COMMUNITY BASED SITUATIONAL ANALYSIS Maternal and ...

COMMUNITY BASED SITUATIONAL ANALYSIS 

Maternal and Neonatal Follow Up Care 

Health Systems Trust and University of Western Cape Consortium 

together with South African Nurses in Business



Research commissioned by: 

The Maternal, Child, Women’s Health and Nutrition Directorate of the National Department of 

Health, South Africa 

Research funded by: 

The Centers for Disease Control and Prevention, South Africa 

Research Report written by: 

• Debra Jackson, School of Public Health, University of the Western Cape 

• Marian Loveday, Health Systems Trust 

• Tanya Doherty, Health Systems Trust 

• Nomafrench Mbombo, School of Nursing, University of the Western Cape 

• Alyssa Wigton, School of Hygiene and Public Health, Johns Hopkins University 

• Lyness Matizirofa, Statistics Department, University of the Western Cape 

• Mickey Chopra, Health Systems Research Unit, Medical Research Council and School 

of Public Health, University of the Western Cape 

• Gugu Nzimande, School of Public Health, University of the Western Cape 

• Eric Cele, Health Systems Trust 

• Mildred Joyi, Health Systems Trust 

• Latasha Treger, Centers for Disease Control and Prevention (South Africa) 

• Pulani Tlebere, National Department of Health (South Africa) 

Suggested citation: Jackson D, Loveday M, Doherty T, Mbombo N, Wigton A, Matizirofa L, 

et.al. Community Based Situation Analysis: Maternal and Neonatal Follow-up Care. Durban: 

Health Systems Trust. 2006. 

The information contained in this publication may be freely distributed and reproduced, as long as the source is acknowledged, 

and it is used for non-commercial purposes. 

Community Based Situation Analysis: Maternal & Neonatal Follow-up Care 

ii

Table of Contents 

ABSTRACT ...............................................................................................................................................................V 

EXECUTIVE SUMMARY .........................................................................................................................................VII 

1. INTRODUCTION...................................................................................................................................................1 

2. OBJECTIVES OF THE SITUATIONAL ANALYSIS.............................................................................................2 

3. METHODS ............................................................................................................................................................3 

4. RESULTS .............................................................................................................................................................8 

4.1. DEMOGRAPHIC AND SOCIO-ECONOMIC INFORMATION ........................................................................8 

4.2. SEMI-STRUCTURED HOUSEHOLD INTERVIEWS....................................................................................11 

SECTION 1: FACTORS ASSOCIATED WITH UTILISATION OF HEALTH SERVICES............................11 

SECTION 2: LEVELS OF AWARENESS OF RISK FACTORS AND SOURCES OF HEALTH 

INFORMATION...........................................................................................................................................14 

SECTION 3: HEALTH SEEKING BEHAVIOUR OF HIV-POSITIVE AND HIV-NEGATIVE WOMEN.........16 

SECTION 4: FAMILY INVOLVEMENT IN PREGNANCY, BIRTH AND CARE OF INFANT ......................16 

SECTION 5: DISCUSSION AND CONCLUSION .......................................................................................16 

4.3. QUALITATIVE RESULTS ............................................................................................................................18 

SECTION 1: NO ANC ATTENDANCE AND HOME BIRTH REVIEW ........................................................18 

SECTION 2: MATERNAL DEATH REVIEW............................................................................................... 23 

5. DISCUSSION: TRIANGULATION AND SUMMARY OF RESULTS..................................................................36 

6. RECOMMENDATIONS: .....................................................................................................................................37 

7. ACKNOWLEDGEMENTS...................................................................................................................................39 

8. REFERENCES....................................................................................................................................................40 

APPENDIX A ...........................................................................................................................................................41 

APPENDIX B ...........................................................................................................................................................59 

LIST OF TABLES 

Table 1: Categories and Number of Study Respondents..........................................................................................8 

Table 2: Demographic Data ......................................................................................................................................9 

Table 3: Utilisation Score .........................................................................................................................................12 

Table 4: Age at death and Suspected Causes of Death in Infants ..........................................................................29 

Table 5: Maternal and Infant HIV Status Correlated with Infant Deaths ..................................................................30 

LIST OF GRAPHS 

Graph 1: Comparing Household Water Source at the Three Sites.........................................................................10 

Graph 2: Comparing Average Travel Times to the Nearest Clinic and Hospital from the Three Sites ...................11 

Graph 3: Sources of Health Information on Pregnancy by Site ..............................................................................15 


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LIST OF APPENDICES 

Appendix A: Quantitative Results 

Appendix 1: Socio-Economic Differences across the Sites 

Appendix 2: Distribution of Selected Measures of Income by Site 

Appendix 3: Mode of Travel and Time to Health Services 

Appendix 4: Factors associated with the Utilisation of Health Services with a Score >=5 

Appendix 5: Barriers to ANC 

Appendix 6: What Sort of Things or People made it Easier to Attend ANC? 

Appendix 7: Why didn’t you go to ANC Earlier? 

Appendix 8: Pregnancy History 

Appendix 9 Family Planning 

Appendix 10: Immunisations 

Appendix 11: Where did you learn about Problems or Warning Signs in Pregnancy? 

Appendix 12: Sources of Information on Pregnancy 

Appendix 13: Source for Best Advice for Making Decisions about Health 

Appendix 14: What are some Dangerous or Warning Signs of a Problem during Pregnancy or Birth? 

Appendix 15: What are some Dangerous or Warning Signs of a Problem in the Woman in the First Month After 

Birth? 

Appendix 16: What Are some Danger or Warning Signs of a Problem in the Baby in the First Three Months 

After Birth? 

Appendix 17: Household Member: What are some Dangerous or Warning Signs of a Problem During 

Pregnancy, Birth or in the 1 st Month after Birth? 

Appendix 18: Utilisation Score by HIV Status 

Appendix 19: Immunisation by HIV Status 

Appendix 20: Quality of Care by HIV Status 

Appendix 21: Family Involvement in Pregnancy - Mother's Interview 

Appendix 22: Family Involvement in Labour/Birth - Mother's Interview 

Appendix 23: Family Involvement in Pregnancy - Household Member's Interview 

Appendix 24: Family Involvement in Labour - Household Member's Interview 

Appendix 25: Family Involvement after the Birth of the Baby - Household Member's Interview 

Appendix 26: Do you think That Poor Health of Women during Pregnancy is an Important Problem in South 

Africa - Household Member's Interview 

Appendix B: 

Appendix 1: 

Appendix 2: 

Appendix 3: 

Appendix 4: 

Appendix 5: 

Qualitative Results 

Maternal Verbal Autopsy case summaries 

Infant Verbal Autopsy Pilot Report 

Facility Sub-Study Report: Paarl Facility Investigation 

Facility Sub-Study Report: Rietvlei Facility Investigation 

Facility Sub-Study Report: Summary 


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Abstract 

Introduction 

There were two overall aims to this project. Firstly, to conduct a community situational analysis 

to determine factors that impact on the utilisation of maternal health services. Secondly, it is 

hoped that the results of the research could be utilised to develop appropriate interventions to 

improve acceptability and utilisation of safe motherhood and PMTCT programmes. 

Objectives 

1. To determine factors influencing utilisation of maternal health services and barriers to 

utilisation of maternal health services (including loss to follow-up of mothers and infants 

in the PMTCT programme). 

2. To determine the level of awareness of risk factors associated with poor maternal and 

perinatal health outcomes among women and men. 

3. To determine the health seeking behaviours of HIV-positive and HIV-negative pregnant 

women. 

Methods 

In order to capitalise on extensive background data and to build on ongoing research, three 

sites were chosen for the research related to objectives 1, 2 and 3, where the HST/UWC 

consortium has longstanding research links. These sites are in the Western Cape, KwaZulu- 

Natal and the Eastern Cape. The three sites in these provinces represent diverse geographical 

settings in South Africa, namely; a peri-urban township, a rural district and a peri-urban farming 

region as well as differences in HIV prevalence and socio-economic situations. 

Semi-structured household interviews with 3 groups of mothers, plus a member of each 

mother’s household were interviewed. All groups randomly sampled: HIV-positive mothers 

enrolled in national PMTCT cohort study; HIV-negative mothers enrolled in national PMTCT 

cohort study, and Women of unknown HIV status sampled from community lists of recently 

delivered mothers. 

Case studies with 3 groups of mothers were also conducted. Groups randomly sampled from 

community lists: No ANC; No ANC with home births; and Home births (with ANC). In addition, 

verbal autopsies using tools adapted from WHO, including Infant verbal autopsies (PMTCT 

cohort) and Maternal verbal autopsies (PMTCT cohort and non-cohort) were conducted. 

Finally, a facility based review of PMTCT follow-up services was conducted using qualitative 

and quantitative case study methodology. Data collection methods consisted of semistructured 

interviews with staff and management involved in the PMTCT programme and a 

review of PMTCT programme records. 

Data analysis used quantitative statistics for the semi-structured interviews and qualitative 

content-theme approach for the case studies and verbal autopsies. Each component was 

analysed separately and then triangulated. 


v

Results 

In triangulating the results across the various sources of data in this study, many consistent 

themes emerged. The following provides a short summary of the primary themes that were 

seen in this analysis: 

• Transport and Distance to Care - biggest problem 

• Communication with Families - very poor 

• Health Seeking Behaviour - good 

• Treatment by health providers and quality of care - mixed 

• HIV/AIDS is a major issue - but cannot overlook basic maternity and neonatal service 

quality 

• Families and Communities - an untapped resource 

Conclusions/Recommendations 

• 24-hour emergency transport services must be available within each community for 

emergency obstetric and paediatric care. 

• Community education about maternal and infant health and danger signs is imperative. 

• Hospital protocols for assessment and treatment of women and infants must be 

reviewed and current standards must be implemented. 

• All facilities must be adequately supplied with the essential medicines and supplies to 

promote maternal and infant health. 

• Sensitivity training for hospital staff working with mothers and infants should be 

explored and communication with families needs to be enhanced. 

• HIV and AIDS services need to be expanded, integrated and comprehensive. 

• Cooperation and communication with families and communities needs to be enhanced. 


vi

Executive Summary 



1. INTRODUCTION 

Reduction of mortality and morbidity of both the mother and the newborn have been identified 

as priority areas needing urgent attention by the Department of Health. The maternal mortality 

ratio for South Africa was estimated in the South African Demographic and Health Survey of 

1998 to be 150/100 000 births. 1 This rate is however, thought to be rising, as the estimate from 

the latest Saving Mothers Report 2 places the estimate at 175-200/100 000 births. The extent of 

morbidity is not known but it is estimated that for every woman that dies of a pregnancy related 

complication, 20 more suffer from morbidity such as vesico-vaginal fistulae which may be 

severe and lead to long term disabilities. 3 

According to the Saving Mothers report, since 1999 non-pregnancy related infections have 

become the main cause of maternal mortality in South Africa (33.7%), 2 with AIDS being the 

main cause. Hypertensive complications of pregnancy are the second commonest (18.1%) 

followed by obstetric haemorrhage (13.8%). Poor transport and lack of intensive care services 

were the major administrative problems reported. Medical personnel oriented problems 

included poor initial assessment and diagnosis of cases especially at secondary level of care, 

failure to follow standard protocols at primary and secondary levels and poor monitoring of 

patients at all levels of care. 

To this end, the Maternal, Child, Women’s Health and Nutrition (MCWHN) directorate, with 

financial assistance from CDC contracted Health Systems Trust (HST) and South African 

Nurses in Business (SANIB) to conduct a community-based situational analysis on maternal 

and neonatal follow-up care. The situational analysis was to be conducted throughout the 

country and the findings of this study are to be used to target interventions aimed at improving 

maternal and infant mortality rates, with a particular focus of enhancing the utilisation of 

services. 

1 

National Department of Health, South African Demographic and Health Survey 1998. Pretoria: Department of Health/Medical 

Research Council/Macro International. 1998. 

2 

NCCEMD, Saving Mothers 1999-2001, Pretoria: National Department of Health/NCCEMD. 2002. 

3 

World Health Organization. Making Pregnancy Safer: Why is this issue important? Fact Sheet No. 276. Geneva: World Health 

Organization. 2004. 


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2. OBJECTIVES OF THE SITUATIONAL ANALYSIS 

HST together with the University of the Western Cape (UWC) took responsibility for providing 

insight for the first three objectives of the project, namely: 




2. To determine the level of awareness of risk factors associated with poor maternal and 

perinatal health outcomes among women and men. 


women. 

3. METHODS 

Research Sites 

Three sites were chosen for the research from communities where the HST/UWC consortium 

has longstanding research links. These sites are situated in the Western Cape, KwaZulu-Natal 

and the Eastern Cape. The three sites represent diverse geographical settings in South Africa, 

namely; a peri-urban township, a rural district and a peri-urban farming region, as well as 

differences in HIV prevalence and socio-economic situations. 

Study Methods 

A cross sectional descriptive study was conducted. Quantitative and qualitative data were 

collected from households that participated in the national PMTCT cohort study (HIV-positive 

and HIV-negative) and from households that did not participate in this study (unknown HIV 

status). From each of the three PMTCT cohort sites, 20 women who were known to be HIVpositive 

and 20 women who were known to be HIV-negative were randomly sampled from the 

list of original participants. 20 women were also randomly selected from the list of births in the 

last 9-12 months generated by Community Health Workers (CHWs) to provide a sample of 

women who were not in the PMTCT cohort study. A husband/partner or other significant 

household member was also interviewed from each of these 60 households to explore 

knowledge and understanding of family members around pregnancy risks and maternity care. 

In addition to the cross-sectional descriptive survey qualitative case-studies of adverse 

outcomes were also conducted. A sub-sample of women/households was purposely selected 

to examine particular cases of interest, for example households with a known maternal or infant 

death, a mother with no antenatal care or who had a home birth. The semi-structured 

interviews in these households were supplemented with a qualitative interview examining the 

circumstances and issues around the event of interest, e.g. the maternal death. Approximately 

20 case studies were to be done in each of the sites. 

Home visits were made to selected women and written informed consent was obtained from all 

women prior to initiation of the interview. Data was collected using semi-structured interviews 

with pregnant women, partners and other key informants by trained field researchers. The 

instruments had modules on basic socio-demographic data, utilisation of and barriers to 

utilisation of maternal health services, knowledge of risk factors associated with poor maternal 

and perinatal health outcomes, frequency of postnatal health service contacts, sources of 

community information on maternal health and PMTCT and attitudes towards maternal health 

services. 


viii

It was not possible to identify participants on the PMTCT programme who had defaulted and 

avoided obtaining infant HIV testing results or full infant immunisation at nine months. A facility 

based qualitative case study, was therefore conducted at two of the three sites (Paarl and 

Rietvlei), to compare PMTCT programmes, which have been in existence for four years, and 

determine what systems factors contributing to the functioning of these programmes. 

Data Capturing & Data Analysis 

Quantitative data were entered into an EXCEL spread sheet and analysed using both SAS 

and EPI-INFO software packages. Primarily descriptive statistics were employed, including 

means and standard deviation for continuous data, and frequencies and cross-tabulations for 

categorical data. A content-theme approach focusing on study questions was used for the 

qualitative analysis. Two researchers from the study team were allocated to each type of 

qualitative interview: The data from the Facility Based PMTCT Follow-up Study is a 

combination of quantitative data from the data available at the two sites and a qualitative 

process description focusing on the follow-up services at each facility and the challenges 

described by the key informants. Finally, data from the quantitative semi-structured interviews, 

the three types of case studies, and the facility review were triangulated. 

4. RESULTS 

Household Interviews 

In total there were 226 respondents. Of these, 68 lived in Paarl, 78 in Rietvlei and 81 in 

Umlazi. Of the 226 respondents 178 were involved in semi-structured interviews and 48 in indepth 

studies. In addition 178 household members were interviewed. The average age of the 

women interviewed (not household members) was similar across the sites between 25 and 27 

years. The mean infant age across sites was similar (p=0.61) There were significantly more 

single women in Umlazi (81%) than at the other two sites (Paarl 69% and Rietvlei 51%). 

The results for a number of socio-economic variables show that participants from Rietvlei have 

significantly poorer resources than those in Paarl and Umlazi. These included poorer water 

source, sanitation facilities, cooking fuel, and lower rates of employment. Women in Rietvlei 

lived substantially longer distances from both the clinic and the hospital than in the other two 

sites. 

In order to examine factors associated with the utilisation of maternity and newborn services, a 

composite index was developed using the six items listed in Table 3 below. One point was 

allocated for each item with a score of 1 indicating better utilisation and 0 poorer utilisation. A 

mean score was then derived, which indicated that Paarl had the best utilisation score and 

Rietvlei the lowest. The score was further dichotomized to =5, with >=5 indicating 

better utilisation of services. Paarl had the highest percentage of women (77%) with a score of 

at least five and Rietvlei the lowest at only 11% (Utilisation Score). 


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Utilisation Score 

Variable Paarl Rietvlei Umlazi Total 

# (%) # (%) # (%) # (%) 

For all pregnancies 

Attended ANC in all pregnancies 60 (100) 57 (95) 55 (95) 172 (96) 

Delivered in Hospital/Clinic for all 55 (92) 48 (80) 55 (95) 158 (89) 

pregnancies 

For last pregnancy 

Began ANC in months 0-4 34 (57) 20 (34) 26 (46) 80 (46) 

1 st infant follow-up visit prior to 6 56 (93) 16 (27) 48 (84) 120 (68) 

weeks of age 

1 st maternal follow-up visit prior 55 (92) 10 (18) 21 (38) 86 (49) 

to 6 weeks post-delivery 

Currently using Family Planning 47 (78) 43 (73) 47 (89) 137 (80) 

Mean Utilization Score (1 point 

for each of above) 

5.1 

(SD=0.85) 

3.3 

(SD=1.1) 

4.5 

(SD=0.82) 

P-value (comparing 

mean differences) = 0.00 

Utilization Score >=5 46 (77%) 6 (11%) 26 (54%) 78 (47%) 

P=0.00 

The following variables were associated with higher utilisation in addition to site (p=5, between mothers who were HIVpositive 

and HIV-negative. There were also no differences in mean number of postpartum 

visits (4 vs. 3, p=0.17). Complete immunisation of children for age was similar across HIVpositive 

and HIV-negative women in Paarl and Rietvlei but significantly lower in children of HIVpositive 

women in Umlazi (19% vs. 82%, p=0.0003). 

Specifically examining stated barriers to care, in Paarl 27%, Umlazi 28% and in Rietvlei 38% of 

women indicated they had problems attending antenatal care. A lack of financial resources for 

transport was the barrier most cited by women. Although money was listed as the biggest 

barrier to care, having money did not significantly promote ANC attendance. Support of family 

and friends was the strongest promoter of ANC attendance. This support varied from 

encouragement to assistance with transport and money. 11-15% of women cited friendly staff 

and good quality care as promoters of ANC attendance. 

With regard to late antenatal attendance the two main reasons for not starting ANC early were: 

the long distances to services and the fact that pregnant women felt fine so they thought it was 

all right to access ANC services later on in pregnancy. The proportion of women who cited the 

latter reason was substantially higher in Rietvlei (61%) compared to 14% in Umlazi and none in 

Paarl. 


x

With regard to knowledge of risk factors by the women, the most well-known factors for 

pregnancy and delivery were hypertension and oedema (75%); for postpartum it was bleeding 

(75%), and for newborns chronic diarrhoea (75%). The majority of other risk factors were 

mentioned by less than 50% of women. Knowledge in household members was similar to that 

of the women. 

The predominant source of information on pregnancy at each of the three sites was the health 

workers (over 80% in all sites), followed by the radio and friends or family. The most trusted 

source of information for making health decisions was also health workers. 

Qualitative Case Studies 

No Antenatal Care and Home Births 

The following themes related to health systems barriers to antenatal care were identified from 

the in-depth interviews: Accessibility of health services was a major issue, including time 

services offered, distance/time to services, and money to travel to services. Another major 

theme was the attitude of nurses with some nurses being very positive, but unfortunately not 

all. Community factors raised by the women who did not attend ANC included: limited financial 

resources, influence of family members, family responsibilities, women don’t realise they are 

pregnant, and difficulty in obtaining time off work. 

Examining themes from the home births, women mention transport, attitude of nurses and lack 

of nurses’ recognising labour as health systems issues which prevented them from making it to 

the hospital or clinic for delivery. With regard to community issues related to place of delivery 

women discussed fear of problems in labour as the primary reason for wanting to deliver in a 

health facility but that fear of labour ward nurses, family responsibilities and themselves not 

recognising labour as reasons why they did not make it to the health facility for delivery. 

There are a number of barriers to accessing both antenatal and maternity services. In many 

cases multiple reasons for not attending antenatal or maternity services were given. It is 

concerning to note a substantial number of home deliveries took place with only children 

present. 

Verbal Autopsies of Maternal Deaths 

The causes of death for the 18 cases were: AIDS = 12 (67%); Other Non-Pregnancy Related 

Infection = 3 (16.5%); and Direct Perinatal Causes = 3 (16.5%). All but one mother died 

postpartum, and all of the AIDS deaths died after a prolonged period of illness. The majority (12 

out of 18) of the deaths occurred in the hospital. Only in one of the non-hospital deaths was 

lack of transport considered a possible contributor. 

The majority of women had sought heath care without delay at the beginning of their illness. 

The women with chronic conditions clearly had regular contact with the public health care 

system, and many also had contact with private and traditional health systems. These women 

appeared to go first to the clinic or hospital in the public sector and when they did not get better 

consulted with either a private doctor, traditional healer or both. 

The majority of deaths in mothers in this study were due to AIDS-related causes. These 

deaths were accompanied by several months of chronic illness and deterioration in health 


xi

status until the women were no longer able to take care of themselves. Most described poor 

health as starting during pregnancy or around the time of delivery suggesting pregnancy may 

have contributed to deterioration in health in HIV-positive women. Many of these deaths 

involved extensive care by family members and continuous health seeking to multiple providers 

during the course of the illness. However, family members received very little if any 

communication from health providers about the condition of the terminally ill woman or her 

care. Denial and/or hopelessness were seen in many of these cases. Interestingly 

hopelessness, denial and lack of disclosure was not seen in the cases in Paarl where hospice 

care was available and the health care and system has been previously described to be of a 

higher quality with more resources. 

Although the majority of deaths appeared to be HIV and AIDS related, there were still deaths 

due to direct obstetric causes. One involved patient related avoidable factors and in the other 

two, health provider avoidable factors. Care must be taken not to overlook basic maternity 

service quality in the face of an often overwhelming HIV and AIDS pandemic. 

Verbal Autopsies of Infant Deaths 

The mean age of the infants who died was 16.7 weeks, ranging from one day to 48 weeks. 

Three babies died under one week of age. Causes of death were primarily infectious diseases 

(Age at death and Suspected Causes of Death in Infants). 

The HIV status of many of the infants was unknown as they died before an HIV test was done. 

To place the above deaths in context - overall there were 75 infant deaths in the Good Start 

Cohort Study. Nine month old mortality rates in infants born to HIV-positive women was 10.1% 

while for those born to HIV-negative women it was 3.7% (p=0.003). 

Age at death and Suspected Causes of Death in Infants 

• Child’s age at death: 

Less than 1 wk - 3 (8%) 

1 - 4 weeks - 2 (5%) 

5 - 24 weeks - 26 (65%) 

25 - 48 weeks - 9 (23%) 

• Suspected causes of death: 

Gastro-intestinal Infection - 16 

Pneumonia - 15 

Prematurity - 2 

TB – 2 

Unknown - 2 

Sudden Infant Death Syndrome - 3 


xii

Themes that emerged from the qualitative results regarding factors that influenced utilisation of 

child health services included: 

• Socio-economic constraints - once again this focuses on transportation issues such as 

no money for transport to the clinic or hospital. 

• Beliefs about causes of illness - “Ishawe Yinyoni" (witchcraft) was blamed for the infant 

death in one case. 

• Lack of awareness of danger signs in infants - several mothers stated that they did not 

realise the seriousness of the child's condition and therefore delayed seeking care. 

• Poor quality of care - in several cases the infants had been seen at the clinic or 

hospital and been sent home without recognition of the seriousness of the illness as 

the child died later that day. 

• Role of traditional healers - traditional healers were used, but again this was only have 

the mothers had taken the infant to the clinic or hospital and the infants condition did 

not improve or the clinic was out of stock of medicines. 

• No difference in health seeking behaviour between HIV-positive and HIV-negative 

mothers. 

These in-depth interviews made it possible to highlight the complex pathways and underlying 

mechanisms that precede the majority of infant deaths in high risk communities. They also 

highlighted many missed opportunities and poor quality of care that suggests many of the 

deaths were potentially avoidable. 

Facility Based Review of PMTCT Follow-up Services 

An in-depth review of the post-partum and newborn follow-up in the PMTCT programme in two 

sites, Paarl and Rietvlei, was conducted using document review and in-depth interviews with 

local service providers. Results suggest that information about the HIV transmission rate to 

infants on the PMTCT programme is not accessible or available at a sub-district or district level. 

As a result local health managers and managers of the PMTCT programme are unable to 

monitor the extent of the success of the PMTCT programme. 

Although the system in Paarl is complex, medicines for the programme, testing kits and 

nutritional supplementation are available, and mothers on the PMTCT programme do not 

default. In Rietvlei however, although the referral pathway is simpler and all nurses are trained 

in VCT, the poor performance of the support services, in particular the pharmaceutical and 

laboratory services and the frequent unavailability of infant formula appear to contribute to 

considerable defaulting from the programme. 


xiii

5. DISCUSSION: TRIANGULATION AND SUMMARY OF RESULTS 


themes emerged. This section provides a short summary of the primary themes that were seen 

in this analysis: 

• Transport and Distance to Care are the biggest problem faced by women and families 

in accessing health services. 

• Communication by health workers with families was shown to be inadequate leading to 

a decreased confidence in the health services. 

• Health Seeking Behaviour is good, and despite often poor treatment and lack of 

communication by the health services, the study showed that most people first seek 

help from the clinic or hospital and only when failed by the Western medical system did 

they access traditional medicine. Women and families appear to only delay or not 

access services when they cannot get there (see transport above) not because they do 

not want to access services, or do not feel the services are valuable. 

