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International Journal of Africa Nursing Sciences
journal homepage: www.elsevier.com/locate/ijans
Assessment of the use of the new maternity case record in improving the quality of ante natal care in eThekwini District, KwaZulu-Natal
CrossMark
Maureen Nokuthula Sibiyaa'*, Reginah Jabulisile Cele5,1, Thembelihle Sylvia Patience Ngxongo
a Department of Nursing, Durban University of Technology, PO Box 1334, Durban 4000, South Africa b eThekwini Municipality, Department of Health, 9 Archie Gumede Street, Durban 4000, South Africa
ARTICLE INFO
Article history:
Received 19 October 2014
Received in revised form 7 April 2015
Accepted 22 April 2015
Available online 30 April 2015
Keywords:
Maternity case records Midwives Record review Antenatal care
ABSTRACT
The national guidelines for maternity care in South Africa recommend that a standardised maternity case record be used by all facilities at all levels of care in order to improve the quality of care for pregnant women. This will facilitate continuity and quality of care for women during pregnancy, labour and post-partum. The aim of the study was to assess the use of the maternity case record in improving the quality of the antenatal care for pregnant women. An exploratory, descriptive study using both quantitative and qualitative design was used to conduct the study. Data was collected through a retrospective record review using a checklist for the quantitative strand, and from midwives using unstructured interviews for the qualitative strand. The quantitative data set was analysed using the Statistical Package for the Social Sciences version 21.0 and the qualitative strand was analysed using the Tesch's method of data analysis. The results of the record review revealed that although the recording was done fairly well, there were a number of activities and interventions that were recorded poorly or not recorded at all in some primary health care clinics. The midwives verbalised that many mistakes and mismanagement of ante-natal care clients emanated from the structure and the design of the new maternity case record. © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
1. Introduction
According to the World Health Organisation (WHO), the maternal mortality ratio in developing countries in 2013 was 230 per 100,000 live births versus 16 per 100,000 live births in developed countries (WHO, 2014). The WHO further states that most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known, and lists the need for pregnant women to have access to antenatal care in pregnancy as one of the solutions. In South Africa, the National Department of Health introduced the Basic Antenatal Care approach during 2007 to be implemented by all primary health care (PHC) facilities rendering antenatal care services (Department of Health, 2008). A traditional approach to antenatal care was used before the introduction of the Basic Antenatal Care approach. In the traditional approach, a low-risk pregnant woman's gestational age determines the intervals between clinic visits, whilst in the Basic Antenatal Care approach the visits are all six weeks apart irrespective of ges-tational age. The Basic Antenatal Care approach focuses on the
* Corresponding author. Tel.: +27 31 373 2606. E-mail addresses: nokuthulas@dut.ac.za (M.N. Sibiya), ndosirjabu@gmail.com (R.J. Cele), thembelihlen@dut.ac.za (T.S.P. Ngxongo). 1 Tel.: +27 31 307 7023.
quality rather than quantity of antenatal care visits, and emphasises that antenatal care visits should be limited and goal directed. The traditional approach involves up to twelve antenatal care visits during one pregnancy (Pattinson, 2005, 2007).
The South African Department of Health recommends that a standardised maternity case record be used by all PHC facilities that are providing maternity services (Department of Health, 2010a). The intention is to improve maternity care services during pregnancy, child birth and postnatal care with the ultimate goal of reducing the number of maternal deaths and untoward pregnancy outcomes. Various strategies have been put in place to curb the problem of high maternal and perinatal mortality, amongst which is the inclusion of Maternal Child and Women's Health services as the priority programme in the country's strategic plan (Department of Health, 2010b).
