Midwife-led units in community settings Cape Peninsula, South Africa

1. Midwife-led units in community settingsCape Peninsula, South Africa Associate Professor Sheila Clow Mr Jason Marcus & Mrs Carol Adams University of Cape Town & Mowbray Maternity Hospital, Cape Town, SOUTH AFRICA 6 June 2010

2. Country-specific context • Large country • Rural-urban divide • Inequitable health services, e.g. • public sector per capita expenditure ~$158 • private sector per capita expenditure ~$942 (6x) • Health indicators • IMR 42.8/1000 (Health Systems Trust, 2007) • MMR 237/100 000 (Hogan et al, 2010) • High GINI co-efficient • Redressing inequities

3. Specific challenges relative to midwifery skills • All midwives are trained as nurses • Profile of nurses is most closely related to the population profile • No distinction on the register for those in current practice • No requirement for relicensing • Few posts designated for midwives • Outreach programme to midwives ad hoc • Access to further training constrained by shortage

4. Promising approaches – a promise that has delivered! • Free-standing midwife-run units • for “low risk” maternity care • close to the people who require it • and integrated in a defined referral system • 8 midwife units • 2 secondary referral hospitals • 1 tertiary academic hospital Initiated in the Cape Peninsula, South Africa in 1974 (prior to the Alma Ata Declaration)

5. Assumptions underpinning the Peninsula Maternal & Neonatal Service • Normal or low-risk pregnancies are well managed by suitably qualified midwives • Tertiary level hospitals focussed on ill patients • inappropriate setting for a normal low-risk pregnancy, and • inappropriate use of expensive resources and infrastructure • Health services should be accessible, acceptable and appropriate to the population, at a cost that is sustainable for the community • No poor options for poor people

6. Scope of Service • Full range from pregnancy diagnosis to 1st week post birth • Limited Emergency Obstetric Care (EmOC) • Advanced midwives are licensed to perform assisted deliveries – vacuum and forceps • Clinical guidelines are evidence based

7. Clinical guidelines are evidence based • Expectations are clear • no inductions, continuous EFM, epidural analgesia • Basic Antenatal Care (BANC) • Better Birth Initiative – including doulas • Prevention of Mother-to-Child transmission (including HIV counselling and testing) • Kangaroo Care • Phototherapy • Baby-friendly Hospital Initiative • Perinatal mental health

8. Total births in the Peninsula Maternal & Neonatal Service, 2008

9. Mitchell’s Plain Midwives’ Unit – selected data

10. Mitchell’s Plain staffing per shift • Antenatal clinic • 2 registered midwives • 2 enrolled nurses • 1 enrolled nursing auxiliary • Labour ward & observation ward • Day duty – 3 registered midwives • Night duty – 2 registered midwives • Postnatal outpatients • 1 enrolled nurse

11. Maternal mortality rates for all 9 provinces Source : Health Systems Trust, 2003

12. PMNS data, 2008 38 292 deliveries • 22 Maternal deaths ~ MMR 57.5/100 000 • 17 died in tertiary level care • 12 were postpartum • 5 = direct causes – 4 Hypertensive • 1 = co-incidental • 16 = indirect causes • 12 Non-pregnancy related infections • 11 known HIV+ • 8 with CD4 < 200 Source : Fawcus, 2009

13. Before the advent of HIV and AIDS … • The PMNS MMR reached 31/100 000 • The MMR for the midwife units was 20/100 000 Source : de Groot 1993

14. Lessons learnt • The system works • Health indicators are the best in the country • Cost effective and frees up higher levels of the service to those requiring it • Some “medium risk” patients can be managed at this level • Creates a space for midwives to practice to their fullest potential

15. Cost effectiveness 13 years after the introduction of this initiative • the number of hospital births was the same • AND there were 9000 births occurring in the midwife units The midwife units have 15% of the bed capacity of the entire service, yet account for 50% of all deliveries Source : de Groot 1993

16. Requirements • Suitably qualified midwives • A tiered referral system to higher levels of care • Clear and agreed referral criteria • Correct use of evidence based clinical guidelines • Standardised documentation • Good communication systems • Regular clinical audit • Reliable transport

17. Suitably qualified midwives • Education • Regulation • Professional • Prescribing • Continuous professional development • Perinatal update - referral hospital • Total shutdown for staff training – 1 day p.a. • PEP (Perinatal Education Programme) • Clinical leadership

18. Added value! A teaching and learning facility for undergraduate and postgraduate students in : • Midwifery • Medicine • Dentistry • Physiotherapy • Occupational heath • Occupational therapy

19. Future possibilities • Incorporate into district health service • Ultrasound scanning and screening • Postnatal care • Tele-medicine / -midwifery

20. Acknowledgements • Emeritus Professor Herman De Groot, Dr John Smith and the visionaries for decentralised primary health care, including maternity care • Miss Squires and the nurse managers who supported the initiative • The registered midwives, enrolled nurses and enrolled nursing auxiliaries which make this work • The mothers who have trusted our care • The medical teams at the Universities of Cape Town & Stellenbosch and the referral hospitals who support this work

21. Programmes leading to registration as a midwife • Diploma course (1 year for RN or RPN, or 2 years for EN) (Reg. 254) • Comprehensive diploma/ bachelor’s degree leading to registration as a nurse and midwife (Reg. 425)

22. Clinical requirements

23. Clinical requirements

24. Legal status of midwifery practice • Nursing Act No.50 of 1978 as amended • R1469 Scope of practice • R2488 (26 October 1990) Conditions under which registered midwives and enrolled midwives may carry on their profession • R387 15 February 1985 (as amended) Acts and omissions • Nursing Bill 2005 (31 August 2005) • SANC Charter of Nursing Practice

25. R1469 as amended Scope of Practice “The scope of practice will entail the following scientifically based acts or procedures which apply to the practice of Midwifery and which relate to the mother and child in the course of pregnancy, labour and the puerperium”

26. R1469 Scope of Practice • Determine health needs of mother and child • Refer where necessary • Prevention & promotion • Monitoring progress of labour, vital signs of mother & child, reaction to situations • Episiotomy, suturing of tears, local anaesthetic • Promote activities of daily living, e.g. exercise & sleep, oxygenation, hygiene, nutrition, elimination • Promote wound healing • Administration of medicine • Promote & facilitate breastfeeding • Establish a health promoting environment • Communication with parents • Assist with operative, diagnostic & therapeutic procedures • Co-ordination of health care • Provide effective advocacy • Care of the dying patient

27. Implications to consider • Status of regulation vis-a-vis protocol / guidelines • Changes required • Needs to be evidence based, responsive to changing evidence • Needs to be responsive to changing health care needs, yet maintaining safety • Clarify who may do what • Skills training • Management of emergencies, e.g. resuscitation, shoulder dystocia, prolapsed cord • Guidelines required

28. Different models • Free-standing birth unit (original model) • Unit linked to a comprehensive health centre (primary level) (geographically close, but operationally still developing the relationships) • Unit on a secondary or tertiary hospital campus but operated separately