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Midwife-led units in community settings Cape Peninsula, South Africa Associate Professor Sheila Clow Mr Jason Marcus & Mrs Carol Adams University of Cape.

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Presentation on theme: "Midwife-led units in community settings Cape Peninsula, South Africa Associate Professor Sheila Clow Mr Jason Marcus & Mrs Carol Adams University of Cape."— Presentation transcript:

1 Midwife-led units in community settings Cape Peninsula, South Africa Associate Professor Sheila Clow Mr Jason Marcus & Mrs Carol Adams University of Cape Town & Mowbray Maternity Hospital, Cape Town, SOUTH AFRICA 6 June 2010

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3 Country-specific context Large country Large country Rural-urban divide Rural-urban divide Inequitable health services, e.g. Inequitable health services, e.g. ◦ public sector per capita expenditure ~$158 ◦ private sector per capita expenditure ~$942 (6x) Health indicators Health indicators ◦ IMR 42.8/1000 (Health Systems Trust, 2007) ◦ MMR 237/ (Hogan et al, 2010) High GINI co-efficient High GINI co-efficient Redressing inequities Redressing inequities

4 Specific challenges relative to midwifery skills All midwives are trained as nurses All midwives are trained as nurses Profile of nurses is most closely related to the population profile Profile of nurses is most closely related to the population profile No distinction on the register for those in current practice No distinction on the register for those in current practice No requirement for relicensing No requirement for relicensing Few posts designated for midwives Few posts designated for midwives Outreach programme to midwives ad hoc Outreach programme to midwives ad hoc Access to further training constrained by shortage Access to further training constrained by shortage

5 Promising approaches – a promise that has delivered! Free-standing midwife-run units Free-standing midwife-run units for “low risk” maternity care for “low risk” maternity care close to the people who require it close to the people who require it and integrated in a defined referral system and integrated in a defined referral system ◦ 8 midwife units ◦ 2 secondary referral hospitals ◦ 1 tertiary academic hospital Initiated in the Cape Peninsula, South Africa in 1974 (prior to the Alma Ata Declaration)

6 Assumptions underpinning the Peninsula Maternal & Neonatal Service Normal or low-risk pregnancies are well managed by suitably qualified midwives Normal or low-risk pregnancies are well managed by suitably qualified midwives Tertiary level hospitals focussed on ill patients Tertiary level hospitals focussed on ill patients ◦ inappropriate setting for a normal low-risk pregnancy, and ◦ inappropriate use of expensive resources and infrastructure Health services should be accessible, acceptable and appropriate to the population, at a cost that is sustainable for the community Health services should be accessible, acceptable and appropriate to the population, at a cost that is sustainable for the community No poor options for poor people No poor options for poor people

7 Scope of Service Full range from pregnancy diagnosis to 1 st week post birth Full range from pregnancy diagnosis to 1 st week post birth Limited Emergency Obstetric Care (EmOC) Limited Emergency Obstetric Care (EmOC) Advanced midwives are licensed to perform assisted deliveries – vacuum and forceps Advanced midwives are licensed to perform assisted deliveries – vacuum and forceps Clinical guidelines are evidence based Clinical guidelines are evidence based

8 Clinical guidelines are evidence based Expectations are clear Expectations are clear ◦ no inductions, continuous EFM, epidural analgesia Basic Antenatal Care (BANC) Basic Antenatal Care (BANC) Better Birth Initiative – including doulas Better Birth Initiative – including doulas Prevention of Mother-to-Child transmission (including HIV counselling and testing) Prevention of Mother-to-Child transmission (including HIV counselling and testing) Kangaroo Care Kangaroo Care Phototherapy Phototherapy Baby-friendly Hospital Initiative Baby-friendly Hospital Initiative Perinatal mental health Perinatal mental health

9 Total births in the Peninsula Maternal & Neonatal Service, 2008

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11 Mitchell’s Plain Midwives’ Unit – selected data

12 Mitchell’s Plain staffing per shift Antenatal clinic Antenatal clinic ◦ 2 registered midwives ◦ 2 enrolled nurses ◦ 1 enrolled nursing auxiliary Labour ward & observation ward Labour ward & observation ward ◦ Day duty – 3 registered midwives ◦ Night duty – 2 registered midwives Postnatal outpatients Postnatal outpatients ◦ 1 enrolled nurse

13 Maternal mortality rates for all 9 provinces Source : Health Systems Trust, 2003

14 PMNS data, deliveries 22 Maternal deaths ~ MMR 57.5/ Maternal deaths ~ MMR 57.5/ ◦ 17 died in tertiary level care ◦ 12 were postpartum ◦ 5 = direct causes – 4 Hypertensive ◦ 1 = co-incidental ◦ 16 = indirect causes  12 Non-pregnancy related infections  11 known HIV+  8 with CD4 < 200 Source : Fawcus, 2009

15 Before the advent of HIV and AIDS … The PMNS MMR reached 31/ The PMNS MMR reached 31/ The MMR for the midwife units was 20/ The MMR for the midwife units was 20/ Source : de Groot 1993

16 Lessons learnt The system works The system works Health indicators are the best in the country Health indicators are the best in the country Cost effective and frees up higher levels of the service to those requiring it Cost effective and frees up higher levels of the service to those requiring it Some “medium risk” patients can be managed at this level Some “medium risk” patients can be managed at this level Creates a space for midwives to practice to their fullest potential Creates a space for midwives to practice to their fullest potential

