ADVANCED ANTENATAL

CARE MODEL – FREE STATE

(AANC)

Ms. W. Motlolometsi

24. AUGUST.2016

INTRODUCTION

• In South Africa, 4452 maternal deaths were

recorded in the 2011 – 2013 triennial report.

•The Free State province contributed to 6% of

these deaths.

• Decline in the mortality ratio compared to the

previous report (8.8%)

HISTORICAL BACKGROUND• In the 2008 – 2010 NCCEMD report, the Free State province rated

amongst the highest in the country with respect to maternal mortality

• 4/5 districts of the province were amongst the 10 worst performing districts in South Africa in terms of the high maternal mortality rates(NCCEMD 2008-2010: 210).

• All 5 districts within the province were listed among the 15 priority districts requiring support to achieve the millennium goals.

• Similarly, the province had the highest perinatal mortality rate of 39.7 per 1000 live births and the highest number of early neonatal deaths at 29, 9 still births /1000 deliveries, compared to all the other provinces (NaPeMMCo, 2008 – 2010 :11 – 13).

Strategies implemented to improve on

outcomes

• Inter-facility transport.

• Aggressive ESMOE training.

• Consolidation of services - Deliveries and CS done at facilities with appropriate capacity.

• Introduction of AANC programme.

The mortality rates decreased by 43% and is sustained since early 2012.

WHY AANC?

• Second South African Demographic Health survey

(2003:14) - 7756 households interviewed.

• 92% of pregnant women in South Africa, presented

themselves at the health care facilities for antenatal care.

• 89% per cent consequently giving birth at such facilities.

• The majority of women with no risks in pregnancy and

childbirth are attended to by the Nurse – Midwives, ADMs

and PHC nurses ( with Midwifery) as their core function.

WHY AANC cont….

• Scope of practice of a midwife - assumption that those who

qualify and are registered to render midwifery care and manage

pregnant women and newborn babies, possess the necessary

competence - knowledge, skills and professional behaviour to

function as independent and accountable practitioners who can

ensure that no woman dies whilst giving life.

• Environment - supportive and enabling (International Journal of

child birth 2011).

• At present, the pregnant women with no risk / low risk factors are

managed at primary health care (PHC) level.

CURRENT CHALLENGES WITH ANTENATAL CARE

• Various workshops and training platforms: Nurse-Midwives skills gaps in risk identification (BANC Implementation).

•Dilution of skills through structured rotation of staff

(PHC Policy – Comprehensive PHC package).

• Poor outreach programs from referral hospitals to primary care facilities within their catchment areas.

-

CURRENT CHALLENGES WITH ANTENATAL CARE cont

• Limited supportive supervision to PHC staff providing basic antenatal care.

• Some facilities provide this care only once per week.

• Many facilities have medical and nursing staff without appropriate knowledge to manage the referred problems.

• None / delay in treatment and referrals - “identified at risk patients” : Facility bottlenecks

- structural

- few doing ANC high risk clinics

- barriers wrt referrals

Demand for advanced antenatal care

• Estimated 20-30% of pregnancies - complication or condition that would

require some form of expert opinion or interaction.

• The AANC service demands - calculated per town in the province based

on a few simple factors:

- Population size (census provide the basis for the calculations and

future estimate using the national population growth rate = is 0.095

(Stats SA)

- Fertility rate- this indicates the number of births in a population=

2.06%.

- Potential problematic pregnancies 20 - 30% of pregnancies.

Plan for advanced antenatal care

10

District Subdistrict TownPopulation 2011

census

Estimated

pregnancies 2014

Estimated

pregnancies

referred to

AANC (High)

Estimated

Advanced ANC

low

Advanced

ANC/week

High

Advanced AANC

cases per month

Clinic days per

month (High)

Required clinic

days per week

(low)

