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The 20th Conference on Priorities in Perinatal Care in Southern Africa was held under the auspices of the Department of Obstetrics and Gynaecology, University of Natal and sponsored by Abbott Laboratories SA (Pty) Ltd i Editor's Note: The articles included in this Proceeding were received electronically and have been included in full as submitted by the presenter/author (without editing). Abstracts were included where articles were not submitted. ii INDEX SESSION 1: AUDIT CHANGING PATTERNS IN MATERNAL MORTALITY IN SOUTH AFRICA 1998-2000. National Committee for the Confidential Enquiry into Maternal Deaths 1 SEVERE ACUTE MATERNAL MORBIDITY AND MORTALITY IN THE PRETORIA ACADEMIC COMPLEX: CHANGING PATTERNS OVER 4 YEARS. H Vandecruys 4 SAVING BABIES: A PERINATAL CARE SURVEY OF SOUTH AFRICA 2000. EXECUTIVE SUMMARY. Complied by RC Pattinson for PPIP Users. 8 NEONATAL DEATHS IN SOUTH AFRICA: CAUSES AND SOLUTIONS. DH Greenfield 12 PERINATAL MORTALITY AUDIT IN A RURAL DISTRICT OF KWAZULU-NATAL: FOCUS ON AVOIDABLE DEATHS. NF Moran 15 THE QUALITY OF INTRAPARTUM CARE AT KALAFONG HOSPITAL, GAUTENG PROVINCE. DR Kgoebane 18 AUDIT ON OBSTETRICAL CARE IN THE MATERNITY WARD OF BAMALETE LUTHERAN HOSPITAL, RAMOTSWA, BOTSWANA. R Pfau 20 SITUATION ANALYSIS OF MATERNITY SERVICES IN REGION E IN THE EASTERN CAPE: PRIORITIES TO IMPROVE THE QUALITY OF PERINATAL CARE IN THE REGION. D Jackson 24 A COMPARISON BETWEEN FOUR MIDWIFE OBSTETRIC UNITS IN THE PRETORIA REGION. NT Mabale 27 CLINICAL CAPACITY SKILLS AUDIT (CCA) IN MPUMALANGA PROVINCE. NP Godi 29 RESTRUCTURING OF THE MATERNITY SERVICES IN BLOEMFONTEIN, FREE STATE PROVINCE. MG Schoon 31 THE EFFECT OF RESTRUCTURING OF THE HEALTH CARES SERVICES ON MATERNITY CARE IN BLOEMFONTEIN. MG Schoon 32 ST MARY"S HOSPITAL MARIANNHILL COMMUNITY OUTREACH CENTRE HIV/AIDS HOME BASED NURSING CARE TRAINING FOR VOLUNTEER COMMUNITY HEALTH CARE WORKERS (ONOMPILO). CM Jones 34 i SESSION 2: HEALTH CARE MANAGEMENT AND EDUCATION BETTER BIRTHS INITIATIVE: INITIATING CHANGE IN OBSTETRIC CARE. H Brown 39 PREGRADUATE MIDWIFERY EDUCATION – A NOVEL APPROACH. C van der Westhuizen 43 CARING FOR CARERS: CRITICAL CARE STRESS INCIDENT DEBRIEFING AS A SALUTOGENETIC INTERVENTION FOR HEALTH CARE PROVIDERS AT ST. MARY"S HOSPITAL – MARIANNHILL AND IN THE SOUTH AFRICAN SITUATION. CM Jones 45 NEW ADDITIONS TO PEP. D Woods 53 PPIP VERSION 2 AND USER MANUAL. E Mitha 55 FROM GUIDELINES TO INSTITUTIONAL PROTOCOLS. E Mitha 56 THE PROTECTED DISCLOSURES BILL (ACT). GR Howarth 57 THE USE OF CD-ROMS IN THE TEACHING OF NEONATAL AND OBSTETRICS SKILLS TO MEDICAL STUDENTS. JD Makin 58 THE "HANDS-ON CHILDBIRTH EDUCATION" PROGRAMME R v/d Walt 59 EVALUATION OF THE HANDS-ON-CHILDBIRTH PROGRAMME. CS Dörfling 61 MODEL FOR AN ENRICHMENT PROGRAMME FOR EXCELLENCE IN NURSING. AE Pullen 68 SUPPORT PROGRAMME FOR MATERNAL HEALTH IN KWAZULU-NATAL (KZN) DISTRICT HOSPITALS. NC Mzolo 72 PROCEEDINGS DATABASE: PROCEEDINGS OF THE PRIORITIES IN PERINATAL CARE CONFERENCES (1982-2000). RV Prinsloo 78 COMPARING CURRICULUMS. CH Venter 79 SESSION 3: ANTENATAL CARE THE EFFECT OF AQUATIC EXERCISE DURING PREGNANCY ON FETAL WELLBEING. SJ McDonald 81 THE ACCURACY OF DOPPLER FLOW VELOCIMETRY SCREENING FOR CHRONIC PLACENTAL INSUFFICIENCY IN PATIENTS WITH UNCERTAIN GESTATIONAL AGE. GB Theron 83 ii OUTCOME OF CONSERVATIVE MANAGEMENT OF VERY PRETERM PREMATURE MEMBRANE RUPTURE WITH ROUTINE ANTIBIOTIC USAGE. CJM Stewart 87 THE TRAUMA OF TRANSLATION: THE DILEMMA OF THE PREGNANT WOMAN IN A MULTILINGUAL, MULTICULTURAL HEALTH CARE SYSTEM. CM Jones 90 VISION OF PRIVATE –PUBLIC SECTOR CO-OPERATION IN COMMUNITY OBSTETRICS: THE EFFECT OF INVOLVING PRIVATE PRACTITIONERS ON THE QUALITY OF ANTENATAL CARE OF THE INDIGENT POPULATION OF TEMBISA. KR Mokhondo 98 SONOGRAFIC PLACENTAL GRADING: A NON – INVASIVE PREDICTOR OF LUNG MATURITY. T Vanderheyden 100 PREVALENCE OF CHLAMYDIAL TRACHOMATIS INFECTION IN EARLY PREGNANCY AT KALAFONG HOSPITAL. R Joubert 101 SESSION 4: LOW-BIRTH WEIGHT NEONATES RESPONSE TO A STANDARDISED FEED DURING THE NEONATAL PERIOD: BIRTHWEIGHT AND LENGTH ARE STRONG DETERMINANTS OF GLUCOSE AND INSULIN CONCENTRATIONS. PA Cooper 102 EPIDEMIOLOGY AND RISK FACTORS FOR FETAL ALCOHOL SYNDROME IN THE WESTERN CAPE PROVINCE. D Viljoen 104 INCIDENCE OF RETINOPATHY OF PREMATURITY IN VERY LOW BIRTHWEIGHT INFANTS BORN AT KALAFONG HOSPITAL. BJ Mitchell 108 INCIDENCE OF POSTHAEMORRHAGIC HYDROCEPHALUS IN VERY LOW BIRTH WEIGHT INFANTS BORN AT KALAFONG HOSPITAL. M Engelbrecht 110 NEONATAL HYPOGLYCAEMIA AT KING EDWARD VIII HOSPITAL: A RETROSPECTIVE ANALYSIS. SD Singh 112 INCIDENCE OF HEARING IMPAIRMENT IN VERY LOW BIRTHWEIGHT INFANTS BORN AT KALAFONG HOSPITAL. HEM van der Watt 115 INTRAVENTRICULAR HAEMORRHAGE IN VERY LOW BIRTH WEIGHT INFANTS AT C.H BARAGWANATH HOSPITAL. M Mokhachane 116 UNINTENDED HYPOCARBIA IN VERY LOW BIRTH WEIGHT INFANTS RECEIVING CONVENTIONAL MECHANICAL VENTILATION: CLINICAL CHARACTERISTICS AND LONG-TERM NEURODEVELOPMENTAL OUTCOME. GF Kirsten 118 DETERMINANTS OF PLACENTAL SIZE. D Woods 120 iii SESSION 5: INDUCTION OF LABOUR A RANDOMISED CONTROLLED TRIAL OF LABOUR INDUCTION WITH MISOPROSTOL AND PROSTAGLANDIN F2 GEL. F. Majoko 122 ORAL MISOPROSTOL AND INDUCTION OF LABOUR: A DESCRIPTIVE SURVEY. A Roodt 124 AGGRESSIVE OR EXPECTANT MANAGEMENT OF LABOUR; A RANDOMISED CONTROLLED TRIAL. WPP Mdluli 128 AMNIOTOMY AND INTRAVENOUS OXYTOCIN FOR THIRD TRIMESTER INDUCTION OF LABOUR: A COCHRANE SYSTEMATIC REVIEW. DJ Botha 130 RANDOMISED CONTROL TRIAL TO DETERMINE THE VALUE OF CLINICAL PELVIMETRY AS A PREDICTOR OF VAGINAL DELIVERY IN WOMEN WITH ONE PREVIOUS CAESAREAN SECTION. S Volschenk 132 SESSION 6: LABOUR WATER AS A METHOD OF PAIN RELIEF: A RANDOMISED CONTROLLED TRIAL. M Taha 134 BIRTH ASPHYXIA REVISITED. D Ballot 139 DEATH FROM LABOUR-RELATED ASPHYXIA AND BIRTH TRAUMA – A SCANDAL AT SOUTH AFRICAN HOSPITALS? E Buchmann 142 THE SAFETY, EFFICACY AND PRACTICALITY OF A METHOD OF HEAD COOLING IN INFANTS WITH HYPOXIC ISCHAEMIC ENCEPHALOPATHY. AN INTERIM REPORT. AR Horn 146 A RANDOMISED CLINICAL TRIAL TO DETERMINE THE EFFECT OF BETA-ADRENERGIC BLOCKING WITH PROPRANOLOL ON LABOUR. MG Schoon 151 PAIN RELIEF AND LABOUR COMPANIONSHIP: A PILOT STUDY AT BAMALETE LUTHERAN HOSPITAL, BOTSWANA. R Pfau 153 SESSION 7: KANGAROO MOTHER CARE THE DEVELOPMENT OF AN IMPLEMENTATION WORKBOOK FOR KANGAROO MOTHER CARE (KMC). A-M Bergh 156 INTERMITTENT KANGAROO MOTHER CARE IN A NEONATAL HIGH CARE UNIT. SD Delport 160 iv PREDICTORS OF SURVIVAL FOR NON-VENTILATED INFANTS WEIGHING < 1000GMS. BJ Cory 162 INTENSIVE CARE MANAGEMENT OF THE HIV EXPOSED NEONATE: CLINICAL AND VIROLOGICAL CORRELATES OF NEONATAL OUTCOME (INTERIM ANALYSIS). M Adhikari 164 IS THE TREATMENT OF BABIES WITH OVERT CONGENITAL SYPHILIS WHO NEED ICU CARE WARRANTED? CH Pieper 167 BUILDING AND USING NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE MACHINES ON SITE, AT GROOTE SCHUUR HOSPITAL, CAPE TOWN. A Horn 169 EVALUATION OF A TRAINING WORKSHOP IN KANGAROO MOTHER CARE (KMC). A-M Bergh 171 CONTINUOUS KANGAROO MOTHER CARE AT A SECONDARY HOSPITAL IN THE WESTERN CAPE. M Franken 175 AUDIT OF A KANGAROO MOTHER CARE UNIT FROM AUGUST 1999 - OCTOBER 2000. E van Rooyen 177 NURSING IMPLEMENTATION OF KANGAROO MOTHER CARE AT KALAFONG HOSPITAL. M Lekalakala ` 181 SESSION 8: HIV AND BREASTFEEDING THE SAINT TRIAL: NEVIRAPINE (NVP) VERSUS ZIDOVUDINE (ZDV) + LAMIVUDINE (3TC) IN PREVENTION OF PERIPARTUM HIV TRANSMISSION. L Thomas 183 EVALUATION OF SAFETY OF TWO SIMPLE REGIMENS FOR PREVENTION OF MOTHER TO CHILD TRANSMISSION (MTCT) OF HIV INFECTION 'NEVIRAPINE (NVP) VS LAMIVUDINE (3TC)+ZIDOVUDINE (ZDV)' USED IN A RANDOMIZED CLINICAL TRIAL (THE SAINT STUDY). G Gray 185 INFLUENCE OF FEEDING MODE ON MOTHER TO CHILD TRANSMISSION OF HIV-1. A Coutsoudis 187 DETERMINATION OF THE EFFECTIVENESS OF INACTIVATION OF HUMAN IMMUNODEFICIENCY VIRUS BY PRETORIA PASTEURISATION. BS Jeffery 189 HIV SEROPREVALENCE AND RAPID TESTING IN UNBOOKED PREGNANT AFRICAN WOMAN. JA Matambo 192 NEVIRAPINE FOR PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV-1: IS IT DELIVERED EFFECTIVELY IN ROUTINE CARE? K Bolton 194 v PRELIMINARY RESULTS OF A DOUBLE BLIND RANDOMISED CONTROLLED TRIAL TESTING THE EFFECT OF VITAMIN A IN MOTHER TO CHILD TRANSMISSION OF HIV- 1. WJ Steinberg 196 CONSENT FOR PARTICIPATION IN THE BLOEMFONTEIN VITAMIN A TRIAL: HOW INFORMED AND VOLUNTARY? WJ Steinberg 199 MOTHER TO CHILD TRANSMISSION OF HIV – A PILOT COMMUNITY PROJECT OF THE PROVINCIAL ADMINISTRATION OF THE WESTERN CAPE (PAWC). E Coetzee 201 BACTERIAL CONTAMINATION OF EXPRESSED BREAST MILK. S.D.Delport 203 SESSION 9: HIGH RISK OBSTETRICS TRADITIONAL HERBAL MEDICATION AND OTHER SELF MEDICATION IN PREGNANCY IN THE EASTERN CAPE. L Mangesi 205 DELIVERY OF PATIENTS WITH EARLY ONSET, SEVERE PRE-ECLAMPSIA. DR Hall 209 PRE-ECLAMPSIA AND DIETARY CALCIUM INTAKE IN GAUTENG AND EASTERN CAPE. GJ Hofmeyr 211 REVERSED END DIASTOLIC FLOW VELOCITY IN VIABLE FETUSES: IS THERE TIME TO WAIT FOR THE EFFECT OF CORTICOSTEROIDS BEFORE DELIVERY? JM du Plessis 215 POOR BASELINE VARIABILITY IN FETAL DISTRESS. FACT OR FICTION ? J van Waart 217 SESSION 10: NEONATAL SUPPLEMENTATION FEEDING PRACTICES OF MOTHERS OF FOUR TO SIX WEEK OLD INFANTS. P Baloyi 222 ENDEMIC NECROTIZING ENTEROCOLITIS: THE IMPACT OF AN AGGRESSIVE BREAST FEEDING PROGRAM. GF Kirsten 224 EFFECT OF A FOOD SUPPLEMENT ON GROWTH DURING THE FIRST TWO YEARS OF LIFE. SD Delport 227 A COMPARISON BETWEEN DAILY AND BI-WEEKLY IRON SUPPLEMENTATION IN PRETERM INFANTS. M Mokhachane 229 INDICATIONS FOR EFFECTIVE USE OF TRIMETHOPRIM – SULPHAMETHOXAZOLE IN HIV EXPOSED INFANTS. K Naidoo 231 vi SESSION 1: AUDIT CHANGING PATTERNS IN MATERNAL MORTALITY IN SOUTH AFRICA 1998-2000 National Committee for the Confidential Enquiry into Maternal Deaths Aim This interim report summarises the changing pattern of maternal deaths in South Africa between 1998 and 2000. It is not intended to report on avoidable factors, substandard care or missed opportunities. Such a comprehensive report was provided in the first Saving Mothers report of 1998, and will be given in subsequent triennial reports, under the title of Saving Mothers: Report on Confidential Enquiries into Maternal Deaths in South Africa (1999 – 2001, etc). Method The report covers the maternal deaths that were reported to the NCCEMD secretariat by 15th March 2001, and that occurred between 1998 and 2000. The definitions used in the Saving Mothers report were used in this report. Results In 2000, there were 940 maternal deaths reported (150 more than in 1999 and 264 more than in 1998) and in 684 (73%) cases the Maternal Death Notification Form and Assessors Report had been received and were entered on the database. There were 402 direct maternal deaths, 264 indirect maternal deaths, 22 unknown causes of maternal deaths and 22 fortuitous deaths. There has been a significant reduction in the proportion of direct causes of maternal deaths (1998-63.3% down to 1999- 59.1% and 2000-58.5%) with a concomitant increase in the proportion of indirect causes of death (1998-33.6% up to 1999-37.5% and 2000- 38.6%). This is largely due to the increased proportion of deaths due to non-pregnancy-related sepsis, mainly AIDS. 1 The "big 5" causes of maternal death in 2000 were non-pregnancy related sepsis (29.7%, mainly deaths due to AIDS), complications of hypertension in pregnancy (22.7%), obstetric haemorrhage (13.5%), pregnancy related sepsis (12.4%, includes septic abortions and puerperal sepsis) and pre-existing maternal disease (8.9%, mainly cardiac disease). These five account for 87.2% of maternal deaths. There has been a significant decline in the number of women dying as a result of complications of an abortion (1998 – 32 cases, 5.7% of all maternal deaths, 1999 – 37 cases, 5.2% and 2000 – 26 cases, 3.9%). The most common cause of maternal deaths in all levels of care was non-pregnancy related sepsis, (level 1 - 27.5%, level 2 - 30.8% and level 3 - 31.2%). Complications of hypertension remain the commonest cause of direct maternal deaths in level 2 and 3 hospitals (44.6% and 46.5% respectively) with obstetric haemorrhage being the commonest direct cause in level 1 institutions (29.7%). Deaths due to complications of anaesthesia are the third most common cause of death at this level. The proportion of deaths occurring in the level 1 institution"s has remained constant at between 27.1% and 28.3% of all maternal deaths. Unfortunately the rate of deaths per 100 000 births cannot be calculated as the number of births per level of care is not known. Only 38% of maternal deaths had HIV testing and 78% of these women were HIV infected. In the category non-pregnancy related sepsis 22% of these maternal deaths did not have HIV testing, including those with pneumonia, tuberculosis and meningitis. Thus, the 131 women reported to have died due to AIDS is an underestimation. A woman was only classified as having AIDS if she complied with the standard definitions for AIDS. All women dying due to septic abortions, whose HIV status was tested, were HIV infected, and 73% of women dying due to puerperal sepsis that were tested were HIV infected. Conclusions There has been continued improvement in reporting of maternal deaths during 2000, but the time taken from notification to the NCCEMD receiving the reports remains a 2 point of concern. In 2000 there has probably been a real increase in the number of maternal deaths in South Africa. The impact of the AIDS epidemic is again clearly demonstrated. AIDS is the commonest cause of maternal death at all levels of care in South Africa and HIV infected women account for very high proportions of women with infectious complications like puerperal sepsis and septic abortions. Complications of hypertension, obstetric haemorrhage and pregnancy related sepsis remain the major direct causes of maternal death. Anaesthetic complications are the third most common cause of death at level 1 institutions. There has been a decline in the number of deaths due to abortion. The lack of decline in the proportion of deaths in level 1 institutions is a cause for concern and may indicate the poor functioning of those institutions or of the referral system. Recommendations Policy guidelines are available for managing hypertension in pregnancy, obstetric haemorrhage, pregnancy related sepsis, vaginal birth after caesarean section and some aspects of HIV/AIDS. These must be widely distributed and implemented by the institutions. An investigation into the giving of anaesthetics at level 1 institutions should be performed. Testing for HIV must be expanded to adequately describe the impact of HIV infection on maternal deaths. Establishing the number of births and at what level they occur is a priority as this will allow for calculation of a national maternal mortality ratio and for level specific mortality ratios. This would indicate the areas of concern more specifically as rates could then be calculated. The full report is available from National Department of Health, Maternal, Child and Women"s Health Directorate, Pretoria 3 SEVERE ACUTE MATERNAL MORBIDITY AND MORTALITY IN THE PRETORIA ACADEMIC COMPLEX: CHANGING PATTERNS OVER 4 YEARS H Vandecruys, RC Pattinson, AP Macdonald, GD Mantel* MRC Maternal and Infant Care Strategies Research Unit, O&G Department, University of Pretoria * Department of Obstetrics and Gynaecology, University of Natal, King Edward VIII Hospital, Durban, South Africa Introduction An audit of severe acute maternal morbidity ("near miss") and maternal mortality was conducted in the Pretoria Academic Complex for the year 2000 and the findings compared with a similar study performed over two years between 1997-9. The aim of this study was to track changing patterns of severe acute maternal morbidity and maternal mortality in the Academic Complex of Pretoria. By performing this audit, priorities for future interventions in the Pretoria Academic Complex can be identified and acted on. Methods The Pretoria Academic Complex serves comprises 4 hospitals, two of which receive tertiary referrals from outside the Gauteng Province. SAMMs and maternal deaths were identified at daily audit meetings and a audit form was completed for all cases fulfilling the definition of "near misses". The audit was performed from 1.01.2000 to 31.12.2000. The data were compared with the data obtained from the original two-year audit from the Pretoria Academic Complex (1.02.1997-31.01.1999). The definitions for primary obstetric causes are the same as those used for the confidential enquiry into maternal deaths in South Africa. The mortality index is introduced. The mortality index is the number of maternal deaths / SAMMs + maternal deaths and expressed as a percentage. It reflects the proportion of women who present as a SAMM and subsequently dies. 4 Results The total number of births in the Pretoria Academic Complex in the first 2-year period was 26152 and for the year 2000 was 13854 births. The total number of SAMMs and maternal deaths for 1997-1999 was 364 (305 SAMMs and 59 maternal deaths) and for the year 2000 was 147 (121 SAMMs and 26 maternal deaths). The data is expressed in rates per 100 000 births. The referrals from outside Pretoria significantly declined from 105 cases per year in 1997-9 to 48 cases for 2000 (p<0.05). The reduction in referrals was most marked from the Highveld Region. This drop has coincided with the upgrading of Witbank Hospital as a referral hospital for the Highveld Region A comparison of the most common primary obstetric causes of SAMMs and maternal mortality for all cases and for Pretoria Region alone is shown in Table 1. Table 1. Comparison of changing rates of primary obstetric causes of SAMM and MD (rate/100 000 births) Cause 1997-9 2000 P All cases Abortion 268 94 <0.001 Hypertension 382 282 NS Postpartum haemorrhage 168 166 NS Pregnancy related sepsis 65 79 NS Non-pregnancy related sepsis 61 58 NS Pretoria Region Abortion 152 87 = 0.1 Hypertension 84 115 NS Postpartum haemorrhage 96 140 NS Pregnancy related sepsis 15 50 =0.08 Non-pregnancy related sepsis 23 58 NS There has been a drop in abortion complications in both SAMMs and maternal mortality. However, there is a trend to an increase in complications due to hypertension, haemorrhage and sepsis (both pregnancy related and non-pregnancy related). 5 The number of Termination of Pregnancies (TOPs) in the public service in the Pretoria Health Region in 1997-1999 was 1182 per year. In the year 2000, there were 1129 TOP"s in the public service, and a further 1429 performed in the private sector by the Marie Stopes clinic, from which 22% were second trimester TOP"s. This private clinic was not functioning in 1997-9. The increase in the number of TOPs performed correlates with the drop in severe morbidity and mortality related to abortions, and is probably causally related. The mortality index is introduced. A high mortality index is shown for pulmonary embolism and non-pregnancy related sepsis. The high rate of maternal deaths due to non-pregnancy related sepsis reflects AIDS. The mortality index for non- pregnancy related sepsis was 50% in 1997-9 and for 2000 was 75%. Of note is the low mortality index for obstetric haemorrhage (antepartum plus postpartum haemorrhage) of 2.2% in 1997-9 and 3.7% in 2000. This indicates that although obstetric haemorrhage is still a common cause of SAMMs it is not a common cause of maternal death in the Pretoria Region. This is probably due to the availability of resources, expertise and good transport systems in Pretoria. Conclusions This study firstly illustrates that audit of severe acute maternal morbidity and maternal mortality is feasible, and the inclusion of SAMMS with maternal mortality allows for more frequent meaningful audits of maternal care to be performed. This allows for early detection of trends and this in turn allows for timeous changes in health strategies. The initial audit report highlighted two major problems. The first was for emergency obstetric care to be decentralised and the second was that the provision of TOP services in Pretoria needed to be expanded, especially for second trimester terminations of pregnancy. 6 The first problem has been effectively addressed by Mpumalanga Province upgrading Witbank Hospital to a Regional Hospital and diverting the obstetric emergencies from the Province first to Witbank Hospital. The second problem had an unexpected solution, namely that the need for easy access to TOP was provided for by a private clinic, rather than Gauteng Province improving their provision of TOP services. This is especially evident in the case of second trimester TOPs. The 2000 audit has highlighted that severe complications of hypertension in pregnancy, obstetric haemorrhage, pregnancy related sepsis and non-pregnancy related sepsis are increasing. The increase in infectious complications can be explained by the increase in prevalence of HIV infected pregnant women. The severe complications due to hypertension and obstetric haemorrhage are a cause for concern. The solutions to these factors could be the implementation of new national guidelines for managing hypertension and obstetric haemorrhage at all clinics and hospitals within the Pretoria Academic Complex. The mortality index is introduced for the first time and can be used as an indicator of the standard of care within the Pretoria Academic Complex. 7 SAVING BABIES: A PERINATAL CARE SURVEY OF SOUTH AFRICA 2000 EXECUTIVE SUMMARY Complied by RC Pattinson for PPIP Users. MRC Maternal and Infant Health Care Strategies Research Unit Aim To estimate a national perinatal mortality rate (PNMR) and to identify the major causes of perinatal mortality and related avoidable factors, missed opportunities and substandard care in South Africa. Setting All Provinces in South Africa gave input, where possible, into the PNMR in their particular Provinces. Furthermore, 27 state hospitals throughout South Africa representing metropolitan areas, cities and towns, and rural areas were the sentinel sites for the documentation of the causes of perinatal death and the avoidable factors associated with the deaths. Method The provincial Health Information Sections and the Maternal, Child and Women"s Health units of the provinces presented their available data. Users of the Perinatal Problem Identification Programme (PPIP) amalgamated their data to provide descriptive data on the causes of perinatal death and the avoidable factors, missed opportunities and substandard care in South Africa. The PPIP users were the sentinel sites. The PPIP sentinel sites were grouped into metropolitan, city and town, and rural areas. The metropolitan grouping reflects urban areas and a fully functioning tiered health care system with ready access to tertiary care. The city and town grouping reflects functioning primary and secondary levels of care, with limited access to tertiary care, and the rural grouping reflects primary care, with less accessibility to secondary and tertiary care. 8 Results Most of the provinces did not have effectively functioning data collection systems at the time of the workshop and were unable to provide accurate data for their whole province regarding births and perinatal deaths within state institutions. However, accurate data was available for Gauteng and the Western Cape. The PNMR for Gauteng was reported as being 32.1/1000 births and for Western Cape reported as 18.4/1000 births. The delegates at the workshop agreed to a minimal data set and the perinatal care indices to be used to describe perinatal care. These will be discussed with the National Health Information Systems of South Africa for incorporation into the national minimum data collection set. At the 27 PPIP sentinel sites a total of 4 155 perinatal deaths with a birth weight of 1000g or more were reported from 123 508 births. The perinatal mortality rates for the metropolitan, city and town, and rural groupings were 30.0, 39.4 and 30.9/1000 births respectively. The neonatal death rate was highest in the city and town groups (14.8/1000 live births) followed by the rural group (12.1/1000 live births) and metropolitan group (7.6/1000 live births). The low birth weight rate was highest in the metropolitan group (18.4%), followed by the city and town group (17.0%) and the rural group (12.5%). In all groups the primary obstetric cause of intrauterine death was unexplained in a significant proportion of cases. The most common primary cause of perinatal death in the rural group was intrapartum asphyxia and birth trauma (7.13/1000 births) followed by spontaneous preterm delivery (4.88/1000 births). The most common primary cause of death in the city and town group was spontaneous preterm delivery (6.07/1000 births) followed by intrapartum asphyxia and birth trauma (5.27/1000 births). The metropolitan group"s most common primary causes were antepartum haemorrhage (7.08/1000 births) and complications of hypertension in pregnancy (4.31/1000 births). Complications of prematurity and hypoxia were the most common final neonatal causes of death in all groups. 9 The presence or absence of avoidable factors was documented in 2 733 cases of perinatal death. Patient related avoidable factors were reported to be present in 35.9% of perinatal deaths, followed by health worker related (29.1%) and administrative (7.4%) avoidable factors. There was insufficient information to assess avoidable factors in 5.4% of cases. The most common patient related avoidable factors was no antenatal care, late initiation of antenatal care or infrequent attendance at antenatal clinic (present in 539 cases – 20%of all cases); delays in seeking medical attention during labour (150 occasions – 5% of all cases); and an inappropriate response by pregnant women to reduced fetal movements (133 occasions – 5% of all cases). The most common health worker related avoidable factors were inappropriate responses by health workers to problems identified during antenatal care (226 occasions – 10% of cases of perinatal deaths whose mothers attended antenatal care); problems of monitoring the fetus during labour (172 occasions – denominator for women in labour with a live baby not available); and delays by health workers in referring patients or calling for assistance (99 occasions – 4% of all cases). Lack of transport was the most common administrative factor recorded specifically in 72 occasions but large proportion of patients" delays in seeking medical help during labour might have been due to transport problems. Conclusions The survey demonstrated some deficiencies in the data collection system. To improve the process of achieving a comprehensive perinatal care survey, a minimal data set for each Province needs to be implemented. To improve the quality of data on the causes of perinatal deaths and avoidable factors data more PPIP sentinel sites need to be established. However, the current data is sufficient to state that the PNMR in South Africa is probably in the order of 40/1000 births, and some readily remedial problems have been identified. These are in the structure of antenatal care, management of labour, resuscitation of the asphyxiated neonate and care of the premature neonate. Focusing attention on these readily remedial priority problems, by ensuring that 10 equipment, protocols and trained health workers are always available and by specifically introducing kangaroo mother care for the care of the premature infants, makes the reduction of perinatal mortality in South Africa feasible and inexpensive. Recommendations Adopt the proposed minimal data set and tool Establish the process for collection of the minimum data set in each province Establish more PPIP sentinel sites Ensure each site conducting births has the necessary equipment and protocols and that the staff are appropriately trained to manage labour and are especially trained in the use of the partogram Ensure each site conducting births has the necessary equipment and protocols and appropriately trained staff to manage asphyxiated neonates Ensure each site caring for premature infants has the necessary equipment and protocols and that the staff are appropriately trained in kangaroo mother care Ensure each site performing antenatal care has protocols in place for where to and when to refer patients and the staff are appropriately trained therein Move to a system where the time and point at which the woman confirms she is pregnant also becomes the woman"s first antenatal visit where she can be classified according to risk and where her further antenatal care is specifically planned The full report is available from the MRC Maternal and Infant Health Care Strategies Research Unit, Kalafong Hospital, Private Bag X396, Pretoria 0001. E-mail firstname.lastname@example.com. It is also available in stiffies and CD from the above address. The report can also be obtained from the Health Systems Trust webpage. 11 NEONATAL DEATHS IN SOUTH AFRICA: CAUSES AND SOLUTIONS *RC Pattinson, +DH Greenfield * MRC Maternal and Infant Care Strategies Unit, University of Pretoria + Neonatal Medicine, Department of Paediatrics, UCT To date, there has been no national survey of perinatal deaths in South Africa. Most of the available data comes from units attached to academic hospitals. Methods Sentinel sites were identified in South Africa where the Perinatal Problem Identificaton Programme (PPIP) was being used to audit perinatal deaths. These sites represented rural, urban and metropolitan areas. The collected data was collated at the MRC Maternal and Infant Strategies Unit, and the combined data are presented. The data for this presentation is for the year 1999 and is for neonatal deaths of infants with a birth weight =/> 1000g. The neonatal mortality rates, and causes of death are presented. Results Perinatal deaths Metropolitan Urban Rural Total Total births 58230 45327 19951 123508 Live births 56919 44196 19572 120687 SBs 1311 1131 379 1821 NNDs 430 654 237 1321 Total deaths 1741 1785 616 4142 12 Neonatal Deaths Metropolitan Urban Rural Total NND Rate / 1000 7.6 14.8 12.1 10.9 NNDR (1000 - 105.8 375.5 1499g) NNDR (1500 - 31.9 171.2 1999g) NNDR (2000 - 9.9 57.2 2499g) NNDR (>2499g) 3.4 10.3 SB : NND Ratio 3.1 : 1 1.7 : 1 1.6 : 1 2.1 : 1 Neonatal causes of Death Metro Urban Rural Total % of NND % of NND % of NND % of NND deaths rate deaths rate deaths rate deaths rate Asphyxia 31.9 2.4 29.1 4.2 41.5 4.9 32.3 3.4 Premature 26.5 2 41.8 6.1 25 3 33.2 3.5 related Other 41.6 3.1 29.1 4.2 33.5 4 34.4 3.6 Discussion The majority (65%) of neonatal deaths are related to birth asphyxia and preterm delivery. Preterm delivery is the most important problem in the towns and cities, and asphyxia the most important problem in the rural areas, but still a significant problem in the towns and cities. The low neonatal death rate in the metropolitan areas is probably related to the better quality of neonatal care, and this may also be reflected in the SB:NND ratio. Strategies to improve the neonatal mortality are: 1. Prevention - particularly improving monitoring in labour. - ensuring appropriate interventions 2. Resuscitation of the newborn. Everyone who does deliveries needs to be competent in at least bag-and-face mask ventilation. 13 Dealing with the preterm (or sick) baby. The essentials of care are: Maintaining the baby"s temperature; Maintaining normal blood glucose levels; Ensuring adequate oxygenation. Where possible, a Gram stain and bubbles test on a gastric aspirate taken within the first hour after delivery can give useful information. The use of aminophyllin A proper care plan for the baby needs to be established, and monitored. The writing of good case notes and maintaining observation charts is essential. Kangaroo Mother Care is probably the single most important intervention for these small babies. These strategies should be backed up by appropriate and ongoing education, audit and support for staff, particularly those working at a primary care and district hospital level. Conclusions The reason for a large proportion of these babies dying appears to be that simple measures are not being done. Getting the basics right will make a significant difference to the neonatal mortality. Kangaroo Mother Care can be expected to make a difference to both morbidity and mortality in small and preterm infants. 14 PERINATAL MORTALITY AUDIT IN A RURAL DISTRICT OF KWAZULU- NATAL: FOCUS ON AVOIDABLE DEATHS NF Moran Department of Obstetrics and Gynaecology, Nelson R. Mandela School of Medicine, University of Natal, Durban. Introduction A prospective perinatal mortality audit was conducted in the Hlabisa District during 1996. The obstetric service was based at Hlabisa hospital, a 450-bed district hospital in rural KwaZulu-Natal. The hospital was staffed by eight doctors, one of whom (the author) acted as the maternity services medical officer. There were three midwives at the hospital with a diploma in advanced midwifery. There were eight midwife-run satellite clinics in the district, which conducted deliveries, but referred complicated cases to the hospital. There were 20 mobile clinic points. This paper describes how the audit was used as a tool to improve obstetric care in the District, by identifying the avoidable deaths, and analysing their causes. Methods A perinatal death was defined as a stillbirth or early neonatal death, weighing 1kg. Deaths occurring during 1996 were identified by daily review of the hospital labour ward and neonatal nursery records. Deaths occurring at the satellite clinics were sometimes only identified at the time of the monthly review of clinic statistics. Upon identification, each death was immediately reviewed by the author, together with the senior midwife on duty, and details were recorded. The details of each case were discussed with the staff involved as well as with the patient. Deaths were either labelled as "avoidable" or not. As proposed by Wilkinson, an avoidable death was defined as one which was clearly due to an error or omission on the part of a member of the health care team. In other words, if the error or omission had not occurred, then, in all likelihood, the death would not have occurred. Deaths due to patient factors or lack of facilities (e.g. transport) were not included. Causes of death were also noted. 15 Results Total deliveries 4869 Hospital deliveries 2984 Clinic deliveries 1730 Babies born before arrival at health facility 155 Twins 65 Triplets 2 Caesarean sections 705 (15%) Peinatal deaths 149 Perinatal mortality rate (PNMR) 30.6 per 1000 deliveries Avoidable deaths 23 (15% of all deaths) Avoidable PNMR 4.7 per 1000 Causes of Death (total 149 deaths) No % Labour-related asphyxia 21 14 1st stage-related 8 5 2nd stage-related 13 9 Unknown (including unexplained IUD) 19 13 Abruptio placentae 18 12 Inadequate information/documentation 16 11 Preterm labour 15 10 Intra-uterine growth restriction (IUGR) 9 6 Eclampsia 7 5 Hypertension in pregnancy 6 4 Diabetes in pregnancy 6 4 Syphilis 5 3 Congenital anomalies 5 3 Chorioamnionitis 5 3 Cord prolapse 4 3 Placenta praevia 3 2 Meconium aspiration 2 1 Ruptured uterus 2 1 Other 6 4 Causes of Avoidable Death (total 23 deaths) No % Labour-related asphyxia 11 48 1st stage-related 6 26 2nd stage-related 5 22 IUGR 4 17 There were no other recurrent causes of avoidable death. 16 Discussion The avoidable PNMR is a more useful statistic than the overall PNMR, as it is a much better reflection of the standard of obstetric and perinatal care being provided by the service. I recommend that the avoidable PNMR be monitored from year to year to assess any change in the standard of obstetric care being provided. Analysing the causes of avoidable deaths over a period of a year highlighted deficiencies in particular areas of the obstetric care provided, namely the management of labour, and the diagnosis and management of IUGR. These areas were then targeted as priority areas where intervention was likely to reduce the avoidable PNMR. The intervention measures immediately implemented were a review of the existing hospital and clinic protocols for the management of labour, and subsequent to that, in-service teaching sessions for both medical officers and midwives, specifically addressing the management of labour and the diagnosis and management of IUGR. The effects of these interventions were not assessed in this study. Although certain types of patient behaviour, as well as lack of facilities such as transport, do cause perinatal deaths, such factors are often a reflection of the poor socio-economic status of the local community. It is often beyond the scope of the average maternity service health worker to make an impact on such factors. The most practical way in which he or she can influence the perinatal mortality rate is by improving the local standard of obstetric care. This is why the audit described above concentrated on avoidable factors related to the obstetric care provided by the midwives and doctors. Conclusion Monitoring of the avoidable PNMR is recommended as a simple, but efficient method of evaluating the standard of obstetric care. By establishing the common causes of avoidable deaths, interventions aimed at improving the standard of obstetric care can be appropriately chosen. 17 THE QUALITY OF INTRAPARTUM CARE AT KALAFONG HOSPITAL, GAUTENG PROVINCE DR Kgoebane, RC Pattinson, GD Mantel MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria and Kalafong Hospital Introduction This is the first audit done on the standard of intrapartum care of women delivering at Kalafong Maternity Unit. The partograph as a legal document designed for the management of labour was used as a tool to audit the quality of care. In this study, the following factors were reviewed: Maternal and fetal condition and the progress of labour. Objective To determine the standard of intrapartum care by analysing the completion of the partograph. To develop the intrapartum audit as a tool for the evaluation of intrapartum care. Methods A prospective study was undertaken. There were 100 consecutive partographs of women who delivered at Kalafong Hospital were collected from April – June 1999. This included low and high risk patients. Results to be presented at Priorities. Discussion The results of poor or inappropriate management of intrapartum care could possibly be related to the following factors: Administrative Staff – Medical/Nursing 18 Lack of equipment e.g. CTG, IVACS etc. Personnel Demotivation Lack of morale Lack of knowledge Poor salaries Ward busy or staff lazy Increased number of patients Inflow of referrals from other hospital. Conclusions The audit has been completed, results obtained, feedback given and possible causes for the poor completion of the partograph identified. A further audit needs to be undertaken and compared to this study in order to attain a higher quality of care in our hospital. 19 AUDIT ON OBSTETRICAL CARE IN THE MATERNITY WARD OF BAMALETE LUTHERAN HOSPITAL, RAMOTSWA, BOTSWANA R Pfau Bamalte Lutheran Hospital, Ramotswa Introduction Accurate and comprehensive obstetrical data is essential for good obstetrical practice. Regular auditing has been shown to be an easy and effective measure to improve obstetrical practice. A major reduction in perinatal mortality was achieved in several institutions by the introduction of regular auditing and feed back of the information to the health care workers. In Bamalete Lutheran Hospital so far only very basic obstetrical data is collected. This is in contrast to the otherwise progressive approach towards obstetrical practice. On a national level major obstetrical data is also lacking. The objectives of the study were to determine a patient profile of women admitted to BLH maternity ward, to determine the use of antenatal care services, to identify the causes for hospital admission during the antenatal period, to assess the delivery services and to collect the major data of the delivered babies. Methods The study was done as a descriptive study in form of an audit. During the study period from 1.4.1999-31.12.1999 a data capture sheet was filled for all women admitted to the BLH maternity ward. In total 923 patients" files and especially the motherhood booklets were analysed. The data sheets were filled by doctors and midwives in two or three steps. Each data entry was at the same time a control checking for the previous data entry. A system of quality control was used to maintain accurate data entry. A pilot study was used to test the data sheet and general acceptance of the study. 20 Results From the 923 data sheets 83,4% were filled completely, 12,1% had minor data gaps and in only 4.4% major parts of information were missing. The women admitted to the maternity ward had a mean age of 26,8 years, with the youngest being 15 years and the oldest 53 years. The teenage (< 19 years) pregnancy rate was 13,9%. High maternal age (> 35 years) was present in 12,1% of patients. The mean gravidity was 2,5, the highest was a gravida 12. 36,6% were primigravidae, 13,5% were grand multigravidae (G >5). The distribution of parity was matching the gravidity. The abortion frequency was 6,9%. 18,8% of the women admitted were admitted before. The majority hereof (71,8%) had one previous admission. The mean gestational age at booking was 20,6 weeks. The corrected figure of patients who did not book for antenatal care at all was 4,3%. 57,4% booked up to 20 weeks, 33,5% between 21 and 28 weeks and 9,1% after 28 weeks. The mean gestational age on admission was 37 weeks. Only 7,5% of the patients were admitted at 28 weeks or less. 8,9% were admitted at 26-34 weeks and 83,6% after 34 weeks. The mean for the number of antenatal visits was 8. 25,2% had only 0-5 antenatal visits. The most frequent diagnose on admission was labour, followed by pregnancy induced hypertension and lower abdominal pain. Summarized into symptom complexes the main problem on admission was labour followed by obstetrical problems and hypertensive disease. On discharge the main diagnose was delivery, then urinary tract infection, followed by pregnancy induced hypertension and false labour. Summarized into symptom complexes delivery is followed by infection and obstetrical problems. Hypertensive disease was present in 5% of all patients, 10,7% were on antihypertensive treatment during labour. 12% of all patients were treated with an antibiotic. A total of 694 deliveries was analysed. In 82,7% a normal vaginal delivery took place, the cesarean section rate was 11,8%. The rate of vaginal breech deliveries was 0,9 %, vacuum deliveries were done in 2,4% of patients. The most frequent indication for operative delivery was cephalo-pelvic disproportion, followed by fetal distress and poor maternal effort. On 34 patients a tuballigation was done post partum (= 4,9% of all deliveries). The mean age of the TL patients was 34 years, the mean gravidity was 4,6. 21 From the total of 694 deliveries only 25,1% got pain relief intrapartum. When Pethidine and Aterax was given, the mean age was 25 years, 54% were primigravidae. 11% of the deliveries were induced, 7,3% hereof with Oxytocin and 3,2% with Prostaglandin tablets. The main indication for induction of labour was postmaturity followed by pre-labour rupture of membranes and pre-eclampsia. In 28,4% of patients labour was augmented with oxytocin. The episiotomy rate was 30,7%. Postpartum haemorrhage was present in 4,5% of patients. In 16,7% labour was complicated by meconium stained liquor. The mean birthweight was 3055 gram. 2,4% of the babies were below 1000 gram.11,9% of the babies had a weight of 1050-2500 gram. 2,9% were above 4000 gram. Low APGAR < 5 was present in 5,2% at 1 minute, 3,5% at 5 minutes and 2,7% at 10 minutes. The mean maturity score at birth was 38 weeks. 