Child Mortality and Infection Control: Eastern Cape Provincial Department of Health and Nelson Mandela Academic Hospital

Meeting report

Opening Statement
The Chairperson informed the Committee that the Eastern Cape Department of Health (ECDoH) would be briefing Members on the recent increase in infant mortality in the province. They would tell the Committee what strategies they were using to prevent further infant mortalities. Officials from the Nelson Mandela Academic Hospital (NMAH) were also asked to attend the meeting, as quite a few babies had died in the Mthatha area. The Committee wanted the NMAH to explain the challenges that the hospital faced. He knew that infant mortality was a problem faced by many provinces. The Committee wanted to meet with all the provinces to hear their strategies for addressing the recent increase in the deaths of babies. 

Mr Phumulo Masualle, Easter Cape Health MEC, apologised for the meeting of 11 August 2010, where only the Head of the Department (HoD) was sent to address the Committee. At the time, the ECDoH was preparing for the health workers strike. 

The Chairperson accepted Mr Masualle's apology. He explained that the Committee wanted the people that were actually involved in the hospitals to participate in the discussion. 

Eastern Cape Provincial Department of Health Briefing
Dr Siva Pillay, Superintendent General: ECDoH, said that the purpose of the presentation was to inform stakeholders about the findings of the investigation undertaken by the National Department of Health (DoH) and the ECDoH on the increase in infant mortality in the province. The ECDoH also wanted to tell Members about the strategies that were developed and being implemented to decrease maternal and infant morbidity and mortality.

A target was set for the DoH to reduce by 2/3’s the under five mortality by 2014 and to reduce by ¾’s maternal mortality. These targets were in line with Millennium Development Goals (MDGs) and the Provincial Growth and Management Plan. The ECDoH was having trouble meeting these targets as the province had a high infant mortality rate as well as a high maternal mortality rate. According to perinatal statistics for January 2010, 90 out of 309 babies died in the Eastern Cape. In February, 83 out of 230 babies died in the province. In March 109 out of 292 babies died, while 102 out of 271 babies died in April.

The OR Tambo District Perinatal Mortality (PNMR) statistics for 2009 showed that the districts hospitals had 29.2 deaths per 1000 live births. The Mthatha General Hospital (MGH) averaged 34.3 deaths per 1000 live births while the Nelson Mandela Academic Hospital (NMAH) averaged approximately 96.7 deaths per 1000 live births. These PNMR rates for the OR Tambo District were unacceptably high when compared with the national average of 18 deaths per 1000 live births. Mortality rates were higher in NMAH than in any other equivalent hospital in South Africa. The OR Tambo district averaged 430 deaths per 1000 live births. The Eastern Cape’s (EC) average overall was 38 deaths per 1000 live births. Compared with the national figure of 18 deaths per 1000 live births, this was unacceptable.

The DoH discussed this matter and a Ministerial Task Team was set up to investigate why there was such a high infant mortality rate in the province. The task team consisted of Professor Jack Moodley, Ms Dolly Nyasulu, Dr Nat Khaole, Dr David Greenfield and Dr Tim Wilson. While in Mthatha, the team was accompanied by Ms Dinah Morapedi, Director of Nursing Services in the ECDoH. The task team found that the NMAH and the MGH accounted for 64% of the neonatal mortality rate in the province. 36% of the neonatal mortality rate was attributed to peripheral hospitals and clinics. The neonatal mortality rate was 3-4 times higher than other provincial tertiary hospitals. The team was also concerned that many of the mothers did not know their HIV status. Of 247 neonatal deaths, 46.9% of the mothers were HIV positive, 18.4% were HIV negative and 34.6% did not know their status. Although HIV infection in the mother was unlikely to cause neonatal deaths, there was a very strong association between being HIV positive and having a high neonatal mortality rate. It was worrying that a third of the mothers did not know their HIV status. There was evidence there was an increasing trend of increased Post-Neonatal Deaths (PNND) for the past three years. Prior to the investigation, the increase was associated with the HIV pandemic. While this was generally the case, it was clear that a significant percentage of deaths were attributable to clinical, administrative and infrastructure factors.