In 2010, the South African Department of Health introduced the new standardised maternity case record as one of the key interventions to improve the care of pregnant women. It is meant to provide a comprehensive record that will be used uniformly and fill the gaps that were evident in the previously used documents. It is envisaged that the use of the case record will overcome unnecessary delays of action/intervention, thereby enabling clear problem recognition which will lead to prompt management with one case record used by all levels of care (Department of Health, 2010a). The case record
http://dx.doi.org/10.1016/j.ijans.2015.04.002 2214-1391/© 2015 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
is given to the woman as a client-held record and should only be retained in the delivery institution on discharge after birth, once a composite discharge summary has been written. The card is designed in such a way that it facilitates the integration of services. The components of the card provide for implementation and recording of TB, HIV, sexually transmitted infections and cancer screening services. These are amongst the conditions that contribute to maternal and perinatal deaths in the country.
2. Maternal mortality rates in South Africa
South Africa has a persistently high maternal and perinatal mortality rate. According to the National Perinatal Morbidity and Mortality Report 2008-2010, there has been no change over the past five years (Department of Health, 2011). This is supported by the results of the Saving Mothers Report 2008-2010 which states that maternal mortality rate has increased when compared with the 2005-2007 report. During 2008-2010, a total of 4867 maternal deaths were reported (National Committee for Confidential Enquiry into Maternal Deaths [NCCMD], 2011). HIV is one of the major challenges facing South Africa today. According to the Saving Mothers Report by the NCCMD, HIV status was unknown in 63.6% of maternal deaths (National Committee for Confidential Enquiry into Maternal Deaths., 2011). HIV prevention services and family planning are also to be prioritised, as is the need to integrate health services for women, new-borns and children. Prevention of termination of pregnancy in adolescents or teenagers is a specific focus recognising that this is the major contributor to maternal and neonatal mortality (Burton, 2013.
The maternity case record is a new intervention to be implemented by midwives, and this necessitates that reorientation of the midwives be done in order to ensure correct and accurate implementation of these two interventions. The NCCMD highlights in the Saving Mothers report the importance of strengthening corrective measures in the province of KwaZulu-Natal (KZN). KZN province has been identified to be amongst the provinces with the highest number of maternal deaths (National Committee for Confidential Enquiry into Maternal Deaths, 2011: 28). eThekwini is the largest and the most densely populated district in KZN and the third-largest city in South Africa. It is therefore, critical that the KZN Department of Health should comply with the appropriate guidelines if it is to succeed in its endeavours to improve the maternal and child health of its citizens.
3. Aim of the study
The aim of the study was to assess the use of the maternity case record in improving the quality of the antenatal care in eThekwini District in the province of KZN in South Africa.
4. Objectives of the study
The objectives of the study were to:
• Describe the midwives' documentation and use of the new
maternity case record during antenatal care service provision.
• Explore the views of the midwives with regards to the new
maternity case record card.
5. Methodology
5.1. Design and data collection
An exploratory, descriptive study using both quantitative and qualitative designs was used to conduct the study. The study was
conducted in two phases. Quantitative design was used in phase 1 and qualitative design used in phase 2. During the quantitative phase a review of maternity case records was conducted. The purpose of this phase was to assess how the midwives were using and documenting the new maternity case records during antenatal care service provision. A descriptive qualitative design was employed during the second phase of the study. The researcher used the qualitative design to gather information from midwives regarding the use of the new maternity case record. Semi-structured interviews were conducted with midwives who were working in PHC clinics.
5.2. Area of study
The study was conducted in the eThekwini District which is one of the eleven districts of the KZN province in South Africa. The antenatal care services for the general public in eThekwini are provided mainly in the PHC facilities. The PHC facilities in the eThekwini district are situated across the three sub-districts to ensure access and equitable distribution of the service to all people of the eThekwini district. There are 45 PHC clinics in the South, 28 in the West, and 29 in the North sub-districts. The health care services in the eThekwini District are jointly provided by the KZN Provincial Health Authority and the eThekwini Municipality. Only the municipality PHC clinics were included in this study.