• Treatment by health providers and quality of care as reported by the mothers and 

families was mixed, as examples of both good and poor treatment and care were cited 

by respondents. 

• HIV/AIDS is a major issue but we cannot overlook basic maternity and neonatal service 

quality. 

• Families and Communities are untapped resources that play a crucial role in 

determining health seeking behaviour and utilisation of services. 

6. RECOMMENDATIONS 

1. 24-hour emergency transport services must be available within each community for 

emergency obstetric and paediatric care. 

2. Community education about maternal and infant health and danger signs is imperative. 

3. Hospital protocols for assessment and treatment of women and infants must be 

reviewed and current standards must be implemented. 

4. All facilities must be adequately supplied with the essential medicines and supplies to 

promote maternal and infant health. 

5. Sensitivity training for hospital staff working with mothers and infants should be 

explored and communication with families needs to be enhanced. 

6. Given that Nevirapine is successful in reducing the transmission of HIV to newborns, it 

is essential that the PMTCT programme functions well and is monitored effectively. 

7. HIV and AIDS services need to be expanded, integrated and comprehensive. 

8. Cooperation and communication with families and communities needs to be enhanced. 


xiv



Final Report 


Reduction of mortality and morbidity in both mothers and newborns has been identified as 

priority areas needing urgent attention by the Department of Health (DoH). The maternal 

mortality ratio for South Africa was estimated in the South African Demographic and Health 

Survey of 1998 to be 150/100 000 births. 1 This rate is however, thought to be rising, and the 

estimate from the latest Saving Mothers Report 2 places it at 175-200/100 000 births. The extent 

of morbidity is not known but it is estimated that for every woman that dies of a pregnancy 

related complication, 20 more suffer from morbidity such as vesico-vaginal fistulae which may 

be severe and lead to long term disabilities. 3 

According to the Saving Mothers report, since 1999 non-pregnancy related infections have 

become the main cause of maternal mortality in South Africa (33.7%), 2 mainly due to with 

AIDS. Hypertensive complications during pregnancy are the second commonest cause of 

mortality (18.1%) followed by obstetric haemorrhage (13.8%). Poor transport and lack of 

intensive care services were the major administrative problems reported. Medical personnel 

related problems included poor initial assessment and diagnosis of cases especially at 

secondary level of care, failure to follow standard protocols at primary and secondary levels 

and poor monitoring of patients at all levels of care. 

Over the past three years prevention of mother-to-child transmission of HIV (PMTCT) 

programmes have been established in most of the African countries of which the majority are 

in the process of scaling up PMTCT programmes to achieve national coverage. These 

programmes have often been implemented in a vertical fashion with little integration into 

existing maternal and child health programmes. Vertical PMTCT programmes interventions 

with sole emphasis on PMTCT may miss valuable opportunities to avert common obstetric and 

postpartum emergencies. 

PMTCT has the potential to strengthen maternal and child health services while reducing 

vertical transmission at the same time. Integration of PMTCT into existing maternal and child 

health services may help to minimise stigma and ‘normalise’ PMTCT interventions as part of 

routine maternity care. Thus the synergy between PMTCT and safe motherhood programmes 

should improve maternal and newborn survival and wellbeing. 

There were two aims for carrying out this project. Firstly, to conduct a community situational 

analysis to determine factors that impact on the utilisation of maternal health services, with a 

focus on PMTCT services. Secondly, to encourage health facilities to use the results of the 

research to develop appropriate interventions for improving acceptability and utilisation of safe 

motherhood and PMTCT programmes as well as to test strategies for integrating PMTCT within 

maternal and child health services. 

To this end, the Maternal, Child, Women’s Health and Nutrition (MCWHN) directorate, with 

financial assistance from Centers for Disease Control (CDC) contracted Health Systems Trust 

(HST) and South African Nurses in Business (SANIB) to conduct a community-based 

situational analysis on maternal and neonatal follow-up care. The situation analysis was to be 

conducted throughout the country and the findings of this study are to be used to target 

interventions aimed at improving maternal and infant mortality rates, with a particular focus of 

enhancing utilisation of services. 

Community Based Situation Analysis: Maternal & Neonatal Follow-up Care 1

2. OBJECTIVES OF THE SITUATIONAL ANALYSIS 

The objectives of the situation analysis were: 




2. To determine the level of awareness of the risk factors associated with poor maternal 

and perinatal health outcomes among women and men. 


women. 

4. To identify available programmes that empower women with appropriate information to 

participate effectively in promotion of the safer motherhood programme. 

5. To assess the available material that provide communities with appropriate and 

necessary information for effective participation in safer motherhood and PMTCT 

programmes as well as reproductive health in general. 

HST together with the University of the Western Cape (UWC) took responsibility for providing 

insight for the first three objectives outlined above. Thus this report covers the findings 

related to objectives one to three from the HST/UWC consortium. 

The HST/UWC consortium was also responsible for providing technical assistance and 

mentoring to SANIB. Findings from the SANIB focus group research on objectives four and five 

will be made available in a separate report. 


3. METHODS 

Description of Research Sites 

In order to capitalise on extensive background data and to build on ongoing research, three 

sites were chosen for the research related to objectives one to three, where the HST/UWC 

consortium has longstanding research links. These sites are in the Western Cape, KwaZulu- 

Natal and the Eastern Cape. The three sites in these provinces represent diverse geographical 

settings in South Africa, namely; a peri-urban township, a rural district and a peri-urban farming 

region as well as differences in HIV prevalence and socio-economic situations. Also 

prospective PMTCT cohort studies have recently been completed at these sites. 

The Paarl District - is a peri-urban/rural area situated 60 km from Cape Town in the heart of 

the Winelands region. The approximate total population for the district is 198 546. Paarl East 

Hospital currently renders 97% of antenatal care services in the district with an average of 210 

- 381 new bookings per month. All deliveries are done at Paarl Regional Hospital. 

Rietvlei in Umzimkulu Sub-district in the Eastern Cape - is situated in one of the poorest 

sub-district of South Africa. The 1998 Demographic and Health Survey estimated an infant 

mortality rate of 99/1000 live births. Diarrhoea, malnutrition and lower respiratory tract 

infections are the major causes of infant mortality. A community survey in the neighbouring 

Mount Frere district found out that 40% of mothers reported delivering their last child at home. 4 

Umlazi - is a peri-urban formal township with interspersed informal settlements situated roughly 

20km southwest of Durban, in the Durban-Ilembe health district in KwaZulu-Natal Province. 

There is one regional hospital, Prince Mshiyeni Memorial Hospital that serves as a referral 

hospital for the surrounding feeder clinics. Maternity services (including a 40-bed antenatal 

ward and 40-bed labour ward) and paediatric services (including a neonatal unit and paediatric 

outpatient services) are available at the hospital. 

District level health indicators cited in the recent South African Health Review 2005 5 for these 

areas showed the following: average ANC visits 2.9 for Alfred Nzo (Rietvlei), 2.9 for eThekwini 

Metro (Umlazi) and 5.7 for West Coast (Paarl); immunisation coverage under 1 year of 92%, 

80% and 97% for Alfred Nzo, eThekwini and West Coast, respectively; and PHC utilisation rate 

(annualised) of 1.5 for Alfred Nzo, 1.9 for eThekwini and 2.8 for West Coast. 

To address objectives four and five focus groups discussions were held by SANIB in rural, 

urban and peri-urban areas in all 9 provinces. As mentioned above, findings from the focus 

groups discussions will be made available in a separate report. 

Study Design 

A cross sectional descriptive study was conducted. Quantitative and qualitative data were 

collected from households which participated in the national PMTCT cohort study as well as 

those which did not participate in this study. This included households with HIV-positive and 

HIV- negative women as well as households with women of unknown HIV serological status. 

Participants were selected randomly for each of the three sub-samples from each of the three 

PMTCT cohort sites. Twenty (20) women who were known to be HIV positive and 20 women 

who were known to be HIV-negative were randomly sampled from the list of original 

participants. CHWs that assisted with the cohort study were asked to identify all women in their 

communities who had delivered a baby in the last 9-12 months for the non-cohort study 

participants. This included women who had home births or did not attend antenatal clinic. 


Twenty (20) women were then randomly selected from the list of births generated by the CHWs 

to provide a sample of women who were not in the PMTCT cohort study. Those who had 

home births and those who did not attend antenatal care were not included in this study but 

were saved for the case studies. A sample of 60 households per site yields 95% confidence 

intervals of ± 7-10% within each site and ± 5-7% for the total sample for the data items listed 

below (assumes strata and sites can be combined). A husband/partner or another significant 

household member was also interviewed from each of these 60 households to explore 

knowledge and understanding of family members around pregnancy risks and maternity care. 

In addition, to the cross-sectional descriptive survey qualitative case-studies of adverse 

outcomes were also conducted. A sub-sample of women/households was purposely selected 

to examine particular cases of interest, for example households with a known maternal or infant 

death, a mother with no antenatal care or who had a home birth. The semi-structured 

interviews in these households were supplemented with a qualitative interview examining the 

circumstances and issues around the event of interest, e.g. the maternal death. Having prior 

data to identify relevant case studies was a key strength of this project. As this component is 

more qualitative in nature, households who had experienced the incidents of interest were 

identified and the key informants in these households interviewed using an in–depth interview 

technique. Approximately 20 case studies were to be done in each of the sites. The majority of 

women were sampled from the Cohort Study, except those with no antenatal care or home 

birth who were selected from non-Cohort Study women identified by CHWs. 

Home visits were made to the selected women and a written informed consent was obtained 

from each woman in the study prior the interview. A written informed consent was also 

obtained from those women who had participated in the PMTCT cohort study. Data was 

collected using semi-structured interviews with pregnant women, partners and other key 

informants. The instruments had modules on basic socio-demographic data; utilisation of and 

barriers to utilisation of maternal health services; knowledge of risk factors associated with poor 

maternal and perinatal health outcomes; frequency of postnatal health service contacts; 

sources of community information on maternal health and PMTCT; and attitudes towards 

maternal health services. 

Where it was found that a household experienced a known maternal or infant death, or women 

did not attend ANC or delivered at home, or defaulted from the PMTCT programme, an 

additional in-depth qualitative interview examining the circumstances and issues around the 

event of interest was administered. Maternal deaths included deaths from the PMTCT cohort 

study, deaths identified in a review of the local hospital delivery register, or deaths identified by 

the CHWs. 

As the interviews included family planning and postpartum care it was decided that women who 

did not access these services would not be examined as a separate sub-group. 

It was not possible to identify participants on the PMTCT programme who had defaulted and 

avoided obtaining their infants’ HIV testing results or full infant immunisation at nine months. A 

facility based qualitative case study was therefore conducted at two of the three sites, to 

compare PMTCT programmes, which have been in existence for four years, and determine 

what systems factors contribute to the functioning of these programmes. The study was 

conducted at Paarl and Rietvlei to determine reasons for defaulting from the programme. 

Umlazi unfortunately did not participate in this sub-study because the researchers were not 

aware at the time that PMTCT defaulters could not be identified at this site either. 


Data Collection 

The study utilised tools that were primarily adapted from established instruments as described 

below. The interviewers had worked as field staff in the Good Start Cohort Study therefore they 

had good experience in both semi-structured and qualitative interviewing techniques. 

However, they received one week of training on the current study tools. A sample of interviews 

done by each field staff during the training was observed and discussed with a project 

supervisor. All study tools were piloted in 3-5 women in each study site and adjustments made 

prior to the interviews. Data was collected via interviews done in the homes of the study 

participants except in Umlazi where some individuals preferred to have the interviews 

conducted at the clinic. 

Semi-structured interviews 

Data was collected from mothers, partners and other key individuals by trained field staff. A 

component of the tool included a knowledge assessment of factors associated with poor 

maternal and infant health outcomes identified by the National Committee for the Confidential 

Enquiry into Maternal Death (NCCEMD) and PMTCT pilot evaluations, including warning signs 

in pregnancy, HIV and AIDS and infant feeding options. The tool was adapted from the original 

PMTCT cohort study tools and the Safe Motherhood Needs Assessment. 6 

Case Studies and Verbal Autopsies 

In-depth interviews were conducted with the mother, partner or key individual. The maternal 

verbal autopsies were all conducted by a midwife, and most of the infant verbal autopsies were 

conducted with the assistance of a doctoral student in public health from Johns Hopkins 

University. Both verbal autopsy tools were adapted from the most recent WHO recommended 

tools for maternal 7 and infant verbal autopsies. 8 

Facility Review 

The review consisted of semi-structured interviews with 16 respondents who were all involved 

in the management and running of the PMTCT programme. These included sub-district HIV 

and AIDS Coordinators, PMTCT Coordinators, maternity matrons, maternity ward and PHC 

clinic staff. 

Data capturing 

Answers to open-ended questions in the semi-structured interviews were reviewed by the 

epidemiologist and a post-graduate statistics student who developed the relevant codes. All 

questionnaires were then post-coded prior to data entry into Excel. Data was entered into an 

EXCEL spread sheet and analysed using both SAS and EPI-INFO software packages. 

Since the demographic data had already been asked from mothers participating in the PMTCT 

cohort study, these participants were not asked these questions again. A list of cohort study 

identification numbers was sent to the cohort study data manager along with a list of 

corresponding socio-demographic variables and this data was forwarded for merging with the 

semi-structured study data. Note that the same question formats and codes were used in both 

studies. 

Quality Assurance 

The tools for the study were developed based on internationally available instruments. Each 

tool was piloted and circulated for comment amongst all researchers involved in the project as 

well as the MCWHN directorate of the NDOH and CDC. 

Field staff were trained and provided with standard operating procedures for interviewing. Data 

entry was regularly supervised and monitored. Completed interviews were checked before 


submission to the data capturer who double entered all data. A randomly selected 10% sample 

of data entered was compared directly to the hard-copy questionnaires and no errors were 

found. This was indicative of a high quality data entry. Data checks were run after data entry 

for out of range values and data inconsistencies and all errors were corrected. 

Data Analysis 

Quantitative data were analysed using EPI-INFO 2002 or SAS . Primarily descriptive 

statistics were employed, including means and standard deviation for continuous data, and 

frequencies and cross-tabulations for categorical data. Socio-demographic data was obtained 

from both semi-structured household interviews and qualitative case studies and are reported 

combined to give an overall description of the study population. Analysis of the semi-structured 

interviews is focused around the three study objectives. Analytic analyses focused only on 

factors associated with utilisation score and comparison of HIV positive and HIV negative 

women. Uncorrected chi-square and corresponding p-values, with alpha set at 0.10, were used 

for the analytic analyses. 

A content-theme approach focusing on study questions was used for the qualitative analysis. 

Two researchers from the study team were allocated to each type of qualitative interview as 

follows: No ANC/Home Births (ML, TD), Maternal Verbal Autopsies (DJ, NM), and Infant 

Verbal Autopsies (AW, MC). The researchers read the notes and completed interview forms 

focusing on the three general themes as outlined by the study questions/objectives. 

The data from the Facility Based PMTCT Follow-up Study is a combination of quantitative data 

from the data available at the two sites; and a qualitative process description focusing on the 

follow-up services at each facility; and the challenges described by the key informants. 

Finally, data from both the quantitative semi-structured interviews, the three types of case 

studies, and the facility review were triangulated. Importantly, the qualitative case-study 

analyses were all conducted independently - i.e. each team of reviewers conducted their own 

analysis without prior knowledge of the results from the other case studies or the results of the 

quantitative household interviews. This lends validity to the common findings across these 

various methods of data collection and analysis as the themes and findings were derived 

independently and only later were commonalities noted across the different sources of data. 

Limitations 

Due to a short study time frame (8 months from initiation until analysis) and limited funding, this 

study has a relatively small sample size for the quantitative component (semi-structured 

household interviews). This limits the study power; therefore, alpha was set at 0.10 when 

examining predictors of, for example the utilisation, outcomes or for comparisons across 

groups. 

Also, when examining overall estimates for quantitative data it must be noted that there was 

block sampling - i.e. even distribution of subjects who were HIV- positive, HIV- negative and 

HIV unknown serological status - such that overall estimates are not adjusted for actual 

population distribution. However, when examined for primary outcomes (utilisation and quality) 

there were not substantial differences across the HIV status groups, suggesting that the 

estimates probably are reasonably representative of the rates in the study sites, which is why 

population weighting was not done in the final analyses. 

The women with known HIV serological status were randomly selected from the sample in the 

larger Good Start Cohort Study of PMTCT. All the infant deaths and the majority of the 

maternal deaths were also selected from the Good Start sample. The Good Start sample 


inclusion criteria required women to have attended ANC or delivered in a hospital, so in areas 

where ANC attendance and hospital delivery are not as high, this sample would not be fully 

representative. For this reason a sample of non-Good Start women was also included as one 

of the strata. These women were identified by local CHWs and from delivery registers. From 

these lists subjects were randomly selected. The lists from the CHWs were not likely to be a 

comprehensive population based sample, but should be reasonably representative of the 

women accessible to the CHWs in the local community in these three study sites. 

As noted above the three study sites were not randomly selected. They were selected to 

represent three of the major types of communities found in South Africa. Therefore, results are 

generally presented by site. However, these sites should be reasonably representative of 

similar communities across South Africa. 

Information bias is expected to be low in this study as the interviewers were all very 

experienced having just completed the three year Good Start Study and had good community 

access. In addition the study tools were adapted either from the Good Start Study or from 

established international tools published by the World Health Organization. However, the 

potential for recall bias exists as the women were being asked to recall events and care during 

their last pregnancy. On average the interviews took place approximately 15 months after the 

index birth. While this is a relatively long recall period, pregnancy and birth are significant 

events in a woman's life and recall is generally thought to be relatively good for major 

components of the event. 

Ethics 

The final study protocol was approved by the Research Ethics Committee at the University of 

the Western Cape. Written informed consent was obtained from all study participants. No 

specific risks or benefits were expected from this study due to its observational nature. 

Participants were informed that they could discontinue participation at any time without any risk 

to future health care. 

Collaboration and Protocol Development 

This project involved collaboration between the South African National Department of Health 

(NDoH), the U.S. based Centers for Diseases Control (South Africa), The University of the 

Western Cape School of Public Health, The Health Systems Trust. The Medical Research 

Council of South Africa, and the South African Nurses in Business (SANIB). All partners 

participated in protocol and tools development; data analysis and reporting of findings. Regular 

meetings of partners were held during the formative, data collection, analysis and reporting 

phases of the project. 


4. RESULTS 

4.1. DEMOGRAPHIC AND SOCIO-ECONOMIC INFORMATION 

The results presented in this section reflect data on all women who participated in the study, 

from the semi-structured interviews and case studies, as well as the information from the key 

informants interviewed (i.e. household members). Detailed tables containing these data can be 

seen in the appendices. Results giving an overview of the number of respondents, their 

demographic profile, socio-economic status and access to health services are presented 

below. 

Number of Respondents 

Table 1 shows the categories and number of respondents per site. In total there were 226 

respondents. Of these, 68 were from Paarl, 78 from Rietvlei and 81 from Umlazi. Of the 226 

respondents, 178 participated in semi-structured interviews and 48 in in-depth studies. In 

addition 178 key informants were interviewed 

Table 1: Categories and Number of Study Respondents 

Paarl Rietvlei Umlazi 

SEMI-STRUCTURED INTERVIEWS 

Total number of HIV+ Good Start mothers 

20 20 20 

interviewed 

Total number of HIV- Good Start mothers 

20 20 20 

interviewed 

Total number of unknown status non- Good 

20 20 18 

Start mothers interviewed 

Key Informant Interviews (Household 

60 60 58 

members) 

IN-DEPTH CASE STUDIES 

Number of maternal verbal autopsies 3 5 10 

Number of infant verbal autopsies 0 10 5 

Number of women with no ANC 

0 1 5 

(facility birth) 

Home births with ANC 2 5 3 

Home births no ANC 2 3 2 

Number of PMTCT mothers with no follow Facility Facility substudy 

0 

up/no infant HIV testing 

sub-study 

Total Number of Respondents per site 68 84 83 

Demographics of Study Respondents 

Table 2 shows the demographic data per site. The average age of the women interviewed (not 

household members) was similar across the sites i.e. between 25 and 27 years. The age of the 

majority of infants (born in last pregnancy) was between 10 and 34 months, with only 20-31% 

of infants less between 0 and 9 months of age. The mean age across sites was similar (Paarl 

14 months, Rietvlei 15 months and Umlazi 16 months, p=0.61). The number of years spent in 

school was slightly higher in Umlazi. In Paarl and Rietvlei the mean of the last standard 

passed was Standard 7 and in Umlazi it was Standard 8. However this difference was not 

significant. There were significantly more single women in Umlazi (81%) than at the other two 

sites (Paarl (69%) and Rietvlei (51%). 


Table 2: Demographic Data 

Average age of mothers across the sites 


Mean 24.97 25.41 26.84 

Std Dev 5.88 6.24 7.36 

# % # % # % 

Age of infants at time of interview 

0 - 4 months 7 (12) 6 (12) 3 (7) 

5 - 9 months 11 (19) 7 (14) 6 (13) 

10 -18 months 18 (31) 24 (48) 18 (39) 

19 - 34 months 22 (38) 13 (26) 19 (41) 

Mean of the last standard of education passed across sites 

Mean 7.65 7.48 8.27 

Std Dev 2.24 2.37 2.11 

Marital Status 

Single, Divorced, Widowed 45 (69) 39 (51) 58 (81) 

Married, Co-habitating 20 (31) 37 (49) 14 (19) 

Total Number 65 76 72 

(n = 213) 

Socio-economic Status 

The results for a number of socio-economic variables show that participants from Rietvlei have 

significantly poorer resources than those in Paarl and Umlazi. As can be seen in Graph 1, forty 

two percent (42%) of the participants in Rietvlei get their household water from rivers or 

streams. In contrast 91% of the participants in Paarl and 80% in Umlazi have piped water 

inside their houses or yards. Also in Rietvlei 95% of the participants had pit latrines while 92% 

of the participants in Paarl and 52% in Umlazi had flush toilets. In addition 66% of the 

participants from Rietvlei use wood as their main cooking fuel whilst 74% in Umlazi and 53% in 

Paarl use electricity as their main cooking fuel. There were also large differences between the 

sites in terms households’ access to employment. In Paarl and Umlazi more than 70% of 

households had someone employed compared to 56% of households in Rietvlei (Appendix A1). 


Graph 1: Comparing Household Water Source at the Three Sites 

60 

50 

40 

Percentage 

30 

Piped-inside 

Piped-yard 

Piped-public 

River-stream 

Borehole/Well 

20 

10 

0 

Paarl Umlazi Rietvlei 

N=232 

Mode of Transport and Travelling Time to Health Facilities 

The information presented in this section was collected from all the women (i.e. 235), who 

participated in both semi-structured interviews and case studies. There were significant 

differences between the sites in terms of the mode of transport and the time needed to reach 

the health facilities (Appendix A3). Women in Rietvlei lived substantially longer distances away 

from both the clinics and the hospitals than in the other two sites. The mean distance to clinic 

for the respondents from Rietvlei was 48kms whilst in Paarl and Umlazi the mean distances 

were 18kms and 25kms respectively. More women walk to clinics in Paarl and Umlazi than in 

Rietvlei because the distances are shorter. The mean distance for respondents from the 

hospital in Rietvlei is 84 kms whilst in Paarl and Umlazi the mean distances are 32 kms and 35 

kms respectively. In all sites women predominantly use taxies or buses to get to the hospitals. 

Graph 2 shows the difference in travel times to the hospitals and clinics in each site. The 

average time to reach the hospital in Rietvlei (84 minutes, standard deviation 66 minutes) is of 

particular concern. 


Graph 2: Comparing Average Travel Times to the Nearest Clinic and Hospital from the 

Three Sites 

90 

80 

Minutes 

70 

60 

50 

40 

Paarl 

Umlazi 

Rietvlei 

30 

20 

10 

0 

Average time to clinic 

Average time to hospital 

N = 232 

4.2. SEMI-STRUCTURED HOUSEHOLD INTERVIEWS 

This section reviews the results from the semi-structured interviews conducted in the 

households with the women and a family member. The section is divided into three parts 

corresponding to the three primary study objectives. Information in this section was drawn from 

the 178 semi-structured interviews. 

SECTION 1: FACTORS ASSOCIATED WITH UTILISATION OF HEALTH SERVICES 

In order to examine factors associated with the utilisation of maternity and newborn services, a 

composite index was developed using the six items listed in Table 3. One point was allocated 

for each item with a score of 1, indicating better, and 0, poorer utilisation. A mean score was 

then derived, which indicated that Paarl had the best utilisation score and Rietvlei the lowest. 

The score was further dichotomised to =5, with >=5 indicating better utilisation of 

services. Paarl had the highest percentage of women (77%) with a score of at least five and 

Rietvlei the lowest at only 11%. 

It is encouraging to note that a high proportion of women across the three sites i.e. 100% in 

Paarl and 95% in Umlazi and Rietvlei attended antenatal care in all of their pregnancies. 

Similarly a high proportion of women delivered in a hospital or a clinic (95% in Umlazi, 92% in 

Paarl and 80% in Rietvlei). Family planning uptake also appears to be high across the sites. 

However, many women failed to comply with the first antenatal visit. Less than half of women 

in Umlazi and Rietvlei and slightly over half in Paarl had their first antenatal visit during the first 

trimester of pregnancy. With regard to postnatal health seeking behaviour, less than a third of 

women in Rietvlei brought their infants to a health centre prior to six weeks of age and less 

than a 25% of mothers had a postnatal check up within six weeks postpartum. 


