Adherence to iron prophylactic therapy during pregnancy in an urban regional hospital in South Africa

Background: Iron and folic acid supplementation plays a major role in the prevention and control of iron-deficiency anaemia in pregnancy. Therefore, this study assesses adherence to prophylactic iron supplementation during the antenatal period in South Africa. Methods: An observational study was conducted in a regional hospital from January to December 2016. HIV-uninfected(n= 100) and HIV-infected (n= 100)] women were enrolled and subdivided into three groups: (a)≤34 weeks (n= 33), (b)34­36 weeks (n= 34) and (c)≥37 weeks (n= 33) gestational age respectively. A structured questionnaire was used for data collection. Data were coded and statistically analysed using SPSS software. Pill count and self-reported data from women (n= 24) at≤34 weeks and 34­36 weeks reflected < 50% adherence and 46% non-adherence, being higher in the HIV-infected women (75%). Nausea was the commonest side effect across all trimesters (79. 2%). Adherence (27.8%) and non-adherence (72.1%) to iron, folic acid and calcium supplementation were found in 88% of women. Conclusion: This study found that adherence to micronutrient supplementation is low in pregnancy, albeit higher in HIV-infected women receiving antenatal care at a regional hospital in Durban, South Africa

Can an enhanced recovery after surgery (ERAS) programme improve colorectal cancer outcomes in South Africa?

Colorectal cancer (CRC) is the third most common cancer worldwide and the fourth most common cause of cancer related deaths. It is estimated that CRC is amongst the top five malignancies in South Africa (SA) with an age standardised incidence rate of 10.2 and 6.1 per 100 000 for males and females respectively. The incidence is projected to increase in South Africa as a result of ageing, a growing population and an increase in prevalence of risk factors

The effect of pregnancy and delivery on anal function in black Africans and Indians

Background: Occult anal sphincter disruption, following childbirth may contribute to the development of anal incontinence (AI). The type and mechanism of injury may differ between first and subsequent deliveries. Objectives: To describe the effect of pregnancy and delivery on the endosonographic morphology of the anal sphincter and on anal sphincter pressures, and to highlight any differences in these between nulliparous and multiparous Black African and Indian women. Methods: One hundred Black African and Indian women delivering at two hospitals in the Pietermaritzburg area underwent anal endosonography and manometry in the third trimester of pregnancy and 24 hours post-delivery. Those with occult injury were followed up at 6 weeks and six months. Participants were asked about bowel symptoms at each visit. Ante-natal and intra-partum obstetric data was also recorded. Results: The majority were Black African (82%), and 76% were multiparous. Symptoms of urgency increased from 9% antenatally to 14.6% post-delivery, decreasing to 8.3% at six months. Symptoms of AI increased from 10% antenatally to 12.5% post-delivery, falling to 3.1% at six months. Internal sphincter defects were more common among primiparous and multiparous women delivering vaginally. There was a significant drop in functional anal length post-delivery, irrespective of the mode of delivery. Anal pressures also fell post-delivery and at six weeks post-partum. However, by six months there appeared to be a return to pregnancy values.Conclusion: Occult anal sphincter injuries and reduced anal pressures occur after delivery, in the absence of clinically detected anal sphincter trauma, irrespective of the mode of delivery

The impact of a modified World Health Organization surgical safety checklist on maternal outcomes in a South African setting: A stratified cluster-randomised controlled trial

