Thesis (MA)--Stellenbosch University, 2010. / ENGLISH ABSTRACT: Hypertensive disorders are one of the leading causes of maternal morbidity and mortality in South Africa. The morbidity and mortality rate can be decreased by early detection and management of hypertensive disorders at primary health care Level. The midwives should therefore be knowledgeable and competent in the assessment and diagnosis of pregnant women who are at risk of developing a hypertensive disorder, and be able to manage the problem. The purpose of the study was to investigate scientifically the knowledge of the registered midwives managing hypertensive disorders in pregnancy working at primary health care level in the Eastern Cape. The objectives set for the study were to investigate the knowledge of the registered midwives in the following areas: • Knowledge about hypertensive disorders • Assessment • Diagnosis • Management A descriptive correlational research design was applied with a quantitative approach to investigate scientifically the knowledge of the registered midwives managing hypertensive disorders in pregnancy. The target population included all the registered midwives working permanently in primary health care clinics in the Buffalo City Local Service Area. A stratified random sample of n=43 (44%) of a population of N=98 clinics both in rural and urban were selected together with a sample of n=101(44%) of N=228 registered midwives working in these clinics. A questionnaire consisting of predominantly closed questions was used for the collection of data, collected personally by the researcher. Ethical approval was obtained from Stellenbosch University, Department of Health and individual informed consent. A pilot study, which did not form part of the study, was conducted to test the questionnaire at the clinics. A 10% (n=10) sample of the registered midwives of 4 clinics participated in the pilot study. The validity and reliability was assured through the pilot study, the use of a statistician, as well as experts in midwifery, nursing and a research methodologist. The data was analysed and presented in tables and histograms. Statistical correlational tests were done to determine any correlations between the variables. Findings obtained show that inadequate knowledge exists among participants with specific reference to knowledge, assessment, diagnosis and management about hypertensive disorders. A statistical correlation was shown between the presence of doctors and the knowledge of the midwives using the Mann-Whitney statistical test (p=0.04). In clinics where there are no doctors’ visits, the knowledge of the staff was higher (0.691), than the total knowledge mean score (0.666). Where doctors are regularly visiting the clinics the mean knowledge score is lower (0.656). These results show that where midwives do not have any additional support as when there are doctors present, individual effort is made to keep up to date as they are practising as independent practitioners. Recommendations are based on the scientific evidence which emphasis further education in advanced midwifery, workshops, conferences, updating their knowledge and weekly in-service training, introduction of a quality assurance and patient education programmes. In conclusion empowering the midwives with the required knowledge about hypertensive disorders will contribute towards decreasing the mortality and morbidity rates. / AFRIKAANSE OPSOMMING: Siektetoestande gekoppel aan hipertensie is een van die vernaamste oorsake van sieklikheid en moedersterftes in Suid-Afrika. Die siektetoestand en sterftekoers kan afneem deur vroeë opsporing en bestuur van hipertensietoestande op primêre gesondheidsorgvlak. Die kraampersoneel behoort dus kundig en bekwaam te wees tydens die assessering en diagnose van swanger vroue wat die risiko loop om ’n toestand van hipertensie te ontwikkel en daartoe in staat te wees om die probleem te kan hanteer. Die doel van die studie is om die kennis van geregistreerde vroedvroue wetenskaplike te ondersoek wat hipertensiewe toestande tydens swangerskap hanteer op Primêre Gesondheidssorgvlak in die Oos-Kaap. Die doelstellings wat uiteengesit is vir die studie, is om die kennis van geregistreerde kraampersoneel in die volgende areas te ondersoek: • Kennis van hipertensiewe toestande • Assessering • Diagnose • Hantering. ’n Beskrywende korrelerende navorsingsontwerp is toegepas met ’n kwantitatiewe benadering om die kennis van die geregistreerde kraampersoneel wat hipertensiewe versteurings in swangerskappe hanteer, wetenskaplik te ondersoek. Die teikengroep het al die geregistreerde kraampersoneel wat permanent in die primêre gesondheidssorgklinieke in die Buffalo City Plaaslike Diensarea werk, ingesluit. ’n Gestratifieerde ewekansige steekproef van n=43 (44%) gekies uit ’n gesamentlike plattelandse en stedelike bevolking van N=98 klinieke met ’n steekproef van n=101 (44%) van N=228 