A 50-year audit of maternal mortality in the Peninsula Maternal and Neonatal Service, Cape Town (1953-2002).

OBJECTIVE: To audit trends in maternal mortality in the Peninsula Maternal and Neonatal Service (PMNS) over a 50-year period, with respect to rates and patterns of causation. DESIGN: Retrospective and prospective audit. SETTING: The PMNS, an integrated perinatal service composed of primary, secondary and tertiary facilities in Cape Town. Population All women giving birth in the area of the Cape Peninsula served by the PMNS over the 50-year period. METHODS: Data on maternal deaths were collected for 1953-2002 inclusive, from annual obstetric and gynaecological reports. Three triennia (1954-1956, 1981-1983 and 1999-2001) were selected for a detailed comparison of trends in rates and causes of death. MAIN OUTCOME MEASURES: Maternal mortality rates (MMRs). Causes of maternal deaths. RESULTS: Total deliveries increased from 7315 in 1953 to 27,575 in 2002. The MMR declined from 301 deaths per 100,000 deliveries in 1953 to 31.2 in the triennium, 1987-1989. From 1999, the MMR increased, reaching 112 in 2002. Comparing 1954-1956 (MMR of 253.9) with 1981-1983 (MMR of 43.8), there was a marked decline in the MMR related to hypertension (80.4 to 11.3), haemorrhage (50.8 to 4.2), abortion (55 to 4.2), suspected pulmonary embolism (25.4 to 2.8), pregnancy-related sepsis (8.5 to 4.2) and cardiac disease (21.2 to 2.8). Comparing 1981-1983 (MMR of 43.8) with 1999-2001 (MMR of 59.4), there was a decline in the MMR associated with abortion (4.2 to 0). The MMR for haemorrhage, suspected pulmonary embolism and cardiac disease remained the same. There was a slight increase in the MMR attributed to hypertension (11.3 to 14.5) and pregnancy-related sepsis (4.2 to 7.3). There was a marked increase in the MMR associated with non-pregnancy-related infections/AIDS (4.2 to 18.2). CONCLUSIONS: The MMR for all causes of maternal death declined significantly from 1953 to 1981 as a result of several interventions. From 1999, there has been a non-significant increase in MMR, predominantly due to the burden of HIV/AIDS-related mortality.

Implementing the differentiated pay structure model. Process and outcomes.

OBJECTIVE: A salaried Differentiated Pay Structure (DPS) model based on the work of Dr. Virginia Cleland was tested on two units. The project objectives were to: 1) create a budget-neutral compensation distinction for different competencies and educational levels; 2) evaluate the effect of the new salaried model on unit costs and pay; 3) determine the effect of the DPS model on job satisfaction, organizational commitment, and anticipated turnover; and 4) assess the impact of professional commitment, professional practice climate, perception of staffing adequacy, and dispositional optimism on job satisfaction, organizational commitment, and anticipated turnover. BACKGROUND: Although there has been long-standing interest in salaried models and reward methodologies, there is a dearth of systematic research associated with specific compensation models. METHODS: A quasi-experimental, non-equivalent control group design was used to examine the effects of the DPS model. RESULTS: Findings demonstrated that nurses were paid more under the DPS model, and that they were paid for more hours than they actually worked (N = 68). No difference in job satisfaction was found between experimental and control groups. For all nurses (N = 232) dispositional optimism was associated with all job satisfaction subscales except pay. Organizational commitment, professional commitment, professional practice climate, and staffing adequacy were also correlated with job satisfaction, perceptions of care quality and anticipated turnover. Older nurses who had worked longer in nursing, and who had more tenure were less satisfied with their coworkers and care quality. CONCLUSION: Further longitudinal research with larger experimental samples is required in order to fully understand the effects of the DPS model in nursing.

The prevalence of domiciliary deliveries in Khayelitsha, Cape Town.

OBJECTIVE: To determine whether the 17% decrease in the number of patients cared for at the Khayelitsha Midwife Obstetric Unit (MOU) between 1991 and 1994 could be ascribed to an increase in home deliveries. METHOD: Survey of Khayelitsha labour ward records, vaccination cards and family planning statistics at various clinics in Khayelitsha, Cape Town. RESULTS: The prevalence of home deliveries in Khayelitsha during the study period was estimated at 8%. Between 1992 and 1994, the number of acceptors at family planning clinics in Khayelitsha increased by 89%. CONCLUSION: As the number of home deliveries had apparently remained static, it was unlikely that an increase in the former had been responsible for the observed decrease in Khayelitsha MOU patients. Other possible reasons for the decline, viz. (i) an increase in hospital deliveries; (ii) an increase in the number of patients returning to the so-called homelands to be delivered there; (iii) an increase in confinements by private doctors and midwives; and (iv) that patients had shunned the MOU, were equally unlikely. The decline in the number of patients cared for at Khayelitsha MOU between 1991 and 1994 was most likely due to the evident success of the local family planning programme.

