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ISSUES IN MEDICINE
Poor maternal outcomes: A factor of poor professional systems design
Marthinus Schoon, MMed (O&G), PhD, is a chief specialist in the Free State Department of Health and a senior lecturer in the Department of Obstetrics and Gynaecology, Free State University, Bloemfontein.Winnie Motlolometsi, MDS, is an advanced midwife in the Mother and Child Unit, Free State Department of Health.
South Africa is struggling to improve maternal and perinatal
outcomes, resulting in failure to achieve the Millennium Goal
for maternal health. Staff attitudes and skills have been
identified as a factor affecting deaths and adverse outcomes
in mothers. Huge training efforts are required from health
departments to ensure that staff have the required skills to
provide the services.
The integrated approach to training of nurse professionals, which includes midwifery as a part of undergraduate training, has a devastating effect on the quality of midwifery. Training of midwifery is unfocused and forced upon those who have no interest in improving maternal outcomes. Maternal care is provided in professional silos by professionals who are not equipped with appropriate skills. Unless this systems design error is corrected, and a single-output training model introduced to professionals providing maternal care, we are unlikely to see a a major change in our maternal outcomes. New models based on inter-professional training and task sharing need to be developed for the country, including redefining of professional accountability for maternal care.
S Afr Med J 2012;102(10):784-786. DOI:10.7196/SAMJ.6130
South Africa is one of the few countries in the world with a
very poor performance regarding maternal and perinatal outcomes.
The National Committee for Confidential Enquiries into Maternal
Deaths has shown no improvement in health outcomes for the past
12 years. The Department of Health (DoH) has recognised that
poor maternal outcomes are of national concern and has initiated
attempts to improve maternal and perinatal outcomes, without any
significant improvement. Why are South African maternal and
perinatal health professionals consistently under-performing, in
spite of efforts to improve results?
Health professionals often blame obvious causes for these shortfalls, including staff shortages, lack of professionalism, staff attitudes and poor management. The Saving Mothers reports1 , 2 over the past decade have regularly linked staff skills issues with avoidable deaths. Schoon et al. 3 confirmed a similar trend in adverse outcomes in the Free State province.
Quality of training
Concerns have been raised regarding the quality of training of health professionals (both doctors and nurses) by academic facilities. The training facilities consistently produce health professionals challenged to work in the typical South African work environment.4 The DoH questions why it has to embark on massive in-service training of the existing health workers to equip them with skills to render the required service needs.
The Maternal and Child Health Unit in the Free State province recently interrogated advanced midwifery training, as one of the nursing colleges intended to start such training in the province. There is no clear job description or scope of practice for advanced midwives in the province, or indeed in the country, and the key question was what their outcomes should be. Since few activities could be assigned solely to advanced midwifery, no consensus could be reached as to what constitutes an advanced midwife. However, the deficiencies in midwifery training in the country were highlighted. This multi-professional debate concluded that the entity of a ‘skilled midwife’ does not currently exist in South Africa, with the exception of a few enthusiasts. Once this was realised, it was substantiated by many observations, including:
• Nurses attending the ESMOE training workshops struggle with the basic management of obstetric emergencies because their knowledge and skills are low compared with what would be expected of a basic midwife (problems with contextual understanding).
• Many medical practitioners also lack the basic skills required to manage obstetric emergencies.
• Medical practitioners and professional nurses differ in their conceptual understanding of maternity care.
• Medical and nurse practitioners have a poor understanding of the systems within which they operate.
• Basic antenatal care is primarily driven at the primary healthcare clinics, rendered by staff with a poor understanding of or lack of interest in pregnancy and antenatal care. Their referral line is to medical practitioners with an equally poor understanding of the processes, leading to unnecessary delays in referral to the relevant expertise.
• There is a management perception that all health professionals are skilled in labour ward management, irrespective of exposure or interest.
• The practice of regularly rotating nurse professionals results in poor levels of competence.
• Maternity staff are inadequately trained to provide the World Health Organization-recommended signal functions at emergency obstetric facilities.
Further problems
Although the international concept of inter-professional education5 has been promoted, we still see a strong silo approach by professional groups, mismatched competencies and professionals not keeping pace with change. Our system is hierarchical with medical practitioners in charge, resulting in non-accountability of other professionals for their actions, which results in poor outcomes.
Probably the most devastating effect on the current maternal services is the integration of midwifery as a subset of the comprehensive nursing training programme. Although this might broaden the nursing perspective, it is unfocused and forced upon those with no interest in maternal care. Maternal outcomes depend on achieving and maintaining a high level of skill. A systems design flaw in the current training results in the poor health outcomes in maternal care seen in the national reports. The problem is accentuated by a rotation system of professional nurses, resulting in incompetence in the labour wards and the clinics.
