Shaping Women's Lives in Mpumalanga

Sub-Saharan Africa has one of the highest maternal mortality rates in the world. In South Africa, women are more likely to die of tuberculosis, HIV/AIDS, or other infectious disease than are men. Between 2000 and 2005, the United Nations estimates that half of the deaths of children below the age of five will be due to AIDS.

Across South Africa, those involved in health care are struggling to improve health services for women and children and prevent these needless deaths. In Mpumalanga Province, Piet Retief Hospital offers such an example.

[A woman keeps her preemie warm in Piet Retief hospital's Kangaroo Care room. Photo by MSH staff.]A woman keeps her preemie warm in Piet Retief hospital's Kangaroo Care room. Photo by MSH staff.As sunlight pours through the windows of the maternity ward of Piet Retief Hospital in Mpumalanga Province, the air is warm and the room serene as a handful of mothers breastfeed their newborns. This was not always the case. As early as one year ago, such a "Kangaroo Care" room did not exist, and mothers and newborns were not routinely kept together after delivery. Moreover, many women did not want to come to the hospital to deliver their children because of other service problems that prevented the hospital from effectively managing maternity care.

In January 2001, the 227-bed Piet Retief Hospital, which serves a largely rural population of more than 100,000, decided to participate in a pilot initiative established by the Mpumalanga Department of Health with assistance from Management Sciences for Health's EQUITY Project and the Quality Assurance Project (QAP). The initiative, using the quality assurance (QA) approach, aimed to institutionalize quality at the hospital and to build the capacity of health staff to monitor and continue progress themselves.

In each of the 16 participating subdistricts, the QA team first trained core groups in basic QA methodologies. Then, baseline assessments identified the most pressing needs at each facility. At Piet Retief, the group decided to focus on the maternity ward. Head nurse Tembi Mtluli explains the problems highlighted by the assessment: "We found many management problems... We didn't have time to do hourly observation of preemies [premature babies], and when patients were not progressing, we didn't report it right away. The protocols were there but were not utilized." All of these factors contributed to a startlingly high perinatal mortality rate of 27.6 deaths per 1,000 live births.

[A mother with her tiny infant in the Kangaroo Care room at Piet Retief Hospital. Photo by MSH staff.]A mother with her tiny infant in the Kangaroo Care room at Piet Retief Hospital. Photo by MSH staff.To make improvements, the team provided hospital staff training which covered basic quality assurance methodologies, such as content of care (standards, protocols, and guidelines) and process of care (systems, attitudes, and motivation). The facilitators also provided much-needed skills-building that resulted in measurable outcomes and increased efficiency.

Through skills development workshops, the staff at Piet Retief learned how to take accurate histories and sharpened their clinic skills in monitoring obstetric patients, observing premature babies and ensuring accurate APGAR scoring, a test that measures the overall health of newborns. As head nurse Mtluli explains: "No one knew APGAR scoring was important. After we were [trained in] quality assurance, we could set indicators and identify priority areas, and things changed quite a lot. Now there is constant supervision and identification of problems."


At Piet Retief, the QA team exceeded initial expectations. Hospital staff improved communication among hospital departments and developed a questionnaire in Zulu and English to get crucial feedback from patients. Staff now systematically review files to discover problems, after which they design in-service education to address those problems. They also set aside a new room for Kangaroo Care, where mothers can nurse their babies in a nurturing environment, using their bodies as incubators for tiny infants.

As a result of their efforts, perinatal mortality rates plummeted to 13 per 1,000 in 2001, while APGAR scoring and accurate history taking steadily increased. Most importantly, the multidisciplinary team has come to recognize that by working and learning together, they are helping shape their patient's lives. More and more women are telling expectant mothers about their positive experiences in the Piet Retief maternity ward, showing other mothers where to turn to give their babies a healthy start in life.

"We were so happy and encouraged through quality assurance. We are seeing the fruits of our labor. More and more people want to come here to find out what we are doing..." — Grace Sidu, Hospital Administrator