Dr. Litty Syam Obstetrician D C S T , Dr. K.K. District Project “High risk clinics” for reducing Maternal and Perinatal Mortality Dr. Litty Syam Obstetrician D C S T , Dr. K.K. District

High risk Pregnancy A “high-risk pregnancy” is one with risk factors that threaten the health or life of the mother or her foetus.

Risk factors Existing health conditions Obesity Multiple pregnancy Young or old maternal age Grand multipara (>5)

Existing health conditions Chronic Hypertension Cardiac disease Diabetes Asthma Anaemia Epilepsy HIV infection

Obesity Increased risk for Preeclampsia Gestational diabetes Stillbirth Caesarean delivery

Multiple Pregnancy Increased risk for Preeclampsia Malpresentations Premature labour PPH Caesarean deliveries

Why ‘High risk clinics’ ? Existing mechanisms in health facilities were not well organized to identify and provide special care to pregnant women with ‘high risk’

High risk clinics – Aim To identify and provide better care to “high risk” pregnant mothers who are likely to develop complications. Training of Doctors and Nurses (BANC, obstetric drill) Identifying High risk Pregnancies Providing special care

BANC / BANC plus Training (Basic Ante Natal Care) For Doctors and Nurses Identify high risk cases using check list Tutorials on PET, Anaemia, Infections during pregnancy, EMTCT, Foetal growth monitoring (SF plotting), Post term pregnancy

Identifying High risk pregnancy Age <16 and >37 Grand multipara Chronic Hypertension Previous caesarean/ any uterine surgery Previous PIH/PET/Eclampsia Previous h/o PPH Previous h/o still birth/neonatal death Repeated 3 or more miscarriages H/o growth retarded babies/ big babies Multiple pregnancy Any abnormal presentation at term Vaginal bleeding Guideline for maternity care in South Africa 2016

Identifying High risk pregnancy Anaemia Rh negative Epilepsy Asthma Diabetes Tuberculosis Known substance abuse Heart diseases Any severe medical condition Extensive vaginal wart that can obstruct vaginal delivery Guideline for maternity care in South Africa 2016

Providing special care High risk Clinics conducted jointly by Doctors and Midwifes. More frequent antenatal visits Referral to higher centre at appropriate time for delivery (34 weeks)

Support by Obstetrician of DCST Frequently visits each facility to conduct “High risk clinic” and give support

Facilities in Dr. K.K. District In 2013 2 hospitals and 9 CHC At present 1 District Hospital and 10 CHC Nic Bodenstein Hospital Ventersdorp Hospital Nic Bodenstein Hospital

First “High risk” clinic - 2013 Nic Bodenstein Hospital, Wolmarnstad (28-02 2013) Ventersdorp 23-05- 2013 Jouberton CHC 2015 Leedoringstad, Tswelelang 2, JB mark, Grace Mokhomo, Promosa, Boiki Thlapi 2016 Botshabelo, Tigane At present 9 /10 CHCs and all hospitals

Analysis of Maternal deaths in Dr K.K. District 2013 - 2017 No. of deaths Cause of death HIV related PET associated PPH Other causes

Cause of death HIV related PET associated PPH Others PCP (Pneumocystis carinii pneumonia) Sepsis Cryptococcal meningitis Miliary TB Drug induced liver injury HIV related PET associated PPH Others Pulmonary oedema HELLP syndrome Eclampsia with Multiorgan failure Intracerebral bleed Abruptio with DIC Post caesarean bleed Secondary Hemorrhage Obstructed labour with imminent Rupture uterus and cervical tear Pulm. Embolism Malignancy Sepsis Rupture spleen Cardiomyopathy

2013 Total deaths - 28

Cause of death Dr. K.K. 2013

2014 Total deaths - 31

Cause of deaths in Dr. K.K. District 2014 (1 unbooked)

2015 Total deaths - 21

Cause of death in Dr K.K. - 2015

2016 – Total deaths - 17

2016 (1 unbooked)

2017 upto June 30 Total deaths - 19

2017

Maternal deaths Dr. K.K district

Maternal mortality ratio Dr. K.K. District (DHIS) 229.9

Trend on different causes of death HIV %

Post Natal deaths

Post natal deaths caused by Cardiomyopathy Pulmonary oedema Pulmonary embolism Secondary haemorrhage Disseminated TB

Summary of Findings Downward trend in maternal deaths over the years Decline in the ratio of deaths due to HIV and PET related causes A few post natal deaths over the years. Tendency for an increase in maternal deaths in 2017 compared to 2016

Conclusion Definite decline in maternal deaths in Dr. K.K. district especially the PET related deaths noted over the years could be the result of many factors. “ H i g h r i s k c l i n i c s ” Mentoring antenatal clinics Various trainings for skills development. Lessons learned through auditing of maternal death files and discussion at Mortality meetings Availability of specialists

Concerns and Recommendations Post natal deaths ? Emphasis needs to be given on improved post natal care to avoid deaths in postnatal period. Increasing deaths in 2017 ? Lack of sufficient number specialists at higher centers and resignation of doctors nurses from primary health care facilities and higher levels, appears to have impacted negatively on the benefits gained over the years through interventions like high risk clinics

Concerns Sustainability of “High risk clinics” ?

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