The utilization of a M idwifery Obstetrical Unit ( Mou ) in a Metropolitan Area

In this study an explorative, descriptive design which is contextual in nature, is utilized. The objective of the study is three-fold: Firstly, to describe the opinions of members o f the community about the reasons for the under-utilization o f the Midwifery Obstetrical Unit (MOU); secondly, to describe the suggestions of the community for improv­ ing the utilization of the MOU and thirdly, to describe intervention strategies for community nurses to improve the utilization of the MOU. Data was collected by means of focus group interviews, and was analysed using Tesch’s (in Cresswell, 1994: 154-155) method of data analysis. Trustworthiness was ensured by using the method of Guba and Lincoln (1985). The respondents were mothers who delivered their babies at the hospital, mothers who delivered their babies at the MOU, members of the Community Health Committee and MOU nurses. Data was collected in two phases. Phase I dealt with the first question: What is your opinion about the reasons for the under-utilization of the M OU? Phase II dealt with the second question: What are your suggestions for improv­ ing the utilization of the MOU? The four groups participated in Phase I as well as in Phase II, the reason being to involve the groups in identifying problems and finding solutions with which they would be comfortable, since it would be their ideas. This whole exercise was, however, carried out in line with the RDP principle of people driven approach or community involve­ ment. The investigation revealed that the community was not utilizing the MOU because of the following reasons: • Negative attitudes of nurses. • Lack of material and human resources. • Poor safety and security measures. • Lack of community involvement/participation. The focus groups then identified the following sugges­ tions for improving the utilization of the MOU: • Change of attitudes by nurses towards the patients. • Availability of material and human resources. • Proper safety and security measures in the MOU. • Community involvement/participation. • Integration of health services. Intervention strategies for community nurses to improve the utilization of the MOU were based on the literature as well as the suggestions made by the focus group respond­ ents because the researcher found the suggestions to be realistic.

In this study an explorative, descriptive design which is contextual in nature, is utilized.The objective of the study is three-fold: Firstly, to describe the opinions o f members o f the com m unity about the reasons for the under-utilization o f the M idwifery Obstetrical U nit (M OU); secondly, to describe the suggestions o f the com m unity for im prov ing the utilization o f the M O U and thirdly, to describe intervention strategies for com m unity nurses to improve the utilization of the M OU.D ata was collected by means o f focus group interviews, and was analysed using Tesch's (in Cressw ell, 1994: 154-155) m ethod o f data analysis.Trustworthiness was ensured by using the method o f Guba and Lincoln (1985).The respondents were m others who delivered their babies at the hospital, mothers who delivered their babies at the M OU, members o f the Com m unity H ealth Com m ittee and M OU nurses.Data was collected in tw o phases.Phase I dealt with the first question: W hat is your opinion about the reasons for the under-utilization o f the M O U ? Phase II dealt with the second question: W hat are your suggestions for im prov ing the utilization o f the M OU?The four groups participated in Phase I as well as in Phase II, the reason being to involve the groups in identifying problem s and finding solutions with which they would be com fortable, since it would be their ideas.This whole exercise was, however, carried out in line with the RDP principle of people driven approach or community involve ment.The investigation revealed that the community was not utilizing the M OU because o f the following reasons:

•
Negative attitudes of nurses.
• Lack o f material and human resources.
• Poor safety and security measures.
• Lack o f community involvement/participation.
The focus groups then identified the following sugges tions for im proving the utilization o f the MOU: • Change o f attitudes by nurses towards the patients.
• Availability of material and human resources.
• Proper safety and security measures in the MOU.
• Com m unity involvement/participation.
• Integration o f health services.
Intervention strategies for community nurses to improve the utilization o f the MOU were based on the literature as well as the suggestions made by the focus group respond ents because the researcher found the suggestions to be realistic.

