Doctoral Degrees (Obstetrics and Gynaecology)
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Item Open Access Fit for purpose? the strengths and weaknesses of Gauteng maternity services health care organisation / configuration in the context of reducing maternal deaths(University of the Free State, 2021-03) Chauke, Hlengani Lawrence; Wessels, P. H.BACKGROUND: Despite the availability of evidence-based and cost-effective interventions that are accessible to low and middle-income countries (LMICs), women continue to die of preventable pregnancy-related causes worldwide. Sub-Saharan Africa (SSA) carries a disproportionate burden of maternal mortality (68% of the global burden) relative to its size (has just below 16% of the world’s total population). The high burden of maternal deaths in SSA, including other LMICs, has been attributed to the failure of its healthcare system, in particular, poor quality of primary healthcare (PHC) orientated district healthcare services (DHS). The DHS-PHC model is the statutory model for service delivery in South Africa. This model has been blamed in studies conducted in low-and middle-income countries (LMICs) for the poor quality of both maternal and general healthcare services. Consequently, calls for the centralisation of maternity services to hospitals have started to emerge, the argument in favour of such a move is that centralising maternity services to hospitals would improve pregnant women’s access to emergency maternity healthcare services and skilled attendants in a timely manner. Others have however argued that a hospital-based model of maternity care is both costly and unsustainable for countries with limited resources and instead this group have called for the strengthening of the DHS-PHC. Informed by contextual realities, various African countries, as well as provinces in South Africa implemented different strategies aimed at strengthening the DHS-PHC model. For example, in the Western Cape and Gauteng, this took the form of a Comprehensive Service Plan (CSP) and Cluster Policy Framework (CPF). The two healthcare frameworks are based on a regional model but differ in philosophy and governance structures. Both models aim to strengthen the district health care system, improve health service efficiency as well as quality of care. Although only signed into policy in January 2019, the CPF model has been in operation in the Charlotte Maxeke Johannesburg Academic Hospital Cluster (CMJAH) since 2016, mainly in the Obstetrics and Gynaecology and Surgical disciplines. Unlike the Western Cape’s CSP model, the Gauteng CPF healthcare model has not been subjected to scientific evaluation since its implementation. Because maternal and neonatal healthcare services are national and provincial priority areas, maternity healthcare services presented a unique opportunity to evaluate the CPF, a healthcare innovation aimed at improving the quality and governance of healthcare services. AIM: The aim of the study was to assess the strengths and weaknesses of the organization/ configuration of maternity healthcare services in Gauteng, in particular, the CPF as implemented in the CMJAH maternity cluster in order to identify gaps/healthcare barriers and use this information to recommend healthcare services improvement strategies. METHODOLOGY: Informed by Stufflebeam’s Context, Input, Process and Product (CIPP) theoretical model /framework, and a convergent mixed method research design, quantitative and qualitative data were simultaneously and independently collected, analysed, results synthesized and merged through a process of triangulation. The quantitative component involved an audit of maternity healthcare facilities in terms of resources (number of facilities, distribution, bed capacity, human resource), service load (deliveries) and maternal deaths. Semi-structured interviews with frontline healthcare workers and their immediate supervisors/managers, facility visits and the review of the cluster morbidity and mortality (M&M) meetings minutes, as well as the Cluster Policy Framework (CPF), constituted the qualitative component. RESULTS: The CPF managed to establish clinical governance, standardised protocol, improved coordination of healthcare services, including creating an enabling environment for support, collaboration and sharing of knowledge and skills among healthcare workers from different levels of care and healthcare. During the period under study, the cluster saw a modest and sustained decline in maternal mortality despite an increase in maternity deliveries. However, the CPF faced challenges in the form of a mismatch between the demand and supply side of healthcare services. The mismatch was due to a number of factors, among those, poor leadership, management, governance, infective implementation of the CPF and a high rate of provincial and international migration. Together with leadership and management challenges, the mismatch between the demand and supply side of healthcare services, resulted in the over burdening of maternity healthcare services, increase in patient adverse events, disgruntled healthcare workers, poor quality of care and an increase in medico-legal challenges thereby setting on the stage, a vicious cycle with no end point. CONCLUSION: Gauteng CPF is an excellent example of health system innovation with a potential to strengthen the quality and coordination of not only maternity but healthcare services in general. The model retains all the advantages of the DHS-PHC model and at the same time, focus on improving clinical governance, distribution and sharing of scare resources. Poor leadership, governance, management lack of effective policy implementation, inadequate infrastructure, shortage and ineffective management of human resources, among other factors, have created bottlenecks and challenges in the health system, limiting the CPF model’s potential. These challenges would need to be addressed in order for the CPF to deliver on its promise. Failure to do so could result in a catastrophic failure of the much-awaited NHI.Item Open Access Severe morbidity and mortality associated with cardiac disease during pregnancy in the Free State public health service(University of the Free State, 2000-11) Schoon, Marthinus Gerhardus; Cronje, H. S.; Ratnam, S. S.English: Cardiac disease in pregnancy is an important component of maternal mortality. No good population based study on the extent of cardiac disease in pregnancy has, as yet, been published. A previous study conducted at this institution aimed to describe the morbidity and mortality of cardiac disease in pregnancy, but no guidelines to define morbidity in these cases were available. In 1999 a model was published by Mantel and eo-workers to define acute morbidity as organ dysfunction or failure that will lead to death without treatment. The aim of this study was to describe