From audits to action: UP data is saving moms and babies

UP researchers have been working with the South African government to collect data on mother, newborn and child deaths across the country since 1997. Now all this data is being put to good use as the Research Centre for Maternal, Fetal, Newborn and Child Health Care designs and implements interventions to save lives and improve the quality of care in South African hospitals and clinics.

The data collected by the Centre pointed to a crisis in the field of maternal and child health in the country and highlighted several causes of preventable death in mothers and babies. These included health concerns like blood loss, infections and HIV, as well as a skills shortage in certain regions and facilities.

Having identified areas for improvement, the Centre is pioneering several initiatives that are already making a difference - saving lives, increasing the skills of health workers, and helping to deliver more healthy infants than ever before.

UP launches new Centre for maternal and child health

After 20 years of contributing to the lives of pregnant women, newborn babies and infants; the South African Medical Research Council's (MRC’s) Maternal and Infant Health Care Strategies Unit has become a fully fledged Centre at the University of Pretoria (UP). A vision of Prof Robert Pattinson, the Research Centre for Maternal, Fetal, Newborn and Child Health Care under the Department of Obstetrics and Gynaecology today boasts a treasure trove of experts and knowledge gathered since the unit’s inception in 1997.

Read more (Page 2)

UP trains healthcare professionals to reduce maternal deaths

The newly launched Research Centre for Maternal, Fetal, Newborn and Child Health Care at the University of Pretoria has collected expertise and data on maternal and child health over two decades. The Essential Steps in Managing Obstetric Emergencies (ESMOE) project is one of many initiatives run under the auspices of the new Centre, aimed at improving primary and secondary maternal and infant healthcare by providing health workers with the necessary skills to handle difficult births.

Read more (Page 3)

Kangaroo Mother Care: UP’s low-tech solution is saving premature babies

Premature babies all over Africa and in developing countries around the world have a greater chance of survival today thanks to the work of University of Pretoria researchers. Prof Anne-Marie Bergh and colleagues have been tirelessly promoting the benefits of Kangaroo Mother Care for almost 20 years, by training nurses and doctors in this low-tech solution that is saving premature and low birth-weight infants.

Read more (Page 4)

Locally made low-cost device reduces stillbirths by half

Researchers at the University of Pretoria have just finished testing a device that could prevent thousands of still births every year. The Umbiflow is a low-cost, low-tech device that detects problems with pregnancies in otherwise healthy women, and ensures that they get the care they need for a healthy birth, before it’s too late.

Read more (Page 5)

A lifelong quest to reduce infant deaths

For most doctors in training, obstetrics is hectic and too busy, but for Dr Felicia Molokoane it is a calling. Her bold career choice has led to her being part of groundbreaking research on the effects of HIV treatment on the growth of babies.

Read more (Page 6)

 

UP launches new Centre for maternal and child health

 

After 20 years of contributing to the lives of pregnant women, newborn babies and infants; the South African Medical Research Council's (MRC’s) Maternal and Infant Health Care Strategies Unit has become a fully fledged Centre at the University of Pretoria (UP). A vision of Prof Robert Pattinson, the Research Centre for Maternal, Fetal, Newborn and Child Health Care under the Department of Obstetrics and Gynaecology today boasts a treasure trove of experts and knowledge gathered since the unit’s inception in 1997.

he new Centre continues in the footsteps of the Maternal and Infant Health Care Strategies Unit, which has been a joint venture between UP and the MRC. Its goals echo those of Prof Robert Pattinson: to seek solutions to the primary and secondary health care levels that are saleable and sustainable.

“By seeking we mean performing research; by saleable we mean solutions that are acceptable to all, namely women, health care workers and health administrators; and by solutions we mean health strategies that have been developed to solve the problems identified,” he says.

Hot on the heels of the Unit’s birth in 1997, the National Committee for Confidential Enquiry into Maternal Deaths (NCCEMD) was established. Working in collaboration with the Unit, NCCEMD has tackled factors associated with maternal deaths by collecting data on the numbers, common causes and avoidable factors.

The unit publishes the findings in the Saving Mothers report, which are published three times in a year and widely distributed at the primary and secondary health care levels. The report identifies preventable maternal deaths that are preventable (such as those due to infections or hypertension-related complications) and suggests areas for improvement.

“These conditions comprise 66.7% of preventable maternal deaths, which could be significantly reduced with adequate knowledge and skills from healthcare providers,” Pattinson says.

The Unit has followed up the Saving Mothers reports with Saving Babies (focusing on perinatal care) and Saving Children (focusing on the healthcare of infants and children up to 18 years that are admitted to paediatric wards).