Uittreksel
In hierdie studie word 'n verkennende, beskryw ende ontwerp benut wat kontekstueel van aard is.Die doel van die studie is d rieledig.E ersten s om die m en in g s van lede van die g e m e e n s k a p m et b e tre k k in g to t d ie re d e s v ir die onderbenutting van die V roedvrou O bstetriese Eenheid te beskryf, tweedens om die voorstelle van die gem eenskap ter verbetering van die benutting van die Eenheid te beskryf en derdens om intervensie strategieë te beskryf ten einde die benutting van die Eenheid te verbeter.D ata is deur middel van fokusgroeponderhoude ingesam el en aan die hand van Tesch (in Cresswell, 1994: 154-155) se metode geanaliseer.Betroubaarheid was deur G uba en Lincoln (1985) se metode bewerkstellig.Die respondente in die navorsing was m oeders wie se babas in die hospitaal gebore is, m oeders wie se babas in die Eenheid gebore is, lede van die G em eenskapsgesondheidskom itee en verpleegkundiges werksaam in die Eenheid.Data is in twee fases ingesamel.Fase 1 het gehandel oor die eerste vraag naamlik: "Wat is u mening aangaande die redes vir die onderbenutting van die Eenheid?" Fase 2 het die tweede vraag behandel naamlik "Wat is u voorstelle ter verbetering van die benutting van die Eenheid?" Die vier groepe het deelgeneem aan fase een en twee van die navorsing.Die rede hiervoor was dat, deur die groepe te betrek by die identifisering van problem e en die vind van oplossings, dit gem ak sal bewerkstellig aangesien dit hulle idees sal verteenwoordig.Die operasie is dus uitgevoer aan die hand van die HOP beginsel van 'n m ensgedrewe benadering o f gemeenskapsbetrokkenheid.

98
Cu ratio n is Decem ber 20 0 0 Die fokusgroepe het die volgende voorstelle ter verbetering van die benutting van die Eenheid gedoen: • V erandering in houd in g van v erp leeg k u n diges jee n s pasiënte.

Introduction
In the past, the com m unity under study was deprived o f m a ternity and obstetric services.The com m unity was subjected to home deliveries and deliveries at hospitals which were situ ated at a distance o f approxim ately 25 km.This subjected the com m unity to a high incidence o f m aternal and neonatal mortality in the M edical Officer o f Health report (1996: 3-6).
The introduction o f the N ational H ealth Policy brought about changes which necessitated the availability of m idwifery and obstetrical units in the previously disadvantaged com m uni ties and the comm unity under study was one of the benefici aries of the proposals in the National Health Plan (1994:100).
In fact, the m idwifery obstetrical unit was built for this com munity and it was officially opened in A ugust 1996.
Despite the availability o f the services, members of the com munity still travel to the hospital for the delivery of their babies, which puts a further burden on the already overcrowded hospital while the M OU remains under-utilized.The under utilization o f the M OU led to a threat o f closure by the Re gional Director, who cited the financial burden of running a unit which was not utilized by the community.The call for closure prom pted the researcher to investigate the reasons why the unit is under-utilized by the community, and to try to find a solution to the problem.
The objectives o f the study were as follows, namely to: • explore and describe opinions o f the community about the reasons for the under-utilization o f the MOU; • explore and describe the suggestions by the community for improving the utilization o f the MOU; • formulate intervention strategies to be utilized by com m u nity nurses to improve the utilization o f the MOU.

Terminology
Terms used are defined as follows:

M idw ife ry obstetrical unit
This refers according to M yles (1991:1).to a unit that caters for the health needs o f a pregnant wom an during labour and post-delivery o f her newborn baby.It is a specialised unit with appropriate equipm ent and trained staff M id w ife M idwife refers to any person registered as a midwife with the South A frican Interim Nursing Council and who has been trained to assess and m ake decisions to save life (M yles, 1991:4).

C om m un ity
In this study community refers to the mothers who delivered their babies at the hospital, m others who delivered their ba bies at the M OU, members o f the Com m unity health C om mittee who live in Eastern Gauteng M etropolitan Area, and M OU nurses working in the above-m entioned area.

