How SA is sav­ing its new­borns

Nurses and doc­tors are hit­ting the books to save in­fants’ lives — and it’s work­ing

Mail & Guardian - - Health - Pontsho Pi­lane and Laura López González

What started as a typ­i­cal Wed­nes­day in Jan­uary for Na­dine Mun­samy quickly turned into her worst night­mare.

“I got home from work just af­ter 5pm. I took a shower and I could feel my baby mov­ing lower, down into my ab­domen,” she re­calls.

She was 24 weeks preg­nant. Mun­samy, 28, had just re­lo­cated from Jo­han­nes­burg to Dur­ban to be closer to her fam­ily. She was liv­ing with her aunt, a re­tired nurse, in the suburb of Westville.

“I told her that my baby was mov­ing down and I asked if this was nor­mal.”

Her aunt be­came con­cerned and told Mun­samy to lie down on a bed with her legs raised. She placed her hands on Mun­samy’s stom­ach and be­gan mes­sag­ing it, hop­ing to calm the fe­tus.

But the baby was still in distress. Within an hour, Mun­samy’s aunt had her rushed to a nearby pri­vate hos­pi­tal from where she was trans­ferred to RK Khan, a gov­ern­ment fa­cil­ity in Chatsworth be­cause she didn’t have med­i­cal aid.

“The nurses prod­ded on my stom­ach to see how far along I was. They told me that I should start push­ing when I get the urge to do so,” Mun­samy re­calls.

Five hours later, there was still no baby.

Then, around 6 o’clock the next morn­ing, it hap­pened: Mun­samy gave birth to a baby boy. He was ex­tremely pre­ma­ture and weighed just 550g.

But al­most as soon as he ar­rived, he was rushed off to the hos­pi­tal’s neona­tal in­ten­sive care unit.

Glob­ally, about 14.9-mil­lion ba­bies were born pre­ma­turely or be­fore 37 weeks of preg­nancy, ac­cord­ing to re­search pub­lished in 2012 in The Lancet med­i­cal jour­nal. Stud­ies have shown that a range of fac­tors from al­co­hol abuse to HIV in­fec­tion and even obe­sity can lead to pre­ma­ture births. For ba­bies, this early de­but can put them at risk of a host of con­di­tions, es­pe­cially dif­fi­culty breath­ing be­cause of their un­der­de­vel­oped lungs, the 2012 re­search shows.

Be­ing born pre­ma­ture is also the sin­gle largest cause of death for new­born ba­bies, or in­fants who die within their first 28 days of life, a 2013 study in the jour­nal Re­pro­duc­tive Health re­veals.

Hours af­ter nurses rushed her baby into ICU, Mun­samy went to see him.

“His tiny body was just ly­ing there in the in­cu­ba­tor. There weren’t any ma­chines to help him breathe or any­thing,” she re­mem­bers.

Ba­bies like hers born weigh­ing less than one kilo­gram, doc­tors warned, rarely sur­vived. This means doc­tors make heart­break­ing choices as they triage in­fants, forc­ing them to al­lo­cate scarce re­sources such as in­cu­ba­tors to the ba­bies with the best chances of sur­viv­ing.

Doc­tors tried to pre­pare Mun­samy. “[The doc­tor] ex­plained to me that if an­other pre­ma­ture baby was born right now and weighed a kilo­gram or more, the hos­pi­tal would have to take my baby out of the in­cu­ba­tor,” she says.

At 11am, a nurse told Mun­samy that her son had died. His life had spanned just over four hours.

To­day, South Africa boasts the world’s largest an­tiretro­vi­ral (ARV) pro­gramme and, as the num­bers of peo­ple on HIV treat­ment rose, deaths among chil­dren un­der the age of five plum­meted, re­search pub­lished in the South African Med­i­cal Jour­nal (SAMJ) in March shows. Be­tween 2005 to 2015, deaths among this group fell by al­most half.

But death rates among new­born ba­bies de­liv­ered in pub­lic fa­cil­i­ties — mostly at district hospi­tals — haven’t changed much in the past decade. About 12 out of ev­ery 1000 ba­bies born alive will die be­fore the age of one month, the SAMJ re­search finds.

Un­sur­pris­ingly, pre­ma­tu­rity re­mains the lead­ing cause of these Top five causes of new­born deaths re­lated to the health sys­tem that were “prob­a­bly avoid­able”:

O In­ad­e­quate fa­cil­i­ties or equip­ment in neona­tal units;

O Hos­pi­tal-ac­quired in­fec­tions; O Fe­tal distress dur­ing labour;

O Women in need of higher level care not re­ferred in time; and

O Lack of avail­able neona­tal

ICU beds and ven­ti­la­tors. — Source: The South African Med­i­cal Jour­nal

deaths, which most of­ten hap­pen within the first week of life.

The SAMJ study com­pared a range of data on neona­tal deaths, in­clud­ing those from the na­tional health depart­ment, Sta­tis­tics South Africa and the Med­i­cal Re­search Coun­cil. It found se­ri­ous gaps in the in­for­ma­tion col­lected, par­tic­u­larly when ba­bies died af­ter leav­ing hos­pi­tal. But it also re­vealed that a lack of spe­cialised fa­cil­i­ties and equip­ment, as well as a dearth of in­ten­sive care unit (ICU) beds and ven­ti­la­tors, were among the top five pre­ventable and health sys­tem-re­lated causes of death among ba­bies.