Suggested

AANC clinics

per month

Fezile dabi Mafube Cornelia 2964 63 21 14 2.3 9.3 0.6 0.5 1

Fezile dabi Mafube Frankfort 31133 657 222 148 24.5 98.2 6.1 4.9 5

Fezile dabi Mafube Tweeling 6465 137 46 31 5.1 20.4 1.3 1 2

Fezile dabi Mafube Villiers 17315 366 123 82 13.7 54.6 3.4 2.7 3

0 11

Fezile dabi Metsimaholo Deneysville 19479 411 139 93 15.4 61.4 3.8 3.1 4

Fezile dabi Metsimaholo Oranjeville 5166 109 37 25 4.1 16.3 1 0.8 1

Fezile dabi Metsimaholo Sasolburg 124461 2628 887 591 98.1 392.5 24.5 19.6 20

0 25

Fezile dabi Moqhaka Kroonstad 119134 2516 849 566 93.9 375.7 23.5 18.8 19

Fezile dabi Moqhaka Steynsrus 9106 192 65 43 7.2 28.7 1.8 1.4 2

Fezile dabi Moqhaka Viljoenskroon 32293 682 230 153 25.5 101.8 6.4 5.1 6

0 27

Fezile dabi Ngwathe Edenville 6294 133 45 30 5 19.8 1.2 1 1

Fezile dabi Ngwathe Heilbron 37635 795 268 179 29.7 118.7 7.4 5.9 6

Fezile dabi Ngwathe Koppies 13803 291 98 66 10.9 43.5 2.7 2.2 3

Fezile dabi Ngwathe Parys 48169 1017 343 229 38 151.9 9.5 7.6 8

Fezile dabi Ngwathe Vredefort 14619 309 104 69 11.5 46.1 2.9 2.3 3

Principles of AANC training

• Ensure that there is an appropriate mix of knowledge and practical skills and the ability to apply the knowledge appropriately.

• Training groups need to be small enough to allow individual attention for

practical support.

• Entry requirement – either advanced midwife or experienced and interested midwife.

• The individuals must have the ability to apply the knowledge in practice.

• Training done over a period of 3 months ( 4 sessions – 3 days).

• Staff recruited for this process must attend all the scheduled training

sessions.

Principles of AANC - Training

• Active reading and preparation prior to the training sessions.

• Participants wrote an exit exam to test the skills transfer and assist

with the privileging process.

• Support structure - Participants will earn CPD points.

1st group of advanced and / experienced midwives from all

five districts within the province were identified and trained as

advanced antenatal care practitioners in October – December

2014. (28)

2nd Group August – October 2015 (42)

WORKSHOP 1 22-24 October Tutor days (6h30min) 2.833333333

(total hours) 18.41666667

(Total Minutes) 1105

DAY 1

Time Theme topic Tutot/ Tutoring type Duration (min) Aims/objectives 07:30 Registration

08:30 General

Overview of maternal and neonatal outcomes in the province Dr. De Beer Lecture/overview 45

Understanding of challenges in maternal health

09:15 General- BANC Basic antenatal care strategy and tools use Ms. W. Motlolometsi Lecture/discussion 45

Understand Basic ANC PHC policy and challenges relating to current strategy

10:00 TEA

10:15 General - BANC Routine antenatal care screening Ms. W. Motlolometsi Discussion/debate 30

All screening including BMI, HCT, genetics

10:45 General - BANC

The antenatal patient at risk- risk identification Ms. W. Motlolometsi Lecture/discussion 30

All basic risk factors that should be identified at ANC

11:15 Anaemia Dr. T. Nondabula Lecture/discussion 105

Understand basic physiology, causes and treatment of anaemia in pregnancy

13:00 LUNCH

14:00 Fetal frowth Normal fetal growth Dr. De Beer Lecture/discussion 60

Understand physiology, calculating gestational age, Direct- indirect measurement of growth,

15:00 Fetal frowth

The placenta and fetal nutrition and oxygenation Dr. De Beer 60

DAY 2 Time Theme topic Tutot/ Tutoring type Duration (min) Aims/objectives

08:00 Fetal frowth Fetal well-being Dr. De Beer Lecture/discussion 60

Understand various aspects of fetal well being including movements, fetal heart, amniotic fluid

09:00 Fetal frowth Placental pathology Dr. De Beer Lecture/discussion 60

Understanding the placenta during normal pregnancy, PET and factors resulting in placental pathology and disease

10:00 TEA

10:15 Fetal frowth

Practical evaluation of fetal growth and well-being Ms. W. Motlolometsi Discussion/ practical 45

Understand methods to document movements and fetal heart. SF measurements

11:00 Fetal frowth Fetal growth restriction Dr. M. Schoon Lecture/discussion 60

Understand causes of growth restriction - fetal malnutrition

12:00 Fetal frowth

Clinical manifestation of fetal growth restriction Dr. M. Schoon Lecture/discussion 60

Understand how to identify growth restriction clinically

13:00 LUNCH

14:00 Fetal growth Consequences of growth restriction Dr. T. Nondabula Lecture/discussion 60

Be able to link growth impairment with stillbirths and small for gestational age babies

15:00 Fetal growth Fetal maturity Dr. M. Schoon Lecture/discussion 60

Understand definitions of maturity, pre-term post term pregancies. Understand lung maturity and fetal maturity

