria. Only the readings of the staff members who had undergone hearing tests were included in the study.

ResultsMost of the energy of the fetal heart lies between 2-4Hz. This means that this energy band lies in the infra-sound spectrum (0-

20Hz) and thus out of the hearing spectrum of the normal ear (20-20000Hz).The mean background noise in the labour ward, while a patient was in labour was 76,9dBA and during quieter times it was 74,7dBA.The loudness of a normal conversation will range between 50-60dBA.The hearing capabilities of the 23 staff members were all within normal limits.The synthesis of the results were as follows:

The frequency of the fetal heart is low.The background noise is

loud.The hearing capabilities of

thestaff were normal.

THUS YOU CANNOT HEAR THE FETAL HEART.

ConclusionOne doesn’t hear the fetal heart, one feels it. The ear picks up the pressure waves and the brain interprets it then as a sound. It is more a tactile response than a sensorial response.

The loudness of the fetal heart and the background noise, makes the interpretation of the fetal heart rate through the Pinard stethoscope inaccurate.The Pinard is still being used extensively, despite the problems around its usage. In a busy labour where a one to one patient-sister relationship is not possible, it is recommended that a Doptone or EFM should be used for intrapartum fetal monitoring.

INTRAUTERINE GROWTH RETARDATION AND THE FETAL GUT: IMPLICATIONS FOR FEEDING THE PRETERM INFANT

Newell SJConsultant in Neonatal Medicine & Paediatrics, St James’s University Hospital

Intrauterine growth retardation is truly defined as the observed loss of normal growth rate in the fetus. In most studies, the presence of a birthweight below the normal range is taken as a proxy for this. The infant with IUGR does not have a normal outcome. The well known data demonstrate that such infants have increased fetal and perinatal mortality with an increase in problems in the neonatal period. In the preterm infant, IUGR is associated with bronchopulmonary dysplasia, NEC and intraventricular haemorrhage and in the longer term neurodevelopmental delay and increased adult mortality and morbidity. Eventual stature in IUGR infants is less than birth weight or gestation matched babies although they may show catch up which occurs in the first

year. Barker’s work on nutritional programming clearly indicates the importance of IUGR. Such infants are at a greatly increased risk of adult onset diabetes in later adult life regardless of their history between birth and that age.An increasing proportion of preterm infants coming for intensive care are growth retarded and currently in our practice this exceeds 30%. It is perhaps not surprising that the gastrointestinal tract suffers the effects of IUGR. There is a parallel with the diving reflex seen in aquatic mammals. The whale dives to the bottom of the ocean and during the dive restricts blood flow to the kidneys and gut while preferentially providing a limited amount of oxygen to the brain, heart and muscles. A similar redistribution of circulation is seen in the growth retarded fetus and is well recognised on ultrasound. In IUGR the blood flow to the gut and the kidneys is reduced in the fetus and newborn infant. Oligohydramnios may be seen. There is reduced intestinal and

pancreatic growth. The clinical consequences of this cascade is fetal echogenic gut, poor intestinal motility, feed intolerance and increased risk of necrotising enterocolitis. Fetal echogenic gut (FEG) has a number of causes. It may be transient and associated with normal outcome (60%). Chromosome anomalies account for some FEG – 15%. Around 13% of FEG is associated with IUGR. In a case control study we compared infants with FEG and the triad of IUGR and abnormal fetal Doppler’s and prematurity with matched controls without FEG. The infants with FEG all showed considerable problems with feed tolerance with abdominal distension, bile stained nasogastric aspirate and later achievement of enteral feeding (15 days) compared with the control infants in whom full feeds were achieved at 4 days. Two of the FEG infants had considerable problems with abdominal distension requiring contrast enema which demonstrated microcolon. None of the infants had cystic fibrosis. Similarly,

infants with absent or reversed end diastolic flow velocity have increased use of PN, increased thrombocytopaenia and increased risk of NEC.How then should we feed the preterm infant with IUGR? The choice of milk is plain: breast milk should be used whenever possible. In a survey conducted in 1987 and repeated in 1994, an increasing proportion of neonatal units in the UK were using preterm formula and this is now second choice. Donor breast milk is much less widely available in the UK as breast milk banks have closed following fear of viral transmission. Other supplements to the feeds may include nucleotides which are associated with better weight gain and increase in head circumference and glutamate. Infants are fed during ventilation. This is now routine in over 70% of neonatal units in the UK. Trophic feeding (TF) is used widely and is associated with increased gastroduodenal mobility, motility, improved feed tolerance, decreased hypoglycaemia and also provides a role for the

mother in the provision of breast milk. Our study of trophic feeding showed that this was associated with increased lactase activity, shorter gut transit, less days of parenteral nutrition, a reduced stay in hospital and a halving of the rate of sepsis.The route of administration has also changed. In 1987 equal proportions using hourly bolus, continuous intragastric feeds and intrajejunal feeds was the method of choice. Intrajejunal feeding is no longer supported. It is associated with less good nutrition, increased NEC and an increased mortality. A majority of units in the UK now use hourly bolus feeds. Randomised studies comparing continuous versus bolus feeding show little difference. Continuous feeding may be associated with a marginally better weight gain whilst bolus feeding may preferentially induce normal gastrointestinal motility. Rapid administration of a bolus feed is associated with small changes in cerebral blood flow velocity but it is not known whether this is clinically significant.

Finally, once enteral feeds have been successfully introduced, 2 feeding regimes are most widely used. Low birth weight formula is given to a maximum of 165mls/kg/day. Fortified breast milk may be given to a volume of 165 or 180mls/kg/day. If breast milk is not fortified some infants will tolerate and benefit from volumes up to and occasionally exceeding 200mls/kg/day. It is common practice to return to the normal pattern of nutrition for the term infant at the time of discharge. Recent data suggest that this is now entirely reasonable. Improved growth is seen if supplements of calories, protein, calcium and phosphate are provided until around 2 months post term. Our policy therefore, is to breast feed ad-libitum or to provide a formula containing these supplements during this period. At discharge, infants should receive a multi vitamin supplement (e.g. Abidec 0.6mls daily) and an iron supplement (around 5mg elemental iron bd) and a folic acid supplement (0.5mg daily).In summary, there is ample

evidence to suggest that the fetus with IUGR will have an unhealthy gut. In the infant who weighs over 1.5kg we feed normally and observe closely. In the infant under 1.5kg who does not require ventilation, feed is electively withheld for the first 24-48 hours. Trophic feeding is given for a 24 hour period and thereafter, milk is increased slowly under observation. If such an infant requires ventilation and intensive care, milk is not given until the infant is stable and most of there infants require parenteral nutrition with trophic feeding in the initial days.

IMPROVING COMPLEMENTARY FEEDING PRACTICES IN CHILDREN AGED 3 TO 12 MONTHS IN THE HIGHVELD REGION, MPUMALANGA, SOUTH AFRICA

Malek E*, Sykes M#, Mohlakoane S+

*Department of Paediatrics, University of Pretoria and Witbank Hospital# Department of Human Nutrition, University of Pretoria and Witbank Hospital+ Mpumalanga Provincial Department of Health, Nelspruit

Keywords: Infant feeding practices

IntroductionGrowth failure in the first year of life, despite high breast feeding initiation rates, indicates a need for closer evaluation of and improvement in infant feeding practices in children under one year of age. Studies have demonstrated that under-nutrition occurs during weaning, and that the early introduction of complementary feeds and other inappropriate weaning practices are common. This study aims to improve young child feeding practices in children aged 3 to 12 months in the Highveld region, using a consultative approach,

incorporating Trials of Improved Practices (TIPs), to inform the Well Child Initiative, the Integrated Management of Childhood Illness Program, the Integrated Nutrition Program, and the Health Promotion Program adopted by the Mpumalanga Provincial Department of Health.

Objectives To describe infant

complementary feeding practices in children aged 3 to 12 months.

To describe the reasons motivating feeding practices.

To identify care giver constraints to improving young child feeding practices.

To test identified improved complementary feeding practices using TIPs.

To formulate recommendations for improved complementary feeding practices for implementation of household level and for use in the Well Child Initiative Program.

MethodFollowing consultation with

Mpumalanga PHC Program Directors, a qualitative research methodology encompassing the use of TIP’s was used for data collection (as this method provides the opportunity to test recommendations for improving household practices at the household level). This study was conducted in two sites in the Highveld region (Kgobokoane – rural, Vosman – peri-urban), focusing on 42 households with children aged 3 to 12 months, subdivided further into three age groups: 3-6 months, 6-9 months, and 9-12 months. Two groups of community health workers were trained in the TIPs approach to conduct 3 visits per household. Data collection tools included a question guide, an analysis framework and a checklist for assessing feeding practices for each age group.