SAMJ au­thors say the death rate of ba­bies such as Mun­samy’s re­mains “un­ac­cept­ably high” for a coun­try with South Africa’s re­sources.

It will be dif­fi­cult for the coun­try to re­duce new­born deaths to the lev­els seen by other mid­dlein­come coun­tries such as Mex­ico and Brazil, says Yo­gan Pil­lay, the na­tional health depart­ment’s deputy di­rec­tor gen­eral for com­mu­ni­ca­ble and non­com­mu­ni­ca­ble dis­ease preven­tion, treat­ment and re­ha­bil­i­ta­tion. These coun­tries have brought neona­tal death rates down to about eight deaths per 1000 live births, 2017 data from the United Na­tions Chil­dren’s Fund shows. Thai­land has done even bet­ter, slash­ing rates by more than half of that.

To join this club, South Africa would need to hire more pae­di­a­tri­cians and en­sure that all neona­tal wards have in­cu­ba­tors, piped oxy­gen, res­pi­ra­tors and trained staff, he says.

Since 2013, the na­tional health depart­ment has started train­ing health work­ers in bet­ter neona­tal care us­ing cur­ricu­lums such as the in­ter­na­tional Help­ing Ba­bies Breathe pro­gramme. Since it launched in 2010, Help­ing Ba­bies Breathe has been used in al­most 80 coun­tries — and in ev­ery coun­try in South­ern Africa, ac­cord­ing to a 2015 eval­u­a­tion.

De­signed by the Amer­i­can Academy of Pe­di­atrics, the pro­gramme is based on ev­i­dence eval­u­ated by a range of in­ter­na­tional ex­perts, in­clud­ing those from South­ern Africa. As part of the course, health work­ers learn what to do when new­borns are strug­gling to breathe, in­clud­ing help­ing to clear their air­ways and how to stim­u­late breath­ing.

In Tan­za­nia, the project sig­nif­i­cantly re­duced the num­ber of ba­bies who died within the first 24 hours of life in eight hospi­tals. In a large 2013 study pub­lished in the jour­nal Pe­di­atrics, re­searchers found that the train­ing pro­gramme slashed death rates even among in­fants who were more likely to die be­cause they were born pre­ma­turely or had a low birth rate.

Key to the pro­gramme is the con­cept of “the golden minute”, says the Lim­popo Ini­tia­tive for New­born Care on its web­site. The cen­tre, which started out as a part­ner­ship be­tween lo­cal uni­ver­si­ties, draws on the Help­ing Ba­bies Breathe pro­gramme as it helps pro­vin­cial health de­part­ments up­skill work­ers.

It’s the idea that, within 60 sec­onds of be­ing born, ev­ery baby should ei­ther be breath­ing well or be ven­ti­lated (breath­ing with as­sis­tance from health work­ers). Some­times this can mean health work­ers place a mask over the child’s face that is con­nected to a large bulb-shaped bag. Health work­ers can man­u­ally squeeze the bag to stim­u­late air flow into a baby’s lungs or masks can be con­nected di­rectly to oxy­gen sup­plies. Health work­ers will also use a small, cof­fee ma­chine-sized de­vice called a con­tin­u­ous pos­i­tive air­way pres­sure (CPAP) ma­chine. These ap­pa­ra­tuses use a stream of com­pressed air to de­liver oxy­gen into the lungs of peo­ple who can’t breathe on their own, Stand­ford Univer­sity in the United States ex­plains on its web­site.

But Western Cape-based paediatrician Alas­tair McAlpine says that, al­though these ma­chines are rel­a­tively sim­ple to use and in­ex­pen­sive, they are rarely avail­able out­side large ur­ban hospi­tals.

“The prob­lem with South African child health­care is that the ter­tiary hospi­tals are fan­tas­ti­cally man­aged and have all the lat­est bells and whis­tles, but out in the pe­riph­eries is where it is needed the most,” he ex­plains.

“If the health depart­ment wants to dent the coun­try’s neona­tal death rate, the fo­cus should be on ru­ral hospi­tals.”

In 2012, the na­tional health depart­ment also rolled out a train­ing pro­gramme de­vel­oped by the Med­i­cal Re­search Coun­cil to 12 dis­tricts that to­gether ac­counted for a large num­ber of ma­ter­nal deaths na­tion­ally, in­clud­ing the East­ern Cape’s OR Tambo and Ekurhu­leni.

Re­searchers found that, by 2016, ma­ter­nal deaths in these dis­tricts had re­duced by al­most a third whereas rates among the coun­try’s other 40 dis­tricts dropped by just 5% in the same time, ac­cord­ing to re­search pub­lished in March in the SAMJ.

But train­ing has lim­its. In Tan­za­nia, Help­ing Ba­bies Breathe may have saved lives but the project couldn’t com­pletely change the odds for atrisk ba­bies with low birth weights, which can be a re­flec­tion of the care moth­ers get be­fore they de­liver. Ba­bies born tiny re­mained more likely to die even af­ter Help­ing Ba­bies Breathe was im­ple­mented, the 2009 re­search showed.

McAlpine says the work to end in­fant and ma­ter­nal deaths needs to start long be­fore ba­bies and moth­ers end up in the de­liv­ery room.

“We need bet­ter an­te­na­tal care so that women are bet­ter taken care of dur­ing preg­nancy.”

Tiny breaths: Un­der­de­vel­oped lungs are one of the big­gest threats to pre­ma­ture ba­bies — and many fa­cil­i­ties and health work­ers aren’t equipped for it. Photo: Khaled Ab­dul­lah/Reuters

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