Background. In South Africa (SA), the Saving Mothers Reports have shown an alarming increase in deaths during or after caesarean delivery.Objective. To improve maternal surgical safety in KwaZulu-Natal Province, SA, by implementing the modified World Health Organization surgical safety checklist for maternity care (MSSCL) in maternity operating theatres.Methods. The study was a stratified cluster-randomised controlled trial conducted from March to November 2013. Study sites were 18 hospitals offering maternal surgical services in the public health sector. Patients requiring maternal surgical intervention at the study sites were included. Pre-intervention surgical outcomes were assessed. Training of healthcare personnel took place over 1 month, after which the MSSCL was implemented. Post-intervention surgical outcomes were assessed and compared with the pre-intervention findings and the control arm. The main outcome measure was the mean incidence rate ratios (IRRs) of adverse incidents associated with surgery.Results. Significant improvements in the adverse incident rate per 1 000 procedures occurred with combined outcomes (IRR 0.805, 95% confidence interval (CI) 0.706 - 0.917), postoperative sepsis (IRR 0.619, 95% CI 0.451 - 0.849), referral to higher levels of care (IRR 1.409, 95% CI 1.066 - 1.862) and unscheduled return to the operating theatre (IRR 0.719, 95% CI 0.574 - 0.899) in the intervention arm. Subgroup analysis based on the quality of implementation demonstrated greater reductions in maternal mortality in hospitals that were good implementers of the MSSCL.Conclusions. Incorporation of the MSSCL into routine surgical practice has now been recommended for all public sector hospitals in SA, and emphasis should be placed on improving the quality of implementation

An overview of cancer research in South African academic and research institutions, 2013 - 2014

BACKGROUND AND OBJECTIVES:Cancer is emerging as a critical public health problem in South Africa (SA). Recognising the importance of research in addressing the cancer burden; the Ministerial Advisory Committee on the Prevention and Control of Cancer (MACC) research working group undertook a review of the current cancer research landscape in SA and related this to the cancer burden.METHODS:Academic and research institutions in SA were contacted to provide information on the titles of all current and recently completed (2013/2014) cancer research projects. Three MACC research working group members used the project titles to independently classify the projects by type of research (basic; clinical and public health - projects could be classified in more than one category) and disease site. A more detailed classification of projects addressing the five most common cancers diagnosed in males and females in SA was conducted using an adapted Common Scientific Outline (CSO) categorisation.RESULTS:Information was available on 556 cancer research projects. Overall; 301 projects were classified as clinical; 254 as basic science and 71 as public health research. The most common cancers being researched were cancers of the breast (n=95 projects) and cervix (n=43); leukaemia (n=36); non-Hodgkin's lymphoma (n=35) and lung cancer (n=23). Classification of the five most common cancers in males and females in SA; using the adapted CSO categories; showed that the majority of projects related to treatment; with relatively few projects on prevention; survivorship and patient perspectives.CONCLUSION:Our findings established that there is a dearth of public health cancer research in SA

Views and Attitudes of Pregnant Women Regarding Late Termination of Pregnancy for Severe Fetal Abnormalities at a Tertiary Hospital in KwaZulu-Natal

Aim. To study the views and attitudes of pregnant women with severe fetal anomalies regarding late termination of pregnancy (LTOP). Methods. Data were collected over a 3-month period using semi-structured interviews of pregnant women with severe fetal anomalies (lethal and non-lethal) detected after 24 weeks' gestation at a single tertiary/quaternary fetal medicine unit in KwaZulu-Natal; South Africa. The interviews were conducted both during pregnancy and within 2 weeks after delivery. The women who underwent LTOP and those who continued with their pregnancies were compared in respect of a variety of demographic and socio-economic characteristics. Results. During the study period; 15 pregnant women with severe fetal anomalies were interviewed. Of these; 5 (33.3) requested termination and 10 (66.6) opted to continue the pregnancy. The women who continued their pregnancies were significantly younger (mean age 25 years; range 20 - 32 years) than those who requested termination (mean age 31 years; range 22 - 35 years) (p0.05). Mean parity was 1 (range 0 - 3) in the patients who continued the pregnancy and 2 (1 - 3) in those who terminated it. The majority of the women were Christians; and there was no significant difference between the groups in their choices. Many women indicated that their partners and immediate family members influenced decision making. All the women said that they were given sufficient time by the hospital staff to make their decision whether to terminate or continue the pregnancy after the options had been explained to them in a non-threatening manner. Before delivery; the common reasons for continuing with the pregnancy included fear of killing an unborn baby; that a baby is God's gift and the baby will be well after it is born; that nature should be allowed to take its course; and that there should be no interference with the pregnancy. The main reasons for opting for LTOP were the cost implications of raising an abnormal baby; that the baby would suffer during his or her life; and being unable to cope with a severely handicapped child. After delivery and seeing the baby; most women felt that they made the correct choice. Conclusion. Despite the small numbers from a single academic institution; this study illustrates that even while pregnant with an anomalous fetus; patients' views and attitudes regarding LTOP for severe fetal anomaly were variable. Younger primigravidas were more likely to continue the pregnancy in the hope that the baby would be born normal. Good support from partner and family after delivery was associated with less regret about the decision that had been made. Larger follow-up studies assessing long-term views and attitudes of women regarding LTOP will be important for comparison with the initial decision-making process and for future prenatal counselling

