The HHAPI-NeSS road map for healthy
babies in South Africa”
Neonatal Survival Strategy Implementation
Plan 2013 -2017
1
Table of Contents
Contents
Table of Contents .................................................................................................................................... 2
Acronyms ................................................................................................................................................ 3
Acknowledgements................................................................................................................................. 4
Executive Summary................................................................................................................................. 5
1. What is HHAPI ................................................................................................................................. 6
1.1 What are the 5 Hs ......................................................................................................................... 6
2.0 How is HHAPI-NeSS and the 5 Hs Achieved .................................................................................. 7
3.0 Achieving HHAPI-NeSS .................................................................................................................. 9
4.0 Priority Areas of Action ............................................................................................................... 10
4.1 Essential Services ........................................................................................................................ 13
4.2 Integrated activities for improving maternal and neonatal care................................................ 14
5.0. Monitoring and Evaluation ........................................................................................................ 10
5.1 Overarching national indicators.................................................................................................. 11
Core Programmatic Indicators ...................................................................................................... 11
6.0 Tools and Resources ................................................................................................................... 11
Appendix 1: Menu of Activities ......................................................................................................... 13
2
Acronyms
APH
Antepartum haemorrhage
AIDS
Acquired immunodefciency syndrome
AGA
Appropriate for gestational age
ANC
Antenatal care
ARV
Anti-retroviral
AZT
Azidothymidine (antiretroviral drug)
BBA
Born before arrival
CHW
Community health worker
CPAP
Constant positive airway pressure
DCST
District clinical specialist team
HIV
Human immuno deficiency virus
ICU
Intensive care unit
KMC
Kangaroo mother care
LBW
Low birth weight
NAMMPEMCO
National Perinatal Mortality and Morbidity Committee
NCCEMD
National Committee on the Confidential Enquiries into Maternal Deaths
NeSS
Neonatal Survival Strategy
NMR
Neonatal mortality rate
NND
Neonatal death
PROM
Prolonged rupture of membranes
3
Acknowledgements (TBD)
4
Executive Summary (To be completed)
5
The HHAPI-NeSS road map for healthy babies in South Africa aims to
provide a road map for improving newborn care in South Africa.
The road map contains no new recommendations, approaches or actions, but rather aims to
provide a framework for operationalizing the key NCCEMD and NaPeMMCo
recommendations for improving newborn and maternal care. The road map outlines clear
steps and roles and responsibilities at all levels of health care delivery, and sets targets and
timelines towards expected results. It also outlines a monitoring plan highlighting regular reviews
at all levels.
1. What is HHAPI - NeSS
HHAPI is an acronym used by NaPeMMCo to summarize their key recommendations regarding the
actions that are needed to improve newborn care and neonatal survival, namely:





Improve the Health System for mothers and babies
Improve the knowledge and skills of Health Care providers in maternal and neonatal care
Reduce deaths due to Asphyxia
Reduce death due to Prematurity
Reduce deaths due to Infection
Implementation of interventions for each of the recommendation forms the basis of the Newborn
Survival Strategy (NeSS).
The HHAPI-NeSS road map also includes the 5 Hs.
1.1 What are the 5 Hs
Improvements in neonatal survival are critically dependent on improvements in the quality of
maternal care. Thus the road map incorporates the key NCCEMD recommendations which
specifically address improvements in maternal care and survival, namely the 5 H’s.
These include
 Reduce deaths due to HIV/AIDS
 Reduce deaths due to Haemorrhage
 Reduce deaths due to Hypertension
 Improve Health worker training and
 Health system strengthening
6
2.0 Interventions to achieve results for HHAPI and the 5 Hs
Essential packages of care for mothers and newborns have been defined and are shown in Annexure
A. Likewise a set of joint priority actions have been identified and are listed in the table below.
RECOMMENDATION INTERVENTIONS
Improve the Health  Ensure 24 hour access to functioning emergency obstetric and neonatal
System for mothers
care (both basic and comprehensive). Dedicated ambulances, maternal
and babies
waiting homes, KMC sites in all hospitals etc.
 Ensure accessible and appropriate contraceptive services for all women
which are integrated into all levels of health care and are available on
site for women post-miscarriage and postpartum women
Improving skills and  Train all health care workers involved in maternity and neonatal care in
skills of Health Care
the ESMOE-EOST programme (including Helping Babies Breathe) and in
providers in
managing healthy and sick newborn infants (SA-INC)
maternal and
 Train all health care workers who deal with pregnant women in HIV
neonatal care
advice, counselling, testing and support (ACTS), initiation of HAART,
monitoring of HAART
Reduce deaths due  Ensure that labour is monitored appropriately by a skilled birth attendant
to Asphyxia
 Ensure all birth attendants are skilled at a minimum in neonatal bag and
mask ventilation
 Ensure that the partogram is used to monitor labour and the fetus and
mother are monitored according to the prescribed norms ensuring
proper data interpretation.
Reduce death due to  Ensure that corticosteroids are given to every women in preterm labour
Prematurity
 Ensure antibiotics are given with preterm premature rupture of
membranes
 Ensure the appropriate hospitals are skilled in the used of nasal CPAP
 Ensure that all mothers of immature infants have easy access to KMC
Reduce deaths due  Promote breastfeeding (especially exclusive breastfeeding)
to Infection
 Ensure strict adherence to basic hygiene in labour wards and nurseries
 Ensure presumptive antibiotic therapy for at risk newborns is available
 Ensure case management of neonatal sepsis, meningitis and pneumonia
Reduce deaths due  Promote “Know your status” and “plan your pregnancy” messages in
to HIV/AIDS
communities and the health sector; ensuring non judgemental
approaches.
 Ensure every maternity facility is able to screen for HIV infection and
perform early initiation of HAART therapy; and to recognise and treat coinfections, especially respiratory infections.
 Ensure that all mothers and their infants receive the full package of
PMTCT interventions
Reduce deaths due  Promote preventive interventions: community education, prevent
to Haemorrhage
prolonged labour, prevent anaemia; use of safe methods for induction of
labour and practice active management of the third stage of labour
(AMSTL).
 Severe obstetric haemorrhage must have the status of a ‘major alert’
requiring a team approach; with immediate attention to diagnosis of the
cause of haemorrhage, resuscitation and stepwise approach to arresting
the haemorrhage.
7
Reduce deaths due 
to Hypertension


