The Prevention of Intrapartum Hiv/aids Transmission from Mother to Child

Opsomming Die oordrag van MIV/VIGS vanaf die moeder na die kind is die hoof oorsaak van MIV/VIGS in kinders en kindermortaliteit. Twee-derdes van die kinders met MIV/ V IG S w o rd g e d u re n d e d ie in tra p a rtu m p e rio d e ge'infekteer (Farley, 2000:1-2). Die doel van die studie was om te bepaal watter tussentredes geregistreerde vroedvroue in p ro v in siale o b stetriese eenhede in Bloemfontein toepas om die risiko van intrapartum oordrag van MIV/VIGS vanaf die moeder na die kind te verlaag om sodoende kindermortaliteit te verlaag. 'n Beskrywende navorsingsontwerp is gevolg. Een-en-vyftig vroedvroue het vraelyste ingevul om te bepaal watter voorkomende praktyke hulle uitvoer. D a a r is b e v in d d a t d ie m e e ste v ro e d v ro u e nie tussentredes im plem enteer om die oordrag van M IV/ VIGS van die moeder tot die kind in die intrapartum periode te verlaag nie. Dit is moontlik dat die vroedvroue nie 'n positiewe impak op kindermortaliteit het nie. Die afleiding w ord deur die navorsers gem aak dat die vroedvroue nie die tussentredes, soos genoem in die studie, implementeer nie omdat hulle nie oor die nodige kennis en vaardighede beskik nie. Uit die navorsing blyk dit dat 67% van die vroedvroue hulle opleiding tussen 1990-2000 voltooi het. Die onvoldoende kennis kan moontlik toegeskryf word aan 'n leemte in die kurrikulum van opleidingsinstansies en die gebrek aan 'n re s e n te b e le id in p ro v in s ia le in s ta n s ie s in Bloemfontein. D a a r w o rd a a n b e v e e l d a t al d ie b e k o s tig b a re tussentredes in die bestaande beleid geinkorporeer moet word. Summary The transmission of HIV/AIDS from mother to child is the main cause of HIV/AIDS in children and child mor­ tality. Two-thirds of children with HIV/AIDS are infected in the intrapartum period (Farley, 2000:1-2). Midwives, through effective practices, can lower the transmission of HIV/AIDS from mother to child in the intrapartum period. The aim of the study was to determine which preventive practices registered midwives in provincial labour wards in Bloemfontein, implement to lower the risk of mother …


Opsomming
Die oordrag van MIV/VIGS vanaf die moeder na die kind is die hoof oorsaak van MIV/VIGS in kinders en kindermortaliteit.Twee-derdes van die kinders met MIV/ V IG S w o rd g e d u re n d e d ie in tra p a rtu m p e rio d e ge'infekteer (Farley, 2000:1-2).Die doel van die studie was om te bepaal watter tussentredes geregistreerde vroedvroue in p ro v in siale o b stetriese eenhede in Bloemfontein toepas om die risiko van intrapartum oordrag van MIV/VIGS vanaf die moeder na die kind te verlaag om sodoende kindermortaliteit te verlaag.
'n Beskrywende navorsingsontwerp is gevolg.Een-envyftig vroedvroue het vraelyste ingevul om te bepaal watter voorkomende praktyke hulle uitvoer.D a a r is b e v in d d a t d ie m e e ste v ro e d v ro u e nie tussentredes im plem enteer om die oordrag van M IV/ VIGS van die moeder tot die kind in die intrapartum periode te verlaag nie.Dit is moontlik dat die vroedvroue nie 'n positiewe impak op kindermortaliteit het nie.Die afleiding w ord deur die navorsers gem aak dat die vroedvroue nie die tussentredes, soos genoem in die studie, implementeer nie omdat hulle nie oor die nodige kennis en vaardighede beskik nie.Uit die navorsing blyk dit dat 67% van die vroedvroue hulle opleiding tussen 1990 -2000 voltooi het.Die onvoldoende kennis kan moontlik toegeskryf word aan 'n leemte in die kurrikulum van opleidingsinstansies en die gebrek aan 'n re s e n te b e le id in p ro v in s ia le in s ta n s ie s in Bloemfontein.