The task team looked at neonatal care. They found that many of the hospitals’ neonatal units were overcrowded and there were not enough incubators, ventilators and medical equipment. There was poor monitoring of patients, a shortage of staff, inadequate training for nurses and doctors and no Kangaroo Mother Care Programme. The team found that many hospitals struggled with the early detection of problems in patients, they were indecisive, and their interventions were too late. There was a shortage of Emergency Medical Services (EMS) and only about 80 ambulances for the whole province. It was found many staff members were not registered with the Health Practitioners Council of South Africa (HPCSA). There was no protocol for referring patients from one hospital to another. The staff seemed to be indecisive, which resulted in delayed referrals. The team found that outreach programmes in the province were inadequate. There was poor training and supervision within the programme. The midwife programme was also found to be inadequate. The increase in infant mortality was also due to the increase in teenage pregnancies, unwanted pregnancies, birthing premature babies, late and defaulting ante-natal care visits, risky behaviour such as indulging in alcohol, mothers not knowing their HIV status and mothers using the drug Cytotec to abort their babies. Another contributing factor to the increase in infant mortality was patient management at District Hospitals (DH). There was poor attraction and retention of staff, as well as poor outreach and training of staff in DH. Most DH could not perform Caesarean Sections (C-Sections) all the time. It was found that the nurse/midwife training programmes were also inadequate. It was a concern that ambulances had to travel such long distances, as most of the Eastern Cape consisted of rural areas. This meant people had to wait quite long for the ambulance to arrive. 

The ECDoH devised a few strategies to improve the province’s health outcomes. They would promote health and education, as well as community mobilisation. Ante-natal Care services would be improved and protocols would be put in place to address early problem detection. The ECDoH would also help to reinforce the choices that people had such as prevention of pregnancy, which would include the use of contraception, or the termination of pregnancy for unwanted pregnancies. The ECDOH wanted to empower nurses at the Primary Health Care (PHC) level. Nurses would be trained in Basic Ante-natal Care. This would include protocols for early problem detection. This would be supported by the Saving Mothers Saving Babies project. Patient Management at DHs would also be addressed. Nurses and doctors were being trained on the Essential Steps on the Management of Obstetric Emergencies. Doctors would also be trained on Anaesthetics and Surgery to do C-sections. There would be team building with nurses and doctors for protocol adherence.

Appropriate equipment and resources would have to be made available to hospitals. This meant that the sector’s budget would have to be re-adjusted. Neonatal outcomes would be improved with the Kangaroo Mother Care programme. Hospitals would be given kits to test for HIV, AIDS and syphilis. Referral systems also had to be improved, which meant that the ECDoH would have to focus on early problem detection and referral protocol. The number of ambulances available to the province was being increased. Air ambulances would be used to transfer emergency patients from far away and deep rural areas. There would be dedicated halfway houses for mother sin late pregnancy in rural areas.

All DHs, Regional Hospitals (RHs) and Tertiary Hospitals (THs) have been instructed to hold perinatal mortality meetings. The Perinatal Problem Identification Programme (PPIP) was being strengthened and a Provincial Adverse Incident Committee on maternal and neonatal deaths was now established.

A perinatal meeting was held on 7 July 2010 to discuss the mortalities in the neonatal unit at the NMAH. The meeting was held to analyse the process and causes of the deaths, the medical management, and to review the quality of records. The ECDoH noted that the number of admissions to the NMAH had increased dramatically over the past three years. But, thanks to outreach programmes and the implementation of the National Commission Recommendations made in June, there has been a dramatic improvement of the PNMR. However, there was still an increased demand for services even though the Obstetrics and Gynaecology department was overcrowded.

Discussion
The Chairperson said that the Committee was devastated when they first heard about the deaths of so many babies in the country, and specifically in the EC. He did not know how the country would meet its Millennium Development Goals (MDGs) for infant and maternal mortalities. He asked what the ECDoHs strategy was to deal with the current situation. The Committee needed hope that the problems were being addressed. The Committee had been told that the HoD had been sent alone because a lack of finances within the ECDoH had prevented anyone else from being able to attend. It was worrying that the ECDoH could not even find the money to send all the necessary people to the meeting. Most of the challenges in the Eastern Cape required money. How would the province find money to address their challenges if they did not have money for flights to Cape Town? He also worried that the lack of finances would result in nurses not being trained. The Committee wanted to assist the ECDoH wherever it could. The ECDoH said there were doctors that could not do Caesarean Sections (C-sections). This was very worrying. How was it possible?

Professor Zandisile Nazo, HoD: Paediatrics (NMAH), replied that the infant mortality rate was decreasing; however, this needed to be substantiated scientifically. More research had to be done in order to do so.

