Reducing maternal deaths by skills-and-drills training in managing obstetric emergencies: A before-and-after observational study.

BACKGROUND: The institutional maternal mortality ratio (iMMR) in South Africa (SA) is still unacceptably high. A key recommendation from the National Committee on Confidential Enquiries into Maternal Deaths has been to improve the availability and quality of care for women suffering obstetric emergencies. OBJECTIVES: To determine whether there was a change in the number of maternal deaths and in the iMMR over time that could be attributed to the training of >80% of healthcare professionals by means of a specifically designed emergency obstetric care (EmOC) training programme. METHODS: A before-and-after study was conducted in 12 healthcare districts in SA, with the remaining 40 districts serving as a comparison group. Twelve 'most-in-need' healthcare districts in SA were selected using a composite scoring system. Multiprofessional skills-and-drills workshops were held off-site using the Essential Steps in Managing Obstetric Emergencies and Emergency Obstetric Simulation Training programme. Eighty percent or more of healthcare professionals providing maternity care in each district were trained between October 2012 and March 2015. Institutional births and maternal deaths were assessed for the period January 2011 - December 2016 and a before-and-after-training comparison was made. The number of maternal deaths and the iMMR were used as outcome measures. RESULTS: A total of 3 237 healthcare professionals were trained at 346 workshops. In all, 1 248 333 live births and 2 212 maternal deaths were identified and reviewed for cause of death as part of the SA confidential enquiries. During the same period there were 5 961 maternal deaths and 5 439 870 live births in the remaining 40 districts. Significant reductions of 29.3% in the number of maternal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.66 - 0.77) and 17.5% in the number of maternal deaths from direct obstetric causes (RR 0.825, 95% CI 0.73 - 0.93) were recorded. When comparing the percentage change in iMMR for equivalent before-and-after periods, there was a greater reduction in all categories of causes of maternal death in the intervention districts than in the comparison districts. CONCLUSIONS: Implementing a skills-and-drills EmOC training package was associated with a significant reduction in maternal deaths.

Midwife-led obstetric units working 'CLEVER': Improving perinatal outcome indicators in a South African health district.

BACKGROUND: South Africa did not meet its Millennium Development Goals with regard to the reduction in maternal and under-5 mortality. Furthermore, many birthing women do not receive intrapartum care with empathy and endure disrespect-ful and abusive care. OBJECTIVES: To implement a multicomponent, context-specific intervention package to change the complex interplay between preventable maternal and perinatal mortality and morbidity and poor clinical governance and supervision in midwife-led labour units. METHODS: A mixed-methods intervention study was conducted in Tshwane District, South Africa, in 10 midwife-led obstetric units (MOUs), from which a purposive sample consisting of five units was selected for the intervention. The intervention took place in three phases: (i) baseline measurement; (ii) implementation of the so-called 'CLEVER' intervention package in the five intervention units, based on the results of the first phase; and (iii) a review of health systems improvements and perinatal outcomes. The intervention had three pillars: (i) feedback of the baseline measurement to the intervention units to raise awareness and solicit participation; (ii) health systems strengthening; and (iii) intensive weekly engagement for 3 months, with further monthly support afterwards. Observation of barriers during baseline activities contributed to the health systems strengthening and improvement strategies during implementation. RESULTS: Perinatal outcome indicators for the year before the intervention were compared with data for the year in which the intervention took place and the year after the intervention. Significant declines were observed in in-facility fresh stillbirths, meconium aspiration and birth asphyxia in the intervention MOUs from 2015 to 2017. The control group showed some decline during the period owing to support from district clinical specialist team members. CONCLUSIONS: CLEVER as a context-specific, multicomponent, clinically focused intervention package may have contributed to improved perinatal morbidity and mortality rates in MOUs.

Obstetrics knowledge and skills training as a catalyst for change.

