Maternal and Infant Health Care Strategies Research Unit

Current projects

Implementation programme for Kangaroo Mother Care (KMC)
Kangaroo mother care (KMC) is a system of caring for small newborn babies that entails skin to skin contact, breast-feeding and early discharge. It has been shown to both reduce neonatal complications and be very cost-effective. Essentially the mother replaces the incubator and the baby spends its time between the mother's breasts. KMC is used until the baby is of sufficient weight to be safe from complications.

Although KMC is clearly of benefit in managing neonates, it is difficult to implement in most hospitals. As a method of caring for neonates, KMC is foreign to most nurses and doctors, who demonstrate considerable resistance to implementing this strategy.

A well-designed implementation package is clearly required and creating such a package is the first aim of this study. Identifying obstructions to the implementation of KMC will be performed by qualitative research, and once the major problems have been identified, a series of meetings will be held to devise ways of overcoming these obstacles, which will be included in the package. The package will then be implemented in sites in Gauteng to test its effectiveness and adjusted accordingly.

Our second aim is to test the effectiveness of a three-visit outreach programme which will be used to implement the tested KMC package:

• The first visit will introduce KMC, explaining its value to caregivers.
• The second visit will entail customising the KMC package to meet the specific needs of the hospital.
• The third visit will assess progress and attempt to solve any new problems.

This outreach programme will be performed using a randomised trial basis in sub-district and district hospitals in KwaZulu-Natal. A telemedicine element in this programme is also being developed.

Private-public sector partnerships in antenatal care (Tembisa)
We believe that if the private sector assists in offering antenatal care to impoverished pregnant women, this could substantially improve the gestational age at which antenatal care is started, as well as subsequent quality of care. In the long term, the effectiveness of private-public sector co-operation in this area could also substantially affect perinatal mortality rates.

Saving babies: a national perinatal mortality care survey
The Perinatal Problem Identification Programme (PPIP) is now being used in approximately 27 sites throughout South Africa. These sites include rural, peri-urban and urban areas, Level 1, 2 and 3 hospitals, in all but 3 provinces. It is possible to link the sites and create an overall picture of the common causes of perinatal death and common problems in perinatal care for the country.

Information submitted to the Provincial MCWH units and PPIP, if combined, could provide a true picture of perinatal care in South Africa. With this information, problems identified can be prioritised and addressed in a logical sequence.

Audit of childhood deaths
At present, there is no tool to audit childhood deaths at peripheral hospitals in order to diagnose where the health system fails. The aim of this project is to develop and test such a tool. A prerequisite for this audit tool is a useable classification of childhood deaths, which will be developed as the first step of the project.

If the audit tool proves to be effective and acceptable to the relevant health care workers (medical officers, paediatricians and professional nurses) it could be used to target interventions where health system failure has occurred.

Severe acute maternal morbidity audit
This audit system examines changing patterns in maternal morbidity and mortality in the Pretoria region, and will soon be extended to the Witbank district.

Pretoria pasteurisation - a potential method for reducing transmission of the Human Immunodeficiency Virus via breastfeeding
Infants of HIV infected women face a 10-15% risk of infection with the virus via breast-feeding. In developing countries, women cannot afford milk substitutes; neither do they have the facilities for making up bottle feeds.

Pasteurisation has been shown to inactivate HIV in human milk, with the milk still maintaining its nutritional value.

• During Phase I of this project, simple and inexpensive apparatus was devised which HIV-infected women could use for expressing and pasteurising their breast milk (referred to as Pretoria Pasteurisation).
• In phase II of the project, Pretoria Pasteurisation was tested to determine whether it inactivated HIV effectively in human milk.

Developing a nursing enrichment programme
Mrs Pullen is currently researching her PhD by developing a nursing enrichment programme at large hospital that offers a combination of secondary and tertiary care. She has conducted qualitative research to identify problems, and developed an intervention model, which she is currently testing at Kalafong Hospital.