Referrals for inadequate progress of labour from the midwife obstetric units to the referral hospitals in Cape Town.

Referrals for inadequate progress of labour from the Midwife Obstetric Units (MOUs) to the referral hospitals are responsible for a significant part (approximately 5%) of the workload of these institutions in the Peninsula Maternal and Neonatal Service Region in Cape Town. It is essential for the maintenance of community credibility in the MOUs that patients who develop complications are timely and speedily transferred to the appropriate referral hospital. A sample of 251 patients, who were transferred from the MOUs to the referral hospitals for inadequate progress of labour in the first half of 1992, was analysed. The study showed that midwives in the MOUs had largely adhered to the Departmental referral criteria for that potentially serious complication of labour and had kept excellent records. The referrals, in terms of eventual outcome for the patients and their infants, had been largely appropriate. Several areas of concern were identified. These included incomplete assessment of the stage of labour on admission and inadequate monitoring of the fetal heart in a number of patients. Provision of analgesia in labour was generally inadequate. Ambulance delay was disturbingly common. Recommendations for measures to redress these management deficiencies are presented.

Provision of a community perinatal service in a developing country.

PIP: In 1980, a community perinatal service (CPS) facility was developed by the University of Cape Town in South Africa. This Peninsula Maternal and Neonatal Service (PMNS) is a model for understanding the objectives and essential requirements for the provision of a CPS. The goals of a CPS are to 1) use a single authority to provide integrated perinatal and family planning (FP) services for all women in a defined geographic area, 2) reduce infant morbidity and mortality to acceptable levels, 3) promote FP and a 2-child norm, and 4) provide education to staff, patients, and the community. A CPS must have a tiered system of perinatal care which has midwife obstetric units (MOUs) as the first level, secondary hospitals as the second, and tertiary hospitals as the third. The MOUs are centered around midwives, with a doctor available as a consultant to the midwives and as a provider of continuing education (CE) to the staff and patients. Staff CE takes place in perinatal mortality meetings, case discussions, orientation classes, refresher courses, outreach programs, and formal CE programs and journals. A loose-leaf, self-instructional perinatal education program is being developed to provide up-to-date information for every midwife and doctor. The midwives also may attend triennial congresses in Cape Town. The objective of patient education is to develop mothers as monitors of their own health and that of their fetuses and newborns. Patient education is achieved through the use of posters, lectures, and audiovisual programs. A CPS also needs appropriate equipment (a list is available from the World Health Organization). The CPS comprehensive referral system must cover all criteria and be respected throughout the region. The criteria must be updated regularly. Adequate communication channels and transportation facilities are also necessary to insure that a patient is transferred under the best conditions. Regular audits are essential and require accurate record keeping. Finally, a CPS must have the support of its community. During its 18 years of operation, the PMNS has 1) developed a very cost-effective system of perinatal care, 2) developed the concept of the MOU as an accessible, affordable, and appropriate primary care facility, 4) channeled low-risk patients from hospitals to MOU care (50% of 29,000 deliveries in 1991 took place in MOUs which have approximately 15% of the beds), 5) curtailed antenatal visits of low-risk patients without maternal or perinatal jeopardy, 6) established protocols for safe delivery in MOUs for medium-risk patients, 7) continued lowering the maternal mortality rate, and 8) achieved community acceptance. Failures are 1) an increase in the number of unbooked patients and infants born before arrival, 2) a static and rising perinatal mortality rate (largely caused by untreated syphilis), and 3) a lack of community involvement. These failures are likely caused by escalating workloads from the 3 informal settlements outside of Cape Town. Overall, the PMNS provides a blueprint for cost effective delivery of perinatal health care for developing and developed countries alike.^ieng

The antenatal prevention of congenital syphilis in a peri-urban settlement.