Table 3: Utilisation Score 

Variable Paarl Rietvlei Umlazi Total 

# (%) # (%) # (%) # (%) 


Attended ANC in all 

60 (100) 57 (95) 55 (95) 172 (96) 

pregnancies 

Delivered in Hospital/Clinic for 55 (92) 48 (80) 55 (95) 158 (89) 

all pregnancies 


Began ANC in months 0-4 34 (57) 20 (34) 26 (46) 80 (46) 

1 st infant follow-up visit prior to 56 (93) 16 (27) 48 (84) 120 (68) 

6 weeks of age 

1 st maternal follow-up visit 55 (92) 10 (18) 21 (38) 86 (49) 

prior to 6 weeks post-delivery 

Currently using Family 

Planning 

47 (78) 43 (73) 47 (89) 137 (80) 

Mean Utilisation Score (1 

point for each of above) 

5.1 

(SD=0.85) 

3.3 

(SD=1.1) 

4.5 

(SD=0.82) 

P-value 

(comparing mean 

differences)=0.00 

Utilisation Score >=5 46 (77) 6 (11) 26 (54) 78 (47) 

P=0.00 

Individual factors associated with high utilisation were also examined (Appendix A4). Women 

who were younger and single were more likely to have higher utilisation, possibly because they 

were seeking support or guidance from health professionals. Having someone employed in the 

household also increased utilisation, although average monthly income and other individual 

items related to socio-economic status were not associated with utilisation score. Living closer 

to the clinic or hospital; not having transport, financial and employment barriers to attending 

ANC or getting to the hospital also contributed to higher utilisation. 

Treatment of respondents by health staff was associated with service utilisation but showed 

somewhat inconsistent results. Poor treatment by health staff was listed as a barrier to ANC by 

only 3% of women. However, 48% of the women who did not cite poor treatment by health staff 

as a barrier to care were more likely to have an utilisation score of >=5. Fifteen percent (15%) 

of the women said friendly staff or nurses were a promoter of ANC attendance, but this was not 

significantly associated with higher utilisation score. Mixed treatment (both positive and 

negative) by health staff during ANC was associated with higher utilisation, but none of the 

measures of satisfaction with care were associated with utilisation. Paradoxically, women who 

cited not being able to always follow health advice had higher utilisation scores. This could be 

explained by the fact that these women were frequent attendees, which gave women more 

opportunities to receive advice they could not follow. Neither pregnancy problems, nor HIV 

status were associated with utilisation. 

Finally, and perhaps most importantly, being told by a family member or friend to attend ANC; 

being told by health staff to return for care after delivery; and health staff discussing family 

planning after delivery were all associated with higher utilisation. These factors indicate that 

support and information from family and health staff may be able to improve attendance to 

maternity and newborn services. There was a positive correlation between the importance that 


household members gave to women's health and women's utilisation of services. Interestingly, 

99% of household members felt women should attend ANC; that the family should make sure 

the woman attends ANC; and women should deliver in a health facility, so these questions 

were not predictive of utilisation due to lack of variability. 

Similar to the overall utilisation score, support items, along with distance to clinic were 

significantly associated with individual utilisation factors such as ANC attendance, and 

postpartum newborn and maternal care and family planning (data not shown). 

Barriers and Promoters to attending ANC: In Paarl 27%, in Umlazi 28% and in Rietvlei 38% 

of the women indicated they had problems attending antenatal care. A lack of money for 

transport was the barrier most cited by women. Although money was listed as the biggest 

barrier to care, having money did not significantly promote ANC attendance. Support of family 

and friends was the strongest promoter of ANC attendance. This support varied from 

encouragement to assistance with transport and money. Eleven to fifteen percent (11-15%) of 

the women cited friendly staff and good quality care as promoters of ANC attendance. 

(Appendices A5 and A6). 

Why didn't you go to ANC earlier? The two main reasons for not starting ANC as scheduled 

were: firstly the long distances to the health facility and secondarily pregnant women felt fine so 

they thought it was alright to access ANC services later in her pregnancy. The proportion of 

women who cited the latter reason was substantially higher in Rietvlei (61%) compared to 14% 

in Umlazi and none in Paarl. It was interesting to note that the long distance to the clinic (cited 

by 28% of the women) and lack of money for transport (cited by 11% of the women) were the 

two most mentioned reasons in Paarl, even though geographically women in Paarl live closest 

to the clinics. (Appendix A7) 

Pregnancy Histories, Family Planning and Immunisations: The total number of births 

recorded in the study women was 105 in Paarl, 135 in Rietvlei and 122 in Umlazi. The average 

parity was 1.75 in Paarl, 2.25 in Rietvlei and 2.10 in Umlazi. There were more women with only 

one pregnancy in Paarl (53% of women vs. 18% in Rietvlei and 41% in Umlazi), while Rietvlei 

had more women with parity >=5 (7% in Rietvlei vs. 2% in Paarl and 5% in Umlazi). 

Complications were recalled by women in 28% - 38% of the pregnancies (Appendix A8). 

Hypertension, bleeding and infection were the most commonly cited complications (data not 

shown). Caesarean delivery was substantially higher in Umlazi (34% compared to 14% in 

Paarl and 25% in Rietvlei, p=0.002). Women working in either regular or irregular employment 

during their last pregnancy was higher in Paarl (35%) compared with 15% in Rietvlei and 28% 

in Umlazi (p=0.04). This is consistent with other socio-demographic trends described earlier. 

Responses to no antenatal care, home births and no skilled attendant at birth were low in all 

sites (Appendix A8) Interestingly current use of family planning was high in all three sites. 

Depo-Provera Injection as was the most commonly used method (Appendix A9). While 

maternity services and family planning utilisation were similar across sites, the level of 

complete immunisation coverage for age was substantially different. Rietvlei had the lowest 

percentage (16%) of children fully immunised while Paarl and Umlazi 71% and 57%, 

respectively (p=0.000). Although the numbers are small, there is a clear trend across all three 

sites for lower complete immunisation coverage in older children compared to younger children 

(Appendix A10). 


SECTION 2: LEVELS OF AWARENESS OF RISK FACTORS AND SOURCES OF HEALTH 

INFORMATION 

2.1. Levels of Awareness of Risk Factors 

ANC and Delivery: Seventy five percent (75%) of the women interviewed knew that 

hypertension and oedema were risk factors. Between 50% and 74% of the women knew that 

decreased foetal movement and bleeding were risk factors, whereas less than 20% were 

aware that a loss of consciousness, anaemia, shortness of breath and a chronic cough were 

risk factors. Twelve percent of women were not aware of any warning signs in pregnancy. 

Women on average were only aware of 8 out of the 23 possible signs on the list. (Appendix 

A14) 

Postpartum - Maternal Risk Factors: Seventy five percent (75%) of the women interviewed 

knew that bleeding was a risk factor. Between 50% and 74% knew that abdominal pain and a 

loss of weight were risk factors. Less than 20% knew that seizures, loss of consciousness, 

anaemia, shortness of breath and a chronic cough were risk factors. Thirteen percent of 

women were not aware of any warning signs associated with postpartum. Women could only 

identify an average of 6 out of the 18 possible signs on the list. (Appendix A15) 

Infant Risk Factors: More than 75% of the women interviewed knew that chronic diarrhoea 

was a risk factor. Between 50% and 57% knew that an umbilical infection and inability to feed 

were risk factors. Less than 20% knew that seizures and a loss of consciousness were risk 

factors. Eight percent of women were not aware of any warning signs in infants. Women could 

only identify an average of 8 of the 18 possible signs on the list. (Appendix A16) 

Household Members – Knowledge of risk factors associated with pregnancy and birth: 

More than 75% of the household members interviewed knew that hypertension and oedema 

were a risk factor. Between 50 % and 74% knew that bleeding was a risk factor. Less than 

20% knew that a poor outcome for a previous pregnancy’ seizures, chronic cough, multiple 

pregnancy, obstructed labour, incision infection and mastitis were risk factors. Four percent of 

household members were not aware of any warning signs in pregnancy, birth or in the first 

month after birth, and household members only knew an average of 8 of the 27 possible signs 

on the list. (Appendix A17). 

2.2. Sources of Health Information 

Where did you learn about problems or warning signs in pregnancy? Almost three 

quarters of mothers learned about warning signs in pregnancy from either the clinic or the 

hospital, suggesting that health care providers are the single biggest source of information 

related to pregnancy risks. In Paarl and Umlazi a quarter of the women interviewed also got 

information from friends or other people. When asked "What should a woman do if she has 

any of these health problems or warning signs?" Ninety eight percent (98%) of women replied 

that the woman should go to a clinic, hospital or doctor to be seen. None of the women 

suggested seeing a traditional healer or traditional birth attendant. (Appendix A11) 

Sources of Health Information on Pregnancy: As can be seen in Graph 3 and Appendix 

A12, the predominant source of information on pregnancy risks at each of the three sites was 

the health workers. This varied from 98% at Rietvlei, to 90% at Umlazi and 85% at Paarl. It is 

interesting to note that Rietvlei as the most rural area relied most heavily on health workers as 


a source of information. CHWs were not a significant source of information on pregnancy risks 

in the three sites. 

With regard to public media, radio was the most cited source of health information (36% in 

Paarl, 42% in Rietvlei and 59% in Umlazi) compared to a much lower percentage for TV and 

newspaper. See graph 3 and Appendix A12. In fact radio was the second overall most popular 

source of information after health workers. This suggests that public media campaigns should 

consider radio as a primary outlet for dissemination of health messages. Radio stations 

listened to were primarily local stations, UKF in Umlazi and Rietvlei and UMWF in Paarl, rather 

than national stations such as SAFM. For television stations, most respondents cited SABC1 

or 2. 

Best Source of Advice for Making Decisions about Health 

Women were also asked which of the above sources of health information provided the "most 

important or best advice for making decisions about health". Once again health workers were 

the first choice, with 63% in Paarl, 92% in Rietvlei and 72% in Umlazi of the women mentioning 

health workers as the best source of health information. Radio was listed as a second choice 

in both Rietvlei and Umlazi, while family members were listed as the second choice in Paarl 

(Appendix A13). 

Graph 3: Sources of Health Information on Pregnancy by Site 

120 

100 

80 

60 

40 

Health Worker 

CHW 

Family 

Friend 

Radio 

TV 

Newspaper/Magazin 

e 

20 

0 


It was interesting to note that Paarl had the lowest percentage of women who mentioned health 

workers as a source of information and the highest reliance on family and friends. This 

correlated with the lowest knowledge of risk factors of the three sites. 


SECTION 3: HEALTH SEEKING BEHAVIOUR OF HIV-POSITIVE AND HIV-NEGATIVE 

WOMEN 

Utilisation by HIV Status 

There was no statistical difference (at alpha 0.10) in any of the utilisation variables, mean 

utilisation score, or percent with a utilisation score of >=5 between mothers who were HIVpositive 

and HIV-negative. There were also no differences in mean number of postpartum 

visits (4 vs. 3, p=0.17) as shown in Appendix A18. 

Complete immunisation of children for age was similar across HIV-positive and HIV-negative 

women in Paarl and Rietvlei but significantly lower in children of HIV-positive women in Umlazi 

(19% vs. 82%, p=0.0003). This latter finding is concerning, and further investigation to confirm 

these results should be considered. (Appendix A19). 

Quality of Care by HIV Status 

HIV-positive and HIV-negative women reported a similar quality of care rendered by both the 

clinic and hospital. However, staff was more likely to discuss HIV and AIDS with HIV-positive 

women. However, HIV-positive women perception was that they received less privacy during 

ANC than HIV-negative women. Staff was more likely to ask HIV-positive women to attend 

post-partum care after birth (Appendix A 20). 

Disclosure was substantially covered in the Good Start Cohort Study, and only 2 of the women 

with unknown HIV status in this study were willing to discuss HIV with the interviewers. From 

the cohort study 69% of women in Paarl, 30% of women in Rietvlei and 48% of women in 

Umlazi had disclosed their HIV status to someone by the time of the initial interview. 9 

SECTION 4: FAMILY INVOLVEMENT IN PREGNANCY, BIRTH AND CARE OF INFANT 

Finally we examined family involvement during pregnancy, birth and care of infant. Appendices 

A21 - A26 summarise results from both the mother and household member questionnaires that 

related to family involvement. The extended family members did seem to be involved in 

pregnancy and infant care. Fewer were involved in birth, but many women and family 

members desired more participation during labour and birth, particularly in Paarl (Appendices 

A22 - A24). Encouragement and responsibility of family members to make sure a woman gets 

to ANC were very high (Appendix A 21 and A 23) and as noted above being advised by family 

members to attend ANC was a significant predictor of overall utilisation (Appendix A4). Overall, 

it appeared that Paarl had the highest level of family participation across the three sites. This 

correlated with earlier data which showed a higher reliance compared with the other two sites 

on family and friends for health information. 

SECTION 5: DISCUSSION AND CONCLUSION 

There were some similarities and differences across the three study sites. As seen in other 

studies, Rietvlei represented the most poorly resourced area, and except for family planning, 

had lower utilisation for the majority of indicators. However, with regard to health knowledge, 

Paarl scored the lowest. Paarl also showed a higher reliance on family and friends for health 

information than the other two sites, although across all three sites health workers were both 

the major source of health information and the source considered to give the best advice for 

making health decisions. Despite Paarl women having lower knowledge, it is clear that rural 

under-resourced sites like Rietvlei are in a more critical need of support from National and 


Provincial governments to improve health infrastructure and quality of care. Lack of service 

delivery is a critical problem in these areas and should be a priority for future strategic plans. 

The strongest predictors of utilisation of maternal and infant services were distance to the 

clinic/hospital and availability of transport, along with whether the hospital staff advised a 

woman to return for postpartum care. While long distances to the health facility and lack of 

transport are difficult problems to tackle, having health staff that are mindful of reminding a 

woman to come for postpartum care is a simple intervention that could improve postpartum 

clinic attendance. The strongest promoter of attendance at ANC was the support of family and 

friends. We therefore need to encourage families to support women, to draw on this potential 

for improving the health of women and infants. 

One final concern is the high rates of complications and extremely high rates of caesarean 

delivery found in Umlazi. Umlazi also had a significantly higher maternal mortality than the 

other two sites in the Good Start Cohort Study. 7 While the majority of these deaths are HIV 

and AIDS related, there were still quality of care issues in this site. In addition, the maternal 

viral loads (i.e. an indicator of HIV and AIDS disease severity) were not higher in Umlazi 7 

suggesting that HIV and AIDS is not necessarily the explanation for the higher mortality rates 

found in this site. Further research is needed in Umlazi to identify why the maternal mortality is 

much higher compared to the other two sites. 


4.3. QUALITATIVE RESULTS 

In this section the results of the sub-samples of women/households which were identified to 

examine particular cases of interest are presented. The reviews of the particular cases of 

interest are discussed separately. 

SECTION 1: 

NO ANC ATTENDANCE AND HOME BIRTH REVIEW 

Methods 

Twenty three women were interviewed using a qualitative case-study design. Six of these 

women received no ANC in their last pregnancy, ten had home births with ANC and seven had 

home births with no ANC. Trained fieldworkers conducted the interviews which occurred in the 

homes of the participants. 

The data collection tool included selected demographics which were collected in the Good Start 

Study. Participants also responded to a number of in-depth questions about antenatal and 

maternity services. These included women’s experiences of ANC in the last pregnancy; the 

barriers experienced in accessing ANC services; a health seeking behaviour; danger or 

warning signs of a problem during pregnancy or birth; women’s experiences of labour and the 

barriers to accessing maternity services during labour. 

The interviews were conducted in the preferred language of the informant and answers 

recorded on the interview schedule. Interview responses were reviewed by two investigators 

and grouped into health systems and community/individual barriers to accessing either 

antenatal or maternity services. 

Results 

Description of Study Participants 

No ANC Attendance: The women’s ages ranged from 18 to 42 with a median of 24. The 

number of pregnancies of the 12 women varied from one to eight. The mean number of 

pregnancies was 2.67, the median two and the mode one. 

Home Births: The women’s ages ranged from 19 to 42 with a median of 28 years. The 

number of pregnancies of the 18 women varied from one to eight. The mean number of 

pregnancies was three and both the mode and the median was two. 

Barriers to Accessing ANC and Maternity Services 

A number of factors contributed to women at all three sites not attending ANC and delivering at 

home. Although these factors overlap, considerably differences exist and these will be 

considered separately. For clarity, the factors contributing to no ANC attendance and 

delivering at home will be considered under two main themes, health systems issues and 

community or individual issues. However, many of the women interviewed described more 

than one barrier which prevented them from accessing either antenatal or maternity services. 


NO ANC ATTENDANCE 

The most commonly reported barrier to accessing ANC was a lack of money. The second 

barrier was fear of that the family would find out that a woman was pregnant. The last barrier 

was lack of realisation by the woman that she was pregnant. 

Health Systems Issues 

Accessibility of health services: Access to the health service was a problem particularly for a 

number of women in Rietvlei. The clinic was too far from the women’s homes to walk to. As 

can be seen from the quantitative data the average time to reach a clinic was 48 minutes. 

Limited financial resources further exacerbated this problem for some of the women. 

For school girls clinic services are not accessible as they are not allowed to miss school in the 

morning and cannot access ANC services in the afternoon due to the chronic problem of clinics 

not attending to patients after lunch. 

Attitude of nurses: A couple of women in Rietvlei said that the positive attitude of the nurses 

was motivating and encouraged them to attend ANC. One woman remarked that: 

“The friendly nurses motivate me, and make me happy, so I am always keen to go back.” 

However a woman from Paarl said: 

“they don’t know [how] to speak to a person, they are rude and they hurt your feeling[s].” 

She attended her first ANC visit at 7 months where the staff: 

“treat(ed) me very badly, they shouted at me for coming late at 7 months.” 

Both young mothers and those who had had multiple pregnancies complained about the 

attitude of the nurses. One mother said: 

“sometimes when a woman goes to the clinic and has had many babies before, 

the nurses will scold her and ask why she’s still getting pregnant.” 

This annoyed her to such an extent that when she felt ill during her pregnancy she resorted to 

traditional medicines. 

Community / Individual Issues 

Limited financial resources: A number of women stated that a limited financial resource was 

a key constraint in affording public transport to antenatal services. The financial vulnerability 

of many women was confirmed by a woman who needed to travel on a taxi for an hour to get to 

the clinic. She asked the father of the child for money to attend ANC, but he refused saying 

that he did not ‘tell’ her to fall pregnant. 

Influence of family members: The influence of family members on pregnant women 

attending ANC appears to be considerable. The influence was always positive. Of the 13 

women interviewed all except one were given information by a female relative. The male who 


advised that the mother of his child go for ANC advised her to attend ANC so that she would 

not be shouted at by the nurses in the labour ward. He had heard that nurses in the labour 

ward shout at women who have not attended ANC. 

Family responsibilities: One woman from Rietvlei had to walk for an hour to get to the clinic 

for ANC. However, she did not perceive this as a barrier to accessing ANC. Her problem was 

that unless her mother was around to look after the other children, she could not go. 

Women don’t realise they are pregnant: A number of women stated that the reason they did 

not access antenatal services was because they did not realise they were pregnant. Although 

this is understandable in the first trimester, it is surprising that women can be pregnant for nine 

months and not realise this. One woman described how her monthly bleeding was affected by 

the injectable contraceptive she used. As a result, she did not realise when the monthly 

bleeding stopped that she was in fact pregnant. She was angry that the nurses at the clinic did 

not realise she was pregnant and gave her a further contraceptive injection during pregnancy. 

Another woman stated that she only realised she was pregnant when her waters broke. 

Stigma: A number of women cited fear of their family or community knowing they were 

pregnant as a reason for not going to ANC. One woman stated: 

“The neighbours like to gossip.” 

Time off work: One woman was not able to go to the clinic due to her inflexible working 

schedule. However she did go to a private general practitioner, but at the hospital was still 

classified as not booked because she did not have a clinic card. 

HOME BIRTHS 

Although the barriers to accessing maternity services were similar to those described for 

antenatal care, there were some significant differences. For many women accessing transport 

to the facility was a barrier, as was the attitude and behaviour of the nurses and a failure to 

recognise the initial signs of labour. These barriers overlap so that a woman who does not 

recognise the onset of labour will have less time available to access transport. 

Health Systems Issues 

Transport: For the majority of women the unavailability of transport to the hospital was the 

reason for a home delivery. Many of these women delivered at night, and by the time transport 

had been located they had already delivered. One woman described how her labour had 

started in the middle of the night. In the light of the morning she sent her son out to find 

transport, but by the time he managed to find transport, the baby had been born. A second 

woman described how when her labour started she walked the 45 minutes to the hospital 

because there was no transport. However, she was unable to get to the ward in time and 

landed up delivering in the hospital yard with no assistance as she was not seen. Later when 

seen by hospital staff she was taken to the ward with the baby and the cord was cut. 

The availability of transport is often dependent on money. The cost of transport in the middle of 

the night is beyond the means of many families. A woman in Paarl described how she went 

into labour, but didn’t have the money to pay for a car to take her to the hospital. As she waited 

for the ambulance she delivered her baby, with the assistance of her neighbours. 


Attitude of nurses: Only one woman chose to give birth at home. Her choice was motivated 

by her fear of the nurses: 

“they ill treat women”. 

She delivered at home being ‘attended’ by her two children aged eight and ten years 

respectively. After she delivered the infant, she sent the children to call a traditional birth 

attendant who helped her deliver the placenta and cut the cord. She stated emphatically that if 

she were to fall pregnant again she would again choose to deliver at home. 

Failure of nurses to recognise labour: Two women went to the clinic in early labour. The 

nurses failed to recognise the onset of labour and sent the women home. The first delivered 

her baby shortly afterwards, with only her three children present. The second delivered her 

baby in the car on the way to the hospital. A third woman described how she went to her local 

clinic believing she was in labour. She was not attended to because staff was attending a baby 

competition function. On returning home she delivered. 

Community/Individual Issues 

Fear of: 

Unanticipated problems in labour: Interviews indicate that of the 17 women who delivered at 

home only one chose to deliver at home. Fear of complications during labour was the reason 

given by many women for choosing to deliver in hospital. One mother who delivered at home 

stated: 

“…it is dangerous and risky at home, you always pray your child is not a 

breech and that you manage to take out the placenta…” 

Many women were aware of the complications that can develop in labour and this contributed 

to their fear about delivering at home. One woman, anxious that either she or her baby might 

die if she delivered at home said: 

“I thought about the fact nobody would assist me at home, 

therefore I had to overcome my fears and go to the hospital.” 

Besides a breech presentation and retention of the placenta complications, other reasons given 

for choosing a hospital birth included a previous caesarean section, pregnancy induced 

hypertension, having twins and a probability of the newborn developing complications. 

Hospital nurses: Fear of the nurses in the maternity ward was a reason many women gave 

for attending ANC: 

“It is difficult to have your baby in the hospital if you do not have a clinic card.” 

One woman even went as far as saying that it was difficult to get a RTHC for your baby if you 

did not attend ANC. 

Family responsibilities: A number of women described being home with only children 

present when labour started. It is unclear whether they delayed leaving home out of concern for 

the children and thus ended up having a home birth. However, one woman stated that she 

could not go to the hospital to deliver as her children would have been left alone. She also 

delayed going to the clinic postnatally, and only went a month after delivery due to the severity 

of the pain she was experiencing in her nipples. 


Failure of the pregnant woman to recognise labour signs: A number of women did not 

recognise the onset of labour. One woman described how she had back pain and went into 

labour during the day when all adults were working in the fields and only children were at 

home. She had to deliver the baby alone and cut the cord. She did not think that the back 

pains were labour pains, as she had not reached her expected delivery date. Some women 

failed to recognise the onset of labour if labour pain started before her due date. 

Rapid progression of labour: For a number of women, particularly those who had had 

multiple pregnancies, labour progressed so rapidly that there was no time to get to a facility to 

deliver. One woman described how she woke up when her waters broke and within 45 minutes 

the baby was born. She believed that the traditional medicines she took during pregnancy 

resulted in her labour being shorter. 

How were barriers for ANC attendance overcome for delivery? A number of women who 

did not attend ANC described why they were able to access maternity services for delivery. 

One woman stated: 

“When labour started the pains were so severe “I forgot I did 

not attend ANC. I just wanted to go there and deliver the baby.” 

A couple of women said that although they were afraid of the nurses in the maternity ward as 

they had not attended ANC, they were more afraid of labour and of something going wrong. 

Another woman said that she had had a caesarean section for her first delivery, because of 

cephalo-pelvic disproportion. She was told at this time that if she had another child she would 

have to have a caesarean section again, so she knew she just had to get to the hospital. 

Conclusion 

There are a number of barriers to accessing both antenatal and maternity services. In many 

cases multiple reasons for not attending antenatal or maternity services were given. It can be 

seen that the existence of one barrier resulted in second on third barriers. It is concerning to 

note a substantial number of home deliveries which took place with only children present. 

Recommendations made by the participants will be included in the section on 

recommendations at the end of this report. 


SECTION 2: 

MATERNAL DEATH REVIEW 

Methods 

Using a qualitative case-study design we reviewed 18 maternal deaths: Three from Paarl, five 

from Rietvlei and ten from Umlazi. The deaths in Paarl were all from the Good Start study. 

Two of the deaths in Rietvlei were of mothers from the Good Start study and a further three 

were identified either from the hospital register or by CHWs. In Umlazi, five of the 14 deaths of 

mothers from the Good Start study were selected for review, along with five of 11 other 

maternal deaths identified from the hospital delivery register in 2004. In Paarl and Rietvlei the 

deaths represent the maternal deaths identified in those study areas in the last two years. In 

Umlazi both groups represent only a sample of the total deaths as noted above (Good Start 

and non-Good Start). The maternal deaths in Umlazi were purposely sampled to represent 

earlier deaths (true maternal deaths prior to 8 weeks postpartum) and more recent deaths to 

reduce potential recall bias on the part of the informant. 

All interviews were conducted by a registered midwife. The interviews were both semistructured 

and qualitative and were conducted in the homes of the informants. The informants 

had all been present in the household at the time of the maternal death, and in most cases 

were caregivers of the mother at the time of death. The informants were 4 husband/partner, 4 

mothers and 4 sisters of the deceased women. Others included the aunts or other relatives. 

The interviews were conducted between one and 27 months after the death of the mother 

(mean 11 months). 

The data collection tool was modified from a WHO “Maternal Death Verbal Autopsy Tool” 

originally developed for use in Ghana and recommended in the Beyond the Numbers Report. 10 

The tool includes selected demographic data as collected in the Good Start Study as well as 

Background, Account of death, Symptoms, ANC, Delivery, Postpartum care and Health 

Seeking Behaviour sections from the Beyond the Numbers Report adapted for local use. The 

interviews were conducted in the preferred language of the informant and answers recorded on 

the interview schedule. Interviews were reviewed by two investigators (one advanced midwife 

and one perinatal epidemiologist/nurse) for causes of death, health seeking behaviour, and 

content theme analysis from qualitative descriptions of events surrounding death. 