2,9% had a score of 34 weeks or below. A total of 16 babies had congenital abnormalities, 2 major (Down"s syndrome, cleft palate) and 14 minor abnormalities. 25% of the babies were admitted. Discussion The data collected matched with the other data collected in the hospital. The study identified the most common problems which led to admission. It clearly showed that BLH maternity unit was delivery oriented. Apart from delivery, hypertensive disease, obstetrical problems and infection were the main problems in the ward. The study described a patient profile with a high rate of teenage pregnancy and a high rate of women with high maternal age. Considering the high percentage of grand multigravidae, the need for better family planning services became obvious. Pain relief seemed to be given inadequately. Especially the young primigravidae were not sufficiently covered. The frequency of augmentation of labour is unexpectedly high. This needs further research. The data showed that routine episiotomies were not done. Unfortunately amnioinfusion was not carried out in cases of meconium stained liquor. The maturity score and the birthweight analysis matched well. 22 Conclusions/recommendations The objectives of the study were achieved. The study revealed data which covers the whole spectrum of obstetrical care in BLH maternity unit. This data can now be compared with national and international data. The data should be disseminated widely to encourage other facilities to join the auditing process. The data is also suitable to guide resource allocation, in-service training, teaching, health education and promotion. The main topics which should be addressed are: Avoiding teenage pregnancy, avoiding non-booking or late booking, family planning, tubal ligation, hypertensive disease in pregnancy and infection. The information should be disseminated in the BLH-School of Nursing, the local council and the Ministry of Health. 23 SITUATION ANALYSIS OF MATERNITY SERVICES IN REGION E IN THE EASTERN CAPE: PRIORITIES TO IMPROVE THE QUALITY OF PERINATAL CARE IN THE REGION D Jackson, W Hall, D McCoy, P Ntlangula, S Masilela, S Yose, H van C de Groot Public Health Programme, University of the Western Cape; ISDS, Health Systems Trust; Department of Health, Eastern Cape Province; Department of Obstetrics and Gynaecology, University of Cape Town. Introduction The objective of this study was to identify the current status of maternity services in Region E in the Eastern Cape Province, and to establish priorities for improving perinatal care in the region. Method Participatory situation analysis methodology including the following components of maternity care in the region: perinatal statistics (deliveries, Caesarean section, maternal mortality, fetal death, neonatal death, low birth weight, perinatal care index); staffing, facilities, equipment, transport & communication, and current problems and strengths. The sample was seven hospitals with delivery services in Region E (70% convenience sample). Initial data were collected via site visits and key informant interviews at each participating hospital by the project team and meetings with district and regional MCWH coordinators during 2000. 24 Results Total deliveries in participating hospitals were 12 572 for 1999. Regional perinatal mortality rate was 56/1000 deliveries. Maternal mortality rate of 167/100000 deliveries. The Perinatal Care Index was 8,1. The low birth weight rate was 6,6%. The caesarean section rate was 9,1%. 3 of 7 hospitals had an Obstetric Specialist on staff. All hospitals had at least 2 Advanced Midwives on staff. 4 of 7 hospitals had regular perinatal audit meetings. 3 of 7 hospitals had established "waiting mothers wards". Driving time to regional referral hospital (Umtata General) ranged from 1.5-4 hours. All hospitals could do vacuum delivery and blood transfusions. One hospital could NOT do emergency caesarean deliveries due to lack of trained doctors on staff. Table 1: Priority Issues The following were priority issues facing the delivery of perinatal services in the region as identified by hospital, district and regional staff: Staffing Facilities & Equipment Inadequate staffing Inadequate or broken equipment Low staff morale Inadequate bed space Limited or no Caesarean section capacity at No or limited waiting mothers ward some sites Selective use of the partogram Transport & Communication Other Issues Inadequate transport and communication No uniform maternal health guidelines with both outlying clinics and tertiary or system of perinatal review/audit referral hospital Antenatal testing and counseling for Inadequate number of emergency vehicles HIV for referral to higher level of care Inadequate interaction at community Phones or radios at clinics not working level, for example with village Poor road conditions to many clinics and traditional birth attendants hospitals which prevent transport & referral, Need for continuing education and especially during bad weather training in areas such as neonatal resuscitation 25 Conclusions Both the perinatal and maternal mortality rates in this region are very high. The perinatal care index, a measure of quality perinatal services, at 8,1, is much higher than the national target of 2,0. Issues were identified by local providers which contribute to the high mortality rates. A plan was devised to combine existing resources in perinatal health in a comprehensive program to address many of these issues, including: regular continuing perinatal education (COPE) of personnel through on-site training by an obstetric specialist and neonatal sister, completion of the Perinatal Education Program (PEP) by nursing staff, participation in the provincial Neonatal Resuscitation (NRP) training program, initiation of regular perinatal audit using the Perinatal Problem Identification Program (PPIP), implementation and adaptation of the National and Provincial Maternal Health Guidelines, improve coordination and administration to address communication and transport issues (HST-ISDS). 26 A COMPARISON BETWEEN FOUR MIDWIFE OBSTETRIC UNITS IN THE PRETORIA REGION NT Mabale*, Dr C van der Westhuizen#, Prof RC Pattinson*# *Kalafong Hospital, #University of Pretoria Introduction Midwifery Obstetric Units have been established in South Africa in response to the health needs of pregnant women. Although various types of MOU"s currently exist, the functioning of the MOU and the quality of midwifery care rendered, have never been documented. This study, aiming at describing and comparing four different types of MOU"s in the Pretoria Region, will contribute towards providing an evidence base needed for effective policy-making. We believe that Midwife Obstetric Units should play an important role in the reduction of maternal mortality and morbidity. Methods and procedures A comparative descriptive design is followed to reach the aim of the study. Triangulation of data collection methods are used to ensure a rich description of the functioning of MOU"s and the quality of midwifery care rendered. The checklists and interview guides used, are the following: checklist for ward statistics (current formats used in the units, together with the Guidelines for Maternity Care in South Africa [Department of Health 1999]); interview guide (Unit managers); interview guide (patient satisfaction and reasons for by-passing MOU"s); analysis of partogram. A sample of four MOU"s in the Pretoria Region is chosen purposively because of their unique characteristics resembling four different types of MOU"s. Systematic random sampling is used to select patient records; a total of 50 records needed from each MOU. Admission books and delivery records, MOU"s guidelines, procedural/protocol documents, inventories of facility"s equipment, stock and supply records are audited. To determine patient satisfaction, patients are selected at random in the postnatal wards. Patients by-passing the MOU are identified at the nearest hospital and 27 interviewed at a non-random fashion, because of the problems of following-up these patients. The content validity of the checklist for ward statistics is based on the current formats used in the units as well as on the Guidelines for Maternity Care in South Africa (Department of Health 1999) and tested during a pilot study. The interview guide (unit managers) is structured according to the study objectives and tested during the pilot study. The interview guide (patients) is based on an instrument developed by Steyn (1998) to assess patient satisfaction with antenatal care, is adapted for the purpose of the study and tested during the pilot study. Analysis of partogram: an instrument developed by the MRC Unit for Maternal and Child Health Strategies is used. Strategies to ensure trustworthiness of data collection and analysis are based on the model of Guba and Lincoln (De Vos 1998:348-350). Descriptive and inferential statistics, as well as Tesch"s approach towards the analysis of qualitative data is used to examine differences between the four MOU"s. Within the scope of this study the researcher does not intend to generalise the findings. Conclusion A preliminary report of the study will be presented. 28 CLINICAL CAPACITY SKILLS AUDIT (CCA) IN MPUMALANGA PROVINCE [Maternal Child and Women's Health (MCWH)Programme] NP Godi Mpumalanga Provincial MCWH Introduction The Department initiated the process of auditing the skills available in all our hospitals. This was to allow for rational restructuring of services and to link that with personnel and the skills available at the different sites. A CCA committee was formed and this included amongst others the Provincial Programme Coordinators and specialists from some of the hospitals. Six teams were formed to represent the spectrum of specialities and services rendered in the health sector. There was no standard format/ tool for the teams to use when doing the audit, so each team had to design its own tool. The analysis of the gathered information will be done jointly by the CCA committee and the Provincial Health Information Unit. The MCWH team comprised of: 3 Obstetricians, a Paediatrician, 3 Midwives (one of whom is an Advanced Midwife) and a Dietician/Nutritionist. The team was split into a Maternal and Women"s Health, Child Health and Nutrition Units to enable the units to focus on the area of their expertise. The audit process started on the 08/02/00 and finished on the 13/04/00. 27 hospitals were visited for the audit process in 13 days during the period mentioned above. The presentation will focus on the Maternal (& perinatal) and Women"s Health group. Method The group designed a simple questionnaire aimed at establishing what services are rendered in the facilities. This was based on the supposed basic minimum requirement to enable the running of safe and standard maternity care services. This was a contribution from the obstetricians and the midwives who individually compiled a list of questions and met to combine their inputs into one questionnaire. The questionnaire covered a broad spectrum of maternal and women"s health care issues, including improvement of quality of care and audit processes in maternity 29 services, expanding new services, actual skills available and health system support including staffing. The questionnaire was piloted at the Witbank Hospital. The other hospitals were visited and the Maternity, Neonatal and Gynaecology units staff were interviewed and the questionnaire completed. The team analysed the questionnaires and submitted findings and recommendations to the Provincial CCA Committee. Findings/Results There are disparities in the capacity of hospitals to render basic (standard) maternity and women"s health services. (Disparities in Human Resource and Staffing, Staff Development and Skills, Support Services for Staff and the System and Availability of Basic & Essential Equipments. The final report of findings will be made available once the CCA committee has released the full report from all the other teams. Conclusion The CCA process was an eye opener to us. It is hoped that the Provincial Management will act positively on the findings and recommendations as submitted. Our team is of the opinion that the recommendations could impact positively on Maternal and Women"s health service delivery. 30 RESTRUCTURING OF THE MATERNITY SERVICES IN BLOEMFONTEIN, FREE STATE PROVINCE MG Schoon, RH Bam Department of Obstetrics & Gynaecology,University of the Orange Free State, Bloemfontein. With the changes in provincial government after the 1994 elections, emphasis was placed on restructuring health services with a priority on maternity services. Pelonomi hospital was an overcrowded all levels of care hospital with sub-optimal delivery facilities and overcrowded antenatal clinics. Although an active planning phase was initiated, it took 5 years for all the levels to come in place. The first change was transferring responsibility of antenatal clinics to the local municipality in 1997. This was accepted with reluctance but the services improved after a short in-service training course was given to personnel of the Bloemfontein municipality. A regular transitional communication forum was developed with good effect. Due to a lot of resistance at various levels and institutions, maternity service meeting was formed chaired by a senior director of health. This instrument played an important part in facilitating the process of change. Towards the end of 1999 the first midwife unit was commissioned and the district hospital labour ward commenced deliveries in May 2000. During March 2000 the Obstetrical High Care unit at Pelonomi hospital was transferred to Universitas hospital and Universitas hospital began functioning as a pure tertiary care center. Although 2 years behind schedule, structural changes to improve neonatal intensive care facilities began in Universitas hospital in December 2000 and the upgraded new maternity unit at Pelonomi will be completed by the end of 2001 A forum chaired by a chief executive officer was created in October 2000 to act as a communication platform between the tertiary center and all regional hospitals. 31 THE EFFECT OF RESTRUCTURING OF THE HEALTH CARES SERVICES ON MATERNITY CARE IN BLOEMFONTEIN. MG Schoon, RH Bam Department of Obstetrics & Gynaecology,University of the Orange Free State, Bloemfontein. Objective of the study During the past 5 years health structuring occurred in the Free State to come in line with national policies. This included development of primary health care facilities and restructuring of the secondary and tertiary level facilities in the province. The aim of this study was to evaluate the effect of the restructuring on maternity services with respect to the different levels of care Study design Descriptive study Methods All deliveries within the Bloemfontein area were evaluated over a six-week period by means of a structured questionnaire. All questionnaires were completed after delivery by the responsible health care professional. A research worker also controlled all delivery registers to assure that questionnaires were completed for all deliveries. Data was collected relating to the institution, the mode of delivery and perinatal outcome. Patient demographics as well as information relating to referrals and risk factors were collected as secondary outcome measures. The caesarean rate and perinatal mortality was also compared to the 1991-1994 delivery data for the same period. . Results During the 6-week period a total of 810 deliveries were documented at institutions in Bloemfontein. There were 295 deliveries (36%) at primary health care institutions. The majority [456 deliveries (56%)] delivered at the secondary hospital and 59 32 (7%) were delivered at the tertiary institution. The caesarean section rate for the different levels of care was 1% for primary health care, 34% for the secondary level and 51% for the tertiary hospital with an overall rate of 26% in the Bloemfontein area - a rise of 7 % compared to the period prior to 1995. The perinatal mortality for the different levels of care were 3.5, 70 and 207 respectively for the different levels of care. Only 22 % of cases managed at the secondary hospital were from institutions outside Bloemfontein. Conclusion Restructuring of health care services in the Free State was a slow process. Although the tertiary institution managed to obtain an optimal tertiary function, difficulty exists in restructuring the primary health care services to render a comprehensive primary care service. Only elective caesarean sections are done at the district hospital in Bloemfontein and the rest referred for secondary care. 33 ST MARY'S HOSPITAL MARIANNHILL COMMUNITY OUTREACH CENTRE HIV/AIDS HOME BASED NURSING CARE TRAINING FOR VOLUNTEER COMMUNITY HEALTH CARE WORKERS (ONOMPILO) B Bond, CM Jones, N Mthalane, AM Mdunge Overview KwaZulu/Natal has a population of approximately six million people of which 4 million live within the Durban Metro Area. Latest statistics reveal that the Province has the most rapidly increasing incidence of HIV/AIDS in the world. It is conservatively estimated that 32.5% of the population of KwaZulu Natal is HIV positive, and 60% of the patients served by St Mary"s Hospital Mariannhill are HIV positive. With an estimated catchment population of over 750 000 people, mostly from low socio-economic conditions, the need for care is understandable. Education programmes have been in operation from 1987 to the present and counselling services began formally in 1991. Then only one person per week was diagnosed as HIV positive, but by 1998 however: Of the 2237 people tested, 1173 were HIV positive – representing 20 new cases per week 60% of all inpatients were estimated to be HIV positive Over 300 new cases (including those tested at the hospital) were being counselled every month The hospital mortuary had to be extended to cope with an increasing number of deaths from HIV/AIDS related illnesses 34 St Mary's Hospital HIV/AIDS Tests 1991 - 1998 3000 2764 2500 Number of Patients Tested 2376 2237 2000 1500 1460 1471 1391 1277 1293 1000 949 985 960 908 555 656 606 552 500 269 477 438 343 234 179 35 117 0 1991 1992 1993 1994 1995 1996 1997 1998 Total Tested HIV Positive HIV Negative The above graph gives the number of HIV/AIDS tests performed at St Mary"s between 1991 and 1998. The reduction in testing around 1997/1998 reflects a reduction in the number of tests performed due to financial constraints as well as the decision not to test people who were terminally ill (dying) and who clinically appeared to be infected. As a result of the transformation and rationalisation of health care provision institutions cut, St Mary"s had to reduce the number of active beds from 340 to 200. This has meant, in common with State and State-Aided hospitals throughout South Africa, St Mary"s is unable to care for all but a small percentage of HIV/AIDS cases requiring nursing, leaving the responsibility for doing so with their families. Each day about 20 severely ill and dying people (mostly HIV/AIDS) are waiting on stretchers in the casualty department of the hospital, hoping to be admitted to an already full hospital. The ability to give quality health care in conditions like these simply does not exist, and this is further compounded by the lack of respect and dignity which arises when people are crowded into admission areas, hospital passages and alcoves. They are on stretchers, sometimes with relatives to help them in their illness and in their dying, and sometimes they are alone in their agony. 35 The cost of keeping one person in a district level bed at St. Mary"s is about R500 per day, and to care for the person in the Casualty is roughly R400 with the intravenous therapy, drugs and testing that is required. Those who can possibly go home are sent home with treatment in the hopes that their families will be able to care for them. Thus, the plan to consult the community, discuss the problems and search for solutions was carried out, as it had been in the past. The Community Outreach Centre In line with the general development of the Health Care system in our country, St Mary"s believes that self care and basic health care should be encouraged amongst all South Africans and that one of the most valuable ways of achieving this is by education to the community through trained Health Care Workers. As a result of this project, the "Community Outreach Centre" was opened in September 1997 and a volunteer force of women from the communities of IMpola; KwaDesai; Thornwood and St Wendolins (KwaSanti) were trained in basic health care matters. Their presence in the community has proved invaluable to both hospital and community alike. By mid 2001 it is hoped, two hundred and thirty five women from nine communities will have received training in various aspects of health care, and will be active in their communities. The Overall Aim of the Community Outreach Centre is to improve the holistic health and quality of life of people through education. The Centre runs a number of projects which try to address some of the major problems facing people living in our local communities, namely: malnutrition, poverty and HIV/AIDS. Funding for all projects is raised through donations – the hospital providing the building and staff only. In 1998, funding was obtained from the Embassy of the Federal Republic of Germany for a "Gardening for Health" Project which is aimed at reducing malnutrition in families living in the communities. Also in 1998, with funding from local businesses and Trusts, the "Child Nutrition" Project was launched. The project 36 aims to reduce malnutrition in pre-school age children by educating mothers in a practical way as to what constitutes a low cost nutritional diet for their child. Early in 1999 fundraising began for a "Mother and Infant Health Care" Project, again utilising the services of trained Onompilo, which is aimed at reducing the incidence of child mortality and promoting the health of pregnant women, newly delivered mothers and infants under the age of two, living in the communities. The British High Commission has made a substantial contribution to the project which has been fully operational from November 1999. HIV/AIDS home based nursing care training project: Because of the large numbers of people already infected with HIV, the hospital believes it can be of greatest service by concentrating its efforts in the hospital"s proven area of expertise – namely by providing practical education in basic home based nursing care and counselling skills to Onompilo to enable them to give practical assistance to families living in the communities who are infected and affected by the disease. Onompilo HIV/AIDS training course: The HIV/AIDS Training Course covers: Infection Control Nutrition Home based Nursing Care Administering prescribed medicines Counselling of sick person and family Respect for the culture and religious beliefs of the terminally ill In addition: Three days "in house" workshops in the counselling of patients will take place at the hospital, under the tutelage of a qualified HIV/AIDS Counsellor. On-going training will be given to Onompilo in their respective communities by visiting Hospital Health Care Workers. 37 Onompilo will be supplied with protective clothing, medical kit, and other essentials needed to practice safe and hygienic home based nursing of patients in the community. Onompilo Incentives It would be totally unrealistic of St Mary"s to expect to run any Community Health Care Project successfully without taking into account the straitened financial circumstances of their voluntary Health Care Workers. Fundraising has been achieved by: St Mary"s Hospital holds 3 to 4 Jumble Sales a year. Twelve Onompilo formed a sewing group which makes patchwork toys, cushions, "hot boxes" and other articles for sale at the Jumble Sales and to hospital staff. Vegetables grown in community gardens are sold. Donations (financial and in kind) are encouraged and obtained in fundraising drives. Money is ploughed back into training Onompilo in small business skill development so that they can supplement their incomes while working in the community as health care workers. Organisation, Evaluation And Monitoring The HIV/AIDS Home Based Nursing Care Training Project is organised, monitored and evaluated by St Mary"s Hospital Mariannhill. Monitoring and evaluation of the project will be provided by: Reports from the HIV/AIDS Community Co-ordinator Progress reports from Onompilo and Traditional Healers and community leaders (formal and informal) as well as individual case histories Reports from Nursing Staff, Clinics, Social Workers and Health Care Workers Hospital HIV/AIDS Statistics 38 SESSION 2: HEALTH CARE MANAGEMENT AND EDUCATION BETTER BIRTHS INITIATIVE: INITIATING CHANGE IN OBSTETRIC CARE H Smith1, H Brown2, J Hofmeyr3, P Garner1, H Rees2, K Dickson-Tetteh2. 1 2 Liverpool School of Tropical Medicine, UK; Reproductive Health Research Unit, 3 Chris Hani Baragwanath Hospital, Johannesburg; Effective Care Research Unit, University of Witwatersrand, Johannesburg. Introduction The Better Births Initiative (BBI) is a new strategy developed by health professionals in South Africa and internationally, to help provide a better quality of childbirth care for women and improve maternal outcomes in low-income countries. The BBI promotes humane and evidence-based childbirth care by: 1) Identifying specific changes that are achievable, and could dramatically improve women"s experiences during labour; 2) Developing and testing innovative methods of bringing about these changes; 3) Developing an agreed strategy (the Better Births Initiative) which is simple, accessible and applicable to low-income countries; 4) Implementing the strategy in local spheres of influence; and 5) Encouraging others to adopt the package. Few studies, focussing on changing practice in healthcare, have been conducted in under-resourced settings, where large infrastructure and financial barriers to change exist. The Better Births Initiative aims to develop and test innovative change mechanisms applied to primary obstetric care in the African region. Methods The objective of this study is to test the effectiveness of a combined educational package, which focuses on a few key areas of midwifery and obstetric care, where there is good evidence from systematic reviews, to bring about change in obstetric practice. The package comprises core materials to raise the demand for change, and innovative management strategies that involve providers in the process of change. Materials include a workshop for labour ward staff with a workbook, posters, video 39 material, a presentation of best evidence for procedures during labour, a reference booklet, and a self-audit mechanism. The study used a randomised pre-post intervention design and was conducted at 10 purposefully selected maternity units in Gauteng Province, Johannesburg. The hospitals were matched according to the number of maternity beds available and level of care; and sites were randomised to receive both the provider workshop and the self-appraisal mechanism (intervention sites), or the provider workshop only (control sites). We conducted baseline exit interviews with 30 women at all sites to determine actual practice during childbirth. We arranged convenient times to visit labour wards at all sites to conduct workshops (and introduced the self-audit mechanism at intervention sites). Four months after the workshops, we conducted follow-up exit interviews with postnatal women to identify any changes in practice at the intervention and control sites. Focus group discussions and in-depth interviews were conducted with labour ward staff to determine any shift in attitude towards evidence-based practice, and to obtain feedback on the materials used. The follow- up period of the study is ongoing. Results Interim follow-up "phone interviews with key staff members at intervention sites suggested that the self-audit of practices used during labour was being utilised, and staff found it a useful tool. Exit interviews will be analysed as matched pairs, and comparisons made both before and after, and between control and intervention sites. Qualitative data form focus group discussions and in-depth interviews will be analysed using methods of content analysis, and emerging themes will be documented. The follow-up phase of the study is ongoing, and the results presented here represent a snapshot of our findings so far (from one matched pair). Table 1 shows changes in practice between baseline and follow-up for selected procedures (using one matched pair as an example). 40 Table 1 Exit interview results from one matched pair Procedure Study site Baseline Follow-up (%) (%) Enema Control 52.6 26.7 Intervention 69.7 63.3 Shaving Control 73.7 30.0 Intervention 3.0 0.0 Episiotomy Control 26.3 14.3 Intervention 24.2 16.7 Supine position Control 78.9 66.7 Intervention 100.0 100.0 From focus group discussions, we found that the use of enemas had been reduced at 6 sites, shaving had been stopped at 2 sites, routine episiotomy had been reduced at 8 sites, all as a direct result of the BBI workshop. At 3 sites opinions had changed regarding use of supine position, but comments suggested that a lack of adjustable beds and skills for managing other birthing positions were preventing change in practice. In-depth interviews with staff were useful for obtaining feedback on the materials used, and comments about the feasibility of implementing the Better Births concept. Table 2 shows a selection of comments from individual interviews at different sites. Table 2 Comments from selected interviews at various sites Topic Positive Negative Workshop: "...has helped to remove "…OK, but we haven"t acted on all the rigidness -the routine parameters" - allows you to explain things" "It opened communication, "concentrates only on patients we talked after you came…it comfort, not providers'" is going to be ongoing" "it is self- empowering…helps us learn to accept things, take the patient the way she is" Materials: "they were good, they "materials are too African…we were user friendly, bright. deal with lots of different Like the calendar - its one women, and the leaflets etc need thing that you read time to include white images too" 41 Topic Positive Negative and again..." Initial "I thought that it wasn"t going reactions: to be possible, especially with... the things we are used to using in the ward. And with the enemas, we thought, oh, god, I"m going to have those big stools. But after experiencing it, I think its easy" "I was happy, because at least it was enlightenment, to move on from the old practice" Self-audit: "that wasn"t difficult, because "You know, what I think it is a right at the beginning we sat good idea when we are well down and we studied how do staffed. Now it seems that one of we plot that, how do we do the reasons we did not do that...in the long run it was particularly well, is that we have very clear, I think because we so much to do, we couldn't just came together...eventually we follow it up". got it right" Discussion The results of this implementation study will determine the effectiveness of this combined strategy for initiating change in practice; in particular it will highlight the added effect of increasing provider responsibility for change by encouraging self- appraisal. The findings so far have been very positive. Three out of five intervention sites have used the self-audit charts, and found them to be helpful in encouraging their colleagues to adopt change. Practice has changed visibly (as the above results clearly show), especially regarding the use of episiotomy, shaving and enemas. We have found that change is possible – even using a two-hour interactive workshop; but staff shortages and rotations make it difficult to initiate and maintain change. Sustained input from committed individuals is essential to reinforce the changes, and to engender support for the Initiative. Analysis is ongoing, and it is anticipated that with minor modifications, and the support of the Department of Health, the BBI package will be used in other provinces in South Africa. There is also interest in adopting the package in other countries. 42 PREGRADUATE MIDWIFERY EDUCATION – A NOVEL APPROACH C van der Westhuizen, J de Kock Department of Nursing Science, University of Pretoria Introduction This paper will be presented in tandem. Firstly, we want to introduce the Midwifery programme as run at the Department of Nursing Science at the University of Pretoria, which is quite a novel approach in midwifery education. Secondly, we want to present the results of the programme evaluation done at the end of last year, together with a synopsis of lessons learned from our experience. We strongly believe in a community-based, problem-based approach in midwifery education where students accept responsibility for learning and demonstrate problem-solving skills, critical thinking and creativity; effective team-building and teamwork; organisational and management skills; information management; language, communication and interpersonal skills; responsible utilisation of scientific knowledge and technology; global perceptions of humanity and the interrelationship between human beings and their environment; and personal and professional development to the benefit of the South African society at large. The traditional approach towards midwifery teaching often lead to inappropriate teaching and content driven curricula. Three years ago we sat down together with our colleagues in clinical practice and brainstormed about the content of midwifery and the best way to reach that. A totally new programme was born. Methods A programme evaluation research design was followed. After implementation of the programme, various variables were identified and changed as the programme continued. At the end of the third year of programme implementation, a semi- structured questionnaire was used to evaluate the students" experience of the programme and a focus group was held to explore the lecturers" experience. The 43 data were coded and analysed with the help of an external coder. Lincoln & Guba"s model was used to enhance trustworthiness. Conclusions Several themes, positive as well as negative, came forward. Students expressed an overall positive experience with this approach. Structure remains a need and various ideas came forward to address this need. A more positive experience in clinical practice, both from the side of the students and midwives were expressed. From the lecturers" side practical problems, such as inadequate student preparation and problems with evaluation of tutorials were expressed. This paper will conclude with a synopsis on lessons learned from our experience. 44 CARING FOR CARERS: CRITICAL CARE STRESS INCIDENT DEBRIEFING AS A SALUTOGENETIC INTERVENTION FOR HEALTH CARE PROVIDERS AT ST. MARY'S HOSPITAL – MARIANNHILL AND IN THE SOUTH AFRICAN SITUATION CM Jones Nurses and midwives (and other health care provision staff) are at the forefront of the changes and challenges in the tumultuous transition of the South African health care system. The Situation Health Care Transition Hospitals and clinics were predominantly situated in urban areas, and offered excellent curative health care to the affluent and to those who were academically interesting. The challenge is, to move budgets, staff and resources from these institutions in order to develop strong preventive, promotive health care programmes with efficient secondary health care services and the continuation of academic research and specialised skills. Effects on Nurses Nurses trained to be excellent "hospital" nurses have suddenly been confronted with nursing situations for which they had not been adequately prepared. They expressed the following:- Nurses who were used to working in curative services within their own language and cultural groupings are now required to offer primary health care and interact directly not only with patients and clients of other groups, but with nurses and other health care providers. Stress arises from difficulties in understanding each other and dealing with the resurgence of emotion which remains from the perception of each other as either victim or perpetrator of the atrocities of apartheid. Nurses used to the hierarchy of hospital-based nursing are now expected to be active in community programmes. They must devolve authority and decision-making 45 about health care provision to the people and accept their evaluation of the service provided. The expectations of the community for first class health care clinics throughout the country have not been met and the people have become hostile to nurses, accusing them of withholding medications and services. Nurses in the public sector, felt the pressure to provide services which are deemed to be the citizen"s right under the new constitution of South Africa but which are in conflict with their moral values e.g. certain types of treatment, or withdrawal of treatment, termination of pregnancy, and euthanasia. As skilled nurses have left the country following their fortunes in Saudi Arabia and the United Kingdom, or leave the profession because of poor conditions of service and increasing stress, newly qualified professional nurses struggle to fill the gaps left by the exodus of these skilled nurses and are often forced to accept great responsibility without adequate practical experience or supportive mentorship. Nurses at St. Mary's Hospital - Mariannhill expressed stress related to cutbacks of services at the hospital after subsidy and reduction of beds and increased demands by the community for health care; frozen posts; additional responsibility without increase in remuneration; little chance of promotion, reduction in perks and study leave; new management structures and increased disciplinary cases. Effects of HIV/AIDS Increased disease and disability in the community. Increased disease and disability in the family of the nurse. Increased disease and disability in nurses themselves Stress and Distress Nurses say that they feel used, not listened to, not consulted, not respected, not important, not praised, and not successful. They say that they have loss of energy, lack of interest, mood swings, feel cynical, anxious, have sleep disturbances, irritability, sense of pessimism, loss of trust, loss of self esteem, inability to make intimate relationships or commitments, hardness of attitude and numbing of emotions. They say that they are unable to sympathise with themselves of with others; they are restless, lack satisfaction with themselves, their families, and their country. They are more dependent on coffee, nicotine, social drugs, and alcohol. 46 They say they make more mistakes and poorer judgements; they are ill more often and recover more slowly. Complaints are nebulous – "backache, flu like symptoms, tension, fatigue, malaise", digestive complaints and high blood pressure. There has been an increase in absenteeism, tardiness, and real and fictitious sick leave. They say that the only time they get any attention is when there has been a tragedy and they are asked to "write a statement" What has been tried ? At St. Mary"s Hospital Mariannhill:- Survey of staff done to identify their perceived needs Flattening of nursing hierarchy organogram and implementation of participative leadership in order to ensure each nurse has access to a senior for assistance and support Salaries reviewed and adjusted according to performance, length of service etc. Ensuring staff have their perceived needs fulfilled as much as possible: adequate rest and recovery (reduction of night duty duration, split shifts stopped, duty hours adjusted to the most convenient schedule for the majority of staff, ensured holiday leave was taken by all staff, discouragement of "moonlighting", introduction of compassionate leave and family responsibility days, introduction of dedicated Occupational Health Nurse) Introduction of middle management courses to empower staff Increasing educational opportunities and in service programmes to motivate staff Clear position profiles made for each nurse and discussed with him/her Personal Development Interview conducted annually Provision of "on duty time" pastoral care and counselling services (in house and externally) for staff After 3 years of strategic managerial action there has been not significant improvement in the perception of staff satisfaction nor in rates of absenteeism and sick leave. One of the associations that was noted was the relationship of sick leave with event which happened to midwives during their working time – unexpected death of a baby, stillbirths, loss of foetal heart in labour, disastrous "breech" 47 deliveries, severe illness or death of a woman in labour, conflict with woman or her relatives. This led us to reconsider and re-evaluate what we, as nurse managers, were doing to assist staff during these times. In so-called "minor" serious events, emphasis was placed on obtaining the correct documentation, statements and incident reports. Interactions with staff were primarily related to investigating the case for evidence of negligence. Only cursory attention was paid to the feelings of the midwives at this stage. Later, midwives involved may have been offered counselling if their informal talks with regional nurse managers were not effective. Midwives expressed that they were unable to relate freely to nurse managers as they continued to associate them with disciplinary issues and felt inhibited to share their thoughts and emotions. Midwives tended to talk a lot to their peers, very little to their authorities, and to have taken recourse to "sick leave" as a way of dealing with their problems. This led us to consider the introduction of CRITICAL CARE STRESS INCIDENT DEBRIEFING (introduced by Mitchel and Evely and adapted by Perren Klinger) as a possible method of intervention which would offer midwives support and enable them to utilise their own strengths and resources to deal with stresses. The model was chosen because it is salutogenetic and unlike other interventions, does not dwell only on identifying and/ or preventing pathology and "Post Traumatic Stress Syndrome". It involves all people who were part of the event who are seen by a team in a group; it does not pretend to be psychotherapy; it does not solve all problems but may mitigate persistant stress reactions; it is primarily a prevention programme; it is not an operational critique but a process designed to stabilise cognitive and affective reactions to a traumatic event. IT ACCELERATES THE RATE OF NORMAL RECOVERY, IN NORMAL PEOPLE, WHO ARE HAVING NORMAL REACTIONS TO ABNORMAL EVENTS. 