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The microcirculation is a vast network of small vessels with a diameter below 100µm. It consists of arterioles that regulate flow to the capillaries, which subsequently drain in venules. Exchange of oxygen and nutrients occurs at the level of the capillaries, which mainly consist of a thin layer of endothelium. With the availability of new imaging modalities, the importance of microcirculatory perfusion in the pathophysiology, prognosis and treatment of conditions with profound haemodynamic is emerging. Parameters of microcirculatory perfusion seem independent of global haemodynamic status and appear to be strong predictors of outcome. Severe pre-eclampsia is characterised by a maternal haemodynamic instability caused by generalised endothelial dysfunction. Many of its symptoms and complications like HELLP syndrome (haemolysis, elevated liver enzymes and low platelets) strongly suggest microcirculatory dysfunction. Our aim was to explore the potential of a new technique that allows visualisation of the microcirculation called SDF (Sidestream Darkfield Imaging) in pregnant women and to analyse microcirculatory perfusion in women with severe pre-eclampsia as compared to healthy pregnant women. Secondly we investigated the influence of HELLP syndrome on the microcirculation in women with severe pre-eclampsia.

23 Women with severe pre-eclampsia were included. In ten of those women, pre-eclampsia was complicated by HELLP syndrome. 23 Healthy pregnant women, matched for maternal and gestational age were included as controls. The sublingual microcirculation was visualized using SDF. This hand-held video microscope emits stroboscopic green light from an outer ring of LEDs which penetrates the tissue to a depth of approximately 3mm. The light is absorbed by haemoglobin of individual red blood cells in superficial vessels. A negative image is transmitted back, after 5x optical magnification, to an isolated synchronised charge coupled device-camera in the core of the probe. This allows high contrast video images of circulating erythrocytes to be recorded with a 286x magnification from the microcirculation of organs covered with a thin epithelial layer The video images are analysed off line looking at perfused vessel density (PVD), microcirculatory flow index (MFI), and the heterogeneity index (HI) in small vessels ( < 20 μm, capillaries) and non-small vessels (20 μm ≤  ≤ 100 μm; mostly venules and arterioles). Interobserver reliability and interobserver agreement was assessed in 15 women. Differences between pre-eclampstic and healthy pregnant women and between pre-eclamptic women with or without HELLP syndrome were analysed after adjustment for several confounders.


Adequate recordings and measurements were obtained in all participants.

Intraclass correlation coefficients and interobserver agreement were good for capillary measurements. We could not observe any significant differences in sublingual microcirculatory perfusion in women with severe pre-eclampsia as compared to healthy controls. Women with HELLP syndrome had significantly lower values of capillary PVD and MFI and significantly higher values of capillary HI as compared to severe pre-eclamptic women without HELLP.


Microcirculatory research has mainly been hampered by technological limitations. SDF allows direct recording of high contrast images and assessment of different aspects of microcirculatory perfusion. Satisfactory images can be obtained at the bedside and with minimal discomfort in pregnant women. Nevertheless, while image recording is relatively straightforward, off line analysis still requires a substantial human input and remains time consuming. Despite increased blood pressures, we did not observe any difference in microcirculatory parameters in severe pre-eclamptic women, as compared to healthy pregnant controls. Apparently, the major macrocirculatory disturbances of severe pre-eclampsia are not reflected in significant differences in sublingual microcirculatory perfusion. Interestingly, when comparing severe pre-eclamptic women with or without HELLP syndrome, we observed significant differences in all aspects of capillary perfusion, with a decrease in PVD and MFI and an increased HI in women with HELLP syndrome.

The suggestion of impaired capillary perfusion in pre-eclampstic women with HELLP syndrome might explain some aspect of the pathophysiology of HELLP syndrome.

The reduced PVD and MFI might be a reflection of microvascular erythrocyte fragmentation and platelet adherence to the damaged endothelial surface in narrowed capillaries. The increased heterogeneity could explain the diffuse pattern of liver cell necrosis in HELLP, where fibrin microthrombi and fibrinogen deposits are often observed both in intact hepatic sinusoids as in areas with hepatocellular necrosis on histology.

Pre-eclampsia is a complex syndrome which groups a broad clinical spectrum with variable degrees of organ dysfunction. Further research in obstetrics should explore microcirculatory perfusion at various sites during the haemodynamic adaptation of normal pregnancy and explore eventual representative areas in pathologic conditions.

Besides facilitating (patho) physiological research in larger populations, future improved versions with rapid bedside analysis also offer perspectives for clinical implications. As in sepsis and cardiogenic shock, microcirculatory perfusion analysis has a potential to improve outcome prediction, selection of candidates for expectant management or monitoring of medical treatment.

Microcirculation in women with severe pre-eclampsia and HELLP syndrome: a case-control study. Cornette J, Herzog E, Buijs EA, Duvekot JJ, Rizopoulos D, Hop WC, Tibboel D, Steegers EAP. BJOG. 2014 Feb;121(3):363-70.

F Onyangunge, J Moodley, M Nene, S M Khedun

Department of Obstetrics and Gynaecology and Women’s Health and HIV Research Group, University of KwaZulu-Natal, Nelson R Mandela School of Medicine, Durban.


Hypertensive disorders are a significant cause of maternal and perinatal morbidity and mortality worldwide including South Africa. Despite years of research, the exact etiliogy of new onset hypertension in pregnancy is unknown. Treatment of this condition is still empirical despite much of the pathophysiology being known. Identifying patients and instituting timeous delivery remains the mainstay of clinical management.

The frequency of preeclampsia (new onset hypertension and proteinuria) varies globally and occurs between 3 and 12 % of all pregnancies. In South Africa, a community based study found a 12 % incidence of hypertensive disorders of pregnancy while a tertiary facility based study reported a prevalence of 18 %.

Primigravidae has been on identified as a risk factor for pre-eclampsia, however there are few reports on the incidence of pre-eclampsia in Black African primigravidae in our setting. According to Saving Mothers Reports (2005-2007 and 2008-2010), primigravidae contribute a significant proportion of maternal deaths due to hypertensive disorders of pregnancy in South Africa. The aim of our study was to perform a clinical audit of all primigravidae at a specialist health facility over a one year period to establish the incidence of pre eclampsia in Black African pregnant women.