ResultsDemographic profile: water was mostly supplied by communal taps (83%), none of the homes had taps. Food was bought from local stores and supermarkets by all households. Food gardens

were seasonal and more common in the rural (52%) than peri-urban (33%) areas. In 41 of the 42 cases, the main care giver was the mother, of whom 65% had completed primary school and 5% had no education.Study group characteristics: 45% of the children studied were female, with a mean age of 6.99 months. The clinic card and birth weight were available in 88%. Of these, the mean birth weight was 3 066 grams, with 12% low birth weight. Ninety percent were up to date with their immunisations, 93% appeared healthy to both mother and the field worker (CHW).Growth curve: in the rural area, the growth curve followed centile lines up in 90%, compared with the peri-urban area where the curve was flat or crossed centiles in 28%. This growth failure was found in the 6 to 12 month age group.Breast feeding practices: 41 of the 42 children were breast fed at the time of the study, the mean frequency was 9.8 times in 24 hours, and care givers intended to continue breast feeding for 12

to 48 months.Complementary feeding practices: early introduction of complementary feeds were precipitated by baby crying and perceived insufficiency of breast milk in 73%. Fluids were introduced by 1 week in 38%, foods by 4 weeks in 36%, and by 12 weeks 88% had received fluids and 82% foods (foods were given later in the peri-urban area (11 weeks) than the rural area (6 weeks) p=0.008. First feeds were soft porridge (31%), water (29%); formula (14%), cereal (14%) and 10% received sugar salt solution (SSS all in rural area). Advice on feeding was given mostly by the grandmother (rural) or self-initiated (peri-urban). Infant formula was given to almost 50% in both areas, commercial cereals more in peri-urban (68%) than rural (32%). Foods given or withheld during illness were also identified.Feeding problems: 40% had more than 1 problem. The most common problems were: at 3-6 months: not breast feeding exclusively, at 6-9 months: semi-solid feeds not nutrient dense

enough, at 9-12 months: solids not nutrient dense enough or amounts inadequate. The use of bottles was an additional common problem in all age groups.Feeding recommendations (rec’s) tested: 2 (65%), 3 (29%) or 4 (21%) rec’s per care giver were offered: 5% did not try any rec’s, 9.5% tried 1 rec, the remainder tried either 2 (64%), 3 (19%) or 4 (2%) rec’s. 7% did not adopt any rec’s, 9.5% adopted 1 rec, the remainder adopted 2 (62%), 3 (19%) or 4 (2%) rec’s. Motivations for adopting rec’s included that baby was satisfied, enjoyed it, or was happy, and that it saved money and was locally available. Constraints for adopting rec’s included the baby was used to the food or bottle, cried, or didn’t like a cup (3-6m), or there was no money (6-12 m).

Conclusion1. Key messages were

identified for each age group for use in health programs.

2. The TIPs method is an effective tool for testing

and improving infant feeding practices.

3. Recommendations to Program Planners include consideration of rural/peri-urban variance of problems, age-group specific recommendations for feeding problems, and the inclusion of the TIPs approach in health promotion training.

RANDOMISED CONTROLLED TRIAL OF A BREAST MILK FORTIFIER TO SHORTEN HOSPITAL STAY IN LOW BIRTH WEIGHT INFANTS

Delport SD*, Goosen S#, Honey EM*, Scholtz E** Department of Paediatrics, Kalafong Hospital and the University of Pretoria# Unie Hospital, AlbertonMRC Unit for Maternal and Infant Health Care Strategies

IntroductionLow birthweight (LBW) infants should be discharged as soon as satisfactory weight gain occurs so that domiciliary biological breastfeeding can be practised. A breast milk fortifier contains amongst other nutritional advantages, an increased caloric density and if added to breast milk facilitates an increased caloric intake which may expedite discharge.

ObjectiveA randomised controlled trial was undertaken to determine the average weight gain in LBW infants receiving their own mothers’ milk as compared with infants receiving their own mothers’ milk and a breast milk

fortifier (Similac Natural Care – Ross Laboratories).

Patients and MethodsLBW infants weighing less than 1.6kg and receiving full enteral feeds at 180ml/kg, were randomised to receive either breast milk (120kCal/kg) or breast milk and a breast milk fortifier (150kCal/kg). Standard anthropometric measurements were performed. Infants were discharged when a weight of 1.8kg was reached.

ResultsA total of 18 infants were enrolled. The infants receiving a breast milk fortifier showed a trend towards a faster increase in weight, length and head circumference and reached the discharge weight on average one day earlier. Differences were not statistically significant due to small numbers.

ConclusionInfants receiving a breast milk fortifier were discharged earlier than infants receiving only breast milk.

THE ADVANTAGES OF BREAST FEEDING

Newell SJConsultant in Neonatal Medicine and Paediatrics, St James’s University Hospital

There are numerous advantages to breast feeding. Many of these are social and will not be discussed. The importance of breast feeding in developing countries is beyond doubt but this paper will give emphasis to the evidence available, supporting the use of breast milk in the breast feeding mother in a more affluent society. Breast feeding in the United Kingdom has become unfashionable and occurs in only 60% of births falling to 40% at 6 weeks and only 25% are breast feeding at 3 months. It is imperative therefore, that health workers understand the advantages behind breast feeding which will empower them when encouraging mother to consider breast feeding their newborn infant.

Advantages of breast milk

Improved gastrointestinal motilityDecreased necrotising enterocolitis

Decreased infectionDecreased allergy

Neurodevelopmental advantageAvoidance of adult disease

In the preterm infant gastric empyting is improved with expressed breast milk which is better tolerated. It is the feed of choice. We are so convinced of this that when an infant arrives on our neonatal unit, having explained the situation to the infant’s mother, we point to the need for her to provide milk for her infant. Support for this is provided by the nursing staff on the unit and a large number of breast pumps are available for this purpose. The avoidance of infection is well established in developing countries but breast feeding for a period of 3 months still leads to significant reduction of gastrointestinal and respiratory tract infections in the UK. In France, it has been estimated that such a reduction in infection would lead to an annual saving of 7 million dollars.

Cow’s milk protein intolerance occurs in 2-4% of the infant

population. Breast feeding has a place in its prevention. Randomised data demonstrates that soya milk has no advantage over a standard cow’s milk formula in the prevention of atopic symptoms. In families with a strong history of atopy, if an infant is fed a hydrolysed milk (e.g. Pregestimil) the incidence of allergic disease is reduced. A similar reduction may be achieved through the use of breast feeding in a mother whose diet contains restricted anitgens (no cow’s milk, egg). Such a maternal diet should only be used with great care. A substantial although slightly less large reduction in allergic symptoms may be seen simply by breast feeding the infant.The role of breast milk in improving neurodevelopmental outcome is more contentious. Here it is extraordinarily difficult to separate the effects of breast feeding from the sort of parent who is likely to breast feed. In the United Kingdom breast feeding is more likely if the parents have higher educational achievements, income and less

socio-economic problems. Nevertheless, all studies that have addressed this issue, have shown improved intellectual outcome even when the social variables are allowed for. We do not however, routinely discuss this with parents when they are making a choice about breast feeding. In one of the East Anglian studies, it was shown that there was a half standard deviation (8 point) advantage in IQ if mothers used expressed breast milk to feed their preterm infants in the first 6 weeks. The advantage of breast milk seems also to pertain to infants with neurodevelopmental problems in whom there may be some amelioration of adverse outcome through breast feeding.A strong candidate for the mechanism behind the advantages of breast feeding is the presence of omega 3 fats within breast milk (e.g. Docosohexaenoic acid). These fats are plentiful in breast milk but not in formula feeds. 60% of our brain is made of fat and a difference in fat structure may be seen between infants who have

been breast fed and those who have been bottle fed.Avoidance of adult disease is not entirely clear. Crohn’s disease appears to be reduced in people who are breast fed and this may apply to multiple sclerosis. Children with juvenile onset diabetes have higher levels of antibodies to bovine serum albumin (cow’s milk protein) and it has been estimated that a 40% reduction in diabetes would be seen if all were breast fed.Breast feeding has some disadvantages. It is not always possible and may be associated with bacterial or viral contamination and needs to be avoided when mother’s are receiving certain drugs. A much more common problem in the preterm infants is its variable energy and protein density. This has been largely overcome through the use of breast milk fortification. This is now almost universal practice in neonatal units in the UK. This usually results in an increase in calories (10kCal/100mls), protein (0.7g/100mls), calcium, phosphate and sodium. The

administration of extra fat has not been associated with anything other than fat deposition in the young infant. A specifically designed powder is added to milk. It is however, possible to fortify breast milk through the addition of hydrolysed formula. A powdered hydrolysed formula is taken and one 25ml equivalent scoop is added to 100mls of breast milk. If breast milk is to be fortified it is important to take account of the variation in its composition in the preterm mother. Initially a concentrated milk is produced which has a very low water content. It is therefore, unreasonable to add fortifier at this stage. By 2-3 weeks of age, the preterm mother produces a milk very similar in composition to the term mother. Our policy therefore, is to routinely add breast milk fortifier to expressed breast milk for low birth weight infants once they are tolerating 90mls/kg/day of expressed breast milk. This continues until they are feeding directly at the breast. We have shown that this does not alter gastric emptying.

There is only one thing wrong with breast feeding in the United Kingdom, not enough women choose to do it.