Summary
The transmission of HIV/AIDS from mother to child is the main cause of HIV/AIDS in children and child mor tality.Two-thirds of children with HIV/AIDS are infected in the intrapartum period (Farley, 2000:1 -2).Midwives, through effective practices, can lower the transmission of HIV/AIDS from mother to child in the intrapartum period.The aim of the study was to determine which preventive practices registered midwives in provincial labour wards in Bloemfontein, implement to lower the risk of mother to child transmission of HIV/AIDS and in doing so to lower child mortality.
A descriptive research design was used.Fifty-one mid wives completed questionnaires to determine what pre ventive practices are used.
The study showed that most of the midwives did not im plem ent the interventions that could low er the chances of HI V/Aids transmission from mother to child during the intrapartum period.Midwives therefore may not have a positive impact on child mortality.The re searchers concluded that midwives do not implement the interventions mentioned in the study because o f a lack of knowledge and skills.Of the midwives who com pleted questionnaires, 67% com pleted their training between 1990 and 2000.This lack of knowledge may be due to a lack in the curriculum of training institutions and of an up-to-date policy concerning the transmis sio n o f H IV /A id s in p ro v in c ia l in s titu tio n s in Bloemfontein.
It is recom m ended that all affordable interventions should be incorporated in the policy.

Introduction and problem statem ent
The transmission of HI V/AIDS from mother to child is the main cause of HIV/AIDS in children.Two-thirds of the chil dren with HIV/AIDS are infected in the intrapartum period (Farley, 2000:1-2).
Researchers maintain that HI V/AIDS transmission from an HIV-positive mother to her child is 15-20% in industrialised countries while it is 25-30% in developing countries such as South Africa.HIV/AIDS transmission is therefore higher in South Africa than in many other countries.The dilemma is that the diseases that occur during pregnancy as a result of HIV infection, occur in those parts of the world that cannot afford expensive and complex interventions, such as antiviral drugs.A global impact on HIV child mortality must therefore be made by means of simple and affordable interventions (Farley, 2000:1-2 (Harley, 2000:69); • Curtail exposure of the neonate to maternal blood and amniotic fluid by rubbing the neonate dry im mediately after birth and bathing it as soon as pos sible after birth (MacGillivray, 1996:482).
In view of the fact that the midwife is fully responsible for the intrapartum care of mother and child, it is her responsi bility to pursue practices that prevent intrapartum HIV/ AIDS transmission (Regulation 2598 of 30 November 1984).

Aim
The aim of this study was to determine which preventive measures were taken by registered midwives in provincial hospitals in Bloemfontein to reduce intrapartum transm is sion of HIV/AIDS from mother to child and thereby to re duce child mortality.

Objectives
The objectives of the study were to:

Research methodology
A descriptive design was used to acquire more information about intrapartum HIV/AIDS transmission.No manipula tion of variables took place.

Data collection technique
After a thorough analysis of the literature regarding intra partum transmission of HIV/AIDS, a structured question naire was used to achieve the objectives of the study.Every question was accompanied by instructions and explana tions so that the respondents knew what was expected of them.An introductory letter in which the aim of the study was explained was attached to each questionnaire.

Sample selection
The researchers included all the registered midwives work ing in the labour wards o f four provincial hospitals in Bloemfontein, therefore a sample was not taken.All the registered midwives excepting the ten who were on leave, were included.The respondents comprised the following: Hospital A, 17 midwives, Hospital B, 17 midwives, Hospital C, 17 midwives and Hospital D, 16 midwives.Sixteen of the respondents did not wish to take part in the study and were omitted.Fifty-one respondents completed the question naire.

Course of the research
After consent was obtained from the Ethics Committee of the Faculty of Health Sciences of the University of the Free State, as well as the management o f the institutions in volved, questionnaires were handed to all the respond ents.Each o f the four researchers was allocated a hospital where she personally handed questionnaires to the re spondents and collected them immediately after they were completed.
Before completing questionnaires respondents gave w rit ten consent to the study.The researchers were available throughout to explain any unclear questions.This increased the response rate.The questionnaires were collected by the researchers directly after completion and evaluated for completeness.No faulty questionnaires (all questions were answered in the correct way) were found and therefore all the questionnaires were used.The researchers coded them personally after which they were sent to the Department of Biostatistics of the University of the Free State for process ing.
All the data was collected within a fortnight after taking into account the off duty periods o f the midwives and re searchers.

