The young woman stands hesitantly at the entrance to the ultrasound room in the maternity ward of Tonga District Hospital, close to the Komati River in the Mpumalanga lowveld.
She has the resolve of a schoolgirl being called into the principal's office, looking forlorn with her clothes crammed into the plastic bag in her hand. Her big eyes are cast down under the veil of the black weave fringe that covers her forehead, the gold loop earrings looking harsh against her dark skin. She looks childlike, her pregnant belly barely visible under the oversized gown supplied by the hospital.
"Ngena s'tsandvwa sami [come in, my love]," Miriam Mathose says softly in Siswati, the language widely spoken in this rural town.
The patient shuffles into the room, then towards the bed next to the ultrasound machine where she takes off her black shoes before hoisting her skinny legs on to the bed. Mathose chats to the patient as she prepares the ultrasound machine.
"How old are you?"
"Can you guess how old I am?"
"Twenty," the patient hazards, squirming under the matron's gaze.
Mathose laughs fondly. She is 40 years old, and the matron in charge of the hospital's maternity ward. She is also part of a cohort of advanced midwives from Mpumalanga and KwaZulu-Natal who completed obstetric ultrasound training last year at the University of KwaZulu-Natal's (UKZN) Nelson Mandela School of Medicine.
The year-long course was part of a partnership between UKZN and the Norwegian University of Science and Technology to help South Africa to realise the United Nations Millennium Development Goal of improving maternal health.
The head of obstetrics and gynaecology at the university, Jayanthilal Bagratee, says the training was aimed at empowering midwives to better handle pregnancy, labour and childbirth-related complications, especially in rural areas because midwives are often the first point of contact between pregnant women and health facilities.
"The majority of women give birth in clinics and district hospitals, so it is important to improve care at that level. Ultrasound examination of pregnancy may help to confirm and accurately date the pregnancy," says Bagratee.
"This information can help midwives to predict intrauterine growth restriction [poor development of the foetus] and to avoid post-term pregnancy, thus assisting in reducing the risk of stillbirth.
Mathose and fellow students have also been taught to recognise certain abnormalities on ultrasounds and therefore will be able to refer complicated pregnancies to hospitals at a much earlier stage than before."
According to the health department's latest maternal mortality report, the top three causes of death of a woman during pregnancy, childbirth or within 42 days thereafter are haemorrhage, which is excessive bleeding during childbirth, pregnancy-related high blood pressure, and HIV. Most deaths due to haemorrhage and high blood pressure or hypertension can be avoided if women have access to good-quality maternity care at health facilities, the report says.
Bagratee says that, although midwives in South Africa had adequate training, continuous on-the-job-training is key to keeping up with developments in medicine.
"Midwives are trained to handle antenatal care and basic delivery. This course is an extension to that training and is meant to equip them to do more. The majority of babies in our country are delivered by midwives," he says.
In the department's report, the skills and knowledge of healthcare providers and shortfalls in the health system are singled out as causal factors of many maternal deaths .
The job requires passion
"Working in maternity requires you to be passionate," says Mathose. "If you are doing something you love, you are always eager to upgrade your skills. It doesn't matter how long you have been in midwifery, there are always new things to learn."
This is her patient's first ultrasound. The young woman was referred to the maternity ward by the antenatal clinic at the hospital. Mathose applies gel and runs the ultrasound transducer over her patient's bulging stomach. The rhythmic pump of the foetal heartbeat is almost immediately visible on the machine's small screen.
Mathose has to check that the foetus is normal and determine its gestational age, an indication of how far along the pregnancy is. She starts off by measuring the foetus's abdomen and its femur – the largest bone in the body that extends from hip to knee. To complete the measurements, Mathose needs to measure the head – a tough task as the foetus is restless.
The heart, umbilical cord and fisted hand all look normal. Her patient is between 24 and 27 weeks pregnant (about six and a half months). She will have to return for another scan the following week to confirm this. Hopefully, the foetus will be calmer and move less so that the measurements can be easily completed.
Mathose says the gestational age is important because it helps to calculate the baby's due date so that the woman can get to a hospital in time for the birth of her child. This would avoid delay in medical assistance during childbirth, which could lead to health complications for both baby and mother.
"This is the same machine that I was using before the training, but now I can do so much more with it. It is like having a cellphone and learning how to use the different applications," Mathose says. "I used to think an ultrasound was just to check on the foetus's development. Now, we use the scan to detect abnormalities so that we can refer patients with complications to hospitals that have specialists and facilities to manage their condition if we cannot manage it ourselves in advance."
The closest referral hospital to Tonga is Rob Ferreira Hospital in Nelspruit, more than 100km away. Although the training she received has helped Mathose and her team to better manage their patients' health, the benefits are limited without access to the right equipment, such as a Doppler ultrasound machine.
Unlike a regular ultrasound, a Doppler ultrasound can also be used to measure blood pressure, which, according to Mathose, could help to save many lives in Tonga as hypertension is common in the area, especially in women who are pregnant for the first time.
But the "unequal distribution of equipment" continues to make it difficult to diagnose complications early. "The hospitals in Nelspruit each have more than one Doppler scanner," she says. "But in district hospitals, only basic ultrasound machines are available. I hope we'll get a Doppler ultrasound soon."
However, even with access to the latest technology, one has to know what is normal in order to recognise abnormalities, something Mathose believes is missing from the basic midwife training that is part of South African nursing courses.
"The training for midwives is not sufficient for graduates to function in public hospitals," she says. When she was studying midwifery at Mpumalanga Nursing College in the late 1990s, Mathose says she had to conduct 20 deliveries to qualify.
"Now, they have to conduct only five deliveries, not enough to prepare them for real-life emergencies. With 20 deliveries, there is the opportunity to experience the various complications that can occur. But if you have never seen an actual postpartum haemorrhage, you won't know how to handle it."
Postpartum haemorrhage, or the loss of huge amounts of blood after delivery, is the second leading cause of maternal death in South Africa. According to the health department, 80% of maternal deaths due to haemorrhage are preventable. The department estimates that 310 in 100?000 women in South Africa die during pregnancy, childbirth or thereafter every year.
However, the Society of Midwives in South Africa says it is not the standard of midwifery training that is the problem, but the lack of enthusiasm for it. Society president Busisiwe Kunene says the country's midwifery training is "the best", but some nurses study midwifery simply to pass because it is a compulsory part of nursing training.
"In addition to nursing, one has to undergo special training to qualify as an actual midwife," she says. "In South Africa, almost all nurses are trained in midwifery, but only a few are true midwives, driven by passion. There are those who do the course to obtain their green bar [which differentiates registered midwives from other nursing specialists]. Some do not even remember all the midwifery terms, let alone procedures, after passing the examination."
And in an article published in pregnancy and childbirth magazine Sensitive Midwifery, Kunene wrote that midwifery training should be kept for those who were "passionate about caring for women" instead of training people who "lack the secret of being a true midwife" or may end up being militant and/or apathetic about deaths.
Mathose wipes the gel residue from her patient's stomach and ultrasound transducer. She completes a report while the patient leaves the room to change. A grey-shaded copy of the foetus' ultrasound scan prints from the machine. "This is for you to keep," Mathose tells the young mother. "It's something to keep the excitement at bay until the baby comes."