Calcium supplementation provided to all women throughout antenatal
care and ensure detection, early referral and timely delivery of women
with hypertension in pregnancy
Severe hypertension, imminent eclampsia, eclampsia and HELLP
syndrome must be recognised as life threatening conditions requiring
urgent attention. All maternity facilities must be able to administer
magnesium sulphate to prevent convulsions, administer rapid acting
agents to lower severely raised blood pressure , provide close monitoring
prior to and following delivery and manage fluid balance safely.
Promotion of Family Planning Services (women, their partners, families
and communities).
KEY STEPS TOWARDS ACHIEVING THE RESULTS OF HHAPI – NeSS
Establish
teams and
focal
persons
Assess
Situation
(bottleneck
analysis)
Develop
costed
evidenceresultsbased plan
tailored to
context
Implement
Plan
Conduct
Ongoing
Monitoring
to track
progress
Conduct
Regular
Reviews
Document
Best
Practices
and lessons
learned
1. Establish teams that consist of champions and drivers at the national, provincial, district, and
facility and community levels. Identify a focal person / team leader that can lead the
process and support the teams, and facilitate implementation of the plan (step 4 below).
2. Assess the situation/Conduct a situation analysis at the national, provincial, district and
facility level. At the provincial, district and facility level, this should include a training
assessment and a services and resources assessment.
3. Develop a costed, evidence and results based plan at each level (provincial, district, facilty).
The plan should be based on the data collected through the assessment above.
4. Implement the plan as per timelines
5. Ensure ongoing monitoring of key indicators at different levels to track progress
6. Conduct regular reviews at each level to identify challenges and make mid course
corrections as needed
7. Document best practices and lessons learned
The diagram below details what each step entails for the specific level.
8
• Identify focal person. team
leader
• establish teams
• Conduct situation analysis
includes training needs
• Identify challenges and
actions needed
• Develop plan
• Select 4-5 priority actions for
year 1 and year 2
• Finalize national training
package
• Train master trainers to
facilitate training
implementation at the
provincial level
• Map existing services, identify
gaps
• Set national level targets for
monitoring
District
Facility
• Identify focal persons
• Conduct facility level
assessment to determine
which facilities will be targeted
• Implement priority actions
• monitor and track progresss
Ongoing
monitoring
Provincial
Ongoing
Monitoring
Ongoing Monitoring
National
• conduct assessment
• identify priority actions
• Ensure essential staff are
trained
• Implement priority actions and
interventions
• monitor and track progress
3.0 Achieving HHAPI-NeSS
The table below details the implementation of HHAPI-NeSS at the National, Provincial, District and
Facility level April 2013 –March 2015.
Activity
Finalize the national training package
Create a Master trainer database
Train master trainers in national training package
Identify provincial focal person
Identify district focal person
DCST teams
Conduct situation assessment (services, resources and training)
Develop a provincial inventory of fully trained, partially trained,
and inadequately trained health care workers
Set national targets for key indicators
Develop training plan based on assessment
Master trainers to conduct provincial training based on training
assessment
Select 4-5 priority areas to achieve HHAPINeSS
Identify specific interventions and actions to address the priority
areas
Implement interventions and activities for year 1
Monitor key indicators
Responsibility
National
National
National
Province
Province
District
Province and
District
Province
Timeline
June 2013
June 2013
June 2013
June 2013
June 2013
June 2013
June 2013
National
Province
Province
June 2013
June 2013
Sept 2013
Province
Dec 2013
Dec 2013
District
Facility
Facility
District
Province
March 2014
June 2013
March 2014
9
Select 4-5 priority areas to be implemented in Y2
Identify specific interventions and actions to address the priority
areas
Implement interventions and activities for year 2
Monitor key indicators
National
Province
District
Facility
Facility
District
Province
National
June 2014
June 2014
March 2015
March 2015
4.0 Priority Areas of Action
To effect change (and improve maternal and newborn survival every level of health management
and care and the community needs to be involved. The recommendations set forth by the two
ministerial committees NCCEMD and NaPeMMCo, as well as the strategies in which actions are
requested from every level of management (including the policy makers to the clinic managers,
health care providers, community and the Faculties of Health Sciences and Nursing colleges, the
College of Medicine and Health Professions Council). These activities are documented in appendix 2.
It is important to highlight that introducing everything/all activities at once is not possible, and
individual districts will need to prioritise and select the interventions that will have the greatest
impact. On a national level, the interventions that will result in the greatest reduction of deaths are
those that focus onpreventing, screening for and managing mothers and their infants HIV infection
(Lancet SA series). The intervention that will result in the second largest reduction in deaths are
those interventions that focus on improving basic and comprehensive emergency obstetric and
neonatal care (Lancet SB series data worked out by Kate Kerber for SA).
A number of training packages and tools for improving and monitoring provision of newborn care
are available and these are listed in Appendix x.
5.0. Monitoring and Evaluation
Continuous monitoring is needed to track progress in implementation. The DHIS child health and
nutrition indicators form the core source of monitoring. Targets for reducing newborn mortality
rates in all facilities have been established, and progress in moving towards these targets will be
tracked.
Monitoring of annual business plans at the district and provincial levels to track progress and
prioritize activities identified as bottlenecks. Special surveys will be implemented as needed to gain
in-depth analysis of the NeSS.
Data flow:
Indicators will be tracked quarterly to monitor and track progress in implementation of activities.
Data will feed into a quarterly data monitoring reports that will be shared at all levels. Data
10
collected at each level will vary in the degree of detail. The most detailed data will be collected at
the facility level, this will feed into district data, provincial data and national data through DHIS. The
national level data will provide a broad overview of progress in the country.
5.1 Overarching national indicators (TBC)
The overarching national indicators will be used at national level and will inform global reporting.
Numerator
Denominator
Source
11121314152012 2013 2014 2015 2016
Core Programmatic Indicators
Indicator
Numerator
Denominator
Source
11201
2
Indicator
Neonatal Mortality
Rate
Child Under-5
Mortality Rate
122013
132014
142015
%Live births < 1.0Kg+
%Live births 1.0kgs 1.49Kgs
%Live births 1.5 -2.5 kgs
Still births (1.0kgs)
ENND < 1.0kgs
ENND 1.0 -1.49kgs
Still births> 2.5kgs
PND
FSB
FSB +ENND
6.0 Tools and Resources
11
15201
6
The following list documents tools and resources that have been developed in South Africa and used
to improve newborn care. Every newborn care plan should consider how these tools should can be
used in order to to achieve HHAPI-NeSS.
Training
 SA-INC (5 days)
 Helping Baby’s Breath
 Routine care for newborns charts and training
 Management of Sick and Small Newborn Charts and Training
 Perinatal Education Programme (PEP) Resource: self study/resource
Additional resource:
 Guidelines for DCST for Improving Maternal and Neonatal Care 2013
 Routine Care -Newborn Record Maternity
 Perinatal Problem Identification Programme
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Appendix 1: Essential Services
Service Delivery
at specific Time
Points
Antenatal care
(mother and
fetus)
Intrapartum
care (mother
and fetus)
Immediate post
partum care
(mother and
neonate)
Monitoring and
evaluation for
respiratory
support eg:
CPAP, IPPV
Immediate post
partum and
continuing care
(mother and
neonate)
Rapid and
successful
communication
and transfer of
the at risk
neonate to the
appropriate
level of care
Services to be included
Early booking at the ANC ensured; the well being of the fetus and mother/
pregnancy is addressed byl roll-out of the BANC system
Early identification of the high risk fetus / pregnancy
Antenatal steroids in premature labour
IAP when maternal infection suspected e.g. in PPROM
Integrate TB screening into at risk patients (+ symptoms or HIV co-morbidity)
Ca supplementation to reduce hypertension risk
Ensure all mothers have tetaus toxoid vaccination (small no’s RSA)
Early and appropriate referral of high risk pregnancy to specialist centres
Early/appropriate implementing of PMTCT with monitoring especially of the viral