Sexual Activity during Pregnancy: a Questionnaire-Based Study

The objective of the study was to determine changes in frequency of sexual activity during pregnancy. A prospective study was conducted using a structured questionnaire to interview 611 healthy pregnant women at a regional hospital in KwaZulu-Natal. Data were analysed using descriptive statistics. Five hundred and fifty-six (91.0) of the 611 women were sexually active during pregnancy. Sexual desire was increased in 102 (18); decreased in 299 (40) and was unchanged in 210 (34). Four hundred and twenty-two (69) engaged in sexual activity until the third trimester of pregnancy. Three hundred and seventy-nine (62) used condoms. The majority (63) found it easier to discuss the topic of sexual activity with midwives rather than with doctors. One hundred and thirty-eight (23) experienced adverse events attributed to sexual intercourse during pregnancy. Religious and traditional practices played a minor role in guiding the practice of sexual activity during pregnancy. Twenty-eight (5) of the 611 women were guided by religious rules while 27 (4) were guided by traditional rules. Our findings confirm that sexual activity is commonly practised in pregnancy. Given the high HIV rates and sexually transmitted infections in the local population; this has important implications for information provided during antenatal care

Breech Presentation at a District Level Hospital

Introduction:The term Breech Trial has led to obstetricians opting for caesarean section as the mode of delivery for this presentation; even in poor countries. The concerns of this approach are the resultant increase in caesarean section rates and their associated complications; particularly in under-resourced countries; which are faced with financial and human resource expertise constraints. Method: This was a retrospective chart review of women who presented at term with a singleton breech presentation at the antenatal and in labour; from January 2005 - December 2007. Results:There was a total of 19;197 deliveries; of which 466 were singleton term breech deliveries; giving a rate of 2.4. Of the 297 women who had antenatal care and had been allocated to planned caesarean section; 271 had the planned operation. There were no neonatal deaths in the planned caesarean section group. The emergency caesarean section group and the group in which no decision was made on the mode of delivery; were associated with a higher maternal complication rate than those who had planned caesarean sections. The highest neonatal complication rate was in those who had unplanned vaginal delivery. Conclusion: In a district hospital in South Africa; the mode of delivery is usually a planned caesarean section. Unplanned vaginal deliveries are associated with significant perinatal mortality

Rising Caesarean Section Rates: an Audit of Caesarean Sections in a Specialist Private Practice

Background: Caesarean section (C/S) rates are increasing world wide; rates in the private sector in South Africa are reported to be particularly high. To the best of our knowledge; there has not been a recent audit of caesarean sections from the private health sector in KwaZulu-Natal. The aim of this study was to carry out an audit of C/S in a private practice. Methods: An audit of the patient records over a period of one year was done. No personal identifiers were noted or reported on. All relevant clinical data was pooled and used to analyse clinical information. Results: There were 364 deliveries in the study period and 209 of these were C/S; giving a rate of 60.4. The majority of the C/S were done for a previous C/S; maternal request and HIV status also contributed to the high rate. Conclusion: The high C/S rate in private practice is probably a window of the increased caesarean section rates world wide. This high rate is in keeping with trends in countries such as South America; and is much; much higher than the ideal rate in low-risk obstetric populations of 10.15suggested by the WHO