TIDAL VOLUME AND ON-LINE RESPIRATORY COMPLIANCE MEASUREMENTS AS PREDICTORS FOR SUCCESSFUL EXTUBATION OF NEONATES BEING VENTILATED FOR HYALINE MEMBRANE DISEASE

Smith J, Pieper CH, Maree DMDepartment of Paediatrics and Child Health and Respiratory Technologist, Tygerberg Hospital

No objective criteria exists for the extubation of neonates that are being ventilated for hyaline membrane disease (HMD). The decision to extubate neonates suffering from HMD is usually based on clinical judgement and blood gas analysis. The purpose of this study was to determine whether objective criteria could be established for the extubation of neonates suffering from HMD.

Material and MethodsThis prospective study enrolled measurements were performed by means of a neonatal volume monitor (NVM-1, Bear Medical Systems, Riverside, CA). We measured the tidal volumes (Vt), minute volume (Ve) and compliance of the respiratory system (Crs). The Crs was

calculated using the Vt and ventilator driving pressure. Arterial blood gases were measured prior to and after the extubation. Successful extubation was defined as the neonate surviving for more than 48 hours without respiratory decom-pensation requiring intubation.

Results40 neonates with a mean birth weight (BW) of 1332g and mean gestational age (GA) of 30.5 weeks were studied at a mean time of 7.3 days after birth. 24 (60%) neonates were successfully extubated and were compared to the 16 (40%) who failed extubation. No differences regarding BW, GA or infants receiving methylxanthines were found between the two groups. The rest of the results are as follows: a) Characteristics of the infants before extubation breathing spontaneously, on 2CMH2O CPAP (Mean value). (b) Crs determined on rate 40/min, driving pressure 13CMH2O.

Success (n=24) Failure (n=16) P valuea) PaO2 (kPA) 9.2 8.9 NS

PaCO2 (kPA) 5.7 6.3 NSpH 7.34 7.30 0.02Vt inspiratory (ml) 6.37 4.9 0.02Vt expiratory (ml) 7.16 5.56 0.004Ve ml/min 421 355 NSResp. rate/min 66 68 NSFiO2 0.25 0.27 NS

b) Crs inspiratory (ml/cmH2O) 0.74 0.47 0.01Crs expiratory (ml/cmH2O) 0.74 0.48 0.0002

Conclusion1. Blood gas analysis and

clinical judgement are not good discriminators to aid in the extubation of neonates ventilated for HMD.

2. Tidal volume and Crs are useful aids in determining whether extubation will be successful or not.

THE ROLE OF KININS AND CYTOKINES IN HYPOXIC ISCHAEMNIC ENCEPHALOPATHY OF THE TERM NEWBORN

Adhikari M, Pillay T, Moodley M, Moodley D, Bhoola KDDepartment of Paediatrics, University of Natal

IntroductionIn developing countries, like South Africa, the incidence of hypoxic ischaemic encephalopathy may be as high as 5% compared to 0.2% - 0.9%, in the developed world. In term infants, early and accurate evaluation of the severity of brain injury following a hypoxic event remains one of the most difficult problems in neonatal care. A biochemical index of brain injury would be highly desirable for the prediction of neurological sequelae and for the development of therapeutic strategies. The objective of this prospective, pilot study was to evaluate the levels of kinins and cytokines in the cerebrospinal fluid and blood and to determine their correlation with the neurological status in the short and long term.

Patients and MethodsThe study population included term asphyxiated newborns admitted to the neonatal unit at King Edward VIIIth Hospital, Durban, South Africa. Clinical signs of HIE were based on the severity rating of Volpe and Hill. The neuroradiological investigations included a cranial ultrasound and Doppler study. A resistance index (RI) of less than 0.5 at 24 hours was regarded as an indicator of poor prognosis. A CT scan was performed within the first two weeks of life. Serum kinins and cytokines in serum and cerebrospinal fluid samples were obtained within the 12-18 and 48-72 hours of age.

Statistical MethodsSAS statistical software was used to analyse the data. In view of the small numbers and wide range for each set of data, log transformation was utilised. Associations were measured using Pearson’s correlation and linear regression.

Results

Clinical and neuroradiology detailsFifteen term infants with a mean weight of 3.13kg (range 2.7-3.8) were studied. Seven of the babies were classified as mild HIE, 4 as moderate HIE and 4 severe HIE. Two of the four babies with severe asphyxia died at 52 hours and 12 days postnatally and, at the last hospital visit (seven months of age), two infants had neurological signs suggesting delayed motor milestones and poor head growth. Of the four babies classified as moderately affected one had signs suggestive of motor milestrone delay. The cranial ultrasound, Doppler and CT scan findings correlated with the severity of the asphyxia as was assessed clinically.Kinin generated, IL6 and IL8 levels (Table)In each of the HIE groups there was no correlation with mean levels of kinins

and cytokines in blood and CSF on day 1 and day 3 except in the mild HIE for IL6 on day 1 and 3 (p=0.01). The wide range for each test on day 1 and 3 for blood and CSF accounts for the lack of correlation. Log transformation and Pearson’s correlation revealed an association between IL6, r=99 on day 1 and day 3 and IL8 levels, r=97 on day 1 and r=99 on day 3 in the blood and CSF among the infants with severe HIE. The numbers in each group of patients studied were small and the actual timing of sampling blood and CSF in individual patients varied on the days of sampling.

Mean & Range Mild HIE Moderate HIE Severe HIEKinin (pg/ml) n=7BL12-18 hour 2.93 (0.9-6.56) 4.7 (0.53-14.17)

2.34 (1.31-5.04)BL 48-72 hours 4.97 (1.26-18.8) 0.90 (0.02-2.01)

2.656 (0.790-4.720)

CSF 12-18 hours 2.33 (1.28-6.68) 2.07 (0.36-3.46)2.34 (2.0-5.52)

CSF 48-72 hours 3.24 (1.16-10.43) 1.99 (1.02-3.74) 1.66 (0.47-3.96)IL6 (pg/ml) n=4BL 12-18 hours 895 (637-1380) 613 (84-659)

10770 (311-40650)BL 48-72 hours 898 (248-1288) 887 (311-2880)

885 (335-1229)CSF 12-18 hours 447 (269-914) 431 (293-811)

1860 (238-6390)CSF 48 – 72 hours 292 (71-565) 2320 (253-76830) 337 (216-405)IL8 (pg/ml) n=4BL 12-18 hours 2624 (60-16879) 118 (70-211) 625 (91-1376)BL 48-72 hours 181 (51-389) 348 (17-951) 194 (36-345)CSF 12-18 hours 597 (17-1625) 600 (26-1810)

816 (29-3161)CSF 48-72 hours 338 (14-2235) 746 (24-1701)

211 (23-393)

DiscussionFew studies have examined the role of cytokines in the CSF following birth asphyxia . This pilot study is the first to evaluate both kinin and cytokines IL6

and IL8 responses to perinatal asphyxia. Blood and CFS levels were measured at two points in time, an early stage of 12-18 hours and later stage of 48 to 72 hours giving two comparative points. The purpose of studying blood and CSF was to determine whether a correlation between blood and CSF levels could be shown, in which event CSF levels would not be required in subsequent studies. In this study

there were no significant relationships between the grades of severity of the HIE and the levels of kinin and cytokines on days one and three in blood and CSF. Further the ranges of kinin and cytokine levels for each category of patient was extremely wide and as such precludes an accurate outcome prediction in the individual infant. However, log transformation revealed a correlation between blood and CSF levels in babies with severe HIE. This study did not find a relationship between levels of IL6 and IL8 and severity of HIE as in the previous studies which had similar numbers of patients and a wide range in levels for each category of

asphyxia. In conclusion, this study has shown value in that the blood and CSF levels of kinins and cytokines showed a strong correlation for severe asphyxia. However, individual levels for the grades of asphyxia were not helpful in predicting the severity of asphyxial involvement. Further studies are required in this exciting biochemical field of kinin and cytokines in the newborn with respect to infection and asphyxia.

THE LONG TERM NEURO-DEVELOPMENTAL OUTCOME OF INFANTS <1250G ELECTIVELY NOT ADMITTED TO THE NEONATAL INTENSIVE CARE UNIT

Van Zyl JI, Kirsten GFDepartment of Paediatrics and Child Health, Tygerberg Hospital and the University of Stellenbosch

IntroductionThe lack of available resources common to developing countries together with the great demand on neonatal intensive care unit (NICU) beds, requires selective admission to intensive care of infants with birthweights <1250g.

ObjectiveTo determine the neurodevelopmental and cognitive outcome of infants <1250g initially denied neonatal intensive care and to compare this with the outcome of those who received intensive care.

MethodsThe study cohort comprised all infants (178) with a birthweight (BW) <1250g admitted to Tygerberg Hospital during 1994. They were predominantly of

mixed race and from a low socio-economic background. The NICU group was admitted to the NICU within the first 48 hours of life. The Neonatal Ward (NW) group was treated in a Level 2 nursery. A complete neurological assessment and Griffiths Mental Developmental Scales were done on the survivors at 24 months of age. Disability was defined as cerebral palsy (CP), sensori-neural (S-N) deafness or a general developmental score (Gen DQ) of <80 for chronological age.