All primigravidae with hypertensive disorders of pregnancy who delivered in the study period (April 2012 to March 2013) were identified and followed till discharge. Relevant demographic and clinical data was recorded in a purpose designed form. Preeclampsia was defined as new onset hypertension (BP: 140/90 mmHg) and proteinuria (≥ 2+ on urine dipstick) after the 20th of pregnancy. Gestational hypertension was defined as new on set hypertension without evidence of proteinuria on a 24 hour specimen. Data on all admissions were obtained from the institution’s DHIS database but all primigravidae admitted to the study site were tracked prospectively and those with hypertension followed till hospital discharge. The clinical management of pre eclampsia at the study site followed that described in the National Maternity Guidelines. The study site was regional hospital in the south of Durban which caters for a population of 2 million and had 20 health clinics under its supervision.


There were 12973 deliveries during the study period. Five thousand eight hundred sixty (45%) were primigravidae and 7113 (55%) were multiparous. One thousand five hundred and twenty (1520) were diagnosed with hypertension. The incidence of hypertension was 11.7%. In the same study time period, 731 (12.5%) primigravidae with clinical evidence of hypertension was delivered or 6% of all deliveries.

Figure 1 Flow diagram of the study population

Total deliveries (n=12973)

Primigravidae (n=5860; 45%)

Multiparous (n=7113; 55%)

Hypertensive (n=1520; 11.7%)

Hypertensive (n=731; 12.5%)

Eclampsia (n=31; 4.24%

Imminent /severe preeclampsia (n=84; 11.49%

Mild to moderate preeclampsia (n=222; 30.37%)

Gestational hypertension (n=394; 53.89%)

The clinical characteristics of all primigravidae with hypertension are shown in table 1.

Table 1 Clinical characteristics of all primigravidae with hypertension (n=731)


Gestational hypertension (n=394)


mild to moderate (n=222)

Severe preeclampsia and imminent eclampsia (n=84)

Eclampsia (n=31)

Age (years;mean)

Gestational age at delivery (weeks ;mean)
Blood Pressure (mm Hg)


Proteinuria (dipstix)
Maternal weight (kgs)

20.9 ±4.3

37 (36-39)
148 .7 ± 11.2

85.0 ±11.2

73.0 ± 14.7

20.6 ± 4.0

36 (35-39)
158.3 ± 15.0

97.4 ± 15

1+ (1+ - 2+)

75.2 ± 15.3

21.8 ± 4.1

35 (35-38)
156.5 ± 13.6

101.1 ± 11.5

2+ (2+ - 4+)

78 ± 16.6

19.6 ± 3.4

35 (34-36)
163.6 ± 14.7

104.8 ± 14.5

2 + (2+ - 4+)

74.8 ± 21.0

Maternal and perinatal morbidity and mortality

There were 130 stillbirths in all primigravidae. Thirty two (24.6%) occurred in hypertensive primigravidae and 98 (75.4%) in non hypertensive primigravidae. There were 11 early neonatal deaths. The overll perinatal mortality rate was 5.9% of all hypertensive primigrvidae. There was 2 maternal death (severe pre-eclampsia (n=1) and eclampsia (n=1)). The mean hospital stay was 6 (range: 2-38) days and 4 (0.6%) and 48 (6.6%) of the hypertensive primigravidae required ICU and MHC care respectively.


The rates of hypertensive disorders in pregnancy are high in South Africa. In our study the overall incidence of hypertension was 11.7% (n=1520) and that in primigravidae was 12.5% (n=731). These figures are at upper range of incidences of hypertesive disorders in pregnancy quoted in the world literature.

In an earlier study conducted in a tertiary teaching hospital in the Eastern Cape, 760 (4.6%) of all the deliveries had hypertensive disorders of pregnancy of which 502 (66%) had proteinuric hypertension. These differences in rates in the same country and in the same racial groups may be due to differing referral patterns as demonstrated by finding of a high number of proteinuric hypertensives in the Eastern Cape. Our study found that gestational hypertesion was the commonest hypertensive sub-category and may indicate that ante natal care attendence was reasonable, detection rates and management were good. However, the high stillbirth rates in both hypertensive and non-hypertensive primigravidae is of concern and requires an in depth investigation.

Primigravidae form a significant workload in the maternity unit regional hospital in which the audit was performed. Further primigravidae are a risk factor for hypertensive disorders of pregnancy. Since most primigravidae are young more attention needs to be given to provision of contraceptive services to all age groups in the population.

Dr Nonhlanhla Sikakane, Dr Yasmin Adam

Department of Obstetrics & Gynaecology, Chris Hani Baragwanath Academic Hospital and the University of the Witwatersrand


Induction of labour (IOL) is necessary when the placental function cannot be relied upon to continue its function of supplying adequate nutrients and oxygen to the foetus. It is also indicated where the risk of the pregnancy to the mother’s health is a concern. In South Africa the incidence of IOL is 9% [5]. The procedure is however associated with risks and should be performed with caution [1].

The established indications of IOL in Soweto include, hypertensive disorders of pregnancy (34%), pre-labour rupture of membranes (30%), post-term pregnancy (15%), intra-uterine death (7%), diabetes (2%) and others (12%) [6].

Every obstetric department should aim to decrease its caesarean section rate, iatrogenic prematurity and cost without increasing maternal and foetal morbidity. The aim of this study is to determine the indications, success rate and complications associated with IOL using oral misoprostol. The rate and indications for caesarean sections, maternal morbidity and mortality, perinatal morbidity and mortality associated with IOL.


Study Design:

A prospective cohort study which recruited women between November 2012 and February 2013 at CHBAH a secondary/ tertiary hospital which delivered 22 603 women in 2013.

Study Population:

This was a period sample where women over the age of 18 and with a gestational age of 38 weeks or more were recruited. Inclusion criteria: singleton viable pregnancy, cephalic presentation, a category 1 CTG, intact membranes.Exclusion criteria: Hypersensitivity to Misoprostol, previous uterine scar, intra uterine fetal death, antepartum haemorrhage, and any woman where continuous fetal heart rate monitoring was indicated.

Oral Misoproostol solution is made up with 200ug of misoprostol in 200mls of tap water (1ug/ml). Parous women start with 10ml(10ug) every 2 hourly for 3 doses and then 20ml (20ug) 2hourly for 3 doses and the 40ml (40ug) 2hourly for 3 doses. Nulliparous women start with 20mls (20ug). The maximum dose in all women is 40mls(40ug) every 2 hours. The misoprostol is continued for 24 hours. In the event that labour does not occur, there is a rest period of 24 hours before the Misoprostol is started again for another 24 hours. The procedure is abandoned after a second cycle and a caesarean section is then performed.
Data Management:

Information was obtained from the medical notes and by interview. SPSS version 13 was used for analysis.