Reliability and validity issues were taken into consideration and these included but were not 

limited to the following: 

• Consent agreement were signed by interviewee and interviewer 

• The Instrument was derived from the literature and ‘pilot tested’ before the final study 

was conducted 

• Interviewers were trained and to ensure familiarity with the subject content 

• Data was reviewed by two different experts who did not participate in conducting 

interviews. 

Results 

Description of Cases 

The ages of the mothers ranged from 22 to 39 (mean age 28). Half of the women were single 

and 28% were cohabiting. All women who died had above a standard 4 education. Seven 

(39%) of the households had a member with regular employment, six (33%) relied on a state 

pension and/or child support grant, with the remainder having no regular source of income. 

The mothers lived between 20 and 120 minutes from the nearest hospital (mean 42 minutes). 

Four of the women were left by their partners when they became ill. During their illness the 


majority of the women (72%) were cared for by female relatives (either by mothers, sisters or 

aunts). Five of the deaths (28%) occurred in women who were having their first pregnancy. 

The age of half of the women who died was known and of these only one fell outside the 

reproductive years (39 years), if South African criteria are used. Most of the pregnancies were 

full term. The demographic profiles were similar to those found in these study sites previously. 7 

Causes of Death 

Generally causes of death fell into 3 categories: 

• AIDS related - 12 (67%) 

• Other non-pregnancy related infection - 3 (16.5%) 

• Direct perinatal causes - 3 (16.5%) 

Deaths were classified as AIDS-related if women were known to be HIV-positive and/or had 

classic symptoms of AIDS (weight loss, chronic diarrhoea, loss of appetite, chronic cough, TB, 

oral lesions, confusion, unable to care for self). There was one known HIV-positive woman 

who died of an acute infection and one woman with chronic diarrhoea with unknown HIV status 

who were also classified as AIDS-related deaths. All but two of these 12 women were no 

longer able to care for themselves at the time of death. 

The women with other non-pregnancy related infections all died with symptoms suggesting 

infection, which lasted one week or less but did not appear to be directly related to pregnancy. 

The HIV serological status of these women was unknown. 

Finally, the direct perinatal causes included placenta praevia with postpartum haemorrhage, 

possible anaesthetic accident and post-partum/perinatal infection. This last case also 

appeared to involve potential negligence as the woman had had two prior caesarean sections 

and was admitted to the hospital in labour but not delivered (by caesarean section) until two 

days later. 

In five of the cases a death certificate was available for review. One stated AIDS, one TB and 

the other three "Natural Causes". 

Time of Death 

All but one mother died post-partum. The only woman who died in the antenatal period was 

five months pregnant with probable AIDS-related symptoms of chronic diarrhoea, weight loss, 

etc. The time of the postpartum deaths ranged from five hours to nine months, with a median of 

one month. It must be noted that the deaths of women involved in the Good Start study in 

Umlazi were selected to favour earlier rather than later postpartum deaths. 

The women with an AIDS-related death had been ill between one week and 12 months, with 

the majority having been ill for more than three months, and a median of 4.5 months of illness 

prior to death. The other two categories died from a few hours to one month after onset of 

illness. All but one died within a week. The woman who died at one month was a likely 

anaesthetic accident who never woke up post-caesarean section and died after one month in a 

coma. 

Place of Death and Availability Transport 

Twelve of the eighteen deaths occurred in a hospital or hospice setting. Four occurred at home 

as they had left the health facility to "die at home". Two deaths occurred on the way to the 

hospital. One was an AIDS-related death who had been in and out of the hospital repeatedly. 


There was no delay from the time of the decision to take her to hospital again and accessing 

transport to the hospital, but she died on the way. 

The other woman who was dead on arrival (DOA) appeared to be indirectly related to transport 

and directly related to the lack of skilled delivery attendant and Basic Emergency Obstetric 

Care in a home birth situation. She died from PPH/Retained Placenta in a gravida five while 

delivering twins at home in Umzimkulu. Although the retained placenta was identified 

immediately by the TBA and husband (himself a Sangoma), he was unable initially to get 

transport to take her to the hospital due to bad weather. Eventually he paid R800 for transport 

which took one hour to reach the hospital, during which time the woman died. In addition to the 

transport delay it was interesting that the husband blamed the TBA for not doing certain 

traditional practices, which he felt would have prevented/treated the retained placenta which 

contributed to his wife’s death. This strong commitment to traditional practices was not 

surprising considering he was a Sangoma himself. However, when a complication arose the 

family was not averse to seeking western medical attention. In this case, due to her strong 

traditional beliefs the woman was unlikely to have chosen a hospital delivery. 

Orphans 

Thirteen of the 18 mothers who died left orphans who were being cared for mostly by 

grandmothers or aunts. None of the infants were being cared for by their fathers. One of the 

infants was sickly, the rest were recorded as being healthy. 

Health Seeking Behaviour 

The majority of women had sought heath care timeously. The women with chronic conditions 

had regular contact with the public health care system. Many also had had contact with private 

or traditional health systems or both, which the considered after failing to get better in the public 

health system. The number of providers seen ranged from one to four with an average of two. 

Four of the 12 (25%) of the AIDS-related deaths had sought treatment from a traditional healer 

prior to their death. 

Delays in seeking health care by the woman or family was seen in only three cases. One was 

the home birth already described above. The second one was an AIDS-related death where 

the patient had to wait for two weeks for her mother to get paid so she could pay for her 

transport and health care before going to the hospital. It is unclear whether this delay 

contributed to the death of this patient who appeared to be in her final stages of her illness. 

Finally, in a woman with postpartum infection (dyspnoea, swelling and finally confusion and 

disorientation) whose family delayed for two days after she became ill before returning her to 

the hospital. The family only acted when she became disoriented. This would in all probability 

be considered an avoidable factor as earlier treatment of the likely infection (e.g. respiratory) 

might have prevented death. 

It became apparent that most of the women with a chronic condition were aware of their HIV 

status and were in regular contact with the health system. However, they were reluctant to 

involve the family in their illness. Although some women had AIDS related ‘warning signs’ 

including being on TB treatment before falling pregnant, they did not appear to take steps to 

avoid falling pregnant. 


Themes 

Hospice 

All three of the Paarl deaths which were AIDS-related died in the local hospice or had been 

admitted to a hospice during the time of their illness. Hospice was not mentioned in either of 

the other sites, although one mother in Rietvlei was described as having been admitted to a ‘TB 

hospital’ in a distant town. In most cases the families were left to care for the women. The 

burden placed on families by the lack of a hospice and home-based care is a major concern. 

One family member alluded to this: 

“…she was not properly fed, on the day of her death, she was lying on the floor…at her house 

she was left alone, her children and partner were not there. She could have lived longer with 

proper care. Many people I know who are HIV positive are still alive and looking well”. 

Blaming the Hospital for Death 

In five of the deaths the family members blamed the hospital/health staff for the woman's death. 

Sometimes this was direct, for example one mother blamed the death of her daughter on a 

‘injection’ she got postpartum after which she became disoriented: 

“…unfortunately, the injection knocked her off and she did not wake up 

thereafter, until she was confirmed dead”. 

One family blamed the hospital for a delay in the diagnosis and treatment of TB in the woman 

who died. They stated that the diagnosis of TB was made at another hospital far away but not 

at the local hospital where she was a regular patient. In another case the boyfriend blamed the 

hospital for allowing the woman to spend two days in labour when she had had two previous 

caesarean sections: 

“The boyfriend is aggrieved that she died due to negligence from (hospital) doctors and nurses. 

He feels that she should not have been allowed to deliver vaginally, because they (health staff) 

knew that her previous delivery was caesarean section”. 

The hospitals were blamed for both a poor quality of care and a lack of communication with the 

family as noted in the next section. 

Poor Communication 

In the majority of cases very little, if any, information about the woman's illness and cause of 

death were given by health care providers to the family. Eleven of the families stated: ‘Nothing’ 

when they were asked what information they got from the health providers. This is concerning 

as in many cases the family was caring for the women at home after discharge or in-between 

hospital admissions. Lack of information and understanding led some families to blame the 

hospital. This leads to mistrust in the community and a lack of confidence in the health care 

system, which may result in delays in seeking care in the future. While the patient’s right to 

privacy is a concern, especially in the case of HIV, many of the women were disoriented and 

could not care for themselves. Frank discussion of the woman's condition, prognosis, and care 

needed with her family would have been appropriate. Guidelines to assist health care 

providers in this regard may be needed. 

Disclosure 

Disclosure of HIV status by women who were known HIV-positive to their family members was 

seen in five of 11 cases (45%). All three of the Paarl patients disclosed, while two of the six 


women from Umlazi (33%) and neither of the two women from Rietvlei disclosed. However, a 

nurse at Rietvlei hospital told one family that the reason the woman was dying was due to 

AIDS. The informant was very angry about this because it was done in front of "neighbours" 

and the privacy of the patient was compromised. 

Denial 

Interestingly denial of HIV was noted in two women. One woman before she died stated she 

did not believe she had HIV because: 

"HIV is contracted by people like sex workers or those that have many boyfriends". 

Another woman claimed she "was poisoned at work because other workers died from the 

same illness". 

‘Non verbal/ silent’ denial was also noted in cases when the deceased would have had AIDS 

related symptoms prior to current pregnancy or with a previous pregnancy. In one instance this 

led to a neonatal death from pneumonia that was never disclosed. In one case, the boyfriend 

blamed the health workers as the main contributor to death although the woman was a known 

HIV client who attended the local hospital regularly. 

Hopelessness 

Three informants described a loss of hope in the women before they died. Two refused to take 

medications, even traditional medications. One respondent stated: 

"She was reluctant to take medication given from hospital because she told us that she got 

AIDS and there is no cure." 

Women were even described as suicidal: 

“She also thinks that her sister would have committed suicide if she had means because she 

kept on telling the family that it was better to die because she had AIDS, hence she refused 

any sort of help given to her.” 

One of the women who refused to accept her HIV diagnosis decided to go home after being 

admitted for two weeks in the TB hospital. The family member stated that: 

"She could see that she won't make it and she wanted to die at home". 

This woman was also described as making preparations for her death and burial and the care 

of her children after her death. On the other hand, one woman described her feelings of guilt at 

being unable to take good care of her dying daughter: 

"In my heart she could have lived longer with proper care. Many people I know who are HIVpositive 

are still alive and looking well." 

Implications of both the hopelessness found in some women that led to non-compliance, but 

potentially an increasing recognition that HIV-positive patients can live and be healthy has 

implications for the roll-out of ARV therapy. 


Conclusion 

The majority of deaths in mothers in this study were due to AIDS-related causes. These 

deaths were accompanied by several months of chronic illness and deterioration in health 

status until the women were no longer able to take care of themselves. Most described poor 

health as starting during pregnancy or around the time of delivery, suggesting pregnancy may 

have contributed to further deterioration in health in HIV-positive women. Many of these deaths 

involved extensive care by family members and continuous health seeking to multiple providers 

during the course of the illness. However, family members received very little if any 

communication from health providers about the condition of the terminally ill woman or her 

care. Denial and/or hopelessness were seen in many of these cases. Interestingly 

hopelessness, denial and lack of disclosure were not seen in the cases in Paarl where hospice 

care was available and the health care and system has been previously described to be of a 

higher quality with more resources. 

Although the majority of deaths appeared to be HIV and AIDS related, there were still deaths 

due to direct obstetric causes. One involved patient related avoidable factors and in the other 

two, health provider avoidable factors. Care must be taken not to overlook basic maternity 

service quality in the face of an often overwhelming HIV and AIDS pandemic. 


SECTION 3: 

INFANT DEATH REVIEW 

Methods 

Using a qualitative case-study design, forty infant deaths were reviewed. The data collection 

tool was adapted from the WHO Infant Verbal Autopsy Tool 6 and incorporated aspects of the 

Matlab IMCI approach as well as approaches utilised in home interviews through the Foetal 

and Infant Mortality Review (FIMR) Programme in the United States. 11 In addition, a Neonatal 

Supplement was designed specifically to assess the experiences of mothers whose babies 

died shortly after birth without leaving the health facility. 

The objective of the infant death review was to investigate factors and barriers influencing the 

utilisation of health services and the level of awareness of risk factors associated with poor 

health outcomes among families with young children. To this end the data collection tool 

included selected demographic data as collected in the Good Start Study, 7 a comprehensive 

account of the context in which infant deaths occurred, motivations that lead to decisions, 

actions or non-actions on the part of families, and perspectives on factors that contribute to a 

breakdown in the public health system. 

Trained fieldworkers conducted the interviews which occurred in the homes of the participants. 

The interviews were conducted in the preferred language of the informant and answers 

recorded on the interview schedule. Interviewers were reviewed by two reviewers, a public 

health physician and a doctoral student doing work in the area of infant mortality to determine 

commonalities, themes, and critical issues. 

All infant deaths reviewed in this study originated from the Good Start Cohort Study. The 

sample consisted of 15 infant verbal autopsies conducted during April 2005 using the tool 

described above. The 10 infants were from Rietvlei and 5 were from Umlazi. In addition, verbal 

autopsies conducted previously in the Good Start Cohort Study using the original WHO Infant 

Verbal Autopsy Tool (un-revised) were also available and have been included where data 

available in sections of this review. Therefore, there were 40 home interviews conducted 

between August 2003 & April 2005 with mothers and caregivers (Paarl-4; Rietvlei-17; Umlazi- 

19). 

Results 

The mean age of the infants who died was 16.7 weeks, ranging from one day to 48 weeks. 

Three babies died under one week of age. Causes of death were primarily infectious diseases 

as shown in Table 4. 

Table 4: Age at death and Suspected Causes of Death in Infants 

• Child’s age at death: 

Less than 1 wk - 3 (8%) 

1- 4 weeks - 2 (5%) 

5 - 24 weeks - 26 (65%) 

25 - 48 weeks - 9 (23%) 

• Suspected causes of death: 

Gastro-intestinal Infection - 16 

Pneumonia - 15 

Prematurity - 2 

TB - 2 

Unknown - 2 

Sudden Infant Death Syndrome - 3 


Table 5: Maternal and Infant HIV Status Correlated with Infant Deaths 

Case # Maternal HIV Status Infant HIV Status 

PA-1 Positive Positive 


PA-3 Positive Unknown 


RT-1 Negative NA 

RT-2 Positive Positive 



RT-5 Positive Negative 

RT-6 Positive Unknown 





RT-11 Positive Negative 







UM-1 Positive Positive 


UM-3 Positive Unknown 

















20 

15 

10 

5 

0 

16 

HIV Status of Infant Deaths 

# per group in sample 

2 

18 

Infant HIV+ Infant HIV- Infant HIV 

Unk 

4 

NA 

(Mom HIV-) 


Maternal and infant HIV status for the 40 cases can be found in Table 5. The HIV status of 

many of the infants is unknown as they died before an HIV test was done. To place the above 

deaths in context - overall there were 75 infant deaths in the Good Start Cohort Study. Nine 

(9) month mortality rates in infants born to HIV-positive women was 10.1% while for those born 

to HIV-negative women it was 3.7% (p=0.003). The infant mortality rate in Rietvlei was also 

significantly higher than in Paarl and Umlazi (15.0% vs. 5.7%, p=0.000005). Infant feeding 

method (ever breastfeeding) was not predictive of infant death in the overall cohort study, but it 

was a significant predictor of late HIV transmission. 7 

This qualitative case-study design provides insight into some of the behavioural, structural, and 

systemic factors that played a role in the deaths of infants in the three sites that was not 

available in the Good Start Cohort Study analysis. 

Factors influencing utilisation of health services 

The results suggest that the utilisation of health services is related to socio-economic 

constraints; beliefs about the cause of illness; an awareness of when care is needed for the 

infant; and the quality of care available. The role of traditional healers is also significant. 

Socio-economic constraints: Some respondents reported that they were unable to take their 

child for health care services even though they realised the child needed it. This sometimes 

occurred because the child was sick in the evening when no transport was available or when 

no one was available to accompany them to a facility (i.e., the caregiver did not feel safe taking 

the child alone). Other respondents reported that they were unable to afford the cost of 

transport to a health facility. One mother in Rietvlei, for example, reported that although the 

local clinic had referred her baby to hospital to treat his dehydration, she didn’t have the money 

to take him there. Over the course of two weeks, she took the child back to the clinic several 

times for help, each time getting referred to hospital. Since this was not an option for her and 

since the child was not getting better, the mother eventually starting mixing the clinic medicines 

with traditional medicines. After three days of this treatment, the baby’s condition worsened and 

he died as they were taking him, once again, back to the clinic. 

Beliefs about the cause of illness: In other cases, beliefs about the cause of the infant’s 

illness sometimes determine whether or not the respondent feels health services are desirable. 

One respondent in Umlazi, for example, reported that her baby became sick at night and she 

was afraid to go to hospital alone in the dark. Her neighbours who heard the baby crying told 

her that there was nothing she could do for the baby because the cause of the illness was 

witchcraft (“Ishawe Yinyoni”). Because the mother then felt that witchcraft was responsible, she 

did not feel that she could send the baby for western medicine. When asked “what would have 

made things better or easier for you?” she stated that the child should have been taken to her 

father’s place to have the cultural ceremony in which the family burns the plant “Impepho” and 

the child is introduced to the ancestors. She also expressed her belief that if the baby had been 

taken to a traditional healer to fight witchcraft she would still be alive. This mother did not 

appear to believe that health services could have prevented the death. 

Lack of awareness of the danger signs for infants: Some mothers are not aware of the 

danger signs indicating their child needs medical attention. Several respondents reported that 

they did not realise the seriousness of their child’s condition until it had progressed to a very 

severe stage. One mother in Rietvlei, for example, reported that her baby vomited for three 

days before the baby’s grandmother decided to take her to a traditional healer for medicines. 

Another mother from Umlazi described how her baby became ill in the evening and, not 


ealising the seriousness of his condition, planned to take the child to a paediatrician in the 

morning. However, the baby died at three o’clock in the morning, before she was able to seek 

health care. 

It is possible that mothers are not being educated by health care providers attending them 

about danger signs to watch for at home. For example, a Rietvlei mother reported that her 

infant was treated at a clinic and then referred to hospital for his cough. This baby was admitted 

to the hospital for a week after which he was discharged and showed improvement. The next 

week, however, the baby started breathing very fast and died after a few days. She reported 

that she did not take him back to hospital because she thought the treatment the hospital had 

already given him would eventually cure him. Had she been instructed on the steps to take if 

the infant’s health deteriorated, it is possible that he would have been taken back to the 

hospital for additional care and could have survived this illness. 

Poor quality of care: The experiences reported by respondents suggest that the quality of 

care received in many instances was sub-standard. For example, some mothers who took their 

infants for care reported that they were sent home with paracetamol or electrolyte sachets 

when perhaps the infant should have been admitted. A mother in Rietvlei reported that she took 

her sick infant to hospital, was given medicine and then sent home. The child died at home 

later that day. In other cases, mothers recounted that their infants died on the way home after 

having been admitted and discharged from hospital. One Rietvlei mother recounted how her 

baby was discharged from hospital while still showing signs of weakness and a sunken 

fontanel. The baby fell asleep on the way home and when she arrived at home she realised the 

baby had died. Another Rietvlei mother reported that her child was admitted for three weeks 

with cough, vomiting and fever. The staff advised the mother to take the child home where she 

then died after two days. 

Some mothers reported taking their infants to a clinic but that the clinic did not have appropriate 

medication. When asked if they have any ideas “for how health care facilities and providers can 

better serve families…with sick infants,” several mothers suggested that it is of primary 

importance that clinics have enough stocks of medicines. One mother stated: 

“It is not nice to go to the clinic seeking help and you end up not getting that help you needed.” 

Another mother suggested that the most important thing needed to improve care is: 

“[i]f facilities could improve on the long hours people (sick people) endure before being 

attended [to].” 

One respondent stated that her baby got sick at night but that she could not get transport until 

the next morning. When they got to the health facility, they had to wait for several hours to be 

seen. By that time, her baby was already gravely ill. 

Many respondents reported that they did not know the cause of their infant’s death. This 

occurred even among some women whose infants had died in hospital. They reported that staff 

did not take the time to explain to them what happened, and they did not feel that they had the 

right to ask. These mothers expressed grave disappointment about their experiences with 

facility staff. For example, one mother who seemed to have accepted the fate of her baby (she 

believed that it was her baby’s death day – "kwase kufike usuku”) became very tearful when 

recounting how she had been treated at the facility. 


The role of traditional healers: In both Umlazi and Rietvlei a common theme from the indepth 

interviews was the desire to use and/or the actual use of traditional healers and 

traditional medicines. In Rietvlei this was quite often at the insistence of the mother-in-law. 

However, in nearly all cases the traditional medicine was sort only after they had been ‘failed’ 

by the formal health sector. For example, in at least three cases, the infant was taken to 

traditional healers after the clinic had informed them that it had no medicine. 

Other initial findings: 

• Sudden Infant Death Syndrome (SIDS) may have played a role in the deaths of at least two 

infants included in the study. In these cases, mothers reported seeing no warning signs 

that the child was ill at all prior to its death. 

• This initial analysis suggests that there are no differences between HIV- positive women 

and HIV-negative women with respect to their care-seeking behaviours for their infants. 

However, more research into this issue is needed. 

• To date, the only specific group that women identified as supportive to them is their local 

HIV Support Group. No mothers identified health staff as providing support to them. 

Several of the mothers whose infants died in hospital specifically stated that they received 

no grief counselling following the death. 

• Mothers reported mixed feelings being interviewed about the deaths of their children. Some 

mothers (especially those who had accepted the deaths of their children) said that it was 

fine and even helpful to participate in the interview. For example, one mother stated that 

“[i]t was a positive experience to share my story and to be visited by the study team.” A few 

others reported that they felt sad and tearful during the interview and it was therefore hard 

for them to recount their experiences. One mother stated that, “[I]t was difficult having to 

relate my experiences with you but I will be happy if I see changes occur [because of the 

study].” 

Conclusion 

These in-depth interviews made it possible to highlight the complex pathways and underlying 

mechanisms that precede the majority of infant deaths in high risk communities. Socioeconomic 

constraints, beliefs about the causes of illness and awareness of when care is 

needed all play a major role in both health seeking behaviour and the ability to access care 

when needed. 


SECTION 4: 

FACILITY BASED REVIEW OF PMTCT FOLLOW-UP SERVICES 

Methods 

Data collection methods consisted of semi-structured interviews with 16 respondents who were 

involved in the management and running of the PMTCT programme at either Paarl or Rietvlei. 

The respondents included sub-district HIV and AIDS Coordinators, PMTCT Coordinators, 

maternity matrons, maternity ward and PHC clinic staff. 

Results 

Voluntary Counselling and Testing 

Human Resources 

In Paarl, neither hospital nor clinic professional nurses were routinely trained in VCT. However, 

Paarl has lay counsellors who were trained by a private psychologist for a month. The 

counsellors were hired on a part-time basis and they usually worked in the mornings. Once a 

month, the counsellors receive emotional support from a psychologist in a four hour group 

session. In addition, the counsellors were supported, supervised and monitored by a local 

NGO. 

In Rietvlei all professional nurses were trained in VCT but staff turnover was a problem. For 

example, in the hospital, staff in the maternity ward had been trained, but due to staff rotation 

there were times when the maternity ward had no VCT trained professional nurses. Therefore, 

the demand for training was ongoing. Also Rietvlei had a two-week training for lay counsellors 

provided by VCT trainers from the sub-district. They had trained five lay counsellors for each 

facility who provided counselling services from 8h00– 6h00 on weekdays. The lay counsellors 

were supposed to be supported, supervised and monitored by the clinic sisters; however, the 

clinic sisters were neither informed of, nor skilled for, this role. In addition, lay counsellors 

remuneration through the District Municipality was problematic and the counsellors were last 

paid in 2003 (two years prior to this study). 

In order to address the challenges associated with the lay counsellors remuneration, 

community based activists (volunteers) who promoted VCT had recently been trained and 

started providing VCT services. However, Rietvlei still has a problem with supervision and 

monitoring these volunteers because the sub-district HIV and AIDS coordinator who is 

mandated to carry out these tasks is too busy to provide this support. 

Referral Pathway 

Paarl: The referral pathway was complicated because ANC services were not provided at the 

PHC clinics. Pregnant women were referred to the hospital Out-patient Department (OPD) for 

ANC. After delivery at the maternity facility in the hospital which is located at another venue, 

patients were discharged and asked to go back to the OPD for post-natal care. PMTCT clients 

were referred from the post-natal ward to another section of the OPD and eventually referred 

back to their local clinic. 

In spite of the complicated referral pathway described above, communication between the 

hospital and clinics was perceived as both effective and efficient by health workers at the 

clinics, OPD and the hospital. For example, all patients who had attended ANC had been 

informed about the PMTCT programme and received VCT if they agreed to participate in the 


programme. This was all clearly documented on client’s ANC card and was verified by 

checking a sample of ANC cards. 

Rietvlei: The referral pathway was very simple - from the local clinic to the hospital for the 

delivery, then back to the local clinic. However, in spite of this, the transfer of information was 

less effective. For example, many of the women in the maternity ward who said they had 

attended ANC in the sub-district had not been informed of the PMTCT or VCT programmes. 

Support Services 

Laboratory Services: The average turn-around time for ELISA tests both at hospitals and 

clinics at the studied 2 sites were similar. However, at Rietvlei, the turn around time was longer 

at certain times due to loss of specimens or laboratory results. Also staff was less confident of 

the results. In addition, clinics had had periods when they have had stock-outs of rapid test kits 

as recent as last year. 

Infant Formula: Paarl had never experienced stock-out of infant formula. Infants in the 

PMTCT programme are provided with the infant formula for six months. On the other hand 

Rietvlei has experienced constant stock-out of infant formula. Although it is stipulated that 

infants in the PMTCT programme are supposed to be supplied with infant formula for one year, 

many clinics are not meeting this requirement. For example, one clinic had no infant formula for 

eight months in 2005. 