48 Process Mental Health Care Professional (e.g Psychiatric nurse) can be trained in the process as well as peer supporters Timing: Debriefing should take place as close as possible to the event with a follow up at 72 hours and 2 weeks, 6 week intervals. Place: Any room where privacy can be maintained and without too many stimuli ( other activity or distractions) Steps: COGNITIVE INTRODUCTION………………………………………..RE-ENTRY *RITUAL FACT………………………………………………….TEACHING THOUGHT………………………………………………SYMPTOMS REACTION EMOTIONAL Introduction Gain co-operation of the group. Explain the process – not an operational critique of how the incident was managed. Remove distractors – pagers, cellphones Encourage mutual help – only counsellors and people directly involved in the incident should be present. Ensure confidentiality (no tapes, notes, reports to authorities) 49 Fact Facts are easy to share, impersonal, non threatening, and allow the scene to be set. The incident is told in story form, sequential information given by each person from their own point of view. The move into emotion often comes with the telling of the story. Emotion is acknowledged and accepted but not dwelt on Thought Participants are asked to express the first thing they thought after they had stopped operating in "emergency" mode. This often releases emotions of anger, guilt, despair. This phase makes the emotion personal and moves the person from the cognitive to the affective domain. The group leader needs to sensitively ensure that this stage does not begin to cause group anxiety and helps individuals to deal with expressions of emotion Reaction At this stage, the group itself will quietly talk among themselves and deal with the personal issues about the incident. "What if"……..questions may arouse emotions and grief. Conversation flows and ebbs; expression of emotion may be verbal or non verbal, subtle or overt. Symptoms This transitional stage begins to move the participants back to the cognitive level. It is important to move from the affective to the cognitive domains in order to allow people to resume normal activities with their usual psychological defences intact. Participants are asked to describe any thoughts, or behaviour that they can remember – trembling hands, confusion, inability to make a decision etc. They may also talk about stress related symptoms such as sleeplessness, nausea, dizziness etc. Participants are encouraged to tell each other if they have also felt the same symptoms. This helps individuals to accept their reactions as universal and not unique. 50 Teaching This flows easily from the Symptom phase and is an opportunity for the group team to explain the reasons for the symptoms, speak of them in a normal manner, give advice on how to manage the symptoms, engage the participants on a cognitive level, asking them to make decisions and accept responsibility for caring for themselves in specific ways –diet, exercise, relaxation techniques. Ritual Perren Klinger finds this stage of vital importance in recognising the cultural value of each group and of the individual participants. The group chooses a symbolic way of "giving the incident over" – this may be by lighting candles, placing flowers at the scene, burning accounts of the incident in a fire of incense etc. Re-Entry This phase allows the group and the individuals to clarify issues, answer questions, make an ending to the session with a feeling of closure. The team are also able to summarise their comments about the group session with words of respect and encouragement. Refreshments are offered at the end of the session to allow a gentle re-entry to normal social interaction between the team and the participants and to help the team to recognise members who may need one on one counselling or further support. Post Debriefing of the Team This is a very important protective factor for the team as it allows them to explore what happened in the group and their own reactions to it. Follow up plans are also made at this time. Follow up services may be: Home visits Chaplain or pastoral care Individual counselling Family sessions 51 Why does it seem to work ? Early intervention and focused attention Opportunity for Safe Catharsis Opportunity to Talk about the Trauma Follows a structure which has a start and finish unlike repeated nebulous ruminations of the facts to all and sundry Presumes a healthy outcome and restoration of equilibrium and functioning while at the same time permitting emotional release within a culturally supportive framework Moves from Cognition to Affective domains and back again in a structured manner Involves Group Support and Peer Support Stresses education and is positively action oriented Allows for Follow up. ST. MARY'S EXPERIENCE Traumatic events: Difficult deliveries with poor outcomes Sudden death of baby (cot death) Armed robbery Sudden death of peer Staff Perceptions: Feel cared for and important Appreciated someone asking how they were before the reports needed to be written Found it reassuring that others were feeling the same about the incident Surprised that others also felt as strongly and even cried about things Felt better and slept better Knew that there was someone to go back to if problems came back Felt more in control of the situation without feeling rigid and like holding a volcano from erupting Forward Planning – Ongoing research of the process for the next 6 months" Plan to train a CISD team so that the service is available to all staff 24 hours a day Encourage doctors to join the process Introduce method to Nursing College staff. 52 NEW ADDITIONS TO PEP D Woods, G Theron, D Greenfield, H de Groot, H Louw Perinatal Education Trust Background The Perinatal Education Programme (PEP) is a self-help course in maternal and newborn care, which enables health care workers to manage their own continuing education. Participants learn both the knowledge and skills needed to improve the standard of care they provide. The success of this method of training has been well documented in controlled studies. With the expansion of health care services, there is a growing need for groups of midwives and doctors to manage their own in- service training. PEP is well placed to meet this important need. Present Situation By the end of 2000, a total of 25 418 Maternal Care and Newborn Care manuals had been used in South Africa. Of the 14 922 nurses who had obtained PEP manuals by the start of 2000,a total of 8 244 had successfully completed the manual and passed the examination (55%). The Perinatal HIV/AIDS manual was the first supplementary course to be introduced and 1 251 manuals had been used by the end of 2000. The Afrikaans translation is now available. All manuals can be obtained from Perinatal Education Trust, P O Box 34502, Groote Schuur, 7937 or phone/fax 021 671 8030. Primary Newborn Care Manual In order to meet the training needs of health professionals who are working in the many level I clinics and hospitals, a supplementary manual on primary newborn care has been written. This manual is adapted from the Newborn Care manual and addresses all the problems of newborn infants, which need to be prevented or managed by staff providing primary care. 53 Content Of The Primary Newborn Care Manual The manual consists of 5 units written in the standard PEP format: Unit 36 Care of infants at birth Unit 37 Care of normal infants Unit 38 Care of low birth weight infants Unit 39 Emergency management of infants Unit 40 Managing important complications in infants Proposed Manual A supplementary manual on the mother and baby friendly approach to perinatal care is planned to promote newer concepts of mother and infant care. The proposed units are: Unit 41 Mother friendly care Unit 42 The advantages of Kangaroo Mother Care Unit 43 The practice of Kangaroo Mother Care Unit 44 Baby friendly care Unit 45 The promotion of mother-infant bonding Web Site A web site has been launched to promote PEP and make the ordering of manuals easier. It will also be used to make the PEP learning material available to health professionals outside South Africa. French, Spanish and Portuguese translations are planned. The PEP website provides information on the historical background, learning methods, contents, implementation, references and evaluation of PEP. The web site address is www.pepcourse.co.za 54 PPIP VERSION 2 AND USER MANUAL JD Coetzee, E Mitha, RC Pattinson MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria The Perinatal Problem Identification Programme (PPIP) is a user-friendly computer programme to develop individualised health centre protocols. PPIP Win is the latest version of the programme. Its improvements from the older DOS versions are: easy to install; extreme ease of use; use of colour graphs in 2- D/3-D to print various statistics; continuous updates available for registered users; codes for causes of death/avoidable factors are all found in the programme. A basic step-by-step manual is available to help even the first time computer user to get started with PPIP. 55 FROM GUIDELINES TO INSTITUTIONAL PROTOCOLS E Mitha, RC Pattinson MRC Unit for Maternal and Infant Health Care Strategies The MRC Unit in Pretoria is in the process of developing a computer-based programme to develop individualised health centre protocols. Each health centre would be able to run the programme, and add their own information in certain areas and then print these out as protocols specific for their centre. Information that could be added would be telephone numbers, referral centres and medication contained in their pharmacy, amongst others. 56 THE PROTECTED DISCLOSURES BILL (ACT) GR Howarth Departments of Obstetrics and Gynaecology, and Bioethics. School of Medicine, University of Pretoria and MRC Unit for Maternal and Infant Care Strategies. The South African Government is busy introducing legislation that will allow for greater transparency of administration. It is important that health care workers, particularly those working in the public sector are aware of the legislation, particularly the Protected Disclosures Bill and the Promotion of Access to Information Act (Act 2, 2000). The poster briefly highlighted the South African Legislative process (the distinctions between Green Paper, White Paper, Draft Bill, Bill and Act), however concentrated on the Protected Disclosures Bill. Prior to the introduction of the Protected Disclosures Act neither the South African common law nor statutory law made provision for mechanisms in which employees may, without fear of reprisal, disclose information related to or of suspected irregular conduct by employers. Introduction of the Act will provide comprehensive statutory guidelines for such disclosure and protection against reprisal as a result of the disclosure. In essence this will mean that any individual that is aware of irregular practices in the work place now has no legally valid excuse not to disclose this information to a higher or external authority. For the health worker this will mean that the moral imperative to report any practises considered to be contrary to the patient's best interest becomes even stronger. The Bill and Act, as well as the distinction between a Bill and Act can best be accessed in their entirety on the web. Protected Disclosures Bill http://www.polity.org.za/govdocs/bills/2000/diclosures.html Access to Info Act http://www.polity.org.za/govdocs/legislation/2000/act.pdf Legistalive process http://www.polity.org.za/govdocs/legislation/process.html 57 THE USE OF CD-ROMS IN THE TEACHING OF NEONATAL AND OBSTETRICS SKILLS TO MEDICAL STUDENTS W De Witt#, JD Makin*, I Treadwell@ Department of Paediatrics# Department of Obstetrics & Gynaecology* Skills Laboratory University of Pretoria Medical School Introduction The purpose of this presentation is to demonstrate the CD-ROMS that have been developed by the Department of Paediatric & Gynaecology in collaboration with the Skills laboratory. These CD-Roms are used to teach basic skills in Obstetrics and Neonatology to third year medical students. These two subjects are taught together in a twelve week block and form part of the new curriculum. 58 THE "HANDS-ON CHILDBIRTH EDUCATION" PROGRAMME R v/d Walt Gauteng Department of Health Introduction The "Hands-on Childbirth Education" Programme was developed as a Childbirth educational package, through a public-private partnership between the National Department of Health and the private sector. The programme aims to make antenatal education accessible, interactive and interesting, and the teaching material used, to inspire the educators and enlighten pregnant women. Content of the programme The programme consists of five modules namely: Keeping healthy in pregnancy Warning signs in pregnancy Labour and Birth Breastfeeding Baby Care A sixth module was developed, on principles of adult educational, in order to teach the childbirth educators methods to make the antenatal educational classes more interactive for the patients. All the information needed by the educator, of all five modules is presented in a file, with bold and consistent use of colours and images, and practical exercises that the patients can do, in order to make the programme more interactive. The programme file is also supplied with visual aids, like a pelvis, a model of a newborn baby with a cord and placenta, which can be used by the educator to make the classes more practical for the patients. 59 Pilot Study Following the development of the programme, it was implemented as a pilot project at eight pilot sites, four in the Gauteng province and four in the North-West province. The pilot sites included hospitals and Midwifery Obstetric Units, from rural to urban. The implementation process included the following; Training the educators to use the programme Supplying all training material needed for the classes Support following the training sessions Identifying stumbling blocks in the implementation process Obtaining feedback from the midwives on the content of the programme Compiling an interim report for the National Department of Health and the private sector on the Pilot implementation National Implementation Following implementation of the programme at the eight pilot sites, the Rand Afrikaans University conducted a further study, which focused on the influence of the programme on the patients as well as the educators experience in using the programme. A final report was compiled and some suggestions were made for changes regarding the content of some of the modules. Following the implementation of these changes, a process for national implementation of the programme was started in February 2001. 60 EVALUATION OF THE HANDS-ON-CHILDBIRTH PROGRAMME CS Dörfling, S Beukes Department of Nursing Science, Rand Afrikaans University The Hands-On Childbirth Programme was designed as an antenatal education package for Government institutions. This simple programme consists of talks to pregnant women using adult education techniques and visual aids. The programme emphasises simple important points in five modules, namely health principles during pregnancy, warning signs in pregnancy, labour, breastfeeding and baby care. The implementation of the programme was done at six pilot sites. An evaluation of the implementation of the programme was necessary before the programme could be implemented on nationally. The only aspects that were evaluated were how the people involved with the programme experienced it. The Aim To explore and describe the experience of midwives and women regarding the Hands-On Childbirth programme. Research Design A qualitative descriptive contextual study was conducted. Research Method Data was gathered by means of phenomenological, semi-structured, individual and focus group interviews Target Population The programme was introduced at the following clinics: Natalspruit Hospital, Bekkersdal West, Empilisweni, Pretoria West, Mogwase Health Centre, Bafokeng Health Centre, Gelukspan Hospital and Madibogo Clinic. A midwife working in the clinic and one from the labour ward participated in the research. All the clinics where the programme was introduced were included in the study (excluding the places 61 where the same Midwife conducted both the programme and the deliveries of the same women). A group of women who attended and completed the programme at the various clinics were asked to participate in a focus group discussion on the day that they completed the programme. One of the sites was omitted where the group had not completed the programme. Interviews Individual interviews were conducted with the midwives working in the clinics. They were asked to describe their experience of the Hands-On Childbirth programme. This was followed by a request to evaluate the various aspects of the programme: the file, the information, the suggested teaching aids, the evaluation forms and the visual aids. Individual interviews were further conducted with working in the relevant labour wards. They were asked to describe their experience of delivering patients that attended the Hands-On Childbirth programme. Focus group interviews were held with the women who attended the programmes. They were asked to describe their experience of the Hands-On Programme, this was followed by questions on the content of the programme: what did they learn about staying healthy during pregnancy, warning signs in pregnancy, childbirth and labour, breastfeeding and baby care. Data Analysis The interviews were recorded, were transcribed verbatim and analysed using the descriptive analysis technique by Tesch (in Cresswell, 1994:155). The data were tabulated according to themes and categories. Literature Control A literature control was done to compare these findings with findings in similar research. Trustworthiness To ensure the trustworthiness of the research, Guba"s model (in krefting, 1999:214 - 222) was used. Guba identifies four criteria for trustworthiness. They are: truth 62 value, applicability, consistency and neutrality. Truth value is ensured by using strategies of transferability, consistency by using strategies of dependability and neutrality by using strategies conformability. Results Data gathered was analysed according to the descriptive analysis method suggested by Tesch (in Creswell, 1194:155) and independent coders were utilised and consensus discussions were held. A literature control was performed to highlight similarities and differences between this study and other similar studies in the past. Responses of the Patients that participated in the groups 1. Feel empowered "So here we gain a lot of things, they provide us with some lectures that we can prepare ourselves when you go to a labour room, you must not be afraid for anything." Literature: The College of Midwives survey (1966:239) had a questionnaire assessment on the attitude of antenatal and postnatal women towards teaching. Two third of the women in both the antenatal and postnatal samples found the classes helpful in that they "prepared them for labour" and " gave confidence generally." (Chamberlain G,1975:289) 2. Gained knowledge Know : The danger signs of labour When to go to the clinic or hospital Warning signs The reasons why things are wrong Advantages of breastfeeding Food to eat Baby care How to stay healthy during pregnancy 63 Alternative positions during labour Not to push during first stage Literature: Health education throughout pregnancy is important not only for its possible effect on overall health status, but also because pregnant women in the 1990 must make numerous informed decisions regarding their health and the health of their foetuses.(Freda et al,1993:237) A survey of antenatal education methods, their uptake and value which, was undertaken in Cardiff evaluated the effect of mothercraft classes on knowledge. Women who attended mothercraft classes tended to have higher scores than those who did not. (Hibbard et al,1979:39) A study that investigated the consumers" and educators" experience of antenatal education, evaluated the effects of class attendance. When the women were asked what they had learnt about at classes, 31.8 per cent could not remember anything and 33.9 per cent only one thing – usually breast-feeding. (Adams L, 1982: 15) Nutrition education is an important aspect of antenatal education, not only for a safe pregnancy and delivery but also to help establish future healthy eating patterns.(Adams, 1982:12) There are some who consider the instruction on the care of the new-born child is best until left after delivery for here the health visitor and midwife can give their full attention to the patient in the hospital ward or in her home. Many women, however, feel insecure if they arrive in labour having had no instruction on this subject and it would seem wise to include something of this even though it may be repeated after childbirth. (Chamberlain G,1975:292) At present in South-Africa women are being discharged after six hours post natal in state hospitals and clinics and there is little time to teach them before discharge, women are not routinely visited at home any more either. 64 Give them more confidence:"Dan weet ons ten minste hoe gaan dit wees om "n baby te hê, en wat om te verwag met die geboorte, en wat om te verwag met die breast-feeding en dine soos daai, so ons weet nou more or less meer wat om te doen. Waar ons voorheen niks geweet het nie. So dit was nogal iets interessant gewees." Literature: The acquisition of knowledge by any means, including attendance at mothercraft classes, reduced maternal anxiety in late pregnancy.(Hibbard et al 1979:45). A survey of antenatal education methods, their uptake and value which was undertaken in Cardiff found Classes alter the quality of the experience by making mothers more confident and more self-reliant. ( Rathbone1973:39) The fear of the unknown can be reduced by a programme designed to give information, and it is probably Relief of this stress which is responsible for the big increase in confidence at the outset of labour. (Rathbone,1973:29) Improve mother-child relationship:"Actually they teaching you how important your baby is." Remove misconceptions: "In our African culture there are some ladies who wash themselves with the muti. Don"t ever wash the baby with the muti…. A drop of "snake brew" in the water and wash….." II. Individual Interviews – Antenatal Antenatal Midwives 1. They learn a lot from patients. 2. Try to correct misconceptions of women. 65 3. Try to be cultural sensitive: "To check on those marks and they must be comfortable the baby is just having marks, because those are birthmarks, they are not dangerous…." Literature: Health education should be presented taking cognisance of the background, frame of reference and culture (Downie, et al.1996:46-47). Health educators should pay attention to food practises, preferences, availability within the different culture groups(Andrews & Boyle,1995:333). The health worker should refrain from using medical terms and jargon because of the difference in social class and level of education of the women involved – it interferes with the clarity of the message. (Clark,1996:190). Midwives should ensure that an interpreter is present, but should also be aware that an interpreter, especially if close to the woman, may be tempted to insert her own views. (Jamieson L,1986:19). The major problem in providing classes for ethnic minorities is the language barrier…..the ideal solution would be to employ health visitors or midwives…who can speak the language and are familiar with the culture(Adams L,1982:15). Literature: Teaching aids should be simple, applicable, understandable, considering the cultural background of the recipient. (Liederken, et al.1990:28). According to Adams L(1982:14) written material can be a very useful teaching aid and worksheets can be used in a teaching situation and should be gone through carefully with the client. 4.Experience problems in teaching e.g. that they had to teach the whole package in one day, because the patients had transport problems. 5.They experienced various problems with the package. Handouts are too expensive to copy and the material should be translated in the patient"s language. The material should be provided to the clinics. The aids should also be culturally sensitive. Literature: Teaching aids should be simple, applicable, understandable, considering the cultural background of the recipient. (Liederken, et al.1990:28). 66 According to Adams L(1982:14) written material can be a very useful teaching aid and worksheets can be used in a teaching situation and should be gone through carefully with the client. Midwives should provide the woman with information written in her own language (Jamieson L 1986:19). 6.They expressed various positive points of package. Suggestions: Tuberculosis and HIV to be incorporated into the programme. Table 3: Labour ward Midwives 1. More co-operative: "It is easier for them to deliver and they understand." They will start teaching others Less mothers deliver before arrival Sensible program Conclusions And Recommendations This programme can add to the knowledge of pregnant women and should continue. Tuberculosis and HIV to be incorporated into the program An expert in this field should evaluate the cultural sensitivity or the lack there of. The problem of transport can be overcome by a roaming clinic The current teaching aids should be adjusted. The clinics that implement the programme should be monitored on a continuous basis and the necessary support should be given. Randomised control trials should be conducted to measure the effect of the programme. 67 MODEL FOR AN ENRICHMENT PROGRAMME FOR EXCELLENCE IN NURSING AE Pullen Department of Nursing in collaboration with the MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria The aim of this study is to develop a Model for an Enrichment Programme, as support system for institutional transformation, to enable nurses to fulfil their professional role in striving for excellence in nursing, in a hospital context. Against the background of the expectations of the nursing profession, and various factors that impact on the quality of patient care, a need was identified to assist nurses within a hospital context to determine their needs in the current dynamic situation. Nurses find themselves in a context where there is a heightened awareness on the quality of patient care. During the last few years there has been wide-spread negative reporting on the state of patient care in government hospitals. The Gauteng Provincial Government deemed it necessary, during 1999, to launch a Commission of Inquiry into Hospital Care Practices. The Commission found that various factors impact negatively on patient care. Some of these factors include financial constraints due to provincial budgetary limitations, and internal constraints experienced by hospitals due to limited resources. Another factor that has an apparent negative impact is the uncaring attitudes of staff to assist patients. The lack of co-operation from certain support staff and pressures brought to bare on the nursing staff is also clearly identified in the report. The critical shortage of staff and the effect it has on already overworked nurses reporting for duty is apparent (Commission of Inquiry into Hospital Care Practices, 1999). An article published in Denosa on "Shock Facts Concerning Patient Care In State Hospitals" states that nurses were feeling the pressure from patients who lashed out at them because of poor services (Denosa, 1999:27). 68 It is expected of nurses to provide care to hospital patients that will enhance the health status of the individual irrespective of where the individual is on the continuum of wellness into illness (Mellish, Brink & Paton, 1998:1-9; Muller 1998:83). Mere competence is insufficient as nurses are expected to continuously strive for excellence in care, as safe, competent, capable practitioners within a legal ethical framework that is demanded by the nursing profession, keeping abreast with technological advances. The nurse as an independent practitioner is authorised and capable of practicing nursing in his/her own right and accountable for evaluating a patient situation on the basis of knowledge and skills, taking decisions and acting in accordance. A willingness to be judged by the norms and values of the profession, and to be subjected to professional discipline if necessary (Muller, 1998:1- 9,26,77,83; SANC, 1992; SANC, 1994:10; Mellish, 1998, et al 1-6). In this study the concept enrichment in nursing is viewed as building competence and self-confidence, in order to solve problems and make effective decisions to bring about change. Enrichment implies a positive affirmation of the feeling of being accepted, valued, loved, and belonging. Enrichment ensures positive motivation, excitement and commitment to strive for excellence to meet personal and professional goals in nursing (Rubin, 1992; Human, 1996; Abruzzese, 1996). Research Aim: The aim of the research is to describe a model for an enrichment programme, as support system for institutional transformation to enable nurses to fulfil their professional role in striving for excellence in nursing. Three objectives are set: Explore and describe the needs of nurses which should be included in a model for enrichment programme for excellence in nursing, within a hospital context, Develop a model for an enrichment programme for excellence in nursing, and Implement, validate and refine the intervention model for an enrichment programme for excellence nursing Research Design: The research design used in the study is as follow: 69 Institutional Case Study Qualitative methodology Participatory Action Research A Grounded Theory Approach was used to identify and describe the concepts associated with the needs of nurses, as experienced by nurses, thus forming the foundation for the conceptual framework in order to develop a model for an enrichment programme in nursing. Data collection and data analysis occurred simultaneously to identify patterns and relationships between these patterns. The identified related concepts form the framework to describe a model for an enrichment programme in nursing (Burns & Grove, 1993:30; Denzin, et al 273-274; Morse & Field, 1996:128-130). Participatory action research was used as a situational, collaborative, participatory, self-evaluative research strategy. By acknowledging the lived experience of the needs of nurses, concepts associated with an enrichment programme was identified and described, thus forming the foundation for the conceptual framework in order to describe a model for an enrichment programme in nursing. Changes in practice are more likely to occur because participants are involved in inquiry and applications of findings. Continuous collaboration in all the phases of the study, between the researcher and the participants, allowing for mutual understanding, consensus, democratic decision-making and common action is essential (Oja & Smulyan 1989:4- 12; Denzin & Lincoln, 1994:328). Research Method: A brief description on the research method used to obtain objective 1 is given: OBJECTIVE I: Explore and describe the needs of nurses which should be included in a model for enrichment programme for excellence in nursing, within a hospital context. 70 Sampling: Theoretical sampling was done whereby data is jointly collected, coded and analysed, thereafter deciding what data to collect next in order to develop a model for an enrichment programme in nursing. The collection process is influenced by the emerging analysis, and participants are therefore chosen as needed rather before the design begins (Morse & Field, 1996:130). Data collection: The exploration and description of the needs of nurses in a hospital context were achieved through in-depth focus groups (n=20), individual interviews (n=20), direct observation, and field notes. Focus group- or individual interviews were held to generate in-depth knowledge of the needs of nurses in the empirical world within a hospital context. The participants included nursing service managers, senior and professional nurses, unit managers, enrolled nurses, nursing auxiliaries, nursing students, patients, and doctors (n=300). To ensure the trustworthiness of data, analysed data was presented at follow up focus groups. Data-analysis: Data-analysis was done through constant comparative method (Morse & Field, 1996:130). Identified concepts related to the needs of nurses as experienced in a hospital context will form the foundation for the conceptual framework in order to develop a model for an enrichment programme in nursing. Results of objective 1: The following schematic diagram represents the preliminary results of the core needs identified (Figure 1.1). Conclusion: A definite need was identified by the participants for such a model. The implementation of the model commenced in February 2001 at a large regional hospital in Gauteng, whereafter it will be evaluated and refined. 71 SUPPORT PROGRAMME FOR MATERNAL HEALTH IN KWAZULU-NATAL (KZN) DISTRICT HOSPITALS NC Mzolo Centre For Health And Social Studies (CHESS), University of Natal Introduction This support programme is an initiative of the Provincial MCWH sub-directorate in KZN, selected regions in KZN and the Centre for Health and Social Studies (CHESS). It is designed to tackle major problems in maternal health in rural hospitals of KZN. A pilot programme was started in October 1999 in region D (Emakhosini), followed by region C (Thukela) in May 2000 and region E (Uthungulu) in July 2000. These regions identified Maternal Health as a priority in their areas. The first year of the programme was regarded as the setting up phase and the second year as a consolidation phase. Problems Encountered On embarking on the support programme numerous problems were encountered that were related to administration, clients, health-workers and management of clinical problems. Administration Poor monitoring of the service e.g. Perinatal Review Meetings (PRM) not conducted regularly or not conducted at all, or not well attended by staff involved in maternal care. Poor communication systems (phones and radiophones) between clinics and hospitals which made the referral system difficult and unsatisfactory. Poor communication among health-workers within the hierarchical structure, as well as between doctors and midwives rendering maternal health care resulting in poor interpersonal relationships. Transport problems sometimes with delays in emergency referrals of up to four hours. 72 Clients Late booking or unbooked clients: This problem resulted in poor antenatal care with complications that could have been prevented during ANC and made plans to cope with problems during labour. Failure of the clients to respond in time to advice (e.g. when referred for ultrasound or for admission) often due to lack of resources (transport and finances). Health–workers Shortage of personnel Frequent rotation of staff resulting in disruption of the continuity of care, unless a few committed members are kept in the team. Inexperienced staff rendering maternal health. Poor working relationships. Demotivated staff lacking a sense of self worth. An overwhelming burden of HIV/AIDS. Staff taking care of clients, peers and family members who are battling with this condition as well fearing for their own lives. Management of clinical problems Poor screening and poor management of clients due to limited knowledge and skills among health workers resulting poor use of the antenatal card and the partogram, i.e. poor history-taking, recording, interpretation of findings, poor decision-making and ultimately poor outcome of labour. Unsatisfactory outcome: In some hospitals the perinatal mortality rates were up to 70/10000. Key Principles In Establishing A Maternal Health Programme 3.1 Building Maternal Health Teams To ensure that the burden of improving maternal health is not carried by one individual e.g. a doctor who may spend a limited time in that facility and then move to another. It was found essential to involve all those members rendering maternal care (recognise intersectoral collaboration) and unite them to strengthen their commitment to the improvement and maintenance of standards. 73 3.2 Establishing Regular (Monthly) Perinatal Review Meetings (PRM) Provide health worker with an opportunity to reflect on their practices, learn new methods and reinforce good practices and together determine solutions to their problems. Equip health-workers with knowledge and skills that will help them monitor and evaluate quality of care by targeting avoidable factors. 3.3 Personal and professional development of each worker These sessions aimed at boosting the morale of the health workers and re- instil enthusiasm for their chosen career as well as increase acceptance of new responsibilities. 3.4 Improvement and strengthen support within facilities as well as external support This programme encourages involvement and commitment by management and also support by district and provincial stakeholders. 3.5 Linking the sub-districts to strengthen the district programme through workshops Develop goals, objectives and indicators together as a district as well as increase commitment to address common problems together. 3.6 Encourage research arising from review of work Demystify fears of research among midwives and promote evidence-based midwifery practice on self-identified local problems. 3.7 Shifting focus from personal care to public care and planning Encourage health-workers to have a vision for Women"s Health in their communities and promote partnership with communities as well as respect for local culture. 74 3.8 Develop reflective practitioners and promote learning organisations Encourage opportunities for reflection on experiences and lessons learned. Promote a culture of learning among health workers and also sharing of resources. 3.9 Work towards sustainability Teams had to identify relevant stakeholders (including the management) with recognised expertise to encourage and strengthen one another. 4. Description of the Programme The support programme commenced following a situation analysis of the maternity services in the province. The regional task teams that identified maternal health identified as the priority and some as part of the Child Survival Project were the first ones to be targeted. Preparatory meeting were held with regional managers, sub- district managers, maternity supervisors MCWHC and PHC co-ordinators, task teams and doctors rendering maternity services in the subdistricts. In each region/district a maternal health team was formed, made up of 8-10 members in each sub-district. Each team is composed predominantly of midwives from various units in maternity (including clinics), maternity and paediatric doctors, a representative from management and the MCH co-ordinator who overseers the programme. Members from social support services were co-opted as the need arose. The responsibility of the teams was to co-ordinate maternal health programmes in the district, participate in planning and training and ensure that feedback is obtained and given to other members rendering maternal care in between the visits by the support team. As circumstances are different in each sub-district, the programme in each district was adapted to meet particular needs of the district. The programme was developed in two phases for two years. The first phase-setting up phase which involved building of teams, establishing a learning community, assisting team in building their knowledge, skills, attitudes, confidence, assessment and monitoring of quality of care. The second phase - consolidation phase assisting teams with management of maternity services and maintenance of standards. 75 The training programme is described as follows: 1. Conduct on-site monthly and when necessary) visits to gain understanding of working environment as well as enable a large numbers of health- workers to attend the meetings. 2. Establishing (where non-existent) and participating in monthly Perinatal Mortality Review Meeting (PRM). Specific ground rules were set up by teams for conducting effective PRMs to ensure that each member is comfortably accommodated as part of the team. The following guidelines were developed to ensure that these meetings were well organized: Preparation for a PRM which includes compiling summaries of perinatal deaths within 24 hours of their occurrence whilst facts are fresh in memory and records still available. Filing of these summaries and reviewed by a team. (record analysis) Records analysis by three persons (doctor in charge of maternity, midwife in charge and person involved in the perinatal death (this needs to go under the item "Preparation for the PRM") Keep up-to-date statistics from hospital and satellite clinics and liaise with the district information officer to give indicators that are essential for reporting and retrieving information, making use of the Perinatal Problem Identification Programme (PPIP) Facilitation of a PRM to stimulate critical thinking and identify actions to be taken A session to reflect on lessons learned that need to be shared with colleagues Encourage members to conduct research projects arising from problems identified during the PRM or any other areas of interest e.g. squatting position for delivery, BBA survey Subjects/topics requiring further investigation and input are delegated to members to search and provide feedback in next PRM Reviewing actions taken following a previous PRM 3. Conduct combined/district workshops that are attended by core members of the Maternal Health Teams from each sub-district. 76 4. Compile reports on each visit and disseminate to relevant stakeholders e.g. MCWH coordinators, participants and regional projects director in each region to identify their own areas of responsibility so as to take action 5. Facilitate implementation of Perinatal Education Programme (PEP) in each district to equip health-workers with knowledge and skills to practice with confidence and competence 6. Provide a learning stimulus and encourage members to keep learning files Lessons Learned The support programme has to be flexible and appropriate to the particular needs of each sub-district i.e. both to service needs and personnel needs. The programme has provided the opportunity of doctors and midwives to learn together. This has a positive influence in improving working relationships. Team involvement in the perinatal review meetings has increased participation and commitment. Use of perinatal "successes", clinical problems and "near misses" as opportunities for learning. The programme has begun to motivate members to seek ways of improving the quality and standards and have been motivated to develop their own protocols and instruments for auditing their records, as well as making use of the provincial manual. The value of having external facilitators (CHESS) has been identified by participants as a positive influence in equipping health workers with skills they need. The need to consider sustainability of the programme has to be addressed as the programme progresses and as health workers become aware of their responsibilities in maternal health. 