Com m un ity H e a lth C om m ittee
This consists o f elected voluntary com m unity representatives (who are in the majority), representatives from health serv ices in the area, non-governm ent organizations w orking in the community, local health practitioners and others accord ing to the N ational Health Plan for South A frica (1994:61).

The Research Method
An exploratory and descriptive research strategy was used to explore and describe the opinions o f mothers who delivered their babies at the M OU, mothers who delivered their babies at the hospital, mem bers of the Com m unity Health Com m it tee and M O U nurses about the under-utilization o f M OU, and also to explore and describe the suggestions o f mothers who delivered their babies at the M O U, mothers who deliv ered their babies at the hospital, Com m unity Health Com m it tee members and M OU nurses to improve the utilization of the MOU.
Data was gathered by means of interviews with four focus groups.The researcher, in her quest to find solutions to the problem acted as the facilitator and asked the respondents the following questions: • W hat is your opinion about the reasons for the under-utilization o f the M OU?
• W hat suggestions do you have to improve the utilization o f the MOU?
A purposive sampling method was used to ensure full repre sentation o f the population which consisted o f the following: • Eight postnatal mothers who delivered their babies at the hospital (Group A) as well as six mothers who delivered their babies at the M OU (Group B), who are residents in the m et ropolitan area in Eastern Gauteng.
• Eight Com m ittee Health members (Group C) o f the spe cific com m unity in the Eastern Gauteng M etropolitan area.
• Six M OU nurses (Group D).
One focus group interview was conducted separatly with each of the four abovem entioned groups o f respondents in order to address the first question namely "W hat is your opinion about the reasons for the under-utilization o f the M OU?A second focus group interview was conducted w ith the same four groups o f respondents in order.toanswer the second question namely "W hat are your suggestions for im proving the utili zation o f the M O U ? Use was made o f interpersonal skills by the researcher in order to stimulate the free expression o f ideas by the four groups o f respondents.
The m ethod o f data an aly sis as d escrib ed by Tesch (in Cresswell, 1994:155).Data m anagem ent included audio-taping o f the eight different focus group interview s and tran scribing it.The most descriptive words were found and it was then categorised into m ain and sub-categories.The data belonging to each category was assem bled in one place for a preliminary analysis.W hen necessary the existing data was recoded.It was then sent to the independent coder for analy sis.This external coder was selected from nurses with a M as te r's or Doctoral degree and who is know ledgable on inter view data analysis.Concensus was reached regarding the cat egories and sub-categories which em inated from the data ob tained.
Trustw orthiness was addressed by m eans o f G uba's model (in Lincoln & Guba, 1985:289-331).Credibility was en sured through prolonged engagem ent, triagulation and the authority o f the researcher.

Results of phase I of the study
The results focus on: The opinions of the fo u r groups of respondents abo u t reasons fo r the unde r u tilizatio n of the M O U The opinions o f four groups o f respondents, nam ely the m oth ers who delivered their babies at the hospital, the mothers who delivered their babies at the M OU, m em bers o f the Com munity Health Com m ittee and M O U nurses, about reasons for the under-utilization o f the M OU, will be discussed under four main categories, namely: • A ttitudes o f M OU nurses tow ards the patients.
• Lack o f material and hum an resources.
• Poor safety and security measures.
• Lack o f com m unity involvem ent/participation.

A ttitu d e s of M O U nurses to w a rd s the patients
The M OU nurses were found to be rude, uncaring, unfriendly, cold and im patient by the m others who delivered their babies at the M OU, mothers who delivered their babies at the hospi tal, as well as members o f the Com m unity H ealth Com m it tee.This was confirm ed by the M OU nurses, who acknowl edged that they were rude and irritable and, notably that they are overw orked because o f the staff shortage in their unit (MOU).A m ongst the M OU nurses, one nurse pointed out that being overworked does not give them any authority to be rude to their patients.
The responses from these four groups that negative attitudes of nurses make the M OU unpopular, hence it is not well uti lized by the community, are confirm ed by the literature.
According to Gillies (1989:397) (1992:20), in which the research ers found that negative staff attitudes were the main reason given by mothers for not utilizing the maternity service.The mothers preferred to deliver at home, thus maintaining their dignity and privacy.
The W hite Paper on H ealth (1997:194) confirm s that the majority o f health workers have poor communication skills and fail to communicate effectively with their patients at dis trict and community levels.
Poggenpoel (1997:30) further confirm ed in her study that nurses com municated ineffectively with patients, they showed little concern, lack o f empathy, intimacy and caring.