ResultsThe NW group (96) weighed significantly less than the NICU group (82) [mean BW 1002.9g vs 1087.5g, p=-0.0001] and was of lower gestational age [29.4w vs 30.1w, p=0.0302]. The survival rate was much lower in the NW group [60.4% vs 80.5%, p=0.0004]. A total of 124 out of the 178 babies survived. Six died after discharge from hospital and three were excluded from follow-up due to severe congenital abnormalities. Ninety-four infants (82%) were seen at two

years of age, 42 (44.7%) were from the NW group and 52 (55.3%) from the NICU group. Two children from the NW group were classified as disabled (one with S-N deafness and one with global developmental delay) whereas 9 children of the NICU group were disabled (6 with cerebral palsy (CP), 2 with S-N deafness and normal motor development and 1 with global developmental delay)[4.8% vs 17.3%, p=0.060]. The mean Gen DQ did not differ significantly between the two groups: NW 89, SD 6 and NICU 84, SD 18.8, p=0.0876. The locomotor subscale quotient was significantly higher in the NW group [92 SD 9.3 vs 85, SD 21.6, p=0.0468]. Disability in the NW group was associated with BW<1000g and single marital status while in the NICU group it was associated with bronchopulmonary dysplasia (BPD), severe intraventricular haemorrhage (IVH) and periventricular leukomalacia (PVL).

Conclusions

Cognitive outcome was not affected by elective refusal of admission to the NICU. Admission to the NICU resulted in a higher survival rate but at a price: these infants more often suffered from locomotor disabilities related to IVH, PVL and ventilatory complications such as BPD.

SHOULD WE VENTILATE THE NEWBORN EXTREMELY LOW BIRTHWEIGHT INFANT: OUTCOMES OVER THE LAST DECADE

Urban MNeonatal Unit, Department of Paediatrics, Chris Hani Baragwanath Hospital

AimAt Chris Hani Baragwanath Hospital newborns with a birthweight of less than 1000g are not routinely ventilated, but the occasional ‘precious’ baby is ventilated. The current study assesses the outcomes of ventilated extremely low birth weight (ELBW) infants.

MethodData from the Neonatal Unit computer database was analysed retrospectively. Twenty-five infants of birth weight 836-995g (mean=949g) were ventilated between 1988 and 1998 for respiratory indications in the first week of life. They were compared to 352 infants of birth weight 1000-1099g (mean = 1043g). In addition, we set out rational criteria for ventilating babies below our weight cut-off

and compared the characteristics of the ventilated ELBWs to this.

ResultsThere were no significant differences in mortality during NICU stay, duration of ventilation, or risk of grade 3-4 intraventricular haemorrhage on head ultrasound. It was often unclear why these particular ELBW infants had been ventilated. While they were more likely to have been booked than the control group (p=0.001), eleven of the twenty five (44%) in no way fulfilled our ventilation criteria.

ConclusionsThe hypothesis that ventilating ELBW infants only occasionally would dramatically worsen outcomes in these infants was not supported, although the sample size was not large enough to exclude relatively small difference from the control group. If neonates smaller than the general weight cut-off are ventilated, clear-cut criteria should be set and adhered to.

THE ETHICS OF SELECTING INFANTS FOR NEONATAL INTENSIVE CARE

Cooper PADepartment of Paediatrics, University of the Witwatersrand

Neonatal care in South Africa can broadly be divided into three tiers:1. Approximately 20% of the

population are covered by medical aid/ insurance and are therefore entitled to private medical aid. Although many medical aid schemes do have some limitations, those covered by medical aid are usually able to be offered a full range of neonatal services without major restrictions. Thus weight/ gestational age limitations are seldom applied unless there is the expectation that medical aid funds will soon be exhausted.

2. Tertiary academic centres and some regional hospitals have facilities to provide neonatal intensive care (NIC), but none of these centres has sufficient beds

to provide NIC to all of those infants in the region who would benefit from such care and rationing is usually practised. For the purposes of this paper NIC refers to assisted ventilation. Refusal criteria include categories such as extremely low birthweight (<1000g), severe birth asphyxia where the neurological prognosis is considered poor and major congenital abnormalities incom-patible with a reasonable ‘quality’ of life. It is estimated that fewer than one-third of infants born outside of the private sector in South Africa have access to NIC.

3. The majority of infants born in South Africa who do not fit into one of the above categories have access to primary and secondary levels of neonatal care, often of varying quality, but for all practical purposes, have no access to NIC.

Government policy over recent years has concentrated on

improving primary and secondary health care and, where tertiary services in the public sector exist, to bring about greater equity in the distribution of these services. Although these policies have met with varying success, the net effect has been to place a greater strain on the rationing required in centres described in category 2 above and the gap in services available between categories 1 and 2 has increased. It is not clear whether future government policies will attempt to narrow this gap, in which case a greater degree of rationing of services will be required in the private sector as well.Since ‘selection’ of infants for NIC currently takes place mainly in academic tertiary centres and the focus is usually around some form of birthweight/ gestational age limit, this will form the basis of this paper. However, the principles invoked will hopefully be able to be applied more widely.

International ApproachesIn developed countries, three broad approaches have been

described:(a) The “wait until certainty”

approach which is largely that used in the United States where treatment is begun on almost every infant who is thought to have any chance of survival and the most important principle is to prevent the death of any infant who might survive with a fairly good outcome even at the expense of more survivors with severe handicaps.

(b) The “statistical” approach determines categories of infants in which treatment may be limited or withheld. Here the most important guiding principle is to avoid creating severely handicapped infants at the expense of the deaths of some infants who may survive to lead normal lives. An example is Sweden where infants born at a gestation of less than 25 weeks and weighing less than 600g may not be offered intensive care.

(c) The “individualised”

approach which is apparently widely practised in Britain is intermediate between the above mentioned approaches. It involves initiating care on any infant who has a chance of survival, but making a decision early, without necessarily waiting until certainty, on whether the individual infant is likely to have a favourable outcome and withdrawing intensive care treatment if it is felt unwarranted.

All of these approaches put the interests of the individual infant at the centre of the ethical dilemma. Even in the case of the statistical approach, the guiding ethical principle is that the interests of the individual infant are best served by not initiating intensive care since the risks of survival with major handicap are too high. There is seldom any mention in the literature which emanates largely from developed countries that there may be physical limitations of resources in the form of intensive care beds or indeed the resources of the

society to care for handicapped children. These approaches may be applicable to the private sector in South Africa, but is not particularly helpful in public sector institutions.The principles that I believe should be applied in public sector institutions in South Africa are those of distributive

justice, which demands that there should be a fair and equitable distribution in society of resources, and the utilitarian maxim of triage whereby resources should be used to provide the greatest good for the greatest number. This, however, is at odds with the traditional view of the doctor/patient relationship whereby the doctor should do his/her best for each individual patient.

In order to examine the triage principle in the practical neonatal setting, data from a previous study was re-analysed. The mean number of ventilator days to produce a survivor in each birthweight category was calculated by dividing the total number of ventilator days for all infants in that birthweight category by the number of survivors. The results are shown in the table.

Table: Mean number of ventilator days to produce one survivor by birthweightBirthweight (g) Number of Days

< 1000g 41.11000-1499g 21.81500-1999g 12.1

>2000g 4.3

It can be seen that the resources required to produce one survivor from

mechanical ventilation with a birth weight <1000g would produce almost

two survivors with birthweight 1000-1499g, more than three survivors with birthweight 1500-1999g and almost ten survivors with birthweight >2000g. Thus, on the basis of the above principles, a

birthweight/gestational age limit for admission to the intensive care unit should be one of the major criteria for admission to or exclusion from intensive care since this would allow a greater number of (larger) infants to benefit. While gestation is usually a better indicator of organ maturity and therefore prognosis, the majority of women delivering VLBW infants in public sector institutions have not attended antenatal clinic. The estimation of gestational age under the

stressful conditions of a critically ill newborn infant in the labour ward, initially by a relatively inexperienced medical practitioner may be substantially inaccurate. Thus for practical purposes, a birthweight limit rather than a gestational age limit is preferable.Due to circumstances forced upon them, neonatologists have been in the forefront of rationing care, perhaps to the detriment of their patients when seen in the broader context of available medical interventions, since it would appear that other areas of medicine have not rationed care so strictly. It is time to put issues such as this into the broader argument of resource allocation and the current widely applied limit of a birthweight >999g for admission to NIC may warrant modification.The following recommendations are suggested:1. The status quo should be

maintained in terms of a birthweight cut-off pending progress on the points to follow – other neonatal conditions warranting NIC

admission should be measured against this in terms of mortality, long term prognosis and resource allocation.

2. Extension of NIC services should take place to ensure greater equity in the geographical distribution of these services.

3. A basic package of hospital services providing equity across all disciplines should be debated and agreed upon, i.e. are heart transplants more worthwhile than ventilating infants weighing <1000g at birth.

4. The issue of the gap in services between those able to access private medical care and the rest of the population needs to be debated. Should there be some form of cross-subsidisation, in which case, further rationing in the private sector would be required?