South Africa faces preventable issues of newborn illness, childhood illness, HIV/AIDS and malnutrition as a result of poverty, which have led the Unit to develop the Perinatal Problem Identification Programme (PPIP). The Unit developed PPIP as a tool to help district hospitals measure the number of perinatal and maternal deaths, and track their causes.

With information the Unit has gathered over the years, the Unit has developed and implemented effective, low-cost solutions where cost is a concern. One example has been the Kangaroo Mother Care (KMC) technique of caring for premature babies, which ensures skin-to-skin contact between the mother and the premature baby.

“The premature baby lies on the bare chest of the mother, which ensures the baby is kept warm,” Pattinson explains. “physiologically the mother concentrates heat to the area, making this method more effective than an incubator.”

This Unit has come a long way on its journey to becoming a centre at UP; on the way it has helped UP become a well-known name across all the districts of South Africa. Under the directorship of Prof Robert Pattinson, the Unit has made a considerable difference at a primary and secondary level of health care in South Africa, and as a Centre will continue this good work on a global stage.

UP trains healthcare professionals to reduce maternal deaths

 

The newly launched Research Centre for Maternal, Fetal, Newborn and Child Health Care at the University of Pretoria (UP) has access to a treasure trove of expertise and data gathered over the last two decades. The Essential Steps in Managing Obstetric Emergencies (ESMOE) project is one of many initiatives run under the auspices of the new Centre and aimed at improving primary and secondary maternal and infant healthcare.

The new Centre succeeds the South African Medical Research Council's Maternal and Infant Health Care Strategies Unit at the University of Pretoria, which has been gathering data on the care of mothers and infants since 1997. From 20 years of knowledge and experience, experts at the Unit have found that a lack of adequate skills and training is contributing to the high prevalence of maternal deaths in South Africa.

The ESMOE programme aims to improve the emergency management of pregnant women and their infants by developing and implementing a training package for emergency care. To do this, researchers collaborated with the Liverpool School of Tropical Medicine to develop an SA-specific training programme for healthcare professionals and students to improve in this area.

A report on a survey led by the director of the Maternal and Infant Health Care Strategies Unit, Professor Robert Pattinson, looked at basic emergency obstetric and neonatal care in 12 South African health districts. Pattinson reports that in the 12 districts surveyed, the required level of emergency obstetric care was not available in most community healthcare centres and in only a quarter of district hospitals.

“We found that less than half the clinics could get their patients with complications to the appropriate hospital in less than an hour,” says Pattinson. “Safe maternity care was not consistently available at many facilities conducting births.”

This survey showed that a concerted effort was needed to train midwives and doctors in vacuum deliveries, manual removal of the placenta and manual vacuum aspiration of the uterus for incomplete miscarriage. ESMOE is specifically designed to meet these needs, among many others.

The training has been a marked success, with a one-third reduction of maternal deaths after training, and an almost 20% reduction in deaths due to blood loss during and after childbirth.

The training programme also exists as a digital platform with myriad resources to help train healthcare workers in subjects such as a surgical safety checklist, guidelines on maternity care, and miscarriage scenarios, among others.

ESMOE has been so impactful that it has caught the attention of the European Union (EU) which has helped the Unit expand ESMOE training from the original 12 districts to all 52 districts in South Africa.

The ESMOE programme continues to provide training for healthcare professionals at South African healthcare centres to help put maternal health at the centre of national plans and support women’s right to safe motherhood.

Kangaroo Mother Care: UP’s low-tech solution is saving premature babies

 

Premature babies all over Africa and in developing countries around the world have a greater chance of survival today thanks to the work of University of Pretoria (UP) researchers. Drs Anne-Marie Bergh, Elise van Rooyen and colleagues have been tirelessly promoting the benefits of Kangaroo Mother Care for almost 20 years, training nurses and doctors in this low-tech solution that is saving premature and low birth-weight infants.

“Globally, 35% of neonatal deaths are due to conditions related to prematurity - problems with temperature control, breathing, and the cardiovascular system,” says Bergh, who oversees education aspects of public health projects for the SAMRC Unit for Maternal and Infant Healthcare Strategies at UP. “In our study, the introduction of Kangaroo Mother Care in South Africa was associated with a 30% reduction in neonatal mortality. It is now recommended by the World Health Organisation as a key intervention around the world.”

Kangaroo Mother Care (KMC) was originally developed in Colombia in 1979 as a solution to overcrowding in a neonatal unit in Bogotá, but was only taken up in other countries in the 90s after more than a decade of research. In essence, mothers and other caregivers are taught to carry their babies skin-to-skin, between the breasts, for 20 or more hours per day. This helps the baby maintain a regular temperature, enhances breastfeeding and dramatically improves a baby’s chance of survival.