La c k of m aterial and hum an resources in the M O U
Lack o f material and human resources in the MOU was iden tified by the four groups o f respondents (A, B, C and D), as one of the reasons why the M OU was under-utilized.They found the M OU to be lacking some o f the facilities which are found in the hospital, such as public telephones, food for the patients, more nurses and doctors, transport and privacy, and this made them believe that the standard of care of the MOU is low compared to the hospital, hence tne community rather visit the hospital and leave their MOU under-utilized.
This response is supported by Van Eeden (1989:140) who found that resources for health are inevitably limited and that consumers and providers are affected by this constraint.It does, however, subject the community to suffering as a result of inadequate infrastructure and the use of an alternative health facility which is inefficient.
Van Coeverden, De Groot, Davey & Howard (1992, 61:35-36) reported that staff shortage in the Peninsula M aternity and Neonatal Unit created a problem for quality care by the midwives who were overworked and could not provide sup port and comfort for women in labour.

Poor s a fe ty and security m easures in the M O U
Lack of safety and security in the MOU was raised by all fours groups (A, B, C and D) as risky and frightening, and they believed that their babies could be abducted, and their valuables could be stolen as the security officer of the M OU is undisciplined and does not carry a gun.The four groups felt that lack o f safety and security in this MOU was one of the reasons for the under-utilization o f the MOU by members of the community.This response is supported by literature which states that an increasing num ber o f criminal activities occur in health centres, including the abducting o f babies, car theft and burglary.Although the snatching o f babies is an interna tional problem, it is more pronounced in Gauteng Province and the following cases were reported: The Star (13 July 1991) reported that baby Frederick Johannes Nagel was snatched from his m other's bedside at HF Verwoerd maternity ward.
Baby M ichaela Hunter, as reported in The Star, 4 M ay 1994, was snatched from a maternity unit (M arymount) by an un known woman who posed as a nurse.
Crim inal activities such as theft and burglary are committed on a daily basis throughout the country, and most o f the cases are not reported, hence there is little literature on such activi ties in health centres.Locally, the following case was re ported: The Outlook, 15 June 1996 reported that a nurse's car was broken into and a radio-tape was stolen from the MOU.
La c k of com m unity involvem ent/ participation

Results O f Phase II O f The Study
The results focus on: The suggestions for im proving the u tilization of the M O U Health Com m ittee and M OU nurses, will be discussed as five main categories, as follows: • Change o f attitudes by M OU nurses towards the patients.
• Availability o f material and human resources.
• Proper safety and security measures.
• Com m unity involvement/participation.
• Integration o f health services.Schroeder (1991:29) states that consumers are at the centre o f the com petitive market, that they expect quality care which encom passes interpersonal and technical care, and their de scription o f quality care is in line with the professional scope o f practice.These consumers will seek out health care set tings that provide quality care and consum er satisfaction.