The obstetric records of patients from Khayelitsha were examined to assess the efficiency of a system for the antenatal prevention of congenital syphilis, and to identify points of breakdown in the process. Seventy-seven (12.7%) of 607 mothers had serological evidence of syphilis, including 10 (32.3%) of 31 mothers who had received no antenatal care. Of 70 patients who required routine management, only 36 (51.4%) received 3 or more of the recommended 4 penicillin injections. Two main weaknesses in the system were identified. One was the centralisation of serological testing. This delayed results reaching the relevant unit, and was responsible for a high cumulative attrition of patients during the many stages necessitated by the centralised testing. The other was a 24.5% attrition of patients referred from the antenatal clinic to a separate sexually transmitted diseases clinic.

The Nursing Practice Personnel Data Set. Implications for professional practice systems.

Existing data about nursing practice personnel has been found to be fragmented, incomplete, and non-uniform. These shortcomings can severely hamper administrative decision making related to professional practice systems in general, and differentiated pay and practice models in particular. The Nursing Personnel Practice Data Set (NPPDS) is designed to remedy these deficiencies by providing available, accessible, reliable, and comparable data about nursing personnel. The authors describe elements of the NPPDS and discuss implementation aims.

The relative risks of caesarean section (intrapartum and elective) and vaginal delivery: a detailed analysis to exclude the effects of medical disorders and other acute pre-existing physiological disturbances.

OBJECTIVE: To compare maternal mortalities attributable to vaginal delivery, elective caesarean section (CS) and intrapartum CS. DESIGN: The number of deaths associated with each method of delivery was ascertained among unselected and among low-risk women by detailed retrospective review of the case-notes of women who died after delivery. The frequency of each method of delivery throughout the study period was ascertained from the computer database and enhanced by analysis of the case-notes of unselected groups of women. SETTING: The Peninsula Maternity Services (Cape Town) during the years 1975-1986 inclusive. SUBJECTS: A total of 108 maternal deaths arising from 263,075 maternities provided accurate information. The relative frequency of vaginal and abdominal delivery was determined from the computer database. The ratio of elective CS to emergency prepartum CS to intrapartum CS was obtained by review of the first 200 operations in the years 1975, 1977, 1979, 1982 and 1984. MAIN OUTCOME MEASURES: (i) Mortality rates associated with the different methods of delivery in unselected women and in women who were healthy before surgery; (ii) mortality rates apparently attributable to the method of delivery. RESULTS: The overall relative risk of mortality associated with caesarean section compared with vaginal delivery was 7 decreasing to 5 after the exclusion of women with medical or life-threatening antenatal complications (eg, haemorrhage, hypertension). The relative risk associated with intrapartum compared with elective sections was 2.3 decreasing to 1.4 after the exclusion of women with medical disorders or life-threatening complications. The relative risk of maternal mortality which was apparently attributable to intrapartum compared with elective sections was 1.7. However, the 95% confidence intervals of these values, even from this large data-set, are wide. Nevertheless, these rates are in broad agreement with an approximation derived from the British confidential enquiries into maternal deaths. CONCLUSION: The attributable relative mortalities of caesarean section compared with vaginal delivery and intrapartum compared with elective caesarean section are lower than the overall relative mortalities of these modes of delivery and are approximately 5:1 and 1.5:1 respectively. These data are crucially important in the decision to recommend elective caesarean section compared with trial of labour.

The Planned Parenthood Association of Southern Africa.

PIP: The chairman's report for the period April 1, 1988-March 31, 1989 is presented detailing the main events of a year. An AIDS education and prevention program was developed at the request of the Life Offices' Association. The Annual General Meeting of the Western Cape Region was held at Groote Schuur Hospital in May 1988. The name of the Family Planning Association of South Africa was officially changed to The Planned Parenthood Association of Southern Africa. A resolution was adopted on the award of Honorary Life Membership of the Western Cape Region. The Regional Office moved to a new location with roomier accommodation. Among educational programs lectures and workshops continued for the public. Some white schools cancelled sex education programs, but demand from colored schools increased, although involvement was still limited. Programs for youth and children continued unabated, and the Claremont Teenage clinic was transferred to new management. The national chairman paid a visit to the region. A report on family planning covering 1977-1988 elicited some negative comments. The decline of colored teenage births in Cape Town was reversed in 1987; there were 300 countries, 16% higher than in 1986. In 1988 hospitals in the regions reported 2937 female and male sterilizations, an increase over the average of the previous 7 years. Various youth and adults projects were envisioned for 1989/1990 whose realization depended on funding.^ieng

Patient classification system evaluation: Part 2, System selection and implementation.