5.3. Sampling process
A three-phased sampling method was used, which included identification of the PHC facilities, sampling of clinic records which consisted of the maternity case records, and sampling of the midwives.
Phase 1: A total of 15% (n = 6) PHC clinics were included in the study, with a total of two PHC clinics included from each sub-district. Monthly statistics for a period of one year (from June 2012 to May 2013) were used. The 31% (n = 18) PHC clinics with a total of less than 50 monthly antenatal care client caseloads were excluded from the study. The sample was gathered from the 69% (n = 41) PHC clinics with a monthly antenatal care client case load of 50 or more clients per month. These clinics were grouped according to the three sub-districts as follows: there were 21 PHC clinics in the South (S), fourteen in the North (N), and nine in the West (W) sub-district. A total of two PHC clinics were randomly selected from each group to give a total of 15% (n = 6) of PHC clinics that were included in the study.
Phase 2: This phase included selecting the records to be reviewed. Purposive sampling of the new maternity case records for the pregnant women who had already had two or more antenatal care visits was done. Reviewing the maternity case record after the midwives have documented more than one consultation record afforded the researcher a better picture of how the maternity case record was used. The records were only for the pregnant women who were attending antenatal care clinic at the time of the study, and only the new maternity case records were sampled. A total of 50 maternity case records were selected in each PHC clinic to give a total of 300 maternity case records for the entire study.
Phase 3: This phase involved sampling of the midwives to be included in the study. Purposive sampling of the midwives who were involved in provision of antenatal care services was done. The inclusion criterion included all midwives working within antenatal care with experience of two years and above. The principle of data saturation was adopted during the study. Sample size in qualitative research is determined by data saturation with no specific rules for sample size (Polit & Beck, 2012). A total of 17 interviews were conducted.
5.4. Data collection process
Data collection was conducted in two phases, namely Phase 1: Retrospective record review; and Phase 2: Interviews with the midwives. A retrospective review of maternity case records of women attending antenatal care at the time of study for a period of three months was conducted. The purpose was to assess the use and documentation of the records. A checklist adapted from Basic Antenatal Care audit tool was used to do a retrospective record review. During Phase 2, semi-structured interviews were conducted. The interviews were conducted by the researcher in a private room at the PHC clinic where the midwives were working during the time that was convenient to the midwives. The minimum time taken for the interview was 20 min and the maximum was 30 min. The researcher used an interview guide with a number of predetermined/guided questions to keep the interview focused, and to ensure that the researcher was able to gather all the relevant information that she intended to collect. The predetermined questions were supported by probing from time to time where necessary during the interview, to get more information or clarity from the responses of the participants (Burns & Grove, 2009). An audio recorder was used to record the interview and also field notes were taken to back up the recorded messages. The data collection tools were pre-tested before they were used in the main study. There were no changes made to data collection tools. The pre-test findings were not included in the main study.
5.5. Data analysis
The quantitative data were reduced and analysed by using the statistical software SPSS version 21.0. Data was analysed using descriptive statistics in the form of averages and percentages. Descriptive statistics including means and standard deviations, frequencies which are represented in tables and for selected elements presented in graphs. Analysis of data from the interviews with mid-wives was done concurrently with data collection in order to monitor and guide against data saturation. At the end of each interview the researcher listened to the recorded responses from the midwives several times, in order to gain a clear understanding of the data collected. The researcher also read and re-read the recorded notes, comparing these with the recorded information. Tesch's method of data analysis was used to analyse the qualitative data. Tesch's method involves the researcher listening to audiotapes and reading and re-reading all the transcriptions to get a sense of the full data, jotting down ideas as they emerge (Tesch, 1992).
5.6. Trustworthiness
Trustworthiness of the results was enhanced through method triangulation. The researcher ensured credibility of data by recording all interviews with the study participants and using direct quotations and narratives by the study participants during data reporting. The researcher strived to ensure authenticity by using direct narratives from the study participants.