geregistreerde vroedvroue wat in die klinieke werk. ’n Vraelys wat hoofsaaklik uit geslote vrae bestaan, is gebruik vir die insameling van data wat persoonlik deur die navorser ingesamel is. Etiese toestemming is verkry van die Universiteit Stellenbosch, die Departement van Gesondheid asook individuele ingeligte toestemming. ’n Loodsondersoek is uitgevoer om die vraelys te toets by die klinieke wat nie deel van die studie was nie. ’n 10% (n=10), steekproef van die geregistreerde vroedvroue van 4 klinieke het deelgeneem aan die loodsondersoek. Die geldigheid en betroubaarheid is verseker deur die loodsondersoek, die gebruik van ’n statistikus asook kundiges in kraamverpleging en ’n navorsingsmetodoloog. Die data is geanaliseer en weergegee in tabelle en histogramme, statistiese korrelasietoetse is gedoen om korrelasies te bepaal tussen die veranderlikes. Die bevindings, bewys dat ongenoegsame kennis bestaan by deelnemers met spesifieke verwysing na kennis, assessering, diagnose en hantering ten opsigte van aangaande toestande van hipertensiewe toestande. ’n Statistiese korrelasie is getoon tussen die teenwoordigheid van geneeshere en die kennis van vroedvroue deur gebruik te maak van die Mann-Whitney statistiese toets (p=0.04). In klinieke waar daar geen doktersbesoeke is nie, is die personeelkennis beter (0.691) as die totale gemiddelde kennistelling (0.666). Waar geneeshere gereeld die klinieke besoek, is die gemiddelde kennistelling laer (0.656). Hierdie resultate bewys dat waar die vroedvroue geen bykomende ondersteuning deur die teenwoordigheid van geneeshere het nie, het individuele moeite gedoen om op die hoogte te bly, aangesien hulle as onafhanklike praktisyns optree. Aanbevelings is gebaseer op wetenskaplike bewyse wat verdere onderrig beklemtoon in gevorderde kraamverpleging, werkswinkels, konferensies, die bywerk van kennis en weeklikse indiensopleiding, die instel van ’n kwaliteitsversekering en opvoedingsprogramme vir pasiënte. Ten slotte die bemagtiging van vroedvroue wat oor die vereiste kennis beskik van toestande van hipertensiewe toestande, sal bydra tot die afname van sterfte- en siektesyfers.

The general health status of pregnant women depends largely on the quality of the antenatal services available to them. The provision of good antenatal services ensures early detection and prompt management of any complication or disease that may adversely affect pregnancy outcome. In order to ensure high quality care, antenatal services need to be evaluated at regular intervals, both from provider and client perspective, to ensure their effectiveness in improving the health status of pregnant women. The midwife, as the first contact person for most pregnant women attending antenatal clinics in South Africa, has the potential to play a major role in improving the health status of these women. However, for the midwife to be effective in achieving this, antenatal services need to be effectively utilized by women. One of the factors that affect utilization of any service is client satisfaction with the service being rendered. This study, therefore, explores the perceptions that pregnant women have of the care that they receive from midwives at the selected antenatal clinics. The objectives of the study are to: {u100083} Explore and describe the perceptions and experiences of pregnant women attending antenatal clinic regarding the care they receive from midwives. {u100083} Make recommendations to assist registered midwives in optimizing the accompaniment of women during the antenatal period. A qualitative, descriptive, exploratory and contextual design was used for the study. The sample was chosen from the target population by means of purposive sampling and data was collected through unstructured interviews with the participants. Before data collection, permission was obtained from the Eastern Cape Department of Health and the Nursing Service Manager of the Gateway clinic, in the district hospital where the research was conducted. The Nursing Service Manager was acting as a Medical Superintendent at the time of the study. Written, informed consent was obtained from all participants before conducting interviews. Trustworthiness was ensured by means of Guba’s model throughout the study, and the aspects of truth value, applicability, consistency and neutrality were considered. Tesch’s eight steps of data analysis were used to analyze the data collected, and four main themes were identified namely: • Women perceive midwives as considerate and knowledgeable • Women perceive midwives as lazy and rude • Women experience mixed emotions about the care they receive from midwives • Though their experiences, women identified certain needs in the services and care they received at the clinic. Conclusions were drawn and recommendations for midwifery practice made based on the results of the study, with the aim of improving antenatal services rendered to pregnant women.