C hanges
It is im portant to restructure the institution within the fram e work o f consum er satisfaction so that the institution can be m arketable and receive comments such as: "Thank you fo r the fin e care you gave m y wife and the com fo r t given to me; I will definitely suggest to frie n d s and fa m ily that your hospital is 'where to go '." (Schroeder, 1991:29-30).
Schroeder (1991:31) further stated that the health issues of the 1989s dealt with accountability for consum er services and that health issues o f 1990 would deal with innovative, costeffective, interpersonal and highly technical care and ways to approach that accountability.Resources to facilitate delivery o f these nursing services in an effective m anner are essential today when cost containment, com petition and nursing short ages are at the norm.
A ccording to U yirw orth et al. (1996:10), health w orkers should change their attitudes to be m ore caring and friendly and, as public servants, they m ust be accountable to the com munity which they serve.
The National Health Plan (1994:20) clearly states that health workers must respect the right to all people to be treated with respect and dignity.The Departm ent o f H ealth's W hite Pa per on the Transformation o f the H ealth System in South A f rica (1997:103) also supports the response that health work ers need to develop a caring ethos and to im prove their atti tudes towards patients and the com m unity at large.The Health Departm ent will work closely with training instructions and professional health organizations to address this issue effec tively.
Nolte (1998:164) recom m ends that the m idwife should adopt a supportive attitude towards a wom an in labour.The mid wife m ust create an en v iro n m en t co n ducive to personal growth, companionship and the prom otion o f social support.
Since the w om an's em otional needs evolve around labour, the presence, com m unication and care o f the m idw ife can diminish anxiety and pain to a large extent.

A va ila b ility of m aterial and hum an resources
The respondents from the four groups suggested that the au thority m ust make available the necessary material and hu man resources to the M OU so that the latter will becom e effi cient and effective like hospital maternity unit.This will at tract the com munity to utilize their com m unity-based MOU.Literature supports the above-m entioned response.
M aternity services should satisfy the em otional and physical needs o f mothers by ensuring that sufficient staff is available and that resources are utilized efficiently and effectively in order to respond better to consum er pressure.
The W HO recom m ended thát the em phasis in finance should be on reallocating resources so that health care obtains a fair share o f the budgeted resources and that supplies should be used to pay for health requirem ents, so that health providers can sustain their services economically.
Gerber (1987:29) reports that the success o f an enterprise or service is based on two foundations, nam ely efficiency and effectiveness.The efficiency o f an enterprise refers to the nature and quality o f the interpersonal relationships within the enterprise.The effectiveness refers to "doing the right things", and is prim arily determ ined by the availability of resources (hum an and material).Resources such as material and equipm ent are static and can only obtain a dynam ic char acter through the intervention o f labour resources (manpower).It is, however, true that the effectiveness and efficiency of human and material resources within an enterprise actually increase or boost the utilization thereof by the consumer.
Deficient primary care currently com pels people to use hos pitals for basic care, which causes overcrow ding in hospitals, leaving prim ary health care centres or clinics under-utilized.
There is consequently a need for an injection o f additional resources to develop prim ary level infrastructure and serv ices, so that the com munity will be attracted to utilize such services (African National Congress, 1994:76).
According to the M OU Policy Document (1995:2), the MOU should have the necessary resources in order to render effec tive services to the community.

Proper s a fe ty and security m easures
The four groups o f respondents (A, B, C and D) strongly emphasized the importance of proper safety and security in MOU to improve the morale o f MOU nurses and patients, to diminish fear, enhance confidence and comfort and, in turn, to attract the community to utilize the MOU.Although not much literature is available on safety and security measures in health facilities, the MOU Policy Document (1995:3) gives some guidelines to support the response by the respondents that the MOU should have a security gate between the labour ward and the reception area, as well as an alarm system which is connected to the local Police Station.

Integration of Local A u th o rity and Provincial H ealth Services
Integration o f services was identified by the MOU nurses [Group D] as a suggestion to improve utilization of the MOU.This group believe that integration o f services will improve staff shortages, co-ordination, com munication and the rela tionship between local authority and provincial staff and, in turn, improve the services at the MOU, thereby automatically improving utilization of the MOU.Their response is sup ported in no uncertain terms by literature.
In the study conducted by Uyirworth et al. (1996:11) it is recom m ended that child spacing and postnatal services be integrated in maternal and child health services to acquaint the black com m unity with maternity services as complete and comprehensive services.The White Paper on Health (1997:98) also supports Uyirworth et al. (1996:11), stating that mater nal and child health services should be comprehensive and integrated and should form an integral part of primary health care services.It should be rendered on a one-stop "supermar ket" basis.