6. Findings of the study: quantitative study
6.1. Gestational age at booking
As can be seen from Table 1, all records 100% (n = 300) reflected that gestational age at booking was recorded.
6.2. Examination
Various elements regarding the recording of examination findings were assessed. These elements together with the findings on
record review are presented in Table 2. The study findings reflected between a range of 57.3-100% (n = 172-300) for these elements with the (mid upper arm circumference) MUAC being the lowest recorded in only 57.3% (n = 172) of the maternity case records
6.3. Bivariate analysis
Further analysis was undertaken by doing a bivariate analysis to see if practices with regard to record keeping were significantly different at different facilities. A chi-square test of independence was also applied. The findings of the bivariate analysis are presented below.
6.4. Recording of each element by the facilities
The study findings revealed that all elements that were being assessed, except for feedback, recorded in more than 50% of the records in the five PHC facilities that were included in the study. All 50 records from the sixth PHC facility had no record of maternal height, MUAC and body mass index (BMI). Similar to the other five PHC facilities included in the study, the other elements namely: symphio-fundal height (SFH), foetal presentation (from 34 weeks), tetanus toxoid given, discussion of labour and transport arrangements were recorded in more than 50% of the records from these PHC facilities. Feedback was the least recorded element in all six PHC facilities, with just 18% (n = 9) being the lowest number of recordings per PHC facility and 50% (25) records being the highest number of records per facility. The findings of the analysis of recording of various elements are presented in Table 3.
7. Summary of the quantitative phase
Whilst the overall findings of the record review revealed that most of the elements assessed were recorded in most maternity case records in each PHC facility, there were several elements that were discovered to be poorly recorded. These included the following:
• Under the section of history the plotting of gestational age on the graph was poorly done, where it was only recorded in 18.5% (n = 55) maternity case records.
• Under the section of examination and findings the recording of MUAC and BMI were poorly done, with MUAC recorded in 57.3% (n = 172) and BMI in 65.3% (n = 196) of the maternity case record.
• In the section on interpretation and decision making, referral and feedback were the two poorly recorded elements, where referral was not recorded in 49% (n = 153) and feedback in 33% (n = 101) of the maternity case records. In this section, record of transport arrangement and discussion of labour with the mother were recorded much better compared to the other elements that were assessed. Transport arrangement was recorded in 88.7% (n = 266) and discussion of labour with the mother recorded in 83% (n = 249) of the maternity case records.
8. Findings of the study: qualitative study
The three major themes that emerged from the interviews with the midwives were:
1. Availability of the maternity case record for use in the PHC facilities;
2. how the maternity case record is structured; and
3. the consequences of the current design/structure of the maternity case record.
Table 1
Record of gestational age at booking.
Element Yes/No Frequency Percent
Gestational age at booking. Yes 300 100.0
Several sub-themes emerged from the second and third main theme. The sub-themes are presented in Table 4.
8.1. Theme 1: accessibility of the maternity case record
The midwives stated that they had some problems accessing the maternity case records. The problems included inadequate supplies of the card, a malfunctioning ordering system, and problems with alternative means of accessing the card. The majority of the midwives reported that there was always a shortage of the cards in the PHC facilities. This interfered with provision of antenatal care services when there was no proper document available to use to make a record.
".. .Well, I think for the whole of this year 2013,I have not seen an original copy of this new maternity case record. We are only using photocopies and they tear easily''
[(W3; Facility 6; Participant 1).]
The midwives verbalised their concern about the ordering system, stating that the system was not working well most of the time. They complained that although they always ensured that appropriate quantities were ordered, the stores department usually cut down the supplies and issued insufficient quantities which were not enough for the number of clients that they had in the antenatal care clinics. The midwives also stated that there were usually delays in delivering the orders from the stores department to the PHC clinics. Thus, most of the time original copies of the maternity case record card was usually out of stock.