77 PROCEEDINGS DATABASE: PROCEEDINGS OF THE PRIORITIES IN PERINATAL CARE CONFERENCES (1982-2000) RV Prinsloo, RC Pattinson MRC Unit for Maternal and Infant Health Care Strategies, University of Pretoria The Proceedings of the Priorities in Perinatal Care Conferences (1982-2000, including IAMANEH 2000) are available on CD-Rom. All articles have been indexed and allocated keywords in the Proceedings database (Access 2000). The database is updated annually as the latest Proceedings are published. Searches can be performed by author, keywords, title (or portion thereof) and by year. These searches can be printed. There are links from the database to the relevant Proceedings. Links can be accessed in the main table of the database. Articles can then be viewed and/or printed. CDs are available from: MRC Unit for Maternal and Infant Health Care Strategies Klinikala Building, Kalafong Hospital Private Bag x396 PRETORIA, 0001 Tel/Fax: (012) 373-0825 E-mail: email@example.com 78 COMPARING CURRICULUMS CH Venter, RC Pattinson Department of Obstetrics & Gynaecology, University of Pretoria MRC Unit for Maternal and Infant Health Care Strategies, Kalafong Hospital, Introduction A new undergraduate curriculum was introduced into the Department of Obstetrics in 1999. In the old curriculum obstetrics and neonatology were taught as separate entities. The new curriculum differs from that of the old, in the sense that Obstetrics and Neonatology are taught as a single entity. The old curriculum consisted of weekly lectures throughout the year, as well as a one-month clinical rotation at a tertiary institution. The new curriculum consists of a 12-week rotational block. During this period the groups rotate at different levels of the health care system, as well as receiving lectures, skills laboratory sessions and case and self-study tasks. Unlike the old curriculum these students are now intimately involved in patient care and management until later in the course. After the practical rotations, both groups were tested by means of an OSCE. The purpose of this study was to determine if by changing the curriculum the students" knowledge and clinical skills as assessed by an OSCE, differed. Methods A comparative study was performed between the two groups of students, where 20 standard OSCE questions were utilised. The OSCE questions were classified according to the Nijmegen Classification systems. All questions fell within the essential knowledge or essential skills category. Results The old curriculum group did significantly better in the practical skills questions. Differences between the two groups were especially marked in the integration and 79 management of problems during the antenatal period (eg. Antenatal Card) or in labour (eg. Partogram). Conclusion More focus should be placed on the understanding of the partogram and antenatal card, as well as identifying and solving these problems. The recommendation would be to appoint clinical tutors to try and improve the clinical skills of the new curriculum students. 80 SESSION 3: ANTENATAL CARE THE EFFECT OF AQUATIC EXERCISE DURING PREGNANCY ON FETAL WELLBEING SJ McDonald1,2,5 , JP Newnhan2,4, SF Evans2, A-M Lynch2,6, C Goodman3 1 King Edward Memorial Hospital, 2Women and Infants Research Foundation (WIRF), 3 4 Human Movement Department, Department of Obstetrics and Gynaecology, University of WA. 5La Trobe University, Vic. 6Health Dept. WA. There is some evidence in the scientific literature to suggest that women who are physically fit throughout their pregnancies may cope better with the energy expenditure demands of labour and birth than sedentary women. At PSANZ Brisbane 2000, the authors reported results from a 13 week (16w-28w gestation) moderate level exercise lap swimming program that showed an increase in maternal physical work capacity of 22% for swimmers when compared to a control group which remained constant. No maternal adverse outcomes were detected related to the swimming program. This paper reports the outcomes of fetal measurements designed to detect any deviation from normal for fetal well-being in a group of women followed through the second and third trimesters of pregnancy. Aim The purpose of this aspect of the study was to measure fetal well-being by means of CTG, intermittent auscultation using a hand held doptone and Doppler flow studies. Method Healthy, nulliparous women who described their exercise level as sedentary for the first 4 months of their pregnancy were invited to participate. Following a baseline bicycle ergometer fitness test using the standard submaximal test of Physical Work Capacity (PWC), the PWC170 , which estimates the workload that a person could achieve at a heart rate of 170bpm, women were assigned to one of two groups: 1. Control Group. The women were asked to complete a daily exercise history diary 81 and to repeat the basic fitness test at monthly intervals throughout the study. They were otherwise free to do what exercises they wished. Fetal heart rates were recorded prior to and following each fitness test. 2. Swimming-exercise group the women were asked to undertake three supervised 40-minute swimming exercise programs per week. In addition, they were asked to complete a daily exercise history diary and repeat the basic fitness test at monthly intervals throughout the study. Intermittent auscultation was recorded prior to and following each swimming session and bicycle ergometer fitness test. A formal CTG was recorded at 28w, 32w, 36w and if possible term gestation. Results Results are reported only on those women who were assigned to the swimming program (n=24). Maternal fitness levels at 16 weeks gestation were similar for both groups (controls 814+/-41kgm/min, n=11 and swimmers 767+/-24kgm/min, n=14). The average distance swum per session doubled over the program duration, increasing from approximately 500m at 16 weeks to approximately 1000m by 28 weeks gestation. Maternal heart rate during swimming averaged 130bpm+/-2bpm (n=14). Fetal heart rate recorded within 5 minutes of the last swimming effort of the session displayed a slight increase (4.3bpm+/-2bpm n=14) above resting values (p=0.02). No values recorded were outside normal limits. 82 THE ACCURACY OF DOPPLER FLOW VELOCIMETRY SCREENING FOR CHRONIC PLACENTAL INSUFFICIENCY IN PATIENTS WITH UNCERTAIN GESTATIONAL AGE. GB Theron, AM Theron MRC Perinatal Mortality Research Unit, Department of Obstetrics and Gynaecology, University of Stellenbosch and Tygerberg Hospital There is a significant association between an increased resistance index (RI) of flow velocity waveforms of the umbilical artery as determined by Doppler ultrasound and complications of placental insufficiency. The RI reduces as the gestational age (GA) advances. Underestimation of the GA could result in an incorrect interpretation of the RI. Objective To determine the proportion of patients whose Doppler indices will change if a clinical method is used to determine GA. Study design: Structure: A cohort analytic study Study population Patients referred to the Fetal Evaluation Clinic (FEC) at Tygerberg Hospital with suspected IUGR, whose GA has been confirmed by ultrasound prior to 24 weeks. Measurements A single observer determined the symphysis–fundus (SF) height at the FEC and the RI. The outcome of all the pregnancies were determined. Data analysis The proportion of patients whose RI would have changed from intermediate (> 75- 95th centile) to low risk or from high risk (> 95th centile) to intermediate or low risk, 83 if GA was unknown, was determined. The GA, as determined by the SF measurement in the referring clinic, was investigated. Results A total of 233 patients were included in the study. The mean (S) GA at the 1st antenatal visit was 13.0 (4.9) weeks and the mean GA of the first ultrasound examination 14.9 (5.1) weeks. The mean gestation at referral to FEC was 28.2 (4.3) weeks. 229 (98.3 %) of the patients were referred to the high-risk clinic, 2 transferred, one went for private care and one remained a low risk patient. The most common reasons for referral to the FEC are summarised in Table I. The mean GA at referral to the FEC was 28,2 (4,3) weeks. The resistance indices of the Doppler ultrasound are shown in Table II. A total of 380 Doppler examinations were performed. A total of 109 (46.8 %) patients required antenatal admission. The reasons for admission are summarized in Table III. Details regarding the onset of labour, method of delivery and the birth weight of the babies are shown in Table IV. The perinatal mortality (PNM) rate was 47.2 / 1000 deliveries, including only babies with a GA of >24 weeks. There were 8 intra-uterine deaths with a birth weight that ranged from 474 – 1550 g* and a GA from 24 - 36* weeks. There were 3 early neonatal deaths with a birth weight that ranged from 882 – 915 g and a GA from 24 - 36 weeks. (*The baby with an I cell syndrome). The proportion of patients whose Doppler index changed when the GA was determined, according ANC SF measurement, is shown in Table V. Determination of GA according to the SF measurement in the clinic would have resulted in a potentially harmful downward shift in 17 (7,3 %) patients. Of these patients, 14 moved from above to below the 75th centile and 3 from above to below the 95th centile. Only 2 of the 17 patients had a normal outcome, 14 babies were light for GA and one had an I cell syndrome. The median GA of patients, whose pregnancies resulted in PNM and those with a Doppler shift, were 24 weeks (range 23 – 29) and 31 weeks (range 23 – 39) respectively. 84 Discussion Adding confidence intervals to the clinical method of determining GA will increase the safety margin. Previous and present pregnancy complications that are associated with chronic placental insufficiency must also be used to determine the need for repeating Doppler ultrasound investigations. Pregnancies resulting in PNM most often do have a past history and develop pregnancy complications at an earlier GA with a smaller error margin when determining GA. Table I : Reasons for referral to HRC (%) Poor obstetric history 71 (31.0) (Previous IUD = 44) Hypertension 65 (28.4) Previous preterm labour 18 (7.9) Previous C/S 12 (5.2) Previous pre-eclampsia 9 (3.9) % of referrals 76.4 Table II : Resistance index centiles (%) <75th 148 (63.8) >75 and <95 64 (27.6) >95 12 (5.2) AEDF 7 (3.0) Reversed flow 1 Table III : Reasons (%) hypertension 37 (33.9) preterm labour 20 (18.3) pre-eclampsia 23 (6.4) APH 7 (6.4) AEDF 5 (4.6) % of admissions 84.3 85 Table IV : Labour and delivery data (%) Onset of labour spontaneous 101 (43.3) induction 95* (40.8) elective C/S 28 (12.0) unknown 9 (3.9) Gestational age at delivery (weeks) mean 36.8 (3.4) median 38.0 range 24 - 42 Delivery NVD 155 V/E 6 Breech 4 C/S 60 (26.7) Birth weight (g) mean 2608 (826) median 2756 range 474 - 4558 LiGA 67 (30.2) (*Includes 2 terminations) Table V : Patients with a changed Doppler index (%) shift 17 (7.3) shift 16 (6.9) total 33 14.2) 86 OUTCOME OF CONSERVATIVE MANAGEMENT OF VERY PRETERM PREMATURE MEMBRANE RUPTURE WITH ROUTINE ANTIBIOTIC USAGE. CJM Stewart, SK Tregoning, G Moller, H Wainwright Rupture of membranes before viability occurs in 0.65% of all pregnancies. The majority of patients presenting with this problem will labour within 48 hrs. The remainder pose a significant management dilemma because of the potential maternal and neonatal morbidity and mortality. There is still no consensus regarding the management of very preterm premature rupture of the membranes (VPPROM). While several recent studies have looked at the outcome for mother and infant with expectant management, with survival rates ranging between 22% and 62%, many of these have been retrospective and the use of antibiotic, steroids and tocolysis was non-existent or uncontrolled. There is now considerable evidence to suggest that prophylactic antibiotics are beneficial in patients with preterm premature rupture of the membranes who are conservatively managed. The Cochrane metanalysis shows a longer latency period and a decrease in infective complications in patients to whom antibiotics are administered. The effect on outcome in patients where the rupture of membranes has occurred before viability has not, however, been studied. The purpose of this study was to report the outcome of expectant management with routine antibiotic usage in pregnancies complicated by VPPROM, and to compare this with the published literature. Method Prospective descriptive study of 78 women with confirmed membrane rupture at less than 28 weeks gestation, managed conservatively. Amoxycillin and metronidazole were given from the time of membrane rupture till delivery. Steroids were administered at 28 weeks. All patients were monitored for signs of infection both clinically and with serial white cell counts and C-reactive protein estimations. Regular ultrasound examinations were also performed to assess growth, amniotic fluid 87 volume and to measure thoracic circumference. Patients were delivered if infection supervened, if there was fetal compromise, if spontaneous labour ensued or if the pregnancy continued to 34 completed weeks gestation. Results The mean gestational age at membrane rupture was 23.3 +3.17 weeks (16.5 - 27.8). Mean latency period was 24.1 +29.1 days (1.5-154) . Eight women (10%) delivered within 48 hours, 25 (32%) within seven days and 55 (70%) within one month. Of note is that 23 (30%) had latency periods of greater than one month. The mean gestational age at delivery was 26.7 +3.92 weeks. There were 81 deliveries of which 36 (43%) survived. Survival was related to gestational age at membrane rupture, latency period, birth weight and gestational age at delivery (see tables). 16 women (20%) developed clinical evidence of chorioamnionitis. There was no increase in the incidence of infection with increasing latency period. Compression abnormalities occurred in 17% of neonates and lung hypoplasia in 18%. When comparing this study with other published literature which did not include antibiotic usage, there was a longer mean latency period (24 vs 15 days) and a lower incidence of choriomanionitis (20% vs 46%). Table 1. Perinatal outcome Gestational age at membrane rupture (wks) < 20 20-24 24-26 26-28 ALL n=14 n= 22 n=24 n=21 n=81 Mean gestation at rupture 17,8 22,2 24,4 26,7 23,3 of membranes Stillbirth 7 8 6 0 21 Neonatal death 4 6 10 5 25 Perinatal survival 3 8 8 16 35 21,4%) (36,4%) (33,3%) (76,2%) (43,2%) ___________________________________________________________ 88 Table 2. Characteristics of survivors and non-survivors Survivors (n=35) Non-survivors (n=37) Gestational age at 24.4+ 3 22.5+ 3.1 * rupture of membranes (wks) Gestational age at delivery(wks) 29.6+ 2.8 25.9+2.3 * Latency period (days) 35.7 +36.4 16.4+ 19.6* Chorioamnionitis 7 8 Steroid administration 25 11 Birth weight (g) 1484 + 619 811+257 ** AFI at rupture of 3.7 2.3 membranes AFI prior to delivery 4.5 2.1 ____________________________________________________________________ *p<0.05 **p<0.001 Conclusion This study shows that conservative management of patients with very preterm premature membrane rupture which includes the routine use of antibiotics, results in an acceptable survival rate with a longer latency period than in other studies. The incidence of infectious sequelae is lower than in other studies with no serious complications. 89 THE TRAUMA OF TRANSLATION: THE DILEMMA OF THE PREGNANT WOMAN IN A MULTILINGUAL, MULTICULTURAL HEALTH CARE SYSTEM CM Jones The cultural and linguistic diversity that makes South Africa the magnificent nation that it is, also presents enormous problems for the provision of health care, both for the caregivers and the community. What is our dilemma ? Varieties of Language and Communication Styles Eleven official spoken languages are formally recognised as means of communication in South Africa, however, the dialects, accents, and interpretations of various groups speaking these languages creates even more diversity of thought and expression. One only has to think of how well the "English" spoken by the Scot, Lillipiudian, or Texan would be understood by the Afrikaaner, Xhosa or Shangaan! Add to this the intricacies of non-verbal cultural body language styles which either hinder or enhance smooth communication and there is even more room for confusion and misunderstanding in the provision of health care in South Africa. History of Cultural Separation Our history of health care offered under the laws of apartheid has further compounded the problem. South Africans studied, lived, socialised and related within legally defined limits. This resulted in stereotyping across racial and cultural borders, and the isolation of people from each other. Black nurses (and other health care providers), albeit, trained in English but only with other black students, have practised in black health care facilities, within the cultural context of this social structure, language and lifestyle. The same can be said of government defined "white, coloured and asian nurses". Although cross- cultural nursing was touched upon in the training curriculum, it was never seriously challenged by practice. 90 Transition and Transformation in South Africa However, after 1994 to the present, South Africans have been battling to make health care institutions culturally acceptable to the majority of people asking for services. Health Care Professionals who were competent, comfortable and efficient within their own language and cultural settings are now challenged to relate equally well in a number of languages and cultural milieus. At the same time they are asked to see a greater number of clients, while having less human and material resources and dealing with the additional stress of communication problems. Effects of Emigration and Immigration With the exodus of doctors and nurses to other countries, many posts have been filled by health care providers from South America, Europe and Africa, who may speak and write one or more of South Africa"s 11 official languages, but who are not comfortable in expressing themselves fluently in them. They may also be here on short-term contracts and therefore, not invested in learning new languages, adopting cultural practices or adapting their attitudes and behaviour while in South Africa. What happens to our women and children who require health care ? The Tower of Babel Where do our Women who require maternal and child health care fit in this "Tower of Babel"? Imagine this scenario - The Xhosa speaking nurse, who has studied nursing in Afrikaans is deployed to a hospital where the population speaks isiSotho and the language of professional exchange is English. She is now asked to serve as an interpreter between a Cuban Doctor (whose professional studies were done in Spanish and whose English is very basic) and a pregnant woman (whose home language is isiZulu but who speaks some Sotho, and very little English.) Unable to help the woman, the Doctor consults with his senior who is from Zaire, and speaks French fluently, but also only speaks and writes basic 91 English. He talks to the second-on-call, a Polish Doctor who speaks German well, but has not quite conquered English. The Zulu speaking general assistant, cleaning the floors, hears there is a problem. Fluent in Spanish because she and her husband were in exile in Cuba, she interprets for the doctor and then returns to her broom! ---oooOOOooo--- Is it any wonder that the quality of care given to this woman is almost entirely dependent on "good guesswork" on the part of both the caregivers and the woman? The Situation Views of Women Requiring Health Care Similarly, does it surprise us to find that women express dissatisfaction with the quality of care they receive, even if it is excellent and appropriate, simply because they do not feel that they have been understood. They also do not feel that they have been part of essential decision-making in the planning of their own care. They also express unhappiness with the "manner of approach" of the health care providers, stating that they: look at the antenatal, labour card or baby card rather than at them when they come into the cubicle; don"t introduce themselves, or "greet them" or give them time to sit down properly before firing off questions; don"t call them by name but just say "Auntie" or "Mother"; "stare" at them and then ask "direct questions" and expect fast "one word" answers; show by words and irritability, that they are busy and the woman must "hurry up and say what is wrong with her"; do not give them privacy when asking intimate questions or examining them; only speak to the interpreter and not to the woman herself and laugh with the nurse or person interpreting and talk about their own business. disregard the relatives who accompany them; make them feel "stupid" and "worthless" and "to blame" for whatever is wrong with them; examine them intimately in a rough, fast manner; 92 don"t tell them the results of their examination; are always "writing on papers" during the consultation; send them out of the consultation area not really "knowing what to do next". Views of the Expatriate Doctors and Other Health Care Providers Doctors who are not able to communicate well with other health care providers and the community are also frustrated. They report: anger and resentment at being considered inferior because they cannot express themselves well; inability to get better paying jobs because of language problems; rejection by the community who only want to be examined by a South African doctor who can talk to them (it is interesting to note that the community is much more intolerant of the black doctor who does not speak the language well than of the white doctor – this increases the tension on these practitioners); increasing interpersonal friction with nurses in particular who resent being translators; the tendency to relate only to those of their nationality with whom they can speak freely and this leads to a sense of social isolation from mainstream South African living; tendency to compare the South African health care system and types of patients with their homeland; Expatriates are sometimes perceived by South Africans as "taking the job" of a South African and there is a sense of increasing xenophobia. Views of Nurses Nurses too, express dissatisfaction with their jobs, stating that they:- feel unskilled in the art of translation and interpretation and resent having to perform this additional task for doctors (or other nurses and health care providers) while there is still so much of their own work to do. They note that this is particularly a problem in the public sector of health care provision. They have seen doctors (and other nurses and health care providers) who "could not possibly learn" the language of the people while working in public institutions, acquire amazing efficiency in the 93 language as soon as they entered private practice where fee payment is dependent upon good communication and patient satisfaction!; are perceived to be guilty of not translating properly when the patient does not get the care or medication which they think they should get. This leads to friction with the community; are blamed if the wrong diagnosis has been made by the doctor since "they must have given the wrong information" or "such a mistake could not possibly happen" otherwise; realise that, in order to save time, they often ask many more questions than the doctor asked, and tend to make a personal diagnosis and try to get this confirmed by the patient. (Woman has raised blood pressure, proteinuria and oedema – so all the questions related to a diagnosis of imminent eclampsia are asked by the nurse). This may mislead the doctor in his/her further examination and diagnosis; feel compromised when the doctor uses abusive language and gestures to the patients and they then try to be peacemakers in order to defuse the situation; are often the buffer between the doctor, nursing management, the community, other nurses and health care providers – this causes tension; are at odds with their nursing hierarchy for spending so much time "doing doctor"s work" when their own is left unfinished.; also feel sorry for the doctors who are supposed to care for patients but cannot talk to them; are aware that they can use the power that they have in speaking the language to gossip about the doctor or refuse to assist him or her. This leads to interpersonal relationship breakdown and poor patient care; feel resentful of doctors and other health care providers who have been in South Africa for 10 years or more and still cannot ask the patient "What is your name ?" or make any effort to learn the language; What can be done ? SUGGESTIONS:- Registering Statutory Bodies: 94 These should provide for the functional testing of the linguistic proficiency of people applying for registration under their jurisdiction and not depend merely on the ability of the applicant to read and write the required language. Employers: Position Profiles and Job Descriptions should be carefully drawn up by the employing body to indicate exactly what level of communication proficiency is the employee required to achieve and within which time frame. Time should be provided by the employer for the employee to attain language skills as part of the skill development program. Should the employee not reach an acceptable level of communication, salary increments and promotion should be withheld until it has been achieved. Should there be no improvement at all, disciplinary action should be taken. This issue should be considered vitally important and doctors (and other health care providers) should not be considered such a scarce and valuable resource that basic communication with the patient is seen to be expendable. Mechanics may be able to function without communication, but that is scarcely the role of a healer. Should the employer still insist that the services of the doctor are essential then a dedicated interpreter must be provided who is not part of the nursing or clerical staff complement. Whether this is the financial responsibility of the doctor or the employer could be negotiated. Ex-patriates, who are not fluent in the mainstream language of the country, should not be immediately deployed to outlying rural hospitals and clinics without passing a basic communication course in the mainstream language as well as the community"s language. Educators: Health care providers and in particular nursing education programmes need to assist the participants to develop skills in the art of interpretation rather than that of verbatim translation. This is a skill that requires development and is not merely acquired along the way after graduation. The link between interpretation and teamwork, patient advocacy and medico-legal hazard prevention needs to be clarified in the learners mind and developed in his/her skills 95 Cross cultural health care provision skills should be assessed with the same enthusiasm as motor clinical skills and not just given lip service. Ongoing professional development should not only be encouraged but obligatory for all health care providers and they should be credited for additional language skills. Employers Ensure the vision and mission of the health service are consistent with the principles of good communication Provide policies and procedures to ensure vision and mission are enabled Make learning languages and understanding cultures possible by: Utilising skilled employees to run in-service programmes Provide time for learning Provide materials Books Audiocassettes and Videocassettes CD ROM programmes Promote and reward staff members who show communication skills and genuine values of respect for the community served by the health service Use Motivational and Disciplinary Procedures to ensure staff compliance Health Care Providers Be creative in attempts to learn the language and customs of the community served Learn how to pronounce the common names of the health service staff and community members and use them Learn like children learn a language – not by just by books but by listening and observing Make use of every opportunity to learn, even if "time" is not given by the employer Make use of aids to communicate with patients – pictures, posters, phonetic flash cards, tape recorders, automatic translators (computerised) If acceptable to the patient, use relatives or friends to be interpreters 96 Ask for community volunteers (Church and Women"s groups) to help interpreting and language proficiency Prepare a history or common question sheet to give to women while they are in the waiting area. They (or with literate relatives or volunteers to assist them) could already have answered a number of routine questions before entering the consultation room. The principles of community development and capacity building which are promoted for the initial and ongoing transformation of our nation are as applicable and as necessary in the transformation of our health care service providers. This demands of us a commitment to better communication and understanding of each other. Let BATHO PELE – PEOPLE FIRST ! be not only the motto of our new health service but of our individual dedication as health care providers. Study This study was conducted by means of focus group and individual interviews in order to obtain the opinions of 20 women receiving maternal care in clinics and hospitals in KwaZulu/Natal, 20 nurses and 10 expatriate health care providers. 97 VISION OF PRIVATE –PUBLIC SECTOR CO-OPERATION IN COMMUNITY OBSTETRICS: THE EFFECT OF INVOLVING PRIVATE PRACTITIONERS ON THE QUALITY OF ANTENATAL CARE OF THE INDIGENT POPULATION OF TEMBISA RC Pattinson, KR Mokhondo, AK Tshabalala, T Chaane, R van der Walt, M Modise Khayalami Independent Practitioners Association, MRC Unit for Maternal and Infant Health Care Strategies and Gauteng Department of Health. Objectives To test the hypothesis that Private Practitioners provide more accessible care to indigent patients from Tembisa than the hospitals and clinics. Setting: Tembisa Township. Background of the Study The normal behavior of all women who think they are pregnant is to have their pregnancy confirmed by a GP within the first three months. The introduction of pregnancy conformation clinics in municipal in clinics at Atteridgeville and Central Pretoria has led to a reduction in gestational age of initiating antenatal care from an average of 22 weeks to an average of 12 weeks.(BS Jeffrey, M Tsuari, LR Pistorius, J Makin, RC Pattinson. The impact of pregnancy confirmation clinic on the commencement of antenatal care. S Afr Med J Feb 2000; 90 (2):153-156) Preparation for the study Gauteng Province"s Antenatal Care Policy Guidelines have been distributed to the GPS, hospital doctors and midwives. Two antenatal training workshops have been held at Tembisa Hospital for doctors, private practitioners and midwives. 98 Method A cohort analytical study on indigent pregnant women in Tembisa. All women delivering at Tembisa Hospital will be included in the study. This population will be divided into two groups. Group A will be those women who confirmed their pregnancy with the private practitioners who will then perform a full examination and fill in intial visit on the motherhood card, in those women desiring to continue with the pregnancy. These women will be requested to go to Tembisa Hospital where a hospital number will be written on the motherhood card and the routine antenatal care and the special investigations will be performed. The antenatal care will follow Gauteng Province"s Antenatal Care Policy. The hospital or private practitioners will record special investigation results on the motherhood card. Should any complications arise, the patients will be referred to Tembisa Hospital for further assessment and management. Group B will consist of a random selection of all the other women who had antenatal care at the public institutions and will be a control group. This group will follow the standard antenatal care process already established at Tembisa Hospital and its clinics . Data All motherhood cards will be collected upon delivery at Tembisa Hospital and the pregnancy outcome recorded. Outcome The gestatitional age at initiation of antenatal care. The quality of antenatal care. Results The study started in October 2000.only data concerning gestatitional age on starting antenatal care is presently available Private practitioners Public sector . No of clients entered 113 113 Average gestatitional age at First visit 18 25 (Range 3-35) (Range 12-38) Study is ongoing. Completion date: end of 2001. 99 SONOGRAFIC PLACENTAL GRADING : A NON – INVASIVE PREDICTOR OF LUNG MATURITY. T Vanderheyden, RC Pattinson, B Jeffery. MRC Unit for Maternal and Infant Healthcare Strategies, Kalafong Hospital, University of Pretoria Introduction The aim of this study was to evaluate the use of sonografic placental grading as a predictor of lung maturity in patients for elective caesarean section. A non-invasive test is needed for patients who decline HIV-testing or HIV positive patients. Methods All patients undergoing amniocentesis and TAP-test in the kalafong hospital prior to elective cesarean section were included. The estimated gestational age, the sonografic estimation of fetal weight, the placental grade (documented with print- out) , the result of the tap test end the neonatal outcome was noted for every patient. The placental grading was done as described by Grannum et al . Results At the time of abstract submission 20 patients have been included in the study. 20 TAP-tests were preformed. The average (unsure) gestational age was 37 weeks. The average EFW was 2.41 kg. The placental grading was 2 in 11/20 cases (55%) and 3 in the other 9 cases. None of the neonates had respiratory problems, none were intubated. Conclusion According to the preliminary results of our study, sonografic placental grading 2 and 3 are a good predictor of lung-maturity. The study is ongoing. 100 PREVALENCE OF CHLAMYDIAL TRACHOMATIS INFECTION IN EARLY PREGNANCY AT KALAFONG HOSPITAL. GH De Wet, R Joubert, E Elliot Department of Obstetrics and Gynaecology, University of Pretoria. Introduction Chlamydia is one of the most prevalent sexually transmitted bacterial infections. It is an important pathogen in several disease processes including being a causal agent for pre-term labour. It also plays a major role in post-abortion infection morbidity. However, chlamydial infection is asymptomatic in a large proportion of women. Increased attention is being paid to early diagnosis and treatment. Objective To determine prevalence of Chlamydia trachomatis infection in early pregnancy at Kalafong hospital. Patients 155 consenting consecutive patients attending the termination of pregnancy clinic at Kalafong Hospital. Specimens First voided urine and a cervical swab from each patient. Results The prevalence of Chlamydia in the tested patients was 25.8% (40/155). Conclusion and suggestion There is a very high prevalence of Chlamydial infection in early pregnancy at Kalafong Hospital. This poses the question of screening for chlamydia in early pregnancy and then treatment of infected patients with erythromycin. 101 SESSION 4: LOW-BIRTH WEIGHT NEONATES RESPONSE TO A STANDARDISED FEED DURING THE NEONATAL PERIOD: BIRTHWEIGHT AND LENGTH ARE STRONG DETERMINANTS OF GLUCOSE AND INSULIN CONCENTRATIONS. IP Gray, NJ Crowther, BJ Cory*, PA Cooper*, M Toman Departments of Chemical Pathology, SAIMR and *Paediatrics, University of the Witwatersrand Studies in Europe, India and the United States have shown that birth weight and weight at one year of age correlate with glucose tolerance, suggesting that birth weight and early infant growth are related to a later propensity for developing type II diabetes. This has led to the "thrifty phenotype" hypothesis which suggests that intrauterine growth retardation results in limitation in the number of pancreatic islet cells which may manifest clinically in later life. Those most at risk appear to be those born with low birth weight who later develop a high body mass index. In South Africa there is a high rate of low birth weight (approximately 16%) while very low birth weight infants (<1500g) make up 2-3% of all deliveries. About two- thirds of low birth weight infants demonstrate intrauterine growth retardation and many of these show "catch up" growth during the first few years of life. Crowther et al studied 7-year old children in Johannesburg who were part of the Birth to Ten Project and showed that low birth weight together with rapid childhood weight gain was associated with poorer glucose tolerance. It is also well known that South Africa has high rates of adult obesity amongst the rapidly urbanizing population. Aim The purpose of this study was to study the response to a standard feed during the neonatal period in infants with birth weight <2000g who were also growth retarded. 102 Methods We have studied 84 infants thus far (target 100) between the 1st and 50th day of life. The mean birth weight was 1300g and gestational age 33.7 weeks, while the mean birth weight at the time of study was 1500g. Each individual was given a standardised formula milk feed of 21ml/kg body weight (Nan7 prepared as per manufacturer"s instructions) after a 4 hour fast. Blood was taken via a heel prick at fasting and 60 minutes after the feed. The study was conducted after full informed consent by the mother and was approved by the ethics committee of the University of the Witwatersrand. Each child was measured at birth and at the time of the tolerance test: parameters were weight, length, head circumference, triceps and subscapular skinfold thickness, and crown-rump and sacrum-heel lengths. The ponderal index was calculated at both study times. Results The only significant correlation with fasting glucose values was the sacrum-heel length (r=-0.39, p=0.004). However, birth weight and weight at time of the meal tolerance test (r=-0.34, p<0.01 for both), length at the time of the test (r=-0.35, p=0.003), sacrum-heel length (r=0.35, p=0.012) all correlated negatively with the 60 minute glucose values. The only significant correlation with fasting insulin values was the weight at the time of the test (r=-0.35, p=0.012), whereas the 60 minute insulin concentration correlated only with sacrum-heel length (r=-0.37, p=0.006). All of the above correlations of glucose and/or insulin with anthropological measurements were corrected for gestational age. However, there was no correlation between gestational age and either glucose or insulin values. Conclusions Although still preliminary, these data show a clear relationship between weight and length measurements and glucose tolerance. This study further underlines the importance of anthropometric indices at birth in determining the metabolic future of the child. In societies in which low birth weight is a common occurrence and there are high rates of later adult obesity, the potential future morbidity should be recognised by policy-makers. 103 EPIDEMIOLOGY AND RISK FACTORS FOR FETAL ALCOHOL SYNDROME IN THE WESTERN CAPE PROVINCE D Viljoen South African Institute for Medical Research and Faculty of Health Sciences, University of the Witwatersrand Fetal alcohol syndrome (FAS) is the most common preventable cause of mental retardation worldwide. In South Africa, problems relating to alcohol abuse are common and multiple publications have described its association with road and pedestrian traffic accidents, serious crime, trauma, assault and domestic violence. A further major complication of alcohol abuse in women is fetal alcohol syndrome. This disorder has not received due attention and is a major contributor to fetal death, paediatric neurodevelopmental delays, growth disturbances and congenital malformations. Terminology The Institute of Medicine Report (1996) suggests the following terminology for use in relation to alcohol-related teratogenesis. These terms cover a wide spectrum of severity and a range of disorders and are applied to children born to mothers following heavy alcohol consumption during pregnancy, which they either admit or for which there is direct evidence. ● Fetal Alcohol syndrome (FAS) This applies to a child who has growth retardation together with central nervous system anomalies and characteristic facial dysmorphology. ● Alcohol-related birth defect (ARBD) This refers to a child with some of the commonly reported alcohol-related structural organ anomalies, but not the full clinical phenotype usually required for a confident diagnosis of FAS. 104 ● Alcohol-related neurodevelopmental defect (ARND) The neurodevelopmental deficiencies common to alcohol-related teratogenesis are present, but without sufficient structural anomalies or phenotypic criteria for a confident diagnosis of FAS. The term "Fetal Alcohol Effects" (FAE) is considered misleading as the diagnosis is often applied loosely to children of mothers who have consumed minimal amounts of alcohol during pregnancy, and who also have a few of the phenotypic or behavioural anomalies seen in cases of alcohol-related teratogenesis. The term has been abandoned in favour of the better-defined terms of FAS, ARBD or ARND. Clinical Manifestations A triad of signs is required for a confident diagnosis, namely: (1) Growth deficiency of all body measurements, both pre-and postnatally. (2) Central nervous system involvement including microcephaly, decreased IQ (average 63), agenesis of corpus callosum, impaired fine motor skills and behavioural anomalies. (3) Facial dysmorphism including mid-facial hypoplasia, short palpebral fissures, short nose with flattened nasal bridge, epicanthic folds, and a long smooth upper lip with thin vermilion border. Epidemiology Studies on the prevalence and risk factors for FAS have been undertaken in the Western Cape Province, Gauteng and, currently, in the Northern Cape Province. 2 These investigations followed a set protocol published previously. The prevalence rates derived for the school-entry population (Grade 1) of a rural community in the Western Cape were as follows:- 1997 Study : 46/1000 (n=982) 1999 Study : 64/1000 (n=840) 105 An increased prevalence of FAS in this community of 62.5% between the assessments undertaken in 1997 and 1999, was found. Reasons for the increased frequency of FAS are unknown but may include the worsening behaviours of alcohol abuse in women, changing socio-economic factors, normal statistical variation, and others. Neurodevelopmental evaluations of FAS-affected children and controls matched for age, sex, ethnicity and school, show highly statistically significant differences using the Griffiths tests standardised for South African populations. TABLE 1 - Neurodevelopmental Assessment of Children Children With Control Children Fetal Alcohol (n=42) P Syndrome (n=46) Mental age Mean 77.5 95.3 SD 13.36 8.5 <.0001 Performance IQ Mean 74.1 94.2 SD 11.13 13.56 <.0001 Verbal IQ Mean 71.7 88.3 SD 12.45 9.66 <.0001 Numerous risk factors have been evaluated for this Western Cape Population, some of which are listed in Table 2. TABLE 2 - Risk Factors For Fetal Alcohol Syndrome Mothers of Children Mothers of with FAS Control Children P Education (yrs) 4.4 6.1 0.027 Religiosity (%) 6.5 41.9 0.019 Gravidity (mean) 3.9 3.1 0.05 Drinks/week (15 ml) 12.6 2.9 <.0001 Heavy drinking partners (%) 77.4 34.5 0.001 There were no differences between mothers of FAS affected-children and controls for occupation, earnings, concomitant drug use (including smoking), or marital status. 106 Conclusions The frequency of FAS is higher amongst rural populations in the Western Cape than any previously reported large community. Urgent prevention efforts are required to remedy this situation and prevalence studies in other Provinces are necessary to identify other at-risk populations. 