DAY 3 Time Theme topic Tutot/ Tutoring type Duration (min) Aims/objectives

08:00 Fetal growth Premature labour Dr. De Beer Lecture/discussion 60

Understand diagnosis and management of premature labour at clinics

09:00 Fetal growth Poly hydamnios Dr. T. Nondabula Lecture/discussion 60 Cause of and clinical actions to be taken

10:00 TEA

11:15 Maternal age

Risks associated with advanced maternal age Ms. W. Motlolometsi Lecture/discussion 60

Understand the mortality risk as well as genetic risk

12:15 Maternal age

Counselling and screening of women with advanced maternal age Ms. W. Motlolometsi / DCST ADM Lecture/discussion 45

Understand what could be offered to older women

13:00 LUNCH

14:00 ANC THE SECOND VISIT Dr. M. Schoon Lecture/discussion 60

Understand the importance of a detailed risk assessment during the second visit including risk assessment and appropriate referral systems

15:00 ANC Counselling/ advice to pregnant women Dr. M. Schoon Lecture/discussion 40

WORKSHOP 2 4-6 November Tutor days (6h30min) 2.769230769 (total hours) 18 18.1 (Total Minutes) 1080 (Total Minutes) 1080

DAY 1 Time Theme topic Tutor/facilitator Tutoring type Duration (min)

09:00 TEST MCQ test testing knowledge from previous session 30 09:30 Hypertension Anormalities of blood pressure in pregnancy Schoon Lecture/discussion 15

09:45 Hypertension Physiology of blood volume, cardiac output and blood pressure in pregnancy Motete Lecture/discussion 75

11:00 TEA

11:15 Hypertension Clinical diagnosis of hypertention and strategies to prevent HT Ramalitsi Lecture/discussion 45

12:00 Hypertension Drugs affecting blood pressure Schoon Lecture/discussion 45

12:45 Hypertension Pre-eclampsia- eclampsia Schoon Lecture/discussion 45

13:30 LUNCH

14:00 Hypertension Chronic hypertension in pregnancy Schoon Lecture/discussion 30 14:30 Hypertension Hypertension, placental changes and fetal growth Schoon Lecture/discussion 30

15:00 Hypertension How should hypertension be managed at clinic level and when to refer Ramalitsi/Motete Schoon Structured discussion 60

DAY 2 Time Theme topic Tutor/facilitator Tutoring type Duration (min)

08:00 Fetal loss Bleeding in early pregnancy Schoon Lecture/discussion 30 08:30 Fetal loss Miscariage Schoon Lecture/discussion 40

09:10 Fetal loss Women with history of previous pregnancy losses De Beer Lecture/discussion 50 10:00 TEAS

10:15 Fetal loss Management of women with a previous congenital abnormality De Beer Lecture/discussion 45

11:00 Counselling PHYSIOLOGICAL Changes in pregnancy Schoon Lecture/discussion 75 11:45 Counselling Minor ailments Motete

13:00 LUNCH

14:00 COUNSELLING Nutrition during/after pregnancy Ramalitsi Lecture/discussion 45

14:45 Counselling Patient's responsibilities, transport and maternity waiting areas Motete Lecture/discussion 45

DAY 3 Time Theme topic Tutor/facilitator Tutoring type Duration (min)

08:00 Medical condition Cardiac disease Schoon Lecture/discussion 60 09:00 Medical condition Lung disease Schoon Lecture/discussion 60

10:00 TEA

10:15 Medical condition HIV in pregnancy Dr Mngumezulu Lecture/discussion 120 12:15 Medical condition Diabetes in pregnancy De Beer Lecture/discussion 45 13:00 LUNCH

14:00 Medical condition Other endocrine diseases in pregnancy De Beer Lecture/discussion 45 15:00 Medical condition Disorders of other organs Schoon 45

PRINCIPLES OF THE AANC PROGRAMME

• Provide advanced antenatal care support to BANC by appropriately skilled personnel

• Strengthen the referral system - direct access to the referral system.

• Screen every pregnant women for risk by appropriately skilled staff

• Provide the advanced support services as close as possible to the client residential area whenever possible.

THE AANC PRACTITIONER

Programme outcomes • The trained AANC practitioners are expected to;

(1) Conduct outreach and visit the identified PHC clinics

(2) Screen and Identify pregnant women at risk during the 2nd antenatal visit consultation

(3) Evaluate the” potential risk pregnancies” identified through BANC screening.

(4) Develop and implement a midwifery management plan

(5) Make a clinical decision regarding the proper place of delivery for the pregnant women assessed. In order to achieve this, direct communication lines between AANC practitioners and the senior professionals in their catchment referral facility will have to be established and maintained.