Permission to performed the study was obtained form the Human Research Ethics committee at the University of the Witwatersrand (M120955) and the CEO at CHBAH.


Two hundred and forty eight women were admitted for an IOL and 142 were recruited for the study. The mean age was 26.86 (SD±5.93). The median parity was 1(IQR=0-1), 66(46.50%) were nulliparous. One hundred and twenty (85.50%) women had attended high school. Only 3 (2%) of the women were smokers.

There were 27(19.00%) who were HIV infected. The BMI was more than 30 (obese) in 77 (54.20%) of the women.The indications for IOL is shown in fig 1 below.

The Bishop’s score was less than 6 in 128 (90.10%).

The mean time from first dose of Misoprostol to delivery was 16.76 hours (SD±9.90) and the median time was 14 hours (IQR=11-20)- see figure 2 below. Most women delivered within 10-20 hours. Twelve (8.45%) needed a second cycle of Misoprostol.

Fifty- four (38.02%) women needed a caesarean section. the main indication for caesar was Fetal distress (n=39 (72%)). Assisted delivery occurred in 8(5.65%) of women. Precipitate labour occurred in 8 (9.30%). Postpartum hemorrhage was noted in 9 (6.42%) of women and 4 of these needed a blood transfusion. There were no women who had hyper-stimulation.

The median birthweight was 3220g (IQR 2910-3580), with a range of 1940 to 4685g. Sixteen babies (59.26%) were admitted for respiratory distress and were discharged well, 7(25.93%) had meconium aspiration and 4(14.81%) were admitted to the neonatal unit for HIE 1-11). These 4 babies are described below.

The first baby was born by caesarean section and had an APGAR of 2 at 1 min and 7 at 5 minutes, was born by caesarean section for a prolonged second stage- time from booking the caesar to performing it was 2 hours. The second baby had an APGAR of 4 at 1 min and 6 at 5 min, was born by caesarean section for fetal distress- time from booking the caesar to performing the caesar was 6 hours. The third baby was born with an APGAR of 3 at 1 min and 5 at 5 min, was delivered vaginally, and had not been monitored. The 4th baby had an APGAR of 2 at 1 min and 6 at 5min was delivered vaginally, and was a face presentation and had a shoulder dystocia.

Discussion and Conclusion:

This method of IOL is successful, but it should not be performed where monitoring is inadequate or cannot be performed. It should only be performed when medically indicated. Mechanical methods may be better even though it may be more labour-intensive.

Dr Sisana Majeke

Senior Lecturer, University of KwaZulu-Natal, School of Nursing and Public Health

Introduction: Antenatal care is one of the effective methods of improving outcomes in pregnant women and their babies. Antenatal care is important because it is one of the key components towards achievement of the Millennium Development Goals 4, 5 & 6. In the KwaZulu-Natal Province which is mainly rural, maternal mortality remains high due to poor clinic attendance, late booking and non-booking. In South Africa, 93% do attend antenatal clinic during their pregnancy in their second or third trimester of their pregnancy and some attend once only (UNICEF, 2003).
Objective of the study was to determine the factors hindering early antenatal clinic bookings by pregnant women attending antenatal care in selected clinics of level 1 hospital of the eThekwini District.
Method: A quantitative descriptive and exploratory research design was used in this study. Systematic random sampling technique used to select respondents. Structured interviews conducted to collect data from 360 pregnant women from in 2013. Statistical Package for Social Sciences (SPSS) version 19 was used for data analysis. All ethical considerations were adhered to. Ethical approval obtained from the University of KwaZulu-Natal Ethics Committee, permission from KwaZulu-Natal Department of Health, information about the study, voluntary participation, individual signed consent obtained from respondents. Confidentiality and anonymity maintained throughout the study.
Results: Three hundred and sixty (360) pregnant women attending antenatal clinics participated in this study. One hundred and twenty (120) were living in urban areas, 120 were from peri-urban areas and 120 were from rural areas.
Table 1: Age groups of the respondents (n=360)

Age group

Urban (n=120)

Peri-urban (n=120)

Rural (n=120)




Less 20 years


22 (18.3%)

27 (22.5%)



20 to 35 years

104 (86.7%)

95 (79.2%)

86 (71.7%)



Above 35 years

4 (3.3%)

3 (2.5%)

7 (5.8%)




120 (100%)

120 100%)

120 (100%)



The mean age of the three groups of pregnant women living in urban area was 26.2 (range: 15-43 years), peri-urban area 26.0 (range: 15-40 years) and rural areas 25.9 (range: 15-42 years). There were no significant difference in ages among the three groups of pregnant women living in their respective areas (p=0.45). Majority of the respondents from the three different residential areas were between the age group of 20 to 35 years (n=285; 79.2%) which is within the acceptable age range for safe motherhood, followed by those less than 20 years (n=61; 16.9%). Fourteen (3.9%) were above 35 years of age, advanced maternal age is a high risk factor that makes pregnant women prone to complications during pregnancy and intrapartum period. The age groups of the three groups of respondents are shown in Table 1.
Table 2: Months when antenatal booking was started in current pregnancy (n=360)

Time (months) of antenatal booking


Peri urban


3 months

4 months

5 months

6 months

42 (35%)

32 (26.67%)


25 (20.83%)

39 (32.5%)

32 (26.67%)

23 (19.17%)

26 (21.67%)

16 (13.33%)

26 (21.67%)

31 (25.83%)


Ninety seven (26.9%) respondents, 42 (355) from urban area (n=42; 39 (32.5%) from peri urban areas (n= 39; 32.5%) and 16 (13.3%) from rural areas (n= 16; 13.3%) had early antenatal booking, in the first trimester at 12 weeks which is three months. Ninety (25%) respondents, 32(26.7%) from urban areas, 32 (26.7%) from peri urban areas and26 (21.7%) were from rural areas had first antenatal clinic visit at 16 weeks, which is 4 months. Seventy five (20.8%) respondents, 21 (17.5%) from urban areas, 21 (17.5%) were from peri-urban and 31 (25.8%) were from rural areas had first antenatal visit at 20 weeks, which is five months.