The World Health Organization (WHO) recommends that of all the live births per year no more than 10-15% of these should be delivered by caesarean section. Despite this recommendation there has been a global increase in the percentage of caesarean section deliveries over the past few decades. In South Africa the percentage is as high as 70% in certain health care institutions which is of concern to midwives. Caesarean section deliveries are needed when the life of the baby, mother or both are at stake. However, this method of delivery bears more disadvantages than advantages to the baby and mother. Despite these disadvantages, some women request a caesarean section in their birth plans while others are influenced by health professionals to request a caesarean section. Therefore, there is a need for labouring women to be guided where possible to have vaginal birth because of its many advantages. This study sought to explore and describe the perceptions of the midwives regarding their role in facilitating the choice of delivery mode for labouring women in public hospitals and midwifery obstetric units (MOUs) of the Nelson Mandela Bay and Sarah Baartman districts. Based on the results of the study, guidelines for midwives in this role were developed. Maputle’sWoman-Centred Childbirth Model (2010) was used as the theoretical lens through which this study was viewed. The researcher selected a quantitative survey design using an explorative, descriptive and contextual research approach. The population consisted of midwives who were working in labour wards at public hospitals and midwife-led MOUs. A non-probability convenience sample was used to collect data using a structured, self-administered questionnaire. The reliability and validity of the data collection instrument were ensured by using various means including a pre-test and an expert panel. Altogether, 300 questionnaires were distributed and 288 were returned. This number excluded the pilot study. Data was collected over a period of three months using the assistance of two fieldworkers. Data was captured and analysed under the supervision of the statistician and supervisors. Analysis was done by means of descriptive analyses that involved the production of frequencies and presented using charts, figures and tables. The major findings of the study are: -The midwives perceived themselves as the main facilitators of a suitable decision by the labouring woman for a safe delivery method - The midwives emphasised the importance of the delivery position preferred by the labouring woman -The midwives indicated that a collaboration between doctors, senior midwives, midwives and midwives in management positions could assist with a decision for a suitable delivery mode option. -The midwives agreed that the culture of the labouring woman should be considered when deciding on a delivery mode and therefore midwifery curriculum should include lessons about cultural diversity. Three principal guidelines were developed, namely: 1. Create an environment that promotes acceptance of a woman’s choice of a delivery mode. 2. Create an environment promoting a collaborative health care relationship 3. Create an environment that is sensitive to cultural needs in the maternity unit Ethical considerations in this study were upheld by maintaining the principles of beneficence, maleficence, autonomy and justice.

The aim of this study was to investigate whether patients were satisfied with midwifery services rendered at the two Community Health Centres in the Eastern Cape Province.The study sites were Empilweni Gompo and Nontyatyambo Community Health Centres. Descriptive quantitative study design was employed, using a questionnaire with closed and open ended questions as the data collecting tool. Likert Scale was used to measure the following variables: quality care variables to measure level of satisfaction with midwifery services rendered and to determine positive and negative perceptions regarding quality of care received during antenatal, labour and postnatal period. Non-random convenience sampling of sixty pregnant women, thirty from each Community Health Centre, with two or more antenatal subsequent visits and forty postpartum women, twenty from each health facility, six hours after delivery if there were no complications. Out of 60 participants interviewed n=60 (100 percent) agreed that individual counseling and importance of HIV testing was explained.The majority of participants n=53(88 percent) disagreed that they were educated about focused antenatal visits. Out of 60 participants interviewed n=41(68 percent) agreed that delivery plan formed part of their ANC visits and n=18 (30 percent) disagreed. Of the 60 participants interviewed n=11(18 percent) agreed that they were told that they had the right to choose labour companions and n=48 (80 percent) disagreed.Out of 60 participants interviewed n=23 (38 percent) stated that they waited a long period of time without being attended to by midwives. In general, the study revealed high satisfaction level with intrapartum and postnatal care due to functional accessibility of both Community Health Centres. Both health centres delivered normal healthy babies and mothers. However, the participants were dissatisfied with antenatal care rendered at the two facilities. The researcher’s recommendations were based on the closing of gaps that were identified with regard to the implementation of Basic Antenatal Care; birth companions: health education deficiency; community involvement and participation.

