Scale of the problem
In South Africa, perinatal deaths are defined as all stillbirths and early neonatal deaths (from live birth to seven full days after birth). While the country has accepted the definition* of reporting and recording all deaths (foetal and neonatal) weighing more than 500 grams, it is uncertain if all hospitals where deliveries take place are correctly reporting all deaths weighing less than 1000 grams, especially stillbirths. This may be influenced by a South African law that requires all defined stillbirths to have a burial and notification of death. In rural areas and busy hospitals, this may be seen as labour intensive for already overworked staff.
The new global guidance will help monitor stillbirths weighing more than 1000 grams. However, what still remains to be addressed are the deaths of babies weighing less than 1000 grams – the extreme low-birth weight (ELBW) infant. In South Africa, prematurity is the driver of mortality. Babies who die weighing less than 1000 grams contribute to over half of all premature deaths. This is problematic as the country does not provide equitable care to ELBW infants, with large disparities in available care within and across provinces. Moreover, admission criteria for ELBW infants is not standardised even within tertiary centres where most of the dedicated specialised care is provided. The wide and growing disparity in available care in South Africa is a contributing factor to the static Neonatal Mortality Rate (NMR).
Furthermore, the private sector, with 6 times more money per patient, caring for 16 per cent of the population, is informing the quality of care that patients now expect from government hospitals, but without the resources to match the demand.
South Africa is also a unique country in the African continent in that it tracks morbidities. With a population of 55 million and an NMR of less than 15 per 1,000 live births, South Africa could benefit looking for solutions (i.e. lessons learnt) from countries like Thailand that have similar NMRs.
In South Africa, the National Department of Health’s Maternal, Neonatal, Child and Women’s Health (NDOH MNCWH) Directorate in conjunction with the three ministerial committees for maternal, perinatal and children’s health have provided the lead in addressing the mortalities and morbidities in women, neonates and children. Since their inception in 2008 by the Minister of Health, all three committees have developed and improved upon the existing plans to address these mortalities in women and children. The strategies and interventions to reduce maternal, neonatal and child deaths are being implemented. The National Perinatal Mortality and Morbidity Committee (NaPeMMCo) in conjunction with the South African MNCHW Directorate are in the process of developing a Stillbirth Plan for the country. This is to formally address the large burden of stillbirths which is double the neonatal deaths and around 14 times that of the maternal deaths. This task should be completed by December 2016 and will have to follow the due process to effect implementation across the country.
The appointment of the District Clinical Specialist Teams (DSCT) for the 52 districts nationwide in 2012, was specifically to aid the implementation of these interventions at district level where specialist care was lacking. To date, there has been a demonstrable change in the quality of maternal, perinatal and newborn care though not necessarily a change in the health outcome indicators (yet). DCST members are appointed at the district level to provide specialist leadership and clinical governance for the district. They include an obstetrician, paediatrician, family physician, midwife, paediatric nurse and primary health nurse. While the teams are not all complete, the maternal (obstetrician and midwife) and paediatric (paediatric nurse and paediatrician) dyads are making slow but definite inroads into how care is delivered across the continuum. The NDOH MNCWH Directorate is in the process of documenting the best practice related to DCST appointments to provide some concrete evidence of how their presence has made a difference to the delivery of quality care at the facility level.
While DCSTs are appointed in all districts, the anaesthetic appointments have proven to be the limiting factors in completing the teams. More than 95% of the nursing posts are filled and half the obstetricians and paediatricians are appointed. Getting the right fit of specialist with public health training has been the limiting factor and both universities and nursing colleges are now producing post graduate diplomas to address this gap. The first groups of candidates for the post graduate diploma in community paediatrics and the masters in nursing for maternal neonatal and child health will graduate in December 2016.
South Africa is also in the process of taking all maternal and perinatal interventions up to scale. This will require good national co-ordination and funding to support the process.
Learn more about how the DCST work by browsing the2014 Handbook.
To read about perinatal mortality and the implementation of perinatal audits in South Africa, please click on the following journal articles published from 2009 to 2015:
- Experiences with perinatal death reviews in South Africa – the Perinatal Problem Identification Programme: scaling up from programme to province to country.
- Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby
- Stages of change: a qualitative study on the implementation of a perinatal audit programme in South Africa
- Perinatal mortality audit: Counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries
Note about the title: PNDSR stands for perinatal and newborn death surveillance and response.
* In the WHO (2016) publication, adapted from Lawn et al. 2011, stillbirths are defined as the following:
- “Stillbirth (early definition – ICD)[:] Birthweight ≥ 500 g; ≥ 22 completed weeks; body length ≥ 25 cm.” (p.19)
- “Stillbirth (international comparison definition – WHO)[:] Birthweight ≥ 1000 g, or if missing, ≥ 28 completed weeks gestation, or if missing, body length ≥ 35 cm.” (p.19)
According to Moxon et al. 2015, cited by WHO (2016)7, perinatal mortality rate definitions vary:
- “Number of deaths in fetuses born weighing ≥ 1000 g and after 28 completed weeks of gestation, plus neonatal deaths through the first 7 completed days after birth” (p.20).
- “Number of deaths in fetuses born weighing ≥ 500 g and after 22 completed weeks of gestation, plus neonatal deaths through the first 7 completed days after birth” (p.20).
- “Some definitions include all neonatal deaths up to 28 days” (p.20).
Acknowledgments: This case study was written by Dr Natasha R Rhoda, Senior Neonatal Consultant at Groote Schuur Hospital, Observatory, Cape Town, South Africa and the chairperson of the National Perinatal Mortality and Morbidity Committee.
 Pattinson, R. & Rhoda, N. (2014). Saving Babies 2012-2013: Ninth report on perinatal care in South Africa. Pretoria: Saving Babies
 McIntyre, D. (2009). The Public-Private Health sector Mix in South Africa. HEU Information Sheet. Cape Town: Health Economics Unit, UCT
 Department of Health: Republic of South Africa. (2015). National Health Insurance for South Africa: Towards Universal Health Coverage. Government of South Africa
 The World Bank. (2016). South Africa. Retrieved September 30, 2015, from http://data.worldbank.org/country/south-africa
 UNICEF, the World Health Organization, the World Bank Group & the United Nations. (2015). Levels & Trends in Child Mortality. New York: UNICEF
 Dorrington, R., Bradshaw, D., Laubscher, R., & Nannan, N. (2015). Rapid Mortality Surveillance Report 2014. Cape Town: Burden of Disease Research Unit & Medical Research Council
 World Health Organization (WHO). (2016). Making Every Baby Count: Audit and review of stillbirths and neonatal deaths. Geneva: World Health Organization.