".. .We experience a lot of problem ordering the card, the hospital from which we order the card takes time to deliver the card even when you have indicated that you need it urgently''
[(S4; Facility 4; Participant 1).]
In the absence of the original copies of the maternity case record, photocopies were made in the clinic. The midwives reported that the photocopied maternity case records were of sub-standard quality compared to the original copies. They are less durable due to the quality of photocopying paper used, and sometimes there is very faint and skewed writing depending on the quality of the photocopying.
Table 2
Record of examination findings.
Element Yes/No Frequency Percent
Maternal height Yes 245 81.7
Weight Yes 300 100.0
MUAC Yes 172 57.3
BMI Yes 196 65.3
BP (each visit) Yes 299 99.7
Heart examination Yes 297 99.0
Correct plotting of SFH Yes 277 92.3
Presence of IUGR detected Yes 299 99.7
Fetal presentation (from 34 weeks) Yes 287 95.7
Fetal heart and movements Yes 296 98.7
Urinalysis Yes 300 100.0
Hb, Rh Yes 293 97.7
Syphilis test results Yes 277 92.3
HIV counselled Yes 300 100.0
Tetanus toxoid given Yes 284 94.7
".. .We usually do photocopying of the cards which is easily torn. I think the supplier of the card itself does not have enough, if they can make a plan on that''
[(N1; Facility 2; Participant 3).]
8.2. Theme 2: structure of the card
The midwives verbalised their concern about the structure of the card. They stated that it interferes with the use, documentation of, and the understanding of the maternity case record.
".. .Clients often complain about the size of the card, stating it does not fit in their bags and also in the event of rain it gets wet, though there are some who really look well after their cards, either putting it in a plastic sleeve or covering it with a book cover but even these do complain that it is too big''
[(N1; Facility 2; Participant 1).]
The midwives reported that the new maternity case record has a beautiful appearance but is not designed properly. They stated that the design of the maternity case record is very confusing with most of the information mixed up, therefore making it difficult to understand. They stated that the card is not user-friendly and does not provide spaces for recording relevant elements for Basic Antenatal Care and Prevention of Mother-to-Child Transmission (PMTCT). Space for recording consent for HIV Counselling and Testing (HCT) is situated separately from the page with full HCT information; it is on the other page hiding below 'risk factors' or 'problem list' space. This results in midwives missing out on recording other relevant elements for Basic Antenatal Care and also forgetting to get the clients to sign the consent for HCT.
".. .The design is very, very poor because the information is all over the book; for an example gynaecological history is with the general information. It is not properly organised, it is mixed up. Also the graph is not designed properly because blocks do not correspond with dates and SFH, space provided for clinical note too little so most of the time we have to add continuation pages''
[(S4; Facility 1; Participant 3).]
They stated that the limited space for writing causes midwives to document scanty information about their findings and client progress, which has an adverse effect on client care. They used abbreviations or make ticks and cross even where it would have been more appropriate to make detailed clinical notes, or record the whole information; this is not practical with this maternity case record. The ticks and crosses may not be understood by the next midwife, thereby creating confusion and mismanagement.
".. .The space is limited since we tell them to start the clinic early, you find that by the time of delivery the space is short or too little, I don't know whether to add progress notes now and again, they are coming now and then so the space is short''
[(N1; Facility 2; Participant 1).]
Table 3
Total number of records with elements being assessed recorded.
Element assessed Facility number
1 2 3 4 5 6
Maternal height 50 50 0 50 50 45
MUAC 45 36 0 36 29 26
BMI 45 36 0 44 37 34
SFH 44 46 43 50 49 45
Facility by foetal presentation (from 49 50 44 50 48 46
34 weeks)
Tetanus toxoid given 50 50 35 50 49 50
Discussion of labour 44 48 32 42 42 41
Transport arrangement 48 46 30 48 48 46
Feedback 9 25 15 18 15 19
Table 4 Themes and sub-themes
Themes Sub-themes
Accessibility of the maternity case record for use in the PHC facilities • Supplies of the maternity case record card in the PHC clinics • Process of ordering card • Alternative means of making card available in the PHC clinics
Structure of the card • Card size • Card design • Writing space • Repetition • Limited questions
The consequences of the current design/ structure of the maternity case record • Communication • Referral system • Poor recording
The midwives also verbalised that the new maternity case record was not user-friendly. The maternity case record consisted of several parts where there was duplication of information. They stated that the repeated recording of similar information wasted time which could be spent on offering care to the clients.