Pharmaceutical Services: Paarl clinics no longer stock Nevirapine tablets. Only the hospital 

has the Nevirapine tablets and administers them to women in labour. No shortages of either 

Cotrimoxizole or Nevirapine were reported by Paarl. In Rietvlei feeder clinics were not supplied 

with Nevirapine tablets for over a year. In addition, Nevirapine syrup was not supplied to the 

clinics in spite of the large number of deliveries which take place in the community that are 

located far from the hospital. 

Routine Monitoring and Evaluation: Routine monitoring and evaluation is a problem at both 

sites. Neither Paarl nor Rietvlei had data on HIV transmission rates from mothers to infants in 

PMTCT programme. According to the PMTCT registers the percentage of women receiving 

Nevirapine in Paarl was 86% compared to 10% at Rietvlei. While in Paarl, 99% of babies 

received Nevirapine protocol compared to 12% in Rietvlei. 

Conclusion 

Information about the HIV transmission rate in infants in the PMTCT programme is not 

accessible or available at a sub-district or district level. As a result, local health managers and 

PMTCT programme managers are unable to monitor the impact of the PMTCT programme. 

Although the referral system in Paarl is complex, medicines for the programme, testing kits and 

nutritional supplementation are available, and mothers in the PMTCT programme do not 

default. On the other hand in Rietvlei where the referral pathway is simpler and all nurses are 

trained in VCT, poor performance of the support service - in particular the pharmaceutical and 

laboratory services; and the frequent unavailability of infant formula appear to contribute to 

considerable defaulting of the mothers from the programme. 


5. DISCUSSION: TRIANGULATION AND SUMMARY OF RESULTS 


themes emerged. Since within each section above, discussion and conclusions specific to that 

section were already included, this section provides a short summary of the primary themes 

that were observed in this analysis: 

• Transport and Distance to Health Facilities is the biggest problem facing women 

trying to access health services 

This study shows that the major barriers to accessing health facilities for both ANC and 

maternity services are lack of transport and the distances that have to be covered. 

• Communication with Families was very poor 

Communication by health workers with families was shown to be inadequate leading to 

a decreased belief in the health services. 

• Health Seeking Behaviour was good 

In spite of often poor treatment and lack of communication by the health services, the 

study showed that most people first seek help from the clinic or hospital and only when 

failed by the Western health system did they access traditional healers. In a few 

people who started off by using traditional healers, they turned to Western health 

services as soon as a serious complication arose. Women and families appear to only 

delay or not access Western health services when they cannot get there (see 

transport above) not because the do not want to access services, or do not feel the 

services are valuable. 

• Treatment by health providers and quality of care was mixed 

This study also shows that women had mixed perceptions on the ‘care’ provided by 

hospital and clinic health workers and the quality of care they received. However, it is 

clear that quality of care issues are a factor impacting on the health of women and 

infants. Therefore, improved health structures and systems, quality of care and 

treatment of women and infants by health workers are needed. 

• HIV and AIDS is a major issue - but cannot overlook basic maternity and 

neonatal service quality 

HIV and AIDS is a huge issue affecting every aspect of health care service. However 

care must be taken to ensure that the quality of basic maternity and neonatal services 

is not overshadowed. 

• Families and Community are an untapped resource 

This research showed that the families and communities are crucial in determining the 

health seeking behaviour of pregnant women and mothers of young children. This 

valuable resource must be exploited to minimise maternal and infant morbidity and 

mortality. 


6. RECOMMENDATIONS: 

24-hour emergency transport services must be available within each community for 

emergency obstetric and paediatric care. This is critical in both rural areas (where other 

forms of public transport are often not available and where many people do not have access to 

private vehicles) and in urban areas where ones safety is compromised if travelling alone. 

Women interviewed mentioned that communities could be more helpful at crisis time like going 

into labour, e.g. pay later for transport accessed. They also wanted more ambulances and 

quicker time to reach patients. Also the women mentioned mobile clinics as a way of bringing 

services closer to them, thus increasing both antenatal and postpartum clinic attendance. This 

is a complicated problem that should be a priority for the Department of Health. However, any 

long term solution will probably also require extensive collaboration and community 

partnerships (see below). 

Community education about maternal and infant health and danger signs is imperative. 

Families should be educated (by both CHWs and health facility staff) on the maternal and infant 

health and danger signs and they should also know that prompt medical attention can save 

lives. While women and their families had some knowledge on danger signs, this was 

incomplete. It must be recognised that women trust most the information from health facility 

based health providers. Therefore, it is imperative that health providers are active participants 

in health education and health promotion. It is also important that health education and 

promotion be comprehensive to include common symptoms of pregnancy, recognising risk 

factors that need urgent treatment, other issues such as maternal nutrition (including 

micronutrients) and genetics, family planning, HIV and other sexually transmitted infections, as 

well as infant feeding and infant care. The Health Promoting Settings Model coordinates 

individual, group and community health promotion both within the health facilities and in 

partnership with communities. This model should be considered for all health facilities 

providing primary health care in South Africa. Finally, for broad community based education 

through the public media, the radio appears to be the preferred channel of communication of 

health information for the majority of women. 

Hospital protocols for assessment and treatment of women and infants must be 

reviewed and current standards must be implemented. Even in this small study, evidence 

of inappropriate treatment and patient discharge were evident. Implementation of national 

initiatives and treatment guidelines such as those promoted by the Saving Mothers and Saving 

Babies Programmes and the Integrated Management of Childhood Illness (IMCI) need to be 

assured at all levels of care. Particular attention to rural and poorly resourced areas is 

needed. For example there is not a single IMCI trained health provider in the entire Umzimkulu 

sub-district where Rietvlei Hospital is located. 

All facilities must be adequately supplied with the essential medicines and other 

supplies to promote maternal and infant health. The current mechanisms used to ensure 

that stock-outs do not happen at any clinic or hospital must be reviewed and strategies should 

be developed to better respond to identified needs. 

Sensitivity training for hospital staff working with mothers and infants should be 

explored and communication with families needs to be enhanced. All families in South 

Africa have the right to be treated with respect when they present at a health facility, and all 

deserve to have full knowledge of the diagnosis and treatment for themselves and their infants. 

This also includes a discussion of cause of death with the family for both women and infants. 

While confidentiality concerns are important, it is clear that families are primary care givers for 


oth sick women and children. Therefore, if the families are not aware of the diagnosis and 

treatment necessary, the health of women and infants will be compromised. This area requires 

at least two approaches. The first is research to understand staff attitudes and behaviour 

towards women and their families, as well as ways to improve staff behaviour towards serving 

clients. Secondly, guidelines for communication to families, which balance confidentiality and 

the need to know, should be developed to assist health care providers in dealing with 

sometimes complicated situations. 

Given that Nevirapine is successful in reducing the transmission of HIV to newborns 7 , it 

is essential that the PMTCT programme functions well and is monitored effectively. 

In Paarl local clinics should provide ANC services and all professional nurses should be trained 

in VCT. In Rietvlei the problems with the laboratory and pharmaceutical services must be 

addressed to improve the performance of the PMTCT programme. In addition PCR diagnostic 

tests should be introduced for testing at 6-14 weeks depending on infant feeding method. 

HIV and AIDS services need to be expanded, integrated and comprehensive. 

Without repeating the statements above, it is unquestionable that quality maternity care 

shouldn’t be traded off within the context of an overwhelming HIV and AIDS pandemic. 

However, based on these findings, addressing HIV and AIDS should also be prioritised, 

especially in the context of women in their reproductive ages. The last report on maternal 

deaths 2 does show AIDS as a major killer. Proactive measures need to be in place that include 

preventive, promotive and curative aspects on the management of HIV and AIDS that should 

start in family planning clinics and continue through perinatal and post-partum services, not 

only during antenatal care. Counselling in particular cannot be regarded as a once-off event - it 

should be an on-going activity and a responsibility of all health care providers. Also, these 

services should focus on both HIV-positive mothers to assure they get the highest quality of 

care, and the HIV-negative mothers to ensure they stay negative. In addition, the majority of 

the mothers who died left behind orphans that are being taken care of by relatives (excluding 

their fathers). It is known that children who have lost their mothers are at higher risk of dying, 12 

therefore, comprehensive programmes for orphans will become increasingly important if we do 

not stem the tide of maternal deaths from HIV and AIDS. Finally, while expansion of 

antiretroviral programmes for both women and children will need to be a major thrust of 

services to address the pandemic, these programmes alone are not enough. A comprehensive 

integrated approach, which addresses equity and underlying health structures will also be 

needed. 

Cooperation and communication with families and communities needs to be enhanced. 

It was clear that communities and families are an untapped resource for promoting 

maternal and infant health. Results from the SANIB focus groups also indicate that families, 

and especially men, want to be more involved in the care of women during pregnancy and 

birth, as well as in the care of infants. Enhancing community support for ANC and 

postnatal/infant services maybe one of the most beneficial ways to increase use of maternal 

and newborn services. While essentially all women and family members interviewed felt ANC 

and hospital delivery were important, and overall use of health services were very high, there 

appeared to be a gap in coordination and communication with families and communities. 

Initiatives like Better Births that promote family involvement during labour and birth, and 

expansion of these efforts to primary care should be supported. There is increasing recognition 

that men need to be considered in the context of women and child health and HIV and AIDS. 

Families, communities and culture were rarely cited as barriers to care in this study, but were 

commonly cited as promoters of care. This is a very positive finding considering that this is not 

the case in many other developing countries. 13 In addition, solving complex issues such as 


transport will likely not be successful without some community participation (see above). 

However, community participation is often very difficult to realise. Findings from this study 

should be used to develop community-based interventions and pilot studies to enhance 

community and family participation in maternal and child health. Recent recommendations by 

WHO and others for ways to improve community participation in maternal and infant health can 

also be consulted. 14 

7. ACKNOWLEDGEMENTS 

The study team would like to thank the National Department of Health and the Centers for 

Disease Control and Prevention (South Africa) for the opportunity to conduct this research. We 

would like to thank our study collaborators, South African Nurses in Business (SANIB); the 

local study staff, the local health services and the mothers and families who participated in this 

research. 


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3 World Health Organization. Making Pregnancy Safer: Why is this issue important? Fact Sheet 

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4 Equity. Primary Health Care in the Eastern Cape Province 1997-2000. Bisho: Equity Project 

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5 Day C and Gray A. Health and Related Indicators. In: Ijumba P, Barron P, editors. 2005 

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6 WHO, Safe Motherhood Needs Assessment. Version 1.1 WHO/RHT/MSM/96.18. Geneva: 

World Health Organization. 2001. 

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make pregnancy safer. Geneva: World Health Organization. 2004. 

8 Anker M, et.al. A Standard Verbal Autopsy Method for Investigating Causes of Death in 

Infants. WHO/CDS/CSR/ISR/99.4. Geneva: World Health Organization. 1999. 

9 Good Start Study Team. The Good Start Study Draft Report. Durban: Health Systems Trust. 

May 2005. 

10 Ronsmans C, Etard F, Walraven G. Verbal Autopsies: Learning from Reviewing Deaths in 

the Community. In: WHO. Beyond the Numbers: Reviewing maternal deaths and complications 

to make pregnancy safer. Geneva: World Health Organization. 2004. 

11 Schaefer, J., Noell, D., McClain, M. (Dec 2002). Fetal and Infant Mortality Review: A Guide 

for Home Interviewers. Washington, DC: American College of Obstetricians and Gynecologists. 

12 Zaba B, Whitworth J, Marston M, Nakiyingi J, Ruberantwari A, Urassa M, Issingo R, Mwaluko 

G, Floyd S, Nyondo A, Crampin A.HIV and mortality of mothers and children: evidence from 

cohort studies in Uganda, Tanzania, and Malawi. Epidemiology. 2005 May;16(3):275-80. 

13 DFID. Reducing maternal deaths: Evidence and action. London: Department for International 

Development. 2004. 

14 WHO. Working with Individuals, Families and Communities to Improve Maternal and 

Newborn Health. WHO/FCH/RHR/03.11. Geneva: World Health Organization. 2003. 


APPENDIX A: RESULTS* 

*Notes to Tables in Results: 

• The percentages are all column percentages for the variable, i.e. percent within each 

site 

• Tables 1 through 3 are on entire sample - semi-structured household interviews and 

case studies with a sample size of 235 (Paarl = 68, Rietvlei = 84, and Umlazi = 83). 

• Tables 4 through 26 are from the semi-structured household interviews with a sample 

size of 178 (Paarl = 60, Rietvlei = 60, and Umlazi = 58). 

• Percentages are calculated excluding missing data so there will be some variation in N 

in each column depending on number of subjects with missing data for the respective 

data item. 


Appendix A1: Socio-economic Variables by Site 

Socio-Economic Variable Paarl Rietvlei Umlazi 

Water Source (n = 232) # % # % # % 

Piped-inside house 36 (53) 1 (1) 47 (57) 

Piped-yard 26 (38) 8 (10) 19 (23) 

Piped-public 6 (9) 26 (32) 16 (20) 

Borehole/well 0 12 (15) 0 

River/stream 0 35 (42) 0 


Type of Toilet in the House (n = 232) # % # % # % 

Flush toilet 63 (92) 2 (3) 43 (52) 

Pit latrine 0 78 (95) 34 (42) 

Ventilated pit latrine 0 0 5 (6%) 

None 4 (6) 1 (1) 0 

Other 1 (2) 1 (1) 0 


Main Fuel used for Cooking ( n = 231) # % # % # % 

Electricity 36 (53) 10 (12) 60 (74) 

Gas 12 (18) 2 (3) 1 (1) 

Paraffin 20 (29%) 15 (18) 19 (24) 

Charcoal 0 1 (1) 0 

Wood 0 54 (66) 1 (1) 


Do you have a working… 

n = 68 n = 82 n = 82 

# % # % # % 

Refrigerator/freezer 46(69) 19 (24) 49 (59) 

Radio 46 (69) 49 (63) 57 (69) 

Television 44 (66) 22 (28) 48 (58) 

Stove 41 (61) 17 (22) 79 (95) 

Telephone/cell phone 37 (55) 33 (42) 47 (57) 

Car 8 (12) 4 (5) 7 (8) 


Appendix A2: Distribution of Selected Measures of Income by Site 

Selected Measures of Income Paarl Rietvlei Umlazi 

Income measure ( n = 232) # % # % # % 

Is anyone living in the household currently employed? 51 (75) 44 (56) 57 (70) 

Total 68 82 82 

# % # % # % 

Source of income of main provider for the household n = 68 n = 82 n = 82 

Regular employment 35 (52) 23 (28) 42 (53) 

Irregular employment 18 (26) 21 (26) 17 (21) 

Home employment 4 (6%) 5 (6) 1 (1) 

Contributions from others 2 (3) 2 (2) 2 (3) 

State pension/grant 20 (29) 42 (52) 12 (15) 

Other 1 (2) 3 (4%) 5 (6) 

Don’t know 0 (0%) 0 (0) 3 (4) 

What kind of grant/pension? n = 68 n = 82 n = 82 

# % # % # % 

Child support grant 13 (19) 38 (46) 21 (26) 

Elderly Pension 15 (22) 24 (29) 15 (18) 

Disability Pension 10 (15) 7 (8) 4 (6) 

Foster care grant 2 (3) 0 (0%) 0 (0) 

Other grant/pension 5 (7) 2 (2%) 1 (1) 

Don’t know 0 (0) 0 (0%) 6 (7) 

Appendix A3: Mode of Travel and Needed Time in minutes to Health Services by Site 

Mode of travel to the nearest clinic (n = 233) 

Paarl # % Rietvlei # % Umlazi # % 

Walk 59 (87) 37 (45) 57 (69) 

Taxi/bus 5 (7) 46 (55) 23 (29) 

Own vehicle 2 (3) 0 (0) 1 (1) 

Other 2 (3) 0 (0) 1 (1) 

Total 68 83 82 

Average time to the nearest clinic (n = 233) 

Mean 17.93 48.30 24.76 

Standard deviation 17.63 37.16 17.24 

Mode of travel to the nearest hospital (n = 233) # % # % 

Walk # % 

12 (15) 12 (15) 

8 (12) 

Taxi/bus 51 (75) 70 (85) 69 (84) 

Own vehicle 3 (4) 0 (0) 1 (1) 

Other 6 (9) 0 (0) 0 (0) 

Average time to the nearest hospital (n = 233) 

Mean 31.91 83.71 35.00 

Standard deviation 17.27 66.04 23.47 


OBJECTIVE 1: 

To determine factors influencing utilisation of maternal health services and barriers to utilisation 

of maternal health services 

Appendix A4: Factors Associated With the Utilisation of Health Services With a 

Score >=5 (High Utilisation) 

Variable 

Rate Difference P-value 

(%) or Mean 

Difference 

Younger Age (Mean age in years) - 21 years 0.043 

Single (%) +15.5 0.055 

Someone in HH Employed (%) +16.5 0.055 

Main HH provider in regular employment (%) +18.4 0.020 

Walk to clinic (%) +25.7 0.020 

Live closer to clinic (Mean travel to clinic in minutes) -12.9 minutes 0.003 

Live closer to hospital (Mean travel to hospital in minutes) -23.9 minutes 0.002 

No problems getting to hospital (%) +21.9 0.065 

No problems attending ANC (%) +23.5 0.005 

No financial barriers to ANC attendance (%) +15.7 0.093 

No transport barriers to ANC attendance (%) +48.8 0.039 

Work/employment not a barrier to ANC (%) +34.1 0.080 

No poor treatment by health staff cited as barrier ANC (%) +48.4 0.075 

Both positive & negative treatment by health staff during ANC 

+36.6 0.018 

(%) 

Unable to always follow health advice (%) +25.2 0.011 

Family or friend told mom to go to ANC (%) +15.5 0.055 

Advised to return for check-up after last birth (%) +40.8 0.000 

Health staff discussed family planning after last birth (%) +19.8 0.058 

HH member thinks someone should stay with woman in labour 

(%) 

HH member thinks women’s health is a priority for South Africa 

(%) 

n = 165 

+22.8 0.016 

+23.3 0.051 


Appendix A5: Barriers to accessing ANC 

Paarl 

# (%) 

Rietvlei 

# (%) 

Umlazi 

# (%) 

Total 

# (%) 

Problems attending ANC 16 (26.7) 23 (38.3) 16 (27.6) 55 (31.0) 

Money 14 (23.3) 17 (28.3) 8 (13.8) 39 (21.9) 

Work/Employment 1 (1.7) 3 (5.0) 3 (5.3) 7 (4.0) 

Family Responsibilities 1 (1.7) 3 (5.0) 2 (3.4) 6 (3.4) 

Transport 0 (0.0) 3 (5.0) 2 (3.4) 5 (2.8) 

Treatment by health staff 0 (0.0) 4 (6.7) 1 (1.7) 5 (2.8) 

Family or Friends 0 (0.0) 0 (0.0) 1 (1.7) 1 (0.6) 

Total Respondents 60 60 58 178 

Appendix A6: What Sort of Things or People Make it Easier to Attend ANC? 

Paarl 

# (%) 

Rietvlei 

# (%) 

Umlazi 

# (%) 

Total 

# (%) 

Family or friend support 44 (73.0) 10 (17.0) 24 (41.0) 75 (43.1) 

Clinic closer to home or 

mobile clinic 

2 (3.3) 19 (33.3) 20 (35.1) 41 (23.6) 

Friendly staff or nurses 2 (3.30) 23 (40.4) 2 (3.5) 27 (15.5) 

Transport available 2 (3.3) 11 (19.3) 10 (17.5) 23 (13.2) 

Good quality care 4 (6.7) 12 (21.1) 4 (7.0) 20 (11.5) 

Had money 16 (26.7) 1 (1.8) 2 (3.5) 19 (10.9) 

None 1 (1.7) 3 (5.3) 1 (1.8) 5 (2.9) 

Had pregnancy problems 2 (3.3) 2 (3.5) 1 (1.8) 5 (2.9) 

Wanted to have healthy baby 0 (0.0) 1 (1.8) 3 (5.3) 4 (0.2) 

Shorter waiting times 0 (0.0) 0 (0.0) 1 (1.8) 1 (0.6) 

Employer released for clinic 0 (0.0) 0 (0.0) 1 (1.8) 1 (0.6) 

Other 4 (6.7) 2 (3.5) 5 (8.8) 11 (6.3) 


Appendix A7: Why Didn't You Attend ANC Earlier? 

Paarl Rietvlei 

# (%) # (%) 

Thought okay to start 

Umlazi 

# (%) 

Total 

# (%) 

0 (0.0) 22 (61.1) 4 (13.7) 26 (29) 

later/felt fine 

Distance to clinic 11 (44.0) 9 (25.0) 5 (17.2) 25 (27.8) 

No money/no transport 6 (24.0) 1 (2.8) 4 (13.8) 10 (11.1) 

Unwanted/hiding pregnancy 4 (16.0) 0 (0.0) 3 (10.3) 7 (7.8) 

If go early too many visits 4 (16.0) 0 (0.0) 1 (3.4) 5 (5.5) 

Sent away by clinic 1 (4.0) 2 (5.6) 1 (3.4) 4 (4.4) 

No Reason 0 (0.0) 0 (0.0) 3 (10.3) 3 (3.3) 

Did not realise pregnant 1 (4.0) 0 (0.0) 1 (3.4) 2 (2.2) 

Other 0 (0.0) 2 (5.6) 8 (27.6) 10 (11.1) 



Appendix A8: Pregnancy History 


(N=60) (N=60) (N=58) 

Total number of births 105 135 122 

Average parity 1.75 2.25 2.1 

Parity = 1 32 (53%) 11 (18%) 24 (41%) 

Parity >=5 1 (2%) 4 (7%) 3 (5%) 

# (%) # (%) # (%) 

No Antenatal Care (% of Total Births) 0 (0) 3 (2) 4 (3) 

Home Birth (% of Total Births) 5 (5) 12 (9) 3 (2) 

No Skilled Attendant at Birth (% of Total 6 (6) 10 (7) 5 (4) 

Births) 

# (%) # (%) # (%) 

Complications (% of Total Births) 29 (28) 46 (34) 47 (38) 

Caesarean Delivery (% of Total Births) 15 (14) 34 (25) 42 (34) 

Worked in regular or irregular employment 

during last pregnancy. 

21 (35) 9 (15) 16 (28) 

Appendix A9: Family Planning 


Are you currently doing anything to prevent # (%) # (%) # (%) 

or postpone your next pregnancy? 

Yes 47 (78) 43(72) 47 (82) 

No 13 (22) 16 (27) 6 (10) 

What are you currently doing to prevent or # (%) # (%) # (%) 

postpone your next pregnancy? 

No sex/abstinence 7 (12) 8 (13) 7 (12) 

Pill 1 (2) 2 (3) 1 (2) 

Injection/Dep-Provera 33 (55) 24 (40) 26 (46) 

Sterilization (for self or partner) 8 (13) 7 (12) 6 (11) 

Condom/diaphragm/cap 2 (3) 5 (8) 9 (16) 

Other family planning methods 3 (5) 2 (3) 0 

Appendix A10: Immunisations 


Complete immunisations for age # (%) # (%) # (%) 

Yes 41 (71) 8 (16) 26 (57) 

No 17 (29) 42 (84) 20 (43) 

Complete immunisations for age by age 

group 

# immunised 

/ # in group 

# immunised 

/ # in group 

# immunised / 

# in group (%) 

(%) 

(%) 

0-2 months 0/0 (0) 0/1 (0) 2/2 (100) 

3-4 months 6/7 (86) 2/5 (40) 1/1 (100) 

5-9 months 9/11 (82) 2/7 (29) 4/6 (67) 

10-18 months 16/18 (89) 4/24 (17) 11/18 (61) 

19-34 months 10/22 (46) 0/13 (0) 8/19 (42) 


OBJECTIVE 2: 

To determine the level of awareness of risk factors associated with poor maternal and perinatal 

health outcomes among women and family members 

Appendix A11: Where Did You Learn About Problems or Warning Signs in Pregnancy? 

Paarl 

# (%) 

Rietvlei 

# (%) 

Umlazi 

# (%) 

Total 

# (%) 

Clinic or Hospital 30 (50.0) 49 (83.1) 50 (86.2) 129 (72.9) 

Friends or other people 24 (40.0) 2 (3.4) 14 (24.1) 40 (22.6) 

Older women or own mother 4 (6.7) 10 (16.9) 0 (0.0) 14 (7.9) 

Current or Prior Pregnancy 3 (5.0) 4 (6.8) 5 (8.6) 12 (6.8) 

Radio/TV 2 (3.3) 8 (13.6) 2 (3.4) 12 (6.8) 

Health Promotion Materials, 

e.g. posters, books 

7 (11.7) 2 (3.4) 0 (0.0) 9 (4.5) 

Other 4 (6.7) 3 (5.1) 0 (0.0) 7 (4.0) 


Appendix A12: Sources of Information on Pregnancy* 


# (%) # (%) # (%) 

Health Worker 50 (85) 59 (98) 52 (90) 

Community Health Worker 8 (14) 2 (3) 3 (5) 

Family 32 (54) 4 (7) 4 (7) 

Friend 20 (34) 0 (0) 8 (14) 

Radio 21 (36) 25 (42) 34 (59) 

TV 15 (25) 6 (10) 17 (29) 

Newspaper 11 (19) 2 (3) 8 (14) 

* All sources cited by mothers 

Appendix A13: Source for Best Advice for Making Decisions about Health 


# (%) # (%) # (%) 

Health care provider 37 (63) 55 (92) 42 (72) 

Radio 6 (10) 2 (7) 11 (19) 

Family member 12 (20) 0 0(0) 

Friends 1 (2) 0 3 (5) 

Television 1 (2) 1 (2) 1 (2) 

Newspapers 2 (3) 0 1 (2) 


Appendix A14: What are Some Dangerous or Warning Signs of a Problem During 

Pregnancy or Birth? 

previous bad obstetric history / abdominal scars / previous 

stillbirth 

Paarl 

# 

Rietvlei 

# 

Umlazi 

# 

Total 

# (%) 

4 8 26 38 (21) 

hypertension / high blood pressure 41 58 55 154 ( 87) 

severe headaches 15 29 21 65 (37) 

swelling of face, hands, feet or legs 30 55 51 136 (76) 

fits/seizures 7 16 12 35 (20) 

loss of consciousness 2 14 6 22 (12) 

anaemia 7 10 8 25 (14) 

pallor/pale 0 8 4 12 (7) 

severe fatigue/exhaustion/unable to do normal daily chores 8 28 28 64 (36) 

Breathlessness/problems breathing/short of breath 4 20 9 33 (19) 

cessation of fetal movement / baby does not move 20 25 53 98 (55) 

abnormal lie / position of foetus /breech (bottom or legs first) 15 21 40 76 (43) 

sepsis / infection 20 15 13 48 (27) 

fever 8 21 13 42 (24) 

cough that lasts several weeks or more 7 19 8 34 (19) 

loose stools (diarrhoea) that last several weeks or more 4 30 15 49 (28) 

foul smelling discharge from vagina (birth canal) 12 22 45 79 (44) 

loss of weight 7 28 12 47 (26) 

bleeding/ haemorrhage 24 45 51 120 ( 67) 

multiple pregnancy / large abdomen 2 6 14 22 (12) 

obstructed / prolonged labour / "sun set two times" 6 15 21 42 (24) 

labour/abdominal pains more than 3 weeks before baby 

is due 

21 24 34 79 (44) 

Waters break early before labour 18 21 47 86 (48) 

Other 35 24 34 93 (52) 

Don’t know 9 3 9 21 (12) 

Average number of danger signs known out of 23 listed 

danger signs (not including other) 

5 9 9 8 


Appendix A15: What Are Some Dangerous or Warning Signs of A Problem in the Woman 

in the First Month after Birth? 