107 INCIDENCE OF RETINOPATHY OF PREMATURITY IN VERY LOW BIRTHWEIGHT INFANTS BORN AT KALAFONG HOSPITAL BJ Mitchell,* SD Delport,* J Grobbelaar# *Dept of Paediatrics, Kalafong Hospital and the University of Pretoria and MRC Unit for Maternal and Infant Health Care Strategies #Dept of Ophthalmology, Kalafong Hospital and the University of Pretoria Introduction A pilot study conducted during 1999 showed that the incidence of retinopathy of prematurity (ROP) was 24.5% in black very low birthweight (VLBW) born at Kalafong Hospital. The incidence of vision threatening ROP necessitating intervention was 4.2%. A service to screen all VLBW infants is in place and ongoing results are reported. Patients and Methods VLBW (<1500 gram) infants are enrolled at birth and screened at six weeks of age by indirect ophthalmoscopy. Examinations are repeated at one to three weekly intervals until retinal vascularisation is complete. Infants who develop threshold disease are treated with laser therapy. Results Over a period of six months (01/04/2000–30/09/2000) a further 101 infants were enrolled of whom 19 died before screening could take place and 14 were not screened. Of the remaining 68 infants, 13 were screened on an inadequate number of occasions to document complete retinal vascularisation and 55 were screened completely. Eight of the 13 inadequately screened infants had no ROP, 4/13 had Stages 1 or 2 and 1/13 had Stage 3. Twenty-one of the 55 adequately screened infants had ROP – 15/21 Stage 1 or 2 and 6/21 Stage 3 of whom three needed intervention. A total of 26/68 infants had ROP, with 3/26 having vision threatening ROP necessitating intervention to prevent permanent blindness. 108 Conclusions The incidence of ROP in VLBW infants born at Kalafong Hospital is 38.2% and the incidence of vision threatening ROP is 4.4%. The incidence of all stages of ROP is higher than previously reported but the incidence of vision threatening ROP has remained unchanged. 109 INCIDENCE OF POSTHAEMORRHAGIC HYDROCEPHALUS IN VERY LOW BIRTH WEIGHT INFANTS BORN AT KALAFONG HOSPITAL M Engelbrecht,* SD Delport,* HM Swanepoel# *Dept of Paediatrics, Kalafong Hospital and the University of Pretoria and MRC Unit for Maternal and Infant Health Care Strategies. #Dept of Ultrasound, Kalafong Hospital and the University of Pretoria Introduction Intraventricular haemorrhage complicated by posthaemorrhagic hydrocephalus are serious complications of immature infants. As proximal impairments, posthaemorrhagic hydrocephalus as well as retinopathy of prematurity are better measures to evaluate quality of neonatal care than distal impairments such as cerebral palsy, growth impairment and reactive airway disease. A prospective, descriptive study was undertaken to determine the incidence of hydrocephalus – presumed posthaemorrhagic – in very low birthweight (VLBW) infants born at Kalafong Hospital. Patients and Methods Consecutive VLBW infants were enrolled at birth and their clinical course documented prospectively. Head circumference was measured at birth and weekly thereafter until discharge. Cranial ultrasound was performed at 4-6 weeks of age by a single sonographer. In the event of dilated ventricles, ultrasound was repeated at two to four weekly intervals. Infants with progressive hydrocephalus received a ventriculo-peritoneal shunt. Both members of twins were enrolled, even if the larger twin weighed more than 1500 gram. Results One hundred infants with a median birthweight of 1230 gram (range 500 - 2115) were enrolled over a period of six months (27/03/2000 – 11/09/2000) of whom 83 were screened. Of these 83 infants, cranial ultrasound was normal in 54. Of the 29 infants with an abnormal cranial ultrasound, 27 had hydrocephalus of whom two 110 infants required a ventriculo-peritoneal shunt because of progression of hydrocephalus. Conclusion The incidence of dilated ventricles in VLBW infants born at Kalafong Hospital is 32.5%. The incidence of progressive hydrocephalus necessitating ventriculo- peritoneal shunting is 2.4%. 111 NEONATAL HYPOGLYCAEMIA AT KING EDWARD VIII HOSPITAL: A RETROSPECTIVE ANALYSIS K Pillay, SD Singh Department of Paediatrics & Child Health, Nelson R Mandel School of Medicine, University of Natal Aim To determine the prevalence and causes of persistent hypoglycaemia among neonates at King Edward VIII Hospital; ii) To determine the response to treatment of hypoglycaemia. Methods Retrospective analysis of all children with persistent hypoglycaemic identified and managed by the Endocrine Clinic during a 12-month period (November 1998- October 1999). Children with one episode of hypoglycaemia, those not evaluated for the cause of the hypoglycaemia and those with severe sepsis and liver failure were excluded from the analysis. Only children aged less than 1 week at diagnosis are included in this report. Hypoglycaemic was diagnosed if the blood glucose was less than 2.5 mmol/l. Results There were 20 children with recurrent hypoglycaemia who were diagnosed before the end of the first week of life. All but 1 were born and managed at King Edward Hospital; 1 child was referred from a peripheral clinics for hypoglycaemia. The commonest cause of hypoglycaemia was hyperinsulinaemia (15/20 [75%]). Other causes were hypercortisolaemia (4[20%]) and galactosemia (1[5%]). Among children with hyperinsulinaemia (HI), 6 (40%) were asphyxia related. There were no children who had a family history of this condition. Among the infants without asphyxia (n=9), 5 (55.5%) were preterm and 3 (33.3%) were small for gestational age. There was a preponderance of boys among this group (male:female=8:1). 112 Of all children with HI, 9 (60%) required medical therapy. All were treated with oral verapamil with a good glycaemic response. There was no requirement for pancreatectomy. Discussion The surprisingly high rate of HI in this study was intriguing. There are very few descriptions of asphyxia-related HI and no understanding of the mechanisms. The high rate of non-asphyxia related HI suggests an incidence of ~1 per 3000 deliveries; far higher than reported incidences from developed countries. As this is a genetically heterogeneous condition with a high rate of sporadic cases, the implications of the high incidence is not known. The clinical appearance of these infants is atypical with high rates of preterm and SGA babies presenting with HI. This phenomenon has only been reported in 1 previous publication. This finding has implications for neuro-developmental outcome. In addition, this finding may provide some evidence in support of the foetal origins of adult disease hypothesis in showing a high rate of HI in low birth weight infants. The response to therapy with verapamil suggests that this is good therapeutic option particularly for developing countries. Conclusions There is a high rate of HI in neonates in an atypical clinical context. There was a good therapeutic response to verapamil. A prospective study to evaluate the incidence of HI in low birth weight infants is required to validate these findings. 113 INCIDENCE OF HEARING IMPAIRMENT IN VERY LOW BIRTHWEIGHT INFANTS BORN AT KALAFONG HOSPITAL HEM van der Watt,* SD Delport,* L Nauta,# JHL Kock,** PR Bartel## * Dept of Paediatrics, Kalafong Hospital and the University of Pretoria and MRC Unit for Maternal and Infant Health Care Strategies # Dept of Communication Pathology, University of Pretoria **Dept of Otolaryngology, Kalafong Hospital and the University of Pretoria ##Dept of Neurophysiology, University of Pretoria Introduction Very low birthweight (VLBW) infants in developed countries receive hearing screening and have a higher incidence of hearing impairment (1.5–9%) than term infants (0.1%) The incidence of hearing impairment in VLBW infants in developing countries has received scant attention. Early diagnosis is of the essence since intervention before the age of 6 months improves the prognosis for emotional, intellectual, speech and language development. Preliminary results of a prospective, descriptive study to determine the incidence of hearing impairment in VLBW infants born at Kalafong Hospital are reported. Patients and Methods Consecutive VLBW infants are being enrolled after birth after the nature of the study has been explained to the mother and her written consent is obtained. The clinical course of each infant is documented prospectively. Hearing screening is undertaken prior to discharge from hospital. Otoscopy and tympanometry are performed to exclude pathology of the external ear canal and middle ear followed by otoacoustic emission (OAE). In the event of an abnormal OAE the latter examination is repeated after 6 weeks. If this examination is also abnormal, an auditory brainstem response (ABR) is performed. 114 Results Sixty infants have been enrolled over a period of 4.5 months (28/08/2000 – 11/01/20001) of whom 36 have been comprehensively screened. Nineteen of these 36 infants failed their first OAE and had to return for a second examination. Sixteen of these 19 infants subsequently had a normal OAE while 3/19 failed it again and received an ABR. Two of these infants had conductive hearing loss and the remaining one possible central hearing loss. Conclusions Preliminary findings show that the incidence of hearing loss in VLBW infants born at Kalafong Hospital is 8.3%. A high false positive rate of 44.4% occurred during the first stage of screening and may have been due to technical problems. 115 INTRAVENTRICULAR HAEMORRHAGE IN VERY LOW BIRTH WEIGHT INFANTS AT C.H BARAGWANATH HOSPITAL. P Angura, M Mokhachane, P A Cooper, R M Mphahlele, E Beckh-Arnold, G Shear. Objectives To determine the incidence, severity and risk of PV-IVH at CH Baragwanath Hospital. To compare the findings with those of the study done in 1989. Methods Prospective study done over a period of three months. All live-born infants with a birth-weight 1750g and 35 weeks gestation, born at CHBH (inborn) or outside (out-born) and referred CHBH neonatal unit within 24 hours of birth, were consecutively enrolled. All infants with birth-weights between 1kg and 1.75kg had their screening sonar done between days 7 to 10 of life and repeated between 4 and 6 weeks or earlier if ready for discharge. The ventilated and infants 1kg had their screening sonar at day 3 of life and repeated at similar intervals as for other infants. Data was then compared to that of the study done in 1989. Results One hundred and thirty two infants were enrolled, but only results for 121 infants were analysed. Forty four percent were delivered by c/s. Sixty one percent received antenatal steroids. Seventeen percent of the mothers received magnesium sulphate. The table below shows some of the comparisons that were done between the 1989 and the present studies. Year 2000 1989 p-value Birth-weight (grams) 1450 1379 0.000 Gestational age 31 32.7 0.022 Booking (%) 73 43 0.000 Overall PV-IVH (%) 26 46 0.0002 Grade 3& 4 IVH (%) 6 9 0.3 Ventilation (%) 26.4 26.2 116 Conclusion The overall incidence of PV- IVH has decreased markedly but the incidence of severe IVH (grades 3&4) has not changed. Booking status in Soweto has improved. 117 UNINTENDED HYPOCARBIA IN VERY LOW BIRTH WEIGHT INFANTS RECEIVING CONVENTIONAL MECHANICAL VENTILATION: CLINICAL CHARACTERISTICS AND LONG-TERM NEURODEVELOPMENTAL OUTCOME C de Wet, GF Kirsten and JI van Zyl Department of Paediatrics, Tygerberg Hospital and the University of Stellenbosch. Severe hypocarbia (PaCO2 < 3.5kPa) in ventilated very low birth weight (VLBW) infants may be a risk factor for an adverse neurodevelopmental outcome since published data are conflicting. Aim To determine risk factors for the development of severe hypocarbia (PaCO2 < 3.5kPa) in VLBW infants and their long-term neuro-developmental outcome. Study design: Retrospective cohort analytical study. Patients and methods VLBW infants (<1500gram) who were ventilated within 48 hours of birth for respiratory distress in the Neonatal Intensive Care Unit (NICU), Tygerberg Hospital, between 1 January 1994 and 31 December 1994 and followed up at the Neurodevelopmental Clinic for a period of 24 months, were studied. Severe hypocarbia (SH) was defined as a PaCO2 level of < 3.5kPa and non-hypocarbia (NH) as a PaCO2 level of > 3.5kPa. Cognitive and motor development at 24 months of age were determined by means of the Griffiths Mental Development Scales and the method of Amiel-Tison respectively. Infants with CP were classified as having hemiplegia, diplegia or quadriplegia. Results: Eighty-nine VLBW infants were studied. Sixty one (69%) infants had SH (PaCO2 < 3.5kPa). The mean birth weight of the SH infants (1197 ± 178) was significantly lower (p = 0.03) than that of the NH infants (1279.4 178.8). Infants ventilated for wet lung syndrome and Grade 1 and 2 hyaline membrane disease (HMD) had a significantly higher incidence of SH than infants diagnosed with Grades 3 and 4 HMD (p = 0.01). The infants with SH and HMD received fewer dosages of 118 surfactant than the infants with NH and HMD (85% vs 32%; p = 0.001). Infants with HMD who received surfactant earlier in the course of the disease rather than later, were also more prone to SH (4.6h ± 5.5 vs 11.2h ± 16.4; p = 0.07). The SH group had a shorter mean duration of ventilation (6.5 ± 11.3 days vs 13.9 ± 18.7 days; p = 0.001) and a shorter mean NICU stay (9.4 ± 12.2 days vs 18.1 ± 20.7 days; p = 0.002) than the NH group. There was no significant difference (p = 0.6) between the mean corrected DQ of the infants with NH (90.9 ± 21.6) or SH (94.1 ± 18) or between their subscale scores neither was any significant association between NH and SH and motor developmental outcome (p = 0.9). Seven (7.9%) infants were diagnosed with CP. There was a trend for an association between a low cognitive score and a low maternal educational level (p = 0.06) and maternal smoking (p = 0.09). Conclusions: Ventilated VLBW infants with mild lung disease and lower birth weights are more prone to develop SH probably due to inappropriate ventilation in the presence of mild lung disease. Even though the results of this study show no association between SH and either a low DQ or CP, VLBW infants with mild lung disease should nevertheless be ventilated with extreme caution to avoid SH which is causal in the development of cystic periventricular leukomalacia. SH should be prevented by means of permissive hypercapnoea, the use of nCPAP and a selective intubation policy in labour ward. 119 DETERMINANTS OF PLACENTAL SIZE D Woods Division of Neonatal Medicine, University of Cape Town Background Maternal weight is known to be an important determinant of both infant and placental weight at birth. Heavy mothers usually deliver large infants and placentas while light mothers often deliver growth retarded infants and placentas. In addition, the birth weight of the infant and placenta are closely correlated to one another. While it is often claimed that placental size restricts fetal growth in underweight women, it is more likely that the placenta, being a fetal organ, is growth restricted along with the fetus when the mother is underweight. Study In order to determine the direct and indirect correlation between maternal, infant and placental weight at birth, 354 consecutive primigravid women, who delivered at term, were investigated. Infant and trimmed placental weights were recorded after delivery, as was maternal weight. Using step-wise regression, with gestational age as a covariant, the correlations between maternal, infant and placenta weight were calculated. Marginal coefficients indicate the direct correlation while partial coefficients indicate the correlation between two variables with the effect of the third variable held constant. Sexes were analysed separately. Results The positive relationship between maternal, infant and placental weight is once again confirmed (Table I) with heavy mothers tending to deliver heavy infants and placenta, and light mothers tending to deliver light infants and placentas. When the marginal coefficients are calculated, the positive correlation between maternal and infant weight at birth remains significant and is not much affected by holding the weight of the placenta constant (Table II). Similarly, the positive relationship between infant and placental weight remains significant and is little 120 affected by holding the weight of the mother constant. In contrast, the positive direct correlation between maternal and placental weight completely disappears when infant weight is held constant. The marginal and partially coefficients are slightly higher for male infants. Table I: Marginal Correlation Coefficients Maternal-infant Maternal-placental Infant-placental Weight weight weight Males 0.4292* 0.3029* 0.5694* Females 0.3635* 0.2580* 0.5550* * p = < 0.001 Table II: Partial Correlation Coefficients Maternal-infant Maternal-placental Infant-placental Weight weight weight Males 0.3278* 0.0788# 0.5104* Females 0.2741* 0.0726# 0.5104* * p = < 0.001 # p = > 0.05 Conclusion The constant positive relationship between maternal and infant weight strongly suggests that the maternal effect on fetal growth is direct and not mediated by placental growth. It is not surprising that the correlation between infant and placental weight remains significant, as the placenta is a fetal organ. The lack of a direct correlation between maternal and placental weight, when the effect of infant weight is held constant, indicates that maternal weight influences the rate of fetal growth and, thereby, indirectly influences placental growth. This study fails to support the hypothesis that the effect of maternal undernutrition in fetal growth is mediated via the size of the placenta. 121 SESSION 5: INDUCTION OF LABOUR A RANDOMISED CONTROLLED TRIAL OF LABOUR INDUCTION WITH MISOPROSTOL AND PROSTAGLANDIN F2 GEL F. Majoko, M. Zwizwai, G. Lindmark, L. Nyström Objectives To compare the effectiveness of vaginally administered misoprostol to extra-amniotic prostaglandin F2 gel for induction of labour in singleton pregnancies at term. Design This was a non-blinded randomised controlled trial with women allocated to receive either misoprostol 50g intravaginally or PGF2 gel 5mg in the extra-amniotic space. Setting The study was conducted in Harare Maternity Hospital (HMH), which is a tertiary centre serving the Greater Harare Maternity Unit and the surrounding district and provincial hospitals. Participants Women who were admitted for induction of labour with a singleton pregnancy in cephalic presentation at term. Interventions The allocated drug was given at the time of recruitment after cervical assessment. The cervical assessment was repeated after 8 hours and a second dose of the drug was administered if needed. Outcome measures The main outcomes were: cervical score change, induction to delivery interval, mode of delivery, rates and indications of operative deliveries, and the neonatal outcome. 122 Results There were no differences in the characteristics of women in the two groups with respect to maternal age, parity, gestational age, indication for induction of labour and Bishop score at recruitment. The need for oxytocin use in labour was reduced in women who received misoprostol (OR 0.36; 95% CI 0.18; 0.73). There were fewer women in the misoprostol group who needed caesarean section for failure to progress (OR 0.11; 95% CI 0.00 – 0.88). The induction to delivery interval was shorter in the misoprostol group, 15.6 versus 23.6 hours (p.< 0.01). There were no differences in fetal outcome. Conclusion Misoprostol 50 g given intra-vaginally is associated with less use of oxytocin in labour, a shorter induction to delivery interval and fewer caesarean sections for failure to progress when compared to extra-amniotic PGF2 gel. 123 ORAL MISOPROSTOL AND INDUCTION OF LABOUR: A DESCRIPTIVE SURVEY A Roodt, L Mangesi, GJ Hofmeyr Effective Care Research Unit, East London Hospital Introduction Labour induction is frequently necessary in the management of pregnancy complications. Recently Misoprostol (Cytotec, Searle, Illinois, USA) has been gaining favour as an effective oral or vaginal agent for labour induction. Misoprostol is registered for use in preventing and treating peptic ulcers, but is not registered for use as a labour induction agent. In order for it to be legalized and regulated for inductions further trials need to be conducted to prove it"s safety and efficacy. This survey was conducted in order to gain insight into the present use of oral misoprostol for labour induction and as a precursor to further research. Midwives need to gain information regarding misoprostol and its use in order to give expert care to pregnant women who need labour induction. At present midwives are administering oral misoprostol without sufficient knowledge regarding its safety and efficacy. Aim And Objectives The aim of this retrospective survey was to determine the safety and potential risks of an oral misoprostol regimen during the induction of labour. Specific objectives included the incidence of: vaginal delivery within 24 hours after the first dose uterine hyperstimulation caesarian section rates meconium stained liquor the need for oxytocin augmentation 124 maternal morbidity and mortality neonatal morbidity and mortality . Research Design And Methodology A quantitative, non-experimental descriptive survey of patient records was undertaken. The records of women who received oral misoprostol for labour induction at the East London Hospital Complex (Frere and Cecilia Makiwane Hospitals) for the period 1 Jan to 31 October 2000 were analysed. The entire population who could be identified retrospectively was studied. One hundred and seventeen (n=117) patient records were surveyed. Data collection was done by using a survey schedule which extracted the information relevant to the specific objectives of the survey. Findings In 108/117 cases, the dosage used was oral misoprostol solution 25–50 micrograms 2–4 hourly. The solution is made up of 200 micrograms of misoprostol mixed with 200 ml of tap water. The most common dosages were 25 micrograms followed by 50 micrograms 4 hourly (40) or 3 hourly (23). In the remaining 9 cases, larger doses were used. The larger doses (up to 400 micrograms) were used in a case of anencephaly, 5 cases of intra-uterine death and in a 24-week pregnancy with severe gestational proteinuric hypertension. The mean time over which misoprostol was given: 27,5 hours. The mean time period from the first dose to delivery was 40 hrs. Primary Outcomes Vaginal delivery within 24 hours: 41 patients delivered vaginally within 24 hours (n =117) which is 35% of the total. 34 patients went into active labour within 12 hours (29%). Uterine hyperstimulation: Uterine hyperstimulation was defined as either hypertonus (single contraction lasting 2 minutes) or tachysystole (6 uterine contractions in 10 minutes for 2 consecutive windows) (Wing et al 1999:1156-1157). There were no documented incidences of 125 uterine hyperstimulation. However, as this was a retrospective study it is likely that cases of hyperstimulation may have been missed. Caesarian section rate: The C/S rate was 20.5% (24 cases). Serious neonatal morbidity and mortality: There were 9 cases in this category equalling 8% of the total. 1 early neonatal death occurred due to anencephaly. The other problems included 1 case of hypothermia, 1 of jaundice, 4 of respiratory distress and 1 of hypoglycaemia. Serious maternal morbidity and mortality: No maternal deaths were recorded but 10 cases (12%) had problems: 3 cases of pyrexia of unknown origin, 2 cases of antepartum haemorrhage, 1 postpartum haemorrhage, 1 upper respiratory tract infection, 1 urinary tract infection and 1 human immunodeficiency virus case (HIV testing was not being routinely offered). Secondary Outcome Only one secondary outcome was analysed and that was oxytocin augmentation. 44 patients received oxytocin augmentation (38%). Complications No cases of uterine rupture were recorded. 4 cases of manual removal of placenta were noted and one delayed delivery of the placenta. One PPH was recorded. 4 vacuum extractions occurred. Meconium stained liquor occurred in 15 (13%) of cases. Only one Apgar score of 7 (due to anencephaly) was recorded. Eight neonatal cases were admitted to the High Care Unit and 1 to the NICU. One case of maternal diarrhoea was noted. 126 Conclusions The great variations in dosages made analysis difficult. A possible reason for the mean time to delivery being 40 hours is that many labour inductions in our complex are for severe pregnancy complications with unfavourable cervices. Results may therefore differ from units where induction is undertaken for more trivial reasons. The fact that no uterine hyperstimulation was identified may be due to the fact that very few patients were monitored continuously using a CTG; the majority being monitored clinically by midwives and student midwives. The one ENND was due to anencephaly and therefore the low rate of fetal/neonatal problems in this high-risk group is reassuring. The maternal morbidity was also in keeping with the high-risk group studied. Only one patient had diarrhoea but was given 10 doses of 400 micrograms over a 44-hour period. Using a low-dose, oral regimen appears to result in a low rate of complications, at the expense of slow response times in some women. Recommendations 1. Safe protocols for labour induction need to be developed. 2. Alternative methods should be used when the response to oral misoprostol is poor e.g. low-dose vaginal misoprostol, other prostaglandins, Foley catheter. 3. There is a need to develop protocols for labour induction with previous caesarian sections where misoprostol is contra-indicated. Table 1: A Comparison of Primary Outcomes between this survey and other randomized controlled trials. Various Randomised Controlled Trials This Survey Oral misoprostol Vaginal misoprostol (n/n (%)) (n/n (%)) (n/n (%)) Vaginal delivery 41 / 117 (35) 285 / 669 (43) 1303 / 2058 (63) within 24 hours Caesarian sections 24 / 117 (20,5) 185 / 1043 (18) 551 / 2997 (18) Serious neonatal 9 / 117 (7.5) 0 / 699 (0) 192 / 1589 (12) morbidity or death (Other trial figures: Alfirevic: 2000 Hofmeyr & Gulmezoglu: 2000) 127 AGGRESSIVE OR EXPECTANT MANAGEMENT OF LABOUR; A RANDOMISED CONTROLLED TRIAL GR Howarth, RC Pattinson, WPP Mdluli, AP Macdonald, M Funk, J Makin MRC Research Unit for Maternal and Infant Health Care Strategies, and Department of Obstetrics & Gynaecology, University of Pretoria. Aim To test whether using aggressive (strict diagnosis of labour, early amniotomy and oxytocin infusion once alert line crossed) or expectant management (use of oxytocin only once action line crossed) of labour influences the outcome of labour. Outcomes evaluated were the number of caesarean sections, the number of assisted deliveries, the use of oxytocin, the use of analgesia in labour, the number of neonates needing resuscitation, and neonatal morbidity. The action line was drawn parallel to and four hours later than the alert line. Design A randomised controlled trial of nulliparous women in labour. Setting University of Pretoria Maternity Units Patients Nulliparous mothers with singleton pregnancies, cephalic presentation at thirty-six weeks or more gestation, or with estimated fetal weight of 2500g or more. Results 696 mothers were randomised, 20 were excluded because of recruitment violations. Of the remaining 676 mothers 348 were managed expectantly and 328 aggressively. The groups were comparable with respect to maternal age, dilatation of the cervix at entry and number of women crossing the alert line. The mean dilatation of the cervix in the expectant group at trial entry was 4.60cm and in the aggressive group 128 4.59cm, 49.7% crossed the alert line in the expectant group and 48.8% in the aggressive group. There were significantly less caesarean sections performed in the aggressive group (23.6% vs 15.2%, p=0.0085; OR 0.58 95% C.I. 0.39-0.88) as well as less assisted deliveries (27.9% vs 19.8%, p=0.018; OR 0.64 95% C.I. 0.44-0.93). Oxytocin was administered to more patients in the aggressive group (24.9%) compared to the expectant group (15.3%), p =0.049; OR 1.55 95% C.I. 1.01-2.33. There was no statistically significant difference in the use of analgesia and neonatal morbidity. Conclusion A significant benefit accrued to the mothers on the aggressive management due to a significant decrease in operative deliveries. 129 AMNIOTOMY AND INTRAVENOUS OXYTOCIN FOR THIRD TRIMESTER INDUCTION OF LABOUR: A COCHRANE SYSTEMATIC REVIEW GR Howarth, DJ Botha Obstetrics and Gynaecology, Kalafong Hospital and University of Pretoria MRC Unit for Maternal and Infant Care Strategies Background Numerous methods of induction of labour have been described, these are now being evaluated by the Cochrane Collaboration. Multiple systematic reviews are being written by different authors, utilising a generic protocol, comparing different methods. This is a description of the systematic review on the use of amniotomy and intravenous oxytocin in the induction of labour. Objectives To determine, from the best available evidence, the efficacy and safety of amniotomy plus intravenous oxytocin for third trimester induction of labour. Search strategy The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and reference lists of articles were searched. Selection criteria Randomised trials comparing amniotomy plus intravenous oxytocin with other methods of labour induction, placebo or no treatment in women due for third trimester induction of labour. Data collection and analyses Trial quality assessment and data extraction were done by both reviewers. 130 Main results Sixteen studies were included, comparison between amniotomy plus intravenous oxytocin and placebo or expectant management (two studies, 422 participants), vaginal prostaglandin (nine studies, 1119 participants), intra-cervical prostaglandin (one study, 90 participants), intravenous oxytocin (two studies, 416 participants) and amniotomy alone (two studies, 500 participants). Primary outcomes: A significant reduction in the number of failed inductions within 24 hours was demonstrated in the combination group versus amniotomy alone (RR 0.03, CI 0.00-0.85) Secondary outcomes: A significant reduction in instrumental vaginal deliveries was shown compared to expectant management (RR 0.18, CI 0.05-0.58). In comparing amniotomy and intravenous oxytocin to vaginal prostaglandins there was no statistically significant difference in the number of caesarean sections performed or instrumental vaginal deliveries. There was, however, a significant increase in postpartum haemorrhage in the oxytocin/amniotomy group (based on one small trial) . Compared to amniotomy alone, there was a statistically significant reduction in instrumental vaginal deliveries. Reviewers conclusions As regards primary outcomes, the combination of amniotomy and intravenous oxytocin appears to be superior to amniotomy alone, when judged by failed induction at 24 hours. Secondary outcomes will be discussed. 131 RANDOMISED CONTROL TRIAL TO DETERMINE THE VALUE OF CLINICAL PELVIMETRY AS A PREDICTOR OF VAGINAL DELIVERY IN WOMEN WITH ONE PREVIOUS CAESAREAN SECTION S Volschenk, E Farrell, BS Jeffery, RC Pattinson MRC Unit for Maternal and Infant Healthcare Strategies, Kalafong Hospital, University of Pretoria Introduction X-ray pelvimetry has been shown to be a poor predictor of successful VBAC. In most units practising VBAC, women are selected for trial of labor on the basis of several factors, including clinical pelvimetry, however this method has never been tested prospectively. Method Women at 36 weeks gestation or more who wished to attempt VBAC were randomised into two groups: pelvimetry revealed & pelvimetry concealed. clinical pelvimetry was performed on all women. In the concealed group, the pelvimetry data was not revealed to the managing clinicians and labor was managed according to a standard protocol. In the revealed group the patient was managed according to the pelvimetry findings. The primary outcome measure was the rate of successful VBAC in concealed and revealed groups. Secondary outcome measures were maternal morbidity and perinatal outcome. Results 127 patients were delivered with equal randomisation to the two arms. There is no difference between the two groups as regards primary or secondary outcomes. Clinically inadequate pelvimetry was a good predictor of failed VBAC, however, in the revealed group several women with inadequate pelves chose to attempt VBAC regardless of this information. Many women with adequate pelves changed their minds and opted for cesarean section. 132 Conclusion Clinical pelvimetry has limited usefulness as a predictor of successful VBAC as the final route of delivery is strongly influenced by the patient"s wishes regardless of pelvimetry findings. 133 SESSION 6: LABOUR WATER AS A METHOD OF PAIN RELIEF: A RANDOMISED CONTROLLED TRIAL M Taha, AGW Nolte, GJ Hofmeyr, CS Dörfling Coronation Hospital, Rand Afrikaans University & University of the Witwatersrand Introduction Labour is painful and efforts to control and relieve pain have been topics of interest since the beginning of time. In Western communities, pain during childbirth has been interpreted as Eve"s punishment for her role in the fall in mankind and was to be suffered by all of her descendants. "And He said to the woman, I will increase your trouble in pregnancy and your pain in giving birth" (Good News Bible). There is a tendency to believe that all sane women must want complete abolition of labour pain, but not all women in labour want to use the same pain relief method. Some women do indeed want complete abolition of pain from the earliest possible stage, but others want the satisfaction of labouring without any kind of pharmacological help. The success of a method also varies among individuals. Human beings seem to have an intrinsic attraction to water and obtain comfort and repose from water. Women often comment on the comfort they feel soon after getting into the water, and later express a reluctance to emerge. Thus it should be no surprise that women in labour would choose to rest in a soothing tub of warm water for relaxation. Women do not only seem to relax, but occasionally appear somnolent in the bath, suggesting an altered mental status that may be due to enhance endorphin production Research Objectives To determine the effect of the use of warm water on the mother's experience of pain during the first stage of labour according to the following: The primary outcome measured will be: Experience of pain during the first stage of labour and 24 hours after delivery 134 Research Design An experimental randomised controlled approach was used because there was a manipulation – the warm water. The study was done at The Coronation Hospital Johannesburg South Africa. Research Method Inclusion criteria: All midwives cases, thus patients who had an uncomplicated pregnancy and an uncomplicated labour and birth is expected. Primipara patients had to be between 4-7cm and multipara patients between 4-6cm cervical dilatation. The reason for this was that the patient will be on the study for at least one hour before delivery. Baseline observations were recorded, blood pressure, pulse, mean arterial pressure, temperature and fetal heart rate. The pain questionnaire consists out of 3 questions were asked. The first question is to determine the level of pain on a scale from 1-10, where 1 is no pain at all and 10 is the worst pain imaginable. In the second question the women"s feelings are indicated by means of faces – how they feel at the moment. The third question is the main outcome relating to pain: describing in words the pain they experience, from no pain at all to unbearable pain. The description in words seems to be the easiest to understand to the patients. The McGill Pain questionnaire was not used because it takes 5 minutes to complete, and during active labour there is normally not a 5-minute period to complete such a lengthy questionnaire. Randomisation took place, if randomised to the water group the patient was put into the bath with a temperature between 34ºC - 38ºC and encouraged to stay in the water as long as possible. If the patient was randomised to the control group, she was encouraged to be ambulant. Thirty minutes after randomisation the blood pressure, pulse, mean arterial pressure, temperature, fetal heart rate and the bath temperature was recorded and the pain questionnaire given to complete. This was repeated at one hour and hourly from there on until delivery or 6 hours after randomisation. Once the patient was fully dilated she was taken out of the bath. Al deliveries were done out of the water. During analysis it was found that one more primiparous patient was allocated to the out of the water group by the randomisation envelopes. The envelopes with the 135 randomisation allocation were re-checked after entering of the data, to confirm this. The allocation of one more primiparous woman in the control group showed no statistical significance on the baseline data. The physiological data showed no difference except for diastolic blood pressure, which was significantly lower in the water group. This difference in diastolic blood pressure remains significantly lower for up to 2 hours after randomisation. The other physiological data show successful randomisation in providing two equal groups with similar physiological data. Pain questionnaire Pain questions were filled in after physiological data were obtained, including cervical dilatation and before randomisation took place. No statistical differences were found on any of the baseline data, confirming that randomisation was successful in providing two similar groups. Primary outcomes The primary outcome of this study was the experience of pain, done at 30 minutes after randomisation, one hour after randomisation and from there on hourly until delivery. Only the women in the water were questioned. Thirty minutes after randomisation, the water group experienced significantly less pain than the control group on all three questions. Most significantly on the third question, describing the pain in words. The literature review suggested that describing the pain will be understood the best by the women, and the researcher experienced during the data collection that the patients understood this question the best. Two patients in the control group and one patient in the water group delivered before one hour and was not included in the one hour analysis, all these patients were multiparas. One hour after the patients were randomised, the water group still experienced statistically less pain, the difference between the two groups were smaller. This can be explained as the labour continues, the pain experienced in both groups becomes more severe, the water group just took longer to experience unbearable pain. This can explain Cammu et al (1994) who called the water as a pain stabilising effect. 136 Two hours after the randomisation the amount of women in the water group who delivered were significantly more than the control group, this differed too much from the sample size calculated to detect a significant difference and the results were unreliable, water n=23 and control n=34. One patient left the hospital before the questionnaire was given to her. Although she was phoned on numerous occasions, and a 24 hour questionnaire and return envelope was posted to her, no response was found. Most of the questionnaires were given at 24 hours after delivery. Some patients who delivered in the morning were discharged on the same day, minimum of 6 hours stay. Their questionnaires were administered before they left the hospital. Within 24 hours, the experimental group in the water remembers the pain they experienced during the labour as less intense than the control group. Secondary outcomes At 30 minutes after randomisation there was a significant decrease in the blood pressure and the mean arterial pressure was significantly lower, this correlated with the literature review. Concern about increased maternal temperature in the water did occur, but no difference was found in the fetal heart rate at 30 minutes of water immersion. No difference in maternal pulse was found. At one hour after randomisation the systolic blood pressure shows no significant difference, but the diastolic blood pressure and mean arterial pressure were significantly lower in the water group. The mother"s temperatures remain statistically significantly higher in the water group, and the increase in the fetal heart rate after one hour of water immersion is reason for concern. This suggests that the fetus did respond on the increase in the mother"s temperature. No significant difference was found between the two groups on pain relief received before randomisation, and on the amount of pain relief given. All the pain relief given to the water group was asked for and given after they left the bath. The amount of augmentation given to the control group was significantly higher. This was to prevent prolonged labour, therefore there was no statistical difference in the delivery time between the two groups, although women in the water group did deliver sooner than the control group. 137 No difference was found between the two groups on decelerations of the fetal heart, mode of delivery, blood loss during delivery, perineal outcomes or Apgar scores. More women in the control group had a family member or support person with her during the labour than the water group. Recommendations In the light of the findings of this study, water should be an option to all women during labour. A bathtub is a once off expense to a health institution and can be utilised to provide quicker labours and less use of analgesia. In the public sector where hardly any epidurals are available and where narcotic pain relief is not readily given, the bath can be useful. The women in this study requested the use of water during labour for future deliveries, and health care providers should take this seriously. The bath or shower can be utilised at home during early labour, but should be available in the hospital setting as well. Because the use of water is new to many health settings in South Africa, the feeling is that a midwife should be present at all times while the woman is in the bath. Due to a huge shortage in the public sector, this will cause a problem as was shown in two hospitals in Johannesburg. A bath for use is available in both hospitals, but the reason why it is not used is a shortage of staff, as the staff cannot allow one midwife to remain with one patient the whole time. 138 BIRTH ASPHYXIA REVISITED D Ballot Department of Paediatrics, University of the Witwatersrand Introduction Birth asphyxia remains a significant cause of death and handicap in South Africa. A previous study in our unit during 1997 (1) showed a birth asphyxia rate of 6 per 1000 live births. It was found that 46% of cases of birth asphyxia were potentially preventable. This survey was conducted to determine whether the situation had improved. Subjects and methods A retrospective chart review was conducted for all inborn babies > 1800 grams birth weight with a 5 minute Apgar score of 6 or less, or a clinical course highly suggestive of asphyxia. The time period under evaluation was from 01/01/2000 to 31/12/2000. Standard statistical analysis was performed using EPIinfo. Results A total of 156 babies with birth asphyxia were delivered during the study period, giving a birth asphyxia rate of 15.8 per 1000 live births. The mean birth weight was 2933 grams (SD 540) and gestational age 39.03 weeks (SD 2.27). The mean Apgar score at 5 minutes was 4.54 (SD 1.5). Forty-four (28.2%) of the babies died, giving a mortality rate due to asphyxia of 4.46 per 1000 live births. The deaths were not evenly distributed through the year, but were concentrated in the first 6 months. After delivery, 21 of the babies were transferred to NICU for ventilation (9 of whom died), 42 were admitted to level 2 care (6 of whom died), the remainder were discharged directly from the labour ward nursery or died soon after admission. The majority of babies were delivered vaginally –114 normal vaginal deliveries (73%), 32 Caesarean sections (20.5%), 8 breech deliveries (5.1%) and two assisted vaginal deliveries (1.3%). (The current hospital average for assisted vaginal delivery is less than 2% and Caesarean section is approximately 33%). There was meconium 139 stained liquor in 22 patients (14.18%). Only two of the births were multiple pregnancies. Antenatal care had been received by 127 mothers (81.4%). Comparison to 1997 The present statistics are compared to those from 1997 in the Table 1. 