Ninety eight (27.2%) respondents attended first antenatal clinic late at 24 weeks. The majority, 47 (39.2%) of pregnant women who booked late at 24 weeks were from rural areas compared to 25 (20.8%) and 26 (21.7%) pregnant women who were from urban and peri-urban areas respectively (Table 2). According to guidelines for maternity care in South Africa (2007:20), booking for antenatal care should begin as soon as a woman has missed one menstrual period and the pregnancy is diagnosed and probably in the first trimester that is at 12 weeks.
Table 3: Factors (barriers) discouraging pregnant women to book early for antenatal care (n=360)

Factors discourage early antenatal booking

Urban (n=120)





Financial constraints


Long hours at clinic

Attitude of health care worker

Uncomplicated previous pregnancy

Cultural background

Hidden pregnancy

12 (10%)

0 (0%)

59 (49.17%)

24 (20%)

17 (14.17%)

0 (0%)

8 (6.67%)


5 (4.17%)


21 (17.5%)

15 (12.5%)

4 (3.33%)

9 (7.5%)

34 (28.33%)

28 (23.33%)

21 (17.5%)

9 (7.5%)

4 (3.33%)

17 (14.17%)

7 (5.83%)

Twelve (10%) pregnant women from urban areas, 17(14.17%) from peri-urban areas and 34 (28.33%) from rural areas had financial constraints and as a result of this problems respondents did not attend antenatal clinic early in the current pregnancy. Transport plays an important role in attending antenatal clinic. Pregnant women living in urban areas had no transport problems while 5 (4.17%) pregnant women living in peri-urban areas and 28 (23.33%) pregnant women from rural areas experienced transport problems. Another most important factors that discouraged pregnant women from attending antenatal clinic early from urban areas (n=59; 49.17%), 49(40.83%) from peri urban areas and 21 (17.5%) from rural areas was long hours spent at the clinic. Furthermore, 24 (20%) pregnant women from urban areas, 21 (17.5%) from peri-urban areas and 9 (7.5%) from rural areas were discouraged by the attitude of health care worker. Parity, seventeen 17 (14.17%) pregnant women from urban areas, 15 (12.5%) pregnant women from peri-urban areas and 4 (3.33%) from rural areas experienced uncomplicated previous pregnancy and did not see the need to attend antenatal care early in the current pregnancy. Cultural beliefs discouraged pregnant women from attending antenatal clinic early as reported by 4 (3.33%) pregnant women from peri-urban and 17 (14.17%) from rural areas. Hidden Pregnancy, was reported by eight (6.67%) pregnant women from urban areas, 9 (7.5%) from peri-urban areas and 7 (5.83%) from rural areas who reported that did not disclose their pregnancy and hence they did not attend antenatal clinic early. The utilisation of antenatal clinic at the rural area was poor compared to the antenatal clinics in the peri-urban and urban areas as more barriers that prevented pregnant women from attending early antenatal clinic in the current pregnancy were more marked in the rural areas than in urban and peri-urban areas. As financial constraints for transport, long distance travelled to the antenatal clinic were indicated as barriers associated with late antenatal booking in pregnant women residing from rural areas than urban and peri-urban areas.

Conclusion: The results of this study suggest that the determinants of late booking for antenatal care are multifactorial. The pregnant women in the rural area attended first antenatal clinic later than those from peri-urban and urban areas. The large disparity in the timing of the first antenatal clinic visit among pregnant women from the different settings suggests the need for special attention for antenatal programme in rural area than urban areas. Health messages to educate youth, both young females and boys below 20 years of age about the disadvantages of teenage pregnancy must be undertaken at home, schools and educational institutions. In addition, health education promoting early and regular antenatal clinic attendance should continue and be strengthened in the community.

  • Guidelines for maternity care in South Africa (2007) A manual for clinics, community health centres and district hospitals. 3rd edition. South Africa: Department of Health.

  • UNICEF (2003) Focused antenatal care: Planning and providing care during pregnancy. Availableat:www.reproline.jhu.edu/english/6read/6issues.htm. Retrieved on 25/08/2013.


D.N. Haddad1, 2, Dr. J.D. Makin1, Dr. R.C. Pattinson1 and Dr. B.W. Forsyth3

MRC Maternal and Infant Healthcare Strategies, University of Pretoria1,

Doris Duke International Clinical Research Fellowship2

Yale University, Department of Pediatrics3


HIV is recognized as the most common cause of maternal deaths in South Africa. HIV-infected pregnant or postpartum women possess nearly eight times the risk of maternal mortality than their non-HIV infected counterparts(1). In the 2012 South African “Saving Mothers” report, the leading cause of maternal mortality, HIV was found to cause an overwhelming 42% of maternal deaths (2) Strengthening HIV services for pregnant women has been identified as necessary means of reducing maternal mortality (3).

Antenatal care provides an important opportunity to address major causes of maternal and infant mortality, which remain inappropriately high in South Africa (4). Antenatal care (ANC) allows for necessary HIV screening as an overwhelming one-third of pregnant women in South Africa are HIV positive and the majority are diagnosed as part of routine antenatal care(5). Early ANC is essential for initiation of appropriate antiretroviral therapy, essential for hindering disease progression and preventing vertical transmission. Antenatal care also provides opportunity screen for other causes of mortality, such as preeclampsia and to provide appropriate guidance regarding important behaviors and pregnancy warning signs. Insufficient ANC attendance was identified in the 2009 ‘Saving Babies” report as one of the top 5 avoidable causes of perinatal mortality(6).

However, the majority of women in South Africa do not present to care before 20 weeks gestational age(7). A number of factors have been identified as potential barriers to care including transportation(8), household commitments(9), time delays, under resourced clinics with increased wait times and decreased resources at the antenatal clinics (9), and lack of perceived benefit(10) in addition to cultural beliefs about jealousy and bewitching and delayed booking at clinic presentation(11). In order to gain further understanding of the fears and concerns that pregnant women in a peri-urban community in South Africa have when utilizing antenatal care services within an environment of changing healthcare policy and community, qualitative interviews were conducted.


1. Elaborate further the systems of belief held by women in the community regarding accessing early antenatal care.

2. To understand beliefs of pregnant women regarding antenatal care and their knowledge of appropriate care practices and perceptions of risks and benefits of antenatal care through the use of qualitative interviews of pregnant women accessing antenatal care.