IMPLEMENTING A NATIONAL NEONATAL RESUSCITATION PROGRAMME

Saloojee HDepartment of Paediatrics and Child Health, University of the Witwatersrand

About 40% of infant deaths in South Africa can be attributed to perinatal causes, i.e. events occurring before or at the time of birth. It is estimated that a quarter of these perinatal deaths may be preventable if there was adequate resuscitation of newborns at the time of birth. This would potentially save 10000 unnecessary neonatal deaths in South Africa each year. In addition, many infants survive an asphyxial episode at birth, but subsequently develop major neurodevelopmental disabilities. There are substantial costs to the individual and the health system in caring for these babies.In August 1998, 250 paediatricians, doctors and nurses completed the American Academy of Paediatrics (AAP) Neonatal Resuscitation Program (NRP) training course in Gauteng and Kwazulu-Natal. The project

was a co-initiative between the AAP and the South African Paediatric Association (SAPA). Participants were trained by instructors from the AAP and received a certificate on completing the free, one-day training course. All participants received a study manual prior to the course. Full sponsorship of the programme was provided by Janssen-Cilag (USA).The American Academy of Pediatrics developed and owns the NRP programme. It is incumbent on all health physicians and nurses caring for newborns in the United States to be certified as having satisfactorily completed this course. There is no similar requirement presently in South Africa. The AAP is keen to support the continued development of the programme in South Africa.It is being suggested that the NRP be initiated as a national programme in South Africa rather than in a piecemeal fashion in individual units or centres. This requires considerable organisation and planning and

this presentation will propose a way forward.

A NEW EDUCATIONAL STRATEGY TOWARDS IMPROVING MATERNAL AND NEONATAL CARE

Hay IT, Pattinson RCMRC Unit for Maternal and Infant Health Care Strategies

Conception, pregnancy, childbirth, the neonate’s wellbeing, growth and development is essentially one health related condition.In traditional undergraduate curricula, the knowledge, skills and attitudes relating to this continuum have been taught by separate disciplines in an

uncoordinated fashion. The student’s exposure to practical Obstetrics is better than to Neonatology. In some academic services the most junior medical staff who have responsibility to manage ill neonates are at a level of Senior House Officer.

Does this really matter?Comparison of the perinatal statistics between Pretoria Region and the Highveld Region emphasise the huge potential for improvement with implementation of proven interventions.

Pretoria region ’96 and ‘97

Highveld region ’96, ’97 and ‘98

Low birth weight 15,4% of 23886 deliveries 13.1% of 24424 deliveriesPMR (> 1000g) 23.3/1000 36.0/1000 (1000-1499g) 145.8/1000 405.7/1000 (1500-1999g) 32.7/1000 115.6/1000SB/NND ratio 2.54:1 2.04:1Perinatal care index 0.41 0.30

Resources, staff attitudes towards care and health service organisation can account for some of these differences. Our assumption is that the knowledge, skills and experience of doctors are an important determinant for optimal maternal and neonatal care and that new

educational strategies are needed.The implementation of the new Problem Orientated Curriculum at the University of Pretoria has created the opportunity

for an innovative approach to intervene within this educational

component.A 12 week block on Pregnancy, Childbirth, the Neonate, Growth and Development has been included in the 3rd year’s curriculum.The Problem Orientated Strategy is based on:1. Fictitious case studies that

incorporate medical, therapeutic, psychosocial, organisational and ethical elements.

2. A series of questions that encourage students to focus on specific learning objectives.

3. Linked training in relevant practical skills.

4. Integration of the pre-clinical, clinical and behavioural science teaching.

5. Utilising educational settings so that the student can understand the clinical context in which he needs to learn the content.

6. The content is outlined in the student guide in the SAQA format that requires specified Capability Aims, Critical Outcomes, Specific

Outcomes, Required Knowledge and Skills and Defined Levels of Competency.

7. Resource materials that are prescribed include, The Perinatal Education Programme, the prescribed Obstetric and Paediatric textbooks, the Cochrane Library and other relevant evidence based references.

8. Cognitive evaluation will be in the form of computer based MCQs. A competency certificate in the skills component will be a requisite. The end of block examination will be in the form of MCQs and a structured OSCE.

Implicit in this strategy is that students will have further exposure to Obstetrics and Neonatology during the clinical years and that their levels of competence will then meet the defined Faculty educational objective of producing a doctor capable of independent practice.

EVALUATION OF THE USE OF THENEONATAL MANUAL OF THEPERINATAL EDUCATIONPROGRAMME

Greenfield DHDepartment of Paediatrics, University of Cape Town

Keywords: Education, neonatal, evaluation

IntroductionThe Perinatal Education Programme has been developed to meet an in-service training need for midwives and doctors in perinatal care. It is based on the principles of co-operative learning and a problem orientated, question and answer educational method. This educational material (a maternal care, and a neonatal care manual) is made available to individuals or groups who wish to update their knowledge and skills in perinatal care. There is a need to know whether the Programme is effective in achieving the objectives of improving the knowledge, skills and patient care practices of those who use it.

MethodsA controlled intervention study

was undertaken at two hospitals in the Eastern Cape, where the Neonatal Manual was studied by midwives in one hospital, and not used in the other hospital. The study hospital was Uitenhage Provincial Hospital, and the “control” hospital was Dora Nginza Hospital in Port Elizabeth.The knowledge of the participants was tested using a multiple choice question paper. Skills were tested at both hospital by doing a structured objective clinical examination (OSCE).These were both tested before the Programme was started and after the Programme had been completed by the staff at Uitenhage Hospital. Patient care practices were assessed by doing chart reviews of the hospital records of selected infants in the six months before and the six months after the use of the Programme.The practices assessed were: observations done, quality of documentation, problem identification, management of the patient and a total for all these four practices. Each of these were assessed for three time

periods, viz. 0 - 12 hours of age, 12 – 72 hours, and >72 hours, and a total score for the whole record.

ConclusionsThere has been a highly significant improvement in cognitive knowledge, skills, and patient care practices of the newborn infant in those midwives who studied the Programme. This improvement was not noted where the Programme was not studied. The Programme can, therefore, be recommended for use in-service

training in neonatal care.The use of the Programme, however, does not exclude the need for clinical input from medical and senior nursing staff. Patient care practices, in particular, can also be improved by constant audit and feedback.

Results

Cognitive knowledge

Before Programme After ProgrammeTest Score Test Score

n mean n mean P Uitenhage 19 62.5 24 105.6 <0.000Dora Nginza 9 71.2 10 91.9 =0.013Maximum Score =119

Skills

Before Programme After ProgrammeOSCE Score OSCE Score

n mean n mean P Uitenhage 22 55.8 22 102 <0.000Dora Nginza 9 66.8 10 64.7 =0.71Maximum Score =123

Patient Care Practices

1. Overall Score: Uitenhage HospitalBefore Programme After Programmen mean % n mean (%) P 191 44 201 59.2 <0.000

2. Overall Score: Dora Nginza HospitalBefore Programme After Programmen mean % n mean (%) P 9 15.8 36 23.9 =0.07

3. Overall Scores: After the ProgrammeUitenhage Hospital Dora Nginza Hospital

n mean % n mean (%) P 201 59.2 36 23.9 <0.000

THE POTENTIAL TO REDUCE PERINATAL DEATHS IN A RURAL REGION THROUGH STUDY OF THE MATERNAL CARE MANUAL OF THE PERINATAL EDUCATION PROGRAMME BY MIDWIVES

Theron GBMRC Perinatal Mortality Research Unit, Department of Obstetrics and Gynaecology, University of Stellenbosch and Tygerberg Hospital

Keywords: education programme, midwives, perinatal deaths

IntroductionThe question may be asked as to whether an intervention such as the study of the Perinatal Education Programme (PEP) by midwives can reduce perinatal death rates? For this reason it was necessary to determine the proportion of perinatal deaths that could be reduced by midwives providing primary obstetric services.

MethodsA prospective controlled trial was conducted in a rural region of the Eastern Cape where PEP had not been implemented before. A study town and two control towns were selected. In the study town

the Maternal Care Manual was studied during 1994 by all midwives involved in perinatal care. The files of all women who had perinatal deaths during 1993 and 1995 in the three towns were drawn and studied. The primary and final causes of perinatal deaths, as well as possible avoidable factors, were identified.

ResultsIn the study and control towns, the files of 102 (79%) if the 129 deaths and 61 (90%) of the 68 deaths respectively were available for analysis. The primary causes of perinatal deaths are shown in Table 1. Medical care related avoidable factors were present with 50% and 48% of perinatal deaths in the study and control towns, respectively (Table 2). No reduction in avoidable factors occurred in the study town.The potential for midwives to intervene with regards to antenatal and intrapartum complications and the type of complications that need to be recognised are summarised in Table 3. All the data of the study

and control towns were pooled for the purpose of this analysis. In the study town 20 (38%) of the 52 cases with medical care related avoidable factors, had the potential to be prevented at the level of care rendered by midwives and 21 (21%) of the 102 perinatal deaths probably had potential for intervention by midwives. The primary causes of these perinatal deaths were congenital syphilis (12) and fetal distress due to cord complications (9). A further 16 (16%) deaths possibly had the potential to be prevented with monitoring of the fetal condition in patients admitted with hypertensive disorders (12) and identification of risk factors for preterm labour (4).

ConclusionAvoidable factors related to medical care, that may have reduced perinatal deaths did not decline in this study. These avoidable factors will, however, only be reduced to a minimum by introducing a system of audit using regular perinatal mortality meetings, involving all midwives and physicians responsible for perinatal care. In the study town 38% of the medical care related avoidable factors and 21% of the perinatal deaths probably had potential for intervention by midwives.

