The damaged generation: Human factor, birth trauma leading causes of disabilities

2013-08-25 14:00

Several senior state obstetricians and paediatricians say working conditions in state hospitals, coupled with a marked decline in the quality of nursing training and a dire shortage of midwives, put mothers and newborns at grave risk.

Dr Hein Odendaal, a leading obstetrician and emeritus professor at Stellenbosch University, said significant numbers of newborns suffered avoidable brain damage.

This was either because their births were dragged out for too long, their mothers’ uteri were overstimulated or because foetal distress was not recognised in time or at all.

Odendaal’s research has flagged the incorrect use of the birth-assisting drug oxytocin – a synthetic hormone used to induce labour or speed up the birth – as a grave hazard to mother and baby.

He and others in the field say more research is needed to establish how many babies end up with avoidable cerebral palsy due to birth complications.

Other experts, who spoke on condition of anonymity as they are employed by the state, agreed.

A paediatrics professor at one of SA’s leading medical schools said up to 50% of children with cerebral palsy in South Africa have the condition because of avoidable birth complications.

The experts pointed to the findings of the Medical Research Council of SA’s annual Saving Babies research programme, which they described as “the tip of the iceberg”.

This research found that the vast majority of full-term babies of normal weight die in their first week of life due to asphyxia or oxygen deprivation.

This shows that it is an alarmingly common occurrence in state hospitals.

The latest Saving Babies report, which analysed data of infant deaths in 588 public health institutions in the 2010/11 financial year, found the leading cause of perinatal deaths to be asphyxia and birth trauma, and also noted the quality of care was poorest in the district hospitals.

“But not all babies subjected to loss of oxygen at birth die,” says one veteran paediatrician who is employed by the state.

Those who don’t suffer consequences for the rest of their lives.

In an editorial for the Obstetrics and Gynaecology Forum journal, Odendaal noted that unchanged ratios of babies dying from birth asphyxia and trauma showed that “the management of labour has not become safer during the last seven years”, and it was likely that some of the deaths could have been due to the “unsafe use of oxytocin during labour”.

He also pointed out that oxytocin was recently added to the list of high-alert medications by the Institute for Safe Medication Practices, an international NGO.

One Gauteng obstetrician said the health department’s policies and guidelines for handling childbirth were excellent, but problems stemmed from the “human factor” in their implementation.

Another state doctor put it more bluntly: “The nurses just don’t listen to the mothers and they don’t administer the correct treatment at the correct time.”

What the health department says

The Gauteng health department ­admits that it is facing a large number of lawsuits as a result of medical negligence in its hospitals.

However, it says the problem is not as bad as it is portrayed.

After being told that Health MEC Hope Papo was unavailable for an ­interview this week, City Press sent a list of questions relating to 336 ­lawsuits amounting to R1.9 billion, 35% of which concern poor maternal care that led to hundreds of children being brain damaged.

When asked if the department ­believed that the number of children brain damaged at birth reflected its standard of care, department ­spokesperson Simon Zwane said it did not.

“Underlying factors such as ­socioeconomic challenges and preconditions of patients contribute to the number of lawsuits,” he said.

“It is also important to note that the number of children delivered in provincial hospitals is more than 200?000 per year and almost all of them do not sustain injury. Those who sustain injuries are a tiny minority.”

However, Zwane said: “We have prioritised the employment and ­training of midwives as a key intervention to address the situation.

“Last year 120 nurses were trained in midwifery and 79 were trained in advanced midwifery and neonatology.

The training of nurses on neonatal ­resuscitation was also carried out to improve the survival of babies and prevent injuries.

“And equipment such as cardiotocography and fetal monitors were ­also purchased.”

Zwane said 34 staff members in the province had been disciplined for negligence last year.

The department had introduced a system of clinical ­audits to ensure continual improvement in the quality of care.

“There is ongoing training in all ­facilities to improve attitudes and communication between staff and ­patients,” he said.

In the 2012/13 financial year, 188 doctors and 203 nurses were trained to manage obstetric emergencies, and nurses were trained to use early ­warning charts, he said.

Chris Hani Baragwanath Academic Hospital faces the highest number of birth-related lawsuits related to babies who sustained brain injuries at birth and later developed cerebral palsy.

The department defended the ­facility’s performance, saying: “It is ­important to note that Chris Hani Baragwanath is a referral hospital and therefore deals with complicated ­cases, so it is not alarming if they have more obstetric litigations than other hospitals.”

Early last year, the hospital brought in advanced midwives from the ­military medical corps to help.

And Zwane said they were doing something about it.

“The hospital has employed more midwives and improved the availability of equipment to address factors that lead to obstetric litigation,” he said.

City Press and Media 24 Investigation’s probe revealed a number of ­cases in which medical devices such as forceps and vacuums were used to tragic effect during deliveries.

Both ­instruments can increase the risk of brain injury if used incorrectly and many countries, including Britain, no longer use them in state hospitals.

Zwane said the department has stopped its doctors from using forceps, but they continue to use the vacuum method as they believe it to be safer.

“There are operational guidelines and standards that conform to ­well-researched international ­standards. Such methods are still ­successfully applied with a high rate of successful deliveries,” he said.

About the R1.9 billion in claims it faces, Zwane said: “While we ­acknowledge there are potential ­liabilities, some of the cases have been successfully concluded, settled and closed at lesser amounts.”

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