SOUTH AFRICA: Rural health facilities struggle to provide healthcare

DURBAN, 15 September (IRIN) - Pregnant HIV-positive women in South Africa can now get nevirapine, an anti-AIDS drug that helps prevent the transmission of the virus to their babies, at every hospital and almost all health centres and clinics.

A single dose of nevirapine is administered to the mother during birth, and a single dose is given to the newborn infant.

But a visit to the maternity ward at Hlabisa Hospital in northern KwaZulu-Natal province illustrates the challenges that the prevention of mother-to-child transmission (PMTCT) programme still faces, particularly in rural areas.

In the last two months the ward has recorded six maternal deaths: all the mothers were HIV-positive, but none had been on antiretroviral (ARV) treatment prior to being admitted to the hospital to give birth.

"Our problem is access to ARV therapy for pregnant mothers - we just have nevirapine [available]," admitted Dr Emmanuel Mbatha, who runs the maternity ward together with Dr Bongisani Manukuza.

Although Hlabisa Hospital received accreditation from the government to provide ARVs in the Umkhanyakude health district in July 2004, doctors said the site was not yet fully operational, and there was little cooperation between the ARV clinic and the antenatal ward.

While most efforts in the antenatal ward are focused on ensuring that the babies are born HIV negative, the physical condition of the mothers is often neglected.

PMTCT interventions, such as administering two single doses of nevirapine, are cheaper than the long-term provision of ARVs to mothers living with HIV/AIDS.

Healthcare workers on the ward acknowledged the inadequate infrastructure and poor post-natal and nursery care. "Once the women have delivered we don't know what happens to the mothers and their babies," Dr Manukuza told IRIN.

For example HIV-positive mothers were counselled to breastfeed exclusively, but there was "no follow-up", he added.

Another major challenge was the prevailing and widespread stigma against HIV/AIDS, which made many pregnant women reluctant to be tested for the virus. Most of those who agreed to be tested did so without the support or knowledge of their partners and husbands, the maternity ward staff observed.

According to Mbatha, HIV-prevalence in the antenatal ward was high, ranging between 60 percent and 70 percent. "It is most unusual for us to see a HIV-negative mother," he commented.

An estimated 36 percent of the pregnant women who attend state antenatal clinics KwaZulu-Natal test positive, making the province one of the hardest-hit areas in the country.

The rundown hospital and its 15 rural clinics serve a population of 222,000; it has 294 beds, but no ambulance service or blood bank. Two young doctors fresh out of medical school run the antenatal ward, which is staffed by two nurses and 16 health workers. There are an average of 55 patients but only 20 beds; full-term women often have to share, while others sleep on the floor.

"It's a mess ... I have so many patients, it's sometimes impossible to see all of them every day. Some days, I have only time to see high-risk patients," Mbatha said.

Staff shortages have restricted the doctors from performing caesarean sections on all HIV-positive mothers to reduce the risk of MTCT, as is recommended by the World Health Organisation (WHO).

In addition, the ward regularly runs out of medicines and medical supplies. Even HIV-testing kits are not always available. "We sometimes even run out of simple cuffs to measure blood pressure," said Mbatha.

The personnel are becoming increasingly frustrated. "Every day, in order to get something, you must fight," a senior member of staff who asked not to be named, told IRIN.

But Mbatha and Manukuza regard themselves as fortunate, because Dr Candice Roberts, a gynaecologist from the Red Cross Flying Doctors service who also runs the maternity ward at Durban's McCord Hospital, has been visiting the antenatal ward once a month for the past three years to help run it more efficiently and conduct difficult caesareans.

The Flying Doctor and Health Outreach Service is a nationwide medical network that provides air ambulance, health outreach and emergency rescue services. Health professionals, most of whom work on a voluntary basis, are flown to rural hospitals to provide clinical services to thousands of patients a year.

"You help [rural hospitals] to do their best ... with the limited resources they have," Roberts said, adding that there was "no incentive for staff to stay here [at Hlabisa Hospital]. Most health workers here are overworked, stressed and strained".

Nevertheless, Roberts noted that there had been gradual improvements: new wards were being built and more doctors and paramedic staff have been employed.

There are no other specialists apart from Roberts at Hlabisa Hospital - no paediatrician, no anaesthetist, no surgeon or optometrist. Without an anaesthetist, for example, patients can only receive spinal anaesthetics that numb the body from the hips down.

Patients have to be referred to the nearest better-equipped public hospital in Empangeni, about 100 km away, for all procedures requiring a specialist. Empangeni is the referral hospital for the region and Mbatha said an ambulance could take up to six hours to arrive because of the demand for medical transport.

The doctors at Empangeni were often reluctant to take patients referred from Hlabisa. "They say they are too busy," Mbatha commented.

It is the patient who suffers most from such administrative wrangles. The most recent example is Khanyile Zungu (not her real name) who sat on her bed in a room full of expectant mothers in Hlabisa, staring blankly at the wall.

A few days before her due date, Zungu had been told that her baby had died. Four weeks later, the baby had still not been removed from her womb.

Not only was Zungu traumatised by the death of her baby, her life was at risk because the placenta had started decomposing.

Health workers had first tried inducing labour to extract the dead body. When this was unsuccessful, Mbatha tried to transfer Zungu to Empangeni Hospital. The operation needed a specialist, but the referral hospital refused to take her.

"We were told to solve the problem ourselves," said Mbatha. Dr Roberts could not perform the operation on her visit because Hlabisa has no anaesthetist. As a result, Zungu had still not had the operation at the time IRIN visited the hospital.

Source: Reuters/IRIN