Conclusions
The MOU nurses demonstrated poor communication skills, lack o f empathy and caring for their patients, and this has led to the developm ent o f dislike o f the MOU by the community at large, hence the under-utilization of the MOU.
Lack of resources in M O U 's reduces the general status o f the M O U 's significantly to the extent that maternity services ren dered in these units (M OU 's) are perceived to be o f a lower standard compared to maternity services rendered at the hos pitals hence the community is over-utilizing the hospitals and leaving the M O U 's under-utilized.
Poor safety and security measures in MOU render the unit unsafe uncomfortable and unpopular for use by the com m u nity.
Lack of com m unity participation in the MOU created lack of accountable sense o f ownership amongst the community.
Change of attitudes by nurses towards their patients will make their services more attractive, acceptable and efficient to the community, and in turn, will improve the utilization o f the MOU.
Availability o f m aterial and hum an resources in the M OU will ensure sm ooth running o f the unit and will definitely attract the community from the hospital to the MOU.
The implementation of com m unity involvement in this area will promote protection o f the M OU nurses and patients by the community and there will be no need to demand that se curity officers carry guns to protect the MOU.
Integration o f services will allow m ulti-purpose use o f re sources, such as personnel and it actually permits more out puts to be achieved.

Recommendations
The intervention strategies serve as recom mendations as tabu lated in table 1 .C R E S S W E L L J W 1994: Research design: qualitative and quantitative approaches.Thousand Oaks California: Sage.C hange o f attitudes of nurses tow ards the pa tients so that they will be caring, supportive, pa tien t, k in d and u n d er standing.

Reference
To create a patient-friendly environ m ent.
To m ake the M O U services more ef fective to the community, in order to enhance utilization.
Arrange in-service training on interpersonal and com m unication skills.
Health workers to be motivated to develop a car ing ethos and to improve their attitudes towards the patients and the community at large.
Encourage health workers to upgrade their edu cational level in order to enhance asser-tiveness, confidence and sympathy in caring for their pa tients.
Incentives in the form of promotion or merit award for best nurse who shows good interpersonal rela tions with her patients and colleagues, as well as the best nursing care to her patients.
There must be fair compensation and recognition for a job well done.
A vailability o f hum an and m aterial resources.
To address the inequitable access to health care caused by lack of resources.
Perform needs analysis pertaining to personnel and equipment, and support services such as medi cation and emergency services.
Ensure that the support services, such as suffi cient stock and equipment, reflect acceptable pro portions.
Establish a co-ordinating committee (composed o f M OU and hospital managers) to address effec tive and equitable allocation o f resources.
Ensure availability of transport on a daily basis to fetch food and stock from the hospital.
Install public phones for patients and relatives.
Ensure that the MOU has a reliable phone with a connecting line to the referral hospital.
The M OU must have access to a reliable ambu lance service.
Install lockers for safekeeping o f patients' and staff's kit and valuables.
Ensure that the M OU gets the same equipment as the hospital maternity unit, to avoid disparities.
Arrange a doctor to visit the M OU daily to exam ine the babies after delivery.
Staff em ploym ent should be in line with the size o f the population to be served.
The staff complem ent should be headed by a m a tron or an advanced midwife with a nursing ad- The staff should consist of advanced midwives, sen ior professional nurses, professional nurses, auxil iary nurses and general assistants.
Adm inistrative clerks, drivers and security guards, who should have a daily coverage o f all catego ries.
Ensure daily staff coverage and make provision for sick leave.

