Growth patterns and clinical outcomes in association with breastfeeding duration in HIV exposed and unexposed infants: a cohort study in KwaZulu Natal, South Africa.

BACKGROUND: Exclusive breastfeeding for 6 months and breastfeeding with complementary feeds until 12 months for HIV exposed and uninfected (HEU) infants or 24 months for HIV unexposed (HU) infants is the current World Health Organisation (WHO) recommendation for low and middle income countries (LMICs) to improve clinical outcomes and growth trajectories in infants. In a post-hoc evaluation of HEU and HU cohorts, we examine growth patterns and clinical outcomes in the first 9 months of infancy in association with breastfeeding duration. METHODS: Two cohorts of infants, HEU and HU from a low-socioeconomic township in South Africa, were evaluated from birth until 9 months of age. Clinical, anthropometric and infant feeding data were analysed. Standard descriptive statistics and regression analysis were performed to determine the effect of HIV exposure and breastfeeding duration on growth and clinical outcomes. RESULTS: Included in this secondary analysis were 123 HEU and 157 HU infants breastfed for a median of 26 and 14 weeks respectively. Median WLZ score was significantly (p < 0.001) lower in HEU than HU infants at 3, 6 and 9 months (- 0.19 vs 2.09; - 0.81 vs 0.28; 0.05 vs 0.97 respectively). The median LAZ score was significantly lower among HU infants at 3 and 6 months (- 1.63 vs 0.91, p < 0.001; - 0.37 vs 0.51, p < 0.01) and a significantly higher proportion of HU was classified as stunted (LAZ < -2SD) at 3 and 6 months (3.9% vs 44.9%, p < 0.001; 4.8% vs 20.9%, p < 0.001 respectively) independent of breastfeeding duration. A higher proportion of HEU infants experienced one or more episodes of skin rash (44.5% vs 12.8%) and upper respiratory tract infection (URTI) (30.1% vs 10.9%) (p < 0.0001). In a multivariable analysis, the odds of occurrence of wasting, skin rash, URTI or any clinical adverse event in HEU infants were 2.86, 7.06, 3.01 and 8.89 times higher than HU infants after adjusting for breastfeeding duration. CONCLUSION: Our study has generated additional evidence that HEU infants are at substantial risk of infectious morbidity and decreased growth trajectories however we have further demonstrated that these adverse outcomes were independent of breastfeeding duration.

Are there decision support tools that might strengthen the health system for perinatal care in South African district hospitals? A review of the literature.

BACKGROUND: South Africa has a high burden of perinatal deaths in spite of the availability of evidence-based interventions. The majority of preventable perinatal deaths occur in district hospitals and are mainly related to the functioning of the health system. Particularly, leadership in district hospitals needs to be strengthened in order to decrease the burden of perinatal mortality. Decision-making is a key function of leaders, however leaders in district hospitals are not supported to make evidence-based decisions. The aim of this research was to identify health system decision support tools that can be applied at district hospital level to strengthen decision-making in the health system for perinatal care in South Africa. METHODS: A structured approach, the systematic quantitative literature review method, was conducted to find published articles that reported on decision support tools to strengthen decision-making in a health system for perinatal, maternal, neonatal and child health. Articles published in English between 2003 and 2017 were sought through the following search engines: Google Scholar, EBSCOhost and Science Direct. Furthermore, the electronic databases searched were: Academic Search Complete, Health Source - Consumer Edition, Health Source - Nursing/Academic Edition and MEDLINE. RESULTS: The search yielded 6366 articles of which 43 met the inclusion criteria for review. Four decision support tools identified in the articles that met the inclusion criteria were the Lives Saved Tool, Maternal and Neonatal Directed Assessment of Technology model, OneHealth Tool, and Discrete Event Simulation. The analysis reflected that none of the identified decision support tools could be adopted at district hospital level to strengthen decision-making in the health system for perinatal care in South Africa. CONCLUSION: There is a need to either adapt an existing decision support tool or to develop a tool that will support decision-making at district hospital level towards strengthening the health system for perinatal care in South Africa.

A health system framework for perinatal care in South African district hospitals: a Delphi technique.

BACKGROUND: The majority of perinatal deaths occurring in low- and middle- income countries are preventable. South Africa is a middle-income country with consistently high perinatal mortality rates and most factors contributing to preventable deaths are linked to the functioning of the health system. Particularly of concern in South Africa is the high perinatal mortality in district hospitals, where most births occur and where intrapartum care is provided to women of low and intermediate risk. Therefore, it is crucial to strengthen the health system for perinatal care in district hospitals. There is currently no consolidated documented framework outlining contextual health system domains and indicators that are key to providing effective perinatal care in district hospitals. The purpose of this study was to derive key health system domains and indicators necessary to measure the performance of the health system for perinatal care in South African district hospitals. METHODS: The Delphi technique was used in collecting data from a panel with experts drawn from disciplines connected with the functioning of the health system for perinatal care in South Africa. The study enrolled thirteen experts from whom data on key health system domains and indicators for perinatal care were derived. The project reference group gave guidance to the development of the framework and ascertained its relevance to the South African setting. RESULTS: The Facility Based Health System Framework for Perinatal Care comprising domains and indicators necessary to measure health system performance in South African district hospitals was derived from data. The broad structure of the proposed framework aligns with the WHO Health Systems Framework. Each critical building block has detailed domains and indicators that illuminate essential facility-level and programme-specific elements that require attention for strengthening the health system for perinatal care. CONCLUSION: The proposed framework can enable district hospital management teams to identify gaps in the health system for perinatal care, which need to be strengthened in order to alleviate the burden of perinatal deaths in district hospitals.