BACKGROUND: Poor emergency obstetric care has been shown by national confidential enquiries into maternal deaths to contribute to a number of maternal deaths in South Africa. OBJECTIVES: To assess whether a structured training course can improve knowledge and skills and whether this can influence the capacity of a healthcare facility to provide basic and comprehensive emergency obstetric care signal functions. METHODS: A baseline survey was conducted to assess the seven basic emergency obstetric and neonatal care signal functions in 51 community health centres (CHCs) and the nine comprehensive emergency care signal functions in 62 district hospitals (DHs). A re-assessment was conducted 1 year after saturation training had been provided in each district. The delegates were trained using a structured training programme (Essential Steps in Managing Obstetric Emergencies, ESMOE) and their knowledge and skills were tested before and after the training. Saturation training was considered to have been achieved once 80% of the healthcare professionals involved in maternity care had been trained. RESULTS: There was a significant improvement in the knowledge and skills of doctors, namely by 16.8% and 32.8%, respectively, of advanced midwives by 13.7% and 29.0%, and of professional nurses with midwifery by 16.1% and 31.2%. The seven basic emergency care functions improved from 60.8% to 67.8% in the CHCs and from 90.7% to 92.5% in the DHs before and after training. If the two signal functions that are not within the scope of practice of professional nurses with midwifery are excluded (viz. assisted delivery and manual vacuum aspiration), the functionality of CHCs increased from 85.1% to 94.9%. CONCLUSIONS: The ESMOE training programme improved knowledge and skills, but there was a modest improvement in the functionality of the facilities. Improvement in functionality requires changes in the structure of the health system, including changing the scope of practice of professional nurses with midwifery and employing more advanced midwives in CHCs.

Systems thinking: A turning point for improving respectful obstetric care in South African health districts.

Poorly functioning health systems and local health systems barriers affect many women giving birth in low- and middle-income countries. The district clinical specialist teams in South Africa are uniquely positioned to provide facilitation and mentoring during interventions for improving the weak primary healthcare system. To ensure success, four key principles should be considered during scale-up of interventions: systems thinking and awareness of contexts and barriers; a focus on sustainability; harnessing factors known to enhance scalability; and respect for human rights and equity. Asking the right questions about the responsibilities of health systems at the micro-, meso- and macro-levels will benefit scale-up processes and sustain innovative pathways to high-quality obstetric care in communities.

Progress with the implementation of kangaroo mother care in four regions in Ghana.

AIM: To measure progress with the implementation of kangaroo mother care (KMC) for low birth-weight (LBW) infants at a health systems level. DESIGN: Action research design, with district and regional hospitals as the unit of analysis. SETTING: Four regions in Ghana, identified by the Ghana Health Service and UNICEF. PARTICIPANTS: Health workers and officials, health care facilities and districts in the four regions. INTERVENTION: A one-year implementation programme with three phases: (1) introduction to KMC, skills development in KMC practice and the management of implementation; (2) advanced skills development for regional steering committee members; and (3) an assessment of progress at the end of the intervention. MAIN OUTCOME MEASURES: Description of practices, services and facilities for KMC and the identification of strengths and challenges. RESULTS: Twenty-six of 38 hospitals (68%) demonstrated sufficient progress with KMC implementation. Half of the hospitals had designated a special ward for KMC. 66% of hospitals used a special record for infants receiving KMC. Two of the main challenges were lack of support for mothers who had to remain with their LBW infants in hospital and no follow-up review services for LBW infants in 39% of hospitals. CONCLUSIONS: It was possible to roll out KMC in Ghana, but further support for the regions is needed to maintain the momentum. Lessons learned from this project could inform further scale-up of KMC and other projects in Ghana.

Does kangaroo mother care save lives?