load /and early HAART
Adequate monitoring of the fetus will ensure early detection of problems
Appropriate and early emergency management and referral
Early and appropriate choices of delivery
Availability of C/S facilities (theatres + staff)
Ongoing fire drills in resuscitation to be diarized for the year
A care giver skilled in resuscitation at every delivery
ESMOE with neonatal resuscitation (HBB integrated as it has a competency test
attached to pass)
Correct management of mother/ fetus / newborn delivered via meconium
stained liquor
Care of the 5 basic neonatal principles:
1. to maintain a normal temperature
2. to maintain a normal glucose
3. treat suspected infection
4. provide oxygen (at appropriate levels) if necessary
5. early feeds (breast milk)
Keep mom and baby together if possible
Early identification of the neonate with respiratory distress allowing;
Early intervention with respiratory support and emergency management e.g.
CPAP (need and clinical management abilities ofstaff)
Early discussion for possible transfer if not improving and bed available at next
level of care
These are non-negotiable strategies:
1. optimize breast feeding/breast milk
2. KMC and KMC follow-up
3. Mother-baby-friendly hospital initiative
4. Optimise PMTCT programme
5. Full Implementation of the EPOC guidelines for mother and baby
This is an independent factor for poor outcome when a sick neonate is
transferred without a good retrieval system
Transport staff (ambumedics / paramedics) require specific training to care for
the sick or preterm neonate
This also includes appropriate (eg. Transport incubators, O2, etc) and rapid
transfers from level 3 hospitals to step-down facilities. This is known as retro –
referrals and are non-acute referrals
13
To these key essential services, the following overarching services can be added:
Monitoring and evaluation
 Audit care at facility level with institutionalising PPIP and making it functional. It requires 3
components which will render it functional:
a. Data capturing of all deliveries, births and perinatal deaths.
b. Entering & identifying the causes of deaths at regular minuted mortality and
morbidity meetings
c. Instituting management change and policies as a result of the facility data
Adequate resources
 Human resources according to the norms and standards
 Equipment - essential list for neonatal nurseries
 Training – in service training must be ongoing to all staff dealing with neonates eg: use of
DCST LINC toolkit, PEP manuals etc
1.2 Integrated activities for improving maternal and neonatal care
The NaPeMMCO and NCCEMD committees have both developed recommendations for reducing
maternal and neonatal deaths based on analyses of maternal and neonatal deaths from 2008-2011.
However, making recommendations is not sufficient, and key interventions that would reduce
maternal and neonatal mortality were identified. Both committees have been through a thorough
process of analysing what it would take to implement these key interventions. A list of key actions
in which all levels of professionals involved in health and the community (role players) are
involved and need to perform so that these key interventions will actually be implemented has been
developed. Figure 1 gives a flow diagram of responsibilities for actions for implementing strategies
for saving lives. There is considerable overlap between interventions to prevent maternal deaths
and neonatal deaths; hence the requested actions have been integrated into requested actions
from all role players to reduce maternal and neonatal deaths as a single entity.
Figure 1. A flow diagram of responsibilities for implementing actions to save lives
14
The recommendations of both committees can be summarised as improving the quality of care
provided for women and/or their neonates in 6 conditions namely HIV infection, obstetric
haemorrhage, complications of hypertension,interpartum care, birth asphyxia, premature babies
and infection in the babies. This would be achieved by improving the training of the health care
providers and the health system by improving access to care through the continuum (during
pregnancy, in childbirth and in the puerperium. (The key interventions for reducing maternal and
neonatal deaths include those given by the WHO but applied the South African situation). Usually
saving lives means improving a combination of the quality of care received and the coverage of the
intervention. The coverage of health care facilities is good in South Africa, and it is the quality of
care provided that needs significant improvement. The quality of care is dependent on the
activities of the health care managers in proving the necessary facilities (i.e. equipment, drugs and
staff) and access for the user which is mainly transport; and is also dependent on the knowledge,
skills and attitude of the health care provider (Figure 1). Hence the recommendations of both
committees have targeted improving the quality of care received by women and their babies by
identifying the key interventions that will reduce maternal deaths due to HIV infection, obstetric
haemorrhage and complications of hypertension and neonatal deaths due to birth asphyxia,
prematurity and neonatal infection. Implementing these interventions involves the health care
managers, health care providers and the user and her community. To achieve full implementation
every level of health care and the community needs to be involved and each role player should be
responsible for some activities which if performed will result in a reduction of maternal and
neonatal deaths.
In addition, strategies have been developed based on the key causes of mortality (NaPeMMCo). The
table below highlights intervention by cause of mortality.
Table: Interventions by Cause of Mortality
KEY CAUSE OF
MORTALITY
Improve the health
system for mothers
and babies:
Improve knowledge
and skills of health care
providers:
Most hypoxic deaths
are as a result of
inadequate intrapartum
care provided by health
care providers.
Reduce deaths due to
INTERVENTIONS
Contraception, including for post miscarriage and postpartum
24 hour access to functioning emergency obstetric and neonatal care
including clear referrals routes with dedicated obstetric and neonatal
ambulances
Maternal waiting homes, KMC sites in all hospitals
CEOs to ensure that there is no rotation of nursing staff providing
neonatal care
Train all health care workers providing maternity and neonatal care in the
ESMOE-EOST programme and in managing the immature infant using the
SA INC toolkit
Train all health care workers who deal with pregnant women in HIV
advice, counselling, testing and support , initiation of HAART, monitoring
of HAART
Train all health care workers in correct management of intrapartum care
(use of the Partogram, 3rd stage of labour)
Every women in labour must be monitored appropriately by a skilled
15
asphyxia:
Asphyxia was the
leading cause of
neonatal deaths in the
birth category >1000g.
70% of death in the
>2,5kg group were
classified as hypoxia
related.
birth attendant
All birth attendants must skilled in at least bag and mask ventilation of the
neonate
The partogram must be used to monitor labour according to prescribed
norms
All complicated and obstructed labours must have access to Caesarean
section when indicated
A birth attendant skilled
in neonatal
resuscitation can
reduce deaths to
hypoxia by up to 40%.
Reduce deaths due to
prematurity:
The use and application
of nasal CPAP at a
district hospital can
reduce mortality of this
group by up to 40%.
Reduce deaths due to
infection:
Infection is the third
largest cause of
neonatal deaths in all
weight categories, but
highest in the 1000g2000g group
Corticosteroids must be given where possible to every women in preterm
labour
Antibiotics must be given to every women with preterm premature
rupture of membranes
All hospitals (especially district hospitals)must have staff skilled in the use
of nasal CPAP
All mothers of immature infants have easy access to KMC
There must be strict adherence to basic hygiene in labour wards and
nurseries. D-germ alcohol sprays, soap, clean water and paper towels
must be available in all nurseries as essential consumables
There must be presumptive antibiotic therapy for newborns at risk of
bacterial infection
There must be case management of neonatal sepsis, meningitis and
pneumonia
As breast milk provides the best nutrition and protection for the preterm
baby, districts should provide breast milk (not preterm formulas) to all
preterm babies by the establishment of human milk banks.
Infection dashboard must be introduced in all neonatal nurseries to
reduce infections by heightening awareness and surveillance of infection
rates.
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APPENDIX 2: ROLES AND RESPONSIBLITIES FOR KEY ROLE-PLAYERS
Below is a menu of activities directed at the various levels of care. Much of the actions are
repetitive, but this is to ensure the activities are carried out at every level of care and that everyone
is pulling in the same direction. Activities are grouped according to the following categories:





Community education;
Access to care;
Health care management;
Health care provider training; and
Monitoring and evaluation.
The tables below highlight activities requested from the various levels. There is a separate table for
each level.
TABLE: ACTIVITIES REQUESTED FROM POLICY MAKERS
Activities requested from Policy Makers (Minster of Health and Provincial MECs)
Community Education


Access to care


Health care management




Promote the message that all pregnant women should be
delivered by a skilled birth attendant in an environment that
has sufficient facilities to ensure a safe birth
Ensure that standard basic educational maternal and neonatal
health messages are developed and available (contents are
given below)
Improve access by
o Considering developing maternity waiting homes in or near
health care facilities
o Considering the use of motor-bike ambulances in remote
areas with community health workers as “ambulance”
drivers
o Fast track the development of national and provincial
staffing and equipment norms for maternity units,
caesarean section theatres and nurseries (based on SA-INC
toolkit)
Promote and integrate contraceptive services at every contact
with health service.
Provide widespread advocacy to achieve the MDGs 4 and 5.
(Prioritise managing HIV in pregnancy; improving intrapartum
care to reduce neonatal deaths due to hypoxia and maternal
deaths due to haemorrhage and hypertension; and managing
small and sick premature baby and the prompt management of
neonatal infections.)
Prioritise and target districts with most severe maternal and
neonatal mortality rates
Promote the establishment, use of and support the district
clinical specialist teams to facilitatethe implementation of the
recommendations
Actively support the following health strategies
o Current HIV and AIDS strategy
o Strategies to prevent and manage obstetric haemorrhage
17
Monitoring and evaluation

and hypertension (detailed below in each section) but
include prevention by iron, folate and calcium
supplementation, taking the blood pressure and measuring
the haemoglobin at antenatal care, provide emergency care
training and protocols for emergencies in obstetric
haemorrhage and hypertension using the ESMOE
programme and by provide facilities appropriately
equipped and staffed for basic (CHCs) and comprehensive
emergency obstetric care (District hospitals and above).
o Promote strategies to improve intrapartum care and care
of the infants with asphyxia and who are born premature
(detailed below). These should include use of the
partogram for every woman in labour, the use of evidenced
based interventions to reduce neonatal deaths, the use of
antenatal corticosteroids and antibiotics for women with
preterm premature rupture of membranes, ensure the
health care providers can resuscitate a newborn babies
using ESMOE and HBB; use the Essential Newborn Care the management of small and sick neonates booklet.
o Promote strategies to prevent neonatal infections. These
should include ensuring that all health care facilities
conducting births have infection control measures in
place, havemilk banks and/or milk pasterurisation at all
facilities to promote breast feeding including those HIV
exposed at birth; KMC practice to be enforced as a basic
requirement for all facilities where babies are born.
Ensure monitoring and evaluation of the implementation of
the recommendations by
o Promoting maternal and perinatal morbidity and mortality
reviews and local use of the data
o Considering making Institutional MMR due to Obstetric
Haemorrhage and Hypertension as indices and suggest
monitoring progress in provinces and districts 6 monthly
o Considering making the fresh stillbirth + early neonatal
death for babies 2.5kg+ rate as a marker to be tracked for
the quality of intrapartum care
o Considering making the early neonatal death rate for
neonates between 1.0kg and 1.49kg as a marker for the
quality of neonatal care.
o Considering introducing an accreditation system for
hospitals for caesarean sections
o Considering introducing an accreditation system for
neonatal care as per SA-INC
o Considering dedicated National Maternal and Perinatal
Audit Units like the UK “CEMCH”
Table: Activities requested from National and Provincial Director Generals/HODs
Activities requested from the National and the Provincial Director Generals/ HODs
18
Community Education










Access to Care




Determine the standard basic health educational
messages but these must include;
o Starting folate supplementation as soon as the
couple start planning a pregnancy
o Importance of booking early and attending
antenatal clinics regularly healthy eating and
iron supplements to reduce anaemia in
pregnancy;
o Importance of attending with any bleeding in
pregnancy ;
o Importance of labour with skilled birth
attendant and early attendance in labour to
prevent prolonged labour;
o Planning of transport when in labour, warning
of dangers of self-use of oxytocic agents to
encourage labour;
o Home base life-saving skills in the event of
home delivery with bleeding (uterine massage,
baby to breast, empty bladder, keep baby
warm with providing skin to skin care (KMC) ,
clamp and cut cord, early breastfeeding).
Start calcium supplementation once pregnancy
diagnosed to reduce hypertension in pregnancy
Know the importance of early warning signs for
eclampsia/severe preeclampsia; i.e. Headache, swelling
blurred vision etc.
Know the importance of early warning signs for
infection of the newborn baby i.e. high pitched cry,
unable to feed, red swollen umbilical stump, etc.)
Encourage all mothers to breast feed their babies
within an hour after birth
Encourage everyone to know their HIV status
To plan their families.
To start antenatal care in the first trimester
Pregnant women must be attended during labour by a
skilled birth attendant in a facility that has the
appropriate resources
Develop Videos, Radio booklets, community theatre,
community health workers, NGOs and women’s groups.
Revitalise education at ANC which should include
neonatal care issues such as care of the preterm baby
Ensure emergency transport facilities must be available
for all pregnant women in need (at any site)Ensure
transport issues are addressed with communities
Consider introducing Maternity Waiting Homes
Ensure transport from L1/CHC to higher levels be
continuously available and preferably on site; in
remote areas consider the use of motor bike
ambulances stationed at clinics and with a CHW as
"ambulance" driver
Ensure criteria for referral and referral routes must be
19
Health Management







Health Care Provider Training

established and utilized appropriately in all provinces
Ensure staffing and equipment norms are established
for each level and for every health institution
concerned with the care of pregnant women and their
babies. This includes adequate staffing levels for 24
hour acute care in labour and postpartum; but also for
maternity theatres and monitoring post-delivery and
post CS. Until norms are provided use the WHO labour
ward norm of one midwife in labour ward per 175
deliveries per year.
Ensure all CHCs can provide basic emergency care,
namely ability to give magnesium sulphate, oxytocics,
antibiotics, manual removal of the placenta, manual
vacuum aspiration of incomplete miscarriage, assisted
delivery, bag and mask ventilation of newborns, and
provide basic routine care of the neonate (as per SAINC ), namely provide adequate warmth for baby
(KMC), treat infections promptly, feeding of preterm
neonates, provision of oxygen for babies in respiratory
distress and monitoring of blood glucose, bag and mask
ventilation of newborns and HIV testing and
antiretroviral treatment if indicated.
Ensure all district hospitals can provide comprehensive
emergency obstetric care, namely basic antenatal care
(listed above) and the ability to give a blood transfusion
and perform a caesarean section.
Ensure all district hospitals can provide routine and
essential newborn care, namely the management of the
small and sick baby (part of SA-INC) and the ability to
provide basic nasal CPAP.
Ensure that district hospitals and CHC can pasteurize
breast milk and thus have the necessary equipment
available for pasteurization and or milk banking
Ensure the supply chain for essential drugs; iron, folate
oxytocin,
ergometrine,
magnesium
sulphate,
antihypertensives (nifedipine & alpha-methyl dopa);
phenobarbitone, midazolam, iron syrup, multivitamins,
antiretroviral drugs to be seen as essential drugs and
never in short supply
Ensure basic monitoring equipment is available
especially
baumanometers,
pulse
oxyimeters,
heamoglobinometers, on-site HIV testing kits,
transcutaneous bilirubinometers, infusion pumps are
appropriate and adapted for neonatal use are available
at all institutions conducting births.
Provide support for the training of doctors and
midwives in ESMOE+HBB, by instructing CEOs to give
time for the doctors and midwives to have the training
and insist on emergency obstetric simulation training
exercises taking place at least monthly in their
institutions
20