Table 1 Primary causes of perinatal deaths (%)Study town Control towns

Preterm labour 26 (25.5) 15 (24.6)Unknown 20 (19.6) 15 (24.6)Antepartum haemorrhage 13 (12.7) 7 (11.5)Peripartum hypoxia 13 (12.7) 10 (16.4)Infection* 12 (11.8) 6 (9.8)Hypertensive disorders 12 (11.8) 6 (9.8)Congenital abnormalities 5 (4.9) 2 (3.3)Other 1 (1.1)

102 61

All deaths due to congenital syphilis, expect one case in one control town due to chrorio-amnionitis.

Table 2 The frequency of avoidable factors in the study and control towns

Study town (%) Control towns (%)Local patients All patients

1993MedicalPatientAdministrativeTOTAL

8 (47)9 (53)

017

11 (44)13 (52)

1 (4)25

12 (44)15 (56)

-27

1995MedicalPatientTOTAL

13 (52)12 (48)

25

20 (51)19 (49)

39

9 (56)7 (44)

16

Table 3 The potential for intervention by midwives with regards to

antenatal and intrapartum complications

Antenatal complications (pooling all the data) Conditions to be recognised- exclude: - hypertensive disorders (24)

* unbooked patients - preterm labour (5)* one visit only - postterm pregnancies (4)

- potential for intervention by midwives - uterus > dates (2) 36 (86%) of the remaining 42 patients

First stage of labour (pooling all the data)- no action in event of:

poor progress fetal distress

- incorrect notation on partogram

THE WHO REPRODUCTIVE HEALTH LIBRARY

Hofmeyr GJDepartment of Obstetrics and Gynaecology, Coronation Hospital and the University of the Witwatersrand

For health workers in developing countries, the practice of evidence-based medicine is particularly important because of the need to direct scarce resources towards interventions which have been shown to be effective, and away from interventions which have been shown to be ineffective or harmful.Currently, the best resource of systematic reviews available is the Cochrane Library, published on disk and CD-Rom by Update Software, Oxford, UK. Unfortunately, the Cochrane Library has limitations in this respect. Firstly it is expensive and requires a relatively high level computer to run it. Secondly, most of the reviews are written from a first world perspective, and do not take into account the limitations and realities facing health workers in

developing countries. The WHO Reproductive Health Library is an electronic journal providing health workers and policy makers in developing countries with up to date information and reviews in the field of Reproductive Health. Areas covered include pregnancy and childbirth, infertility regulation, sexually transmitted diseases, and neonatology.In the library, Cochrane systematic reviews are reproduced with permission from the Cochrane Collaboration, and are accompanied by commentries written by experts with experience of working in developing countries to place the reviews in the context of the realities of working in a developing country situation.The second issue of the RHL will be presented, and copies made available for delegates.

OBSTETRICAL HAEMORRHAGE – PREVENTABLE KILLER?

Schoon MG, and the Near Miss Study GroupDepartment of Obstetrics & Gynaecology, Free State University, Bloemfontein

ObjectiveTo evaluate serious morbidity and mortality relating to obstetrical haemorrhage in 3 defined populations in South Africa.

Study PopulationAll women with a near miss at the referral hospitals and all deaths of pregnant women residing in a] Free State Regions A and B, b] Pretoria/Mamelodi, c] Soweto.

Study SampleAll cases with obstetrical haemorrhage as a primary cause of death or near miss during a 24 month period.

MethodsAll cases with near miss (organ dysfunction) and deaths were evaluated by a clinical researcher using a structured clinical form. Near miss markers, primary cause of death and final organ

dysfunction were established in all cases. The researcher determined avoidable factors and an interview was conducted with each survivor, or relatives in the case of a death.

ResultsThere were 135 cases of obstetrical haemorrhage resulting in 10 deaths (7.4%). The conversion of near misses to deaths were 22.2%, 2.4% and 4.5% respectively for the Free State, Pretoria and Soweto.Four of the 6 deaths in the Free State occurred outside the referral hospital. The 2 deaths at the referral hospital were a postpartum haemorrhage with a cardiac arrest on arrival at the referral hospital and an abruptio thought to be terminal AIDS and, therefore, not resuscitated.

Conclusions7.4% of near misses die as a result of obstetric haemorrhage. The high proportion of deaths in the Free State relate to transport problems, delay in referral to secondary hospitals and other management problems.

Appropriate management could reduce mortality due to obstetric haemorrhage.

MISOPROSTOL VERSUSMETHYLERGOMETRINE FOR THE PREVENTION OF POSTPARTUM HAEMORRHAGE: A DOUBLE BLIND RANDOMISED TRIAL

Amant F, Spitz B, Timmerman D, Corremans A, van Assche FADepartment of Obstetrics and Gynaecology, University Hospitals Leuven, Belgium

IntroductionThe use of prostaglandins in the postpartum period was first described in 1976. Misoprostol has no clinically significant vasoactive properties in humans and can be stored at room temperature. Recently, misoprostol, an oral prostaglandin E1 analogue, was found to be effective in the prevention of PPH. The aim of our study was to compare in a double-blind randomised setting the administration of 200g IV methylergometrine with 600g oral misoprostol in the third stage of labour.

MethodsThe study box contained either 2 capsules of misoprostol (2x300g) with an ampuole

containing placebo, or 2 capsules with placebo and an ampuole containing methylergometrine (200g). The study boxes and capsules were indistinguishable in the two groups and both groups did receive the full package of active management of the third stage equally. After delivery of the baby, women were administered the contents of the study box. One hour after delivery participants were asked to quote side effects (nausea, vomiting, diarrhoea, hot flushes, fever, shivering, headaches or vertigo) using a Visual Analogue Scale (VAS). On postpartum day three, the haemoglobin and haematocrit levels were measured.

Statistical MethodsWe looked at the difference in haemoglobin levels before and after delivery in 33 patients in our normal setting, using methylergometrine. A sample size of 60 patients in each group was required to obtain a power of 90%. A sample size of 100 was chosen in order to be well above the limit.

ResultsOne hundred women were included in each group. The demographic characteristics and labour variables are compatible in both groups and cannot explain differences in outcome. Women receiving misoprostol showed a tendency for increased need of therapeutic oxytocic therapy (12.8% vs 4.4%) (p=0.065). The need for manual removal of the placenta was similar in both groups, 3% in the methylergometrine and 4% in the misoprostol group. Four out of 93 women (4.3%) had a clinically estimated blood loss >500ml in the methylergometrine group, while 8 out of 96 (8.3%) in the misoprostol group (p=0.57). Only one patient (1%), receiving misoprostol, had a blood loss of more than 1000ml. The median length of the third stage of labour was similar for both groups (p=0.88). In each group one patient (1%) needed a transfusion. A significant difference in side effects was found for shivering (p=-.0001): in the misoprostol group 36 of 86

patients (42%) indicated a score of 8 or more on the VAS scale, while only 8 of 94 patients (8.5%) in the methylergometrine group experienced heavy shivering. There is no difference between the groups in the occurrence of nausea (p=0.15), vomiting (p=0.44), diarrhoea (p=0.3), hot flush (p=0.07), headaches (p=0.78) or vertigo (p=0.16). There was no significant difference in systolic and diastolic blood pressure and haemoglobin and haematocrit three days after delivery between both groups. Only a difference in temperature one hour after delivery was found. A rise in temperature equal to or more than 38oC occurred in 3% and 34%, respectively for methylergometrine and for misoprostol (p=0.0001). A rise in temperature equal to or more than 39oC only occurred in the misoprostol group (8%).

DiscussionWomen receiving misoprostol needed further oxytocic drugs and there was a tendency towards increased blood loss.

This finding is not surprising since absorption probably only occurs in the stomach. Haemorrhage early in the third stage of labour is probably not prevented by misoprostol. However, no differences were found between the two groups in haemoglobin or haematocrit levels three days after delivery. This finding might be explained by a sustained contraction of the uterus and subsequent reduction of blood loss in the hours after delivery in patients treated with misoprostol. This explanation might be an argument for combined prophylaxis of PPH: parenteral uterotonic for the prevention of uterine bleeding immediately after delivery and oral misoprostol for the reduction in blood loss in the hours following delivery. Only three percent in the methylergometrine group had a body temperature equal or more than 38oC. In contrast, in the misoprostol group, 34% suffered from fever that spontaneously resolved after 5-6 hours.In summary, this study shows that the use of misoprostol for

the prevention of postpartum haemorrhage is associated with a tendency for an increased need for additional oxytocic drugs. Side effects (rise in temperature and shivering) are self-limiting, but uncomfortable for the patient and should be balanced with oral intake and stability in room temperature. In a setting where storage conditions are poor and sterile needles are a problem one might accept these side effects. We could not detect a difference in mean haemoglobin three days after delivery, but larger studies are needed to prove that misoprostol is equally effective for the prevention of postpartum haemorrhage. Such a trial is currently being undertaken by the WHO. If misoprostol reduces blood loss more in the hours following delivery, then a combination therapy of ‘rapid onset’ parenteral and ‘slow onset’ oral uterotonic drug might be a new future direction in the prevention of PPH.