Dr Pillay told the Committee that the ECDoH was experiencing some financial constraints, but they were not taking it lying down. There were five key strategic interventions that the ECDoH was in the process of implementing. The first part of the intervention was the social compact, where the ECDoH would be asking health training institutes to reserve 50% of their space for community selected trainees. The ECDoH hoped to encourage these trainees to stay in community health centres and rural areas.

Professor Geoffrey Buga, HoD: Obstetrics and Genealogy (NMAH) answered that some doctors could not do C-sections because they were not gaining enough experience in different aspects of medicine. Some doctors did an average of four C-sections during their training. There were not a required number of C-sections that they had to do. These are done under close supervision. However, once these doctors do their community service, they would have to do C-sections on their own. Many times there would be complications and the doctors would be performing the surgery under even more pressure. There were also doctors that worked in rural areas that received training in foreign countries such as Tunisia and other countries in Europe. There were some doctors from Tunisia that said that they had never even delivered a baby. The majority of patients in the Eastern Cape that required C-sections were referred to NMAH. This was why the C-section rate was so high. Doctors spent most of their time doing C-sections for other hospitals that were supposed to know how to do them. This would also account for the over-crowding at the hospital's postnatal ward.

Ms M Segale-Diswai (ANC) said the presentation upset her, but she was glad that the ECDoH was aware of the challenges they faced. She asked how effective the ECs primary healthcare sector was. The presentation gave her the impression that the primary healthcare sector was not working. It also showed her there was lack of management, but this could be due to lack of finances. It seemed that protocols for healthcare were not available or they were not being followed. She wanted to know how the ECDoH would improve healthcare management. There was no Kangaroo Mother Care programme, which was supposed to form part of healthcare management. The amount of human resources that had to be available in the healthcare facilities were not up to scratch. What was the ECDoH’s plan for clinic revitalisation?

Professor Nazo replied that the NMAH was built by people that did not have knowledge of Kangaroo Mother Care. This programme was essential for reducing infection rates and the use of incubators. The hospital was not structured to cater for the programme; however, space was being identified at Mthatha Hospital for the Kangaroo Mother Care. This meant that babies would have to be transferred to Mthatha Hospital.   

Mr D Worth (DA, Free State) said that the Members of the National Council of Provinces (NCOP) visited the Eastern Cape recently. They found that babies were sharing incubators. This was unacceptable even though the Committees understood there was a shortage of equipment. It was also found that the ambulances were inadequate. Many ambulances did not have basic equipment such as oxygen tanks. He asked how challenges with the referral system were going to be resolved as many people were being sent to the wrong hospitals. There seemed to a shortage of accommodation in certain areas for doctors and other healthcare workers. He asked the ECDoH to comment on this.

Mr Masualle answered that the rural nature of the province provided the ECDoH with serious challenges, especially in terms of attracting skilled personnel into those areas. Some of the facilities in deep rural areas did not have proper accommodation for doctors. Even South African-trained doctors that were born in those areas did not want to stay there. The ECDoH wanted to address the issue of lack of accommodation; however, it was more than just their issue now. There were matters of safety that also had to be addressed.

The Chairperson added that Professor Nazo had to be commended for his work in the rural areas. He was raised in a rural area and continued to work there.

Professor Nazo answered that when the NMAH was first commissioned, they had sixty babies in the unit at any given time. This has not changed. The unit was only given 32 beds. There was no space for sixty babies. There were incubators, but there was not enough space to fit so many incubators in one unit.

Professor Buga addressed the question on referrals and protocols. There was a clear hierarchy in terms of which patients should be prioritised and which hospital they should be sent to when an illness is identified at a primary healthcare level. This did not require any written rules. Everyone that worked in these hospitals knew what the protocol was and what their own capabilities were. However, a number of patients “cut through” and went to level 1 or 2 hospitals instead of going to primary healthcare facilities. This resulted in overcrowding the upper levels of the healthcare systems. At the moment, this system was not working too well. There was a task team that was formed to look at the referral system within the whole of the EC. They would also be looking at updating protocols.

Ms T Kenye (ANC) said that it was of great concern that there were so many babies that were being born by mothers that did not know their HIV status. However, the ECDoH could not assume one of the reasons that so many babies were dying was because mothers did not know their status. She noted that the NMAH was in the Transkei area, which was mostly rural. This could be the reason mothers were not attending antenatal clinics. The lack of equipment in hospitals indicated there was a lack of management. How was the ECDoH attending to this problem? The lack of ambulances was also of concern to the Committee.