(6) Act as mentors and do corrective training in cases where competency gaps are identified in relation the nurse-midwives and PHC nurses at PHC Clinics.

PRINCIPLES OF AANC - IMPLEMENTATION

18

TOWN 1

Clinic A

TOWN 1

Clinic b

TOWN 2

Clinic A

TOWN 3

Clinic A

TOWN 4

Clinic A

BASE

FACILITY

TOWN 1

Advanced ANC

professional

All 2nd Visits

At risk patientsManage referral chain

ROLES AND RESPONSIBILITIESDISTRICT MANGEMENT TEAMS

• Ensure that the identified pool are trained according the provincial training plan for AANC.

• Identify the most suitable location for providing AANC within existing PHC clinics with a base service at the dedicated community health centre or hospital in the sub-district

• Plan for outreach support transport of these individuals to the sites outside of their normal service point (dedicate appropriate budget for this process).

• Allocate the AANC staff as complementary to maternity units to ensure that the advanced ANC does not fail because the dedicated staff is expected to provide the essential maternity service.

• Staff shortages should not be sighted as a reason why this service could not be introduced and sustained.

How will this be operationalized?• Provision of transport to the facilities/Towns where required (cost

effectiveness and improve accessibility)

• Availability of appropriate equipment and infrastructure for AANC implementation.

• A medical practitioner in caesarean section sites to provide support for advanced antenatal care implementation.

• Budget allocation - Is the activities included in the district health plan?

• Monitoring programme implementation - Who in each district will be responsible for the data collection and forwarding the data to the DCST members?

• At what platform will the performance of the AANC clinics be discussed.

MONITORING AND EVALUATION:

COMPARATIVE AND DESCRIPTIVE STUDY - OBJECTIVES

1. Evaluate the PHC structures that should support the implementation of the

AANC program

Tool: Ideal clinic dashboard

2. Evaluate the performance of the AANC trained practitioners

2.1 Patients’ Records

(2.1.1) Women with low risk pregnancies at 2nd visit – (BANC Audit tool)

(2.1.2) Women with high risk pregnancies Identified, managed and treated by AANC

practitioners

(Tools: BANC principles of good care and IMPAC )

MONITORING AND EVALUATION

2.2 Interviews

• 2.2.1 Interviews Schedules -Interviews with the AANC practitioners.

• 2.2.2 Semi – structured questionnaires - One-to-one interview with Clinic supervisors and

functional midwives.

3. Evaluate and describe the outcomes of the AANC programme

MONITORING AND EVALUATION

• The key data elements to monitor;

- number of cases referred for AANC

- number of cases referred for hospitalisation.

- Mortality outcomes for the various sub-districts (still births and neonatal

deaths)

- Maternal complication rates (near-miss rates).

- A baseline data collection before the intervention is possible as all maternity

wards are currently collecting a standard set of maternity indicators.

MONITORING AND EVALUATION

4. Collaboratively develop a reproducible framework to

strengthen the implementation of AANC

Tools: Independently develop framework based on data and validate

with provincial team

AANC REGISTER ( DATA SHEET)

v3

VENUE TOWN

AANC

PRACTITIONER MONTH

DATEPATIENT’S NAME AND FOLDER

NUMBER

NUMBER

OF 1ST

VISITS

NUMBER OF

PATIENTS SEEN

BY

PRACTITIONER

NUMBER

OF 2ND

VISITS

NUMBER

OF HIGH

RISK

FOLLOW-

UP

NUMBER

OF

PATIENTS

REFERRED

COMMENTS

(REFERRAL SITE AND

DIAGNOSIS)VISIT CONFIRMED

BY CLINIC IN

CHARGE

TOTAL

MOBILE ULTRASOUND MACHINES

• Total number procured : 20

• Distribution per district

Exp clinic visits/month

Pregnancies/ month

1 sonar/ 213 patients

Actual distribution

FD 104 756 3.5 4

Lejw 141 998 4.7 4

MM 153 1157 5.4 4

TM 165 1140 5.4 5

Xhariep 42 226 1.1 3

605 4278 20.1 20

AANC IS ONE OF THE PROVINCIAL PRIORITY INTERVENTIONS

INVEST IN THE LIVES OF MOTHERS AND BABIES

ACKNOWLEDGEMENTS

•Prof. Yvonne Botma – Supervisor

•Dr. Martiens Schoon – Provincial Specialist and Co-Supervisor

•District Clinical Specialist Teams ( ADMs) – All Districts

•Advanced Midwives - AANC practitioners