MISOPROSTOL VERSUS SYNTOCINON: A RANDOMISED DOUBLE BLIND PLACEBO CONTROLLED PHYSIOLOGICAL STUDY OF INTRA-UTERINE PRESSURE DURING THE THID STAGE OF LABOUR

Bamigboye AA, Hofmeyr GJ, Nikodem CDepartment of Obstetrics and Gynaecology, Coronation Hospital and University of the Witwatersrand

Keywords: postpartum haemorrhage, misoprostol, randomised trial

ObjectiveTo compare duration and frequency of uterine contractions following administration of misoprostol via the oral and rectal routes versus intramuscular syntometrine and placebo in the third stage of labour.

DesignA randomised double blind placebo controlled physiological study.

SettingLabour ward of a university teaching hospital.

Participants

Thirty-six low risk women undergoing normal vaginal delivery.MethodsThe women were randomised into four groups: group A received 600mg rectal misoprostol as the active agent and two other placebos; group B received 600mg oral misoprostol as the active agent and two other placebos; group C received 10 international units syntocinon imi and two other placebos; group D received no active agent, all were placebos. Intrauterine pressure was measured using catheter tipped pressure transducer. Buccal temperature was recorded at 30 minutes and 60 minutes following drug administration and occurrence of shivering noted. Comparisons were by the chi square test, Fisher’s exact probability test, relative risks with 95% confidence intervals, and the Mann-Whitney test.

Outcome measuresFrequency and duration of contraction following 30 minutes of drug administration, occurrence of temperature above

37.2 degrees celsius and shivering.

ResultsThe results will be presented at the conference.

TITRATED ORAL MISOPROSTOL SUSPENSION FOR INDUCTION OF LABOUR. A PILOT STUDY

Matonhodze BB, Hofmeyr GJCoronation Women’s and Children’s Hospital, University of the Witwatersrand

AimTo ascertain if misoprostol suspension, given orally in a titrated form, will be effective and safe for induction of labour in viable pregnancies.

MethodsEighteen women with pregnancies more than 34 weeks, who had no contraindication to induction of labour, were enrolled after informed signed consent. A tablet of misoprostol (200g) was dissolved in 200mls tap water and given to the women to drink 2-hourly, starting with 20mls for three doses, then 40mls till established labour.

ResultsEighteen women were enrolled. Thirteen (72%) delivered vaginally, five (27%) by Caesarean section. Two had meconium stained liquor, two had

hyperstimulation syndrome and two needed augmentation.

ConclusionTitrated oral misoprostol suspension is effective and relatively safe for the induction of labour in viable pregnancies.

INFLUENCE OF BACTERIAL VAGINOSIS ON THE ABSORPTION OF MISOPROSTOL

Jivkov BI, Hofmeyr GJCoronation Hospital for Women and Children, University of the Witwatersrand

ObjectiveTo determine whether the presence of Bacterial Vaginosis (BV), by altering the pH of the vagina, may influence the absorption of misoprostol.

DesignA prospective descriptive study was conducted on women undergoing termination of pregnancy on demand, according to the Choice on TOP Act 92 of 1996.

Outcome MeasuresThe presence of Bacterial Vaginosis was based on the Amsel criteria – the appearance of vaginal discharge, the altered pH of the vagina, the positive bedside amine “whiff” test and clue cells on wet prep. The failure of misoprostol tablets to dissolve, the time until onset of bleeding and/or cramps, the size

of dilatation of the cervix, were compared between BV +ve and BV –ve subjects.

ResultAlthough the study results had already been collected at the time of writing, the data was still being analysed.

THE IMPACT OF THE PREGNANCY CONFIRMATION CLINIC ON ANTENATAL CARE

Tsuari M, Jeffrey BS, Pistorius LR, Pattinson RC, Makin JDMRC Unit for Maternal and Infant Health Care Strategies, Department of Obstetrics and Gynaecology, Kalafong Hospital and University of Pretoria

Keywords: antenatal care, perinatal outcome, health system compliance

ObjectiveTo introduce a pregnancy confirmation clinic as part of antenatal care and to determine whether this would alter the gestational age at which patients commence antenatal care.

SettingThree municipal antenatal clinics in Atteridgeville and Central Pretoria.

MethodA pregnancy confirmation clinic was set up at three sites. At the clinic any woman wishing to confirm whether she was pregnant was offered a urine B-HCG. If this test was positive, on-site testing for syphilis, anaemia, Rhesus status, urine dipstix,

clinical examination and ultrasound examination were performed. Women with abnormal test results were commenced on appropriate treatment immediately and women requiring further medical care or investigation were referred appropriately.

ResultsThe study recruited 382 women, 145 of whom were defaulters from contraception. Half of the women (191) had a positive pregnancy test. The mean booking gestation was 12 weeks 4 days (standard deviation 5 weeks. Range 5 weeks to 25 weeks 2 days). Treatable conditions with the potential to influence pregnancy outcome were identified in 19.4% of the pregnant women. Forty three of the pregnant women intended to terminate the pregnancy.

ConclusionIt is possible to shift the commencement of antenatal care to an earlier gestation.

ROUTINE EXTERNAL VERSION FOR ABNORMAL PRESENTATION – THE SUCCESS RATE AND OUTCOME WITHIN AN OBSTETRIC SERVICE

Theron AM, Theron GB, Smith MMRC Perinatal Mortality Research Unit, Department of Obstetrics and Gynaecology, University of Stellenbosch and Tygerberg Hospital

Keywords: breech presentation, external version

IntroductionThree randomised trials of external cephalic version at term show that the procedure significantly reduces the incidence of breech presentation at birth and that the rate of caesarean section may be halved. This study examines a policy of routine external version within an obstetric service.

MethodDuring 1996 all antenatal patients within the Tygerberg Hospital obstetric service with a diagnosed abnormal presentation at a gestational age of > 35 weeks were identified (Group I). Patients at a gestational age of >

35 weeks admitted with previously undiagnosed breech presentations in labour, were included for analysis (Group II). These patients were prospectively studied to detemine whether external versions were considered and the success rate of versions attempted. The routes of delivery, perinatal complications of both these groups were determined.

ResultsDuring 1996 there were 7612 deliveries conducted at Tygerberg Hospital and the attached midwife obstetric units, excluding 2075 (21.4%) low birth weight babies (<2500g). A total of 148 (1.9%) patients with abnormal presentations (breech 140, transverse 5, oblique 1) that may have qualified for external versions were identified antenatally (Group I).External versions were attempted on 111 (75.0%) of these patients and were successful at first attempt in 51 (45.9%) cases. The reasons for not attempting external version in 37 (33.3%) patients, were reduced liquor in

16 (43.2%), hypertension/preeclampsia 4, placenta praevia 3, uncertain 3 and miscellaneous 9 cases. 42 patients were considered for a second external version > 1 week later of which 28 were attempted And 11 (39.3%) successful. The reasons for not attempting external version in 14 (33.3%) patients, were spontaneous version to vertex in 6, reduced liquor in 5 cases and other reasons 3. The gestational ages at which the versions were attempted and the persons conducting these versions are summarised in Table 1. 70 patients, with previously undiagnosed breech presentations, were admitted in labour at a gestational age of > 35 weeks (Group II). The routes of delivery of patients in Group I and II are shown in Table 2. Antenatal, intrapartum and neonatal complications occurred with a very low frequency.

DiscussionThe success rate of the first attempt at external versions conducted mainly by registrars under field conditions within an obstetric service is below 50%. A second attempt following a failed version > 1 week later should be considered. The eventual proportion of breech deliveries was reduced by about half if abnormal presentation were diagnosed antenatally. However, the caesarean section rate in this group did not differ from the group in labour with undiagnosed breech presentations at or close to term.

Table 1 Gestational ages at which versions were attempted and persons conducting versions

Mean gestational age:- 1st attempt

- 37.2 weeks (s=3.6)- 2nd attempt

- 38.3 weeks (s=2.1)

External version conducted by:- registrars 87- consultants 6- medical officers 5- midwife 1- unknown 12

Table 2 Routes of delivery in patients in Group I and IIGroup I (%) Group II (%) p-value

Caesarean sectionNormal vertex deliveryBreech deliveryUnknown

53 (35.8)56 (37.8)34 (23.0)5

27 (38.6)-43 (61.4)

0.8

Total 148 70

DOES HIV SERO-POSITIVITY CHANGE THE POST-OPERATIVE MORBIDITY OF CAESAREAN SECTION PATIENTS?

Urbani G, Goosen H, Bam R,de Vries M, Cronje HSDepartment of Obstetrics and Gynaecology, University of the Free State

ObjectiveA comparison between the post-caesarean section morbidity in HIV-positive and negative patients.

DesignCross-sectional study.

MethodA total of 305 consecutive patients were included in this study that was done in the Pelonomi and Universitas Hospitals. Patients were followed-up from the morning after their caesarean section until discharge and were seen daily by one of the same two researchers. At inclusion HIV and RPR tests were done on each patient with the appropriate informed consent. Complications that arose were then diagnosed,

noted and treated according to a certain set of guidelines drawn up beforehand. The results of the bloodtests were not blinded due to the ethical dilemma of counselling the patients in the event of sero-positivity. In HIV positive patients CD4 and CD8 counts were assessed.

