Evaluation of the effects of a district clinical specialist team on maternal and women’s health services in the Ekurhuleni district

Abstract

Background: Over the last two decades, maternal and child health have received renewed interest in South Africa, in the context of high maternal and child mortality. Since 1994, several initiatives have been taken by the government to improve the maternal health services in South Africa, without producing the desired results. The District Clinical Specialist Team (DCST) is the latest of these initiatives and probably the most innovative among them.These teams are expected to work at a district and sub-district level to improve maternal and child health services in South Africa through improvement of both the quality of health care and health outcomes for mothers, newborn and children and their performance will be judged by the impact on routinely collected data from DHIS (NDoH. 2012c).

Aim of this study: To explore, in a district health setting (Ekurhuleni District), the various obstetric intervention measures undertaken by the DCST over the last eight years (2012-20) within the current policy framework for the establishment of the DCST; to document the effect of the DCST interventions on the changes in maternal health indicators by analysing the maternal health data after the introduction of the DCST in the district, and lastly to document the knowledge and perceptions about DCST among the district managers and health professionals.

Methodology: The setting of the study was the Ekurhuleni Health District (one of the five districts of Gauteng province) and its three sub-districts. This study included analysis of routinely collected maternal health related data from all health facilities in the district (District Health Information System), review of all maternal deaths, review of documentation of all the interventions and key informant interviews of the managers and health professionals (n=20).

The study was initiated after obtaining necessary approval from the Human Research Ethics Committee (medical) of the University of the Witwatersrand, Ekurhuleni Health District Research Committee and Gauteng Province.

Results: This study analysed the data in quarters from 2011-12 quarter 1 to 2019-20 quarter 4 as reported in the District Health Information System.

The study showed that there were overall improvements in reproductive, antenatal, and postnatal indicators whereas there was equivocal success with the intranatal indicators.

For reproductive health indicators, there was a significant increase in Couple year protection rate during this period; however, the District could achieve the Provincial target (55%) only in three quarters. However, the significant decrease in Termination of pregnancy rate from 2011/12 is of concern, which could possibly be attributed to decreases in the North and East Sub-districts.

For antenatal indicators, there was a significant improvement in antenatal indicators (namely in the Antenatal First visit before 20 weeks’ rate as well as ANC patients initiated on ART rate) during the study period implying improvement in the antenatal care in the District.

For intranatal indicators, there was a significant increase in the Total deliveries in facility, which is predominantly ascribed to the North Sub-district. The significant increase in the teenage pregnancy (measured as Delivery in facility under 18 years rate) was of concern, which is possibly attributed to the East Sub-district. There was a significant increase in Delivery by Caesarean section rate, which is possibly due to increase at East and North Sub-districts. There was also a significant increase in the Live birth to HIV positive women due to increases in the North and South Sub-district. However, there were no significant changes in the Delivery in facility rate.

In terms of postnatal indicators, there was a significant improvement in the postnatal indicators (namely Mother Postnatal visits within 6 days rate) which possibly can be attributable to South Sub-district.

For outcome indicators, there was a significant decrease in all the mortality indicators (Maternal mortality ratio, Stillbirth rate, Neonatal mortality rate and Perinatal Mortality rate) across all three sub-districts during this period with best performance in the East Sub-district.

Maternal deaths in three sub-districts in the Ekurhuleni district: There was a significant decrease in Total maternal deaths from 2011/12. Although In-facility maternal deaths decreased significantly, Maternal deaths outside health facilities increased slightly. The Total Maternal death in the East Sub-district was consistently lower than the North and South Subdistricts. Analysis of maternal deaths in different gestational period: there was no significant decline in maternal deaths in all periods (namely antenatal, intranatal and postnatal) from 2011/12. Again, the maternal deaths in East Sub-district were consistently lower than North and South Sub-districts. In terms of analysis of causes of maternal deaths, it showed that the data for primary causes of maternal deaths were collected from the second quarter in 2014- 15 as a part of the DCST intervention. There were significant declines in maternal deaths due to haemorrhage, HIV, and medical conditions with no changes in deaths due to other causes and more importantly, there was an increase in death due to hypertension.

Obstetric intervention measures undertaken by the DCST in the Ekurhuleni District: The study reviewed various DCST reports generated in the last nine years and categorized the findings in accordance with the DCST Policy framework. The analysis showed that DCST members were active in all four pillars namely: Clinical effectiveness, Clinical risk management, Professional development and Accountability for Maternal, Newborn, Child and Women’s Health (MNCWH). However, it was difficult to link their activities with the underperformance of the districts. The action plan mentioned in the reports were not clearly articulated and followed up which would require further attention.

Knowledge and perception about DCST among district health managers and health professionals in the Ekurhuleni District: Interviews with key stakeholders from different levels of the District health services in the Ekurhuleni Health District (n=20) revealed seven themes, four of which are similar to the DCST policy framework (namely clinical effectiveness, clinical risk management, professional development, accountability for maternal and child health) and other three newer themes (namely clinical work, monitoring and evaluation, leadership and governance). All the participants acknowledged the key role of DCST members as a change agent and their positive impact for improvement of MNCWH services, which reflected on the improvement of MNCWH indicators. Their role as a clinician, communicator, mentor, negotiator, trainer, and researcher were highlighted.

Conclusion: Maternal health services should move beyond the focus on emergency obstetric care, to a broader approach that encompasses preventive and early interventions and integrations with existing services, as countries would like to achieve its SDG targets. This study was planned against this background to develop a comprehensive understanding of maternal health services within a district in South Africa. It further studied the role of DCST members, which were introduced in 2012 as change agents to improve the MNCWH services across the country as a part of PHC re-engineering to prepare the country for the introduction of National Health Insurance (NHI) and Universal Health Coverage (UHC). The study looked at their activities through the lens of the DCST policy framework and found that their relative success, in improving the maternal health services, was evidenced in improvement of maternal health indicators as well as in the DCST interventions and echoed by key stakeholders in the District. The findings of this study should be used by the District management to further improve its maternal health services by instituting evidenced based action plans and further operational research into severe maternal morbidity and stillbirths and perinatal mortality. Lastly, the important suggestions (such as improved emergency transport services, improving human resource and employing additional DCST members) provided by the participants should be looked at to improve maternal health services.