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Referral of Pregnant Women from District Hospitals to a Regional Hospital in the Eastern Cape Province

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Referral of Pregnant Women from District Hospitals to a Regional Hospital in the Eastern Cape Province REFERRAL OF PREGNANT WOMEN FROM DISTRICT HOSPITALS TO A REGIONAL HOSPITAL IN THE EASTERN CAPE PROVINCE BY EDWARD MUGERWA–SEKAWABE SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MAGISTER ARTIUM IN HEALTH AND WELFARE MANAGEMENT IN THE FACULTY OF HEALTH SCIENCES AT THE NELSON MANDELA METROPOLITAN UNIVERSITY PORT ELIZABETH SUPERVISOR: MRS L JANTJES CO-SUPERVISOR: MRS A G KLOPPER SEPTEMBER, 2007 Woman of Africa, Sweeper, Smearing floors and walls with cow dung and black soil, Cook, ayah, the baby on your back, (And another in your tummy [researcher’s addition]), Washer of dishes, Planting, weeding, harvesting, Storekeeper, builder, Runner of errands…, Woman of Africa What are you not? (Okot p’Bitek [Ugandan poet]) (i) ACKNOWLEDGEMENTS To my wife Anna Deborah, and our children Edward Muyenga, Kyate Madeleine and Suubi William, for your unending love and support. To my supervisors, Mrs L Jantjes and Mrs A G Klopper, for your constant guidance and encouragement. To Dr. Jacques Pietersen, of NMMU Unit for Statistical Consultation, for all statistical analyses and advice. To Mrs Yulinda Sharrock, for all the secretarial work. To the records clerks at the Frere Hospital maternity registry, for timeously finding the maternity case records. (ii) DEDICATION This study is dedicated to my parents Nehemiah and Madeleine for all the love and for shaping my future. (iii) TABLE OF CONTENTS Page Acknowledgements (i) Dedication (ii) Table of Contents (iii) List of Appendices (viii) Glossary (ix) List of Figures (xiii) List of Tables (xiv) List of Graphs (xvi) Abstract (xvii) CHAPTER 1: OVERVIEW OF THE STUDY 1 1.1 Introduction 1 1.2 Problem statement 3 1.3 Research question 5 1.4 Research goal and objectives 5 1.4.1Research goal 5 1.4.2Research objectives 5 1.5 Research design and methods 6 1.5.1 Research design 6 1.5.2 Research methods 7 1.5.2.1 Research population and research sample 7 1.6 Data collection and analysis 8 1.6.1 Role of researcher 8 1.6.2 Data collection 9 1.6.3 Data analysis 9 1.6.4 Validity of measuring instrument 10 1.6.5 Reliability of measuring instrument 10 (iv) Page 1.7 Ethical considerations 11 1.7.1 Nonmaleficence 11 1.7.2 Confidentiality 11 1.7.3 Beneficence 11 1.7.4 Approval 12 1.8 Envisaged chapters 12 1.9 Dissemination of results 12 1.10 Summary 13 CHAPTER 2: LITERATURE REVIEW 14 2.1 Introduction 14 2.2 Public Health Care System in South Africa 14 2.3 Maternity Care in South Africa 16 2.3.1 The National Health System 16 2.3.2 The National Committee for Confidential Enquiries into Maternal Deaths in South Africa 18 2.3.3 The Guidelines to Maternity Care in South Africa 20 2.3.4 The Primary Health Care Package for South Africa 20 2.4 Referral systems 22 2.4.1 The concept of a referral 23 2.4.2 The incidence of referrals 24 2.4.3 The referral process 24 2.4.4 The feedback process 26 2.4.5 The ideal referral process 27 2.4.6 Audit of the referral system 28 2.5 Summary 28 (v) Page CHAPTER 3: RESEARCH DESIGN AND RESEARCH METHODS 30 3.1 Introduction 30 3.1.1 Research goal 30 3.1.2 Research objectives 30 3.2 Research design 31 3.2.1 Quantitative research 31 3.2.2 Exploratory research 32 3.2.3 Descriptive research 33 3.2.4 Contextual study 33 3.3 Research methods 34 3.3.1 Research population 34 3.3.2 Research sample 34 3.4 Data collection and analysis 35 3.4.1 Role of researcher 35 3.4.2 Data collection 36 3.4.3 Data analysis 37 3.4.4 Validity of measuring instrument 37 3.4.5 Reliability of measuring instrument 38 3.5 Ethical considerations 39 3.5.1 Nonmaleficence 39 3.5.2 Confidentiality 40 3.5.3 Beneficence 40 3.5.4 Approval 41 3.6 Summary 42 CHAPTER 4: DATA ANALYSIS AND INTERPRETATION 43 4.1 Introduction 43 4.2 Descriptive statistics 44 (vi) Page 4.2.1 Age distribution of the referrals 44 4.2.2 Gravidity and parity of the referrals 44 4.2.3 District municipalities and hospitals of origin of the referrals 46 4.2.4 Attendance for antenatal care 47 4.2.5 Number of antenatal visits 47 4.2.6 Diagnosis at district hospitals 48 4.2.7 Diagnosis at the regional hospital 49 4.2.8 Comparison of diagnoses between district and regional hospitals 50 4.2.9 Reasons for referral 51 4.2.10 Adequacy of referral 51 4.2.10.1 Clinical details of referral notes 51 4.2.10.2 