To assess the impact of the introduction of kangaroo mother care (KMC) in hospitals using the Perinatal Problem Identification Programme (PPIP) in South Africa, a survey was conducted of the PPIP sentinel sites in South Africa requesting information on the practice of KMC in the hospital and if practised, when it had been initiated. Data on live births and the neonatal deaths of infants weighing between 1000 and 1999 g for each institution were obtained from the national PPIP database and, where applicable, divided into two periods, before and after the introduction of KMC. The practice of KMC and PPIP data could be combined for 40 of the hospitals that had responded to the survey. Of these, eight hospitals had not initiated KMC by January 2005, 21 had PPIP data for a period after KMC had commenced and 11 had PPIP data for periods before and after the introduction of KMC. The neonatal death rate (NNDR) for all hospitals with no KMC or before the introduction of KMC was 88.14/1000 live births, whereas the NNDR for hospitals with KMC or after the introduction of KMC was 71.43/1000 live births [relative risk (RR) 0.81; 95% confidence interval (CI) 0.72-0.91]. For the 11 hospitals that had reliable PPIP data for periods before and after the initiation of KMC, the NNDR was 87.72/1000 live births before KMC and 60.76/1000 live births after KMC had been introduced (RR 0.62; 95% CI 0.53-0.73). The large and significant reduction in the NNDR of neonates weighing between 1000 and 1999 g was associated with the introduction of KMC.

Medical students' perceptions of their development of `soft skills' Part I : A qualitative research methodology

Background: Following the introduction of a new; integrated; problem-oriented undergraduate medical curriculum at the University of Pretoria (UP) in 1997; a research project was undertaken to study interpersonal skills; professional attitudes; teamwork; ethics and related topics - which have come to be known collectively as `soft skills'. This contribution is the first of two articles on the professional socialisation of medical students and their development of `soft skills'. It describes the particular qualitative methodology developed for; and applied to; the study of soft skills among medical students at UP. Methods: This paper describes the aim of the study; reasons for adopting a qualitative research approach to achieve this aim; the theoretical orientation underpinning the qualitative approach that we considered most suitable; the design; the sampling; the data management and analysis; and the methods that we deployed to ensure the credibility of the findings. Research Design: The aim of the study was to explore the subjective meanings that students attributed to soft skills; as they understood them. These subjective meanings involve the way students interact meaningfully with fellow students; lecturers and other individuals participating in the medical and clinical education programme; and the way they construct shared conceptualisations of soft skills and medical education in their lives and social world. A qualitative approach was considered most appropriate; as this study set out to uncover subjective and diverse meanings that do not necessarily amount to generalisable truths. The particular qualitative strategy or design used was that of an extended case study; or `casing'; within the modernist theoretical orientation of symbolic interactionism. Elements of process evaluation were incorporated into the design to account for the process of curriculum reform within which this study was embedded.We recruited participants for this study from two cohorts of students. The first group; who completed their studies in 2001; had followed the traditional curriculum; while the second group; who completed their programme in 2002; had followed the reformed curriculum. The data collection tools were face-to-face individual interviews; focused group interviews and solicited autobiographical sketches. The utilisation of more than one method or data source enabled triangulation or cross-checking of findings. We followed an inductive reasoning approach; which means that we did not search for data to test any hypotheses that had been formulated prior to commencing the study; but focused instead on building constructs that were grounded in or reflected intimate familiarity with the students' world. Conclusion:The modernist qualitative research approach enabled us to uncover; describe and illuminate the subjective points of view on soft skills as expressed by final-year medical students before and after curriculum reform. More specifically; by carrying out an extended case study we were able to perform a process evaluation of the curriculum reform in terms of soft skills and the professional socialisation of the students. This paper outlines how qualitative research methods enabled us to capture and explore aspects of the inner life (social worlds) of these students. Whether they would be the same; similar or different in another setting are questions for further exploration or research - questions prompted by our study in a manner that illuminates the qualities that may be inherent in these subjective meanings

Medical students' perceptions of their development of 'soft skills' Part II: the development of 'soft skills' through 'guiding and growing'