3. To identify barriers and underlying themes that keep women from presenting to the clinic for ANC.


In order to further understand the complex factors that influence a woman’s decision to seek care, individual interviews were conducted with women presenting for antenatal care at Phomolong clinic located near Kalafong Hospital in Pretoria. This clinic was selected for its high volume of antenatal care participants in addition to the high proportion of women who presented for antenatal care after 20 weeks gestational age. Semi-structured interviews were conducted and women were asked a series of open-ended questions regarding general knowledge about ANC, community-held beliefs, perceived barriers to ANC, cultural beliefs and superstitions in addition to any recommendations for improvement of ANC services. The interviews were audio recorded and subsequently transcribed and analyzed for themes using grounded theory analysis.


Twenty-one interviews were conducted. All of the participants were black females aged 21 to 39 living in or near the township adjacent to the clinic. Six of the twenty-one women were HIV positive and 13 were HIV negative with two women HIV status unknown with pending test results. The majority of women had at least 1 prior pregnancy with only four primagravidas.

Most women are aware of the widely publicized public health initiatives that encourage women to attend ANC at the time of discovery of pregnancy or within the first three months. In our interview group, 20 of 21(95.2%) women were aware that they were supposed to be in the clinic before 3 months of pregnancy. However, even in our small subset of patients 11 of 21(52.4%) did not present to ANC before 3 months. The majority of women also perceived HIV testing as a mandatory part of ANC.

1. Fear of HIV Testing

No, they don’t want to [test]. Because they are pregnant, they don’t have a choice….’

A. Perceived Community Stigma and Subsequent Discrimination

Due to the exposed public nature of the clinic setting, women were afraid that others would discover or simply make assumptions about their HIV status. The fear of possible stigma and subsequent discrimination and alienation prevented women from seeking the care they knew they were meant to have.

...because you are worried about HIV. When I talked to one pregnant lady, she told me that she was almost six months but she said she didn’t come because she is afraid that she can be tested for HIV, then she might be positive then she would be stressed and so on...I told her that it’s still the same, because even during the delivery they are going to test you and you will still be stressed and perhaps by that time the child will be infected as well.”

Because people are...you know black they are too much gossip, too much talk. And they can gossip about you; ah she’s sick, she’s drinking HIV tablets, she’s drinking this and that. That’s why, they scared”

they are afraid of their husbands and their families because when she came here, when she has to report to her husband normally they come and say I am HIV positive and maybe our child might be HIV positive and there is a problem that she might think that the husband will say you are the one with the problem.’

B. Psychological Stress

“…if you know you are sick, you will die faster…especially with HIV.”

Yes, they are scared. They think that it is big, no maybe they can think too much and they can die before time.”

C. Lack of Necessity if Feeling Healthy

Especially if a women was not experiencing any disease signs or symptoms, but rather considered herself to be healthy—it was perceived to be advantageous to avoid distressing views that would cause detrimental effects to both the mother and the baby.

because I think I am healthy I am ok, I don’t care to go to the clinic to get tested. I hear a lot of people talk about that. I am healthy. Do you think I am fine? They think so.”

D. Fear of Death and Harm to Baby

There was also a fear of death and/or harm to both the mother and the baby that encouraged avoidance of testing. Although a majority of women were able to articulate the protective benefits of ART for both the mother and the child when asked, there still remained a fear of mortality inflicted by HIV.

Others believe that if [they] come and get tested and they are positive it’s useless for them to come to the clinic because the baby is going to die’

2. Contemplated Termination

With close proximity to a major tertiary hospital and easy access to termination services, abortion existed as a possibility for addressing an unplanned or unwanted pregnancy. However, this was not yet an accepted cultural option. Many women contemplated termination, but were subsequently persuaded otherwise by a partner or family member and decided to keep the pregnancy, leading to late antenatal care presentation.

I wanted to go to clinic to have abortion…but my boyfriend talked to me, he said don’t worry let’s…don’t do this it’s not good’

Others might regret why they are pregnant and they want to do abortion. And then sometimes when they are thinking about doing abortion, it becomes late for abortion then they come too late’

3. Previously Described Barriers

A. Clinic Conditions

1. Staff Attitudes

they won’t go to the clinic because the nurses are rude and they don’t treat them well”

2. Long Queues, Wait Times

Like the queues early in the morning, you have a queue there at half past seven when they open and if I come here at 7:30am I will go home at maybe 4:20pm. They waste a lot of time…’

they don’t have that energy to come because of the queue at the gate.”

B. Fear of Jealousy and Bewitching

There was a widely reported belief that if others learned of the pregnancy early, they would become jealous and bewitch the mother and cause harm to the baby.

You know especially these ladies, they are very jealous, you can’t trust nobody…they can kill your child, especially blacks they can make muti, they can do this, maybe when you are pregnant you can give birth maybe 7 months. Maybe you can lose your child, you understand?’

C. Lack of Perceived Benefit

Pregnancy was seen as a biologically safe behavior that did not require healthcare workers intervention especially in the early stages.

Also, I didn’t have problem for this pregnancy that’s why I didn’t come to clinic.’

I didn’t get sick. So that’s the important thing why I didn’t come earlier’

D. Delayed Scheduling at ANC Booking

I went to the clinic after three months because I know there is that antenatal care after three months, so I was surprised to hear that I should come back after five months”


There are a number of competing factors in the lives of pregnant women that confound their decision to visit the clinic. Practical barriers such as transportation, clinic conditions, harsh treatment by the staff and long waiting lines make attendance cumbersome especially if there is little perceived benefit from the visit. Cultural barriers such as fear of jealousy and possible bewitching in addition to fear of stigma surrounding HIV status and disease introduce further complexity. Women are often not empowered to make demands of their own healthcare due to a complex myriad of social and cultural factors.