cardiac disease in a specific population by utilising this model and to try to determine the impact of the disease on the health system. From 1 January 1997 to 31 December 1998 all the available information of patients who presented with cardiac disease was documented. A research assistant was responsible to ensure that the completed hospital records of all the patients who were managed in Health Regions A and B of the Free State Province was available for evaluation. Ward registers and cardiac sonar reports in the regional and tertiary care hospitals (Pelonomi and Universitas) were also scrutinised to ensure that al possible cases were included. All cases with severe acute morbidity according to the Mantel criteria were classified as complicated. The information of the patients was also stratified as either part of the index population if they resided in Regions A or B (the population that was specifically targeted) or as the referred population if they lived in one of the other Regions and were referred to one of the two hospitals. During the 2-year study period 67 patients with cardiac disease were treated. In the study population there were 42 cases (prevalence of 0.12% of all deliveries in Regions A and B) and 31 (74%) were complicated and 11 (26%) uncomplicated. Rheumatic heart disease occurred in 14 (33%) of the cases whilst the majority (23, 54%) of the cases had cardiomyopathy. Four maternal deaths (9%) occurred which comprised 11.7 /100 000 deliveries in Regions A and B. Patients with valvular disease had predominantly mitral valve disease. Mitral regurgitation was the most common lesion, single or in combination with other lesions. Patients with mitral stenosis who were managed with beta-blockers developed less lung oedema. There were only five patients who had prosthetic valves of whom one (20%) died. This dramatic decrease in numbers compared to our previous report is probably due to an aggressive attempt to prevent pregnancies in this group of patients. As reported in the rest of Africa, cardiomyopathy was the most common lesion. It occurred in 1:4000 deliveries that took place in Regions A and B. Hypertension was present in 48% of these women. Only one case with a congenital abnormality and two cases with pericarditis were reported. The most expensive group to treat were those cases who were categorised according to the applied model as complicated cardiac disease. They also had significantly less specialist visits compared to the uncomplicated cases. The proposed model of acute morbidity is useful to evaluate cardiac disease in pregnancy and to monitor progress in the management of these patients. Specialist visits decrease the number of complications and should be encouraged. Management of patients with cardiac disease who did not receive antenatal care is expensive and communities should be informed of the advantages of antenatal care. Women with cardiac disease in pregnancy need specialist expertise and should preferably be evaluated and counselled prior to the onset of pregnancy.Item Open Access Evaluation and management of a rectocele in a resource limited setting(University of the Free State, 2017-01) Henn, Etienne Wilhelm; Wessels, P. H.English: INTRODUCTION: A rectocele can be expected in approximately 11-19% of women and is present in 40-85% of women requiring pelvic floor surgery for other disorders. There is considerable international variation in the evaluation and management of these women, particularly in regards to surgical treatment. The healthcare environment of the Free State is one with limited resources and innovative clinical approaches are often required to allow for optimal service provision to continue. OBJECTIVES: The objective of this thesis was to research the assessment and management of women who presented with rectoceles in a resource limited setting through innovative and frugal methods, whilst maintaining a pragmatic clinical inclination. METHODOLOGY: The methodologies included the linguistic and cultural psychometric validation of pelvic floor questionnaires, the randomized assessment of the clinical impact that transperineal ultrasound has on patient management, the randomized evaluation of the value which a rectopexy might add in combination with a sacrocolpopexy, the retrospective review of a rectocele plication and description of this novel surgical technique, the retrospective review of the benefit which a perineal body repair in combination with a posterior repair might confer as well as the randomized assessment for non-inferiority of a rectocele plication compared to a defect-specific repair in women with rectoceles. RESULTS: The PFDI-20, PFIQ-7 and PISQ-12 pelvic floor questionnaires were validated in South African women for the languages of Afrikaans and Sesotho and shown to be responsive to clinical change. The integration of transperineal ultrasound findings resulted in an alteration of the definitive management plan in 37.6% of women and this was most evident for those with posterior compartment disorders. A rectopexy was not found to add significant clinical benefit in women with advanced multi-compartment pelvic organ prolapse who underwent an extensive sacrocolpopexy. The rectocele plication procedure, which involves the repair of the anterior rectal wall though a vaginal approach, was found to result in anatomic success of 88.6% after a mean follow-up period of 27 months with an associated significant improvement in symptoms and quality of life. The addition of a perineal body repair in those women who underwent a rectocele plication was not observed to be of any clinical benefit in this population. The randomized assessment of a rectocele plication compared to a defect-specific repair demonstrated that the new procedure was not inferior to the existing operation in regards to anatomic outcome. The anatomic success rates were 92.3% and 76.9% respectively (p=0.2485, 95% CI -13.6; 42.5). The rectocele plication did however demonstrate significantly superior symptomatic and functional outcomes compared to a defect-specific repair after 1 year. A significant observation was that of voiding dysfunction in this population of women with isolated rectoceles. This was the second most prevalent initial complaint and it was significantly improved (p= 0.0011) after surgical correction of a rectocele in both the retrospective and prospective evaluations. CONCLUSION: This research compilation demonstrated that a thorough assessment of women with posterior compartment disorders through the use of validated instruments and standardized investigations in combination with innovative surgical procedures resulted in clinical outcomes not inferior to those reported elsewhere in the literature. It emphasized that pragmatic innovation in a limited resource healthcare environment can produce internationally equivalent clinical results.