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Background and status of (inter)national research: Dermatological conditions are widely prevalent worldwide and have a physical, psychological, and social burden for patients. Existing patient-reported outcome measures (PROMs) do not comprehensively capture the full impact that patients experience due [for full text, please go to the a.m. URL]

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Gert Sibande District is a predominantly rural district in Mpumalanga Province, South Africa (SA), with a population of just over 1.1 million. It has a high prevalence of HIV infection and pregnancy-related hypertensive disease. In 2010 the district was one of the worst-performing health districts in SA, with a maternal mortality ratio of 328.0 per 100 000 births. Various programmes were introduced between 2010 and 2017 to address major causes of maternal and perinatal morbidity and mortality in the district. The focus has been on HIV-related morbidity, the direct obstetric causes of maternal and perinatal morbidity and mortality, and health systems strengthening. During the period 2010 - 2017, there was a steady decline in institutional maternal mortality with a drop of 71% in maternal deaths over a period of 6 years, from 328.0 per 100 000 births to 95.0. However, the ratio levelled off in 2016 and 2017, mainly as a result of a changing disease profile. The stillbirth rate showed a decline of 24.4% over a period of 8 years. With perseverance, rapid response and evidence-based strategies it was possible to more than halve the institutional maternal mortality ratio within 6 years. However, with the changing disease profile, conditions such as hypertensive disease in pregnancy should be prioritised and new strategies developed to further reduce maternal and perinatal mortality and morbidity.

BACKGROUND: South Africa did not meet its Millennium Development Goals with regard to the reduction in maternal and under-5 mortality. Furthermore, many birthing women do not receive intrapartum care with empathy and endure disrespectful and abusive care.OBJECTIVES: To implement a multicomponent, context-specific intervention package to change the complex interplay between preventable maternal and perinatal mortality and morbidity and poor clinical governance and supervision in midwife-led labour units.METHODS: A mixed-methods intervention study was conducted in Tshwane District, South Africa, in 10 midwife-led obstetric units (MOUs), from which a purposive sample consisting of five units was selected for the intervention. The intervention took place in three phases: (i) baseline measurement; (ii) implementation of the so-called 'CLEVER' intervention package in the five intervention units, based on the results of the first phase; and (iii) a review of health systems improvements and perinatal outcomes. The intervention had three pillars: (i) feedback of the baseline measurement to the intervention units to raise awareness and solicit participation; (ii) health systems strengthening; and (iii) intensive weekly engagement for 3 months, with further monthly support afterwards. Observation of barriers during baseline activities contributed to the health systems strengthening and improvement strategies during implementation.RESULTS: Perinatal outcome indicators for the year before the intervention were compared with data for the year in which the intervention took place and the year after the intervention. Significant declines were observed in in-facility fresh stillbirths, meconium aspiration and birth asphyxia in the intervention MOUs from 2015 to 2017. The control group showed some decline during the period owing to support from district clinical specialist team members.CONCLUSIONS: CLEVER as a context-specific, multicomponent, clinically focused intervention package may have contributed to improved perinatal morbidity and mortality rates in MOUs.

Objective. To describe the prevalence and natural history of absent end-diastolic velocities (AEDV) in the mnbilical artery of the fetus between 16 and 24 weeks' gestation, and to evaluate its role as a screening test.Design. Population-based descriptive study.Setting. Tygerberg Hospital, Tygerberg, South Africa. The hospital serves a population from the lower socio-economic bracket.Subjects. Doppler velocimetry was performed at routine ultrasound examinations for confirmation of gestational age in 496 women.Main outcome measures. The occurrence of perinatal death, small-for-gestational-age (SGA) babies and proteinuric hypertension.Results. Forty-four (8,9%) patients had AEDVs at the first examination, but AEDV persisted in only 1. In this case, severe proteinuric hypertension developed unexpectedly at 29 weeks' gestation and the fetus needed delivery because ofpersistent late decelerations of the fetal heart rate pattern. There was a significant association between the group with AEDV at first examination and the development of proteinuric hypertension (P

Objective. To establish the effectiveness in an indigent urban population of Uricult Trio as a screening test for asymptomatic bacteriuria in pregnancy and in diagnosing urinary tract infections (UTI) in symptomatic pregnant women. likelihood ratios were established for positive and negative Uricult Trio test results.Subjects. Two populations of patients from the Pretoria region were involved: (J) asymptomatic pregnant women attending the antenatal clinic for the first time or presenting in labour; and (iI) pregnant women with symptoms suggestive of UTI.Method. A midstream urine specimen was collected from the two populations of patients, plated onto the Uricult Trio and sent to the laboratory for culture.Results. The prevalence of asymptomatic bacteriuria in this population was 23%, and for women with symptoms suggestive of UTI, 29%. The likelihood ratios for a positive test were 1.8 and 1.5 for asymptomatic and symptomatic patients respectively. The likelihood ratios for a negative test were 0.35 and 0.44 for asymptomatic and symptomatic patients respectively. Escherichia coli was the causative agent . in 36% of cases.Conclusion. Uricult Trio is not effective as a screening test for asymptomatic bacteriuria in pregnancy or for diagnosing UTIs in women with symptoms suggestive of infection.

Objective. To introduce a pregnancy confirmation clinic as part of antenatal care and to determine whether this would alter the gestat:!-0nal age at which patients commence antenatal care.Setting. Three municipal antenatal clinics in Atteridgeville and Central Pretoria.Method. A pregnancy confirmation clinic was set up at three sites. At the clinic any woman wishing to confirm whether she was pregnant was offered a urine [3-HCG test. If this test was positive, on-site testing for syphilis, anaemia and rhesus status, dipstick testing of the urine, clinical examination and ultrasound examination were performed. Women with abnormal test results were commenced on appropriate treatment immediately and women requiring further medical care or investigation were referred appropriately.Results. The study recruited 382 women, 145 of whom were defaulters from contraception. Half of the women (191) had a positive pregnancy test. The mean presenting gestational age was 12 weeks 4 days (standard deviation 5 weeks, range 5 weeks - 25 weeks 2 days). Treatable conditions with the potential to influence pregnancy outcome were identified in 37 of the pregnant women (19.4%) Forty-three of the pregnant women intended to terminate the pregnancy.Conclusion. It is possible to shift the commencement of antenatal care to an earlier gestational age.

BACKGROUND. There are several factors in the healthcare system that may influence a woman's ability to access appropriate obstetric care. OBJECTIVE. To determine the delays/barriers in providing obstetric care to women who classified as a maternal near-miss. METHODS. This was a descriptive observational study at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. One hundred maternal near-misses were prospectively identified using the World Health Organization criteria. The 'three-delays model' was used to identify the phases of delay in the health system and recorded by the doctor caring for the patient. RESULTS. One or more factors causing a delay in accessing care were identified in 83% of near-miss cases. Phase I and III delays were the most important causes of barriers. Lack of knowledge of the problem (40%) and inadequate antenatal care (37%) were important first-phase delays. Delay in patient admission, referral and treatment (37%) and substandard care (36%) were problems encountered within the health system. The above causes were also the most important factors causing delays for the leading causes of maternal near-misses - obstetric haemorrhage, hypertension/pre-eclampsia, and medical and surgical conditions. CONCLUSIONS. Maternal morbidity and mortality rates may be reduced by educating the community about symptoms and complications related to pregnancy. Training healthcare workers to identify and manage obstetric emergencies is also important. The frequency of antenatal visits should be revised, with additional visits in the third trimester allowing more opportunities for blood pressure to be checked and for identifying hypertension.