In addition, shifts in national policy intended to improve HIV testing and diagnosis and subsequent fast-tracking access to treatment have had unintended consequences. In 2010, national guidelines in South Africa transitioned from the standard opt-in policy where HIV testing required separate consent to the current opt-out policy where HIV testing and Voluntary Counseling and Testing for HIV (VCT). Plan B+ adopted by South African Ministry of Health in 2013 recommends initiation of anti-retroviral therapy (ART) for all HIV positive women at 14 weeks(12). Widespread public health campaigns followed, educating women about the importance of antenatal care within the first three months of pregnancy following national and international guidelines with most women interviewed being able to articulate this recommendation.
Although evidence-based policy provisions are in place for accessing sufficient care during pregnancy, successful community and cultural implementation do not automatically follow. There exists in the community general knowledge about guidelines encouraging women to attend antenatal clinics early in their pregnancy, yet individual fears of illness and suffering hinder a woman’s capacity to seek the care she hears she needs for her and her baby. Being perceived as sick with subsequent marginalization keeps women from seeking the care they know they need, especially in a community with high HIV prevalence and disability (13). The clinic waiting area serves as the main arena for competing social dynamics of jealousy, fear and mistrust in the community.
Misconstrued cultural perceptions often lead to unintended consequences of policy interventions. Cultural jealousy runs deep, further complicating adequate service delivery. Deeply engrained sentiments of community mistrust coupled with heightened fear of jealousy from surroundings keep women from presenting to the clinics for early care. There exists a need to engage community understanding about the vast public fears surrounding illness.

Addressing cultural concerns and improving community knowledge is imperative in improving antenatal care attendance, and further work must be done to elucidate the effect of these factors on early ANC. The data collected from these interviews will be used to inform a more widely circulated questionnaire which will be used to quantify the levels of different factors impacting ANC attendance.


1. Calvert C. CR. The Contribution of HIV to Pregnancy-related Mortality: A Systematic Review and Meta-analysis. Aids. 2013

2. Moodley J and RC Pattinson, Saving Mothers 2008-2010: Fifth report on the Confidential Enquiries into Maternal Deaths in South Africa. 2011.

3. Moodley J, Pattinson RC, Baxter C, Sibeko S, Abdool Karim Q. Strengthening HIV services for pregnant women: an opportunity to reduce maternal mortality rates in Southern Africa/sub-Saharan Africa. BJOG : an international journal of obstetrics and gynaecology. 2011 Jan;118(2):219-25. PubMed PMID: 21159120.

4. Trends in Maternal Mortality: 1990 to 2010 (WHO, UNICEF, UNFPA and The World Bank): WHO Global Health Observatory. Available from: http://www.who.int/gho/countries/zaf/country_profiles/en/.

5. Dept of Health. The 2011 National Antenatal Sentinel HIV & Syphilis Prevalence Survey in South Africa 2011.

6. Saving Babies 2010-2011: Eight Report on Perinatal Care in South Africa 2013. Report No.

7. In: (DHIS) DoHIS, editor. Extracted January 2012 ed2010/2011.

8. Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC pregnancy and childbirth. 2009;9:34. PubMed PMID: 19671156. Pubmed Central PMCID: 2744662.

9. Brighton A, D'Arcy R, Kirtley S, Kennedy S. Perceptions of prenatal and obstetric care in Sub-Saharan Africa. International Journal of Gynecology & Obstetrics. 2013;120(3):224-7.

10. Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS medicine. 2013;10(1):e1001373. PubMed PMID: 23349622. Pubmed Central PMCID: 3551970.

11. Solarin I, Black V. "They told me to come back": women's antenatal care booking experience in inner-city Johannesburg. Matern Child Health J. 2013 Feb;17(2):359-67. PubMed PMID: 22527767. Pubmed Central PMCID: 3587683.

12. South African Antiretroviral Guidelines 2013 Department of Health, Republic of South Africa

13. Nyblade L, Jain A, Benkirane M, Li L, Lohiniva AL, McLean R, et al. A brief, standardized tool for measuring HIV-related stigma among health facility staff: results of field testing in China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis. J Int AIDS Soc. 2013;16(3 Suppl 2):18718. PubMed PMID: 24242266. Pubmed Central PMCID: 3833189.

J Kanku

To assess the level of knowledge of primary health care personnel on perinatal HIV matters and the prevention of transmission of HIV from mother to child according to the 2010 PMTCT guideline.


An observational descriptive study using a questionnaire was administered to a sample of professional nurses, assistant nurses and lay counsellors from Jouberton Health Centre. The questionnaire consisted of twenty multiple choice questions and were derived from the Perinatal HIV manual of the Perinatal Education Programme (PEP) .16 The PEP is written as course material for long distance learning for midwives, doctors, nursing and medical students.16 The questions were chosen by the investigator to reflect knowledge of the 2010 PMTCT Guidelines.4 They included questions on HIV and AIDS during pregnancy and its management; the prevention of mother –to child transmission and management of HIV exposed new born infants. Information regarding each health care personnel’s role in counselling and delivering PMTCT- related services and the training they received was obtained.

The Jouberton community health centre in the district of Dr Kenneth Kaunda in the North West province provides a comprehensive antenatal care service and a delivery suite for normal vaginal deliveries. The clinic has an average of 80 deliveries per month; about 15 first antenatal care visits are done weekly and an average of 30 subsequent antenatal visits are done weekly. Jouberton Township is part of the Matlosana municipality which has a population of 398676.17

The Jouberton health centre register recorded a HIV positive prevalence amongst pregnant women as 29% in the financial year 2012 -2013 (126/436). Out of the 135 HIV exposed infants tested, only one PCR test (0.7%) was positive.

The questionnaire was administered to health care personnel who were willing to participate and who were on duty over three consecutive days in September 2012. The clinic had 17 professional nurses, 10 lay counsellors and 5 assistants nurses employed during the time of this research
Data Analysis

Statistical analysis was done using SPSS version 16. Ratios were compared using the Chi2-test or the Fischer exact test when expected numbers were less than 5. Mean scores were compared using the Student’s t-test. A p-value of <0.05 was considered to be statistically significant.

Ethical consideration

A standard consent form format was used and informed written consent was obtained. The results were to be kept confidential with opportunity given to each participant to obtain their results. If the results were to be published, then no identifying details were linked with the participants’ results. Authorization to do the research was obtained from the district research committee led by Family Physician, Prof. C Van Deventer.


All health care personnel approached at the time of the study agreed to participate. Fourteen (82.4%) professional nurses; 4 assistant nurses (80.0%) and 10 lay counsellors (100%) out of those employed at the clinic were recruited. Those that were not recruited were not on duty on the days the study was conducted.

Table I presents the details of the PMTCT- related services provided by the health care personnel within each category recruited to the study. Details regarding the training they received is stated in Table II.

T2.4%ntage recruitednumbers of participants ineach health personnel category are displayedal place or two.BUt ult and respurceThe mean score of all the health personnel tested was 70%. The mean scores for each health personnel category were: 81.1%for the professional nurses; 61.3%for the assistant nurses and 63.5%for the lay counsellors. Table III presents these results in more detail.