Monitoring and evaluation









Ensure Emergency Obstetric Simulation Training
exercises are preformed routinely at every institution
conducting births, these must include neonatal
resuscitation
Ensure these key activities become part of the key
performance areas of the appropriate managers.
Introduce a national standardised birth registeras the
major data sourcefor DHIS and audit programmes
Introduce a national standardized neonatal register for
all district hospitals as per the SA-INC toolkit
Ensure death review meeting occur where maternal
death notification forms are completed and neonatal
deaths are discussed and minutes are kept of the
meeting
Consider making Institutional MMR due to obstetric
haemorrhage and hypertension as indices and monitor
progress in districts and provinces 6 monthly
Consider making the fresh stillbirth + early neonatal
death for babies 2.5kg+ rate and the early neonatal
death rate for neonates between 1.0kg and 1.49kg as a
indices for the quality of intrapartum and neonatal care
respectively and monitor progress in districts and
provinces 6 monthly
Consider introducing process evaluation of maternal
deaths due to haemorrhage and hypertension,
intrapartum asphyxia and prematurity over 1 kg.
Consider introducing an accreditation system for
hospitals for caesarean sections
Consider introducing an accreditation system for
district hospitals as per SA-INC
Have six monthly reports on proportion of women
testing for HIV, proportion found positive, proportion
started on ARVS and on dual therapy, proportion HIV
infected mothers and infants seen within 6 days of
discharge and at 6 weeks, proportion of HIV exposed
infants that have a PCR at 6weeks and proportion of
HIV infected mothers that have a CD4 count at 6 weeks
TABLE: ACTIVITIES REQUESTED FROM PROVINCIAL MCWH MANAGERS AND DISTRICT MANAGERS
Activities requested from the provincial MCWH managers and the District Managers
Community education




Ensure the standard basic maternal health educational
messages are spread throughout the district including;
Starting folate supplementation as soon as the couple
start planning a pregnancy, healthy eating and iron
supplements to reduce anaemia in pregnancy;
Importance of booking early and attending antenatal
clinics regularly
Importance of attending with any bleeding in
21









Access to Care





Health Management


pregnancy ;
Importance of labour with skilled birth attendant and
early attendance in labour to prevent prolonged labour;
Planning of transport when in labour, warning of
dangers of self-use of oxytocic agents to encourage
labour;
Home base life-saving skills in the event of home
delivery with bleeding (uterine massage, baby to
breast, empty bladder, keep baby warm with providing
skin to skin care (KMC) , clamp and cut cord, early
breastfeeding).
Start calcium supplementation on diagnosis of
pregnancy to reduce hypertension
Know the importance of early warning signs for
eclampsia/severe preeclampsia; i.e. Headache, swelling
blurred vision etc.
Know the importance of early warning signs for
infection of the newborn baby i.e. high pitched cry,
unable to feed, red swollen umbilical stump, etc.)
Encourage all mothers to breast feed their babies
within an hour after birth
Develop Videos, Radio booklets, community theatre,
community health workers, NGOs and women’s groups.
Revitalise education at ANC which should include
neonatal care issues such as care of the preterm baby.
Encourage everyone to
o Know their HIV status
o To plan their families.
o To start antenatal care in the first trimester
o Pregnant women must be attended during
labour by a skilled birth attendant in a facility
that has the appropriate resources
Address transport issues with communities
Consider introducing Maternity Waiting Homes
Ensure availability of emergency transport facilities for
pregnant women in need (at any site)
Ensure transport from L1/CHC to higher levels be
continuously available and preferably on-site especially
in remote areas. Consider the use of motor bike
ambulances stationed at clinics and with a CHW as
"ambulance" driver
Ensure criteria for referral and referral routes are
established and utilized appropriately.
Ensure staffing and equipment norms are established
for each level and for every health institution
concerned with the care of pregnant women and her
baby and form part of accreditation criteria for
maternal services.
Ensure adequate staffing levels for 24 hour acute care
in labour and postpartum; but also for maternity
theatres and monitoring post-delivery and post CS.
22










Until norms are provided use the WHO labour ward
norm of one midwife in labour ward per 175 deliveries
per year.
Ensure all CHC can provide basic emergency care,
namely ability to give magnesium sulphate, oxytocics,
antibiotics, manual removal of the placenta, manual
vacuum aspiration of incomplete miscarriage, assisted
delivery, bag and mask ventilation of newborns, and
provide basic routine care of the neonate (as per SAINC ), namely provide adequate warmth for baby
(KMC), treat infections promptly, feeding of preterm
neonates, provision of oxygen for babies in respiratory
distress and monitoring of blood glucose, bag and mask
ventilation of newborns and HIV testing and
antiretroviral treatment if indicated.
Ensure
all
district
hospitals
can
provide
comprehensive emergency obstetric care, namely
basic antenatal care and the ability to give a blood
transfusion and perform a caesarean section.
Ensure dedicated telephonic linkages for consultation
for emergencies between referring and referral site are
available. (Use the standard SBAR charts for referrals)
Ensure that district hospitals and CHC can pasteurize
breast milk and thus have the necessary equipment
available for pasteurization and or milk banking
Ensure the supply chain for essential drugs; iron,folate
oxytocin,
ergometrine,
magnesium
sulphate,
antihypertensives (nifedipine & alpha-methyl dopa),
phenobarbitone, midazolam, iron syrup, multivitamins,
and antiretroviral drugs
Ensure basic monitoring equipment is available such as
baumanometers,
pulse
oxyimeters,
heamoglobinmeters,on-site
HIV
testing
kits
transcutaneous bilirubinometers, infusion pumps are
appropriate and adapted for neonatal use are available
at all institutions conducting births.
Ensure that all women in labour are monitored on the
partogram and provide continuing medical education
on the use for the partogram
Introduce practical skills training and training for
caesarean section
Introduce Early Warning Charts. Postoperative and
postpartum monitoring must occur, be audited and
enabled with appropriate equipment and early warning
monitoring charts.
Protocols on the management of important maternal
conditions (especially HIV/AIDS, obstetric Haemorrhage
and hypertension) causing maternal deaths must be
available and utilised appropriately in all institutions
(including facilities only providing antenatal and
postnatal services) where women deliver. All midwives
23