An assessment of the standard of care in four types of midwife driven maternity units in the Pretoria region, Gauteng
The project will audit the standard of care and establish women's wishes regarding midwife driven units.

A midwife driven unit is an entity where the midwife is responsible for the care of patients in labour. There are three main models:

1. a stand alone unit;
2. a unit where a medical officer is on the premises of a community health centre; and
3. a unit within a larger labour ward.

This study will determine the best model for health practice by taking patient wishes into account, and correlating these with the standards of practice noted within the respective units.

Kiddynet - a paediatric hospital information system
The first phase of this project was developed at Medunsa where a program was written in MS Dos in order to maintain accurate record keeping and facilitate clinical audits. This program was initiated in the paediatric department on one PC and is currently being rewritten in MS Access and customised to run on a departmental network.

Magnesium sulphate for the prevention of eclampsia (MAGPIE Trial)
A world-wide multi-centre randomised placebo controlled trial is currently underway to investigate whether magnesium sulphate prevents eclampsia.

Uricult Study
Bacteriuria in pregnancy is related to several pathologies including lower and upper urinary tract infection and preterm delivery. Recognition and treatment of asymptomatic bacteriuria has the potential to reduce perinatal mortality and morbidity as well as maternal morbidity. Formal urine culture is, however, expensive and often fraught with logistical problems in the antenatal clinic setting.

The main objective of this project is to find an accurate method of on-site testing in order to identify women with asymptomatic bacteriuria so that treatment can be begun with minimal delay to prevent subsequent complications.

Phase I of this project investigated the accuracy of urine dipstix when compared with a gold standard of cultures. The findings were that urine dipstix performed poorly and is not an adequate means of on site diagnosis of asymptomatic bacteriuria.

In Phase II, an on site semi-quantitative culture system (Uricult Trio® Orion Diagnostica, Finland) will be tested. Once again the gold standard used will be urine culture by conventional methods.

Vaginal birth after caesarean section (VBAC)
Vaginal delivery following a previous cesarean delivery has been shown to be safe.

Clinical pelvimetry is frequently used to determine whether the woman is likely to achieve a vaginal delivery, although the accuracy of clinical pelivimetry as a predictor has not been tested. In this trial, clinical pelivimetry will be tested for its accuracy as a predictor of successful vaginal delivery following previous cesarean section.

The effect of a food supplement on growth - and the incidence of infections during the first two years of life (Beikost)
The nutritional value of weaning foods for infants may be inadequate, leading to nutritional deficiencies of which iron-deficiency anaemia is an example. Infants receiving an inadequate diet are also more prone to infections and sub-optimal growth.

By adding a supplement containing essential vitamins and micronutrients to a staple food such as maize meal porridge, the intake of these nutrients during a critical period of infant growth and development, will be facilitated.

In this study, supplementation is initiated at 5 months of age, the time when most infants are introduced to weaning. Infants are randomised to receive a supplement containing protein, carbohydrates and fat with, or without, micronutrients. The supplement is mixed into soft porridge and does not interfere with breast-feeding, which we recommend remains the mainstay of nutrition during infancy.

Infants are assessed at monthly intervals from birth until two years of life to monitor growth and document episodes of infection and illness.

Prevention of neonatal nosocomial sepsis
Nosocomial (hospital related) sepsis is the most important cause of death in low birthweight infants.

Neonatal neutropaenia is associated with pregnancy induced proteinuric hypertension and is a risk factor for nosocomial sepsis.

Antenatal administration of steroids to induce lung maturity may mask neonatal neutropaenia at birth, but these infants remain at risk for nosocomial sepsis. GCSF increases the absolute neutrophil count and if administered after birth may prevent neutropaenia and the incidence of nosocomial sepsis.

A comparison between the third (new curriculum) and fourth (old curriculum) medical students with respect to pregnancy, childbirth and neonatalogy
The new curriculum introduced in obstetrics and neonatolgy is being evaluated by comparing students' performances on the old and new curricula, with respect to their knowledge and skills.