/ 2 September 2011

Neonatal deaths haunt SA

Neonatal Deaths Haunt Sa

Sister Mapaseka Mokoena* holds the life of Chris Hani Baragwanath Hospital’s smallest patients in her hands. The Soweto-based nurse has worked in the hospital’s busy neonatal ward for four years and she is passionate about her job.

But she is resigning this month.

“Nothing is sadder than watching babies die,” she says. “Especially when such deaths can be avoided.”

Mokoena is taking her skills and her passion to the private sector. She can no longer cope with the “constant struggle” of neonatal nursing in a state hospital. The problem: too many babies and not enough nurses.

“A neonatal ward should accommodate only 35 newborns, but we look after 45. I often have to oversee four babies at once. The reality is that you can’t offer your full attention to each child. There’s just not enough time,” she says.

Mokoena feels the shortage of “simple things”, such as soap and paper towels, leads to unnecessary infections. Disposable syringes, which are meant to be used once, are routinely sterilised and recycled. This too can cause infections, which are often fatal.

Every month nurses like Mokoena compile reports. They record how many babies have died and the reasons for their deaths. They also suggest ways to improve the quality of neonatal care in the ward. “But no one ever follows up on these reports,” says Mokoena. “Inspectors come, but nothing gets done to improve conditions.”

Since 2007 the Neonatal Nursing Association of South Africa has been trying to stem the tide of “disillusionment and frustration” among those who care for society’s “most frail and fragile”.

Association director Ruth Davidge agrees that neonatal care does not receive enough attention from the health sector, despite ongoing media coverage of infant mortality cases. She points out that HIV/Aids has had a significant impact on the number of premature births nationally, because HIV-infected mothers are more likely to deliver their babies preterm (before 37 weeks). Premature newborns are more vulnerable to infection and need specialised nursing. But in South Africa, says Davidge, neonatal training is very limited.

“Hospitals often choose between inexperienced midwives, paediatric nurses and critical care nurses to work at neonatal units,” says Davidge. Junior nurses are posted to neonatal wards “against their will” and quickly become intimidated by the demands of such a specialised form of healthcare.

In rural areas the problems are worse. Dr Richard Cooke, spokesperson of the Rural Health Advocacy Project, points out that “many [rural] hospitals lack facilities, such as ambulances, and often don’t have enough incubators”.

Cooke believes that prevention is better than cure. If mothers access quality healthcare early in their pregnancy, many potential problems can be avoided. “We need to take healthcare systems to communities,” he says. “Government can start by implementing mobile clinics, especially in villages, which are far from hospitals.”

Health Minister Dr Aaron Motsoaledi launched one such clinic — funded by mining giant Kumba Iron Ore — in the Northern Cape in July. In his address Motsoaledi spoke frankly about the challenges facing the country’s neonatal health sector: “We have 20 000 stillbirths every year. The number of babies that die before they reach five years has reached 75 000.”

Speaking to the Mail & Guardian after the ceremony, he admitted that South Africa might not achieve the millennium development goal of reducing child mortality by 2014, but was adamant that it remained a priority. “If you solve the problems facing children and women, you have solved 60% of the problems facing the healthcare system,” he says.

Motsoaledi maintains that the integration of community-based health workers in hospitals is a prerequisite for transformation. This would also involve placing paediatricians and neonatal specialists in each district “to avoid the deaths of more children”.

He says government will establish an independent “office of standards compliance” to ensure that South Africa’s hospitals and clinics meet minimum health standards.

But Mark Heywood, director of the public interest law NGO Section 27, believes it will take more than this to transform neonatal care in South Africa. For Heywood, the key word is “accountability”.

“One of the many gaps in the healthcare sector is the lack of oversight. In many cases of babies dying in hospitals it is often unclear who should be held accountable,” says Heywood.

Mokoena not only agrees with him, she also takes the argument one step further. “Nurses are not just part of the problem, they are vital to any solution,” she says.

“Government should listen more to us, not just to experts and academics. We are the ones on the ground and we have to carry the burden. Every time a child dies, you feel you have failed. People don’t understand the conditions under which we work. But where does the finger point when something goes wrong? At the nurse.” * Not her real name

The morbid facts
June 2011: Five premature babies died at Jubilee Hospital in Hammanskraal, north of Pretoria, allegedly because of broken incubators.

January 2011: Twenty-nine babies died at the Cecilia Makiwane Hospital in East London and the authorities kept quiet, not even reporting the matter to the provincial government. An independent investigation was conducted by the provincial department of health.

May 2010: Six babies died at the Charlotte Maxeke Johannesburg Academic hospital. The department of health and social development established a task team to investigate the circumstances surrounding the incident. In each case the cause of death appears to be related to a highly virulent outbreak of gastroenteritis in the premature baby unit. The team also found the following deficiencies regarding the facility and resources: lack of routine supplies, such as roller towels or antiseptic sprays, as well as inadequate hand-washing.

On the same day 11 babies died at the Natalspruit hospital on the East Rand. Health officials were adamant that the Natalspruit babies had not died after contracting diarrhoea.

January to May 2010: About 200 premature babies died at the Nelson Mandela Academic Hospital in the Eastern Cape. Deaths were blamed on poor ventilation and oxygen systems at the hospital. A task team from the Eastern Cape department of health was established to investigate. — Sources: www.health-e.org.za, www.info.gov.za and www.samedical.org/newsroom