Background: This paper reports on medical students' views on the ways in which their `soft skills' were developed. It is the result of a study on soft skills among two groups of students before and after curriculum reform at the School of Medicine of the University of Pretoria. One of the aims of the reform was to provide more teaching and learning opportunities for the development of soft skills. Soft skills include professional interpersonal and social skills; communication skills; and professional and ethical attitudes.Methods: As symbolic interactionism was used as the theoretical framework to guide the research; qualitative methods were used to collect the data. A purposive-theoretical sample of 42 final-year medical students from the traditional curriculum and 49 from the reformed curriculum was recruited. Data were collected by means of focus groups; individual in-depth interviews and autobiographical sketches.ResultsThe same categories of comments emerged from the data collected from the study participants from both the traditional and the reformed curriculum. The students ascribed their behaviour related to soft skills to personality and innate features. They had varying opinions on whether soft skills could be taught; but there was as a strong feeling that teaching should focus on principles and guidelines for dealing with difficult situations. They believed that; in the end; they should take responsibility for their own development of soft skills. Most participants felt they could at least grow through exposure to teaching activities and the observation of role models. They also indicated that they had developed their soft skills and constructed their own identity through their interaction with others. Their definition of situations was shaped by their interactions with doctors and educators; fellow students and other health professionals. Interaction with patients was considered the most important. For both groups of students their third year was a watershed; as it is the first year of more intensive patient contact and the beginning of serious learning from interaction with patients. The views on the development of soft skills differed very little between the traditional and reformed curriculum groups; except that students who had followed the reformed curriculum felt more prepared through the increased teaching and training efforts. Further consideration needs to be given to the intention of the changed curriculum compared to the actual effect.The way in which the participants in the study described their development of soft skills could be categorised as a complex interplay between `being' and `becoming'. Instead of using the word `acquisition' of soft skills; `development' seemed to be more appropriate. The metaphor of `guiding' and `growing' also captures the development of these skills better than the terms `teaching' and `learning'. Conclusion: Teaching activities in the clinical years should be adapted with a view to facilitating the students' professional growth. New models for the development of medical educators should be created and institutional barriers should be investigated

Medical Students' Perceptions of their Development of 'Soft Skills' - Part I: A qualitative Research Methodology

Background: Following the introduction of a new; integrated; problem-oriented undergraduate medical curriculum at the University of Pretoria (UP) in 1997; a research project was undertaken to study interpersonal skills; professional attitudes; teamwork; ethics and related topics - which have come to be known collectively as 'soft skills'. This contribution is the first of two articles on the professional socialisation of medical students and their development of 'soft skills'. It describes the particular qualitative methodology developed for; and applied to; the study of soft skills among medical students at UP.Methods: This paper describes the aim of the study; reasons for adopting a qualitative research approach to achieve this aim; the theoretical orientation underpinning the qualitative approach that we considered most suitable; the design; the sampling; the data management and analysis; and the methods that we deployed to ensure the credibility of the findings.Research Design: The aim of the study was to explore the subjective meanings that students attributed to soft skills; as they understood them. These subjective meanings involve the way students interact meaningfully with fellow students; lecturers and other individuals participating in the medical and clinical education programme; and the way they construct shared conceptualisations of soft skills and medical education in their lives and social world. A qualitative approach was considered most appropriate; as this study set out to uncover subjective and diverse meanings that do not necessarily amount to generalisable truths. The particular qualitative strategy or design used was that of an extended case study; or 'casing'; within the modernist theoretical orientation of symbolic interactionism. Elements of process evaluation were incorporated into the design to account for the process of curriculum reform within which this study was embedded. We recruited participants for this study from two cohorts of students. The first group; who completed their studies in 2001; had followed the traditional curriculum; while the second group; who completed their programme in 2002; had followed the reformed curriculum. The data collection tools were face-to-face individual interviews; focused group interviews and solicited autobiographical sketches. The utilisation of more than one method or data source enabled triangulation or cross-checking of findings. We followed an inductive reasoning approach; which means that we did not search for data to test any hypotheses that had been formulated prior to commencing the study; but focused instead on building constructs that were grounded in or reflected intimate familiarity with the students' world.Conclusion: The modernist qualitative research approach enabled us to uncover; describe and illuminate the subjective points of view on soft skills as expressed by final-year medical students before and after curriculum reform. More specifically; by carrying out an extended case study we were able to perform a process evaluation of the curriculum reform in terms of soft skills and the professional socialisation of the students. This paper outlines how qualitative research methods enabled us to capture and explore aspects of the inner life (social worlds) of these students. Whether they would be the same; similar or different in another setting are questions for further exploration or research - questions prompted by our study in a manner that illuminates the qualities that may be inherent in these subjective meanings

Development of a conceptual tool for the implementation of kangaroo mother care.