17 Cost effectiveness 13 years after the introduction of this initiative the number of hospital births was the same the number of hospital births was the same AND there were 9000 births occurring in the midwife units AND there were 9000 births occurring in the midwife units The midwife units have 15% of the bed capacity of the entire service, yet account for 50% of all deliveries Source : de Groot 1993

18 Requirements Suitably qualified midwives Suitably qualified midwives A tiered referral system to higher levels of care A tiered referral system to higher levels of care Clear and agreed referral criteria Clear and agreed referral criteria Correct use of evidence based clinical guidelines Correct use of evidence based clinical guidelines Standardised documentation Standardised documentation Good communication systems Good communication systems Regular clinical audit Regular clinical audit Reliable transport Reliable transport

19 Suitably qualified midwives Education Education Regulation Regulation ◦ Professional ◦ Prescribing Continuous professional development Continuous professional development ◦ Perinatal update - referral hospital ◦ Total shutdown for staff training – 1 day p.a. ◦ PEP (Perinatal Education Programme) Clinical leadership Clinical leadership

20 Added value! A teaching and learning facility for undergraduate and postgraduate students in : Midwifery Midwifery Medicine Medicine Dentistry Dentistry Physiotherapy Physiotherapy Occupational heath Occupational heath Occupational therapy Occupational therapy

21 Future possibilities Incorporate into district health service Incorporate into district health service Ultrasound scanning and screening Ultrasound scanning and screening Postnatal care Postnatal care Tele-medicine / -midwifery Tele-medicine / -midwifery

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23 Acknowledgements Emeritus Professor Herman De Groot, Dr John Smith and the visionaries for decentralised primary health care, including maternity care Emeritus Professor Herman De Groot, Dr John Smith and the visionaries for decentralised primary health care, including maternity care Miss Squires and the nurse managers who supported the initiative Miss Squires and the nurse managers who supported the initiative The registered midwives, enrolled nurses and enrolled nursing auxiliaries which make this work The registered midwives, enrolled nurses and enrolled nursing auxiliaries which make this work The mothers who have trusted our care The mothers who have trusted our care The medical teams at the Universities of Cape Town & Stellenbosch and the referral hospitals who support this work The medical teams at the Universities of Cape Town & Stellenbosch and the referral hospitals who support this work

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26 Programmes leading to registration as a midwife Diploma course (1 year for RN or RPN, or 2 years for EN) (Reg. 254) Diploma course (1 year for RN or RPN, or 2 years for EN) (Reg. 254) Comprehensive diploma / bachelor’s degree leading to registration as a nurse and midwife (Reg. 425) Comprehensive diploma / bachelor’s degree leading to registration as a nurse and midwife (Reg. 425)

27 Clinical requirements 1 year diploma 4 year diploma 960 hours ANC 60 hours Not specified Antenatal women 3030 Witness deliveries 55 Deliveries1515 Local Anaesthetic excluding pudendal block excluding pudendal block + epidural EpisiotomyPerformance15 Perineal suturing suturing of 1 & 2 degree tears Night duty at least 1/12 and no more than ¼ hours Not specified

28 Clinical requirements 1 year diploma 4 year diploma pelvic assessments Not specified 5 conducting deliveries Not required 5 care of women in labour Not required 25 (at least 3 through all 4 stages of labour) internal examinations 15 sufficient number (no more than 5 rectal) postnatal care Not specified 5 mothers & babies x 2 days 5 mothers & babies x 5 days exam at the routine postnatal visit Not specified 3

29 Legal status of midwifery practice Nursing Act No.50 of 1978 as amended ◦ R1469 Scope of practice ◦ R2488 (26 October 1990) Conditions under which registered midwives and enrolled midwives may carry on their profession ◦ R February 1985 (as amended) Acts and omissions Nursing Bill 2005 (31 August 2005) ◦ SANC Charter of Nursing Practice

30 R1469 as amended Scope of Practice “The scope of practice will entail the following scientifically based acts or procedures which apply to the practice of Midwifery and which relate to the mother and child in the course of pregnancy, labour and the puerperium”

31 R1469 Scope of Practice Determine health needs of mother and child Refer where necessary Prevention & promotion Monitoring progress of labour, vital signs of mother & child, reaction to situations Episiotomy, suturing of tears, local anaesthetic Promote activities of daily living, e.g. exercise & sleep, oxygenation, hygiene, nutrition, elimination Promote wound healing Administration of medicine Promote & facilitate breastfeeding Establish a health promoting environment Communication with parents Assist with operative, diagnostic & therapeutic procedures Co-ordination of health care Provide effective advocacy Care of the dying patient

32 Implications to consider Status of regulation vis-a-vis protocol / guidelines Status of regulation vis-a-vis protocol / guidelines Changes required Changes required Needs to be evidence based, responsive to changing evidence Needs to be evidence based, responsive to changing evidence Needs to be responsive to changing health care needs, yet maintaining safety Needs to be responsive to changing health care needs, yet maintaining safety Clarify who may do what Clarify who may do what Skills training Skills training Management of emergencies, e.g. resuscitation, shoulder dystocia, prolapsed cord Management of emergencies, e.g. resuscitation, shoulder dystocia, prolapsed cord Guidelines required Guidelines required

33 Different models ◦ Free-standing birth unit (original model) ◦ Unit linked to a comprehensive health centre (primary level) (geographically close, but operationally still developing the relationships) ◦ Unit on a secondary or tertiary hospital campus but operated separately


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