Paarl 

# 

Rietvlei 

# 

Umlazi 

# 

Total 

# (%) 

hypertension / high blood pressure 31 49 37 83(47) 




anaemia 6 13 9 28 (16) 

pallor/pale 1 12 7 20 (11) 


breathlessness/problems breathing/short of breath 3 16 10 29 (16) 


fever 5 21 15 41 (23) 


postpartum abdominal pain 28 39 47 114 (64) 

puss/foul discharge/redness/pain at c-section or episiotomy 

incision 

19 19 49 87 (49) 

redness/pain/puss around nipples 11 19 23 53 (30) 

loss of weight 8 49 51 108 (61) 

bleeding / haemorrhage 44 50 54 148 (83) 

loose stools (diarrhoea) that last several weeks or more 5 25 10 40 (22) 


Other 24 21 19 64 (36) 

Don’t Know 15 2 6 23 (13) 


dangerous signs (not including ‘other’) 3 8 7 6 


Appendix A16: What Are Some Dangerous or Warning Signs of A Problem in the Baby 

during the First Three Months after Birth? 

Paarl Rietvlei Umlazi Total 

# # # # (%) 

inability to feed adequately or cessation of sucking 30 36 35 101 (57) 

weak or abnormal cry or cessation of crying 15 40 15 70 (39) 

fits/ seizures 5 15 3 23 (13) 

lethargy or loss of consciousness 6 10 7 23 (13) 

redness/ discharge (pus) at umbilicus 14 44 45 103 (58) 

skin infection/ pustules 18 27 51 96 (54) 

redness/discharge from eyes 8 18 22 48 (27) 

fast breathing/problems breathing/chest-draw-in/ 

grunting breathing 

22 32 42 96 (54) 


fever 29 31 46 106 (60) 

unusually cold body temperature 7 22 10 39 (22) 

yellow discoloration (jaundice) of skin 45 27 51 123 (69) 

persistent vomiting and/or distension abdominal (swelling) 12 25 30 67 (38) 

loss of weight 20 23 14 57 (32) 


loose tools (diarrhoea) that lasts several weeks or more 37 48 52 137 (77) 

oral thrush/ white sores in the mouth of the child 15 48 54 117 (66) 

sunken top of head (sunken fontanelle) / dehydration 1 39 31 71 (40) 

Other 13 11 12 36 (20) 

Don’t Know 11 1 3 15 (8) 


danger signs (not including other) 5 9 9 8 


Appendix A17: Household Member: What Are Some Dangerous or Warning Signs of a 

Problem during Pregnancy, Birth or in the 1 st Month after Birth? 

Paarl 

# 

Rietvlei 

# 

Umlazi 

# 

Total 

# (%) 

previous bad obstetric history / abdominal scars / previous stillbirth 2 5 8 15 (8) 

hypertension / high blood pressure 48 53 55 156 (88) 


swelling of face, hands, feet or legs 40 43 53 136 (76) 



anaemia 6 14 3 23 (13) 

pallor/pale 0 7 10 17 (10) 


breathlessness/problems breathing/short of breath 11 27 28 66 (37) 

cessation of foetal movement / baby does not move 19 17 43 79 (44) 

abnormal lie / position of foetus /breech (bottom or legs first) 14 19 34 67 (38) 


fever 16 28 20 64 (36) 



Loose stools (diarrhoea) that last several weeks or more 8 22 20 50 (28) 

loss of weight 9 24 40 73 (41) 

bleeding/haemorrhage 22 45 48 115 (65) 

multiple pregnancy / large abdomen 4 9 13 26 (15) 

obstructed / prolonged labour / "sun set two times" 3 15 9 27 (15) 

labour/abdominal pains more than 3 weeks before baby is due 24 19 17 60 (34) 

Waters break early before labour 12 22 35 69 (39) 

postpartum abdominal pain 5 36 32 73 (41) 

puss/foul discharge/redness/pain at c-section or episiotomy incision 4 10 15 29 (16) 

redness/pain/puss around nipples 2 15 7 24 (13) 

Other – specify 38 17 22 77 (43) 

Don’t know 6 0 2 8 (4) 

Average number of danger signs known out of 27 listed danger 

signs (not including other) 

5 9 11 8 


OBJECTIVE 3: 

To determine the health seeking behaviours of HIV-positive and HIV- negative pregnant 

women. 

Appendix A18: Utilisation Score by HIV Status 

Variable HIV-positive HIV-negative 

# (%) # (%) 


Attended ANC in all pregnancies 56 (93) 59 (98) 

Delivered in Hospital or Clinic in all pregnancies 51 (85) 55 (92) 


Began ANC in months 0-4 25 (42) 33 (55) 

1 st infant follow-up visit prior to 6 weeks of age 41 (68) 43 (73) 

1 st maternal follow-up visit prior to 6 weeks post-delivery 32 (54) 27 (46) 

Currently using Family Planning 46 (79) 46 (77) 

Mean Utilisation Score =1 point for each of above (Std 

Deviation) 

4.2 (1.3) 4.4 (1.1)) 

P=0.98 

Utilisation Score >=5 28 (50%) 30 (51%) 

P=0.93 

n = 60 n = 60 

Appendix A19: Immunisation by HIV Status 


Complete immunisations for age by HIV # (%) # (%) # (%) 

status 

HIV-positive 14/20 (70) 1/15 (7) 3/16 (19) 

HIV-negative 12/20 (60) 1/16 (6) 14/17 (82) 

p-value 0.51 0.96 0.0003 


Appendix A20: Quality of Care by HIV Status 

Variable HIV-positive HIV-negative p-value 

# (%) # (%) 

ANC 

Privacy during visits 50 (85) 57 (95) 0.06 

Staff spoke about pregnancy progress 47 (80 49 (82) NS 

Able to ask questions 32 (54) 34 (57) NS 

Asked to return for another visit 56 (97 59 (100) NS 

Treated positively by health staff 48 (81) 45 (75) NS 

Rate care as excellent 33 (57) 27 (45) NS 

Would recommend service 59 (100) 58 (98) NS 

Able to follow health advise 11 (19) 15 (25) NS 

In Hospital 

Advised to return for check-up after birth 40 (70) 33 (55) 0.09 

Health staff discussed family planning 48 (84) 51 (85) NS 

Treated positively by health staff 43 (75) 43 (72) NS 


Would recommend hospital 55 (97) 57 (95) NS 

Postpartum 

Staff discussed HIV/AIDS 34 (76) 26 (58) 0.07 

Staff discussed breastfeeding 29 (64) 31 (67) NS 

Staff discussed family planning 30 (67) 27 (59) NS 

Privacy during visits 39 (89) 36 (86) NS 

Staff asked to return for another visit 39 (87) 32 (76) NS 


n = 60 n = 60 


OTHER TABLES: 

Family Involvement in Pregnancy, Birth and Care of Infant 

Appendix A21: Family Involvement in Pregnancy** 


Was mother advised to go for ANC by family # (%) # (%) # (%) 

or friends? 

Yes 43 (72) 32 (53) 40 (69) 

No 17 (28) 28 (47) 17 (29) 

Who advised you to go for ANC? # (%) # (%) # (%) 

Husband/father 5 (8) 3(5) 3 (5) 

Mother 20 (33) 15 (25) 19 (33) 

Sister 3 (5) 6 (10) 1 (2) 

Aunt/cousin/other female relative 5 (8) 3 (5) 5 (9) 

Friend 3 (5) 2 (3) 6 (10) 

Any other male relative 1 (2) 1 (2) 2 (3) 

Other advisers 1 (2) 1 (2) 2 (3) 

Husband/mother 1 (2) 0 0 

Mother/sister/friend 2 (3) 1 (2) 1 (2) 

Aunt/other female relative/grandmother/friend 1 (2) 0 1 (2) 

Mother/sister/aunt/cousin/other female relative 2 (4) 0 0 

Did mother get information on problems in 

pregnancy from family members or friends? 

Yes 32 (54) 4 (7) 4 (7) 

No 27 (46) 56 (93) 54 (93) 

Where do you usually get information about 

your health - woman answered 

family/friends? 

Yes 32 (54) 4 (7) 4 (7) 

No 27 (46) 56 (93) 54 (93) 

Woman felt family/friends were the best 

source of health information. 

Yes 20 (34) 0 8 (14) 

No 39 (66) 60 (100) 50 (86) 

**From Mother’s Interview 


Appendix A22: Family Involvement in Labour/Birth*** 


Did anyone stay with you during labour or # (%) # (%) # (%) 

birth? 

Yes 12 (20) 3 (5) 1 (2) 

No 48 (80) 56 (93) 57 (98) 

Did you like or would you have liked having # (%) # (%) # (%) 

family/friends with you during labour or 

birth? 

Yes 50 (85) 22 (37) 32 (56) 

No 9 (15) 36 (61) 24 (42) 

*** From Mother’s Interview 

Appendix A 23: Family Involvement in Pregnancy**** 


Relationship to mother of household 

# (%) # (%) # (%) 

member interviewed 

Husband 10 (17) 4 (7) 4 (7) 

Mother 17 (28) 15 (25) 11 (19) 

Grandmother 7 (12) 5 (8) 5 (9) 

Mother-in-law 2 (3) 10 (17) 1 (2) 

Sister/other female relative 20 (33) 25 (42) 18 (32) 

Other relative 3 (5) 1 (2) 18 (32) 

Father/father-in-law 1 (2) 0 0 

Should other household members make 

# (%) # (%) # (%) 

sure women gets ANC? 

Yes 60 (100) 60 (100) 57 (98) 

No 0 0 1 (2) 

Why should household members ensure 

# (%) # (%) # (%) 

women get ANC? 

Family members are responsible 11 (19) 30 (50) 11 (19) 

To get help/advice from health staff 15 (25) 5 (8) 9 (16) 

Best for the mother/baby health 15 (25) 12 (20) 5 (9) 

Unbooked are treated badly 0 3 (5) 2 (3) 

To check problems/baby growth 19 (32) 14 (24) 34 (59) 

Get financial help 1 (2) 1 (2) 0 

****From Household Member’s Interview 


Appendix A24: Family Involvement in Labour 


In this community is it difficult to get to a # % # % # % 

health facility? 

Yes 34 (57) 33 (55) 20 (34) 

No 26 (43) 27 (45) 38 (66) 

Why is it a problem/not a problem to get to # % # % # % 

the health facility? 

Transport problems 29 (49) 13 (22) 13 (23) 

Financial problems 14 (24) 21 (36) 1 (2) 

Health facilities are close/many 10 (17) 21 (36) 22 (39) 

Transport available 13 (22) 9 (15) 24 (42) 

Health facilities too far 2 (3) 12 (21) 0 

Transport/financial problems 0 2 (3) 0 

Ask help from neighbours 1 (2) 0 0 

Afraid of AIDS 1 (2) 0 0 

Should a woman deliver with family or 

# % # % # % 

friends in the room? 

Yes 44 (73) 12 (20) 20 (34) 

No 15 (25) 46 (77) 37 (64) 

Both 1 (2) 0 1 (2) 

Why/Why not deliver with a relative or 

# % # % # % 

friend in the room? 

To make sure she is taken care of 17 (28) 2 (3) 9 (16) 

Nurses do not allow 3 (5) 3 (5) 2 (3) 

Privacy/culture 5 (8) 15 (25) 12 (21) 

Labour support 21 (35) 5 (8) 10 (17) 

Other 14 (23) 34 (57) 25 (43) 

To ask questions 1 (2) 0 0 

Were you with the mother during birth of # % # % # % 

her last baby? 

Yes 8 (14) 1 (2) 3 (5) 

No 52 (87) 59 (98) 55 (95) 


Appendix A25: Family Involvement after the Birth of the Baby 


Do you help with care for the baby? # (%) # (%) # (%) 

Yes 59 (98) 57 (95) 56 (97) 

No 1 (2) 3 (5) 2 (3) 

What do you do to help the baby? # (%) # (%) # (%) 

Gives advice 2 (3) 1 (2) 2 (3) 

Do everything 12 (20) 1 (2) 2 (3) 

Financial assistance 1 (2) 1 (2) 1 (2) 

Feed the baby 29 (48) 36 (61) 26 (45) 

Look after the baby 20 (33) 6 (10) 20 (34) 

Bath the baby 16 (27) 26 (44) 24 (41) 

Are there other HH members who help the 

# (%) # (%) # (%) 

baby? 

Yes 34 (57) 43 (72) 45 (76) 

No 26 (43) 15 (25) 12 (21) 

# (%) # (%) # (%) 

What do they do to help the baby? 

Bath/wash the baby 14 (23) 19 (32) 15 (26) 

Feed the baby 21 (35) 27 (45) 17 (29) 

Look after the baby 11 (18) 4 (7) 2 1 (36) 

Appendix A 26: Do You Think That the Health of Women During 

Pregnancy is an Important Problem in South Africa? ****** 


# (%) # (%) # (%) 

Yes 56 (93) 42 (70) 46 (79) 

No 4 (7) 18 (30) 10 (17) 

Both 0 0 1 (2) 

******From the Household Member’s Interview 


Socio-Economic Variable Paarl Rietvlei Umlazi 

Water Source (n = 232) # % # % # % 

Piped-inside house 36 (53) 1 (1) 47 (57) 

Piped-yard 26 (38) 8 (10) 19 (23) 

Piped-public 6 (9) 26 (32) 16 (20) 

Borehole/well 0 12 (15) 0 

River/stream 0 35 (42) 0 


Type of Toilet in the House (n = 232) # % # % # % 

Flush toilet 63 (92) 2 (3) 43 (52) 

Pit latrine 0 78 (95) 34 (42) 

Ventilated pit latrine 0 0 5 (6%) 

None 4 (6) 1 (1) 0 

Other 1 (2) 1 (1) 0 


Main Fuel used for Cooking ( n = 231) # % # % # % 

Electricity 36 (53) 10 (12) 60 (74) 

Gas 12 (18) 2 (3) 1 (1) 

Paraffin 20 (29%) 15 (18) 19 (24) 

Charcoal 0 1 (1) 0 

Wood 0 54 (66) 1 (1) 


Do you have a working… 

n = 68 n = 82 n = 82 

# % # % # % 

Refrigerator/freezer 46(69) 19 (24) 49 (59) 

Radio 46 (69) 49 (63) 57 (69) 

Television 44 (66) 22 (28) 48 (58) 

Stove 41 (61) 17 (22) 79 (95) 

Telephone/cell phone 37 (55) 33 (42) 47 (57) 

Car 8 (12) 4 (5) 7 (8) 


APPENDIX B1: MATERNAL VERBAL AUTOPSY CASE SUMMARIES 

MATERNAL DEATH REVIEWS - INDIVIDUAL CASE ANALYSIS: Community Situational Analysis UWC/ HST 

Objective 

1 1. To determine factors influencing the utilisation of and barriers to utilisation of maternal health services including PMTCT 

Demographic Data and 

Household Infromation a 

Acccessbility of Health 

Services (Transportation) 

HIV 

Status PMTCT Age Education Status Carer Source of Income Method Time Cost Referal Hops Site 

Case 1 Unknwn ? 22 std 10 single Aunt Grant R 500 Bus 15min 6,00 25min/taxi Mlazi-info 

Case 2 Unknwn ? unknwn std 10 Cohab Boyfriend Regular R 400 walk 15min N/A 30min/taxi Mlazi-info 

Case 3 Positive Yes unknwn std 10 Cohab Boyfriend Iregular 200 Taxi 30min 7,00 20min/taxi Mlazi-info 

Case 4 Unknwn unknwn 27 not shown single Wasn’t sik Grant 800 walk 10min N/A 30min/taxi Mlazi-info 

Case 5 Unknwn unknwn unknwn std 4 maried/mn Wasn’t sik Regular Nil shown walk 10min N/A 45min/taxi Mlazi-info 

2hrs taxi& 2hrs 

Case 6 Positive unknwn 31 std 6 Cohab Mother Nil 200 walk 1hour N/A walk 

Umzimku 

Case 7 Unknwn unknwn unknwn std 5 single Granny Old Pension Taxi 30min 8,00 30min/taxi Umzimku 

Case 8 known nil 25 std 7 single Mother Regular 350 Taxi 30min 5,00 45min/taxi Umzimku 

Case 9 Unknwn nil 28 std 10 single Mother Regular 770 Taxi 45min 6,00 90min/taxi Umzimku 

Case 10 Unknwn unknwn 39 std 10 maried/mn Husbnd Chld grant 850 Taxi 1hour 16,00 1hr/taxi Umzimku 

Case 11 Positive Yes unknwn std 10 single sister Chld grant 340 walk 10min 9,00 20min/taxi Paarl 

Case 12 Positive Yes 30 std 6 separated Aunt grant,employd, 1,600 walk 15min 20,00 20min/taxi Paarl 

Case 13 Positive Yes 24 std 7 single Mother grant 1,600 walk 10min 10,00 20min/taxi Paarl 

Case 14 Positive Yes unknwn std 10 single sister grant 400 walk 1 hour 7,00 30min/taxi Mlazi-info 

Case 15 Positive Yes 27 std 10 single Brother Grant 300 Taxi 20min 6,00 30min/taxi Mlazi-info 

Case 16 Positive Yes unknwn std 6 Cohab Aunt Grant 300 walk 20min 7,00 30min/taxi Mlazi-info 

Case 17 Positive Yes 31 std 9 Cohab Mother Emplymnt 800 walk 10min 7,00 45min/taxi Mlazi-info 

Mlaziinfo 

Case 18 Positive unknwn unknwn std 7 maried/mn Husbnd Emplymnt 700 walk 20min 1hr/taxi 



APPENDIX B2: INFANT VERBAL AUTOPSY REPORT 

Background 

Infant mortality is one of the most important indicators of health and development, and much 

research has focused on determining the causes of death for infants in resource-poor settings. 

It is well known, for example, that distal socioeconomic factors such as income, social status 

and education are closely related to child health outcomes, as are intermediate environmental 

and behavioural factors. 1 Less well researched, however, are the perceptions of mothers and 

caregivers regarding the processes and events leading up to and surrounding the death of their 

infants. Few studies have endeavoured to let families in resource-poor settings tell their own 

stories directly, an approach that is likely to provide additional insights into the supports 

received and problems and barriers encountered during their child’s illness, as well as insights 

into how the health and social service system can more effectively respond to the needs of 

these families. 

The aim of this pilot study was to develop research methods that will enable a better 

understanding of the behavioural, structural, and systemic factors that play a role in the deaths 

of infants in the Good Start study settings. Specific objectives were to test and refine data 

collection instrumentation and methods, and to present preliminary themes emerging from the 

data. Subsequent research will utilise the instruments and methods resulting from this pilot in 

order to present a comprehensive account of the context in which infant deaths occur, 

motivations that lead to decisions, actions or non-actions on the part of families, and 

perspectives on factors that contribute to a breakdown in the public health system. This 

information will support the Good Start study’s efforts to investigate factors and barriers 

influencing utilisation of health services and the level of awareness of risk factors associated 

with poor health outcomes, particularly among families with young children. 

This paper describes the data collection and analytical methods used, as well as the 

preliminary findings of the pilot study. 

Methods 

Sample and recruitment: Between August 2003 and April 2005, interviews were conducted 

with mothers and caregivers whose primary residence was in one of the three Good Start study 

sites (Paarl, Rietvlei or Umlazi) and who had a child in the home die prior to his or her first 

birthday. Potential participants were identified during a routine home visit when the Good Start 

field research worker discovered that an infant had died. The field research worker then asked 

if the mother or caregiver would participate in an interview focused on the events occurring 

prior to the infant’s death. If the mother or caregiver was willing to participate, a mutuallyagreed 

upon date and time for the interview was scheduled. 

As shown in Table 1, the sample primarily consisted of biological mothers, however in cases 

where the infant’s mother was not available or was not the primary caregiver, an interview was 

conducted with the other individual in the household who was the primary caregiver for the 

infant. When neither of those individuals was available, the interview was not conducted. In 

1 Mosley, W.H. & Chen, L.C. (1984). An analytical framework for the study of child survival in developing countries. 

Population Development Review. 10 (suppl): 25–45. 


total, 40 interviews were conducted. Table 1 presents an overview of some additional 

descriptive characteristics of the study population and their infants. 

Table 1: Descriptive Characteristics of the Pilot Study Population and their Infants 

Characteristic 

Rietvlei 

N (%) 

Paarl 

N (%) 

Umlazi 

N (%) 

Total 

N (%) 

Interviews conducted 17 (43) 4 (10) 19 (48) 40 (100%) 

Type of respondent 

Mother 

Caregiver 

Unknown 

8 

3 

6 

4 

0 

0 

19 

0 

0 

31 (78) 

3 (.08) 

6 (15) 

Age of respondent (years) 

15-19 

20-29 

30-39 

40-49 

50-59 

60+ 

Unknown 

Education (standard) 

6 or less 

7-10 

University 

Unknown 

Marital status 

Single 

Cohabiting 

Married 

Unknown 

Child’s age at death (weeks) 

Less than 1 

1-4 weeks 

5-24 weeks 

25-52 weeks 

Sex of child 

Male 

Female 

0 

8 

1 

0 

0 

1 

7 

4 

5 

0 

8 

5 

0 

3 

9 

2 

1 

11 

3 

0 

1 

0 

0 

0 

0 

3 

0 

0 

0 

4 

0 

0 

0 

4 

0 

0 

1 

3 

0 

12 

5 

1 

0 

0 

1 

1 

4 

0 

14 

3 

1 

1 

14 

1 

1 

14 

3 

0 (0) 

21 (53) 

6 (15) 

1 (.03) 

0 (0) 

1 (.03) 

11 (28) 

5 (13) 

9 (23) 

0 (0) 

26 (65) 

8 (20) 

1 (.03) 

4 (1) 

27 (68) 

3 (.08) 

2 (.05) 

26 (65) 

9 (23) 

8 

9 

2 

2 

7 

12 

17 (43) 

23 (57) 

Note: Most figures are presented as numbers rather than percentages because of the small sample size. Those 

percentages that are presented do not always add to 100 due to rounding. 

Development of Instrumentation: Over the piloting time period, several iterations of an 

interview instrument were used, the first of which was based largely on a “social autopsy” 

instrument used in the Matlab Integrated Management of Childhood Illness (IMCI) Evaluation 

Study. 2 Information obtained from this early instrument was sometimes vague and resulted in 

an incomplete account of the events leading up to the infant’s death. Later versions of the 

instrument evolved in an attempt to obtain a more complete picture of mother’s and caregiver’s 

attitudes, perceptions and recommendations for improving health care services for families with 

young children. In addition, these later versions aimed to ensure both the suitability of content 

2 Arifeen, S.E. & Bangladesh, M.C.E. (Dec 2001). The Matlab IMCI Evaluation Study - A Multi-Country Evaluation 

Project. Progress Report. Geneva: World Health Organization. 


areas covered during the interview and the appropriate wording of questions within the South 

African context. 

After numerous discussions within the study team regarding the appropriateness and clarity of 

questions, a penultimate instrument evolved from this pilot study. This instrument incorporates 

aspects of the Matlab IMCI approach as well as approaches utilised in home interviews through 

the Fetal and Infant Mortality Review (FIMR) Programme in the United States. 3 Information is 

obtained on the socio-economic situation of the family, the progression of the child’s illness 

leading to death, the first and last interactions the child had with various health providers 

preceding his or her death, perceptions of the infant’s health care, social supports available to 

the mother/caregiver, and any recommendations the mother/caregiver has for how the public 

health system and local community can respond better to the needs of families with sick 

infants. In the future, the instrument will explore better the use of local traditional healers and 

the role they play in providing health care to infants. 

In addition, based on the piloting experience, a Neonatal Supplement was designed specifically 

to assess the experiences of mothers whose babies died shortly after birth without leaving the 

health facility. 

Development of Research Approach: In addition to identifying necessary changes to the 

instrumentation, piloting provided valuable information regarding the approach to be used in 

future research. For example, it is apparent from piloting that it will be most appropriate to have 

field workers administer all interviews with mothers and caregivers in the local language without 

a second researcher in the same room. This was found to be the case because many of the 

respondents have become familiar and comfortable with the field workers involved with the 

Study over time, and also because it is critical to do whatever possible to respect the privacy of 

the respondents, particularly due to the sensitive nature of the study topic. It is hoped that by 

only having to speak with one person in future interviews, the respondents will feel more 

comfortable speaking candidly about their experiences and perspectives. 

Preliminary Findings 

This pilot study provided valuable information relating both to the methods and approach to be 

used in future research, as well as an initial glimpse into some of the behavioural, structural, 

and systemic factors that play a role in the deaths of infants in the Good Start study settings. All 

interviews obtained were analysed to determine commonalities, themes, and critical issues. A 

summary of these initial findings is presented below with the important caveat that additional 

research is needed to ensure a comprehensive understanding of the experiences of women 

living in the Good Start study sites who have lost infants. 