AIM: To develop a conceptual tool to assist healthcare workers and management in the implementation of a kangaroo mother care programme. METHODS: A qualitative research approach was followed and methods included on-site observations and informal conversational interviews, as well as unstructured, in-depth interviews with senior managers, doctors and nurses at two large training hospitals in the north of South Africa. A consultative process was used to refine the tool. RESULTS: The patterns that emerged from the data were captured in a diagram, entitled: "Main issues in the establishment of kangaroo mother care". In addition, a set of core questions was developed to assist in decision-making at institutional level. CONCLUSION: The diagram and questions contain concepts that could be adapted and used by a healthcare facility's multidisciplinary team in planning the implementation of kangaroo mother care and in reviewing the progress made in the implementation and the quality of the kangaroo mother care provided.

Obstacles to and motivation for successful breast-feeding.

This study determined obstetric physiotherapists' perceptions about major obstacles to and methods of motivation for successful breast-feeding by means of the Friedman non-parametric procedure for the two-way analysis of variance. Three categories of obstacles were identified: maternal obstacles, health professionals and society. Maternal obstacles mentioned most were insufficient motivation (25%) and knowledge (24%), anxiety (14%), fatigue (14%), and employment (14%). Obstacles related to health professionals included lack of support for mothers (20%), inappropriate lactation management (19%), lack of knowledge (15%), negative attitudes (5%), and staff shortages (5%). With regard to society, lack of support (27%) and life-styles (29%) were identified as significant obstacles. The two most significantly important methods of motivation were information and education (53%) and contact with other breast-feeders (27%). It is concluded that breast-feeding education efforts can be improved by identifying obstacles to breast-feeding and methods of motivation and that the Friedman test may be a statistical procedure to consider for determining priorities.

Sexually transmitted disease surveillance in a child abuse clinic.

The sexually transmitted disease surveillance system instituted at the Child Abuse and Neglect (CAN) clinic of the Transvaal Memorial Institute for Child Health and Development was evaluated after 1 year. The presenting complaint of the vast majority of the 227 patients was sexual abuse. In more than half (52%), child abuse was medically proven, and it was highly suspected in another 18%. In only 6% did no abuse take place. About half the patients suffered non-penetrative sexual abuse, 40% penetrative abuse and 10% suffered non-sexual abuse. Smears for gonorrhoea were positive in 2 out of 152 patients; for Chlamydia in 1 out of 140; for Gardnerella and Trichomonas in 2 and 1 case, respectively. Syphilis serology yielded 3 positive results out of 162, and hepatitis B, 6 out of 143. No positive results were found in tests for HIV and herpes. With the exception of hepatitis B tests, all positive results occurred in children considered on clinical grounds to have medically proven or highly suspected sexual abuse. These results will allow modification of the surveillance system and testing of those children more likely to test positive, while doing fewer tests overall.

Breast-feeding practices in a private maternity hospital.

An interview questionnaire study of 51 breast-feeding mothers was conducted to assess the stated policy of breast-feeding promotion in a private maternity hospital. A mean period of 20.6 hours elapsed after delivery before initiation of breast-feeding, and 39.9 hours elapsed before rooming-in took place. At least 47.1% of babies received prelacteal feeds, 94.1% were routinely test-weighed, and 56.9% received complementary feeds. A patient-administered questionnaire is proposed to provide hospital management and attendant medical practitioners with essential feedback that could assist them to close the gap between policy and practice.