The Chairperson noted that there was a shortage of management in the EC; however, there had also been talk of corruption in the province. There were quite a few disciplinary hearings taking place as well as dismissals.

Mr Masualle replied that the management function had to be strengthened, as management decisions had to be respected and followed.

Professor Nazo answered that the report did not say that HIV was the cause of all the neonatal deaths. However, there was a strong association between HIV infection in the mother and neonatal “wastage”. The reason for this was because of an increase in pre-term deliveries. Pre-term labour due to exposure to HIV was on the increase, therefore there was an increase in infant mortality.

Dr Pillay added that there were budgetary challenges, but the ECDoH was acquiring new, better ambulances.

The Chairperson stated that the Eastern Cape consisted of approximately 64% rural area. Sometimes, in those areas, the people had their own systems and culture. For example, some people were required to give birth to their first child at the place they were born. This also required traditional birth attendants. He asked if the ECDoH dealt with traditional birth attendants.

Professor Buga replied that there was a programme to train traditional birth attendants in the 1980's and 1990's. The World Health Organisation (WHO) spoke quite highly of the programme at the time. But, they soon discovered that it was not feasible to train these people and make them an effective part of the healthcare delivery system. Therefore, the countries were allowed to train traditional birth attendants if they wanted to, but it was no longer an internationally accepted practice.

Ms Nomvula Kwadjo, Director: Saving Mothers Saving Babies (ECDoH), added that the programme for traditional birth attendants was not a strategy to address infant and maternal mortalities. The ECDoH came up with the strategy to use halfway houses as “waiting rooms” for expecting mothers that were close to their birth dates. These houses would be situated close to hospitals. The Eastern Cape was unique in that it was mostly made up of rural areas. Therefore, these halfway houses were essential.

Mr D Kganare (COPE) told the ECDoH that the Minister of Health said that the ECs Provincial Joint Operations Centre (PROVJOC) had only started operating on 24 August 2010. He asked why the PROVJOC had only started operating so late compared to the other provinces. He wondered if the financial shortages experienced in the ECDoH were because they were over-spending on their budget every year. The fact that there were so many mothers that did not know their HIV status showed there was a problem with HIV testing and counselling initiatives and that HIV testing campaigns were not being effective. He noted that the presentation did not make much mention of maternal mortality rates.

Mr Masualle replied that the Minister could have been referring to an operating centre that would have been inclusive of all government services, including police services and the army. The ECDoH had been struggling with this initiative. The truth was that the ECDoH had been struggling to get other departments to join the initiative and decided to go solo. A command centre had been established during the strike where all the ECDoHs facilities and services were being managed. This had been established over the previous weekend. He suspected that this was what the Minister was referring to, but the centre had been established before 24 August as a departmental specific initiative.

Mr Masualle said that the budget that was made available to the ECDoH did not take into account many of the initiatives that the ECDoH wanted to implemented. The budget matters were referred to the Executive Council of the Eastern Cape. There were also concerted efforts to engage with the National Treasury. The budget was not enough to meet the basic level of services that the ECDoH made provision for. There was not much that the ECDoH could achieve with the corruption that was taking place in the sector. 

Professor Buga replied that 18 mothers had died so far this year. But, 78% of the deaths were from mothers that had full-blown AIDS. A number of the mothers had not had any HIV testing done. Some of their tests were done when they were admitted. Many of the babies born to these mothers died as well.

Ms Kwadjo added that there had been some improvement in maternal mortalities. However, there were challenges that had to be overcome.

Ms E More (DA) clarified that a ministerial task team was formed and an investigation into perinatal care in South Africa took four years to complete. Four years was a long time. She noted that the presentation did not cover infection control and what the ECDoH was doing to address the matter. This was important as many deaths at hospitals were due to infections caused by a lack of hygiene. According to Mr Sizwe Kupelo, Media Liaison Officer (ECDoH), 23 out of 54 deaths that occurred in January 2010 were due to a compressor that could not supply oxygen adequately. She asked if this problem had been fixed.

Professor Nazo explained that if one looked at the causes of deaths of babies over the past few years, one would see that there was an increase in deaths caused by infections. However, the Committee had to differentiate between an infection in the unit and an outbreak of infections in the unit. There had not been an outbreak of infections in the unit, but there was an increase in deaths caused by infections over the past few years. In 2006, infections accounted for 6.5% of the cause for neonatal deaths, in 2008 infections accounted for 17% of neonatal deaths, and in 2009 it accounted for 26% of neonatal deaths. There was definitely a problem of infection control. The ECDoH was helping the NMAH with the problem.