How can nurse executives assure optimum patient classification system performance? This two-part series advances a framework for patient classification system (PCS) evaluation. Using an expanded definition of a PCS, Part One (JONA, June) presented a discussion of the six system elements considered essential to a fully operational PCS. Part Two offers a description of PCS selection criteria as well as keys to successful system implementation. Application of this evaluation framework allows for rapid problem identification and remediation, assists with PCS selection and enhances overall system performance.

Patient classification system evaluation. Part 1: Essential system elements.

How can nurse executives assure optimum patient classification system performance? This two-part series advances a framework for patient classification system (PCS) evaluation. Using an expanded definition of a PCS, part one presents a discussion of the six system elements considered essential to a fully operational PCS. Part Two offers a description of PCS selection criteria as well as keys to successful system implementation. Application of this evaluation framework allows for rapid problem identification and remediation, assists with PCS selection, and enhances overall system performance.

Perinatal health in the peri-urban township of Khayelitsha, Cape Town. Part I. Mothers and their newborn infants.

The satellite 'city' of Khayelitsha lies some 40 km south-east of the centre of metropolitan Cape Town. The first phase of the development, Town 1, including a large 'squatter' area, accommodates approximately 150,000 people at present. It is envisaged that ultimately the entire 3,200 ha site will house between 250,000 and 350,000 people. In order to obtain useful planning information for future community obstetric and neonatal health care services, a survey of all births within the Peninsula Maternal and Neonatal Service (PMNS) during 1986 was undertaken. Of a total of 2,113 mothers from Khayelitsha, 2,000 (94.7%) gave birth to a live singleton infant. The mean maternal age was 26.2 years, 15.1% of mothers being under 20 years of age. The mean parity was 3.03, and 18.3% of mothers were having their first baby. Only 3.1% of mothers booked early (in the first trimester); however, 91.9% were booked before delivery. The average number of prenatal visits was 3. The largest proportion of mothers (43.1%) delivered at the Heideveld midwife obstetric unit (MOU). There was an overall pre-term rate of 7.6%, while 8.8% of infants were of low birth weight (LBW) (less than 2,500 g). In addition, 51.4% of the LBW infants were born at term. The mean birth weight was 3,160 g. The largest proportion of mothers (53.6%) were residents of the 'squatter' area. No statistically significant differences in obstetric features, maternal characteristics and pregnancy outcome were discernible between the squatter, site-and-service, and core housing areas of Khayelitsha, with the exception of higher maternal weight, earlier booking and more antenatal visits in the group from the core housing area.

Perinatal health in the peri-urban township of Khayelitsha, Cape Town. Part II. Infant mortality.

Estimates of infant mortality suggest that the rate during the past 14 years for families living in Khayelitsha at present was approximately 130-160/1,000. In contrast, the infant mortality rate for infants born in Khayelitsha during 1986 was 50.3/1,000. The highest rates occurred in the post-neonatal period in 'squatter' families, infection being a common cause of death. Mortality rates should fall further with improved housing.

The Cape Town Teenage Clinic.

Over a 6-month period 265 white females aged under 24 years attending the Teenage Clinic of the Western Cape Region of the Family Planning Association were interviewed at their first visit; 81% were sexually active. The age of menarche and the parents' marital status were important parameters of socio-sexual behaviour. The earlier the menarche, the higher the prevalence of coitus at a younger age, and the shorter the interval between menarche and the first coitus. Young age at first coitus, in turn, was associated with a higher prevalence of multiple sexual partners and smoking, and a longer period of unprotected intercourse before attending the clinic than among those who first attempted intercourse at a later age. Of those who had first experienced coitus at under 17 years, 37% came from single-parent families, compared with 12% of those in whom coitus was delayed until over 19 years of age. The important health and educational implications are discussed.

The obstetric scene in Cape Town, 1974-1983. A ray of demographic hope.

The age and parity distributions of all black and coloured maternity patients whose babies were delivered by the Peninsula Maternal and Neonatal Service in Cape Town in 1974 were compared with those for the trienniums 1978 - 1980 and 1981 - 1983. The numbers and percentages of teenage pregnancies, grand multiparas and pregnancies in women greater than 34 years were analysed. Over the decade there was no change in these three demographic parameters among blacks. In contrast there was a marked decline in the percentage and number of grand multiparas and a slight decrease in the percentage of women over 34 years among the coloured patients. The prevention of teenage pregnancies must remain the major demographic priority in Cape Town.