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Maternal and Infant Health Care Strategies Research Unit


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Research highlights 

Developing effective antenatal care
The major development in this project was the innovation of pregnancy confirmation clinics.

Late initiation, or the total absence of antenatal care, are strongly associated with poor pregnancy outcomes. Research has, however, indicated that the vast majority of women confirm their pregnancies within the first three months, with impoverished women only seeking care after 5 months.

An innovation was initiating antenatal care at the point of confirming the pregnancy. A trial established that this was, indeed, possible and that it decreased the mean gestational age of initiating antenatal care from 22 weeks to 12 weeks.

The next step was to implement this process. As most women confirm their pregnancies at a general practitioner before being referred to clinics for further care, we involved GPs in antenatal care by asking them to encourage pregnant patients to start antenatal care at the time the pregnancy was confirmed.

Currently, a public-private partnership trial is being conducted with GPs in Tembisa, the doctors and midwives of Tembisa Hospital and the Gauteng Department of Health, whereby the GP starts antenatal care when the pregnancy is confirmed and continues providing antenatal care, with the hospital providing the laboratory and pharmacy resources, and also being the point of referral.

Other smaller trials have been conducted to test effective methods for the screening of syphilis, anaemia and asymptomatic bacteriuria.

Developing appropriate intrapartum care
The unit has just completed two randomised controlled trials in labour.

The first trial was to establish which protocol was more effective in managing uncomplicated labour: an aggressive protocol of O'Driscoll, or an expectant protocol of the WHO. The trial demonstrated clearly that aggressive management lead to a significant reduction in caesarean sections at no increased risk to the mother or infant.

The second trial evaluated the efficacy of using clinical pelvimetry to manage pregnant women who had had a previous caesarean section. This trial showed that clinical pelvimetry plays a very small, and perhaps negligeable, role in managing these women.

Our next trial involves developing simple methods to augment labour safely.

Developing appropriate care for the ill parturient
The major causes of death of pregnant women are complications of hypertension, AIDS, puerperal sepsis and obstetric haemorrhage.

Policy guidelines have been written for these conditions, some by members of the unit. The next phase is to develop implementation strategies for these guidelines.

The implementation strategy will be based on the one used for the Kangaroo Mother Care implementation trial, with implementation workbooks also being developed.

The unit is also involved with the Magpie trial that is investigating the role of magnesium sulphate in preventing eclampisa in women with pre-eclampsia. The unit has randomised over 600 women for this trial and is ahead all other units world-wide, in this regard.

Effective management of birth asphyxia and prematurity in secondary and primary level institutions
The major study in this project is the Kangaroo Mother Care (KMC) Implementation Trial. This trial stemmed from information from the Perionatal Problem Identification Programme (PPIP), which highlighted the fact that the number of neonatal deaths of premature babies was unacceptably high.

KMC is a strategy whereby the high neonatal mortality can be significantly reduced with a major cost saving to the health care system. Managing neonates by the KMC method does, however, requires a paradigm shift in the beliefs and attitudes held by health care workers currently dealing with neonates.

There are only a few functioning KMC units in South Africa and these were analysed to establish the problems encountered when setting up such a unit.

Using this information, a KMC implementation workbook was designed, in order to assist any institution through the process of establishing a KMC unit, with questions being posed relevant to the implementation of such a programme within the respective institution.

This workbook is currently being tested by four hospitals in Mpumalanga and a researcher is facilitating the process. The strength of this programme is that the hospital develops its own structure, policies and protocols appropriate to its individual circumstances.

The effective management of premature babies has also been addressed by the DEXIPROM Trial, and the research programme investigating the prevention of nosocomial infections with GCSF - both being randomised, controlled trials.

Improvement of the nutritional status of infants
The biggest challenge facing medicine in South Africa is the HIV/AIDS epidemic. Every aspect of medicine is affected, with the transmission of HIV to the infant being a major problem, especially via breast-feeding.

The unit has contributed to finding breast-feeding solutions for HIV-infected mothers by testing a novel concept of pasteurising breast milk, using the principle of passive heat transference. Pasteurisation traditionally requires milk to be heated to between 590C and 630C for 30 minutes. This requires costly apparatus, as there are only two temperatures that can be measured without using a thermometer, namely that of ice and boiling water.

In this study, breast milk is pasteurised by the process of passive heat transference by taking boiling water, placing breast milk in a container in the water, and allowing it to cool. We have found that if 500ml of water in a one litre aluminium cooking pot is boiled, and between 50ml and 150ml of breast milk is placed in a standard peanut butter jar in the water, the milk heats up to between 590C and 630C for approximately 15 minutes. This process is called Pretoria Pasteurisation and is very inexpensive, requiring almost no technological support. Thus, almost any mother can pasteurise her own milk.

The next step was to check if this process destroys HIV. This study has been successfully completed and no living virus could be demonstrated in breast milk from either HIV-infected mothers who expressed their breast milk, or in HIV naive breast milk spiked with HIV.

Over and above killing the virus, a significant advantage of this inexpensive method is that about 80% of the essential ingredients (antibodies, vitamins, etc.) of breast milk are unaffected.

The next phase of the study is to investigate whether this strategy can be implemented in neonatal high care wards and KMC units.

The final phase will be to assess whether HIV-infected mothers are motivated to give their infants breast milk by using this method at home.

The qualitative research approach used in developing the KMC workbook (described above), was also applied to this project.

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Last updated:
18 March, 2015
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