Impact of Introduction of a Colposcopy Service in a Rural South African Sub-District on Uptake of Colposcopy

Objective.To describe the establishment of a colposcopy service at a district hospital in a rural sub-district of the Western Cape; South Africa; and assess its impact on colposcopy uptake. Design. A retrospective double-group cohort study using a laboratory database of cervical cytology results; clinical records and colposcopy clinic registers.Setting. The Overstrand sub-district; where 80 000 people are served by seven clinics and a district hospital in Hermanus; 120 km from its referral hospitals in Cape Town and Worcester. A colposcopy service was established at Hermanus Hospital in 2008.Subjects. All women in the sub-district who required colposcopy on the basis of cervical smears done in 2007 and 2009.Outcome measures. Numbers of women booked for colposcopy at distant referral hospitals in 2007 and at the district hospital in 2009; the proportions who attended colposcopy; the time from cervical smear to colposcopy; and comparison between the two years.Results. Uptake of colposcopy booked at distant referral hospitals was 67 in 2007. Uptake improved by 18 to 79 for the district hospital colposcopy service in 2009 (p=0.06). When patients from an area with no public transport to the district hospital were excluded from analysis; the improvement was more marked at 22 (p=0.02). The delay from cervical smear to colposcopy improved significantly from 170 to 141 days (p=0.02).Conclusion. Establishment of a colposcopy service in a rural sub-district increased uptake of colposcopy and decreased the delay from cervical smear to colposcopy. The service removed 202 booked patients in one year from the colposcopy load of the referral hospitals

Early onset severe pre-eclampsia: expectant management at a secondary hospital in close association with a tertiary institution.

OBJECTIVES: Early onset severe pre-eclampsia is ideally managed in a tertiary setting. We investigated the possibility of safe management at secondary level, in close co-operation with the tertiary centre. DESIGN: Prospective case series over 39 months. SETTING: Secondary referral centre. POPULATION: All women (n= 131) between 24 and 34 weeks of gestation with severe pre-eclampsia, where both mother and fetus were otherwise stable. METHODS: After admission, frequent intensive but non-invasive monitoring of mother and fetus was performed. Women were delivered on achieving 34 weeks, or if fetal distress or major maternal complications developed. Transfer to the tertiary centre was individualised. MAIN OUTCOME MEASURES: Prolongation of gestation, maternal complications, perinatal outcome and number of tertiary referrals. RESULTS: Most women [n= 116 (88.5%)] were managed entirely at the secondary hospital. Major maternal complications occurred in 44 (33.6%) cases with placental abruption (22.9%) the most common. One maternal death occurred and two women required intensive care admission. A mean of 11.6 days was gained before delivery with the mean delivery gestation being 31.8 weeks. The most frequent reason for delivery was fetal distress (55.2%). There were four intrauterine deaths. The perinatal mortality rate (> or =1000 g) was 44.4/1000, and the early neonatal mortality rate (> or =500 g) was 30.5/1000. CONCLUSIONS: The maternal and perinatal outcomes are comparable to those achieved by other tertiary units. This model of expectant management of early onset, severe pre-eclampsia is encouraging but requires close co-operation between secondary and tertiary institutions. Referrals to the tertiary centre were optimised, reducing their workload and costs, and patients were managed closer to their communities.