Results1. According to preliminary

analysis the HIV positive and HIV negative groups did not differ in relation to age, gestation, mass, length of stay in hospital, type or reason for caesarean section.

2. The overall HIV-rate was 18.8%.

3. The RPR-rate was found to be 14% and statistically higher in the HIV positive group.

4. The incidence of booked patients was 84% and the median hospital stay for both mothers and babies was 4 days.

5. The HIV positive group had statistically significantly more endometriosis and

the antibiotic use was more frequent.

6. There was no difference in the two groups in relation to those who received blood, temperature spikes higher than 37.5oC, incidences of pulmonary, bladder or incisional infections nor was there a difference in the neonatal outcome. Wound hematoma and deniscence did not differ between the two groups.

7. Of the HIV positive patients 19/55 (34.5%) had CD4 counts of less than 400 and 5/55 (9%) less than 200.

Conclusions1. The HIV incidence was in

accordance with estimated rates for our area.

2. As can be expected, the RPR-rate was higher in the HIV positive group.

3. Contrary to popular perception only the endometriosis incidence was higher in the HIV positive group.

PRETORIA PASTEURISATION – A POTENTIAL METHOD FOR THE REDUCTION OF VERTICAL TRANSMISSION OF HUMAN IMMUNODEFICIENCY VIRUS VIA BREASTFEEDING

Jeffrey BS*, Mercer KG*MRC Unit for Maternal and Infant Health Care Strategies, Department of Obstetrics and Gynaecology, University of Pretoria and Kalafong Hospital

Keywords: Human Immunodeficiency Virus, breastfeeding, pasteurisation

ObjectiveTo develop and test a simple and inexpensive method of pasteurisation of human milk.

MethodsThe principle used was the transfer of heat from a large volume of hot water to a smaller volume of milk. Volume of water and sizes, shapes and materials of containers were varied in order to find the combination of these factors which would provide the desired temperatures.

ResultsThe apparatus providing the desired temperatures most effectively were a 1 litre

aluminium pot containing 450ml water and a glass peanut butter jar. Milk temperature remained between 56oC and 62.5oC for between 10 and 15 minutes depending on the combination of variables. The peak temperature and duration of time in the ideal temperature range was sensitive to volume of water and type of container used but minimally sensitive to volume of milk, starting temperature of milk and ambient temperature.

ConclusionPretoria pasteurisation is feasible. The method requires refinement and further testing under different conditions.

LESSONS LEARNED IN ESTABLISHING A RANDOMISED CONTROLLED TRIAL TO INVESTIGATE THE EFFECTS OF VITAMIN A ON VERTICAL TRANSMISSION OF HIV-1

Chikobvu P, Steinberg WJ, Joubert G, Viljoen JI, Coetzee M, Kriel J, v/d Ryst EDepartment of Obstetrics and Gynaecology, University of the Free State

Keywords: HIV mother to child transmission, vitamin A, lessons learned

ObjectivesTo describe problems encountered in setting up a randomised controlled trial to investigate the effect of Vitamin A in reducing vertical transmission of HIV-1 and suggest possible solutions. This trial is an interdepartmental project at the UOFS, involving clinical departments, laboratories and biostatistics.

BackgroundThe overall mother-to-child HIV transmission rate has been reported as ranging from 20-40% in Africa, in contrast to 10-20% in the USA and Europe. Results of the ACTG (Aids Clinical Trial

Group) 076 trail, released in 1994, showed that Zidodine (AZT) administered to HIV infected pregnant women and their newborns reduced the transmission rate by about two-thirds. However, the implementation of these strategies in Africa is hampered by financial constraints. Vertical transmission of HIV therefore remains a serious problem for many developing countries, where the majority of HIV positive mothers cannot afford AZT. A relatively cheaper method of reducing vertical transmission is therefore needed. Semba et al demonstrated that maternal Vitamin A deficiency is associated with vertical transmission of HIV. A double blind randomised controlled trial to determine the effect of oral administration of Vitamin A to HIV positive pregnant women, subsequently lactating or non-lactating mothers and their infants on the vertical transmission of HIV was set up in Bloemfontein, South Africa.

Screening processTo identify possible participants

for the study, voluntary HIV screening was commenced in September 1997. Establishing the screening process was difficult. Eighty three percent of those approached each month are willing to have an HIV test. It is also realised that the counselling process necessitated extensive manpower. Voluntary patient screening is coupled with pre- and post test counselling. Pretest counselling is organised in groups at the first antenatal visit. Post test results are conveyed during individual counselling sessions to all patients.

Results of screeningTwo thousand and forty three patients were screened from September 1997 to January 1999. 595 were identified as positive which yields a prevalence rate of 23.4%, which compares well with the figure of 22.8% obtained for the Free State by the Annual Antenatal HIV Survey of the MRC/Department of National Health. Only about 50% (296) of the positives identified have been recruited into the study as 27% of those identified as positive did

not come to collect their results and 12% were unwilling to join the study for various reasons. Eight percent denied the positive results and 2% did not meet the inclusion criteria.

Short description of women included in the studyAge: mean age 26 years (10% in the teenage category). Parity: 77% fall into the primigravida or parity one category. Gestational age at inclusion: 50% in the second trimester and 50% in the third trimester. Haemoglobin: 12% have a haemoglobin below 10mmol/l. CD4/CD8: The study of helper and suppressor cells of the study population reveals a CD4 count that falls below the normal range in 43% of cases. The CD8 counts are slightly elevated within the normal range resulting in a low CD4/CD8 ratio, with 73% of the study population falling below our normal range.

Ethical dilemmasBreastfeeding adviceWe are currently following the consensus statement of WHO/UNICEF and UNAIDS which

advises formula feeds even in developing countries provided they are available and safely used. We are, however, unsure about the applicability in our situation at times, since a large proportion of mothers do not have access to electricity and tap water and cannot afford the formulas.

Placebo armWhen the study started, no conclusive evidence regarding the effect of Vitamin A on vertical transmission was known and therefore it was decided that a placebo group could ethically be included.

Follow up of the trial patientsMost patients included in the study attended their antenatal clinic follow-up appointments. The main follow-up problem experienced was when the patients transferred from the antenatal clinic to the postnatal clinic. By January 1999, 225 patients had delivered and 215 patients should have come for their first postnatal visit, yet only 137 came for their follow-up appointments. Fourteen patients were terminated from the study because their babies died and nineteen were lost to follow-up.

Reasons identified for poor follow up include: Patients moving to new areas. If the baby died, the mother

thought it was unnecessary to continue clinic visits.

Antenatal visits are seen as “routine” visits, but postnatal visits in that frequency are not routine and may require explanations at home.

Not all patients give correct addresses which makes it difficult to find them.

Possible solutionsA non-governmental organisation such as Hospice has been approached to help with the follow-up of patients at their homes, which has met with some success. A minimal fee to cover transport costs is paid for each post delivery visit to try and increase attendance.

ConclusionThe running of a trial of this nature is fraught with problems, the most important being the loss to follow-up. Furthermore, this study highlights the potential problems that may be encountered with the large scale introduction of measures to prevent vertical HIV transmission. The use of non-governmental organisations like Hospice can help with the tracing of patients.

One strength of this project has been good inter-departmental co-operation.

INTERIM ANALYSIS OF EARLY EFFICACY OF VARIOUS SHORT-TERM ADV/3TC COMBINATION REGIMENS IN PREVENTING MOTHER-TO-CHILD TRANSMISSION OF HIV-1: THE PETRA TRIAL

McIntyre JA on behalf of the PETRA Trial Study Team

Following the success of the ACTH 076 ZDV regimen in reducing mother-to-infant transmission of HIV-1, various international and national health agencies initiated a number of clinical trials in developing countries to study antiretroviral regimens that would be applicable, accessible and sustainable in these settings.The PETRA Trial, conducted under the auspices of UNAIDS in South Africa (1 site in Durban and 1 in Johannesburg), Tanzania (1site in Dar es Salaam) and Uganda (2 sites in Kampala), is unique among these studies, because of its large sample size, multinational character, multiplicity of HIV subtypes, use of combination therapy, and inclusion of an intrapartum-only treatment arm. This study will also address efficacy in a

population that is largely breastfeeding. It is an ongoing randomised, double-blind, placebo-controlled trial into which 1798 women have been enrolled. Respective placebo controlled regimens are: a) ZDV/3TC given at week 36 of pregnancy until delivery + intrapartum administration + for one week following delivery (mother + child), b) ZDV/3TC intrapartum + for one week following delivery (mother + child), c) ZDV/3TC intrapartum, d) placebo only.Based on an interim analysis of HIV-1 DNA PCR results at age 6 weeks of 1042 infants, there was a highly significant reduction in HIV-1 transmission for arm A when compared to placebo (RR=0.396; 95% CI: 0.248-0.632; p=0.001) and a trend for arm B. The intrapartum-only arm C was no different from placebo. There was a significant difference in infant mortality rates at 6 weeks between the arms: the lowest mortality being observed in arm A. Interim data on > 1400 infants will be presented, including HIV-1 results in plasma. Data on the long-term efficacy, which may be

influenced by breastfeeding, are not available yet.