Improving perinatal outcomes in a rural hospital

An evaluation of perinatal outcomes at South Africa's McCords Hospital, the site of a decentralized education program that trains advanced diploma midwives (ADMs), suggests that this educational innovation has the potential to contribute to the aim of safe motherhood. The site of the evaluation, Hlabisa Hospital in northern KwaZula, Natal, serves 150,000 rural people. Since May 1991, data have been collected on over 10,000 consecutive deliveries. The perinatal mortality rate per 1000 deliveries rose from 26.9 in the May-December 1991 period to 39,0 in 1992 and then fell to 29.6 in January-September 1993. However, the percentage of these deaths classified as avoidable dropped from 18.6% to 7.8% to 5.8% in these three time periods. In addition, the proportion of perinatal deaths that occurred in the 7 village clinics operated by hospital staff fell from 16.7% to 9.6% to 2.7%. The marked rise in the hospital's perinatal mortality rate during the study period is considered to reflect the diversion of increased numbers of high-risk deliveries to the hospital. At the clinics, where ADMs make regular visits to identify high-risk pregnancies and hold teaching sessions with midwives, care improved significantly, as evidenced by the drop in perinatal mortality at these facilities without any decline in the number of overall deliveries. At the time of the study, 5 ADMs were based at the hospital, but the goal is to place and ADM in each of the village clinics. Since the decentralized education approach does not require midwives to spend time away from their villages, it is particularly suited to the training of indigenous health workers.