In the absence of sophisticated care for small and sick newborns, KMC is a life-saving strategy for keeping the baby warm and reducing the chance of infection. Skin-to-skin care is also used worldwide to help premature babies bond with their parents. But that’s not all: Bergh says studies are starting to show the positive effects of KMC on long-term brain development.

Bergh and Van Rooyen first started working to implement KMC in South Africa in 1999. They started at Kalafong hospital in Pretoria where Van Rooyen heads the KMC unit, and over the next 10 years developed multimedia training materials, techniques and methods for sustainable implementation, as well as tools to evaluate the success of their efforts.

“When we started working with KMC, it was a new thing,” says Bergh. “Nobody knew how to implement it.”

Now, Bergh and Van Rooyen are world experts in getting KMC to work, regardless of the context. Since 2007, when they evaluated a project implementing KMC in Malawi, they have worked with African countries like Ghana, The Gambia, Mali and Rwanda (to name a few), as well as Asian countries like Indonesia, India and Bangladesh. This work, often in partnership with development agencies and ministries of health, either involves helping countries assess the needs of the country, implement a KMC programme, or review the success of such an implementation.

Bergh says that KMC is gaining ground globally as an important life-saving intervention in newborn care.

“Since 2014, the Every Newborn Action Plan has put its focus more strongly on initiatives to save premature and low birth-weight babies,” she says. “Each country has its own specialised plan, but KMC is in there as a key intervention - it’s been identified as high impact, life-saving, and cost-effective.”

In SA, KMC is in place in hospitals all over the country, and it forms part of the newborn care taught to new doctors and nurses. Bergh says that it might not always be implemented in the same way - the methods are designed to be adaptable to different situations, skill levels and institutions - but the outcome is the same: newborn lives are saved.

Locally made low-cost device reduces stillbirths by half

 

Researchers at the University of Pretoria (UP) have just finished testing a device that could prevent thousands of still births every year. The Umbiflow is a low-cost, low-tech device that detects problems with pregnancies in otherwise healthy women, and ensures that they get the care they need for a healthy birth, before it’s too late.

The Umbiflow was developed in 2005 by the Council for Scientific and Industrial Research (CSIR), in partnership with the Medical Research Council of South Africa (MRC). It is a low-cost alternative to commercially available ultrasound devices that measures the rate of blood-flow from the placenta to the fetus. Problems with blood flow means problems with pregnancy, says Dr Spencer Nkosi, a University of Pretoria researcher and medical doctor who is testing the Umbiflow device in the general population.

“The Umbiflow gives us a measure of placental function. After measurement, we group pregnant women into normal or abnormal placental function,” he says. “Women with abnormal function are directed to a high-risk clinic, where they get weekly or fortnightly checkups depending on our findings.”

Still births and other abnormalities are extremely high in South Africa and other developing countries, for reasons that are not altogether clear; in South Africa specifically, research from the Research Centre for Maternal, Fetal, Newborn and Child Health Caresuggests that there are around 20 000 stillbirths every year. Many of these pregnancies seem completely normal, with mothers that appear healthy.

Nkosi explains: “One in ten healthy women that we scanned had an abnormal placental flow. Our question was, can Umbiflow help us identify fetuses at risk? When we did the trials in Mamelodi, we found that with Umbiflow we can reduce stillbirths almost by half.” Even more promising, the CSIR found and Nkosi confirmed that the device is as accurate as a commercial ultrasound machine, while being far cheaper and much easier to use. It is an ideal tool for hospitals in poor and rural areas that don’t have the resources of their urban counterparts.

The Umbiflow device uses a technology known as continuous wave doppler to measure the rate of blood flow in the placenta, runs an algorithm, and outputs a value. The closer that value is to one, the lower the placental bloodflow is. A value of one represents a condition called absent flow, which means that the fetus is in real danger of dying.

According to Nkosi, absent flow was alarmingly common among the women in his study.

“Internationally, a low-risk population has absent flow in 0.3% of pregnancies; we found absent flow in 1.2%. That’s four times higher than the international reported average.”

Absent flow is commonly related to hypertension or developmental issues, but in Nkosi’s study these weren’t causing problems. He says he doesn’t yet know why this is occurring, and hopes that future research will provide an answer.

The next step in this research will be to test the Umbiflow on a national scale to see if it has the same positive results around the country. If so, Nkosi says this is a “eureka moment” for neonatal care in South Africa and the rest of the developing world.

A lifelong quest to reduce infant deaths

 


For most doctors in training, obstetrics is hectic and too busy, but for Dr Felicia Molokoane it is a calling. Her bold career choice has led to her being part of groundbreaking research on the effects of HIV treatment on the growth of babies.

