A newly collated Medical Research Council (MRC) report cites healthcare workers as saying that 20% of the 23 000newborn babies who die in South Africa each year could probably have been saved.
The bombshell report comes against the background of the dismissal of deputy health minister Nozizwe Madlala-Routledge shortly after she declared there was crisis at East London’s Frere Hospital over its high infant death toll and other aspects of care.
Madlala-Routledge was publicly repudiated by Health Minister Manto Tshabalala-Msimang and President Thabo Mbeki.
Two senior doctors at the East London Hospital Complex, the medical superintendent of Cecilia Makiwane Hospital, Nokuzola Ntshona, and Nared Pandey, head of clinical services for the complex, have since been suspended for backing Madlala-Routledge in statements to the media.
Ntshona told the Sunday Times that Frere was hastily spruced up and fitted with equipment — including some taken from her own hospital without authority — before a visit by Tshabalala-Msimang. She had previously written a letter to Mbeki detailing concerns about the hospital.
Another letter she submitted to Parliament’s health committee during its visit to the East London Hospital Complex last week reportedly quoted a paediatrician as saying that 200 children a month were dying in each hospital from bacterial infections.
The latest Saving Babies 2003-2005 report, compiled annually by the national Perinatal Problem Identification Programme (PPIP) and collated by the MRC, covers the period October 2003 to March 2006. It cites the healthcare workers who provide data as saying that 20% of perinatal deaths were ”clearly avoidable by addressing factors within the health system. The intrapartum [during birth] period was the area in which clearly avoidable deaths were most frequent.”
In rural areas, cities and towns, 25% of neonatal deaths were avoidable, compared with about 12% in metropolitan areas.
The report remarks that there has been a ”disturbing” lack of progress in reducing infant mortality in South Africa. Since the national database began in 2000, neither the perinatal (including still and live births) nor the neonatal (after birth) death rate had changed. By contrast, Malawi had managed to quarter its perinatal death rate over the past five years.
The report adds that the avoidable deaths ”are not complex or expensive to prevent — improving the quality of care during childbirth is a top priority”.
Madlala-Routledge told a press conference she had come to the ”shocking realisation that some of these deaths were avoidable and that the situation is not unique to Frere Hospital”.
The report details avoidable or modifiable factors that could reduce deaths among infants and classifies them as patient, healthcare-worker or administration related. The latter included insufficient equipment and staff.
Delays in seeking medical attention during labour are ”mostly due to lack of transport from home to a healthcare institution”, it says, estimating that transport problems had played a role in 656 infant deaths.
Other South African studies have found the main obstacles for women seeking antenatal care are getting to the clinics — in terms of opening times, costs and time of travel — and the attitude of nurses. The report says these should be considered health system problems.
Using data from 15 hospitals, a sub-division of the PPIP system, the Child Healthcare Problem Identification Programme (Chip) found that more than half of infant deaths occurred before the child turned one.
The majority (58%) of clinical records were incomplete, inadequate or missing. The HIV status of half the children was unknown at the time of their death, and in 65% of cases it was uncertain whether the child received nevirapine to reduce its chances of acquiring HIV from the mother.
Fewer than one in five children dying of PCP — a pneumonia commonly associated with HIV — were known to have been given prophylactic antibiotics to prevent the disease, the Chip found.
The report says that for each child who died, there are an average of 2,3 occurrences of ”sub-standard care that may have contributed to that child’s death”.
Of these ”modifiable” factors, 78% occurred within the health service.
”For each death there was more than one instance of sub-standard/modifiable care attributable to clinical personnel, and most were due to insufficient case assessment, monitoring and management,” it says.
A total of 807 ”administer-related” modifiable factors, or 52 per 100 deaths, was noted, mostly involving inadequate facilities and a lack of personnel, particularly professional nurses.
Writing in the foreword, Dr Joy Lawn says that the neonatal mortality rate in South Africa is, at 21 per 1 000 live births, lower than the regional average of 41 per 1 000 live births but higher than countries with comparable average national incomes.
A significant factor noted by the Saving Babies report is HIV infection, which is thought to increase spontaneous pre-term deliveries but may also contribute to the high rate of ”unexplained” deaths in the womb.
Previous research has found that HIV was a factor in four out of five deaths among children under the age of five and implicated in two out of every five maternal deaths.
It details serious problems with the prevention of mother-to-child transmission programme, identifying ”inadequate counselling and the continued lack of universal testing for mothers, gaps in nevirapine prophylaxis to mother and babies, poor feeding choices and follow-up/identification of infants receiving PCP prophylaxis or ART”.