5 Finlayson, K. and S. Downe, Why do women not use antenatal services in low- and countries? A meta-synthesis of qualitative studies. PLoS Med, 2013. 10(1): p. e1001373. 6 Solarin, I. and V. Black, "They told me to come back": women's antenatal care booking experience in inner-city Johannesburg. Matern Child Health J, 2013. 17(2): p. 359-67. 7. Barry, O.M., et al., Development of a measure of the patient-provider relationship in antenatal care and its importance in PMTCT. AIDS Care, 2012. 24(6): p. 680-6. income
1 1:256 Reactive Brazil 1:256 Premature, low birth weight, pneumonia cardiorespiratory arrest Yes Unknown 2 1:256 Reactive South Africa No titer Hepatomegaly, sudden death Yes Unknown 3 1:64 Reactive Brazil 1:16 Thrombocytopenia, hepatomegaly No Infected in utero 4 Reactive, no titer performed Not performed Brazil No titer Elevated transaminases, thrombocytopenia, jaundice, sepsis No Infected in utero 5 1:1024 Reactive Brazil 1:64 Fetal distress, neonatal jaundice, anemia No Uninfected 6 Nonreactive Reactive Brazil 1:4 Rash on extremities No Uninfected
Table 1: Infrastructure to support neonatal nurseries in district hospitals in Beds/Infrastructure KZN Norm Compliant Too Many Minimum HC beds set up and ready 2 8 15 16 Wall oxygen points 2 per HC bed 1 per IC bed 2 4 33 Has portable oxygen functioning 1 per nursery 13 NA 26 Suction points 2 per HC bed 1 per IC bed 2 7 30 Portable suction 1 per nursery 31 NA 7* Electrical points 12 per HC bed 1 3 34* Medical air or compressor 1 per nursery 15 24 CPAP machine 1 per nursery 14 25 Wall thermometer 1 per nursery 16 22 *missing data Table 2: Equipment levels in neonatal nurseries in KwaZulu-Natal district hospitals Equipment KZN Norm Compliant Too Many Multifunction monitors 1 per HC bed 7 10 21* BP cuffs (both term and preterm) 12 26 Oxygen blenders 1 per HC bed 1 38 Head boxes 0,5 per O2 point 7 32 Glucometers 1 per cubicle 33 6 Stethoscopes 1 per HC bed 4 35 Infusion pumps 2 per HC bed 4 4 30* Syringe drivers 4 per HC bed 0 38* *missing data Natal
Peak TSB LEVELS Out of 156 jaundiced Duration of admission <200 13 1 to 2 days 136 cases 200-299 48 3 to 4 days 99 cases 300-399 81 5days+ 141(29.6%) cases 400+ 14 OUTCOME Total live births from 2007 to2012 33,602 54 died NND reported by ppip from 2007-2012 443 (NMR 13/100 422 survived When 54 NND in G9&G10 are added 497 NND or NMR 15/1000 LIVE BIRTHS CHANGING PATTERN OF NEONATAL DEATHS IN MADADENI DISTRICT HOSPITAL- A REVIEW OF 1071 DEATHS FS BONDI INTRODUCTION Neonatal (0 to 28 days) mortality is declining globally. Since 1990, neonatal mortality rate (NMR) fell from 33 to 20 per 1000 live births (1). However, in 2013, 2.8 million babies still died in the neonatal period and the proportion of under-five mortality (U5M) deaths during the neonatal period has increased in every region of the world. In South Africa (SA), infants below one month of age account for 40% U5M (2)
2000-2499 37 29 13 5 84 7.8 2500+ 116 93 36 15 260 24.4 Total 474 374 179 44 1,071 100.0 TABLE 2. Year All live births SCBU admissions NND NMR ENMR IHMR 2003 6616 2977 146 22 17 4.9 2004 6870 2658 185 27 13 6.9 7357 2846 143 22 19 5.0 2006 6538 2924 162 25 22 5.5 2007 6713 2908 115 17 17 3.9 2008 6593 790 97 15 14 12.3 2009 6007 544 89 15 12 16.3 2010 5064 590 46 9 7 7.8 2011 4978 707 46 9 7 6.5 2012 4203 663 44 10 6 6.6 TOTAL/average 60,939 17,607 1,071 17.1 13.4 7.5
Figure 3 – Mode of delivery The majority of vacuums were performed in nulliparous women: 71.8%. Another 12.9% were having their second child and the remaining 15% were para 3 or above. Guidelines indicate that the fetus should not be premature if vacuum is to be attempted. The generally accepted weight cut off for this is 2500g. A total of 18 babies (5.6%) were <2500g. This was presumably due to misjudgement of the size of the baby (half were ≥2200g) but this aspect was not analysed further, although it provides an important learning point. The indication for vacuum was not well recorded in the delivery register (only ¼ of the time), but of those, recorded indications were for prolonged second stage, fetal distress or poor maternal effort in a 6:1:1 ratio. Fetal outcomes Initial Apgar scores were ≥8 in 65.1%, 5-7 in 24.1% and <5 in 10.5% of successful deliveries, but this improved markedly to 90.8% ≥8 by 5 minutes, while 7.6% were 5-7 and only 1.3% <5. Of the four cases who had 5-minute Apgars of <5, three resulted in ENNDs. (Three babies who were IUDs but delivered by vacuum were excluded from the Apgar analysis.) The spread of Apgar scores at 1 and 5 minutes differed between practitioners, but all except one had an 80% rate of Apgars ≥8 by 5 minutes. (There were no 5-minute Apgars <5 for this doctor, however.) Further details of this sub-analysis are available but not included here due to space. Figure 4: Apgar scores at 1 minute Figure 5: Apgar score at 5 minutes
9 other significant complications were recorded in the register as having occurred in successful vacuum deliveries: 5 PPH, 3 shoulder dystocia and 1 cephalohaematoma. All had apparently good outcomes. Discussion Although vacuums are by definition high risk deliveries, the overall outcomes of this cohort of patients, delivered by mostly junior generalists in a deeply rural district hospital, are reasonably good and within the range of outcomes reported from elsewhere, including developed countries. The rate of vacuum assisted deliveries is within ranges reported from elsewhere, but is one of the highest rates in South Africa. Comparison with the 2012/2013 Saving Babies report suggests that 7.7% of all vacuums performed at district hospital in South Africa are done at Zithulele, but only 0.6% of the deliveries. With respect to neonatal outcomes, there were no stillbirths. The neonatal mortality rate, NMR, (including failed vacuums but excluding known IUDs) was 11.9 per 1000. As expected this is a bit higher than the overall NMR of 9.3 per 1000 for all babies >1000g in our unit, but significantly more than the 4.3 per 1000 for babies over 2500g in the same period. The NMR is higher than we’d like, but in our setting where relatively junior staff manage challenging labours, we propose that our vacuum rate is a good thing as it saves caesarean sections and their concomitant risks, while maximising fetal outcomes. The large number of practitioners involved – most of whom had performed few or no vacuum deliveries prior to working at Zithulele – shows that skills can be passed on between generalist doctors even in a rural environment. Because this was a register review it is possible that other neonatal complications, such as conjunctival haemorrhage were under diagnosed and or under reported. Maternal outcomes were good, with generally few recorded complications. There is a possibility that this may partly be due to recording omissions. The main complication was maternal perineal injury. There was a relatively high rate of third degree tears