Proper safety and secu rity m easures
To create a safe and sound environm ent for patients and staff.
The Following m ust be installed: • A security wall or fence and entrance gate.
• A security door for labour ward entrance.
• Security windows alarm system which is con nected to the local Police Station.
• There m ust be an adequate num ber of security officers on duty.
• Security officers must be trained in advanced safety skills.
C o m m u n ity in v o lv e ment and participation.
To im plement a people-driven process (RDP) To create a sense of ownership.
To prom ote responsive and appropriate services delivery.
To mobilise and promote accountabil ity.
Establish a sound community health committee.
Have regular meetings with the Community Health Com m ittee or Health Forum.
Involve the community in planning and im plem ent ing their health-related projects.
Together with the Health Committee, identify and prioritise com m unity health needs.
Ensure participating process.
Ensure that the com m unity and individuals are involved as respected partners in their health-re lated issues.
Ensure collaborative, integrated planning and de cision-m aking.
Encourage communities to take greater responsi bility for their own health.
The M OU staff should maintain good relations with the com m unity through regular interaction.
E ducate and inform the com m unity about the health-related issues affecting their lives; in the same process, traditional values and beliefs should be respected.
Advertise the MOU.Unify the fragmented health services at all levels into a com prehensive system.
Integrate provincial and local authority health per sonnel.
Integrate the activities of provincial and local gov ernments in a way which maximises effectiveness and efficiency.
Creates same conditions o f employment, including benefits o f all available health resources.
Integrate fam ily planning, postnatal care, labour, cervical screening and child welfare services.
Reorganise health system based on Primary Health Care Services with effective referral system.
1 0 6 C u ratio n is Decem ber 2000 Suggestions by the four groups [A,B,C,D] namely mothers who delivered their babies at the hospital, mothers who de livered their babies at the M OU, mem bers o f the Community of a ttitu d e s by M O U nurses to w a rd s patients Change o f attitudes o f M OU nurses tow ards the patients was suggested by mothers who delivered their babies at the hospi tal (Group A), mothers who delivered their babies at the M OU (Group B) and members o f the Com m unity Health Com m it tee (Group C]) and that nurses need to change their attitudes to be more caring.M OU nurses (Group D) confirm ed that they would change their attitude.They requested the author ity to em ploy more nurses and to increase their salaries.The nurses also indicated that they would explain their situation to their patients with a view to regain the respect o f their patients and this would improve utilization o f the M OU by m em bers o f the community.The above responses are sup ported by a num ber o f literature sources.The question o f attitude changes is further supported by a policy docum ent for maternity services in the U nited King dom (1986) w hich indicates that m idw ives should have a supportive, caring and comforting attitude tow ards women in labour and lastly to prepare and strengthen them for the task o f motherhood.The World Health Organization (W HO) (1992:3) recommends that every woman has a fundamental right to proper neonatal care and that social emotional and psychological factors are decisive factors in the understanding and implem entation of proper care.

A
FR IC A N N A T IO N A L C O N G R E S S (ANC) 1994: Re construction and Development Programme.A policy frame work (RDP).Johannesburg: Um anyano Publications.A FR IC A N N A TIO N A L C O N G R E S S (ANC) 1994: Com m unity participation FP Programme.Economic and Political Week, 9 August: 1935-1936.
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To create a one-stop service for mother and child care services.
embers o f the Com m unity Health Com m ittee (Group C) and the M OU identified lack o f com m unity involvement as one o f the reasons for the under-utilization o f the MOU.The Health Committee members felt that there was a lack of knowl edge about the Reconstruction and Developm ent Programme as well as comm unication between the community and M OU nurses, while the M OU nurses indicated that the community was not interested in health related m atters, hence the con cept of com m unity involvem ent was not im plem ented and this created lack o f interest with the result that the M OU is under-utilized by members o f the community.The above re sponse is supported by the literature, including the follow ing: According toBang (1986Bang ( :1395Bang ( -1396) )the health care in this country is characterised by a provider-driven approach and the community is at the receiving end.This creates apathy and dependency am ongst com m unities.The World Bank Publications further confirm that a lack of community involvem ent/ participation leads to a lack o f ac countability and no sense o f ow nership on the part of the com munity in Action fo r Better Health inAfrica (1992:11).