Audit of a new model of birth care for women with low risk pregnancies in South Africa: the primary care onsite midwife-led birth unit (OMBU).

BACKGROUND: South Africa's health system is based on the primary care model in which low-risk maternity care is provided at community health centres and clinics, and 'high-risk' care is provided at secondary/tertiary hospitals. This model has the disadvantage of delays in the management of unexpected intrapartum complications in otherwise low-risk pregnancies, therefore, there is a need to re-evaluate the models of birth care in South Africa. To date, two primary care onsite midwife-led birth units (OMBUs) have been established in the Eastern Cape. OMBUs are similar to alongside midwifery units but have been adapted to the South African health system in that they are staffed, administered and funded by the primary care service. They allow women considered to be at 'low risk' to choose between birth in a community health centre and birth in the OMBU. METHODS: The purpose of this audit was to evaluate the impact of establishing an OMBU at Frere Maternity Hospital in East London, South Africa, on maternity services. We conducted an audit of routinely collected data from Frere Maternity Hospital over two 12 month periods, before and after the OMBU opened. Retrospectively retrieved data included the number of births, maternal and perinatal deaths, and mode of delivery. RESULTS: After the OMBU opened at Frere Maternity Hospital, the total number of births on the hospital premises increased by 16%. The total number of births in the hospital obstetric unit (OU) dropped by 9.3%, with 1611 births out of 7375 (22%) occurring in the new OMBU. The number of maternal and perinatal deaths was lower in the post-OMBU period compared with the pre-OMBU period. These improvements cannot be assumed to be the result of the intervention as observational studies are prone to bias. CONCLUSIONS: The mortality data should be interpreted with caution as other factors such as change in risk profile may have contributed to the death reductions. There are many additional advantages for women, hospital staff and primary care staff with this model, which may also be more cost-effective than the standard (freestanding) primary care model.

Birth defects following exposure to efavirenz-based antiretroviral therapy during pregnancy: a study at a regional South African hospital.

OBJECTIVES: To determine the prevalence and type of birth defects among infants following exposure to efavirenz-based antiretroviral therapy (EFV-based ART) during pregnancy. METHODS: A Pregnancy Registry was established to enable prospective follow-up of women taking EFV-based ART. In women who conceived on EFV-based ART, EFV was switched with another drug if they presented during the first trimester but was continued if they presented at or after 14 weeks' gestation. Pregnant women needing lifelong ART were commenced on EFV-based ART from 14 weeks' gestation onwards. Infants were followed up for 6 weeks after birth. RESULTS: Between January 2006 and December 2008, 623 ART-naive pregnant women initiated EFV-based ART in the second/third trimester and 195 women conceived on EFV-based ART. Birth defects were observed in 16 of 623 live births [2.6%; 95% confidence interval (CI) 1.5-4.2] and in six of 184 live births (3.3%; 95% CI 1.2-7.0) from women exposed to EFV in the second/third trimester and first trimester, respectively. The prevalence of birth defects was not significantly different between the first and second/third trimester EFV exposure (prevalence ratio 1.27; 95% CI 0.50-3.20; P = 0.301). CONCLUSION: No significant increase in the prevalence of birth defects following exposure to EFV-based ART in the first trimester was observed in this cohort. However, the limited number of first trimester EFV-exposed infants precludes definitive conclusions on the teratogenicity or safety of EFV.