Out of Programme Experience

Details

A comparison of Neonatal Care in South Africa

by Rebecca Stephenson - ST2 Paediatric trainee

As a Paediatric trainee, I feel very fortunate to have completed a 12 month OOPE (Out-Of-Programme-Experience) working as a Paediatric Medical Officer in KwaZulu Natal province, South Africa.

This was organised through Africa Health Placements who work tirelessly to recruit health care staff to needy institutions throughout South Africa. ¹

Upon arrival on warm African soil, I was pleasantly surprised to find my first 2 month placement was at a tertiary neonatal unit at Greys Hospital, Pietermaritzburg. Having just completed 12 months at Liverpool Womens Hospital Neonatal department it was inevitable to contrast and compare the experiences!

On my first day, I was greeted by a sea of tiny babies in incubators with bleeping monitors and blue phototherapy ambiance – very similar to a NICU back home. The unit has 24 beds in total (9 ICU beds and 9 high care). It serves a population of approximately 3 million with a birth rate of 53000 per year.

On the shop floor there is a hard working nursing team, a team of Medical Officers/Registrars who rotate through the unit every 2 months and one very dedicated single-handed consultant. Interestingly there are no neonatal practitioners (although that’s not to say that the nurses lack skills. One in particular could throw in a peripheral arterial line without blinking).

As my first day commenced, I followed another Medical Officer to a 27 week preterm delivery. Not the large, well-prepared team of senior staff that I am accustomed to but just the two of us watching the delivery progress through a frosted window. The lack of panic was explained by the fact that for infants < 28 weeks gestation or < 900 grams, there was only the basics of oxygen warmth and fluids on offer ² . A true survival of the fittest! Even CPAP had to be considered on an individual basis for these babies.

A similar protocol on ventilation and resuscitation applies to babies with severe HIE and the unit doesn’t offer cooling.

There is a high incidence of pre-eclampsia in South Africa and lot of the premature babies were ‘stressed’ so it was interesting to see how well these babies did, despite the restricted support they received.

I soon got into the swing of things.

The main goal of every day was caring for your tiny patients and taking telephone referrals from the obstetric team and peripheral hospitals. On average the unit has 80 admissions a month. Unlike in the UK, the peripheral hospitals often have limited paediatric trained staff, limited resources (ventilators and surfactant) and to make matters worse, were 3 or 4 hours’ drive away. Prioritising bed space is always a challenge but it was dis-heartening on many occasions to have to delay a transfer of easily treatable cases like RDS or Jaundice because we didn’t have the space.

Cases like this were a real reminder of the health care issues faced here; poor road networks, lack of dedicated retrieval services and fewer staff! In the area served by Greys Hospital there are 60,000 children to every paediatrician.

My first on-call approached. Gulp|

On-calls commenced at 4pm at the end of your working day and continued until 12 midday the following day! I would be the only doctor on the NICU overnight. Between the nurses and ‘phone a friend’ consultant at home, I had to look after the unit plus deliveries and referrals.

On one particularly memorable on-call, I had a very busy unit with a sick surgical baby, a baby with RDS who needed escalating ionotropic support throughout the night and baby with a neck tumour who self-extubated at 6 in the morning! I nearly passed out with relief to see the day team arrive.

Interesting ‘African’ cases were abundant, we saw neonatal tetanus, congenital syphilis, congenital CMV, listerosis, an extrauterine pregnancy baby that delivered at 32 weeks and several cases of transfusable jaundice (now thankfully rare in UK).

Of course one can’t work in South Africa for long without appreciation of the HIV burden. 43% of mothers in the district are positive³. Our exposed babies were started on anti-retroviral prophylaxis at birth and breast feeding encouraged. ⁴ The exposed infants received pasteurised breast milk when possible. Pasteurisation is a fascinating technique of ‘flash heating’ the breast milk which denatures the virus and reduces transmission rates of the virus.⁵

Every day on the NICU was made enjoyable by the passionate ‘hands-on’ consultant who gave regular bedside teaching and also squeezed in the odd Zulu lesson and impersonations of South African bird song to remind you that life exists outside the NICU.

This OOPE placement was superb for honing practical skills like exchange transfusion, intubations, arterial lines and I owe a lot to Liverpool Womens for giving me excellent grounding in Neonatal care which helped ease the transition to work in South Africa. I gained some unusual skills like performing Ballard scores on my premature babies – which is unnecessary in the UK but in South Africa gestation prior to delivery is not always known!

A very inspiring job all round and perhaps I became a little more broody than I realised as 9 months later I delivered my own South African neonate Noah Sabelo born 15th January 2012. So I will return to the UK with a new son as well as some fond memories, some new ideas as a result of experiencing neonatal care in 2 different worlds.

Footnotes

1. Africa Health Placements. Available from: http://www.ahp.org.za/
2. Child Health Resource Package, Department of Paediatrics, Pietermaritzburg Hospitals Complex,Kwazulu-Natal Department of Health, South Africa; 2007. Available from: http://www.kznhealth.gov.za/chrp/documents/Guidelines/Guidelines%20Neonates/Referring/Neoantal%20referral%20criteria%20CHeRP%202007.pdf
3. The National Antenatal HIV and Syphilis Prevalence Survey, South Africa, 2010, National Department of Health. Available from: http://www.healthe.org.za/documents/85d3dad6136e8ca9d02cceb7f4a36145.pdf
4. Guidance on global scale-up of the prevention of mother to child transmission of HIV: towards universal access for women, infants and young children and eliminating HIV and AIDS among children / Inter-Agency Task Team on Prevention of HIV Infection in Pregnant Women, Mothers and their Children. Available from: http://www.unicef.org/aids/files/PMTCT_enWEBNov26.pdf
5. Jeffery BS et al. Determination of the effectiveness of inactivation of human im­munodeficiency virus by Pretoria pasteurization. Journal of Tropical Pediatrics, 2001, 47(6):345–349