2000 1997 Asphyxiated babies 156 44 Asphyxia rate 6 / 1000 15.8 / 1000 P < 0.0001 Mortality 28.2 % 12.5% P = 0.05 Birth weight 2933 (540) grams 3061 (658) grams Gestational age 39.03 (2.27) weeks 38.9 (2.2) weeks 5 minute Apgar 4.54 (1.5) 4.7 (1.8) Antenatal care 81.4 % 77 % MSL 14.18 % 27 % P < 0.05 C section 20.5 % 29 % Assisted 1.28 % 17 % P< 0.001 NVD 73 % 54 % P < 0.05 Babies ventilated 13.46 % 40 % P < 0.005 Discussion and Conclusions It is clear that the problem of birth asphyxia has worsened considerably over the past 3 years. Both the birth asphyxia rate and the mortality due to birth asphyxia are significantly worse than in 1997. The vast majority of these patients are big term booked babies. This was a retrospective review and specific reasons for the increase in the rate of birth asphyxia were not evaluated, however, some differences are apparent. The assisted vaginal delivery rate of asphyxiated babies is the same as the hospital average, whereas the Caesarean section rate in the asphyxiated babies is lower than the hospital average. Both these modes of delivery are done less frequently than in 1997. This would imply that a significant number of high-risk babies are not being identified and that appropriate obstetric intervention is not being given. Similarly the amount of reported meconium stained liquor is significantly lower in 2000 than in 1997. Is this a real reduction in MSL or is MSL (and foetal distress) being missed? The delivery numbers during 2000 had increased by approximately 20% compared to 1997, an increase out of keeping with the 300% increase in the birth asphyxia rate. A limitation of the survey is that the question of fresh stillbirths is not addressed. It is possible that the stillbirth rate has declined resulting in an increase in the birth asphyxia rate. Fewer babies were 140 ventilated in 2000 compared to 1997, however this does not account for the massive increase in mortality due to birth asphyxia. Of 21 babies ventilated in 2000, 9 demised. Several changes have occurred in the delivery service since 1997. The Johannesburg hospital labour ward is functioning more as a tertiary referral centre for high-risk deliveries than in 1997. The increase in the number of cases of birth asphyxia may reflect the increase in the number of high- risk obstetric patients being handled. The complicated obstetric cases from Edenvale hospital and Alexandra clinic are being referred for delivery straight in to labour ward at Johannesburg hospital. Previously, most of these cases were referred to other centres. In many of these cases, there are long delays in the transfer process, resulting in babies in poor condition being delivered in Johannesburg hospital. A midwife obstetric unit was established in 1998 and handles most low risk deliveries. A number of cases of birth asphyxia have originated from the MOU and it appears that the MOU staff is still on the learning curve for identifying signs of foetal distress. Both of these circumstances represent possibly preventable causes of birth asphyxia. Previous research has shown that up to 46% of birth asphyxia in South Africa is related to preventable causes (1), unlike developed nations where most asphyxia is regarded as unavoidable. In order to address the problem of the unacceptably high incidence of birth asphyxia, it is vital that birth asphyxia rates become part of standard morbidity and mortality statistics and those preventable causes of asphyxia are identified and rectified. It is acknowledged that the diagnosis of foetal distress is difficult and the role of scalp pH monitoring to assist in this regard may be considered. 141 DEATH FROM LABOUR-RELATED ASPHYXIA AND BIRTH TRAUMA – A SCANDAL AT SOUTH AFRICAN HOSPITALS? E Buchmann, R Pattinson, N NyathikaziUniversity of the Witwatersrand, University of Pretoria, Department of Health Introduction The death of a baby from birth asphyxia or trauma is always tragic and often unnecessary. In addition, for every death, there are several survivors of birth trauma or asphyxia who grow up with some degree of brain damage. The national perinatal mortality survey identified asphyxia and birth trauma as a serious problem in South African Hospitals, worthy of discussion in a separate paper. Methods Audit data from the Perinatal Problems Identification Programme (PPIP) for 2000 were obtained from 23 hospitals, of which 4 were in metropolitan (58230 deliveries), 12 in town and city (45327 deliveries), and 9 in rural areas (19951 deliveries). More details of the methodology are available elsewhere in the Proceedings (Pattinson). Data for perinatal death from asphyxia and birth trauma were extracted and analysed. Results Table 1 shows the contribution of asphyxia and trauma to perinatal mortality, and the absolute perinatal mortality rate due to asphyxia and birth trauma for metropolitan, town and city, and rural areas. 142 Table 1. The contribution of asphyxia and trauma to perinatal mortality and the absolute perinatal mortality rate due to asphyxia and birth trauma for metropolitan, town and city, and rural areas (N=550) Birth asphyxia and trauma Perinatal mortality rate for as a percentage of all birth asphyxia and trauma perinatal deaths per 1000 births Metropolitan 10.8 3.2 Town and city 16.7 5.8 Rural 26.4 7.7 A more detailed description of causes of birth asphyxia related deaths is shown in table 2. This is not broken down according to whether the hospital was rural, town and city, or metropolitan. Some detailed data were not available from a number of hospitals, so the denominator is only 366. Deaths from trauma (N=40) were caused by stuck breech (48%), instrumental delivery (20%), ruptured uterus (20%) and other maternal injuries (12%). Table 2. Causes of death from labour-related asphyxia (N=366) Number Per cent Labour 264 72 Cord prolapse 45 12 Cord around the neck 29 8 Meconium aspiration 28 8 Table 3 shows avoidable factors for the 406 perinatal deaths related to labour asphyxia or birth trauma. A breakdown of the different groups of hospitals was not possible. Table 3. Avoidable factors for perinatal deaths related to labour asphyxia or birth trauma (n=406). Number Percent Delay in seeking medical attention during labour 150 37 Signs of fetal distress not interpreted correctly 100 25 Fetus not monitored 72 18 No response to poor progress in labour 28 7 Second stage prolonged without intervention 21 5 Partogram not used 14 3 Inappropriate use of forceps or vacuum 14 3 143 Discussion Although the data are limited in detail, this collection of information on birth asphyxia and trauma is the largest yet from South Africa, and is representative of hospitals throughout the country. A limitation is the self-selection of the sentinel sites. The presence of enthusiasts who audit perinatal deaths using the PPIP programme may be associated with a similar enthusiasm for obstetrics and neonatology in those centres. Therefore, the true figure for perinatal asphyxia and trauma related mortality in South Africa may be higher. Significantly more asphyxia and trauma related deaths occur at rural hospitals, where a rate of 7.7 per 1000 indicates an almost 1% chance of an otherwise uncomplicated pregnancy ending with a perinatal death from labour asphyxia or trauma. Hospitals in urban areas had lower rates, but these were still much higher than those in developed countries. The findings of avoidable factors in these deaths have provided some ideas for improvements as follows: Women who delay in seeking medical attention during labour: mothers" waiting areas should be provided in all rural hospitals to ensure access to safe delivery for all women. In addition, antenatal care must provide pregnant women with a delivery plan and open discussion on how they will get to hospital when labour pains start. Fetal monitoring: it is likely that midwifery staff shortages severely hamper attempts to ensure that all fetuses are monitored during labour. Affordable technologies, such as hand-held Doppler, may help in facilitating fetal monitoring. Cardiotocography is not a feasible option for general use in South Africa. Prolonged labour: partogram-based labour management protocols must be taught and learned. Prolonged second stage of labour is a hazard that should be recognized and managed according to clear and proven protocols. 144 Perinatal audit meetings should be instituted at all clinics and hospitals with labour wards. Only through local audit can problems be identified and solutions devised to address the problems that are identified. Conclusion Perinatal death from asphyxia and trauma is tragic and preventable. The data in this report will provide useful information for health planners and politicians involved in health care provision. Recommendations for research and action can now be based on a solid base of facts as provided by this survey. 145 THE SAFETY, EFFICACY AND PRACTICALITY OF A METHOD OF HEAD COOLING IN INFANTS WITH HYPOXIC ISCHAEMIC ENCEPHALOPATHY. AN INTERIM REPORT. AR Horn, DL Woods, CM Thompson, M Kroon*, I Els Neonatal Medicine, Groote Schuur Hospital, Cape Town, * Mowbray Maternity Hospital, Mowbray, Cape Town (Funded in part by The Institute of Child Health, Red Cross War Memorial Hospital) Introduction Several animal studies have shown the neuroprotective effect of hypothermia after fetal hypoxia.1-5 Focal cerebral cooling has achieved similar neuroprotection6-8,with fewer systemic complications as a higher core temperature is permitted. Optimal brain temperature for neuroprotection is thought to be 32 - 34C9 and a trial using an expensive cooling coil around the head of human infants10 safely reduced nasopharyngeal temperature to 34.5 0.3C and rectal temperature to 35.7 0.2C. A rectal temperature above 35C was found to be safe. The aim of this study was to devise a cheaper alternative to the cooling coil and evaluate the efficacy and safety of this method. A frozen ice pack covered in orthogrip was used to induce cerebral hypothermia and mild systemic hypothermia by application to the heads of term newborn infants with hypoxic ischaemic encephalopathy. Specific Objectives 1. To determine the most practical method of applying the ice pack, controlling environmental temperature and selecting monitoring sites, to maintain nasopharyngeal temperature at 34 ± 0,5°C and rectal temperature at 35,5 ± 0,5°C. 2. To continually monitor and record temperatures in the nasopharynx and rectum and on scalp and abdominal skin, before, during and after cooling. 146 Thereby showing temperature gradients between these sites to suggest that cerebral cooling has occurred. 3. To make recommendations regarding the appropriate site to monitor temperature. 4. To monitor possible local and systemic side effects of the ice application. 5. To compare short term outcome in infants that are cooled vs those who are not cooled. Methods Infants who met the entry criteria below were randomised into either cooled or not cooled groups after obtaining maternal (and paternal if applicable) consent. Entry Criteria 37 or more weeks gestation and less than 9 hours old with clinical signs suggesting hypoxic ischaemic encephalopathy11 plus the following two features. 1. Fetal Hypoxia, suggested by one of the following: a) Fetal distress suspected because of an abnormal cardiotocograph. b) Base deficit of 9 or more on umbilical arterial or neonatal arterial acid-base analysis done within the first hour after birth. c) Haematuria and protienuria. 2. Delay in establishing respiration (in the absence of sedation with opiates), suggested by either: a) 5 minute Apgar score of < 7 OR, b) The need for assisted ventilation. Exclusion Criteria (Any of the following) FiO2 > 50%, hypoglycaemia or acidosis not responding to treatment, obvious sepsis, major congenital abnormalities. After randomising, phenobarbitone 20mg/kg was administered intravenously to both the cooled and the non-cooled infants (in order to standardise the groups and sedate the cooled babies) and the cooled group had the ice pack applied. The heater/incubator was servo controlled to skin temperature between mattress and 147 body (approximates to core temperature), which was set to 36.5°C and reduced by 0,2C every 30 minutes. Ice packs were replaced at ~2 hourly intervals to maintain target temperatures. Temperatures were recorded with time lapse video surveillance. Cooling was continued for 48 to 72 hours. Temperatures were also monitored in the control group. Rectal temperatures were accepted in the range of 34.5 -36C. Both groups were monitored for local and systemic effects of hypothermia. Temperatures, oxygen saturation, pulse rate, respiratory rate and blood pressure were monitored continuously and recorded 2 hourly during the period of cooling and blood sugar was measured 4 hourly. Blood gases, electrolytes, and haematological indices were also monitored before, during and after the period of cooling. Short-term neurological assessments were done at the time of discharge and 18-week assessments are pending. Results 6 infants (3 cases and 3 controls) had been studied by the time of writing. Themodynamic findings Table 1: Average temperatures during the cooling vs. normothermic controls. Site Control Infants Cooled Infants Fontanelle 36.2 0.2C 21.5 3.9C Nasopharynx 36.1 0.3C 33.6 0.5C Rectal 37.3 0.3C 35.3 0.3C Rectal - Naso 1.2 0.2C 1.7 0.3C Gap Other significant observations regarding temperature control and monitoring are; 1. The fontanelle temperature is normally about 0.5 degrees cooler than the surface abdominal skin in control infants, in incubators. 2. The lowest fontanelle temperature was 11C in the cooled infants. 3. The nasopharyngeal temperature shows a wide variation in individual temperatures but there is a trend towards a wider gap between nasopharynx and rectal temperatures as cooling progresses. This suggests that using intermittent 148 nasopharyngeal temperatures to monitor cooling is not reliable and the site is only useful if monitored continuously to establish trends. 4. Incubator temperatures of up to 38C are needed during cooling. This suggests that the ice pack is inducing the cooling which must, therefore be occurring via the brain. 5. The back temperature (infant lying on the probe) approximates more reliably to the core (rectal) temperature than the surface abdominal temperature. Haemodynamic and Respiratory findings In the cooled group blood pressure rose progressively, respiratory rate and pulse rate dropped. Post cooling values are similar to precooling values. Table 2 demonstrates the difference between cooled and control infants. Table 2: Haemodynamic and respiratory measurements - cooled vs control Parameter Control (Av range) Cooled (Av range) Mean Blood Pressure (mmHg) 49 3 53 5 Respiratory Rate (bpm) 58 5 31 5 Pulse Rate (bpm) 128 8 115 7 Other events during cooling The following adverse events were recorded , none of which were clinically significant. *Bradycardia In one of the cooled infants. This was fleeting and was associated with a core temperature < 34C. *Hyperglycaemia Two episodes in the cooled group. These were associated with intravenous drip pump problems and not related to the cooling per se. *Metabolic acidosis The cooled group had a greater base deficit during cooling ( - 7.3 VS - 3.6 ) but Ph remained normal. 149 *Prolonged INR The cooled group average INR was 0.6s longer than the control infants, during the period of cooling. No active bleeding occurred. Short term outcome Table 3: Short term outcomes. Cooled vs. control infants. Outcome Control ( range ) Cooled ( range ) Cold injury 0 0 Death 0 0 Max HIE Score 91 70 Days to Score 0 82 8.7 1 Days to full feeds 71 5.3 1.5 Creatinine > 60 day 5 0 0 Interim conclusions The small number of infants studied prevents drawing conclusions regarding outcome. However, the method of cooling was shown to be effective and without significant side effects. The ice pack safely induced nasopharyngeal and rectal hypothermia to the desired range, and high incubator temperatures were required soon after initiation of cooling to keep systemic temperature above 35°C. Nasopharyngeal temperatures may be misleading if used intermittently but were useful to establish a trend with continuous monitoring. Surface abdominal skin temperature did not always have a direct relationship to core temperature. Servo control of core temperature is therefore necessary for optimal temperature control and this is achieved by servo control to skin temperature between body and mattress. This pilot study provides a framework for a multicentre randomised controlled study. 150 A RANDOMISED CLINICAL TRIAL TO DETERMINE THE EFFECT OF BETA- ADRENERGIC BLOCKING WITH PROPRANOLOL ON LABOUR. MG Schoon, JBF Cilliers, RH Bam, I Niemand Department of Obstetrics & Gynaecology, University of the Orange Free State, Bloemfontein, South Africa Objective of the study Dysfunctional labour is a common problem in labour wards, particularly in the traditional disadvantage communities. Women who are anxious during labour have high adrenaline levels and this might lead to dysfunctional uterine contractions as adrenaline probably plays an important role in the suppressing of retraction in labour contractions. Study design Double blind randomised controlled trial Methods The study population consisted of women who presented in active labour with a cervical dilatation rate of less than 1 cm per 1-hour period. Subjects were given either propranolol 2mg or a matching placebo after informed consent was obtained. Standard protocol for managing labour were maintained which included pain relieve and oxytocin infusion. The following information were documented: age, gravity, parity, maternal weight, blood pressure and pulse before and one hour after medication was given, quantity of oxytocin given before/after medication, time and method of pain relieve, time and method of delivery, apgar score, foetal weight, indication for caesarean section and any complication experienced . Results Among the 53 women enrolled in the study, 25 received propranolol and 28 the placebo. The median time from when the medication was given until delivery was 151 210 minutes in the propranolol group and 218 minutes in the placebo group (p=0.68). In the propranolol group 13 (52 %) caesarian sections were done and in the placebo group 11 (40.7 %). There was no statistically significant difference between the two groups in the number of caesarian sections done (p=0.59). None of the caesarian sections were done for fetal distress. In the propranolol group 8 (61.5 %) caesarian sections were done for poor progression and 5 (38.5 %) were done for obstruction of labor whereas in the placebo group 7 (63.6 %) caesarian sections were done for poor progression and 4 (36.4%) were done for obstruction of labor. Again the difference between the two groups were not statistically significant (p=0.75). The average apgar scores at 5 minutes were 8.92 in the propranolol group and 8.96 in the placebo group (p=0.89). Oxytocin was given in 5 (20%) of the propranolol group before the medication was given and in 10 (35.7%) of the placebo group (p=0.33).The only statistically significant difference between the two groups in this study was the number of cases where oxytocin augmentation was used after the medication was given. In the propranolol group only 7 (28%) received oxytocin after the propranolol was given whereas in the placebo group 17 (60.7%) received oxytocin after the placebo was given (p=0.03). Conclusion Beta-adrenergic blocking with propranolol does not reduce the caesarean rate or the duration of labour but reduces the need for oxytocin. 152 PAIN RELIEF AND LABOUR COMPANIONSHIP: A PILOT STUDY AT BAMALETE LUTHERAN HOSPITAL, BOTSWANA R Pfau, A Mühlendyck (Stud.cand.med.) Bamalete Lutheran Hospital, Ramotswa / Botswana Introduction Most midwifery textbooks recommend various methods to facilitate pain relief during labour. Nevertheless it seemed that in Bamalete Lutheran Hospital (BLH) the midwives were reluctant to give pain relief in form of Pethidine. Hydroxyzine Hydrochloride (Aterax) was introduced and intensive teaching done to educate the midwives on pain relief. Thereafter it seemed necessary to assess, if the needs for pain relief were met in BLH labour ward. (Pethidine + Aterax was the best option for pain relief because epidural anaesthesia was not possible.) Labour companionship is not implemented in the maternity unit of Bamalete Lutheran Hospital (BLH) despite the fact that during the past ten years several attempts were made to do so. The labour ward is technically well equipped. The staffing is adequate and all the obstetricians over the past years tried to practice modern obstetrics. Why then are labour companions underutilized in BLH? Methods It was decided to do a pilot study. This study should then guide the further research process. On the first or second day after delivery 100 newly delivered mothers were interviewed. Two researchers conducted the interviews in the study period 9.11.99 to 16.12.1999 on all newly delivered patients during the ward round. The interviews were conducted on a questionnaire. The questionnaires were statistically analysed with epi 6 info. Results The youngest patient was 16 years, the oldest 44 years. The mean was 26 years. There were 8% of teenage pregnancies of 18 years or less; 12% of the parturients 153 were above 35 years. Of the patients 41% were primigravidae, 53% gravida 2 to 5 and 6% were grand multi-gravidae of more than 5 pregnancies. Of the patients 75% delivered normally per vagina, 15% per Cesarean Section. Face to pubis, breech or vacuum deliveries were 2% respectively. The hours in labour as plotted in the partogram were analysed. The mean was 6,4 hours, the maximum 25 hours and the minimum 0 hours, which means the woman came and delivered immediately. The patients were asked how many hours they were in labour. The reported mean was 8,6 hours, the maximum 30 hours, the minimum 0 hours. Pain relief (Pethidine + Aterax) was given to 21% of the patients. 77% of patients had to endure labour without pain treatment. When labour was augmented 40% of the patients did get pain relief. When labour was not augmented only 12% of patients were given pain relief. The patients had to quantify the experienced labour pain as very severe, severe, tolerable and mild: 47% rated very severe, 25% severe, 18% tolerable and 7% mild. Asked to compare the pain with that of the last delivery 32% said it was worse, 10% said it was the same and 11% experienced less pain. From the primigravidae 51% experienced very severe pain. Only 4% described their pain as tolerable. 26% of the primigravidae got pain relief. The patients were asked what they would want to change during the next delivery: 28% mentioned they would want more pain relief. Of the patients 12% had a labour companion, 88% were alone with the midwives; 62% wished to have a labour companion next time, 37% did not want a labour companion during the next delivery. Asked whom they want as a labour companion 31% mentioned the mother, 17% the partner and 14% others (mainly other family members or a friend). From the patients who had no labour companion 58% wished to have a companion next time. Only one patient who had a companion during her delivery did not want to have a companion next time. While 11 from the 12 patients who had a companion this time also wanted to have one next time. From the primigravidae 65% wished to have a labour companion next time. The answers to the question why the patient did not want a labour companion were summarized in three categories: 8% declined a labour companion due to the tradition, 33% out of shame and 58% mentioned various other reasons. 154 Conclusions The study revealed that the patients" need for pain relief was not met in BLH. Almost half of the patients experienced labour pain as very severe, another quarter of the patients as severe. That means almost three quarters of the patients suffered a lot during labour. But only about one fifth of the patients got pain relief. More than half of the women who were in labour for the first time had very severe pain. Often it is assumed that with more deliveries women get used to the labour pain. This study showed that one third of the parturients found pain worse than previously. The study revealed that more research in the field of pain relief in BLH has to be done. The study showed that the patients" wish to have a labour companion was not met at BLH. More than 60% wished to have a labour companion but only 12% had one. Almost all women who had a companion wished to also have one in future deliveries. The person most mentioned as a companion was the mother, only 17% wanted their partner to be present. The study revealed that there is a serious need for further research. The questions to be answered are: What hinders patients to have a labour companion if the majority wishes to have one? How can these obstacles be overcome? 155 SESSION 7: KANGAROO MOTHER CARE THE DEVELOPMENT OF AN IMPLEMENTATION WORKBOOK FOR KANGAROO MOTHER CARE (KMC) A-M Bergh, AE Pullen, E van Rooyen, S Delport, Rl Mkohondo, M Lekalakala, B Pattinson Faculty of Health Sciences, University of Pretoria and MRC Research Unit for Maternal and Infant Health Care Strategies, Kalafong Hospital Introduction Kangaroo mother care (KMC) has proven to be an effective intervention to reduce neonatal mortality and morbidity rates for low birth weight babies. With more and more hospitals interested in KMC as part of their standard neonatal care, a need was identified for more information and education for health workers wanting to introduce a KMC programme. One way of introducing or institutionalising a new health care intervention is through outreach programmes with a strong educational component. Many programmes fail to ensure optimal implementation or a commitment to a constant improvement of practice. The process described here was aimed at addressing these shortcomings. Aims • To describe the development of a workbook for the implementation of KMC based on an action research programme • To illustrate how qualitative and quantitative research methodologies could be combined with a view to introduce new interventions more effectively or to improve practice The research process A draft implementation workbook for KMC was developed as a result of an action research programme under the auspices of the MRC Research Unit for Maternal and Infant Health Care Strategies at Kalafong and Witbank Hospitals. The research 156 commenced very modestly with the tracing of the implementation process by means of a qualitative investigation using observations and in-depth interviews as research strategies. From this first phase a few tools were developed for a better understanding of the implementation from a managerial and institutional point of view. At that stage the idea was to develop a checklist of a few pages which people could use when starting a KMC ward in their health care facility. This would be used in conjunction with other resources such as articles and videos. As the process continued, new insights emerged on what would be a useful educational intervention to combine with the introduction of a new health care intervention, in this case, kangaroo mother care. The effectiveness of the workbook will still be further tested by means of a randomised controlled trial with three groups. The first group, which will serve as a control group, will receive the workbook and the resources developed around it (a "package"). The second group will receive the package plus three sites visits: (1) to introduce the package; (2) to customise the package for the particular setting; (3) to assess the effectiveness of the intervention. The third group will receive the package plus some contact time through telemedicine. The following is a graphic representation of the research process: 157 The underlying philosophy The research process was grounded in a philosophy of the democratisation of management through the active participation of all roleplayers in the development of KMC policies at all levels of health care. It went through various stages of consultation and participation. The findings of the first phase of the research, especially the tools for understanding the implementation process, was workshopped first with nurses in the KMC ward at Kalafong, then presented at a conference and finally workshopped with a group of health workers and health officials, mainly in Gauteng province. In the process, the researchers came to realise that each setting would be different and that one cannot develop a blueprint type of checklist for implementation. Instead, a draft workbook was developed from all these inputs. It then went through as few rounds of consultations with the same health workers, as well as with additional health workers working in KMC in other settings. The workbook saw three drafts and will now be tested at four sites in Mpumalanga. The way in which the workbook is structured also reflects the assumption that health care workers in each health care setting have to find solutions which fit their setting best and that the handing down of guidelines from the top or blueprints for implementation are not the best way of getting health workers involved in the introduction of a new intervention and taking ownership of implementation decisions. Apart from the first two parts which are descriptive, the rest of the 100-page workbook consists of questions for which health workers have to find answers in the course of establishing a KMC programme in their facility. Health workers are guided by means of these questions to adopt a comprehensive approach, to detect possible pitfalls and to anticipate scenarios for their own facility. No answers are given - they have to seek these answers themselves through workshopping together, using the accompanying resources, seeking opportunities to attend seminars and visiting already established KMC units or wards. Health workers have to construct their own knowledge and should not merely be passive recipients of facts. Although the questions are structured around certain themes, the way in which each institution"s answers to these questions are formalised in policies and protocols should be uniquely tailored for that institution. This approach is very much in line with notions 158 of diversity, empowerment of health workers, participatory management and lifelong learning. What is in the workbook? Adopting a participatory process in which people construct their own meaning about how KMC should be practised, implies that there is very little information in the workbook on what KMC is about or how to practise it. We also distinguish between a KMC philosophy, a KMC programme and a KMC unit: The KMC philosophy is part of the broader approach which should underpin all perinatal care, namely the encouragement of skin-to-skin contact and breastfeeding. • A KMC programme refers to the "system" according to which KMC is practised in a particular health care facility. This requires careful planning to introduce and sustain. • A KMC unit refers to the physical space allocated for the practice of KMC. Although it can be a special section inside the neonatal ward it often refers to a facility created to enable mothers to practise continuous KMC prior to discharge of the baby. The workbook is about helping people to implement a KMC programme and to monitor their progress and the quality of care. This comprises more than merely establishing a KMC unit or ward. The guidance is conceptualised around seven main parts. The first two parts are the introduction and a part on the implementation of a KMC programme. The latter is the theoretical "product" of the first phase of the research and is meant to help health workers understand the implementation of a KMC programme more holistically. Then there is a short part for provincial departments or health ministries (part 3), but the main focus of the workbook is on all the things that have to happen within a health care facility as a whole before KMC can be implemented (part 4) and establishing intermittent and continuous KMC (parts 5 and 6 respectively). Currently the seventh part, caring for KMC babies after discharge, is under construction and will be further developed during the testing of the workbook. Conclusion The use of this participatory approach may also be useful for institutionalising other new health care interventions. 159 INTERMITTENT KANGAROO MOTHER CARE IN A NEONATAL HIGH CARE UNIT SD Delport Department of Paediatrics, Kalafong Hospital and the University of Pretoria and MRC Unit for Maternal and Infant Health Care Strategies Introduction Continuous kangaroo mother care (KMC) offers protean advantages to low birthweight infants in minimal care units. The advantages of intermittent KMC in neonatal intensive and high care units are increasingly being recognised. Worldwide the most important cause of death in these units is nosocomial sepsis. Concerted efforts are needed to prevent nosocomial sepsis in developing countries in particular, where the prevalence has been reported to be as high as 40% with a mortality of between 40% and 70%. The incidence of nosocomial sepsis in the neonatal high care unit (NHCU) at Kalafong Hospital in around 20%. During October 1999, 24 infants were admitted of whom 10 (41.7%) developed life-threatening nosocomial sepsis and 8/24 (33.3%) died. Exclusive breastfeeding was implemented from 11 November 1999 and intermittent KMC from 1 July 2000. The effect of these policy changes on the incidence of nexrotising enterocolitis and life-threatening sepsis was investigated. Patients and Methods Data were retrieved by retrospective chart review from 1 May 1999 to 30 November 1999 and from 1 May 2000 to 30 November 2000, representing epochs before and after the policy changes. Infants with a birthweight <2000g who were admitted primarily to the NCHU and remained there for longer than three days were studied. Infants who developed necrotising enterocolitis (NEC) grade III or IV or life- threatening sepsis necessitating admission to the NICU were documented. 160 Results Of 142 admissions during the first seven months (01/05/1999-30/11/1999), 20/142 (14.1%) infants developed NEC or life-threatening sepsis of whom 14 died (mortality 9.9%). Of 95 admissions during the second seven months (01/05/2000- 30/11/2000), 5/95 (5.3%) infants developed NEC or life-threatening sepsis of whom two died (mortality 2.1%). Intermittent KMC was administered to 48 of these 95 infants for an average period of 15 hours per infant during their stay in the NHCU. Conclusions Exclusive breastfeeding and intermittent KMC in a NHCU are effective measures in the prevention of severe nosocomial sepsis. The implementation of intermittent KMC in a NHCU is however fraught with difficulties. 161 PREDICTORS OF SURVIVAL FOR NON-VENTILATED INFANTS WEIGHING < 1000GMS. BJ Cory, PA Cooper Department of Paediatrics, University of the Witwatersrand and the Johannesburg Hospital. Introduction Babies weighing < 1000gms ELBW ( extremely low birth weight infants ) are seldom ventilated in the Johannesburg group of provincial hospitals. In spite of this our survival figures appear to have improved over the past 2 decades and our recent data is suggesting a survival rate approaching 50%. Aim The aim of this analysis was to examine factors that may be associated with this improved survival rate in ELBW infants. Method Data on all babies admitted to the labour ward nursery between July 2000 and the middle of January 2001, was reviewed. All data from outborn infants was also reviewed, these outborn infants were either BBA (born before arrival ) infants or infants transferred in from outlying hospitals. This data was then compared with a control group. For the control group we compared data from the more than 7000 deliveries at the Johannesburg Hospital between January and December 1999. Results 38 infants weighing <1000gms were admitted to the labour ward nursery during this period, this was 30% more than was admitted for the same period the previous year. Maternal age Age Study Group Control Group <20 18% 10% >30 36% 30% 162 Looking at maternal age, there was a tendency for the mothers in the study group to fall in the age groups younger than 20 years or older than 30 years when compared with the control group, but this difference did not reach statistical significance. Mortality 10 ( 26%) of the infants weighing <1000gms survived. There was no significant association with the type of delivery, booking status or the use of antenatal steroids on survival rate. Pregnancy induced hypertension was the most commonly recorded antenatal problem. Age at death 12 ( 43%) of the deaths occurred within the first 6 hours, with most of the babies dying within the first week of life. Of the 5 babies born weighing <800gms there were no survivors. There was an increase in survival rate with an increase in birth weight, with 7 of the 19 babies weighing between 900 and 999gms (37%) surviving. Maternal age versus survival rate Maternal age Survival <30 years 9/25 (43%) >30 years 1/10 (8% ) * *p = 0.09 There was a tendency for babies born to mothers over the age of 30 years to have a poorer outcome but this did not reach statistical significance when analysed. Conclusion There were more babies found weighing <1000gms than expected from the routine statistics resulting in a poorer survival rate than expected. This is probably as a result of active versus passive surveillance, where a number of babies dying in the first few hours after birth are not recorded in our routine statistics. There was a trend towards babies of mothers aged over 30 years with a poor obstetric history having a 163 poorer outcome. However, there did not appear to be any other obvious associations with mortality, given the small numbers analysed. 164 INTENSIVE CARE MANAGEMENT OF THE HIV EXPOSED NEONATE: CLINICAL AND VIROLOGICAL CORRELATES OF NEONATAL OUTCOME (INTERIM ANALYSIS) M Adhikari, PM Jeena, P Pillay, A Moodley, T Pillay Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, University of Natal Background and literature The burden of HIV-1 in mother-neonate pairs at King Edward VIII Hospital is high, approximately 34% of all women attending antenatal clinic at the hospital are HIV-1 infected. The risk of vertical transmission of HIV-1 is 20%-34%. Over the last year, a number of ill neonates born to HIV-1 infected mothers have been documented at the neonatal unit King Edward VIII Hospital. Approximately 40% of these neonates demised during the neonatal period; the majority requiring intensive care therapy prior to death. The decision to accept or refuse intensive care therapy to any neonate on the basis of maternal HIV-1 status is difficult. The presumed high mortality and often prolonged intensive care requirements in some of the neonates of HIV-1 infected mothers, coupled with limited provincial resources required a review of the guidelines for the intensive care management of neonates born to HIV- 1 infected mothers. This study aimed to compare clinical and virological factors associated with adverse outcomes in HIV-1 exposed neonates requiring neonatal intensive care therapy in the first 28 days of life. Method All neonates requiring intensive care therapy at the neonatal unit, King Edward VIII Hospital from 1st July to 15th December 2000 were included in the study. Consent for HIV testing of the mother and baby was obtained by a trained HIV counsellor and a HIV-1 Elisa test performed on the mother. Where the mother was HIV infected, blood for viral load, T lymphocyte subsets analysis (CD4/CD8) were performed on the mother and neonate, in addition, a PCR was performed on the latter. The primary end point of the study was survival while secondary outcomes included 165 clinical and viral characteristics. Outcome, especially with regard to death was correlated with clinical features (growth, frequency and nature of infections, acute and chronic) PCR, T lymphocyte subset analysis. Outcomes were compared in the HIV-1 exposed and non-exposed neonates. Results Sixty-eight babies were admitted to the NICU, 40 mothers (61%) consented to HIV testing. Eighteen (45%) were HIV infected, following post-test counselling 11 of the 18 positive mothers consented to PCR testing of the babies. Twelve (66%) of the HIV exposed compared to 18 (82%) of the non-exposed babies survived (p value 0.3) One of the 11 babies tested was PCR positive HIV exp HIV non- exp p value MATERNAL DATA Age 18-35 yrs 15 21 0.56 Parity 0 1-4 7 9 0.82 ANC 14 18 0.80 Obstetric complications 11 14 0.48 Delivery vaginal 8 6 CS 8 13 0.83 NEWBORN DATA Birth weight <1.49 kg 12 9 0.85 >1.5 kg 6 13 0.1 LFD 8 12 0.55 Indication for ICU HMD 10 13 0.82 Pneumonia 3 2 0.6 ICU complications 11 15 0.23 Clinical problems 16 19 0.90 Pos ETT culture 10 9 0.25 Antibiotics 2nd line 14 15 0.67 NICU stay 7 days 8 15 14 days 5 4 > 14 days 3 3 0.48 Hb g/dl 11.4 12.3 0.35 WCC (X109/L) 8.2 9.8 0.46 Abs lymphs (X106/L) 4047 4845 0.42 Platelets (X109/L) 198 202 0.46 CD4(/L) 1649 1566 0.48 Exp = exposed neonates non-exp = non-exposed neonates 166 Comment These interim results of HIV exposed infants admitted to neonatal intensive care provide reassurance that expensive resources are appropriately utilised. No significant differences in birth weight, growth, need for intensive care, complications of ventilation, associated medical problems, number of infections experienced, antibiotic usage, duration of stay in ICU, haematological parameters and T lymphocyte subsets were found comparing the HIV exposed and non-exposed neonates. A comparison of HIV exposed survivors and deaths showed no specific indicators of poor prognosis. Further the in utero transmission rate on an early PCR was 9%. The latter and the lack of difference in mortality and morbidity between the two groups studied support intensive care for HIV exposed neonates. The numbers of mothers refusing testing was an unusual finding. The completed study and longer term outcomes may provide further information which may influence the present conclusion. The results of this study are in keeping with the findings of paediatric and adult intensive care study conducted at King Edward Hospital. 167 IS THE TREATMENT OF BABIES WITH OVERT CONGENITAL SYPHILIS WHO NEED ICU CARE WARRANTED? R Van der Merwe, CH Pieper Introduction As resources are continuously dwindling, intensive care beds should be allocated to babies with possible good outcomes. Previous research at Tygerberg (1992) and Barragwanath (2000) showed that 50% of babies with clinical signs of congenital syphilis at birth and who need ICU care die. Aim To determine the current survival and clinical course of babies with congenital syphilis who need ICU care. Method A retrospective review was done of all babies with overt clinical signs of congenital syphilis who needed intensive care from 1992-1998 was done at a tertiary institution to determine the antropometric data, clinical course and outcome of these babies. Results 41 babies were included in the study. Their mean birthweight was 1429g, GA 31 weeks and 40% were small for dates. 