1. 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.
2. Recommend strategies to reduce the PNMR based on this information.
All Provinces in South Africa gave input, where possible, into the PNMR in their particular Provinces. Furthermore, 44 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.
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 Program (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 and comprised the sentinel sites. The 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.
Some provinces have developed effective data collection systems at the time of the workshop and were able to provide accurate data for their whole province regarding births and perinatal deaths within state institutions. 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.
A total of 3045 perinatal deaths of 1000g or more were reported from 78 343 births at the sentinel sites. The perinatal mortality rates for the metropolitan, city and town and rural groupings were 38.4, 43.4 and 25.5/1000 births, respectively. The neonatal death rate was highest in the City and Town groups (16.5/1000 live births) followed by the Rural and Metropolitan groups (11.1 and 10.7/1000 live births respectively). The low birth weight rate was highest in the Metropolitan group (21.4%), followed by the City and Town group (18.6%) and the Rural group (13.7%).
Unexplained intrauterine deaths were a common grouping of primary cause of death in all groups. The most common primary cause of perinatal death in the Rural group was intrapartum asphyxia and birth trauma (rate 6.28/1000 births) followed by spontaneous preterm delivery (6.07/1000 births). The most common primary cause of death in the City and Town group was spontaneous preterm delivery (7.48/1000 births) followed by antepartum haemorrhage (7.0/1000 births) and intrapartum asphyxia and birth trauma (6.8/1000 births). The Metropolitan group’s most common primary causes were antepartum haemorrhage (6.82/1000 births), spontaneous preterm labour (5.33/1000 births) and complications of hypertension in pregnancy (5.19/1000 births). Neonatal deaths due to complications of prematurity and hypoxia were the most common final neonatal causes of death in all groups.
Patient related avoidable factors were reported to be present in 39.3% of perinatal deaths, followed by health worker related (24.6%) and administrative (14.0%). Lack of sufficient information to evaluate the case was present in 5.1% of cases. No, late initiation or infrequent attendance for antenatal care (present in 688 cases) was the most common avoidable factor. This was followed by an inappropriate responses by health workers to problems identified during antenatal care (305 occasions); inappropriate response by patients to poor fetal movements (227 occasions); delays in seeking medical attention during labour (177 occasions); delays in referring patients or calling for assistance (173 occasions); transport delays (162 occasions) and problems of monitoring the fetus during labour (106 occasions).
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 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.
Solutions for improving pregnant women and their baby’s care and reducing the PNMR rate at institutions
1. Ensure each site conducting births has the necessary equipment and protocols and that the staff is appropriately trained to manage labour and are especially trained in the use of the partogram. Introduce a quality assurance tool to assess the success of the training.
2. Ensure each site conducting births has the necessary equipment and protocols and appropriately trained staff to manage asphyxiated neonates. See that training programmes in neonatal resuscitation are accessible to all staff involved in conducting childbirth.
3. Ensure each site caring for premature infants has the necessary equipment and protocols and that the staff is appropriately trained in kangaroo mother care. See that implementation programmes are available to the staff.
4. Ensure each site performing antenatal care has protocols in place for where to and when to refer patients and the staff is appropriately trained therein. Introduce a quality assurance tool to assess the success of the training.
5. 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. If this is not practice, establish what barriers there are and attempt to overcome them.
Improve the process
1. Continue to establish more PPIP sentinel sites
2. Hold regular Provincial MCWH – PPIP sentinels site meetings
1. What are the barriers to implementing on-site screening for syphilis?
2. What is the primary pathology related to unexplained IUDs?
3. What is the feasibility of introducing nasal CPAP for managing premature infants in cities and towns and rural areas?
Valuable information obtained from the Perinatal Care Survey must be conveyed to the appropriate bodies.
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