1. 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

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

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

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

5. Obesity Increased risk for Preeclampsia Gestational diabetes
Stillbirth
Caesarean delivery

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

7. 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’

8. 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

9. 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

10. 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

11. 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

12. 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)

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

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

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

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

17. 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

18. 2013 Total deaths - 28

19. Cause of death Dr. K.K. 2013

20. 2014 Total deaths - 31

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

22. 2015 Total deaths - 21

23. Cause of death in Dr K.K

24. 2016 – Total deaths - 17

25. 2016
(1 unbooked)

26. 2017 upto June 30 Total deaths - 19

27. 2017

28. Maternal deaths Dr. K.K district

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

30. Trend on different causes of death
HIV %

31. Post Natal deaths

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

33. 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

34. 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

35. 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

36. Concerns
Sustainability of “High risk clinics” ?

37. Thank you