11 of the 41 (26%) babies died. All babies had hepatosplenomegaly. The babies spent a mean of 10 days in the ICU, requiring 7 days of ventilation. The non-survivors died soon after admission (<6 days), but the survivors required a mean of 1.2 days extra oxygen and 3 days of hyperalimentation. Conclusions Compared to previous studies, the survival of infants with overt signs of congenital syphilis who required intensive care improved markedly. The high mortality and 168 morbidity as well as the enormous cost of intensive care could have been prevented antenatally. 169 BUILDING AND USING NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE MACHINES ON SITE, AT GROOTE SCHUUR HOSPITAL, CAPE TOWN I Els, A Horn, B Muller, L Hendry, G Manuel Neonatal Medicine, Groote Schuur Hospital, University of Cape Town Introduction Nasal Continuous Positive Airway Pressure (NCPAP) has been shown to reduce the need for more invasive ventilation in neonates with hyaline membrane disease ( Ho et al, Continuous distending pressure for respiratory distress syndrome in preterm infants, Cochrane Library, 4, 2000.) and post extubation atelectasis ( Davis PG, Henderson-Smart DJ, Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants. Cochrane Library, 4, 2000.). It may also have a role in preventing apneoa of prematurity, although this has not yet been proved. Most ventilators are able to deliver NCPAP via an adaptor, but this is not a cost effective use of the ventilator. Dedicated NCPAP machines are available commercially at a cost of ~ R30 000.00. The most important part of these machines is the specialised nasal prong, which incorporates a special flow system that facilitates easier breathing by reducing turbulence and is light weight, so it is easy to attach to the nose. We set out to build a machine ourselves as a cost saving measure after Prof G Kirsten suggested a possible design and now report our methods. Methods An Oxygen mixer and flow meter are connected directly to a humidifier. A Brittan Health Care non-heated circuit for NCPAP administration is connected to the humidifier. A pressure manometer (-10 to +40cm) is connected to the pressure tubing of this circuit. Air flow is set at 6 - 10L/min and this will deliver a pressure of 3 - 5cmH2O respectively. The Humidifier may be set at no.9 as temperature testing shows that this will deliver a maximum inspired temperature of 36.8C. (This only 170 applies if a fisher and paykel MR410 humidifier is used). Nostrils may be protected using a granuflex "mask" and should be suctioned 3 hourly. The in line water trap needs to emptied 1-2 hourly. The cost of the new parts required ( not including the circuit) is: Oxygen Mixer R7 500 Humidifier R3 500 Flow meter (0-15L/min) R 110 Pressure Manometer R 250 Stand R 500 Accessories R 250 Total R12 110 If second hand parts are used the saving is considerable. Results 2 Machines have been built and are used regularly. More than 30 infants have been managed from July - December 2000. One infant suffered a pneumothorax - a known complication of NCPAP. There were no other complications. Thus this mode of suppling NCPAP is safe, cost effective and was built in our hospital almost entirely from spare parts. 171 EVALUATION OF A TRAINING WORKSHOP IN KANGAROO MOTHER CARE (KMC) A-M Bergh, AE Pullen, E van Rooyen Faculty of Health Sciences, University of Pretoria and MRC Research Unit for Maternal and Infant Health Strategies Introduction With more and more hospitals interested to introduce kangaroo mother care (KMC) as part of their standard neonatal care, a need was identified for more information and education to health workers. Two one-day seminars attended by 37 participants each were held at Kalafong Hospital in November 2000. With the provision of continuing education within the framework of the Skills Development Act, more and more demands will be made on the quality of education and the long-term effect thereof. Objectives To evaluate $ the quality of two KMC workshops $ the potential long-term effectiveness of these workshops Methods All participants were given an evaluation questionnaire to complete at the end of each workshop. The sections dealing with the usefulness and quality of the presentations and the organisation of the workshop were done by means of a structured, 5-point scale in a table format. The section on the impact of the workshop on participants and their future needs was in the form of open-ended questions. The latter was analysed according to acceptable qualitative data analysis methods. Similar responses were grouped together, further coded and categorised in order to identify response patterns. 172 Results The response rate to the questionnaire for both workshops was 86,5%. Scale ratings $ For all sessions between 87% and 100% of participants indicated that they found the sessions useful or very useful and between 81% and 96% indicated that they found them of either good or excellent quality. There was a tendency for participants to allocate the same value on the scale for both quality and usefulness of presentation. $ The practical session in the KMC unit and the session on models and roleplayers were rated slightly lower on both usefulness and quality. These two were >hands-on= sessions where the facilitators used handouts and groupwork and not slide presentations as in the other sessions. $ The second workshop=s participants rated five of the sessions more than 10% higher in the category Avery useful@ and four of the sessions more than 10% higher in the category Aexcellent@. $ Both workshops rated well in terms of organisational matters. Qualitative analysis of responses to open-ended questions The following categories and patterns emerged from the qualitative content analysis of the responses to the open-ended questions: $ Most popular session: visit to the kangaroo ward $ Most important Alessons@ learnt from the workshop: - what is KMC - specific points about KMC KMC position, nutrition and discharge institutionally related aspects - roleplayers bonding of the mother-infant dyad education and empowerment of the mother and benefits for her benefits for the baby 173 staff issues such as commitment and reduced staffing - the importance of KMC - implementation of KMC general and institutionally related $ Aspects on which more information was needed: how to start - implementation of KMC, particularly in the ward more practical and hands-on experience how to involve and motivate all roleplayers KMC discharge $ Implementation problems expected: changing mindsets and resistance to change infrastructure, particularly space and physical structure resources (equipment; human resources; financial aspects) $ General comments on the workshop: remarks and recommendations on organisational matters presentation, handouts and notes notes of thank you Conclusions and Recommendations $ Participants appear to have enjoyed the workshop and to have found it useful, although they were confronted with many problems to overcome before implementation could start. More or longer practical sessions could be included. $ The 5-point rating scale was not a valid instrument for determining the quality of the workshops and participants tended to conflate issues of usefulness with issues of quality. As all participants were either unfamiliar with or relatively new in the practice of KMC, it could be expected that they would find all information sessions useful. 174 Peoples understanding of quality differs according to the type of presentations they have been exposed to and their expectations of a workshop, namely being a passive receiver or an active participant. The two "hands-on" sessions were rated slightly lower that the other sessions on usefulness and quality, probably because they required active participation and had less entertainment value. $ Possible reasons for the higher rating of the second workshop in terms of usefulness and quality: Facilitators were better prepared for the second workshop and knew what to expect. The second group had different dynamics and was perceived by the facilitators as livelier and more participating. This could, inter alia, be ascribed to the fact that some of the participants were from the same hospitals as those who had attended the first workshop and could have been influenced by the feedback. $ A new strategy which includes follow-up on the work done by participants should be devised to measure the long-term impact of the workshops. $ KMC workshops could take a different format and should become more diversified and specialised as more and more hospitals start with implementation. 175 CONTINUOUS KANGAROO MOTHER CARE AT A SECONDARY HOSPITAL IN THE WESTERN CAPE M Franken, M Wates and G Kirsten Departments of Paediatrics; Karl Bremer and Tygerberg Hospitals Introduction KMC is the preferred method of care for very low birth weight infants at the majority of hospitals in the Western Cape The enormous benefits of intermittent kangaroo mother care (IKMC) to the well being of infants and parents as well as cost savings and a reduced nursing work load are well established. Most institutions are, however, reluctant to practice continuous KMC (CKMC) due to limited beds for mothers and a fear of infant death during CKMC. Aim To determine the short term outcome of infants (birth weight < 1800g) nursed with early CKMC. Study design Cohort analytical. Patients and methods 61 infants admitted between 15th May and 15th November 2000 to the eight-bedded KMC ward at Karl Bremer Hospital, a secondary hospital in Bellville, were studied prospectively. Infants were nursed by means of CKMC regardless of birth weight or gestational age once they were stable and off intravenous fluids and supplementary oxygen. 176 Results: Number 61 Mean birth weight(g); SD; range 1504; SD 257; range 808 to 1800 Mean gestational age(w); SD; range 31.8; SD 2.9; range 25 to 40 Mean weight(g) at start of CKMC; range 1552.9; SD 184; range 1040 to 1830 Mean total hospital stay(d); SD; range 29.8; SD 16.7; range 8 to 84 Number with infection 0 Number died 0 Conclusions: CKMC can be practiced safely in a secondary hospital regardless of the weight at onset of CKMC. Recommendations More maternal beds should be made available at all hospitals where VLBW infants are treated so that CKMC can become the standard method of nursing these infants before discharge. 177 AUDIT OF A KANGAROO MOTHER CARE UNIT FROM AUGUST 1999 - OCTOBER 2000 E van Rooyen, A-M Bergh, AE Pullen MRC-Unit for Maternal and Infant Health Care Strategies, Department of Paediatrics Kalafong Hospital & University of Pretoria Introduction A 30 bed Kangaroo Mother Care (KMC) unit was established at Kalafong Hospital where continuous and intermittent KMC is practised. It was opened on 6 July 1999. It replaced the existing 12-bed Low Care Neonatal Unit where premature babies were cared for by conventional nursing methods. KMC consists of infant-to-mother skin-to-skin care, exclusive breast-feeding when possible, and early discharge from hospital. It is well known due to many research studies that KMC has many benefits, babies can safely be held skin-to-skin even at a weight of 700 grams, there is no increase in infections and nosocomial infections may decrease. In the unit we tried to adhere to these concepts with a few exceptions. Formula feeds were given to babies whose mothers chose not to breast-feed because they are HIV positive. Early discharge was not always possible in babies who suffered from chronic lung disease and who were oxygen dependent. All babies discharged from the unit were followed up at a weekly clinic, which is held in the unit. Aim To conduct an audit of all admissions to the KMC unit over a 15-month period and to look at: The number of babies admitted each month. Admission and discharge weight categories. Average length of stay in the unit. Breast-feeding practices and HIV-infection-rate. Infection and mortality rate. The follow-up clinic attendance rate. 178 Research Method All patients admitted to the KMC-unit from August 1999 - October 2000 were included in the audit. An audit form was completed for each admission. The same form was used to record follow-up clinic attendance. Data was analysed statistically. Conclusion Very low birth weight babies were successfully cared for in the unit. The average stay in the ward was 2 weeks. The shortest stay was 2 days and the longest was 71 days. Most mothers continued to breast-feed. Formula was used mainly by mothers who were HIV-positive. The infection rate was low and only one death occurred in the unit. The follow-up clinic had an acceptable attendance record. Limitations and recommendations The HIV infection rate in the unit was only 14%, which is not a true reflection of the HIV rate at Kalafong Hospital. The results were not always recorded on the audit form. Many babies stayed in the unit for a long period of time because of chronic lung disease and this influenced the average stay in the ward. For future audits it should be helpful if the audit form incorporate the diagnosis. Admissions to the KMC-unit from August 1999 to October 2000 A total of 381 patients were admitted Oct-00 26 Sep-00 21 Aug-00 33 Jul-00 27 Admissions per Month Jun-00 18 May-00 30 Apr-00 31 Mar-00 28 Feb-00 25 Jan-00 24 Dec-99 21 Nov-99 13 Oct-99 22 Sep-99 31 Aug-99 31 0 5 10 15 20 25 30 35 Number of Patients admitted each month 100 80 60 40 West East 20 North 0 Qtr Qtr Qtr 1st 2nd 3rd Qtr 4th 179 Admissions to the KMC-unit according to weight categories 79% of admissions weighed less than 1,751 kg 4% 1% 4% 12% 13% Under 1,000 kg 1,001 - 1,250 kg 1,251 - 1,500 kg 1,501 - 1,750 kg 1,751 - 2,000 kg More than 2,000 kg 26% Unknown 40% Discharges from the KMC-unit according to weight categories 42% discharged patients weighed less than 1,751 kg 3% 1% 11% Less than 1,500 kg 41% 1,501 - 1,750 kg 1,751 - 2,000 kg 2,001 - 2,500 kg More than 2,500 kg 44% Patients transferred back to the High Care-unit Only 7% of patients had to be transferred back for possible nosocomial infections. Two patients died, one in the unit and one in ICU. Transferred out Died 7% 1% Not transferred 92% 180 NURSING IMPLEMENTATION OF KANGAROO MOTHER CARE AT KALAFONG HOSPITAL M Lekalakala, E van Rooyen, A Bergh, A Pullen, R Mokhondo, R Pattinson Kalafong Hospital Introduction Kangaroo Mother Care or KMC is essentially a nursing intervention. There is solid evidence that this intervention has been evaluated and found to be better than the conventional practice. Effective implementation is not possible if all the staff involved have not received a thorough grounding. Kangaroo Mother Care has been introduced at Kalafong Hospital since July 1999. A need was identified to train nursing staff in KMC. Training workshops were held to address this need. The poster presents the Core issues that were addressed from a nursing perspective. Objective The objective is to present the core issues included in the workshops presented on the Nursing implementation of KMC. Method Two workshops were presented. During these workshops both theory and practice were included in the programme. The participants evaluated the workshops. Training programme for nursing staff included: Guidelines for implementation Legal and ethical aspects Patient Rights Teamwork in KMC Policies, procedures and protocols to be considered Skills development Nursing care of mother an neonate Guidelines for patient information Evaluation of nursing effectiveness Risk management Specific issues related to the management of a KMC Unit Research including audit 181 Conclusion: During the interaction with participants they indicated a definite need for such Workshops and also advanced training programmes. Training nurses in KMC is a valuable method to ensure successful implementation. 182 SESSION 8: HIV AND BREASTFEEDING THE SAINT TRIAL: NEVIRAPINE (NVP) VERSUS ZIDOVUDINE (ZDV) + LAMIVUDINE (3TC) IN PREVENTION OF PERIPARTUM HIV TRANSMISSION. L Thomas for the Saint Trial investigators Effective Care Research Unit Background Two short course anti-retroviral regimes previously demonstrated to be effective in prevention of mother to child transmission (MTCT) of HIV1 within six weeks of birth were compared in a randomised open label trial conducted in South Africa. Methods 1306 HIV positive mothers were randomised to one of two arms. Arm A: 200mg Nevirapine intra-partum was given to the mother and this dose was repeated 24 to 48 hours post-delivery. The baby also received a dose of Nevirapine post-partum. Arm B: multiple doses of ZDV + 3TC was given to the mother during labour and both mother and infant had to take ZDV + 3TC one week post-delivery. HIV1 status of the infant was determined at birth (0 – 2 days) and at 4 weeks and then again at 6 – 12 weeks using the DNA (Roche Amplicor) ASSAY. HIV1 status at birth was confirmed using the RNA (Roche Amplicor) ASSAY. The primary analysis focussed on the incidents of peripartum infection defined as infection intra-partum and post- partum up to 10 weeks confirmed at two consecutive visits. Intra-uterine infections, neo-natal deaths and infants lost to follow-up were excluded from the primary analysis but used in Kaplan – Meier estimates of all perinatal HIV infection. Results Intra-uterine infection rates were 7.19% (46\652) for Nevirapine and 5.9% (38\649) for ZDV\3TC respectively. There were 9 (1.4%) perinatal deaths in the Nevirapine arm and 17 (2.6%) in the ZDV\3TC arm. Mother to child transmission (MTCT) rates 183 by Kaplan-Meier estimates were 12.7%, and 9.5% for NVP and ZDV\3TC arms respectively. There were no significant differences between arms. Conclusion Both regimes were effective with result comparable to those observed with NVP in HIVNET012 and with the ZDV\3TC in PETRA. Arm B compared to current South African MTCT rates in excess of 20% , both the simple NVP regimen and the more involved and expensive ZDV\3TC regimen demonstrated comparable efficacy and prevention of mother to child transmission of HIV1 in the peripartum period. 184 EVALUATION OF SAFETY OF TWO SIMPLE REGIMENS FOR PREVENTION OF MOTHER TO CHILD TRANSMISSION (MTCT) OF HIV INFECTION 'NEVIRAPINE (NVP) VS LAMIVUDINE (3TC)+ZIDOVUDINE (ZDV)' USED IN A RANDOMIZED CLINICAL TRIAL (THE SAINT STUDY) G Gray, The SAINT Study Team Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Soweto, RSA, South Africa Background The SAINT Study was conducted in South Africa to compare the efficacy of a short course of NVP with a short course of ZDV+3TC for prevention of MTCT of HIV. The assessment of safety is critical for MTCT prophylaxis. Methods SAINT was a randomized, open label, multicenter trial that enrolled 1306 HIV positive pregnant women and their infants. Women presenting in labour or very late during pregnancy were counseled and tested for HIV. HIV+ women who gave informed consent were randomized to NVP (200 mg dose during labour, and a second 200 mg dose 24 - 48 hours after delivery) or to ZDV (600 mg, then 300 mg q3h during labour and 300 mg BID subsequently) plus 3TC (150 mg BID) during labour, and then for 7 days. Respectively, the children were given a single 6 mg dose of NVP at 24 to 48 hours after birth, or ZDV (12 mg BID) plus 3TC (6 mg BID) for 7 days. Adverse events (AEs) were collected for up to 84 days. An analysis of the full patient data will be presented; interim analysis data is presented here. Results Available for analysis were the first 528 mothers and 532 infants entered into the study. There were 7 (2.7%) all causality serious AEs (SAEs) reported for 264 NVP mothers and 4 (1.5%) for 264 ZDV+3TC mothers. There were 15 (5.7%) all causality SAEs for 265 NVP infants and 26 (9.7%) for 267 ZDV+3TC infants. There were no treatment related SAEs in mothers or infants in either group. Four deaths 185 occurred in infants (ZDC+3TC: 3; NVP: 1). None were related to treatment. There were no maternal deaths. Conclusion The interim analysis of deaths and serious adverse events suggests that both treatment arms are similar and safe. The final analyses of AEs and deaths will be presented. 186 INFLUENCE OF FEEDING MODE ON MOTHER TO CHILD TRANSMISSION OF HIV-1 A Coutsoudis, K Pillay, E Spooner, L Kuhn, HM Coovadia for the South African Vitamin Study Group. Department of Paediatrics and Child Health, University of Natal Introduction Previous studies designed to examine the influence of breastfeeding on mother to child transmission (MTCT) of HIV have not examined the influence of pattern of breastfeeding. This study therefore aimed to examine the effect of exclusive and non-exclusive (mixed) breastfeeding on MTCT of HIV. Study Design Prospective cohort study conducted in 2 hospitals in Durban, South Africa including 551 HIV-infected pregnant women who self-selected to breastfeed or formula feed after being counselled according to the UNAIDS guidelines. Breastfeeders were counselled and encouraged to practice exclusive breastfeeding for 3-6 months. Main Outcome Measures The cumulative probabilities of detecting HIV infection over time were estimated using Kaplan-Meier methods and compared in 3 groups of infants: 157 formula fed (never breastfed); 118 exclusively breastfed to > 3 months; and 276 mixed breastfed. Methods At each follow-up visit (1 wk, 6 wk, 3, 6, 9, 12 and 15 months) information was collected on exactly what solids and liquids the infant had received and the age each item was first introduced. Bloods were also taken at these visits for later determination of HIV status (RNA-PCR tests on samples <9m). 187 Results The 3 feeding groups did not differ in any risk factors for MTCT and the probability of detecting HIV at birth was similar. The cumulative probabilities of HIV infection remained similar among never and exclusive breastfeeders up to 6 months 0.194 (95% CI: 0.136-0.260) and 0.194 (95% CI: 0.125-0.274), respectively, whereas the probabilities among mixed breastfeeders soon surpassed both groups reaching 0.261 (95% CI 0.205-0.319) by 6 months. By 15 months the cumulative probability of HIV infection remained lower among those who exclusively breastfed > 3 months than among other breastfeeders (0.247 vs 0.359). In time-dependent Cox model, exclusive breastfeeding carried a significantly lower risk of HIV transmission than mixed feeding (hazard ratio 0.56 [95% CI: 0.32-0.98]) and a similar risk to never breastfeeding. Conclusion Infants exclusively breastfed for 3 months or more have no excess risk of HIV infection over six months from those never breastfed and have lower risk for infection than those receiving mixed breastfeeding under 3 months of age. These findings, if confirmed elsewhere, can influence public health policies on feeding choices available to HIV infected mothers in developing countries. 188 DETERMINATION OF THE EFFECTIVENESS OF INACTIVATION OF HUMAN IMMUNODEFICIENCY VIRUS BY PRETORIA PASTEURISATION. BS Jeffery*. L Webber#, KR Mokhondo*, D Erasmus# *Department of Obstetrics and Gynecology, Kalafong Hospital and University of Pretoria & MRC Maternal and Infant Health Care Strategies Research Unit. # Department of Medical Virology, University of Pretoria Background The risk of transmission of the human immunodeficiency virus (HIV) via breastfeeding is between 10 and 17. A method has been devised by which HIV infected women may express and pasteurise their breast milk in a domestic setting using inexpensive apparatus and a simple technique in order to inactivate the virus. The method, Pretoria Pasteurisation has been shown to be reliable under a wide range of conditions and maintains milk between 56º and 62,5º for between 12-15 minutes. This study was devised to determine whether Pretoria Pasteurisation effectively inactivates HIV in human milk. Methods Samples of expressed breast milk were obtained from a group of HIV infected lactating women and a group of HIV negative women. The samples of milk from the HIV negative women were inoculated with high titres of cell associated and cell-free HIV. Each sample was divided into a control portion and a study portion. The study portion underwent Pretoria Pasteurisation. Control and pasteurised samples were inoculated into lymphocyte co-culture for a period of 35 days. All co-cultures were sampled weekly and analysed by serological and molecular methods for p24 antigen, cell free HIV RNA and integrated DNA. Results A total of 26 samples from known HIV seropositive women and 25 samples from women of unknown or negative HIV serostatus were processed. All of the women were antiretroviral therapy naïve. 189 Baseline Data Viral RNA was detected in the milk of 21 of 26 (80%) of the known HIV positive women. The mean serum viral load was 50 728 copies/ml (± 23 057 copies). The mean milk viral load was 422 000 copies/ml (± 358 650 copies). In nine patients the milk viral load was higher than the serum viral load. Specimens from known HIV positive women Control specimens: Five of the control specimens had evidence of viral replication. The control specimens that had evidence of viral replication were those from patients with high milk viral loads. Pasteurised specimens: None of the pasteurised specimens from HIV seropositive women had evidence of any viral replication by persisting or increasing p24 antigen or an increase or plateau of viral load. Two pasteurised specimens showed a transient appearance of p24 antigen on one occasion which was then undetectable for the remainder of the culture period. In both of these samples, the RNA viral load was undetectable after the baseline measurement and remained undetectable throughout the 35 day culture period. None of the pasteurised specimens showed increasing titres of viral RNA Spiked specimens from women of HIV negative or unknown serostatus Control specimens: Four of the control specimens in this group displayed evidence of viral replication in co-culture. Pasteurised specimens: No pasteurised specimen displayed evidence of viral replication or any increase in RNA viral load. 11 control and pasteurised pairs of specimens were tested for integrated viral DNA. This was identified persistently in 5 of the controls up to day 35 but was undetectable in 10 of the 11 pasteurised specimens at all samplings following pasteurisation. Discussion In a total of 51 milk specimens processed, no evidence of HIV replication has been found in any specimen following Pretoria Pasteurisation. If 95% confidence intervals are applied to this finding, this would give an upper limit of six percent possibility of the presence of HIV capable of replication being present in human milk following 190 Pretoria Pasteurisation8. In order to reduce the size of this statistical limit, it would be necessary to process a much larger sample. Added to this is the fact that should any viable HIV persist in any specimen following pasteurisation, it will be at substantially lower viral load than before pasteurisation and hence present a significantly reduced risk of infection to the infant9. The transient appearance of p24 antigen in pasteurised specimens presented some concern as to whether this could indicate a low level of viral replication in these samples or if it simply represented remnants of the antigen that were detected by the assay or a non-specific serological reaction. This phenomenon was investigated further with a set of five sub samples that were autoclaved and then inoculated into co-culture. In four of the five samples, p24 antigen was detectable following autoclaving, at similar quantities to that detected in the pasteurised specimens. This confirms that the transient identification of p24 antigen represents the detection of remnant fragments without the presence of viral replication or a non-specific serological reading may have occurred, especially in view of the nature of the specimens. Conclusion Pretoria Pasteurisation effectively inactivates HIV in human milk as well as in culture medium and can be offered as a feeding option for the infants of HIV positive women. Acknowledgements This study was funded by UNICEF, South Africa and the MRC Unit for Maternal and Infant Health Care Strategies. 191 HIV SEROPREVALENCE AND RAPID TESTING IN UNBOOKED PREGNANT AFRICAN WOMAN JA Matambo Nelson R Mandela School of Medicine, University of Natal, Durban Objectives To determine the seroprevalence of HIV-1 infection by rapid testing and its assosiation with syphilis serology in women who do not receive antenatal care. Setting A tertiary hospital, Durban, South Africa Methods Pregnant women who have not attended an antenatal clinic for the index pregnancy and presenting to the labour ward during a 3 month period received pre-HIV test counselling. Following informed consent, blood samples were tested for HIV-1 antibodies by a rapid test (Capillus). The remaining aliquots of blood samples were sent to the laboratory for HIV confirmation by standard ELISA and syphilis serology by a conventional method. Results One hundred and sixty women fulfilled the study criteria, of whom 14(9.7%) refused to be tested for HIV. HIV seropositivity was confirmed in 66 of the 146 (45.2%, 95% CI 37.9-52.5) women. Sensitivity and specificity of the rapid test were 97.0% (95% CI 88.5-99.5) and 100% (95% CI 84.3-100) respectively. The positive and negative predictive indicies were 100% and 97% respectively. Thirty nine (26.7%) were positive for syphilis, of which 19 (48.7%) were also HIV positive. The average age of the study participants was 26 years, 34.2% were nulliparous and the mean gestational age at presentation was 35 weeks. There were no significant differences in the demographic characteristics between the HIV infected and uninfected women. 192 Conclusion The HIV seroprevalence in women who did not seek antenatal care was 1.5 times higher than that quoted for antenatal attendees at the same institution. The Capillus HIV rapid test was efficient, easy to perform and results reliably interpreted by the nursing team. The high HIV seroprevalence among women with positive syphilis serology confirm a strong association between these two sexually transmitted diseases and syphilis is a useful marker for HIV testing particularly in women who do not seek antenatal care. 193 NEVIRAPINE FOR PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV-1: IS IT DELIVERED EFFECTIVELY IN ROUTINE CARE? M. Urban1, M Chersich2, M Lucic1 1 Dept Paediatrics, Coronation Hospital. 2Peri-natal HIV Research Unit, Chris Hani Baragwanath Hospital. Introduction At Coronation Hospital it is routine clinical practice to provide nevirapine for prevention of mother-to-child transmission of human immunodeficiency virus type one (HIV). The objective of the study was to assess the proportion of HIV-infected women and infants receiving nevirapine, and how this could be improved. Methods Retrospective review of 299 records of consecutively delivering women with live- born infants in October 2000. Information was obtained on HIV status and on missed opportunities for HIV testing, obtaining HIV results, and providing nevirapine. Results Of a total of 299 records, 181 (61%) had ante-natal HIV serology results. Of those tested, 27 (16%) were sero-positive. Of those tested, HIV results were not obtained by the hospital staff for 22 women (7% of all subjects). It was estimated that there were missed opportunities for HIV testing in 24 (8%) at ante-natal follow-up, and in a further 39 (13%) during hospital admissions prior to the onset of labour. A total of 14 women (52% of the known HIV-infected) and four infants (15% of the known HIV-infected) received nevirapine. Applying the HIV prevalence rate of 16% to the sample we would estimate 48 women to be HIV-infected. Only 29% and 8% of the estimated number of HIV-infected women and infants respectively received nevirapine. 194 Discussion During routine clinical care at our hospital, there were frequent missed opportunities for HIV testing, obtaining HIV results and for providing nevirapine to those diagnosed, to the extent that less than one-third of the estimated number of HIV- infected women and/or children received nevirapine. However, if all missed opportunities were avoided then almost ninety percent would receive nevirapine prophylaxis. Conclusion Any strategy for prevention of mother-to-child transmission of HIV must be closely monitored to avoid short-comings which could seriously impact on both effectiveness and cost-effectiveness. 195 PRELIMINARY RESULTS OF A DOUBLE BLIND RANDOMISED CONTROLLED TRIAL TESTING THE EFFECT OF VITAMIN A IN MOTHER TO CHILD TRANSMISSION OF HIV-1. P Chikobvu, E van der Ryst, G Joubert , WJ Steinberg, JI Viljoen, J Kriel, M Kotze Departments of Biostatistics, Virology, Obstetrics and Gynaecology, Paediatrics and Haematology UOFS Introduction and Aim Mother to child transmission of human immunodeficiency virus ( HIV-1) is a serious problem in many developing countries. A randomized control trial was initiated in Bloemfontein, Free State, to investigate the possible preventive role of Vitamin A in Mother-to-child transmission of HIV. The study population is HIV positive pregnant mothers attending Pelonomi, Universitas Hosital and MUCPP Health Centre antenatal clinics. Methods Voluntary screening (coupled with pre- and post-test counseling) was introduced at Pelonomi hospital and MUCPP Health centre antenatal clinics from September 1997 to January 1999. HIV positive patients were reminded about the trial during post- test counselling and requested to participate. Following recruitment, patients were randomized into either the placebo or the control arm of the study. Follow-up continued until the baby was 18 months old. Results The preliminary results obtained so far are presented. As at the time of presentation (March 2001) not all the data of the patients were finalized, therefore the chief investigator has not allowed us to "break the code" yet. The results presented are therefore not yet stratified according to Vitamin A and placebo groups. Screening at antenatal clinics was initiated against some resistance of nursing personal and patients. During the period of Sept 1997 and January 1999, two thousand nine hundred and forty nine (2949) women were counselled, and 2543 196 agreed to testing for HIV. Of these five hundred and ninety five tested positive for HIV-1 on Elisa. This amounts to a prevalence rate of 23.4% in this population, which compared well to the National Department of Health figure of 22.7% for the Free State during the same time frame. Three hundred and three women were enrolled into the study. Many of the remaining positive mothers did not give consent for enrolment or did not return for the results. To date of those that were enrolled, the HIV results of 153 babies are known and the results presented in this paper. Ninety-one (91) mother and baby pairs were followed up until 18 months. In answering the question, whether the group of mothers that we have results for the babies differs from the group that we have no results for the babies, with respect to inclusion data at recruitment, these groups were compared with all the data available. There was no significant difference found in any of the demographic parameters, symptoms, abnormalities on examination or any of the hematological results of these two groups. At three months 153 infants HIV results were known as measured by the PCR (and P 24). One hundred and twenty three were negative and 30 positive giving an overall transmission rate of 19.6% for this sample. It seems to be the first time that MTCT of HIV was measured in the Free State. At three months the positivity rate was calculated for the breast-feeding group, non-breast-feeders as well as mixed feeders. These amounted to 3/27 (10%) for the breast-feeding group; 23/70 (24.7%) non-breast-feeders; and ¼ (25%) in the mixed feeders group. The perinatal mortality rate was assessed to be 46/1000 which is slightly higher than the baseline rate for that population which is 31/1000. The infant mortality rate was calculated at 86/1000. These are best possible scenario figures. All babies that have died and we had results of were PCR positive for HIV. 197 Comparing the mode of delivery with infant positivity at three months, the vaginal deliveries had a transmission rate of 17.4% compared to 28.2% for the caesarean sections. At three months there was a correlation found between the babies low CD 4 and CD 8 counts as well as hemoglobin, neutrophils and platelet counts and their positivity rates, however no correlation was found between there CD4/CD8 ratios, hematocrit and white blood counts. At three months, there was a correlation found between the mothers CD4/CD8 counts and eosinophil counts and the babies positivity, however the clinical significance of this is not clear. No correlation was found between the mothers CD4 and CD8 counts her hemoglobin hematocrit or platelets and the babies positivity. When looking for a correlation between abnormal findings of the maternal examination on enrollment and the fetal HIV transmission, there was no correlation found between the mothers systematic examination of her central nervous system, cardiovascular system, gastrointestinal system, ENTract or dermatological examination. There was a slight correlation with anaemia and lymphadenopathy, however not statistically significant. The only statistically significant correlation was that with abnormalities of the respiratory system of the mother on enrolment, however the numbers were small. Conclusion Maternal-to-child-transmission of HIV in the Free State was measured for the first time to our knowledge and was measured at 19.6 % at three months postpartum as indicated by PCR (and P24). Unfortunately the results are not yet stratified according to Vitamin A group and the placebo group, therefore no measure as to the possible efficacy of vitamin A in reducing MTCT of HIV can be made from this study at this stage. 198 CONSENT FOR PARTICIPATION IN THE BLOEMFONTEIN VITAMIN A TRIAL: HOW INFORMED AND VOLUNTARY? G Joubert , P Chikobvu, E van der Ryst, WJ Steinberg, JI Viljoen, J Kriel, M Kotze Departments of Biostatistics, Virology, Obstetrics and Gynaecology, Paediatrics and Haematology UOFS Introduction and Aim Voluntary informed consent is a prerequisite for HIV testing, as well as participation in a clinical trial. The aim of this study was to investigate whether the consent for HIV testing and subsequent participation in the Bloemfontein Vitamin A trial was informed and voluntary. The trial investigates the effects of Vitamin A on the transmission of HIV from mother to child. Methods The sample for this descriptive study consists of all the Vitamin A trial participants who attended the postnatal follow-up visits during the period July - October 1999. A retired nursing matron, fluent in Sesotho, Afrikaans and English, using a structured questionnaire conducted private interviews. Selected information was obtained from the patients' trial case record form. Results Of the 96 patients approached for inclusion in this study, 4 (4.2%) refused to participate. The median education level of respondents was standard 8 (Grade 10), with nearly 90% having standard 6 (Grade 8) or higher. Knowledge about HIV transmission and prevention was generally good, but the minority could correctly describe what HIV (26.1%) and AIDS (44.6%) are. Ninety five percent stated that they understood the counseling for the HIV test. Only 3.3% stated that they were forced into taking part in the trial, but 92.3% stated that they felt they would no longer get good medical care if they withdraw from the trial. Knowledge about the trial was poor, with only 40.2% being able to correctly describe the medication used, 199 only 28.3% could describe the reason for the trial and only 30.4% knew how long their participation would continue. Conclusion Although the participants still have a number of questions regarding HIV/AIDS, consent given for HIV testing was voluntary and informed. However, although the participants felt that their participation in the trial was voluntary, their knowledge about the trial was poor. This could have serious ethical implications and demonstrates that great care should be taken to ensure that patients understand the information given to them. A possible solution might be to repeat this information at each visit. 200 MOTHER TO CHILD TRANSMISSION OF HIV – A PILOT COMMUNITY PROJECT OF THE PROVINCIAL ADMINISTRATION OF THE WESTERN CAPE (PAWC) E Coetzee In January 1999 PAWC decided to implement the research trial done in Thailand at a community in Cape Town, i.e. Khayelitsha. There are 2 midwife obstetric units in Khayelitsha each with separate administrative authorities. After 6 months 3463 patients had booked of whom 2836 had accepted voluntary testing. The mothers were treated with AZT 300mg b.d. for 36 weeks and then 300mg 3 hourly in labour. On assessment of the programme it was found that only 50% of mothers had received any AZT during the antenatal period and/or labour and that 20% had never received AZT at all. The programme at that time was deemed to be a failure and the reasons for the problems were sought and corrective action was planned and instituted. Problems that were identified were: 1) A top down approach with not enough community involvement 2) Not sufficient attention was given to the increased workload that the nurses had to carry because of the programme. 3) Not sufficient counsellors were appointed and their integration into the MOU was inadequate. 4) Time from taking blood to obtaining test results was too long i.e. an average of 8 days. 5) The multiplicity of administrative authorities involved made adequate communication and planning impossible. 6) Mothers were delivering preterm or were being mis-assessed for gestational age. Remedial action which was taken include: 201 1) The formation of a local committee to oversee all aspects of the project. 2) More counsellors were appointed 3) The nursing staff were involved and motivated 4) AZT was started at 34 weeks instead of 36 weeks 5) Support groups were organised for mothers 6) Better links to the baby clinics were organised. In the 2nd half of 2000, 2790 mothers accepted testing. There was general acceptance of on-site testing by the mothers. Twenty point three percent of mothers were HIV positive; 67% of mothers were started on AZT at 34 weeks and 45% received at least 4 weeks of AZT. Almost all mothers received AZT in labour. It was felt that the corrective action had resulted in much better programme compliance. Conclusion MTCT programme should be community based and administered. Counselling services must be adequate. The nursing staff must support the programme. Rapid on-site testing is essential. A holistic approach should be adopted. 