He said there was a misunderstanding concerning the compressor and the media must have reported the story incorrectly. There was never a compressor failure. The unit was supported by four compressors, one of which became dysfunctional. However, the unit was still powered by three compressors. The 23 deaths that occurred were due to hypoxia, which was also known as infant asphyxia. The babies suffered from lack of oxygen during birth.

Ms C Dudley (ACDP) said it had been mentioned many times that nurse and midwife training was inadequate. What was being done to address the problem? What could the Committee do to help? She wanted to know how it was possible that Cytotec was so readily available on the “streets”. Was anything being done about it?

Ms Kwadjo replied that the fact that Cytotec was so freely available to the public was a problem. This schedule 2 drug was not actually supposed to be used for the termination of pregnancies. The youth had to be educated about the drug. The ECDoH was in the process of building relationships with Non Government Organisations (NGOs) to do this.

Dr Pillay added that Cytotec was an anti-inflammatory drug used by people that had peptic ulcers. It was not supposed to be used for abortions. The ECDoH had to look at re-scheduling the drug and re-assessing where the dug would be made available. Carte Blanche showed that the drug was being sold on the streets for R200-R300. It could also result in maternal deaths. This matter had to be addressed urgently.

Mr M Waters (DA) asked what percentage of the ECs provincial budget was allocated for health. The lack of management in hospitals seemed to be a huge problem. He asked what the situation was with the Chief Executive Officer (CEO) in the NMAH. He asked if the management of the NMAH had asked for additional funding from the province for additional incubators. If they did, why were the additional incubators not provided? It was shocking that some doctors could not perform C-sections. This was something that the Committee needed to address with the Health Professions Council of South Africa (HPCSA) and other relevant bodies.

Mr Masualle answered that approximately 26% of the province's budget was allocated to its health sector. Of the ECDoHs budget, approximately 63% was allocated to the cost of employment. This was quite a challenge as there were many reports of over-spending, particularly in the area of the cost of employment. This crowded out the ability to attend to the infrastructure and resources needed for quality healthcare. Over the past few years, there was a phenomenon that occurred that yielded a situation in which the ECDoH grew disproportionately, very large, in relation to other non-core areas of the health sector. A huge component of the finances had to be allocated to human resources, which were basic support services, relative to growing the clinical part of healthcare services. Unfortunately, the area of strengthening support systems has not been very strong. For example, support systems for drug management. This was another area of great expenditure. What happened after the drugs left the depot was of great concern to the ECDoH. Many times there was no record of where the drugs ended up. The ECDoH now knew that this was an area infected with corruption. There was no monitoring mechanism in place to assess the situation. He was aware that these were structural problems that had to be addressed.

The Chairperson added that all training doctors had to participate in all the different rotations in hospitals before they could register as medical practitioners. It was worrying that there were doctors in the Eastern Cape that could not do C-sections. Even before a doctor was allowed to specialise in a particular field, they had to learn how to do C-sections.

He said that there had been a tender to deal with procurement of medicines. Unfortunately he nothing seemed to be happening. This was sad because the tender would have helped to address the corruption issue.

Ms A Luthuli (ANC) noted that the problems in the Eastern Cape were huge. The issue of the budget and lack of finances in the ECDoH made the situation even worse. The ECDoH had to focus on “calculated targeting” to address the situation. Educating the public was very important and formed part of primary healthcare. It would solve a lot of the problems that the country was faced with. It was important to have people capable of managing the ECDoH and the hospitals in the province.

Dr Pillay replied that a lot of focus was put on management services; however, core functions of health services had been neglected. This was being addressed presently. The Department of Public Service and Administration (DPSA) was contracted to do an evaluation of all the middle and senior management in the department. Both the DPSA and the National Treasury would help the ECDoH to restructure its organogram. 

The Chairperson thanked the ECDoH for briefing the Committee their plans to address infant mortalities. Health has been prioritised by the government, as Parliament was worried that it would not meet the MDGs. The Committee was concerned about the lack of resources in the ECDoH. Members were aware that they were underfunded. The Committee was very happy that corruption within the ECDoH was being addressed, and they hoped that many of the other challenges would be resolved when they met again.

The meeting was adjourned.