The questions that were scored poorly (≤ 50%) by either all the health personnel or any one of the health care personnel categories are represented in Table IV.

The mean score of all tested was 70%. The professional nurses scored the best with a mean score of 81.1%. According to the Perinatal Education Programme from which the index study questionnaire was derived, the required rate on examination of the course material to be able to achieve a competency certificate was 80%.18 The lay counsellors mean score was 63.5% and the assistant nurses was 61.3% which suggests that their knowledge of the 2010 PMTCT guideline is lacking. However, the assistant nurses’ role in the counselling and implementation of PMTCT within the Jouberton clinic is limited. (Table II) Overall there was a statistical difference in the mean scores between the professional nurses and lay counsellors (p=0.001).

Many of the professional nurses (71.4%) and lay counsellors (100%) had stated that they had received training on Voluntary Counselling and Testing for the prevention of mother-to-child transmission (VCT for PMTCT). However, only 42.9% of the professional nurses and 20% of the lay counsellors said that they had received provision of ARVs for PMTCT. NIMART (nurse initiated management of ART) and PALSA Plus are amongst the formal training offered to the staff.

The Wits Reproductive Health and HIV Institute (WRHI) and the Children’s HIV Association (CHIVA) are NGOs that provide onsite support in the local clinics. They help the staff identify patients who qualify for HAART and help initiate HAART. It appears that the health care personnel did not perceive this onsite support as training.

Mnyani and McIntyre found a mean knowledge score of 64.4% (Mean 5.15 (SD ±1.85) out of 8 questions) when they tested professional nurses, auxiliary nurses and lay counsellors workers in antenatal clinics in Soweto on the less comprehensive 2008 PMTCT guidelines in 2009 (percentages calculated from data presented in tables). 14 When they compared knowledge between professional nurses and lay counsellors they found no significant difference between the mean scores. [5.41 (SD ±1.56) for professional nurses vs 5.19 (SD±1.89) for lay counsellors (P=0.586)]. 14

Even though health knowledge is only one factor in providing quality care, these is proof that quality of counselling translates to patient knowledge and is a factor in adherence to PMTCT interventions.19

The index study’s questionnaire revealed that knowledge was lacking in certain aspects of HIV/ AIDS and its management in pregnant women and HIV exposed new born infants which is required for the implementation of the Department of Health’s 2010 PMTCT guideline.
Maternal death and HIV

AIDS is an important cause of maternal death in South Africa was correctly identified by 30 % of lay counsellors, 25% of assistant nurses and 50% of professional nurses. (Table IV) No other study, to our knowledge, has previously explored health personnel’s awareness of the link between increased maternal death and HIV infection.

This low level of awareness is probably due to most maternal deaths occurs occurring in hospitals and primary health care personnel may be less sensitized to the increase in maternal deaths due to HIV . The poor awareness of the impact of HIV on the maternal mortality rate can be considered a limitation in achieving MDG No 5 which focused on reduction of maternal death and improvement of maternal health.
Lifelong HAART for HIV positive women and HIV women at great risk to transmit HIV to their babies,

Thirty percent of lay counsellors, 57.1% of professional nurses and none of assistant nurses were accurate in terms of pregnant women eligible for HAART. In addition, 40% of lay counsellors and 85.7% of professional nurses and 25% of assistant nurses correctly identified that pregnant women who have clinical signs of advanced HIV disease have the highest chance of transmission of HIV. (Table IV)

This could be a reflection of only 42.9% of professional nurses, 20% of lay counsellors and none of the assistant nurses had received training on the provision of anti-retroviral for PMTCT. (Table II).

The Southern Africa HIV Clinicians Society and the South African 2010 PMTCT guideline recommend that HAART be commenced indefinitely in pregnant women who are at stage 3 or stage 4 of the WHO classification of HIV or have a CD4 count of less than 350. 4,20 HAART will reduce viral load and this will result in a lower transmission of the virus to the baby, HAART will also improve maternal health, protect the women against opportunistic infection and prevent non pregnancy related maternal death due to HIV from occurring.20

It is important for the health personnel to grasp the importance of HAART to prevent maternal death and HIV infection of the baby. Women with advanced HIV disease will probably have a high viral load and subsequently will have a greater chance of transmitting HIV and a greater chance of contracting opportunistic infections which can lead to maternal death during pregnancy.
The recommendations for the reduction of maternal deaths include training of health care workers who deal with pregnant women on HIV advice, counselling, testing and support, initiation of ARVS, monitoring of HAART and the recognition, assessment, diagnosis and treatment of severe respiratory infections.21
Feeding method for infants born from HIV positive mothers

Twenty percent of lay counsellors, 25% of assistants nurse and 50% of professional nurses knew that the choice of feeding method depends on the home conditions of each individual mother. However, only 50% of lay counsellors, 57.1% % of professional nurses and none of the assistant nurse had received training on infant feeding counselling and support for HIV-positive women.

Mnyani and McIntyre found that 43.8% of healthcare workers in Soweto in 2009 knew the risk of MTCT and exclusive breastfeeding. In addition only 77.5% of health care workers knew the risk of MTCT and extended breastfeeding. 14 This indicates that the lack of knowledge regarding risk of each feeding method is not unique to the staff of Jouberton clinic.
Accurate choice of feeding method is of paramount importance for the survival of any new born baby and especially for HIV exposed infants. No ambiguity should be accepted during the counselling of mothers on the choice of nutrition for their infants.
The South African strategic plan for maternal, new born, child and women‘s health and nutrition outlines the adoption of the 2010 WHO feeding guidelines which recommends exclusive breastfeeding until six months old, after which complementary feeds are introduced. HIV exposed, uninfected infants receive low-dose nevirapine until cessation of breastfeeding at one year in order to make breastfeeding safe for HIV-infected mothers22
Doherty et al insist that trained health care personnel must give high quality, unambiguous and unbiased information on the risk of HIV transmission through breastfeeding, ARV prophylaxis to reduce the risk of transmission and the risk of replacement feeding.23 The feeding of infants born from HIV positive mothers is of paramount importance. When feeding is not appropriately discussed and the correct method of feeding chosen, transmission of HIV to the baby can occur with resultant morbidity and mortality. The majority of participants chose the answer of exclusive breastfeeding without assessing the back ground condition of the mother. Despite the fact that many of the patients from the developing countries have general similar living conditions, it is wise to have one to one feeding counselling and to empower the mothers to make appropriate decisions for their babies.
Doherty et al emphasize that exclusive breastfeeding is not the most appropriate option for all HIV positive women in South Africa because of the huge difference in socio economic status between populations, rural and urban areas and provinces23
Questions with significant statistical difference between professional nurses and lay counsellors

Three questions revealed a significant difference between the knowledge of the professional nurses and lay counsellors. The questions were about the anaemia side effect of AZT (p<0.001); the prophylactic use of co-trimoxazole to be given to HIV infected babies (p=0.011) and the HIV positive women at highest risk of transmitting the virus to their infants (p=0.029). (Table IV)

This study exposed a better knowledge among professional nurses compared to lay counsellors. There is a need for lay counsellors to know which women are at greatest risk of MTCT of HIV and to understand side effect of drugs (AZT) and indication of drugs (co-trimoxazole).This knowledge is important for them to provide comprehensive treatment counselling.

