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A comparison of neonatal care - Dr Rebecca Stephenson
As a paediatric trainee I feel very fortunate to have completed a 12-month OOPE (out of programme experience) working as a paediatric medical officer in the KwaZulu-Natal province of South Africa. This was organised through AHP who work tirelessly to recruit healthcare staff to needy institutions throughout the country. 1
Upon arriving on warm African soil I was pleasantly surprised to find my first two-month placement was at a tertiary neonatal unit at Greys Hospital in Pietermaritzburg. Having just completed 12 months at Liverpool Women’s Hospital neonatal department it was inevitable to contrast and compare the experiences!
On my first day I was greeted by a sea of tiny babies in incubators with bleeping monitors and blue phototherapy ambiance – very similar to a NICU back home. The unit has 24 beds in total (nine ICU beds and nine high care). It serves a population of approximately 3 million with a birth rate of 53 000 per year. On the shop floor there is a hard working nursing team, a team of medical officers/registrars who rotate through the unit every two months and only one very dedicated consultant. Interestingly there are no neonatal practitioners (although that is not to say that the nurses lack skills. One in particular could throw in a peripheral arterial line without blinking).
As my first day commenced I followed another doctor to a 27-week preterm delivery. Not the large, well-prepared team of senior staff that I am accustomed to but just the two of us watching the delivery progress through a frosted window. The lack of panic was explained by the fact that for infants who had less than 28 weeks’ gestation or who weigh under 900 grams – there is only the basics of oxygen, warmth and fluids on offer.2 A true survival of the fittest! Even CPAP (continuous positive airway pressure) had to be considered on an individual basis for these babies. As there is a high incidence of pre-eclampsia in South Africa, a lot of the premature babies were ‘stressed’. It was interesting to see that quite a few of these babies were doing well despite the restricted support they received and made it out into the big world a few weeks later. A similar protocol on ventilation and resuscitation applies to babies with severe HIE and the unit does not offer cooling.
I soon got into the swing of things. The main goal of every day was caring for your tiny patients and taking telephone referrals from the obstetric team and peripheral hospitals. On average the unit has 80 admissions per month. Unlike in the UK, the peripheral hospitals often have limited trained paediatric staff, limited resources (ventilators and surfactant) and to make matters worse are often three or four hours’ drive away. Prioritising bed space is always a challenge but it was disheartening on many occasions to have to delay a transfer of easily treatable cases like RDS or jaundice because we did not have the space.
Cases like this were a real reminder of the healthcare issues faced here; poor road networks, lack of dedicated retrieval services and fewer staff! In the area served by Greys Hospital there are 60 000 children to every paediatrician.
My first on-call approached. Gulp! On-calls commenced at 16:00 – the end of your working day – and continued until noon the following day. I would be the only doctor at the NICU overnight. Between the nurses and ‘phone-a-friend’ consultant at home, I had to look after the unit, deliveries and referrals.
On one particularly memorable on-call, I had a very busy unit with a sick surgical baby, a baby with RDS who needed escalating inotropic support throughout the night and a baby with a neck tumour who self-extubated at 06:00. I nearly passed out with relief to see the day team arrive.
Interesting cases were abundant; we saw neonatal tetanus, congenital syphilis, congenital CMV, listeriosis, an extrauterine pregnancy baby that delivered at 32 weeks and several cases of transfusable jaundice (now thankfully rare in the UK).
Of course one cannot work in South Africa for long without appreciation of the HIV burden. Around 43% of mothers in KwaZulu-Natal are HIV-positive.3 Our exposed babies were started on antiretroviral prophylaxis at birth and breast feeding encouraged.4 The exposed infants received pasteurised breast milk when possible. Pasteurisation is a fascinating technique of ‘flash heating’ the breast milk which denatures the virus and reduces transmission rates of the virus.5
Every day at the NICU was made enjoyable by the passionate ‘hands-on’ consultant who gave regular bedside teaching and also squeezed in the odd Zulu lesson and impersonations of South African bird song to remind you that life exists outside the NICU.
This OOPE placement was superb for honing practical skills like exchange transfusion, intubations, arterial lines and I owe a lot to Liverpool Women’s for giving me excellent grounding in neonatal care which helped ease the transition to work in South Africa. I gained some unusual skills like performing Ballard scores on my premature babies – which is unnecessary in the UK but in South Africa gestation prior to delivery is not always known.
A very inspiring job all round and perhaps I became a little more broody than I realised as 9 months later I delivered my own South African neonate Noah Sabelo born on 15 January 2012. So I will return to the UK with a new son and some fond memories, some new ideas as a result of experiencing neonatal care in two different worlds.
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1. Africa Health Placements. Available from: http://www.ahp.org.za/
2. Child Health Resource Package, Department of Paediatrics, Pietermaritzburg Hospitals Complex, KwaZulu-Natal Department of Health, South Africa; 2007.
3. The National Antenatal HIV and Syphilis Prevalence Survey, South Africa, 2010, National Department of Health. Available from: http://www.healthe.org.za/documents/85d3dad6136e8ca9d02cceb7f4a36145.pdf
4. Guidance on global scale-up of the prevention of mother to child transmission of HIV: towards universal access for women, infants and young children and eliminating HIV and Aids among children/Inter-Agency Task Team on Prevention of HIV Infection in Pregnant Women, Mothers and their Children. Available from: http://www.unicef.org/aids/files/PMTCT_enWEBNov26.pdf
5. Jeffery BS et al. Determination of the effectiveness of inactivation of human immunodeficiency virus by Pretoria pasteurization. Journal of Tropical Pediatrics, 2001, 47(6):345–349