Factors influencing utilisation of health services: Preliminary findings suggest that the 

utilisation of health services is related to feasibility, desirability, an awareness of when care is 

needed for the infant, and the quality of care available. 

Poor feasibility: Some respondents reported that they were unable to take their child for care 

even though they realised the child needed it. This sometimes happened because the child 

was sick in the evening when no transport was available or when no one was available to 

accompany them to a facility (i.e., they did not feel safe taking the child alone). Other 

3 Schaefer, J., Noell, D., McClain, M. (Dec 2002). Fetal and Infant Mortality Review: A Guide for Home 

Interviewers. Washington, DC: American College of Obstetricians and Gynecologists. 


espondents reported that they were unable to afford the cost of transport to a facility. One 

mother in Rietvlei, for example, reported that although the local clinic had referred her baby to 

hospital to treat his dehydration, she didn’t have the money to take him there. Over the course 

of two weeks, she took the child back to the clinic several times for help, each time getting 

referred to hospital. Since this was not an option for her and since the child was not getting 

better, the mother eventually starting mixing the clinic medicines with traditional medicines. 

After three days of this treatment, the baby’s condition worsened and he died as they were 

taking him, once again, back to the clinic. 

Lack of desirability: In other cases, beliefs about cause of the infant’s illness sometimes 

determine whether or not the respondent feels health services are desirable. One respondent 

in Umlazi, for example, reported that her baby became sick at night and she was afraid to go to 

hospital alone in the dark. Her neighbours who heard the baby crying told her that there was 

nothing she could do for the baby because the cause of the illness was witchcraft (“Ishawe 

Yinyoni”). Because the mother then felt that witchcraft was responsible, she did not feel that 

she could send the baby for western medicine. When asked “what would have made things 

better or easier for you?” she stated that the child should have been taken to her father’s place 

to have the cultural ceremony in which the family burns the plant “Impepho” and the child is 

introduced to the ancestors. She also expressed her belief that if the baby had been taken to a 

traditional healer to fight witchcraft she would still be alive. This mother did not appear to 

believe that health services could have prevented the death. 

Lack of awareness of the danger signs for infants: Preliminary findings suggest that some 

mothers are not aware of the danger signs to look for when their child needs medical attention. 

Several respondents reported that they did not realise the seriousness of their child’s condition 

until it had progressed to a very severe stage. One mother in Rietvlei, for example, reported 

that her baby vomited for three days before the baby’s grandmother decided to take her to a 

traditional healer for medicines. Another mother from Umlazi described how her baby became 

ill in the evening and, not realising the seriousness of his condition, planned to take the child to 

a paediatrician in the morning. However, the baby died at three o’clock in the morning, before 

she was able to seek care. 

It is possible that mothers are not being told (by the staff who tend to the ill child) the 

appropriate danger signs to watch for at home. 4 For example, a Rietvlei mother reported that 

her infant was treated at a clinic and then referred to hospital for his cough. This baby was 

admitted to the hospital for a week after which he was discharged and showed improvement. 

The next week, however, the baby started breathing very fast and died after a few days. She 

reported that she did not take him back to hospital because she thought the treatment the 

hospital had already given him would eventually cure him. Had she been instructed on the 

steps to take if the infant’s health regressed, it is possible that he would have been taken back 

to the hospital for additional care and could have survived this illness. 

Poor quality of care: The experiences reported by respondents in this pilot study suggest that 

the quality of care received in many instances was sub-standard. For example, some mothers 

who took their infants for care reported that they were sent home with panado or electrolyte 

sachets when perhaps the infant should have been admitted. A mother in Rietvlei reported that 

she took her sick infant to hospital, was given medicine and then sent home. On that same day 

the child passed away at home. In other cases, mothers recounted that their infants died on the 

4 It is important to note that some mothers may in fact be told about danger signs to watch for and just do not 

remember what they have been told when they return home. 


way home after having been admitted and discharged from hospital. One Rietvlei mother 

recounted how her baby was discharged from hospital while it was still showing signs of 

weakness and a sunken fontanelle. The baby went to sleep on the way home and when she 

arrived at home she realised the baby had died. Another Rietvlei mother reported that her child 

was admitted for three weeks with cough, vomiting and fever. The staff advised the mother to 

take the child home where she then died after two days. 

Some mothers reported taking their infants to clinic but that the clinic did not have the 

appropriate medicine. When asked if they have any ideas “for how health care facilities and 

providers can better serve families…with sick infants” several mothers suggested that it is of 

primary importance that clinics have enough stocks of medicines. One mother stated, “It is not 

nice to go to the clinic seeking help and you end up not getting that help you needed.” Another 

mother suggested that the most important thing needed to improve care is “[i]f facilities could 

improve on the long hours people (sick people) endure before being attended [to].” One 

respondent stated that her baby got sick at night but that she could not get transport until the 

next morning. When they got to the health facility, they had to wait for several hours to be seen. 

By that time, her baby was already gravely ill. 

An important finding relating to quality of care is that many respondents reported that they did 

not know the cause of their infant’s death. This occurred even among some women whose 

infant had died in hospital. They reported that staff did not take the time to explain to them what 

happened, and they did not feel that they had the right to ask. These mothers expressed grave 

disappointment about their experiences with facility staff. For example, one mother seemed to 

have accepted the fate of their baby (she believed that it was her baby’s death day – "kwase 

kufike usuku”) but she became very tearful when recounting how she had been treated at the 

facility. 

Other initial findings: 

• Sudden Infant Death Syndrome (SIDS) appears to have played a role in the deaths of at 

least two infants included in the study. In these cases, mothers reported seeing no warning 

signs that the child was ill at all prior to its death. 

• This initial analysis suggests that there are no differences between HIV positive women 

and HIV negative women with respect to their care-seeking behaviours for their infants. 

However, more research into this issue is needed. 

• To date, the only specific group that women have identified as supportive to them is their 

local HIV Support Group. No mothers have identified health staff as providing support to 

them and in fact, several of the mothers whose infants died in hospital specifically stated 

that they received no grief counselling following the death. 

• Mothers reported mixed feelings about being interviewed about the death of their child. 

Some mothers (especially those who had accepted the death of their child) said that it was 

fine and even helpful to participate in the interview. For example, one mother stated that 

“[i]t was a positive experience to share my story and to be visited by the study team.” A few 

others reported that they felt sad and tearful during the interview and it was therefore hard 

for them to recount their story. One mother stated that, “[I]t was difficult having to relate my 

experiences with you but I will be happy if I see changes occur [because of the study].” 

Discussion 

The information resulting from in-depth interviews such as those used in this pilot study has the 

ability to highlight the complex pathways and underlying mechanisms that precede the majority 


of infant deaths in high risk communities, including those which may have been previously 

undetected by quantitative research. Instead of focusing on what is happening and who is 

affected, this method will provide new information to help us understand why the deaths occur. 

In addition, the methods tested during this pilot study show promise for providing useful insights 

for clinical and public health practitioners working with families, by highlighting the particular 

realities associated with the social context in which these families live. The information 

generated with this approach may help some practitioners better comprehend issues like noncompliance 

among their clients. 

It is important to reiterate that these are preliminary findings based on small samples in the 

Good Start study sites. Additional interviews conducted prospectively as infant deaths are 

identified within the Good Start study have the potential to provide critical information about the 

behavioral, structural and systemic factors associated with infant death in these areas. Future 

research also has the potential to benefit public health by supporting the development of 

recommendations for how service systems and public policies can better match the real life 

circumstances of women and infants at risk. Rarely are such recommendations based on 

client-generated data, although it can be expected that this will strengthen their relevance and 

appropriateness. 


APPENDIX B3: FACILITY SUB-STUDY REPORT: PAARL 


Paarl General Hospital and the facilities which refer to this hospital were identified as a pilot site 

for the implementation of the PMTCT programme in early 2001. In the Western Cape the 

PMTCT programme has always fallen under the HIV and AIDS Directorate. 

The Paarl District falls within the West Cape Winelands Region. The Paarl General Hospital is 

run by the Provincial Administration of the Western Cape (PAWC) and is presently being 

upgraded to be the Regional Hospital. The Paarl East Hospital which is also known as the TC 

Newman Hospital is run by Paarl District (PAWC). This “hospital” functions as the outpatients 

department of the General Hospital. Presently, the PHC clinics in and around Paarl fall under 

the Local Municipality. However, in June, the management of the local clinics will be taken 

over by the provincial health administrators and all health workers will be transferred from the 

local municipality to the provincial administration. 

This investigation into the PMTCT program at a number of facilities in the Paarl District was 

undertaken on the 10 and 11 March 2005. 

2. VCT 

2.1 Lay counsellors 

Pregnant women are all encouraged to have a VCT test. The counselling both at the hospitals 

and clinics is done almost exclusively by lay counsellors who are supported, monitored and 

paid by AGAPE, a local NGO. These counsellors attended a month long training course run by 

a private psychologist. In the hospital, the lay counsellors are available from Monday to Friday, 

from 8.00 to 14.00. The contribution of lay counsellors at the three different clinics visited 

varied. At Mbekweni clinic a very dedicated lay counsellor’s work and contribution to HIV 

services was considered invaluable by the nurse responsible for PMTCT. At Nedeberg Clinic 

there had been problems with a lay counsellor who was only available for six months last year. 

When available he had only worked twice a week in the afternoon for two hours. At J.J du 

Preez le Roux clinic, the lay counsellor worked three mornings a week. 

AGAPE is the local NGO responsible for the counsellors. They are allocated money by PAWC 

and are responsible for the training, monitoring, supporting and supervising the work of the lay 

counsellors. The counsellors are paid R1600 per month. There was uncertainty about the 

future functioning of AGAPE at the time of the investigation as they had not been allocated 

money for the administration and monitoring of the lay counsellors. It was understood that this 

work would become the responsibility of the District HIV/STI/TB Coordinator. 

To provide support for the lay counsellors, AGAPE had organised a monthly session with a 

psychologist where lay counsellors could “debrief” and get support in their demanding work. 

2.2. Nurses and VCT 

None of the professional nurses in either the maternity or postnatal wards at Paarl General 

Hospital had VCT training. At the clinics some of the nurses have been trained in VCT, but 

others had not. 


2.3. Testing of Patients 

At Paarl General Hospital the Abbot Test was used as the first test for HIV/AIDS and the 

Parasheek as the second test. If the results were discordant blood was sent for an ELISA. 

The turn around time for an ELISA test was less than 24 hours and in fact, was usually the 

same day. 

All the clinics were using the Determine Test as the first test for HIV/AIDS and the Parasheek 

as the second test. If results were discordant blood was sent for an ELISA. The turn around 

time for an ELISA test at the clinics was two to four weeks. 

When Paarl was established as a pilot site for the PMTCT programme, training on testing was 

conducted. No formal training on testing has been conducted since this time. As a result, very 

few of the staff who are presently doing the testing had received any formal training. This was 

especially noticeable in the clinics where staff had recently been rotated. In the absence of 

formal training nurses teach one another at their respective clinics how the testing is done. 

If a woman is admitted to the maternity ward in early labour and has not been tested, she 

would be counselled and tested. However if she was in active labour and four centimetres or 

more dilated she would not be counselled and tested. 

No facilities have ever run short of Rapid Test Kits. The tests are distributed by the District 

HIV/STI/TB Coordinator. 

3. POLICIES AND GUIDELINES 

At all facilities the Western Cape revised edition of the PMTCT protocol could be quickly 

located. However none of the clinic staff were aware of the changes to the protocols for 

women on HAART. This was of concern as a number of women on the PMTCT programme 

were on HAART. All hospital staff interviewed were aware of the changes and concerned 

about the implications of HAART on the PMTCT program. 

4. REFERRALS 

Pregnant women who present at their local clinic are referred to TC Newman Hospital for 

antenatal care. No antenatal care was provided at the clinics. During ANC clinics pregnant 

women are encouraged to test for HIV. Those who tested positive and agreed to go on the 

PMTCT programme have a sticker documenting this information put into their antenatal cards. 

The sticker enabled maternity ward staff at the hospital to identify women on the PMTCT 

programme. 

Having delivered in the maternity ward of Paarl General Hospital women were transferred to 

the postnatal ward. On discharge the Road to Health Card (RTHC) of the baby was clearly 

marked with a sticker to enable clinic staff to identify that the baby was on the PMTCT 

programme and was given nevirapine. On discharge mothers were told to report to the “post 

natal ward” at the TC Newman Hospital within 3 days of having given birth. (This is in fact the 

outpatient ward of the Paarl General Hospital). At the postnatal ward at TC Newman Hospital, 

women and their babies were given a routine postnatal check up. PMTCT mothers were then 

referred to the “gynae ward” of the TC Newman Hospital before being discharged to the 

different PHC clinics. 


Staff at all facilities felt that the referral system was effective and the loss of patients was not 

due to problems in the referral pathway. As an outsider I found the referral pathway very 

complicated with so many steps that I wondered how many women got lost in between the 

different facilities which they had to go to. 

5. SERVICE INTEGRATION 

5.1. ANC and Child Health Services 

Both hospital and clinic staff feel that the PMTCT programme is well integrated into ANC and 

child health services. It appeared to be well integrated into the ANC services, but given the 

limited time available it was not possible to determine the extent to which it was integrated into 

child health services. 

5.2. ART Services 

Hospital staff were aware of the changes to the PMTCT protocol for women on HAART. Their 

major concern with the implementation of the PMTCT programme were the problems they were 

encountering in integrating HAART and the PMTCT programme. On admission to the labour 

ward many women do not have their ART tick sheet available and are unclear about their 

adherence to ART treatment. This has implications for the administration of nevirapine and 

thus negatively influences the PMTCT programme. 

6. RECORDING, MONITORING AND EVALUATION OF THE PMTCT PROGRAMME 

In the post natal ward at Paarl General Hospital the sister in charge was very efficient. All 

information related to the PMTCT programme was filed in one file, which made for easy access 

and efficiency. This included protocols, registers for VCT and choice of infant feeding as well 

as referral stickers for Road to Health Cards (RTHC). The registers were correctly filled in 

and up to date. Each month a form is filled in by the maternity and post-natal ward staff and 

submitted to the District HIV/STI/TB Coordinator. The following information is captured on this 

form: 

• The client’s name 

• Was the client given nevirapine? 

• Is the client on AZT? 

• What was the date of delivery? 

• The type of delivery? 

• Feeding option chosen? 

• AZT/nevirapine given to baby? 

• Mother’s address 

A newly developed register has been developed for clinic use and was referred to by one of the 

clinic sisters as “the new PMTCT baby register”. However this was only in use at one of the 

clinics visited. The “old PMTCT register” was still in use at one of the clinics. It captures the 

same data as the new register, but in a slightly different format. 

The following information is captured on “the new PMTCT baby register”: 

• The number of new babies arriving at the clinic 

• The number of babies on the PMTCT programme 

• The number of babies who died 

• The number of mothers who died 


• The number of babies exclusively breastfed 

• The number of babies exclusively bottle fed 

• Number of tins of formula dispensed 

• The number of babies receiving cotrimoxazole 

• The number of babies who had a PCR test at 14 weeks 

• The number of babies who had a PCR test at 14 weeks + 

• The number of babies who had PCR tests at 9 months, 12 months and 18 months 

On a monthly basis the District HIV/STI/TB Coordinator pulls together the data from the 

different facilities about the PMTCT programme to provide information on the PMTCT 

programme in the area. The detailed information is attached below as Appendix 1. The 

information in the table below could be derived from the data made available. The results of 

the PCR tests done on infants at 14 weeks were not available at the time of the investigation. 

The District HIV/ST/TB coordinator was not able to provide this information within three weeks 

of having completed the investigation. 

Indicators 

Values 

% of women given nevirapine during labour 86% 

% of newborns given nevirapine 99% 

% of newborns given AZT since the introduction of HAART in 

100% 

April 2004 

% of women opting to formula feed 82% 

N= 340 

7. COORDINATION, SUPPORT AND SUPERVISION 

The District HIV/STI and TB Coordinator was only appointed to her post in January this year. 

In addition two other staff responsible for oversight of the programme within the hospital and 

clinics were also appointed recently. The facility staff interviewed felt that given time these 

three new members of staff would soon be in a position to supervise and support them more 

actively. 

Hospital staff reported that they had been supported by the district in the past and been visited 

and informed by the district HIV coordinator of changes to the programme. However, they 

have never had any provincial support. At the beginning of this year a person was appointed at 

the hospital to be in charge of the PMTCT programme at the hospital and provide support to 

those in the hospital providing PMTCT related services. No support from the incumbent had 

been provided at the time this investigation took place. 

Clinic staff reported that they received support from the previous district HIV Coordinator who 

had left at the end of 2004. Since she left they have had no further support. Staff at TC 

Newman Hospital who were involved in the PMTCT programme felt supported by the new 

District HIV/STI/TB coordinator. 

Facility staff reported that the bimonthly PMTCT programme coordination meetings, but had not 

taken place for five months. However a meeting was planned for the week following this 

investigation. In the past these meetings were successful in minimising the problems that 

arose as patients moved from one facility to another and provided a forum where changes to 

the programme could be discussed. These meetings were attended by staff involved in 

PMTCT from the maternity ward, post labour ward, TC Newman Hospital and PHC clinics. 


8. HUMAN RESOURCES 

The District HIV/STI/TB Coordinator had received no formal training on the PMTCT 

programme. Initially she learnt about the programme when studying midwifery. Since this time 

she has received training informally at events such as the case study conducted weekly by the 

head of the HAART services in Paarl. She received informal training on the Rapid Test Kit 

from someone at TC Newman Hospital. She is now responsible for training all new staff in the 

district on all aspects of the PMTCT programme. 

Unfortunately for this investigation all clinic staff had been rotated a month before the 

investigation was conducted. It is normal practice within the local municipality that professional 

nurses at clinics are rotated every two years. As a result the staff interviewed, although 

responsible for the PMTCT programme at each clinic had very little knowledge of the 

programme. Only one clinic nurse interviewed had received formal training in the PMTCT 

programme. The other staff interviewed who were responsible for running the PMTCT 

programme from February 2005, had received no formal orientation or training to the 

programme. The one said: “I informed myself about the programme by reading.” A number of 

the other staff interviewed said they learnt about the programme from other staff at the facility. 

It was noticeable that the Paarl General Hospital staff who had been in their positions for much 

longer, were much more knowledgeable about the programme, its intricacies and problems. 

Staff in the hospital had attended a day long course on the PMTCT programme when it was 

first introduced. Since this time they had received ongoing in-service training from the District 

HIV co-ordinator on changes to the programme. 

9. PHARMACEUTICAL SERVICES 

9.1. Supply of Drugs 

No facilities had ever experienced a stock out of nevirapine tablets, nevirapine syrup or 

cotrimoxazole. Short supplies of stock were quickly replenished. The clinics reported that they 

no longer dispensed nevirapine tablets to women at the 28 th week of pregnancy. This was 

done to avoid confusion in the maternity ward, as it is often difficult for staff to determine 

whether a woman in labour had taken her nevirapine tablets or not. In the maternity ward 

women are now routinely given nevirapine tablets when they are four centimeters dilated. 

According to the protocol nevirapine tablets are not administered if a woman arrives in the 

labour ward with the head crowned. Nevirapine syrup is given to all babies whose mothers are 

enrolled on the PMTCT programme. 

The dispensing of nevirapine tablets and syrup is recorded in registers in the maternity ward. 

Cotrimoxazole is not given to babies in the hospital. These babies are referred to TC Newman 

Hospital for prophylactic cotrimoxazole. 


10. NUTRITIONAL SUPPLEMENTATION 

No facility reported that they had ever run short of either multivitamins or infant formula. On 

discharge mothers are given two tins of formula. They then get more formula from their local 

clinic. Although initially infant formula was supplied for a year, it is now supplied for six months 

only. 

11. LABORATORY SERVICES 

All facilities reported that they were satisfied with the laboratory services both for ELISA and 

PCR tests. The turn around time for an ELISA is less that a day within the hospital. It was 

surprising that in spite of the proximity of clinics to the hospital (no more than a ten minute 

drive) and the availability of telephones and faxes, the turn around time for an ELISA test at the 

clinics is between two and four weeks. 

PCR tests are done on infants at 14 weeks in the Western Cape to determine the infants are 

infected with HIV. Blood for these tests is drawn at the clinics and specimens are sent to the 

local laboratory. The turn around time for a PCR test is between one and three weeks. 


• A number of clinic sisters felt that the children on the programme deteriorate considerably 

when infant formula is no longer supplied after six months. Their recommendation was that 

the infant formula be supplied for a year. 

• The uncertainty around AGAPE and the lay counsellors should be resolved by renewing 

the contract and in future, renewing the contract timeously. 

• Professional nurses should be trained in VCT. 


DATA FROM PMTCT REGISTER 

Page 

Number 

TOTALS 

Transferin 

during 

labour 

On 

HAART 

FOR CLIENTS ON DUAL THERAPY 

ONLY (NOT HAART) 

Adequate 

AZT 

Antenatally 

(>2wks) 

Received 

NVP in 

labour 

Yes No Yes No 

AZT given 

in Labour 

Ward 

Live 

Birth 

Delivery Outcome 

Stillbirth 

BBA 

T/O in 

Labour 

Medication for Baby 

NVP 

Given 

AZT 

Given 

AZT 

TTO 

Feeding Choice on 

Discharge 

Column 1 5 6 7 8 9 10 16 17 18 19 20 21 22 23 24 25 

JAN 20 0 0 0 0 17 3 0 19 0 1 0 20 0 0 17 3 

FEB 29 0 0 0 0 27 2 0 27 0 2 0 29 0 0 21 8 

MAR 36 0 0 0 0 36 0 0 36 0 0 0 36 0 0 29 7 

TOTAL 85 0 0 0 0 80 5 0 82 0 3 0 85 0 0 67 18 

APR 30 0 0 4 26 24 6 22 26 0 4 0 26 26 26 27 3 

MAY 27 0 0 24 3 24 3 26 26 0 1 0 27 27 27 21 6 

JUN 27 0 0 26 1 26 1 26 28 0 0 0 28 28 28 21 7 

TOTAL 84 0 0 54 30 74 10 74 80 0 5 0 81 81 81 69 16 

JUL 20 0 0 17 3 17 3 18 20 0 0 0 20 20 20 16 4 

AUG 34 0 0 28 6 30 4 30 34 1 1 0 35 35 35 33 2 

SEP 22 0 1 16 5 18 3 17 20 0 2 0 22 22 22 16 6 

TOTAL 76 0 1 61 14 65 10 65 74 1 3 0 77 77 77 65 12 

OCT 25 0 0 10 15 19 6 10 24 0 1 0 25 25 25 19 6 

NOV 38 0 2 33 3 35 1 35 38 0 0 0 38 38 38 28 10 

DEC 32 0 1 23 8 21 10 23 31 1 1 0 32 32 32 28 4 

TOTAL 95 0 3 66 26 75 17 68 93 1 2 0 95 95 95 75 20 

TOTALS 340 0 4 132 70 294 42 207 329 2 13 0 338 253 253 276 66 

Formula 

Breast 


APPENDIX B4: FACILITY SUB-STUDY REPORT: RIETVLEI 

1. DISTRICT OVERVIEW 

Rietvlei Hospital was identified as one of the pilot sites for the PMTCT programme. The 

programme was started at Rietvlei Hospital in early 2001. Responsibility for the 

implementation of the programme has been the responsibility of both the Provincial Maternal 

and Child Health and the HIV/AIDs directorates. Umzimkhulu is one of the three sub-districts 

of Alfred Nzo district. In Umzimkhulu all services fall under the auspices of the Eastern Cape 

Provincial Health Department. 

Implementation of the programme within Umzimkhulu has been the joint responsibility of 

Rietvlei Hospital and the Umzimkhulu sub-district health office. Although the district office was 

responsible for the implementation of the programme at the fourteen PHC clinics in the area, 

Rietvlei Hospital has taken a leading role in the training and coordination of the programme. 

This investigation into the PMTCT programme within facilities in the Umzimkhulu sub-district 

was undertaken on three days early in March 2005. 

2. VCT 

2.1. Lay counsellors 

Five volunteers were attached to each clinic and the hospital. Most volunteers were trained in 

VCT. Those not trained received VCT training in early March 2005. The training was provided 

by PHC nurses within Umzimkhulu who have been identified and trained as VCT trainers. The 

training was two weeks long. The volunteers were supposed to be supported and monitored in 

their work by the clinic sisters at each clinic. However this does not happen. 

In addition to being counsellors a couple of volunteers at each facility were also trained as 

“Personal Sellers.” The personal sellers were trained by the South African Nurse Tutorial 

Services (SANTS). The training course was five days long and focused on HIV/AIDS 

education in the community. The personal sellers are expected to talk about HIV/AIDS in the 

community, promote VCT and encourage community members to access HIV/AIDS services 

via VCT. The Umzimkhulu HIV/AIDS Coordinator is expected to monitor the work of the 

personal sellers. Given her other responsibilities, she feels that she is unable to do this 

adequately. She expressed concern about the work of the personal sellers as the number of 

people accessing VCT services at the clinics had not increased since they started promoting 

VCT in the community. She felt that the training of the personal sellers could have been better. 

The volunteers are paid R500 a month. Their wages are from the Eastern Cape Department of 

Health channeled through the District Municipality. They were paid for six months work in 

2003, but have not been payed since then. Attempts have been made in the last month to 

address the problem, but administrative problems continue to plague the process of 

remuneration. Cheques made out to the volunteers could not be cashed as incorrect names 

were written on the cheques. 

Pre-test counselling was done exclusively by the volunteers. At some of the clinics and the 

hospital the volunteers also do the post-test counseling. The focus of the volunteers work was 


counseling and not ongoing support of people on PMTCT or ARV services. (The ARV 

programme only started recently in the district. It has not yet been rolled out to the clinics). All 

volunteers worked daily from Mondays to Fridays. At the hospital they work from 8.00 to 16.00. 

At some of the clinics they work from 8.00 to 13.00 and at others until later in the afternoon. 