202 BACTERIAL CONTAMINATION OF EXPRESSED BREAST MILK SD Delport,* IM Vickers# *Dept of Paediatrics, Kalafong Hospital and the University of Pretoria and MRC Unit for Maternal and Infant Health Care Strategies #Dept of Microbiology, Kalafong Hospital and the University of Pretoria Introduction Low birthweight infants receive expressed breast milk (EBM) before the sucking reflex has matured. Milk is expressed manually and administered as a bolus via a nasogastric tube. Superfluous EBM is refrigerated at 2-4 degrees Celcius and used within 24 hours. Bacterial contamination of EBM occurs with skin commensals (Staphylococcus epidermidis and Streptococcus viridans) in the majority of cases. But potentially harmful pathogens such as E. coli and Klebsiella spp may also contaminate EBM and could be a source of infection for the infant. A pilot study was undertaken to determine the bacterial contamination of EBM fed to low birthweight infants within the first week of life. Patients and Methods Mothers who had delivered a low birthweight infant and chose to breast feed were counselled and requested to express milk for culture within one week of delivery. After handwashing, the mother expressed an initial sample (1ml), followed immediately by a second sample of the same volume. Milk was collected in sterile containers cleansed in a 1% hypochlorite solution and cultured within 30 minutes of collection. The number of colony-forming units (CFU)/millilitre was determined. Results Twenty-four women were enrolled (23/10/2000 – 12/12/2000). Thirty-five initial samples and 34 second samples were cultured. The median number of CFUs/ml in the initial samples was 11000 (range 20 – 100 000). No sample was sterile. Commensals namely Staphylococcus epidermidis and/or Streptococcus viridans grew in 19/35 samples while 16/35 grew pathogenic bacteria namely Staphylococcus 203 aureus, Klebsiella pneumoniae, Enterobacter, Acinetobacter lwoffi, Acinetobacter baumanii, Alkaligenes faecalis and Proteus mirabilis. The median CFUs/ml of the second samples was 15 000 CFUs/ml (range 100 – 100 000). Commensals grew in 18/34 samples while 16/34 grew pathogenic bacteria found in the first specimens as well as Serratia marcescens. Conclusions EBM can be contaminated by pathogenic organisms. The initial milk expressed does not contain more CFUs/ml. Meticulous handwashing techniques should be employed in an attempt to limit contamination of EBM to commensal organisms. 204 SESSION 9: HIGH RISK OBSTETRICS TRADITIONAL HERBAL MEDICATION AND OTHER SELF MEDICATION IN PREGNANCY IN THE EASTERN CAPE L Mangesi, GJ Hofmeyr Cecilia Makiwane Hospital, East London Hospital Complex Effective Care Research Unit, University of the Witwatersrand Introduction The presence of MSAF sometimes results in meconium aspiration syndrome which contributes to increased perinatal morbidity and mortality. Ziadeh & Sunna (1999) showed an increase in perinatal mortality from 2 per 1 000 with clear amniotic fluid to 10 per 1 000 with meconium). Mitri et al (1987) suggested that women who take self-medication such as isihlambezo and/or castor oil should be treated as high risk patients for passage of meconium. A study conducted at King Edward VIII Hospital suggested that there was a positive correlation between the use of traditional herbal medication and MSAF and the rate of caesarian section (Mabina, Pitsoe & Moodley, 1997). Most hospitals in the Eastern Cape have limited human and material resources. Cecilia Makiwane Hospital has a significant number of patients who present with MSAF when membranes rupture. It is not known which self-medication pregnant women in this area take and how it affects their pregnancy outcome. Most drugs taken in pregnancy can cross the placenta and expose the fetus to teratogenic or toxic effects. The Department of Health is presently forming partnership with traditional medical practitioners. Health professionals are labeled as having a negative attitude towards the use of traditional herbal remedies. This further justified a need for a study to be conducted in this area, as health care workers need to be better equipped for referrals from indigenous practitioners. 205 Method Data collection A convenience sampling method was used. This was a quantitative study which prospectively observed the relationship between the use of traditional herbal and/or other self-medication, and the outcome of pregnancy. The setting of the study was the postnatal wards of Cecilia Makiwane Hospital where the researcher visited the participants. The interviews were structured and a one to one approach was used during interviews. Verbal consent was sought after informing the participants about their right to refuse without affecting their management. Data sheets filled in by the researcher sought the information on traditional herbal and/or other self-medication used, when this medication was last taken, reasons for taking and where the medication was obtained. After the data were collected from participants, the participants" records were used to ascertain clinical details such as the description of amniotic fluid, Apgar scores and mode of delivery. Information about the medications was sought from a herbalist in Mdantsane. Data Analysis The collected data were analysed manually. The proportion of women who took traditional herbal and/or other self-medication was calculated. The number of those who had MSAF after taking traditional herbal and/ or other self-medication was compared with those who had MSAF without taking any self-medication. The different groups were further analysed for caesarian section deliveries and Apgar scores of 7/10 or less at 5 minutes. Those who took traditional herbal and/ or other self-medication within the last seven days of pregnancy were further analysed for low Apgar scores, caesarian section deliveries and MSAF. Results Many participants who took self-medication took a combination of different self- medications. The reasons for taking self-medication varied from pregnancy discomforts, growth and health of the baby and prevention of neonatal rash to 206 prophylaxis against the evil spirits. Most of the medications were bought from chemists. Most of the participants were advised by their mothers or older women in their families to take these medications. Medications that were commonly taken in pregnancy were "umchamo wemfene" which was mostly taken for prevention of neonatal rash, castor oil which was mostly used for constipation, camphor was used by most women for bloated abdomens, "umgcantsi wehashe" was commonly used for quick and easy labour as it was thought that difficult labour was as a result of sorcery, and "ubuthuvi bentini" was used by most participants for prophylaxis against evil spirits. "Umchamo wemfene" was taken by 37 participants, castor oil was taken by 21, camphor was taken by 8 participants, 7 took "umgcantsi wehashe", 5 participants took "isihlambezo" and 2 took "ubuthuvi bentini" (see figure 1). The herbalist consulted reported that "umchamo wemfene was to be used in one litre measure of cold water and was to be taken in measurements of ¼ cup daily. "Ubuthuvi bentini" was also to be added to one litre of cold water and was to be taken as ¼ cup daily. Both these medications could be taken from 3 months of pregnancy. These medications could also be combined together. "Umgcantsi wehashe" was to be taken as a piece and was to be added to one litre of water and was to be used from 8 months of pregnancy. Isihlambezo was to be taken as directed on the bottle. Of 299 participants who were interviewed, 79 (26.4%) took traditional herbal and/ or other self-medication and 220 did not take any self-medication. Of the total population 84(28%) had MSAF. Of 220 participants who did not take any self- medication, 62 (28. 2%) had MSAF. Twenty two (27. 8%) of those who took traditional herbal or other self-medication had MSAF. Of 36 participants who took self-medication in the last 7 days of pregnancy, 7 (19. 4%) presented with MSAF when membranes ruptured. Of the total population, 125 (41.8%) delivered by caesarian section, 92 (41.8%) of those who did not take any self-medication, 33 (41. 7%) of those who took these medications, and 14 (38. 8%) of those who took self- 207 medication in the last 7 days of pregnancy, two of which were for fetal distress according to the CTG tracing. Of the total number 15 (5%) had low Apgar scores, 14 (6.4%) of those who did not take any self-medication, 1 (1.3%) of those who took these medications, and none of those who took self-medication in the last 7 days of pregnancy had low Apgar scores (See figure 2). Discussion Previous studies showed a relationship between the use of traditional herbal medication and/ or other self-medication, and MSAF (Mitri et al., 1987 and Mabina et al.,1997). This study did not show a correlation between the use of traditional herbal medication and other self-medications, and the outcome of pregnancy such as Apgar scores, MSAF and the rate of caesarian section. Limitations to this study included the fact that the interviews were conducted by a nurse in nurse"s uniform and in hospital. This might have negatively influenced the results as some participants might have hidden the fact that they used traditional remedies. This study does not answer the questions such as the effects that these self-medications might have on labour. The oxytocics, sedatives, analgesics and exposure of the patient to general anaesthesia might also have had some influence to the outcome of pregnancy. Conclusion The numbers studied were small, and thus the power of the study to show differences was small. Keeping in mind the limitations mentioned, the study does not show any correlation between the use of traditional herbal and/ or other self- medications, and MSAF, caesarian section deliveries and low Apgar scores. Recommendations Of importance is the fact that more than one in every 4 women reported using traditional herbal and/ or other self-medication during pregnancy. Very little is known about the constituents and effects of traditional medication. Routine history taking should include an enquiry about self-medication taken. Further research in this field is necessary. 208 DELIVERY OF PATIENTS WITH EARLY ONSET, SEVERE PRE-ECLAMPSIA DR Hall, HJ Odendaal, DW Steyn. Department of Obstetrics and Gynaecology, Tygerberg Hospital and University of Stellenbosch; MRC Perinatal Mortality Research Unit, Tygerberg, South Africa. Introduction and Objective Once the decision to deliver a patient with early onset, severe pre-eclampsia has been taken, the delivery mode must be decided. Caesarean section is clearly indicated when fetal distress is present but when this is not the case, issues relating to induction of labor need to be considered. Evidence is however limited and practice patterns vary. Due to concerns regarding long inductions and a sense of urgency because of possible deterioration in maternal or fetal status, certain clinicians advocate Cesarean delivery, especially before 32 weeks" gestation. Higher Cesarean delivery rates have not always shown benefit for very-low-birthweight infants. Cesarean section also increases the maternal risks and the chance of a longitudinal uterine incision is higher amongst preterm babies. Most clinicians practicing expectant management of pre-eclampsia individualise the mode of delivery, reserving Cesarean section for obstetric indications and not for prematurity alone. The policy of the unit where this study was performed has been to attempt vaginal delivery in selected patients with early, severe pre-eclampsia. The study was performed to evaluate the results and safety of this approach. Method Five-year prospective case series. Delivery course and neonatal outcome were examined for 335 women with viable singletons. Results Induction was successful in 45% of attempts. Women exposed to labor had longer (5.5 days, p < 0.0001) admission to delivery periods and were more often delivered 209 for maternal indications (RR 2.87; 95% CI, 1.98-4.16). Their babies were born 1.6 weeks older (p < 0.0001) and 352g heavier (p < 0.0001) than those delivered before labor. Babies exposed to labor needed intensive care less often (RR 0.4; 95% CI, 0.27-0.58), had lower rates of severe hyaline membrane disease (RR 0.26; 95% CI, 0.11-0.59) and sepsis (RR 0.56; 95% CI, 0.33-0.93), and were discharged earlier (p < 0.0001). Figure 1. Delivery outcome. Successful: n = 46 (45%) Induction/labor n = 103 + 12 Unsuccessful: fetal distress n = 38 (37%) failed labor n = 19 (18%) Severe PE < 34 wks n = 335 Cesarean before labor n = 220 Emergent n = 214 Elective n = 6 Induction/labor group includes 103 inductions and 12 patients with spontaneous labor. Successful and unsuccessful categories (%) refer to the induction group. Conclusion Exposure to induction/ labor in selected patients is not detrimental to neonatal outcome in early, severe pre-eclampsia. 210 PRE-ECLAMPSIA AND DIETARY CALCIUM INTAKE IN GAUTENG AND EASTERN CAPE GJ Hofmeyr, L Mangesi, A Roodt, VC Nikodem, L Thomas Effective Care Research Unit, University of the Witwatersrand; East London Hospital Complex & Coronation Hospital, Johannesburg Introduction Pre-eclampsia is a major cause of maternal and perinatal death, particularly in many low-income countries. However, a low prevalence of pre-eclampsia was reported from Ethiopia where the diet contained high levels of calcium (Hamlin 1962), and among Mayan Indians in Guatemala, who traditionally soaked their corn in lime before cooking (Belizan & Villar 1980) These observations were supported by other epidemiological and clinical studies and led to the hypothesis that an increase in calcium intake during pregnancy might reduce the incidence of high blood pressure and pre-eclampsia among women with low calcium intake. A possible mode of action for calcium supplementation is that it reduces parathyroid release and intracellular calcium, and so reduces smooth muscle contractility. Calcium supplementation is attractive as a potential intervention to reduce the risk of a woman developing pre-eclampsia. It is relatively cheap and readily available. Systematic review of randomised trials of calcium supplementation to prevent pre- eclampsia has shown variable results (Hofmeyr 2000). While studies in populations with low dietary calcium intake showed significant reductions in pre-eclampsia, the largest trial to date showed little effect, possibly because the women studied were not identified as having low calcium intake (Levine1997). The WHO (Department of Reproductive Health and Research) is thus undertaking a large scale randomised trial in communities with low calcium intake. Prospective participating centres undertook dietary surveys to determine calcium intake in local populations. 211 Methods This survey was carried out at the East London Hospital Complex (Cecilia Makiwane and Frere Hospitals), and Coronation Hospital, Johannesburg, in the second half of 2000. A dietary questionnaire was designed, using the 24-hour recall method. Nulliparous women attending for antenatal care before 20 weeks of gestation were asked to participate in the study. Consent was verbal. Women were asked to recall all their food and fluid intake over the previous 24 hours, and amounts were estimated using everyday measures. In East London the interviews were conducted by a dietician. At Coronation Hospital the interviews were conducted by a research midwife under the supervision of a dietician. All the data forms were analysed by two dieticians for calcium content, using computerised food content tables. Assuming a standard deviation of 200mg, a sample size of at least 62 was needed to estimate the mean calcium intake per day with a maximum error of estimation of 50mg, with 95% confidence. Results Forty women attending Cecilia Makiwane and Frere Hospitals and their clinics, and 41 attending Coronation Hospital were surveyed. As the results from the two sites were very similar, they have been combined for this analysis. The median dietary Calcium was 567mg (interquartile range 212 to 874). The recommended daily allowance (RDA) is 1200mg. Thus half the women had intakes of less than 50% RDA, and more than a quarter had below 20% of RDA. Table 1. Dietary calcium levels Daily calcium intake (mg) n <300 (25% RDA) 30 (37%) <600 (50% RDA) 41 (51%) <900 (75% RDA) 63 (78%) <1200 (RDA) 71 (88%) 212 Discussion The calcium content of some common staple diets and other foods, and cost of calcium sources, are shown in tables 2,3 and 4. What is striking is that maize, the predominant staple diet among low-income South Africans, contains almost no calcium at all. Table 2. Calcium content of common staple diets and other foods Staple diets: Calcium (mg per 100g) 1. Samp or porridge (maize) 1 2. Rice 8 3. Wheat 24 4. Samp and beans 29 5. Yam 30 Other foods: 1. Potatoes 10 2. Cabbage 39 3. Egg 60 4. Spinach 73 5. White bread 120 5. Milk / sour milk 120 7. Tinned pilchards (fish) 300 8. Cheese 700-720 Table 3. Calcium content of common South African diets Staple diets: Calcium (mg per 100g) 1. Samp or porridge (maize) 1 2. Samp and beans 29 3. White bread 120 Sometimes in the diet: 6. Milk / sour milk 120 7. Spinach 136 Depending on income, may eat occasionally: 1. Tinned pilchards (fish) 300 2. Cheese 700-720 3. Poultry 120 213 Table 4. Approximate cost of calcium sources. Approximate cost of 1200mg calcium: Ca. Carbonate tablets 4X 300mg R4.00 Ca. Carbonate antacid tabs R4.00 (R0.70*) Fresh milk 1 litre R3.00 Cheese 170g R3.50 Powdered milk 130g R4.00 *price to Coronation Hospital buying in bulk (Titralac: Ca. Carbonate 420mg = elemantal Ca. 168mg, glycine 180mg) Conclusions Dietary calcium intake was very low in both the populations studied. The main reason for this is that maize, the most prevalent staple diet in South Africa, contains almost no calcium. Given the large contribution of pre-eclampsia to maternal and perinatal mortality and morbidity in South Africa, the upcoming WHO Multicentre Randomised Trial of Calcium Supplementation for the Prevention of Pre-Eclampsia is of great importance to maternal health in this country. Thromboxane Aspirin Prostacycline O2 Free radicals AntiOxidants: Vit E, C, Allopurinol Everything ever measured Vasoconstriction Low platelets CNS Kidney damage Liver damage Ca Hypertension Haemorrhage damage Proteinuria Liver enzymes DEATH CVA Subcapsular liver Eclampsia Kidney Liver haemorrhage failure failure 214 REVERSED END DIASTOLIC FLOW VELOCITY IN VIABLE FETUSES: IS THERE TIME TO WAIT FOR THE EFFECT OF CORTICOSTEROIDS BEFORE DELIVERY? JM du Plessis, DR Hall, K Norman, HJ Odendaal Introduction Reversed end diastolic flow velocity (REDFV) in the umbilical artery with Doppler examination is an ominous finding and is associated with a high perinatal mortality rate of up to 50% or more. In her meta-analysis of antenatal corticosteroid therapy, Crowley showed a noted reduction in the frequency of respiratory distress syndrome and overall perinatal mortality with the use of corticosteroids. Methods We identified six cases of severely preterm, but viable pregnancies, with the REDFV and structurally normal fetusses. None of these women had received antenatal corticosteroids. All six patients received 12 mg betamethasone on admission and 24 hrs later. Fetal heart rate patterns were monitored six hourly for 15 min. The aim was to deliver by 48 hrs after the first dose of betamethasone, unless fetal distress necessitated earlier delivery. A good outcome was defined as a live baby that was discharged from hospital. Results The mean gestation was 29 wks and a mean of 33 hrs was gained by conservative management. The mean birthweight was 977g. There were no stillbirths and only one neonatal death in our series. Only four babies required NICU care and the mean hospital stay was 21 days. Discussion Although REDFV is an ominous sign, we believe that there is an important benefit to be gained with delaying delivery by 24-48 hrs, for the effect of corticosteroid 215 therapy. This can be achieved with intensive fetal monitoring during the waiting period, with earlier delivery if fetal distress develops. 216 POOR BASELINE VARIABILITY IN FETAL DISTRESS. FACT OR FICTION ? J van Waart, H J Odendaal Department of Obstetrics and Gynaecology,Tygerberg Hospital. Introduction Poor variability of the fetal heart rate (FHR) pattern is always associated with severe fetal hypoxaemia1 and acidemia.2 Obstetricians and neonatologists generally accept these findings. However, in a retrospective study of 289 patients 3, it was found that the poor FHR variability in 33 patients remote from term correlated poorly with umbilical artery blood gases at birth. In that study 43% of the 289 patients were hypertensive, had pre-eclampsia (PE) or had suspected placental insufficiency. A second study from the same unit4, confimed the findings of the first study when they compared poor FHR variability (< 5 beats / min) for more than 60 minutes with umbilical artery blood gas values at birth. In both these studies 3,4 vaginal and caesarean section deliveries were included. It may be possible that changes in blood gas values during delivery could have been responsible for the poor correlation between low FHR variability and neonatal acidemia. In an extension of the last study, we again compared the FHR baseline variability within 6 hours before delivery with biochemical indicators of fetal distress at birth. However, this time all fetusses were delivered by caesarean section. Materials and Methods The study was designed as a cohort analytical study conducted at a university hospital. Patients were recruited from the special care obstetric unit and the labour ward. Inclusion criteria: Patients with severe pre-eclampsia (PE) and/or placental insufficiency as indicated by absent or reversed end diastolic Doppler flow velocity (AEDFV/REDF) in the umbilical artery, confirmed within 24 hours, with a gestational age between 27-34 weeks and delivered by caesarean section. 217 Exclusion criteria: Caesarean section done within 48 hours after administration of corticosteriods, when delivery was done for prolonged (> 60 minutes) poor baseline FHR variability (<5 beats / min), congenital abnormalities, caesarean section done for fetal distress after induction of labour and multiple pregnancies. Patients selected and admitted to the special care obstetric unit were managed according to a specific protocol5. Electronic FHR monitoring was performed six- hourly. If the recording was assessed as being reactive or non-reactive with good FHR baseline variability (> 5 beats / min), the recording was stopped after 10 minutes and repeated in 6 hours. If the tracing showed poor baseline variability it was continued for one hour and repeated immediately. If poor variability persisted or if late decelerations were present, the woman was delivered by caesarean section for fetal distress. A small number of patients were also delivered for maternal reasons despite reassuring FHR patterns. Doppler flow velocity waveforms of the umbilical artery were assessed weekly. The resistance index (RI) was used to quantify end diastolic velocity. Anaesthesia was standardised. All, but one patient received spinal anaesthesia. Immediately after delivery the umbilical cord was double clamped and umbilical artery blood collected in standardised heparinised tubes for blood gas analysis and in standard laboratory tubes for serum lactate, serum glucose and nucleated red blood cells. Blood gas analysis was done within 30 minutes after collection. Lactate and glucose analysis were done within 1 hour of collection and nucleated red blood cell count determined within 24 hours from collection. The paediatricians attending the delivery assessed one and five minute Apgar scores. On completion of the study all FHR tracings were assessed by one person (HJO) blinded to the fetal outcome. The pattern was defined as good if it was reactive, or if the baseline variability was > 5 beats / min for at least one hour. A poor pattern was defined as one having decreased baseline variability (< 5 beats / min). Late and variable decelerations were defined independent of baseline variability, as were accelerations. Growth restriction was defined as a birthweight less than the 10 th percentile. 218 The data was analysed with Epi Info Version 6 Software. The means were compared using the Mann-Whitney test, proportions were compared using the chi- square test or (in the case of small numbers) the Fischer extact test. Results Nineteen patients were included in the study. Ten FHR recordings demonstrated poor and nine good baseline variability. Ten of the nineteen FHR tracings had no decelerations, four had late decelerations, three had variable deceleration and in two, decelerations were unspecified. Eighteen of the nineteen FHR recordings had no accelerations. Two of the ten fetusses in the poor baseline variablity group had fetal distress (pH < 7.1; BE < - 12 mmol/l). One had AEDFV but no decelerations of the FHR. The other one had a RI > 95th centile and clinical signs of abruptio placentae. The other patients had no fetal distress. All the patients in the poor FHR baseline variability group were delivered for fetal distress. Three of these patients also had late decelerations. Deliveries in the good baseline FHR variability group were for HELLP syndrome with AEDFV (one patient), repeated variable deceleration in a growth restricted fetus (one patient), poor fetal growth on ultrasound (three patients), REDF (two patients), fetal bradychardia (one patient), late decelerations and difficult blood pressure control (one patient). pH, pO2, pC02, base excess (BE), serum glucose, serum lactate, nucleated red blood cells, five minute Apgar scores, haemoglobin and gestation at delivery were compared between the poor and good baseline FHR variability groups (Table 1). No significant differences were found in any parameter. Only two of the ten patients in the poor variability group had pH < 7.1, (also the only two patients to have BE <-12 mmol/l). The RI of both these patients on Doppler flow velocimetry were <1. Three patients had poor baseline variability as well as late decelerations on FHR pattern. All three had severe PE. None of the three patients had biochemical evidence of fetal distress. One of the three patients had AEDFV, one had a RI > 95 th centile and the other patient had a RI between the 75 and 95th centile. 219 Bethametasone (12 micrograms intramuscularly) was administered to seven of the ten patients in the poor variability group before delivery. The shortest time interval between administration of the bethamethasone and delivery was 65 hours. The range of time intervals was 65 – 144 hours. Discussion Criteria to define an acute intrapartum hypoxic event6 underline the importance of making the right decision about timing of delivery when challenged with poor FHR baseline variability in isolation. Literature in this regard is conflicting with some authors supporting the fact that poor FHR variation is (always) associated with severe hypoxaemia1 and academia2. Other authors3,4 found that reduced FHR variation is rarely associated with metabolic acidaemia. Reasons for the differences may be that two different methods were used to assess baseline variability. It is also possible that the duration of abnormal FHR patterns, preceding the sampling of the umbilical artery, was longer than the six hours we used. It is difficult to know when to deliver the preterm fetus with prolonged poor variability of the FHR but without decelerations. The decision is further complicated by the use of betamethasone which causes significant reduction in FHR variability that can last up to 24 hours 7 and sometimes up to 72 hours8. As we monitor FHR patterns electronically every 6 hours, fetal distress (if present) would be of short duration as the preceding FHR pattern was reassuring. This finding is supported by the comparable nucleated red blood cell (nrbc) values in the poor variability group (nrbc = 53.5) and the good variability group (nrbc = 54.71). This indicates no compromise in the metabolic state of the poor variability group when compared to the good variability group, although the pH values in the poor variability group are slightly lower (7.18 vs 7.24 with p = 0.345). Our results would thus suggest that in a specific subgroup of patients with poor FHR variability only (in the absence of REDF), delivery could be postponed until late decelerations occur. This would be of particular importance in very preterm fetusses where betamethasone has not yet been given or given less than 48 hours earlier. It is important to remember that an increase in gestational age from 28 to 29 weeks at 220 delivery improves neonatal survival from just 72% to 92% at 29 weeks9. Although numbers in our study are small, it supports the findings of two earlier studies from this unit that poor baseline variability in isolation is a poor predictor of fetal distress. Immediate delivery for this pattern is therefore not essential. We believe that careful individualisation taking gestational age, the severity of maternal disease and fetal conditions (severity of IUGR and oligohidramnios), FHR pattern (type of decelerations, if any), umbilical artery doppler velocimetry (no REDF present) and the effect of betamethasone (< 48 h after administration) into consideration, could be very helpful in preventing inappropriate early delivery especially round about 28 weeks of gestation. Our results would confirm the findings that the FHR pattern of the compromised fetus is not the direct result of intra-uterine asphyxia but of some other factors associated with the underlying maternal / fetal condition. Table I : FHR baseline variability POOR GOOD P-VALUE (n = 10) (n = 9) PH 7.18 7.24 0.345 (7.25, 6.83 7.36,0.15) (7.25, 7.15 7.29,0.05) PO2 (kPa) 2.51 2.71 0.727 (1.90, 1.60 6.10, 1.34) (2.85, 1.30 4.00, 0.78) PCO2 (kPa) 7.54 6.43 0.133 (7.20, 5.10 10.80, 1.73) (6.60, 3.90 7.40, 1.02) BE (mmol/l) -8.56 -7.64 0.700 (-7.0, - 23.5 -2.1, 5.93) (-7.5, -13.5 -7.5, 3.09) s-glucose 5.18 5.68 0.555 (mmol/l) (4.05, 3.0 11.1, 2.73) (3.5, 2.715.7, 5.02) s-lactate 4.94 2.88 0.218 (mmol/l) (2.70, 1.79 13.30, 4.12) (2.53, 1.56 4.64, 1.17) Nucleated rbc 53. 5 54.71 0.964 (per 100 wbc) (37, 4 132, 49.12) (46, 6 138, 44. 84) Haemoglobin 14.65 14.94 0.734 (g/dl) (14.2, 13.3 17.0, 1.21) (14.1, 12.4 17.8, 1.79) 5 min Apgar 7.6 8.6 0.297 score (8, 2 10, 2.21) (9, 5 10, 1.41) Gestation (w) 29.8 32.2 0.101 (30.0, 27.0 34.0, 3.12) (33.0, 27.0 34.0, 2.57) Rbc = red blood cells Wbc = white blood cells Values are given as the mean (median, range and standard deviation). 221 SESSION 10: NEONATAL SUPPLEMENTATION FEEDING PRACTICES OF MOTHERS OF FOUR TO SIX WEEK OLD INFANTS P Baloyi, U E MacIntyre Department of Paediatrics and Child Health, MEDUNSA Objective The aim of this study was to describe the feeding practices of infants ages between four and six weeks attending the post natal clinic at Ga-Rankuwa Hospital Methods A convenience sample of mothers attending the postnatal clinic at Ga-Rankuwa hospital between October 1997 and May 1998 was used. Mothers were interviewed at the time of their postnatal check-up, usually four to six weeks after delivery. All interviews were conducted by trained interviewers using a structured interview schedule in the mothers" own language. Results A total of 150 mothers were interviewed. Mean age of the infants was 38 days (sd=12.3 days). Exclusive breast feeding was practiced by 10 (6.7%) mothers. In addition to breast milk, 45 (30%) mothers gave water, 87 (58%) gave solids and formula feeds and water and 13 (8.6%) gave formula feeds. Solids (most often soft porridge) had been introduced by 56 (37%). Of the mothers giving water, 58(44%) added sugar and 34 (26%) added gripe water. The most frequent reasons for giving formula feeds in addition to breast milk was that breast milk was "not enough". Water was given because the baby was "thirsty" or to "loosen the stools" Conclusion Infant feeding recommendations are that exclusive breast feeding should continue until four to six months of age. This study has shown that, in the population served 222 by Ga-Rankuwa Hospital, most infants are given food, other than breast milk, by the second month of life. The reasons for and consequences of the early introduction of complementary foods requires urgent investigation 223 ENDEMIC NECROTIZING ENTEROCOLITIS: THE IMPACT OF AN AGGRESSIVE BREAST FEEDING PROGRAM GF Kirsten1, CL Kirsten1, C Pieper1, H Orth2, MF Cotton1 Departments of Pediatrics1 and Microbiology2, Tygerberg Children"s Hospital and the University of Stellenbosch. Introduction Tygerberg Children's Hospital is a tertiary referral hospital for lower socio-economic urban and rural patients (38 000 deliveries p.a.). The low birth weight and the very low birth weight (VLBW) rates are 22% and 6% respectively. The neonatal wards are overfull and the nurse : infant ratio is very low. Previously, early discharge of mothers was the norm and very little breast feeding took place. Infants were nursed in incubators and were formula fed. There were frequent outbreaks of nosocomial infection due to extended spectrum beta- lactamase-producing Klebsiella pneumoniae (ESBLKp). Necrotizing enterocolitis (NEC) was endemic. Lucas et al (Lancet 1990; 336(8730):1519-23) showed that NEC occurred less frequently in breast fed VLBW infants. Aim To determine the impact of an aggressive breast feeding and skin-to-skin nursing program on the incidence of NEC and ESBLKp gut colonization in infants <1 800g. Study Design Cohort analytical study. Patients and Methods The Neonatal Unit of Tygerberg Children's Hospital consists of a neonatal intensive care unit (NICU), a step-down unit post-NICU and a level II ward. An aggressive breast feeding program was introduced on 1st May 1998 for all infants in this Unit. Its key elements were to: 1) motivate all mothers to breast feed; 2) commence skin- 224 to-skin nursing and breast feeding as soon as possible; 3) encourage local mothers to spend each day with their infants; 4) postpone transfer of rural mothers; 5) obtain rooming-in accommodation in the hospital; 6) motivate and educate staff on the importance of breast feeding; 7) extend this program to rural hospitals. 573 infants with birth weights <1 800g who were admitted to the level II ward over a 24-month period were studied. The control group (290), admitted between 1/5/97 and 31/4/98, were predominantly formula fed and nursed in an incubator. The study group (283), were admitted between 1/5/98 and 31/4/99 and received predominantly expressed breast milk and intermittent skin-to-skin care. Rectal swabs were obtained weekly from all the infants in the Neonatal Unit for surveillance for ESBLKp colonization. Results The clinical data of the infants are shown in Table 1. The mean hospital stay decreased from 23.316.8 days to 18.411.7 days (p=0.0002). NEC decreased from 29 (10%) to 8 (2.8%) (p=0.004) (Table 2). Gut colonization by ESBLKp decreased from 31.9% to 16.5% (p=0.0001) for the entire Neonatal Unit, and from 11.8% to 5.8% (p=0.003) in the level II ward (Graph 1.) in the control and study groups respectively. Table 1: Clinical data (mean, SD) Pre – BM* BM p n = 290 n = 283 BW (g): 1 367 ± 271 1 401 ± 280 0.1 Range 600 – 1 800 530 – 1800 GA (wks): 31.3 ± 2.9 31.4 ± 2.6 0.6 Range 23 - 41 24 – 38 * Breast milk 225 Table 2: Incidence of necrotizing enterocolitis Pre - BM BM p NEC: number 29 (10%) 8 (2.8%) 0.004 OR 3.82 Gr I 10 2 Gr II 12 3 Gr III 7 3 Surgery 9 3 30 25 20 % 15 10 5 0 r t r l l 7 8 v v p n n e a u u a 9 9 o o e a a S J J M M y- y- S N J N J a a M M 11.8% * 5.8% * *p=0.003 Graph 1: Gut colonization with ESBLKp per month (%) - level II ward Summary There was a significant decrease in the incidence of NEC and of gut colonization with ESBLKp after the introduction of the breast feeding and skin-to-skin program. Conclusions We speculate that gut colonization with Klebsiella pneumoniae may contribute to the pathogenesis of NEC and provide evidence that breast feeding is protective. Breast milk and skin-to-skin nursing should form an integral part of the management of infants with birth weights <1 800g. 226 EFFECT OF A FOOD SUPPLEMENT ON GROWTH DURING THE FIRST TWO YEARS OF LIFE SD Delport,* IT Hay,* PJ Becker# *Dept of Paediatrics, Kalafong Hospital and the University of Pretoria and MRC Unit for Maternal and Infant Health Care Strategies #Dept of Biostatistics, Medical Research Council Introduction Inadequate nutrition during the first year of life results in suboptimal growth and leads to an increased susceptibility to infections. The rate of weight gain in infants from developing countries as compared to infants from developed countries is higher during the first month and then decreases progressively from the second month. A given deficit in weight carries a greater risk of death in infants, and a nutritious weaning diet is therefore of the essence to facilitate optimal weight gain. A randomized double blind controlled trial was undertaken to determine whether a fortified food supplement administered from five months of age prevents growth faltering during infancy. Patients and Methods Consecutive term, appropriately grown infants whose mothers lived in Atteridgeville or Mamelodi were enrolled at birth after maternal consent was obtained. They were followed up monthly until two years of age. Anthropometric indices, illnesses and diet were documented at each visit. Infants were randomised to receive a fortified or unfortified food supplement to be stirred into porridge from five months until two years of age. The fortified supplement contained macro- and micronutrients that would supply the recommended daily allowance (RDA) of these nutrients in addition to the presumed intake of breast milk. The unfortified supplement contained only macronutrients in similar concentrations as provided by the fortified supplement. The Z-scores for weight, length, head circumference and weight for length were determined at 3-monthly intervals until 24 months of age as well as biochemical indices of nutrition. 227 Results Two hundred and thirty-eight infants were enrolled over a period of 18 months (26/03/1995 - 25/09/1996). At one month 120/238 returned for follow-up of whom 81 were followed up until 12 months, 59 until 15 months and 65 until 24 months of age. The Z-scores for weight, length, head circumference and weight for length were similar in the two groups. The Z-scores for weight for age decreased below average after seven months in both groups and remained below average. The Z- scores for weight for age were predominantly above average for the duration of the study for both groups. The reason being that the Z-scores for length for age were below average in both groups. Conclusion The anthropometric indices of infants receiving a fortified food supplement added to their weaning food are similar to those of infants who receive an unfortified food supplement. 228 A COMPARISON BETWEEN DAILY AND BI-WEEKLY IRON SUPPLEMENTATION IN PRETERM INFANTS. R. Mphahlele, H. Saloojee Division of Neonatology, Department of Paediatrics, Chris Hani Baragwanath Hospital Introduction The premature infant is at risk of developing iron deficiency anaemia. This usually occurs by four months of age but may occur as early as two months in smaller preterm infants. Iron has traditionally been given on a daily basis. We compared twice-weekly iron supplementation with the traditional daily regimen. Objectives To compare the effectiveness of iron supplementation given twice a week against daily iron supplementation in very low birth weight infants (i.e infants weighing less than 1500g at birth) Methods Design: A prospective, analytical, interventional study was done using a non-blinded design. Subjects: All well very low birth weight who were admitted to the neonatal unit and who survived to four weeks of life were eligible for the study. Infants were enrolled into the study at four weeks postnatal age and immediately randomized into one of two groups. Group A received iron from four weeks of life given twice a week at a dose of 2mg/kg/dose. (Cases) Group B received a daily dose of iron from four weeks of life given at a dose of 2mg/kg/day (Controls). Subjects were followed up to the age of six months. Primary outcome measures used were haemoglobin and serum ferritin. Weight gain and infections were secondary outcome measures. Results 200 patients were enrolled between March 1998 and February 2000. There was a 60% follow-up rate at 6 months. There was no statistical difference in haemoglobin 229 levels between the two groups at 4 weeks, 4 months and 6 months of age. There was a statistically significant difference in haemoglobin levels at 10 weeks of age, the mean haemoglobin of the subjects in Group A being 8.4 g/dl vs 9.1 g/dl in Group B (p=0.004). Ferritin levels were not different between the two groups. There was no difference in weight gain, number of infections or admission rate between the two groups. Mortality was similar in both groups: 8.1% in Group A vs 5.9% in Group B (p=0.73). Conclusion Iron supplementation given twice weekly at a dose of 2mg/kg/dose is as effective as daily iron at 2mg/kg/day in very low birth weight babies. Haemoglobin levels were similar in both groups except at 10 weeks where subjects receiving twice weekly iron had lower haemoglobins. The difference is unlikely to be clinically significant. Infants grew at similar rates and had similar rates of infection. This study shows that iron can safely be supplemented twice weekly and is as effective as daily iron supplementation in very low birth weight babies. 230 INDICATIONS FOR EFFECTIVE USE OF TRIMETHOPRIM – SULPHAMETHOXAZOLE IN HIV EXPOSED INFANTS K Naidoo, D Moodley, M Adhikari, J Moodley Department of Obstetrics & Gynaecology and Department of Paediatrics. University of Natal Aim To investigate the effectiveness of opportunistic infection prophylaxis guided by the onset of HIV related clinical signs in a HIV exposed infant. Background During the Petra trial standard practice for initiation of opportunistic infection prophylaxis was guided by the infant manifesting signs of disease. In the absence of reliable laboratory diagnosis in developing countries, onset of clinical signs and symptoms of perinatal HIV infection of site are used as guidance for the use of Trimethoprim–sulphamethoxazole as prophylaxis against opportunistic infections. Methods A cohort of 235 infants born to HIV seropositive women (Petra study) were followed up for a period of 18 months. Laboratory and clinical data were obtained from visits scheduled at birth, one week, 6 weeks, and 3 monthly until 18 months. Clinical parameters at each subsequent visit was compared with baseline and Trimethoprim–sulphamethoxazole chemoprophylaxis was initiated on first clinical evidence of HIV infection according to WHO staging of disease in children. HIV status was subsequently confirmed by laboratory diagnosis at 6 weeks by PCR on stored samples and on ELISA at 12 months. Results of PCR were not available during follow-up of infants. Statistical analysis included correlations between onset of clinical signs and commencement of therapy and laboratory diagnosis of HIV infection. 231 Results 200 patients remained uninfected of which none received prophylaxis (100% sensitivity). 24 were confirmed HIV infected of which 15 received treatment (62% sensitivity). The median age at which patients were first identified and therapy initiated was 10 weeks (4-52). The median duration of treatment was 28 weeks. The median duration of patient follow-up was 44 weeks (10-104) In infected patient who did not receive therapy the median age of demise was 16 weeks and in these that demised despite treatment the age of death was 28 weeks. Estimates done via a Kaplan Meier survival analysis depicts a bimodial survival pattern. Those infants who manifest disease early in life demise by 12 months and others with a slower onset of disease have a 75% survival rate at 18 months. In addition the graph also demonstrates that interventions between 4 and 6 weeks of age would have a greater impact on long-term survival. This study demonstrates that Trimethoprim–sulphamethoxazole is inadequate in preventing pneumocystic carrineii pneumonia if used only once clinical features of HIV infection become apparent. 232
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