Health Care Provider Training






Monitoring and Evaluation


and doctors must be trained on the use of these
protocols.
An eclampsia box must be on the resuscitation trolley
of all institutions conducting births and must include a
checklist of action for managing eclampsia
An obstetric haemorrhage box must be on the
resuscitation trolley of all institutions conducting births
and must include a checklist of action for managing
obstetric haemorrhage
Protocols on the management of important neonatal
conditions (especially neonatal infections, hypoxic
babies and premature babies) causing neonatal deaths
must be available and utilized appropriately in all
institutions (including facilities which only provide
antenatal and postnatal services) where women
deliver. All midwives and doctors must be trained on
the use of these protocols bound in a pocket-sized
booklet for easy access.
Provide support for the training of doctors and
midwives in ESMOE and SA-INC, by instructing CEOs to
give time for the doctors and midwives to have the
training and insist on emergency obstetric simulation
training exercises taking place at least monthly in their
institutions
Ensure midwives, MOs in CHCs, District Hospitals and
above undergo ESMOE and HBB training
Ensure health care institutions performing deliveries
perform and score Emergency Obstetric Simulation
Training exercises at least monthly and involve all their
maternity staff. These must also include neonatal
resuscitation. (A roster of those attending and the score
must be passed onto the CEO of the institution)
Ensure these key activities become part of the key
performance areas of the appropriate managers.
Training should be provided for all health professional
working in maternity units in practical obstetrical and
surgical skills. Skills should be provided in anaesthesia,
especially in level 1 institutions
Ensure training of midwifery staff, neonatal nurses and
doctors in KMC, oxygen administration, where
appropriate nasal CPAP, infection prevention and
prompt treatment, , fluids and feeding the preterm
baby, temperature and glucose control, PMTCT /
HAART, immunization of preterm babies (Late NND),
management of HIE / hypoxic babies Management of
LBW babies, and training in Infection control.
Ensure the introduction of the national standardised
birth register to be the major source of data for DHIS
and audit programmes
Introduce a national standardized neonatal register for
all district hospitals as per the SA-INC toolkit
24








Check data submitted by institution to DHIS
Ensure death review meeting occur where maternal
death notification forms are completed and neonatal
deaths are discussed and minutes are kept of the
meeting
Consider making Institutional MMR due to Obstetric
Haemorrhage and Hypertension as indices and monitor
progress in districts and provinces 6 monthly
Consider making the fresh stillbirth + early neonatal
death for babies 2.5kg+ rate and the early neonatal
death rate for neonates between 1.0kg and 1.49kg as a
indices for the quality of intrapartum and neonatal care
respectively and monitor progress in districts and
provinces 6 monthly
Consider introducing process evaluation of maternal
deaths due to haemorrhage and hypertension,
intrapartum asphyxia and prematurity over 1 kg.
Consider Introducing an accreditation system for
hospitals for caesarean sections
Consider Introducing an accreditation system for
district hospitals as per SA-INC
Have six monthly reports on proportion of women
testing for HIV, proportion found positive, proportion
started on ARVS and on dual therapy, proportion HIV
infected mothers and infants seen within 6 days of
discharge and at 6 weeks, proportion of HIV exposed
infants that have a PCR at 6weeks and proportion of
HIV infected mothers that have a CD4 count at 6 weeks
TABLE: ACTIVITIES REQUESTED FROM CEOS
Activities requested from the CEO's of institutions
Access to Care




Health Care Management
Communicate with District Managers to ensure
emergency transport facilities are available for all
pregnant women and neonates in need (at any site)
Communicate with District Managers to ensure
dedicated transport ambulances are available for
neonatal emergencies and staffed by paramedics
trained in neonatal emergencies and care sport issues
to be addressed with communities;
Ensure criteria for referral and referral routes are
established and utilized appropriately
Ensure that that no patient is refused access when a
transfer is requested from lower level to higher of care
or vise-a-versa
If a CEO of a CHC:
 Ensure CHC can provide basic emergency care, namely
ability to give magnesium sulphate, oxytocics,
25
antibiotics, manual removal of the placenta, manual
vacuum aspiration of incomplete miscarriage, assisted
delivery, bag and mask ventilation of newborns and HIV
testing and antiretroviral treatment if indicated.
 Ensure CHC can provide routine care of the neonate,
provide adequate warmth for baby (KMC), treat
infections promptly, feeding of preterm neonates,
provision of oxygen for babies in respiratory distress
and monitoring of blood glucose.
 Ensure that all clinicians are aware of referral criteria
If a CEO of a District Hospital:
 Ensure the hospital can provide comprehensive
emergency obstetric care, namely basic antenatal care
(listed above) and the ability to give a blood transfusion
and perform a caesarean section.
 Ensure all district hospitals can provide routine and
essential newborn care, namely the management of the
small and sick baby (part of SA-INC) and the ability to
provide basic nasal CPAP.
For CEOs of District Hospitals and higher:
 Ensure CPAP machines must be available at every
institution where premature births occur
 Make available dedicated telephonic linkages for
consultation for emergencies between referring and
referral site. (Use the standard SBAR charts for
referrals).
 Ensure adequate staffing levels for 24 hour acute care
in labour and postpartum; but also for maternity
theatres and monitoring post-delivery and post CS.
Until norms are provided use the WHO labour ward
norm of one midwife in labour ward per 175 deliveries
per year.
 Ensure the supply chain for essential drugs; iron, folate
oxytocin,
ergometrine,
magnesium
sulphate,
antihypertensives (nifedipine & alpha-methyl dopa),
phenobarbitone, midazolam, iron syrup, multivitamins,
and antiretroviral drugs to be seen as essential drugs
and never in short supply
 Ensure basic monitoring equipment is available such as
baumanometers,
pulse
oxyimeters,
Doptones,
heamoglobinmeters, transcutaneous bilirubinometers,
infusion pumps are appropriate and adapted for
neonatal useand on-site HIV testing kits are available at
all institutions conducting births
 Ensure that all women in labour are monitored on the
partogram and provide continuing medical education
on the use for the partogram
 Ensure postoperative and postpartum monitoring must
occur, be audited and enabled with appropriate
equipment and using the early warning monitoring
charts.
26


Health Care Provider Training





Monitoring and Evaluation


Protocols on the management of important maternal
conditions (especially HIV/AIDS, obstetric haemorrhage
and hypertension) causing maternal deaths must be
available and utilised appropriately in all institutions
(including facilities which only provide antenatal and
postnatal services) where women deliver. All midwives
and doctors must be trained on the use of these
protocols.
o An eclampsia box must be on the resuscitation
trolley of all institutions conducting births and
must include a checklist of action for managing
eclampsia
o An obstetric haemorrhage box must be on the
resuscitation trolley of all institutions
conducting births and must include a checklist
of action for managing obstetric haemorrhage
Protocols on the management of important neonatal
conditions (especially neonatal infections, hypoxic
babies and premature babies) causing neonatal deaths
must be available and utilized appropriately in all
institutions (including facilities which only provide
antenatal and postnatal services) where women
deliver. All midwives and doctors must be trained on
the use of these protocols bound in a pocket-sized
booklet for easy access.
Ensure All Midwives and MOs in CHCs, District Hospitals
and above undergo ESMOE training
Ensure Emergency Obstetric Simulation Training
exercises involve all their maternity staff and are
performed and scored at least monthly. (A roster of
those attending and the score must be passed onto the
CEO of the institution)
Training should be provided for all health professionals
working in maternity units in practical obstetrical and
surgical skills. Skills should be provided in anaesthesia,
especially in level 1 institutions
In District Hospitals and above introduce training for
caesarean section
Ensure training of midwifery staff, neonatal nurses and
doctors in HBB, KMC, oxygen administration, where
appropriate nasal CPAP, infection prevention and
prompt treatment, , fluids and feeding the preterm
baby, temperature and glucose control, PMTCT /
HAART, immunization of preterm babies (Late NND),
management of HIE / hypoxic babies Management of
LBW babies, and training in Infection control.
Introduce the national standardised birth register to be
the major source of data for DHIS and audit
programmes
Introduce a national standardized neonatal register for
27
all district hospitals as per the SA-INC toolkit
 Consider Introducing an accreditation system for
district hospitals as per SA-INC
 Encourage the use of infection dash boards at all
neonatal nurseries to provide infection surveillance
 Check data submitted by institution to DHIS
 Ensure death review meeting occur where maternal
death notification forms are completed and neonatal
deaths are discussed and minutes are kept of the
meeting
 Consider making Institutional MMR due to obstetric
haemorrhage and hypertension as indices and monitor
progress in districts and provinces 6 monthly
 Consider making the fresh stillbirth + early neonatal
death for babies 2.5kg+ rate and the early neonatal
death rate for neonates between 1.0kg and 1.49kg as a
indices for the quality of intrapartum and neonatal care
respectively and monitor progress in districts and
provinces 6 monthly
Consider introducing process evaluation of maternal deaths
due to haemorrhage and hypertension, intrapartum
asphyxia and prematurity over 1 kg.
TABLE: ACTIVITIES REQUESTED FROM DISTRICT CLINICAL SPECIALIST TEAMS
Activities requested from district clinical specialist teams
Access to Care