An Audit of PMTCT Services at a Regional Hospital in South Africa

Background : Prevention of mother-to-child transmission (PMTC) is a major intervention world-wide in the fight against the HIV pandemic; and has resulted in markedly reduced rates of mother-to-child transmission rates in well-resourced countries. However; our impression is that barriers to implementation of the programme exist at all levels of health care at all facilities providing maternal care. Aim To conduct a clinical audit of the PMTCT programme at a regional hospital. Methods Data was collected from an analysis of antenatal and medical records of women who attended antenatal care and delivered at a regional hospital from January-December 2007. Results :Of the 499 records analysed; 479 women (96) were offered testing; 473 accepted. Of those tested; 227 (48) were HIV positive. Only 15 (6.1) of the 246 who tested negative; were re-tested. CD4 counts were only done in 159 (70) of the 227 HIV-positive women. More importantly; only 134 (84.3) received their results. Of the 227 HIV positive women; only 131 were given 200mg Nevirapine at 28 weeks gestation; 185 (81.5) took Nevirapine before delivery; 143 took Nevirapine 2 hours before delivery and 84 (37) took Nevirapine 2 hours before delivery. 208 (91.6) of the babies were given Nevirapine at the correct time. Discussion This audit shows that progress has been made in the implementation of PMTCT of HIV at this regional hospital by the high uptake of HIV testing; however barriers to full implementation are caused by the lack of integration of testing; counselling and obtaining CD4 count results

Cardiac Disease in Pregnancy : Cardiovascular Topic

This study was a retrospective review of patient charts of a relatively large number of patients with cardiac disease in pregnancy in a developing country. Ninety-five patients were evaluated; the majority (n = 36) were in the age group 21-25 years. Rheumatic heart disease was the commonest aetiology; eight women required balloon mitral valvuloplasty and one had a valve replacement at 32 weeks' gestation. There were no maternal deaths but morbidity was high; 13 patients were admitted in cardiac failure; nine had atrial fibrillation and three required intensive-care management. There were 86 live births of the 97 deliveries. Cardiac disease in pregnancy is associated with high maternal morbidity and adverse foetal outcomes; this was related to late presentation and problems with anticoagulation. Clinical assessment remains a key factor in timeous referral and appropriate investigations

Obstetric Urinary Fistulas in KwaZulu-Natal - What is the Extent of this Tragedy?

Background. This study describes the demographics and clinical characteristics of women with obstetric fistulas attending the urogynaecological unit at King Edward VIII Hospital (KEH); KwaZulu-Natal (KZN); South Africa. Method. A prospective clinical review of all women admitted with the diagnosis of an obstetric fistula at KEH from 1999 to 2003. Results. A total of 41 cases from the rural areas of KZN and the Eastern Cape were identified. The mean age was 29 years (range 15 - 51 years); and 21 were primi- gravidas; 14 of whom had unplanned pregnancies. All were from low socioeconomic backgrounds and had limited or no access to antenatal care; either due to their social cir- cumstances or to lack of health care facilities. The duration of labour was prolonged in all; there were 5 live births; and 2 neonatal deaths. Conclusion. Obstetric fistulas are still common in KZN and the Eastern Cape; and occur mainly in women from rural areas

Health Care Attendance Patterns By Pregnant Women In Durban; South Africa

"Background: High rates of perinatal mortality and morbidity and maternal mortality in South Africa remain a major problem. The Saving Mothers and Saving Babies Reports identified patient-related factors as possible causes. Among the patient-related factors was non-attendance; or attendance late in pregnancy; for antenatal care in public hospitals. It would appear that pregnant women confirm their pregnancies by visiting general practitioners; but do not attend antenatal care in the public sector. The aim of this study was to determine healthcare attendance patterns among pregnant women in Durban; South Africa.Methods This was a descriptive study. Participants were recruited and categorised into ""early booker""; ""late booker"" and ""unbooked in labour"" groups. All the participants were interviewed individually using a structured questionnaire. Results: The majority of participants presented for formal ""booking"" late in pregnancy; 47.9""booked"" at a gestationalage of six months after the last menstrual period. Among the ""early bookers""; the majority (94.4) had confirmed their pregnancy by four months of amenorrhoea; and 60.6of these confirmed their pregnancies within the public health sector. All the ""early bookers"" began antenatal care prior to the 20th week of gestation.A total of 66.9of the ""late bookers"" and 66.7of the ""unbooked"" women also had their pregnancies confirmed at four months amenorrhoea; but 49.0of the ""late bookers"" and 59.8of the ""unbooked"" women confirmed their pregnancies in the private health sector. The ""late bookers"" also showed a delay of two to three months between confirming the pregnancy and booking visits. Of the women in this study; 49visited a general practitioner (GP) to confirm the pregnancy after two to four months of amenorrhoea. This figure rose to 53.0if only the ""late bookers"" and the ""unbooked"" were analysed. Further; 35.3visited a GP more than once; either for antenatal care or because of ill health. ConclusionIt is imperative for GPs to understand the role of antenatal care and to refer pregnant women appropriately."