Knowledge of the South African 2010 PMTCT guideline amongst the professional nurses at Jouberton clinic was acceptable. However, knowledge amongst the lay counsellors and assistant nurses can be improved. Poor knowledge was noted in some important aspects of the PMTCT amongst all categories of health care personnel. This included the link between HIV and increased maternal mortality which is the leading cause of maternal deaths in South Africa. In addition, knowledge that starting HAART for pregnant women who qualified will further reduce the risk of mother to child transmission and will help maintain maternal health and the feeding method for HIV exposed babies needs to be improved.

Displaying the PMTCT guidelines in different consulting rooms and organising a one day workshop to discuss the guidelines are two recommended measures to improve health personnel knowledge at Jouberton clinic. This survey has revealed areas of PMTCT services that should be focused on during such training. This will help further reduce HIV-related maternal and child morbidity and mortality.
A-M Bergh1, JD Makin1, RC Pattinson1, S Baloyi1, D Haddad1, D Amoko2, M Mokwena2, R Taute2, S Engelbrecht3, D Nyasulu3, J Makgatho3

1 MRC Maternal and Infant Health Care Strategies Unit, Obstetrics and Gynaecology Department, University of Pretoria; 2 Mpumalanga Department of Health; 3 Program for Appropriate Technologies in Health (PATH)

The National Department of Health has put the scale-up of the Essential Steps in Managing Obstetric Emergencies and Emergency Obstetric Simulation Training (ESMOE-EOST) programme as a priority intervention for decreasing maternal and perinatal mortality in South Africa.1,2 In the first 12 priority districts direct training of 80% of staff providing maternity and newborn care services in ESMOE core skills is taking place (saturation training), using an off-site training model. This entails taking delegates to a venue outside of the hospital and the training is completed in 2 or 3 day courses. The logistics of running this is complicated and time consuming and the disruption to services is considerable. On-site ESMOE-EOST saturation training combines the concept of facilitator-mentors and EOST exercises (‘emergency drills’ or ‘fire drills’) in a way that ensures all the modules of ESMOE are covered and that all health care providers involved in maternity care are trained through the running of regular EOST exercises in their facilities. The on-site training approach was anticipated to have a less disruptive effect on services and to be more cost efficient. This model may also have the potential of firmly establishing a culture of regular emergency drills and the regular use of data in the quality assurance activities of an institution.


  • To explore the processes involved in an alternative on-site saturation training model

  • To compare the ability of on-site-training facilities to conduct EOST exercises (Nkangala District) with that of facilities that had received off-site saturation training (Gert Sibande District) in order to establish if on-site training would be a possible method to use going forward

Process and methods

There were 8 steps in the development of the on-site ESMOE-EOST saturation training model:

  1. Development and adaptation of ESMOE core-skills training material

  2. Meeting with stakeholders and partners

  3. Individual site visits to: (a) promote awareness; (b) get further buy-in and commitment; (c) discuss selection of ESMOE facilitator-mentors (EFMs) with set criteria; and (d) conduct the standard ESMOE baseline assessment of functionality with respect to emergency obstetric care

  4. Orientation of master trainers in new approach

  5. Three-day off-site orientation in ESMOE core and mentoring skills (2 EFMs per site: 1 doctor, 1 midwife) – ending with individualised schedules (plans of action) per site (see box)

  6. Implementation of on-site saturation training schedules – 3-month period (July- Sept 2013):

    • Conducting regular emergency obstetric and newborn simulation training sessions (emergency drills) and other practical exercises included in the ESMOE modules

    • Regular support visits and other forms of support from the study team, members of the district clinical specialist team (DCST) and other district officials (e.g. maternal, child and women’s health coordinators)

    • Recording of all drills done, scores for drills and drill attendants – available for audit by supervisors

    • Regularly aggregating data from the standard birth register (including PPIP data), submitting a monthly summary on the standard ESMOE forms to the MRC Unit for Maternal and Infant Health Care Strategies

    • Monthly meetings of the core supervision team to receive feedback, discuss progress with the intervention and attend to issues needing a response

  7. Accountability meeting after 3 months: feedback by EFMs and support personnel on progress

  8. Endline assessment:

    • Evaluation of facilities’ ability to conduct emergency drills by means of unannounced drills scored by external evaluators

    • Collation of relevant district and provincial data collected regularly (including PPIP and MaMMAS)

    • Collation of data collected on the implementation process (e.g. number of drills conducted; number of staff trained; evidence relating to improvement in knowledge and skills)

  • Individual and focus group interviews (24 interviews; 72 participants)

Orientation in the on-site saturation training method (3 days)

  • Pre- and post-assessment of knowledge and skills on 12 modules

  • Special sessions on mentoring

  • Three sessions running concurrently – 2 hours per session

  • Participants per session: 6 (plus 2 observers)
    (Total: 18 participants plus 6 observers)

  • Sequence of each training session (with slight variations for some topics):

(1) Participants perform an emergency drill without any prior warning

Drill is scored (guidelines on the scenario sheet)

(2) Discussion of the drill performance with scenario sheet and flipcharts:

  • Clinical performance (sequence of activities, skills)

  • Execution of the drill (role assignment, communication, teamwork, documentation)

(3) Individual practice of skills if required (e.g. shoulder dystocia, breech delivery)

(4) Repetition of drill and scoring

  • End-of-training activities:

  • Written plans of action (with specified timelines and allocation of responsibilities)

  • Reflection on how to put mentoring into practice

  • Evaluation of the training by participants

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