Health Care Management


Monitor and where necessary support the appropriate
health manager to ensure that emergency transport
facilities are available for all pregnant women and
neonates in need (at any site)
Monitor and where necessary support the appropriate
health manager to ensure transport issues are address
with communities;
Monitor and where necessary ensure criteria for
referral and referral routes are established and utilized
appropriately to functional emergency maternity and
neonatal facilities.
Monitor and support the appropriate health manager
to ensure the CHC can
o provide basic emergency care, namely ability to
give magnesium sulphate, oxytocics, antibiotics,
manual removal of the placenta, manual vacuum
aspiration of incomplete miscarriage, assisted
delivery, bag and mask ventilation of newborns
and HIV testing and antiretroviral treatment if
indicated.
provide routine newborn care, namely bag and mask
ventilation of newborns, provide adequate warmth for
28










baby (KMC), treat infections promptly, feeding of
preterm neonates, provision of oxygen for babies in
respiratory distress and monitoring of blood glucose
Monitor and support the appropriate health manager
to ensure the district hospitals can
o provide comprehensive emergency obstetric care,
namely basic antenatal care (listed above) and the
ability to give a blood transfusion and perform a
caesarean section.
o provide routine and essential newborn care,
namely the management of the small and sick
baby (part of SA-INC) and the ability to provide
basic nasal CPAP
Monitor and provide health care manages support to
ensure adequate staffing levels for 24hour neonatal
care. Norms are provided with the SA-INC toolkit and
should be applied to all district hospitals.
Monitor and support the appropriate health manager
to ensure availability of CPAP machines where large
numbers of premature babies are born (see CPAP
criteria at district hospital)
Monitor and support appropriate health managers to
ensure dedicated telephonic linkages for emergency
consultation between referring and referral site are
available. (SBAR charts)
Train maternity staff in the use of early warning
monitoring charts and SBAR chart use.
Monitor and provide health care manages support to
ensure adequate staffing levels for 24 hour acute care
in labour and postpartum; but also for maternity
theatres and monitoring post-delivery and post CS.
Until norms are provided use the WHO labour ward
norm of one midwife in labour ward per 175 deliveries
per year.
Monitor and support appropriate health managers to
ensure availability of blood for transfusion at institution
where caesarean sections are performed
Monitor and support appropriate health managers to
ensure supply chain for essential drugs; iron, folate
oxytocin,
ergometrine,
magnesium
sulphate,
antihypertensives (nifedipine & alpha-methyl dopa),
phenobarbitone, midazolam, iron syrup, multivitamins,
and antiretroviral drugs to be seen as essential drugs
and never be in short supply
Monitor and support appropriate health managers to
ensure basic monitoring equipment (baumanometers,
pulse oxyimeters, heamoglobinmeters, transcutaneous
bilirubinometers, infusion pumps) are appropriate and
adapted for neonatal use and on-site HIV testing kits
are available at all institutions conducting births
Monitor and ensure adequate intrapartum care, and
29





Health Care Provider Training







ensure it is audited and enabled with appropriate
equipment and correct usage of the Partogram to
identify high-risk deliveries.
Monitor and ensure postoperative and postpartum
care, and ensure it is audited and enabled with
appropriate equipment and using the early warning
monitoring charts.
Monitor and support appropriate health managers to
ensure that an eclampsia box is on the resuscitation
trolley and aaction checklist for managing eclampsia is
included
Monitor and support appropriate health managers to
ensure that an obstetric haemorrhage box is on the
resuscitation trolley and aaction checklist for managing
obstetric haemorrhage is included
Monitor and support appropriate health managers to
ensure the maternity theatres are of the appropriate
standard
Ensure that an adequate system is in place to provide
accessible advanced antenatal care
Train midwives and MOs in CHCs, District Hospitals in
ESMOE and HBB
Introduce practical skills and CPAP use in respiratory
distress training of the neonate
Monitor Emergency Obstetric Simulation Training
exercises and ensure they involve all their maternity
staff and are performed and scored at least monthly.
(A roster of those attending and the score must be
passed onto the CEO of the institution)
Introduce practical skills for caesarean section in
District Hospitals and above
Ensure protocols on the management of important
conditions (especially HIV/AIDS, obstetric Haemorrhage
and hypertension) causing maternal deaths are
available and utilised appropriately in all institutions
(including facilities which only provide antenatal and
postnatal services) where women deliver. All midwives
and doctors must be trained on the use of these
protocols.
Ensure Protocols on the management of important
conditions (especially neonatal infections, hypoxic
babies and premature babies) causing neonatal deaths
must be available and utilized appropriately in all
institutions (including facilities which only provide
antenatal and postnatal services) where women
deliver. All midwives and doctors must be trained on
the use of these protocols bound in a pocket-sized
booklet for easy access.
Ensure protocol for breast milk pasteurization and or
milk banking process is available
30





Monitoring and Evaluation









Train maternity staff in the use of infection dashboards
for infection surveillance.
Train appropriate MOs in obstetric anaesthesia,
especially in level 1 institutions
Train appropriate MOs in the use of CPAP, especially in
level 1 institutions
Ensure that training is provided for all health
professional working in neonatal nurseries in practical
neonatal skills. Skills should be provided in KMC,
breastfeeding promotion, PMTCT, CPAP use and bag
and mask ventilation for neonatal resuscitation,
especially in level 1 institutions.
All Midwives and MOs in CHCs, District Hospitals and
above must undergo HBB training
Monitor and where necessary support the appropriate
health manager to ensure that the national
standardised birth register is introduced and used as
the major source of data for DHIS and audit
programmes
Monitor and where necessary support the appropriate
health manager to ensure that the national
standardized neonatal register is introduced for all
district hospitals as per the SA-INC toolkit.
Assess each facility with respect to its ability to provide
the signal functions for obstetric and neonatal care (see
appendix 2)
Check data submitted by institution to DHIS and
correlate this with the institutional PPIP data to identify
gaps within the data sets.
Ensure death review meetings occur where maternal
death notification forms are completed and neonatal
deaths are discussed and minutes are kept of the
meeting
Use Institutional MMR due to obstetric haemorrhage
and hypertension as indices and monitor progress in
districts and provinces 6 monthly
Use the fresh stillbirth + early neonatal death for babies
2.5kg+ rate and the early neonatal death rate for
neonates between 1.0kg and 1.49kg as a indices for the
quality of intrapartum and neonatal care respectively
and monitor progress in districts and provinces 6
monthly
Introduce process audits of maternal deaths due to
haemorrhage and hypertension, intrapartum asphyxia
and prematurity over 1 kg.
Encourage labour wards, theatres and OPDs to monitor
and chart own progress as way of getting buy in to
make changes, e.g. theatres to have chart for numbers
of PPH after caesarean section to be entered monthly
on notice board in theatre to monitor progress and to
31