Health Care Attendance Patterns by Pregnant Women In Durban; South Africa

"Background: High rates of perinatal mortality and morbidity and maternal mortality in South Africa remain a major problem. The Saving Mothers and Saving Babies Reports identified patient-related factors as possible causes. Among the patient-related factors was non-attendance; or attendance late in pregnancy; for antenatal care in public hospitals. It would appear that pregnant women confirm their pregnancies by visiting general practitioners; but do not attend antenatal care in the public sector.Aim: The aim of this study was to determine healthcare attendance patterns among pregnant women in Durban; South Africa.Method: This was a descriptive study. Participants were recruited and categorised into ""early booker""; ""late booker"" and ""unbooked in labour"" groups. All the participants were interviewed individually using a structured questionnaire.Results: The majority of participants presented for formal ""booking"" late in pregnancy; 47.9 ""booked"" at a gestational age of six months after the last menstrual period. Among the ""early bookers""; the majority (94.4) had confirmed their pregnancy by four months of amenorrhoea; and 60.6 of these confirmed their pregnancies within the public health sector. All the ""early bookers"" began antenatal care prior to the 20th week of gestation. A total of 66.9 of the ""late bookers"" and 66.7 of the ""unbooked"" women also had their pregnancies confirmed at four months amenorrhoea; but 49.0 of the ""late bookers"" and 59.8of the ""unbooked"" women confirmed their pregnancies in the private health sector. The ""late bookers"" also showed a delay of two to three months between confirming the pregnancy and booking visits. Of the women in this study; 49 visited a general practitioner (GP) to confirm the pregnancy after two to four months of amenorrhoea. This figure rose to 53.0 if only the ""late bookers"" and the ""unbooked"" were analysed. Further; 35.3 visited a GP more than once; either for antenatal care or because of ill health.Conclusion: It is imperative for GPs to understand the role of antenatal care and to refer pregnant women appropriately."

Occupational exposure to HIV amongst health care workers in the maternity unit at King Edward VIII hospital; Durban; South Africa

The increasing HIV sero-prevalence amongst pregnant women places health care workers in busy labour wards at high risk of occupational exposure to HIV. Aim: The aim of this study was to determine whether there has been a change in the prevalence of needle-stick and sharps injuries at King Edward VIII Hospital; Durban; South Africa; since the first study done on the issue in 1999; and if so - the reasons. Design: A cross-sectional retrospective survey assessing the prevalence of needle-stick and sharps injuries which occurred from January 2003 to December 2003. Setting: The study was conducted at the Department of Obstetrics and Gynaecology; King Edward VIII Hospital; Durban; South Africa. Method: Staff members in the labour ward; including doctors; nurses; student nurses; and supportive staff; i.e. cleaners; porters; and messengers were interviewed and asked to fill in a structured questionnaire. Results: Healthcare workers (114) were interviewed over a period of 1 year; from January to December 2003. 49 of the 90 (54) who agreed to participate reported an incident of exposure to patients' body fluids; 19 of who were through sharp injuries (21); forty percent of exposures occurred with known HIV infected patients; whereas at least 28 of patients sero-status was unknown at the time of the exposure. Only 61 of the sharps injuries were reported; and of these; only a third of the health workers completed the prescribed 4 week course of prophylactic antiretroviral treatment. Conclusion: This study showed an increase in the number of HIV exposures amongst health workers; and most of these are as a result of lack of adherence with preventative measures. Improved reporting mechanisms which ensure confidentiality may assist health workers to deal with this