An example of how nursing provides the backbone of healthcare — and how it can be part of a model for best practice — comes from Limpopo.
Some eight years ago, it was apparent that the province was losing lots of babies due to preventable causes, explains advanced midwifery nurse Lolly Mashao. She was appointed to co-ordinate a provincial initiative of the University of Limpopo (through the Department of Paediatrics in Polokwane) and the national Department of Health’s Mother and Child Health Directorate.
“It was a province-wide project. It was clear we had serious problems: firstly, babies were dying simply due to immaturity — they were too small to survive; secondly, many babies were born with intrapartum asphyxia (impaired oxygen delivery during labour). These were the main problems we tackled.”
Lolly Mashao’s team consisted of a retired neonatologist, Professor Attie Malan, Dr Dave Greenfield, advanced midwife Zo Mzolo from the University of KwaZulu-Natal’s Centre for Rural Health, and paediatrician Dr N Robertson. The initiative was named LINC (Limpopo Initiative for Newborn Care).
“We wanted to find out what the contributory factors to the mortality rate were. In 2003, we did a situation assessment in the province, looking at how the hospitals were caring for the newborns who were really sick.” The team focused on the 37 hospitals in the province.
Sister Mashao explains that Limpopo has pretty good antenatal care, so pregnant women were being advised to have their babies in hospitals, and in fact upwards of 80% did so, with a tiny percentage going to clinics to give birth and the remainder giving birth at home. Thirty of the hospitals are district hospitals, six are secondary hospitals (which are able to provide neonatology) and just one is a tertiary hospital (tertiary hospitals usually offer a neonatal intensive care unit).
Simple solutions
The team found a few crucial challenges that were affecting outcomes for vulnerable newborns:
- Lack of skill and knowledge on the part of the medical staff in managing very vulnerable babies such as the intrapartum asphyxia cases and the preterm or low birth-weight babies;
- Lack of proper facilities — for example, there were usually no dedicated areas in which to nurse these babies;
- Less than acceptable levels of available equipment.
Their response was to develop an in-service training programme aimed at both professional nurses and doctors. “But we realised that most of the care of the very ill babies was being done by staff nurses and nursing assistants, so we trained them as well,” says Sr Mashao. The team visited all the hospitals and helped them to identify rooms which were suitable for neonatal care.
“We wanted the unit to be attached to the maternity ward — very often the babies were scattered round the hospital, which is not ideal — and in many cases there was a washing area off the ward which could be converted. We also assessed the equipment and gave input to the hospitals on what was really needed. We trained them on how to use the equipment we recommended and the hospitals did indeed buy it and use it.”
In addition, the LINC team persuade hospitals not to rotate nurses out of the neonatal units. It is, of course, normal practice for nurses to be moved from ward to ward to learn new skills and maintain existing ones; but in this case, keeping them in one unit and allowing them to build up a huge fund of experience and knowledge about nursing vulnerable babies has paid off.
Kangaroo care
One of the ‘upgrades’ in neonatal care which obviously fills Sr Mashao with excitement is the implementation of ‘kangaroo care’. First introduced in Bogota, Colombia, where healthcare facilities faced a shortage of caregivers and resources for preterm babies, this technique has been scientifically proven to improve outcomes for vulnerable newborns.
The baby is held (by the mother or another caregiver) in a pouch against the skin for several hours every day. It has been shown to decrease the risk of infection in hospitals, to reduce the chance of lower respiratory infections (so dangerous for the low birth weight or preterm baby) and boost breast-feeding.
“Some hospitals were offering kangaroo care, but it was not best practice. So we trained the nursing staff in this technique and showed them how to create a home-like unit which was welcoming to the whole family, so that the father, the granny or the aunt could also come in for a few hours and do kangaroo care.” The improvement in outcomes for the newborn was significant, and now, throughout the province, healthcare workers are buying in to this care.
Incentives for hospitals
LINC developed an accreditation programme which saw hospitals being thoroughly assessed for awards. If they achieve 60% on their score, they get Silver status, if they get 70% it’s Gold, and the hospitals which score over 80% are Platinum. “It’s been an excellent tool to motivate hospitals to improve,” says Sr Mashao. “We’ve managed to accredit 21 out of the 37 hospitals in the province — some of the very small hospitals have different challenges to overcome, of course.”
Between 2006 and 2009, the team measured a decline in neonatal mortality of 8% across the province. (These rates look at deaths between birth and seven days.) This is an average, of course; some districts, like Sekukene, saw a reduction of 20%, while others racked up lesser figures.Sr Mashao is especially thrilled with the achievements at Malamulele Hospital, in the far north near Punda Maria, which has reduced its mortality rate from 11 per 1000 births in 2006 to 5.9 per 1000 in 2009.
“Malamulele was accredited early, in 2006, but they don’t have highly sophisticated equipment there. However, they do have a good kangaroo care programme which teaches mothers essential skills they can use at home. They also have good community involvement. But primarily, they have wonderful, dedicated, loving nursing staff. Malamulele offers a model which shows us how to achieve good outcomes. And what they have done is very nurse-driven. Nurses are the backbone of the whole thing!”