effective antenatal care
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.
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.
appropriate care for the ill parturient
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
management of birth asphyxia and prematurity in secondary and primary level
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.
of the nutritional status of infants
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
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
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.