''.. .There is a repetition from the first page and second page tends to provide the same information that requires clients' particulars"
[(W4; Facility 5; Participant 2).]
The midwives commented that in the section for history taking questions were limited and incomplete, and important questions were omitted such as mental state, liver failure, jaundice and kidney failure. These investigations are very important in case the client needs to be started on anti-retroviral treatment. As questions are incomplete, midwives ask their own questions in order to make sure they do not miss out on risk factors.
".. .It is not easy to identify risk factors because without full history you end up missing important information and you find that at times you question the patient on your own or when doing examination so it is not easy at all because things are missing''
[(W 4; Facility 5; Participant 2).]
8.3. Theme 3: consequences of the current design
The majority of participants stated that the new maternity case record does influence communication between them negatively because of scanty, abbreviated or no recording at all; others say it does not.
".. .It hasn't influenced communication, it is still the same there is no change, because when you refer the patient to hospital there is no feedback you get the doctors notes only which are unclear and scribbled and the follow up dates but no feedback for what action was taken''
[(S4; Facility 1; Participant 3).]
The midwives stated that the new maternity case record has greatly improved the referral process. This is one positive comment that the midwives verbalise about the use of the new maternity case record.
''.. .For us as a clinical team in level one it has improved our service, made it easier to refer the patient because everything is documented on the chart so the client is always carrying one booklet from clinic to clinic to hospital and back to the service and there is more improvement''
[(N1; Facility 2; Participant 2).]
The midwives complained that the card is complex with too many small boxes to be filled in, which creates a lot of confusion and also results in inaccurate and incomplete documentation.
".. .Communication level amongst the health providers is very poor in case of patients that are received from other provinces, information which is recorded in the maternity case record is very scanty, it is time consuming for particular services to go and phone to find out about patients results''
[(S4; Facility 1; Participant 1).]
9. Discussion of the results
Patients' records are among the most basic of clinical tools and are involved in almost every consultation (Pullen & Louden, 2006). Records are used to give a clear and accurate picture of the care and treatment of patients and to assist in making sure they receive the best possible clinical care. It was noted during the study that although all PHC clinics were using the new maternity case record card, not all PHC clinics were using the original document: some PHC clinics were using the photocopied maternity case record card. A maternity case record is a legal requirement by the South African Nursing Council (SANC). According to the SANC nurses should keep accurate records and the health records should be stored for a minimum of five years (South African Nursing Council., 2001). The Health Professions Council of South Africa (HPCSA), which is another regulatory body for health professionals, provides guidelines for record keeping in which they state that the health records should be stored for a period of not less than six years as from the date they became dormant (Health Professions Council of South Africa, 2008). The HPCSA prescribed that where paper-based records are used the recording document should be made of a durable material and be legible. It must be written using durable ink in order to ensure that the record would last for the five/six year period as stipulated by the controlling bodies. During the interviews the midwives verbalised that photocopied cards were made from poor quality paper which often tear easily, and that during the process of photocopying some of the information became skewed and distorted, all of which interfered with proper recording. The maternity case record card assists midwives to communicate with doctors, with other relevant healthcare professionals, and amongst themselves. It is therefore essential to ensure that the assessed needs of the pregnant women are met comprehensively and in good time (Pullen & Louden, 2006).