Medical training occurs in tertiary settings, and students and interns are continuously exposed to abnormalities with little exposure to management of normal pregnancies, early identification of complications, and prevention strategies. Training of medical students in non-academic units is suboptimal.6 Service training platforms are poorly defined and there is an unhealthy competition between medical and nursing students to access normal deliveries.
Improving outcomes
We are unlikely to see major changes in the outcomes unless the underlying systems design error is addressed to ensure appropriately skilled health workers for maternal care.
As maternal services are so important to the country, attention must be given to ensure that women have access to appropriate services. ‘No significant progress in maternal mortality reduction can be achieved without a strong political decision to empower midwives and others with midwifery skills, and a substantial strengthening of health systems with a focus on quality of care rather than on numbers, to give them the means to respond to the challenge.’7 Women want pregnancy follow-up as close to home as possible, as long as there are no problems. When they know that advanced skill is required to manage pregnancy complications, they are prepared to travel long distances to obtain the appropriate care.
Inter-professional education and task sharing could improve outcomes in maternal care. All pregnant women are exposed to the same processes, i.e. pregnancy for a 9-month period, delivery of the baby and the puerperium. All professionals providing a similar service, irrespective of the professional group into which they fall, should do so with similar standards and outcomes. This could be divided into a few key subsets or modules that may differ according to professional grouping, including:
• Basic maternal ambulatory care, including basic antenatal care and postnatal care (focus on normality, risk identification, health promotion and basic fertility control)
• Advanced maternal ambulatory care (including confirmation of risks with appropriate therapeutic approaches in pregnancy and the puerperium)
• Basic labour care (including identification and management of obstetric emergencies, miscarriage management and management of normal labour)
• Comprehensive labour care (including inpatient care, management of obstetric emergencies and operative deliveries)
• Advanced obstetric care (including maternal-fetal medicine, obstetric intensive care and advanced puerperal care).
Training of this sort could be done in modules and provided to all health professionals qualifying for a module. This will ensure that the same standard of training and skills is provided to all the relevant health professionals, thus eliminating educational waste and enabling better use of resources.
In essence, if someone provides basic antenatal care, they must have a certificate indicating that they are qualified and skilled to do so. If they manage complicated pregnancies in the antenatal period, they should possess an advanced antenatal care certificate. This would apply to professionals irrespective of their professional grouping. Primary care nurses or clinical associates providing basic antenatal care should therefore possess the first certificate. Advanced certificates should be included in medical practitioner training by default in view of doctors’ professional responsibility, but could also be required for midwives classified as advanced for antenatal care.
The current service platform design does not allow a single professional to provide comprehensive antenatal, intrapartum and postpartum care. The public sector antenatal and postnatal service is provided at clinic level, but deliveries at hospitals are managed by a different group of professionals. The skills required to render clinic-based antenatal and postnatal services, and to conduct deliveries with or without complications, also differ substantially.
We cannot afford to produce sub-optimally trained health professionals and then expect them to provide quality maternal services. A single-output standard should be the national norm irrespective of professional groupings. This requires inter-professional educational reform and redefining of professional accountability for maternal care. The current professional scope and training design for maternal care are flawed, and require urgent revision if South Africa is to improve maternal health outcomes.
1. National Committee on Confidential Enquiries into Maternal Deaths. Saving Mothers: Fourth Report 2005-2007. Pretoria: Department of Health, 2009. http://www.doh.gov.za/docs/reports/2011/saving_b.pdf (accessed 24 August 2012).
2. National Committee on Confidential Enquiries into Maternal Deaths. Saving Mothers: Fifth Report 2008-2010. Short Report. Pretoria: Department of Health, 2012. http://www.doh.gov.za/docs/reports/2012/savingmothersshort.pdf (accessed 24 August 2012).
3. Schoon MG, Kabane S, Whitaker S. Maternity related adverse outcomes in the Free State province. Priorities in Perinatal Care Conference Proceedings 2011. http://www.perinatalpriorities.co.za/database (accessed 27 June 2012).
4. Schoon MG. Discussion platform between midwifery educators and health professionals in the Free State province. South African Journal of Obstetrics and Gynaecology 2011;17(2):28-30.
5. Blue A, Mitcham M, Smith T, Raymond J, Greenberg R. Changing the future of health professions: Embedding interprofessional education within an academic health center. Acad Med 2010:85(8):1290-1295. [http://dx.doi.org/10.1097/ACM.0b013e3181e53e07]
6. Farrel E, Pattinson RC. Out of the mouths of babes – innocent reporting of harmful labour ward practices. South African Journal of Obstetrics and Gynaecology 2005;11(1):4-5.
7. Fauveau V, Sherrat D, De Bernis L. Human resources for maternal health: Multi-purpose or specialists? Human Resources for Health 2008;6:21.
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