“When I did my internship, none of the others wanted to do obstetrics,” she says while reminiscing on being given a choice of departments at a busy district hospital early on in her career. “I chose it and I felt welcome - I belonged in the department.”

Molokoane’s journey begins during her early years as an undergraduate at the then University of Natal (now the University of KwaZulu-Natal (UKZN)). There she was inspired to focus on obstetrics and HIV at a time when the disease was still steeped in stigma and denialism in South Africa.

Describing herself as “short and tiny”, Molokoane never imagined herself conducting vaginal examinations and dealing with HIV-positive mothers as an obstetrician. That all changed when a Professor Moodley encouraged her in her third year at the University of Natal.

“The interest started because the professor paid so much attention to teaching me these things,” she says.

As an intern at Jubilee District Hospital, she got hands-on hospital experience - from the use of sonars to dealing with crises such as doctor shortages. She even volunteered occasionally as she came to enjoy obstetrics. She especially loved helping patients - usually in pain and crying, and oblivious to what would happen to themselves or their babies.

“Seeing them feel fulfilled after the delivery really gave me a love for obstetrics,” she explains.

Molokoane came to the University of Pretoria (UP) to specialise in obstetrics at the institution she was advised was the best in the country. She also recalls that as an intern, she was trained in part by a consultant who studied at UP.

“I applied to study as a registrar in 2006,” she says. “Training in obstetrics is hard, but the teaching and support I received from UP was amazing.”

After completing her training, she became a consultant at UP in 2010 and has been part of the Department of Obstetrics and Gynaecology ever since.

She is currently a consultant in charge of the Maternal and Fetal unit at Kalafong Hospital in Gauteng, after qualifying as a subspecialist in Maternal and Fetal Medicine in 2015. Her time is now mostly occupied by her research into fetal growth in HIV-positive mothers, where she is particularly looking at the effects of antiretrovirals (ARVs) on growth and pregnancy outcomes.

Molokoane’s research was inspired by a study done by Professor Ute Feucht from the Department of Paediatrics and Child Health, who found that there was poor growth associated with HIV-exposed children in whom the mothers had been on ARV therapy during the pregnancy.

“South Africa has been hit hard by HIV/AIDS, and ART is a key public health strategy to prevent mother-to-child transmission of HIV. However, recent evidence of low birth-weight and premature deliveries in mothers on ART has experts concerned,” she says. “In dealing with uninfected, HIV-exposed infants, we are trying to find the exact causes of suboptimal growth throughout the child’s development.”

The study is being undertaken by the South African Medical Research Council's Unit for Maternal and Infant Health Care Strategies at UP, which consists of a multidisciplinary team of researchers. While she is a member of the antenatal part of the team as an obstetrician, other research conducted by the Unit include paediatricians and immunologists, among others.

“We are aiming to start recruiting patients from December, but we are waiting for the Tshwane Ethics District to approve the study,” she says. Building on previous studies, she intends to root out the causes of growth problems associated with the use of ARVs.

“If they are causing harm to fetuses, we would have to talk to the policymakers about it,” she says. “Maybe we need to change the regime that we are using to reduce the impact on fetal growth.”

For Molokoane, the study brings her journey into obstetrics and the impact of HIV in South Africa full circle, and while she may physically still be “short and tiny”, she is quickly growing into a giant of the obstetrics field.

 

November 1, 2017

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Table of contents

Researchers
  • Professor Robert Pattinson
    Professor Robert Pattinson conducts research at the South African Medical Research Council (SAMRC) and at the University of Pretoria’s (UP) Maternal and Infant Health Care Strategies unit, which he was the director of until his retirement. He no longer does clinical work and focuses only on research.

    Prof Pattinson, who did his undergraduate studies at the University of the Witwatersrand and his postgraduate studies at Stellenbosch University, has had a long association with UP, having been involved in research at the University for 30 years. “Opportunities were the best here,” he says.

    His research aims to reduce the deaths of mothers and babies; he is also working on preventing stillbirths. A recent highlight for Prof Pattinson was being awarded an SAMRC Gold Medal for Research.

    “Another recent milestone of ours was developing an innovative strategy to reduce stillbirths by between a third to half,’ says Prof Pattinson. “I hope that we will achieve a significant reduction in stillbirths as we did by significantly reducing maternal deaths by 29% through developing and implementing the Essential Steps in Managing Obstetric Emergencies and Emergency Obstetric Simulation Training programmes in South Africa.”

    Prof Pattinson’s advice to prospective and undergraduate students is short and sweet: “Work hard.”

    He has many hobbies and interests, including reading, hiking, cycling, kayaking and diving.
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