All records that were reviewed reflected that gestational age at booking was recorded. The estimation of pregnancy dates is important for the mother, who wants to know when to expect the birth of her baby, as well as for the health care providers so they may choose the times at which to perform various screening tests and assessments (Mongelli, 2012).
During the interviews midwives stated their concerns that there was no space provided in the maternity case record for them to record the findings on abdominal girth measurement. Bloemenkamp (2005) suggests that clinical palpation and fundal height and girth measurements have a large range of error when predicting foetal weight. The measurement of maternal abdominal girth to assess foetal growth has been discredited as far back as 1985. The study on fundal height and abdominal girth measurements during pregnancy, which was published in 1985, already discredited the use of maternal girth measurement to assess foetal growth. The study stated that compared to abdominal girth measurements, fundal height measurements were more valid predictors of the gestational weeks and foetal size (Bloemenkamp, 2005).
Record keeping is for future use and continuation of clients' management and treatment, and promotes good communication
amongst midwives within the clinic and other facilities (Woods, 2003). If midwives do not document complete information on the maternity case record card, this leads to poor communication. In a study which was conducted by Ngxongo and Sibiya (2013), midwives in two of the facilities which participated in the study indicated that they had stopped providing Basic Antenatal Care because they had run out of Basic Antenatal Care checklists. Although according to Basic Antenatal Care guidelines, pregnant women should ideally be attended to by the same midwife during each and every consultation visit in order to ensure continuity of care; this is usually not possible in the current health system of South Africa (Pattinson, 2007).
10. Conclusion
The findings of the study show negative factors regarding the new maternity case record, and it is clear that it is not user-friendly. The negative perceptions of midwives about the understanding of the new maternity case record were identified. About 99% of the midwives believe many mistakes and mismanagement of antenatal care clients emanate from the structure and the design of the new maternity case record. The midwives blame the poor recording on the structure of the card. The mid-wives complained that the card is complex with too many small boxes to be filled in, which creates a lot of confusion and also results in inaccurate and incomplete documentation. The mid-wives stated that other midwives fail to document all the information required for the client, and spaces are often left blank. Most of the time the following information is not recorded: height, MUAC, BMI, whether SFH measurement correlates with dates, and the antenatal care graph not plotted. Concerns were also raised regarding the availability of the card and the problems that arose from the use of photocopied record cards There are still more gaps to be filled in, as communication between managers, supervisors, doctors and midwives needs to be free and open to avoid confusion and to improve the quality of care. The responsibility for changes to the new maternity case record design falls under the Department of Health, if the Minister of Health has accepted the recommendations.
11. Limitations of the study
Although the study area included the three sub-districts in the eThekwini district, the limitation was that only PHC clinics that were under the control of the Municipality were included; those that were under KZNPA were not included in the sample. Whilst the researcher strived to ensure research rigor in the manner in which she presented herself during the interviews, some of the participants that she was interviewing did not take the interviews very seriously in the beginning as they were her work colleagues. This was in relation to the manner that they were responding to the interview questions, and they had to be requested to take the interviews seriously. The researcher did not use an independent researcher to co-audit the records.
12. Recommendation
Input should be invited from the implementers during the design phase of a new recording system and feedback should be obtained from them once the new recording system has been
introduced so as to evaluate whether the system is working well. Managers should assist staff by ensuring that the card ordering system is working well. Logistics required to ensure adequate and sustainable supplies of new maternity case record should be put in place before the new maternity case record is implemented. Supportive supervision and in-service education should be strengthened to ensure that midwives gain adequate support and guidance, especially during the times when the new maternity case record is being implemented. Team work, involving all relevant stake holders, such as people working in stores department where the new maternity case records are being ordered and those from transport department, who are responsible for delivering the new maternity case record to the PHC clinics, should be encouraged to facilitate co-operation amongst all stakeholders
Conflict of Interest
The authors declare that they have no conflict of interests.
Acknowledgements
Authors would like to acknowledge the Durban University of Technology for funding this research study.
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