Management prior to decision to refer 52 4.2.10.3 Timelines of referral 53 4.2.11 Availability of clinical records 54 4.2.11.1 The antenatal card 54 4.2.11.2 The partogram 54 4.2.12 Assessment of transport adequacy 55 4.2.12.1 Stabilisation prior to transfer 55 4.2.12.2 Hospital contact 56 4.2.12.3 Accompaniment in ambulance 57 4.2.13 Appropriateness of referral 57 4.2.14 Mode of delivery 58 4.2.15 Maternal outcome of the referrals 59 4.2.16 Neonatal outcome 60 4.2.17 Birth weights of neonates 60 4.2.18 Duration of stay at the regional hospital 61 4.2.19 The discharge summary 63 4.3 Summary 64 (vii) Page CHAPTER 5: DISCUSSION OF FINDINGS, CONCLUSIONS, RECOMMENDATIONS, THE REFERRAL STRATEGY AND THE RESUMĖ 65 5.1 Introduction 65 5.2 Goal and objectives 65 5.2.1 Research goal 65 5.2.2 Research objectives 65 5.3 Discussion of findings 66 5.3.1 Profile of pregnant women referred 66 5.3.1.1 Age distribution of the referrals 66 5.3.1.2 Gravidity and parity of the referrals 67 5.3.1.3 Area and hospitals of origin of the referrals 68 5.3.1.4 Attendance for antenatal care 68 5.3.2 Diagnosis of the referral 69 5.3.3 Communication between hospitals 69 5.3.4 Management prior to referral 70 5.3.5 Timelines of referral 70 5.3.6 Accompaniment during transfer 70 5.3.7 Appropriateness of referrals 71 5.3.8 Mode of delivery 71 5.3.9 Maternal outcome 72 5.3.10 Neonatal outcome 72 5.3.11 Discharge summary 72 5.4 Conclusions 73 5.5 Recommendations 73 5.5.1 Implications of study to clinical practice 74 5.5.1.1 Numbers of maternity care providers 74 (viii) Page 5.5.1.2 Communication between hospitals 75 5.5.2 Implications of study to education 75 5.5.2.1 Involvement of specialist obstetricians 75 5.5.2.2 Education 75 5.5.3 Implications of study for further research 76 5.6 The referral strategy 76 5.6.1 The proposed referral record 77 5.6.2 The proposed feedback record 77 5.6.3 The proposed referral strategy 80 5.7 The résumé 84 Bibliography 85 Appendix 1: Map indicating hospitals referring pregnant women to the Frere Hospital, East London 94 Appendix 2: Data capture sheet 95 Appendix 3: Approval for statistical consultation at NMMU 96 Appendix 4: Approval to access medical records by hospital authorities 97 Appendix 5: Approval to access medical records from Epidemiological Research & Surveillance Unit, Department of Health Eastern Cape 98 Appendix 6: Approval from NMMU Research Ethics Committee (Human) 99 Appendix 7: Approval of Research Proposal from Faculty of Health Sciences, NMMU 100 Appendix 8: List of risk factors in antenatal care, during labour and in the puerperium, requiring management at a District Hospital 101 (ix) GLOSSARY The Perinatal Education The “PEP programme” equips midwives with skills to Programme (PEP) handle basic childhood conditions (Woods and Theron, 1993:2). Maternity Care The term “maternity care providers” will be used to refer to Providers a doctor and/or midwife or both, as defined in the relevant Acts (Act 56 of 1974 (section 1 (iv) and Act 33 of 2005 (section 31 (1(b)). Doctor A “doctor” is a medical practitioner registered by the Health Professions Council of South Africa in terms of Act 56 of 1974 (section 1(iv) as amended (South Africa, 1974). Midwife A “midwife” is a person registered or enrolled as such under section 31 subsection 1(b) of the Nursing Act 33 of 2005 (South Africa, 2005). Levels of Maternity Levels of Maternity Care are defined as follows: Care • Level 1 services include clinics, community health centres and district hospitals. Services are provided to out-patients and in-patients by advanced midwives, midwives with PEP training, full time medical officers and visiting specialist obstetricians (Department of Health, 2000:12-14). • Level 2 services (Regional hospitals) provide Level 2 services and some Level 1 functions to clinics and community hospitals near the regional hospital. In addition to the staff mentioned under district hospitals, full time specialist obstetricians are available to give input on management of patients with complicated medical problems (Department of Health, 2000:15). • Level 3 hospitals are also known as central or tertiary hospitals. These perform the functions mentioned under Level 1 and Level 2 hospitals and they also have specialised equipment for the management of very ill or difficult obstetric patients (Department of Health, 2000:16). (x) Antenatal Card The “antenatal card” is the principal record of pregnancy (Department of Health, 2000:18).
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