The purpose of this study was to identify the need for a training programme and to develop the training programme to meet the needs of traditional birth attendants in the management of pregnancy, labour and puerperium. The study was conducted in the Flagstaff district which is one of the districts of the north eastern region (region E) of the Eastern Cape. The target group consisted of all the traditional birth attendants who availed themselves at the residential clinics of Flagstaff district and the number is not known as not all traditional birth attendants who presented themselves are recognized by their communities as traditional birth attendants. The study was a quantitative descriptive design and the data was collected by means of structured interviews using a questionnaire that was designed by the researcher. According to the findings the traditional birth attendants are functioning without being formally trained before. They lack knowledge and skill in the management of pregnancy, labour and puerperium. Some of their practices are reason for concern, for example cephalic versions and not using protective devices. There is a need for the development of the training programme in the Flagstaff district. This programme was developed from the information obtained from the data-analysis and is given as annexure F / Health Sciences / M.A. (Advanced Nursing Sciences)

The purpose of this study was to identify the need for a training programme and to develop the training programme to meet the needs of traditional birth attendants in the management of pregnancy, labour and puerperium. The study was conducted in the Flagstaff district which is one of the districts of the north eastern region (region E) of the Eastern Cape. The target group consisted of all the traditional birth attendants who availed themselves at the residential clinics of Flagstaff district and the number is not known as not all traditional birth attendants who presented themselves are recognized by their communities as traditional birth attendants. The study was a quantitative descriptive design and the data was collected by means of structured interviews using a questionnaire that was designed by the researcher. According to the findings the traditional birth attendants are functioning without being formally trained before. They lack knowledge and skill in the management of pregnancy, labour and puerperium. Some of their practices are reason for concern, for example cephalic versions and not using protective devices. There is a need for the development of the training programme in the Flagstaff district. This programme was developed from the information obtained from the data-analysis and is given as annexure F / Health Sciences / M.A. (Advanced Nursing Sciences)

Basic Antenatal Care (BANC) is a way of training or upgrading the knowledge and skills of all nurses, midwives and doctors involved in antenatal care at the primary health care level so that the minimum care can be provided effectively. This study was conducted to investigate the implementation of the BANC program by midwives in the Mdantsane clinics during February 2009. Methods: A descriptive study design was undertaken targeting midwives providing antenatal care to pregnant women, in 14 clinics of Mdantsane. Data was collected from 25 midwives in the clinics, and from 140 ANC cards of women attending ANC on the day of their visit to the clinic. Results: The majority of midwives providing BANC in Mdantsane clinics were not trained in BANC. There were 10 trained midwives and 15 not yet trained. A total of twenty five midwives were involved in the study. The number of visits according to the BANC schedule was well known by the midwives in the study. The content of the visits was well known for the first visit, but for subsequent visits, the participating midwives could not state exactly what they do on these visits. They perceived BANC as something beneficial for both midwives and pregnant women with 24 of the participating midwives rating BANC as advantageous. In completing an ANC card, the midwives scored between 48 percent and 100 percent. Under examination, they scored between 52 percent and 100 percent. Lastly on interpretation and decision making, they scored between 0 percent and 92 percent. This could have troubling consequences for the health status of the mother and baby. Weaknesses in providing antenatal care identified in the study included participating midwives failing to fill in the last normal menstrual period (LNMP) and the estimated date of delivery (EDD), which was a worrying observation. Plotting of the gestational age at first visit was also not carried out well as only 47 percent of the midwives in the study did this, meaning that there would be a miscalculation of the gestational age thereafter throughout the pregnancies. The body mass index (BMI) was not calculated as the maternal height and weight were not written on the ANC card. This should be completed in order to check the nutritional status of the pregnant woman to help supplement, if malnourished, and educate on diet, if overweight. Only 17 percent of the midwives in the study plotted the foetal presentation. Failure to plot foetal presentation could lead to complications during delivery because women with abnormal presentations could end up delivering in a clinic instead of the hospital.Conclusion: This study showed that even though midwives are implementing BANC among pregnant women, it is not being carried out correctly. Therefore the programme will not be as beneficial as it would be if put into practice correctly. This is highlighted by the lack of knowledge from the untrained midwives regarding the content of care on subsequent visits. Thus there is an urgent need for BANC training to be conducted and monitored at various sites.