provide incentives to improve
Form part of an accreditation system for hospitals for
caesarean sections
Form part of an accreditation system for district
hospitals as per SA-INC
Review six monthly reports on proportion of women
testing for HIV, proportion found positive, proportion
started on ARVS and on dual therapy, proportion HIV
infected mothers and infants seen within 6 days of
discharge and at 6 weeks, proportion of HIV exposed
infants that have a PCR at 6weeks and proportion of
HIV infected mothers that have a CD4 count at 6 weeks
TABLE: ACTIVITIES REQUESTED FROM WARD PRIMARY CARE TEAMS
Activities requested from Ward Primary Care Team
Community Education

Ensure that standard basic educational maternal health
messages are promoted in the community
 Encourage everyone to know their HIV status
 Encourage pregnant women to start antenatal care in
the first trimester
 Encourage the community to plan their families
 Encourage breastfeeding in all newborns, including HIV
exposed babies
 Address transport issues with communities;
 Discourage unsafe cultural practices e.g. cow dung to
umbilical stump
 Ensure mother and infant in the postnatal period are
seen and examined within 6 days of delivery (3 days of
discharge) and at 6 weeks
 Ensure contraceptive use is discussed and where
appropriate prescribed.
Provide access to pre-counselling services and information
in preparation of premature birth
TABLE: ACTIVITIES REQUESTED FROM HEADS OF CLINICAL DEPARTMENTS
Activities requested from Heads of Clinical Departments
Health Care Management

Ensure that their departments have protocols on
monitoring/preventing and management of the
conditions mentioned above
 Pregnant Woman with HIV infection
 Pregnant Woman in labour
 Obstetric haemorrhage
 Hypertension
 Infant with Intrapartum asphyxia
 Preterm infant
32


Health Care Provider Training

Monitoring and Evaluation

 Infections
Using specilaists on the “labour ward floor” in the
larger regional and tertiary hospitals
Defining the functioning of specialists so they play a
greater role in clinical care , support and outreach and
less as a ‘consultant”
The full use of specialists to teach trainees CS and
emergency life saving surgical procedures
Introducing more robust maternal and perinatal
morbidity meetings making these compulsory for all
regional and tertiary hospitals
TABLE: ACTIVITIES REQUESTED FROM DOCTORS
Activities requested from all doctors involved in care of pregnant women
Community Education
 Ensure they offer all pregnant women information on,
screening for and appropriate management of nonpregnancy related infections (especially HIV and TB)
and common medical disorders
Access to Care
 Ensure they promote professional attitudes and ethical
behaviour
 Ensure a non-judgemental approach to people infected
with HIV
Health care Management
 Ensure contraceptive use is discussed and where
appropriate prescribed.
 Ensure that standard basic educational maternal and
neonatal health messages are promoted in the
community
Health Care Provider Training
 Ensure they undergo ESMOE + HBB training
 Ensure they participate in emergency obstetric
simulation training exercises
 Where applicable be trained in practical obstetrical and
surgical skills. Skills should include anaesthesia,
especially in level 1 institutions
 Where applicable be trained in practical neonatal skills.
Skills should include CPAP training, especially in level 1
institutions
TABLE: ACTIVITIES REQUESTED FROM MIDWIVES AND NURSES
Activities requested from the midwives and all nurses involved in the care of pregnant women
Access to Care


Health Care Management


Ensure they promote professional attitudes and ethical
behaviour
Ensure a non-judgemental approach to people infected
with HIV
Ensure contraceptive use is discussed and where
appropriate prescribed.
Ensure that standard basic educational maternal and
33
Health Care Provider Training



neonatal health messages are promoted in the
community
Ensure they undergo ESMOE + HBB training
Ensure they participate in emergency obstetric
simulation training exercises
Ensure they offer all pregnant women information on,
screening for and appropriate management of nonpregnancy related infections (especially HIV and TB)
and common medical disorders
TABLE: ACTIVITIES REQUESTED FROM NURSING COLLEGES AND DEPARTMENTS
Activities requested from Nursing Colleges and Nursing Departments in universities
Health Care Management

Ensure managing pregnant women and their babies
with HIV infection, premature babies, prevention and
management of hypoxic ischeamic encephalopathy and
early recognition and treatment of neonatal infections
Health Care Provider Training

Provide training and monitoring of professional
attitudes and ethical behaviour
Ensure that standard basic educational maternal health
messages are taught
Ensure the contents of the ESMOE + HBB course are
included in their curriculum
Ensure training in the early warning charts and SBAR
referral system is provided
Ensure managing pregnant women and their babies
with HIV infection, hypertension in pregnancy and
obstetric haemorrhage are priorities in the training
Discuss with medical schools to standardise midwifery
training
Ensure morbidity and mortality auditing is taught and
becomes part of the ethos of nurses





Monitoring and Evaluation

TABLE: ACTIVITIES REQUESTED FROM MEDICAL SCHOOLS
Activities requested from medical schools
Health Care Management

Health Care Provider Training



Ensure managing pregnant women and their babies
with HIV infection, premature babies, prevention and
management of hypoxic ischaemic encephalopathy and
early recognition and treatment of neonatal infections
Provide training and monitoring of professional
attitudes and ethical behaviour
Ensure the contents of the ESMOE + HBB course are
included in their curriculum
Ensure training in the essential newborn care SA-INC
manual
34





Monitoring and Evaluation

Ensure training in the early warning charts and SBAR
referral system is provided
Ensure managing pregnant women and their babies
with HIV infection, hypertension in pregnancy and
obstetric haemorrhage are priorities in the training
Ensure that standard basic routine newborn care are
taught at undergraduate level
Ensure that standard basic educational maternal and
neonatal health messages are taught
Discuss with nursing schools to standardise midwifery
training for doctors
Ensure morbidity and mortality auditing is taught and
becomes part of their ethos
TABLE: ACTIVITIES REQUESTED BY HPCSA
Activities requested from HPCSA
Health Care Provider Training
Make successful completion of the ESMOE +HBB course a
requirement for registration as a community service
doctor
TABLE: ACTIVITIES REQUESTED FROM COMMUNITY
Activities requested from the community
Community Education

Adhere to the basic maternal and neonatal health care
messages
Access to care

Accept responsibility for their health and live a healthy
life style
Ensure the pregnant women make provision for
transport when they going into labour

35
ANNEXURE 4: DISTRICT DATA AND TARGETS FOR NEWBORN CARE
36