Usually three volunteers remained at the clinic providing counseling services whilst the other 

two go out to the community to promote VCT. 

2.2. Nurses and VCT 

All clinic nurses are trained in VCT. The training on VCT was two weeks long and conducted 

by sub-district VCT trainers. This training included use of the Rapid Test Kit. Due to the 

constant rotation of staff, training for new staff is provided regularly. At the hospital, although a 

number of staff have been trained in VCT, they are scattered throughout the hospital, and at 

times no VCT trained staff are in the maternity ward. 

2.3 Testing 

At two of the clinics visited the staff were not clear about the protocol for testing patients. The 

Rapid Test Kits available at the clinics were First Response and Parasheek. The clinic which 

was clear about the protocol stated that they use the First Response test as the initial test and 

Parasheek as the confirmatory test. If the results were discordant, blood was sent for an 

ELISA. 

In the middle of 2004 Abbott tests were replaced with Parasheek tests. No explanation or 

demonstration was provided to the HIV/AIDs coordinator or the clinic supervisors on how the 

Parasheek tests worked. As a result, clinics were not able to do confirmatory tests for a couple 

of months last year. According to one of the clinic supervisors Rapid Test Kits also ran out at 

other times during last year. 

Most of the staff have received some training on how to use the rapid test kits. This training 

was provided in one of the following ways: 

• It formed part of the VCT training 

• It was demonstrated by the regional head of the National Health Laboratory Services 

• It was demonstrated by a person from the Regional Training Centre in Umtata 

The quality of support received from the laboratory was perceived differently at the different 

clinics interviewed. At one of the clinics the turn around time for an ELISA test was said to be 

one week and that results for all tests sent were received. At another the turn around time was 

said to be a month and results for only half of the tests sent were received. The third clinic was 

a mixture of both responses. 

2.4. Testing of Patients 

According to the clinic staff the PMTCT programme was well integrated into the antenatal care 

programme and all women attending antenatal care were encouraged to have a VCT test. 

However according to maternity ward staff at the hospital, a number of women arriving in 

labour had attended ANC but were not aware of VCT or the PMTCT programme. 

Women who arrive at the labour ward are counselled and tested if not in active labour. Initially 

even those in active labour were counselled and tested, but this is no longer the case. 


3. POLICIES AND GUIDELINES 

Three of the four facilities were able to locate either the protocol or a handout summarising the 

protocol with ease. In the Eastern Cape the age for testing children is one year. However, at 

two of the clinics, the knowledge of the protocol by the nurse interviewed was limited. For 

example, in the protocol the recommended dose of cotrimoxazole for infants is determined by 

weight and is given three times a week. However, two of the staff interviewed said the 

prescribed dose should be 5mls twice daily every day. However, it must be said, that at the 

clinics in Umzimkhulu, one person is in charge of PMTCT and at two of the clinics as this 

person was not present other staff were interviewed. 

4. REFERRALS 

4.1. Referrals from the clinics to the hospital 

All antenatal care services are conducted at the PHC clinics. According to clinic staff all ANC 

clients are informed about VCT and PMTCT services. For women who test positive the clinics 

mark the antenatal card with a code specific for each clinic or “RVD +ve”. Both codes used are 

known by the hospital and were agreed to at a quarterly PMTCT coordinating meeting between 

hospital and clinic staff. When nevirapine is given to a women, it is documented on the 

antenatal card. Hospital staff felt that this form of identification for referral purposes is sufficient 

and that they can identify women who have agreed to go on the PMTCT programme. 

4.2. Referrals from the hospital to clinic 

The hospital used two methods of referring patients back to the clinics. Firstly, letters are 

written to the clinic informing the staff that the mother was on the PMTCT programme and had 

been given nevirapine. Initially this letter was written in triplicate. The first copy was given to 

the mother, the second copy was sent to the district office and a third copy was kept in the 

ward. Now a single letter is written and given to the mother. Secondly, the outpatient and 

Road to Health cards (RTHC) are marked with a code and nevirapine administered is 

documented. 

Although clinic staff felt that the referral system from the hospital to the clinic functioned, the 

hospital staff were not as confident. Two concerns with the referral of women to the clinics 

were expressed: 

• At times clinic staff are not given referral letters. Maternity staff see mothers still holding 

onto the letter when they come back to the hospital outpatients department with ill children. 

• At times the code written by the hospital staff on the RTHC is scratched out. 

4.3. Tests for One Year Old Infants 

According to the protocol one year old infants on the PMTCT programme are supposed to have 

a rapid test to determine their HIV status. Infants are referred to the hospital for this test. It 

was not clear why children are referred to the hospital for this test and it is not done at the 

clinic. A number of the staff interviewed expressed concern as to why children were referred to 

the hospital for this test. Each of the three clinics visited expressed frustration that the hospital 

does not give them feedback on the results of these tests and that the only source of feedback 

they have is the mothers themselves. Considerable effort and time on the part of the 

researcher was necessary to try and trace the results of the rapid tests done on infants at one 


year. It has not been possible to locate this information even with the assistance of the 

regional head of laboratory services in the area. 

5. SERVICE INTEGRATION 

5.1 ANC and Child Health Services 

Clinic staff felt confident that the PMTCT programme is completely integrated into ANC 

services. The hospital staff were not as confident that this is the case. The district office staff 

claimed that PMTCT is fully integrated into child health services. Given the short time available 

for this sub-study, it was not possible to gauge the extent of this integration. 

5.2. ART Services 

The ART programme has been operational at Rietvlei Hospital since December. Thirty two 

patients so far have been enrolled on treatment. There was little integration between the ART 

and PMTCT programmes. The sister in charge of the ART clinic felt that the referrals from the 

clinics are very slow, as are the referrals from the maternity ward. She had been to the 

maternity ward to encourage the staff to refer PMTCT clients to the ARV clinic. However, at 

the time that the research was conducted, there were no PMTCT clients on ARVs. 

6. RECORDING, MONITORING AND EVALUATION 

6.1 Hospital 

Initially in the maternity ward there was a separate register for clients on the PMTCT 

programme. However, to increase confidentiality it was decided that PMTCT clients should not 

be recorded in a separate book. They should be recorded in the maternity register with all 

other deliveries. A red dot is used to identify PMTCT clients. In my opinion it is very easy to 

identify PMCT clients in the maternity register and the system is not confidential. 

No information on the PMTCT programme is submitted to the Sub-District Information Officer 

by the hospital. However, on a monthly basis the maternity ward submits data on the PMTCT 

programme to the Provincial Maternal and Child Health Directorate. This data includes six HIV 

related data elements: 

• Number of HIV results available on admission for delivery 

• Number of HIV tests done in the maternity ward 

• Number of women refusing to have an HIV test 

• Number of nevirapine doses given to women in labour 

• Number of live births to HIV positive women 

• Number of nevirapine doses to babies born to HIV positive women 

6.2. Clinics 

Monthly the clinics submit data on a number of data elements related to the PMTCT 

programme to the sub-district Information Officer at the Umzimkhulu Sub-District Office. These 

include: 

• Number of pregnant women tested for HIV 

• Number of pregnant women tested HIV positive 

• Number of pregnant women tested HIV positive reported taking NVP 


• Number of pregnant women tested HIV positive who received NVP 

• Number of pregnant women tested HIV positive whose infants got NVP 

• Infants of HIV positive NVP women receiving infant formula 

• Infants of HIV positive NVP women with exclusive breastfeeding 

• Infants of HIV positive NVP women HIV tested 

• Infants of HIV positive NVP women tested HIV positive 

• Cotrimoxazole eligible clients started – new 

• Cotrimoxazole receivers this month - total 

The Umzimkhulu HIV/AIDs director does not feel the figures are accurate, reliable or useful in 

any way. Numerous attempts were made to get this data from the sub-district information 

officer, to no avail. She was either out of the office or not in a position to assist me. 

6.3. Feedback 

Neither the hospital or clinic receive feedback or evaluation of the progress of the PMTCT 

programme at their facilities or within the Umzimkhulu sub-district. There is no information 

available on the outcome of the PMTCT programme in Umzimkhulu. 

7. COORDINATION, SUPPORT AND SUPERVISION 

When initiated as a pilot project, a coordinating committee for PMTCT in Umzimkhulu was set 

up. This committee comprised hospital, clinic and district office representatives and dealt with 

a number of issues such as setting up referral systems. However, this committee last met in 

October 2003, six months ago. 

When Rietvlei was first set up as a pilot project provincial support was provided. “The 

provincial PMTCT coordinator used to run in and out – not often – but she did come”. For over 

a year though, the district has had no PMTCT support visits from the province. 

At Rietvlei Hospital support and supervision of the PMTCT programme is provided by the 

matron in charge of maternity. In the rest of the Umzimkhulu sub-district from early 2001 to 

June 2004, the programme fell under the sub-district MCWH coordinator. However, since her 

appointment in June 2004, the sub-district HIV/AIDs coordinator has increasingly taken over 

responsibility for the programme. She continues to be supported by the MCWH coordinator. 

According to the Umzimkhulu MCWH coordinator, it is better that the PMTCT programme falls 

under the HIV/AIDS Coordinator, as she has direct access to the provincial HIV/AIDS 

directorate. The Umzimkhulu HIV/AIDS Coordinator attends quarterly HIV/AIDS directorate 

meetings where problems with the PMTCT programme are resolved more quickly than in the 

past. 

The Umzimkhulu HIV/AIDS Coordinator feels that she provides support to clinics by visiting 

them to discuss all HIV related services including PMTCT. She has visited four clinics in the 

last quarter. However none of the three clinics visited felt supported. The one clinic was last 

visited by the HIV/AIDS Coordinator eight months ago and the last time they got a support visit 

specifically for the PMTCT programme was 2003. The second clinic said they never get 

support visits. “We only get visits from people wanting information.” 


8. HUMAN RESOURCES 

When the PMTCT programme was started as a pilot programme, staff were provided with both 

orientation and training. The matron in charge of maternity attended a week at the UWC winter 

school conducted by Prof. Besser. On returning to Rietvlei Hospital, she passed on the 

information to other staff in the maternity ward and the sub-district. 

All the clinic staff interviewed had attended a three day training course on the PMTCT 

programme run by the Umzimkhulu PMTCT trainer who is stationed at the hospital. At this 

training course they received a handout summarising the protocol. In addition they had all 

attended a training two week training course on VCT which included use of the rapid test kit. 

Both the hospital and sub-district office staff interviewed mentioned that a rapid turn over of 

staff limited the success of the programme. No sooner were all staff trained than another 

professional nurse left and was replaced by someone needing training in both VCT and 

PMTCT. Training in PMTCT and VCT was ongoing but difficult given the staff shortages within 

Umzimkhulu. The following problems arise when training is planned: 

• The PMTCT trainer is from the hospital. If she conducts training there is often no one left 

in the maternity ward who knows about the PMTCT programme. 

• Staff from the hospital cannot be sent on the training as there is a shortage of staff in the 

wards. 

• Clinics may have to close for the duration of the course as there are no additional staff to 

relieve staff who are being trained. 

9. PHARMACEUTICAL SERVICES 

9.1. Supply of Drugs 

Nevirapine 

The hospital had never run out of either nevirapine tablets or syrup. According to the national 

protocol (Version 5, 23 May 2001) clinics should be supplied with both nevirapine tablets and 

syrup. However, the clinics in Umzimkhulu had never been supplied with nevirapine syrup for 

two reasons: 

• They do not routinely do deliveries. 

• Nevirapine is only supplied in big bottles, most of which would expire before use if 

distributed to individual clinics. 

Women in the sub-district who were on the PMTCT programme, who had not delivered in the 

hospital, were expected to travel to the hospital to get nevirapine syrup for their babies. This in 

my opinion is not an acceptable practice. Women deliver at home usually as a result of 

transport problems. To expect a woman who has just delivered to pay up to R60 to travel to 

the hospital for nevirapine syrup is unrealistic. In the community it is now acceptable practice 

for women who have just delivered to take their babies to the clinics for immunisations. If the 

clinics were stocked with nevirapine syrup, women on the PMTCT programme could be 

encouraged to take their children to the clinics within 72 hours of delivery to ensure that their 

babies can get nevirapine syrup. 


The lack of initiative and application by the district pharmacist is discouraging. To avoid 

possible wastage of nevirapine syrup at the clinics, the syrup could easily be decanted into 

smaller bottles of one or two doses for distribution to the clinics. 

Problems with the supply of nevirapine tablets to the clinics was a frustration mentioned by all 

staff interviewed. Two of the clinics said that they had not had nevirapine tablets in stock for a 

year, in spite of asking for these on numerous occasions. According to the Umzimkhulu 

HIV/AIDS Coordinator the pharmacist has two reasons for not providing nevirapine tablets to 

the clinics. Firstly as the tablets issued had expired at a number of clinics he thought, that 

should he issue more, these too will expire. Secondly, he wanted to design a recording system 

for the dispensing of nevirapine. 

The HIV/AIDS Coordinator was extremely frustrated with the pharmacist who she found 

inflexible and “he moves sooooo (sic) slow”. Although she had taken this up with the subdistrict 

manager, the issue was still unresolved. Every person interviewed recommended a 

small regular supply of nevirapine as essential for improving the PMTCT programme in the 

sub-district. 

Cotrimoxazole 

Neither the hospital nor clinics had ever been short of cotrimoxazole. On discharge from the 

hospital, mothers on the PMTCT programme were given a month’s supply of cotrimoxazole for 

their babies. The clinics also supplied cotrimoxazole for these infants on a regular basis. 

However two of the clinics did not know the correct dosages for cotrimoxazole for babies on the 

PMTCT programme. They both reported that they would prescribe co-trimaxozole 5mls twice a 

day although the protocol recommends cotrimoxazole 5mls three times a week on a Monday, 

Wednesday and Friday. 

9.2. Drug Management 

Within the hospital both the nevirapine tablets and syrup were kept in the schedule 6 and 7 

drug cupboard. The dispensing of these drugs was recorded in the schedule 6 and 7 drug 

register. 

All clinics reported that they recorded the dispensing of both nevirapine tablets and 

cotrimoxazole. One clinic had a separate register for both drugs. The second clinic used to 

have a register for nevirapine “but it is lost as we haven’t had to use if for long (sic).” They 

recorded the dispensing of cotrimoxazole in the tick register. At the third clinic both drugs 

dispensed were recorded in the tick register. 

10. NUTRITIONAL SUPPLEMENTATION 

In the Eastern Cape the policy is that infant formula is provided for a year to children on the 

PMTCT programme. The disruption to supplies of infant formula was expressed by everyone 

interviewed as a major problem. Within the last twelve months (February 2004 to February 

2005) infant formula was unavailable for a number of months at each clinic. By checking the 

register where the dispensing of tins is recorded it was possible to determine that at the first 

clinic infant formula had been unavailable for five months. At the second clinic it had been 

unavailable for six months and at the third clinic it had been unavailable for eight months. 


Each clinic had a register in which the number of tins given to each client on the PMTCT 

programme was documented. At one of the clinics, since August last year, only four tins of 

formula were given to each client instead of the recommended eight tins. When asked why this 

was done, the sister interviewed said it was because there was a backlog and so many clients 

needed formula after the last period of not having had formula available. 

The disrupted supply of infant formula was of great concern to all those interviewed. In further 

discussion around the problem, staff mentioned that the problem was further confounded by 

the unavailability of pelargon at local stores in the area for the last few months. 

According to the HIV/AIDS Coordinator the problem with the supply of infant formula occurred 

at a provincial level and had arisen due to problems around the renewal of the contract. 

In my opinion this is a major problem which must be addressed as a matter of urgency. The 

health department is behaving irresponsibly and unethically by persuading mothers to formula 

feed by giving them infant formula and promising to provide this for up to one year. However 

not only are mothers unable to get more milk from the clinics, but they cannot even buy it at the 

shops. 

Two of the clinics mentioned that mothers who agreed to exclusively formula feed had often 

started to mix feeds on returning home from the hospital. In addition mothers who agreed to 

exclusively breast feed had been unable to stop breast feeding at three months without mixing 

feeds at this time. They was done to minimize suspicions from family members who assumed 

the sudden cessation of breast feeding was because the mother was HIV-positive. 

11. LABORATORY SERVICES 

Those interviewed at the hospital felt satisfied with the laboratory services. The turn around 

time at the hospital for ELISA tests is a couple of days. The opinion of the clinics regarding the 

support of the laboratory services was less positive. The turn around time varied from one to 

three weeks at the different clinics interviewed. In addition frustration was expressed about 

specimens which were sent in December and January to the laboratory, but no results were 

ever received. On discussion with the Umzimkhulu TB coordinator it appears that the turn 

around time does vary as the laboratory is short staffed. The problems experienced over 

December and January were as a result of this. 


12.1 Pharmaceutical Services 

• Nevirapine tablets should be available at all clinics all the time. 

• Clinics should keep small quantities of nevirapine syrup to administer to newborns on the 

PMTCT programme who are born at home. 

• A recording system to monitor the dispensing of both nevirapine tablets and syrup should 

be developed and introduced to all clinics. 

• Clarification on the recommended doses of cotrimoxazole for infants on the PMTCT 

programme is necessary for clinic staff. 


Nutritional Supplementation 

• Infant formula should be available at all clinics all the time. 

• The message regarding feeding options should be clarified and simplified. 

VCT 

• Rapid test kits and confirmatory tests should be available at all clinics all the time. 

Referral System 

• Links between the hospital and clinics need to be strengthened. 

• The referral system must be tightened to reduce the number of patients who get lost. 

Follow Up at One Year 

• Infants of one year old should be tested at their clinic and not referred to the hospital. This 

would facilitate the follow up of children on the programme. In addition it would make it 

possible to measure more effectively the outcome of the programme. 

Clinic Services 

• The PMTCT programme should be more actively promoted at a clinic level, so that all 

mothers attending antenatal care are educated fully about the PMTCT programme. 

Coordination of the Programme (My suggestion) 

• To implement the recommendations of the staff which are listed above, quarterly 

coordination meetings should be instituted. 

DATA AVAILABLE FROM RIETVLEI HOSPITAL – March to September 2003 

Number of live births born Nevirapine given to 

mothers 

Nevirapine given to 

babies 

March 174 24 25 

April 172 27 33 

May 178 14 22 

June 209 20 30 

July 212 15 29 

August 171 10 20 

September 276 23 14 

Total 1392 133 173 


APPENDIX B5: FACILITY SUB-STUDY REPORT: 

SUMMARY 

THEMES PAARL RIETVLEI 

VCT Lay Counsellors 

Lay Counsellors 

• Lay counsellors trained by a private psychologist for a month. 

• Lay counsellors trained for two weeks by VCT trainers from the sub-district. 

• Counsellors supported, supervised and monitored by an NGO. They work 

part-time only (usually only in the mornings). 

• Five lay counsellors are attached to each facility to provide counseling from 

8.00 – 16.00 on weekdays. 

• Once a month they have a debriefing session with a psychologist. • Lay counsellors supposed to be supported, supervised and monitored by 

• Two weeks before the start of the new financial year, funding of the NGO 

had not been confirmed by PAWC. 

the clinic sisters, but they have never been told how or what to supervise, 

support or monitor. 

• Remuneration is through the District Municipality, but has been problematic. 

The counsellors were last paid in 2003. 

• Personal sellers have recently started work. They promote VCT in the 

community. The sub-district HIV/AIDS Coordinator is to supervise and 

monitor their work, but she is usually unavailable. 

Professional Nurses 

• PNs are not routinely trained in VCT. 

Testing using Rapid Test Kits: 

Tests Used 

Hospital: 1 st test = Abbott Clinic: 1 st test = Determine 

2 nd test = Parasheek 2 nd test = Parasheek 

Confirm = Elisa Confirm = Elisa 

Turn Around Time for an Elisa 

• Hospital: 1 – 2 days 

Professional Nurses 

• All PNs are trained in VCT. However, staff turnover is a problem. No 

sooner are all staff trained than someone leaves and more training has to be 

organized. 

• In the hospital a number of staff in the maternity ward have been trained, but 

due to staff rotation there can be times when no one in the maternity ward 

has VCT training. 

• As part of the VCT training staff are trained how to use rapid test kits. 

Additional training on the use of rapid test kits has been done. 

Testing: 

Tests Used 

Hospital: Not sure Clinic: 1 st test = 1 st Response 

2 nd test = Parasheek 

Confirm = Elisa 

Turn Around Time for an Elisa 

• Hospital: 1 – 2 days 



• Clinics: 2 – 4 weeks 

VCT 

VCT 

POLICIES 

AND 

GUIDELINES 

REFERRAL 

PATHWAY 

Stock outs of Rapid Test Kits 

• Never 

Patients in the Maternity Ward 

• All patients who have attended ANC have been told about the PMTCT 

programme. Those that agree to go on the programme have had VCT. 

• At all facilities the revised edition of the protocol in the Western Cape could 

be located by the staff. 

• All hospital staff were aware of the changes to the protocol since the 

introduction of the HAART programme. 

• The integration of the HAART and PMTCT programmes was a major 

concern to hospital staff as many patients do not arrive at the maternity 

ward with their ART tick sheet available, so that their adherence to ART 

treatment is unclear. 

• Although the clinic staff had the revised edition of the protocols none of 

them were aware of the changes since HAART began. 

• The referral pathway is complicated: 

- Pregnant women are all referred from their local clinic to TC Newman 

Hospital for ANC. 

- After delivery patients are discharged and have to go to the post-natal 

ward at TC Newman Hospital. PMTCT clients are referred from here to 

the “gynae ward” at TC Newman and eventually are referred to their 

local clinic 

• Transferring information between the hospital and clinics is both effective 

and efficient: 

- Small stickers or pieces of paper with all relevant information are 

• Clinics: 2 weeks 

• However, over December and January due to shortage of staff in the lab, 

the TAT was over a month. 

• Results for some tests “get lost” 

Stock outs of Rapid Test Kits 

• Have had stock outs of rapid test kits. 

• Last year when Parasheek test kits were brought in to replace the Abbott 

ones, no one taught the staff what to do, so no 2 nd tests were done for a 

couple of months. 

Patients in the Maternity Ward 

• Staff in the maternity ward say that many of the women who have attended 

ANC in the sub-district have not been told about the PMTCT programme or 

had VCT. 

• At all facilities a protocol or summarised version of the protocol could be 

located by the staff. 

• At two clinics staff did not know the correct dosage of cotrimoxazole which 

should be given to infants prophylactically. 

• The referral pathway is simple from the local clinic to the hospital for the 

delivery and then back to the local clinic. 

• Transferring information is less effective: 

- In referring pregnant women from the clinic to the hospital, ANC cards 

are marked with a code which identifies from which clinic the woman 



attached by the clinic staff to the ANC card for the information of the 

comes. This appears to work relatively well. 

maternity ward staff. 

- In referring children on the programme back to the clinic, RTHCs are 

- Similarly small stickers or pieces of paper with all relevant information 

are attached by the maternity ward staff to the RTHC and ANC card for 

the information of the clinic staff. 

marked with a code and a referral letter is written. However, no 

duplicate of this letter is kept so the referral relies on the patient. Often 

maternity ward staff see mothers returning to the hospital with sick 

children with this letter. Staff fear that stigma in the community 

contributes to mothers not taking their children back to the clinics. 

• Infants at one year are referred back to the hospital for a rapid test kit to 

determine whether they are HIV positive or not. No one could explain why 

this test is not done at a clinic level. 


THEME PAARL RIETVLEI 

ROUTINE 

MONITORING AND 

EVALUATION 

HUMAN 

RESOURCES 

CO-ORDINATION, 

SUPPORT, 

SUPERVISION 

PHARMACEUTICAL 

SERVICES 

NUTRITIONAL 

SUPPLEMENTATION 

LABORATORY 

SERVICES 

• No information on transmission rate to children at 14 weeks 

• 86% of women delivering at hospital receive nevirapine 

• 99% of newborns administerd nevirapine 

• 100% of newborns given AZT since April 2004 

• 82% of women opting to formula feed 

• Hospital staff very knowledgeable about PMTCT programme. 

• All clinic staff were newly rotated at the time of the investigation so 

they were new to the PMTCT programme and have not received any 

training about the programme. 

• Clinic staff appear to “specialize” and the person allocated to 

PMTCT becomes an expert whilst others know very little about the 

programme. 

• No bimonthly PMTCT coordinating meeting held for five months. 

Meeting scheduled with agenda set for week after investigation 

• Newly appointed District HIV/STI/TB Coordinator and two PMTCT 

support staff (one in the hospital) have not received any training on 

PMTCT. 

• Supervision and support at facilities has been lacking over the last 

few months due to the replacement of the previous coordinator. 

• There has never been a shortage of a nevirapine or cotrimoxazole 

• Nevirapine tablets are not stocked at the clinics anymore 

• Is supplied to infants on the programme for 6 months 

• Never a shortage 

• Staff satisfied with quality 

• TAT for an ELISA 2 – 4 weeks 

• TAT for a PCR 1 – 3 weeks 

• No information on transmission rate to children at 12 months 

• 10% of women who delivered at Rietvlei hospital receive nevirapine 

• 12 % of newborns born at Rietvlei administered nevirapine 

• No other data available 

• Considerable training and support was provided when Rietvlei was launched 

as a pilot site. Provincial support has since dried up. 

• Training is provided regularly by the PMTCT trainer of the sub-district due to 

the rapid turnover of staff. This is however, very disruptive of services both 

in the maternity ward and in the clinics. 

• Clinic staff appear to “specialise” and the person allocated to PMTCT 

becomes an expert whilst others know very little about the programme. 

• PMTCT programme falling under HIV/AIDS directorate. 

• No support for PMTCT provided to clinics. 

• PMTCT coordinating meeting not held for 6 months. Present coordinator 

about to leave. A replacement has been identified. 

• No nevirapine tablets at clinics for a year 

• Nevirapine syrup has never been supplied to clinics (bottle is too big) 

• Is supplied to infants for 12 months. 

• Shortage last year for up to 8 months. 

• One clinic supplying 4 instead of the recommended 8 tins. 

• Staff not satisfied with quality 

• TAT 1 – 3 weeks 

• TAT over December a month and results got lost due to a shortage of staff 

in the lab

COMMUNITY BASED SITUATIONAL ANALYSIS Maternal and ...

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