Data analysis
Descriptive statistics, i.e. frequencies and percentages for categorical data and averages and standard deviations or medians and percentiles for continuing variables were cal culated.The analysis was carried out by the Department of Biostatistics.

Validity and reliability
Validity represents the constancy of the collected informa tion.Testing o f validity focuses on three aspects, i.e. sta bility, ecovalence and hom ogeneity (B urns & Grove, 1997:327-330).
In this study stability was difficult to ensure as the re spondents did not repeat the study.However, the results would have remained unchanged if the study were to be repeated within the same time period, because the actions and views o f the midwives would have remained constant.Also, there was only one version o f the measuring instru ment.
Content validity was ensured by determining from the re view of the literature the measures that can be taken to reduce HIV transmission from mother to child.All these aspects were included and the questionnaire was subm it ted to domain experts for evaluation.
The reliability of a measuring instrument is determined by the degree to which it reflects the information being exam ined (Bums & Grove, 1997:330-334).
Content-related reliability in this study was ensured by vir tue of the fact that recently published literature such as journal articles, books and research reports were used in compiling the questionnaire.The questionnaire was also submitted for evaluation to experts on HIV/AIDS.Respond ents could com plete the q u estio nn aire in E nglish or Afrikaans.
Related measures were grouped together in the question naire.

Pilot study
A pilot study was conducted in the labour ward o f a private hospital in Bloemfontein.The aim was to identify lack of clarity in the questionnaire, enhance the validity and reli ability o f the m easuring instrum ent and to refine data colleciton and data analysis.No lack o f clarity was experi enced by the midwives and the instrument was left un changed.

Ethical issues
W ritten consent was obtained from the Ethical Committee o f the Faculty of Health Sciences o f the University of the Free State and the hospitals in question.
Respondents have the right to self-determination, there fore: • The range and aim of the study was explained to them and and they were able to decide whether to participate; • They could withdraw from the study if they so wished; • They were not exposed to physical or psychologi cal harm if they chose not to take part; • No reward was offered for participation.
Respondents have the right to privacy therefore private information, for instance a respondent's attitude to HIV/ AIDS infected patients, was handled confidentially.
Anonymity was ensured by virtue of the fact that ques tionnaires were numbered and nameless and respondents could not by any means be traced.Collected information was not used for any purpose other than that indicated in the research proposal.There was no discrimination in terms of race, culture or social prejudice and all respondents were therefore equitably treated.Respondents were protected and were not exposed to any physical or psychological harm or discomfort while filling in the questionnaire.

Interventions that reduce HIV/Aids transmission
Registered midwives are compelled by their scope of prac tice to be knowledgeable about interventions and prac tices that may reduce intrapartum HIV/AIDS transmission.Some o f these practices will be discussed.

Vaginal douche
The vaginal passage is cleansed with a 0.25% chlorhexidine solution and 12.5 ml chlorhexidine is added to 5 litres of water.Other solutions that may be used are nonoxynol-9 and benzalconium chloride.Nonoxynol-9 (known as a sper micide) is effective against HIV infections in vitro, but it can cause genital ulceration and vaginitis if used for long periods, thereby increasing the risk o f HIV transmission.Benzalconium chloride is also effective in vitro and is welltolerated.It renders other infective agents that increase the risk of HIV transmission harmless (Van Coeveren de Groot, 1995:13;Woods, 1998:18).
A vaginal douche therefore reduces exposure of the baby to the HIV/AIDS virus.
Artificial rupture of the membranes M embranes ruptured for more than four hours before de livery are associated with increased transmission o f HIV/ AIDS from mother to child.The ruptured membranes pro vide a route of entry for ascending infections.Routine arti ficial rupture of the membranes must therefore be avoided as far as possible (Evuan, 2000:218, Brocklehurst, 1998:3).Artificial rupture of the membranes may cause haemorrhage as well as the rupture of abnormal blood vessels.The mem branes should therefore be kept intact for as long as possi ble to avoid foetal exposure to maternal blood and vaginal secretions (Nichols & Zwelling, 1997:911).

Invasive foetal monitoring
Invasive foetal monitoring techniques should be avoided.
The puncture or attachment area is a direct access route for the HIV/AIDS virus (Van Coeveren de Groot, 1995:15).

Performing an episiotomy
Performing an episiotomy on a mother with HIV/AIDS must be avoided.The risk of HIV/AIDS transmission is increased as the baby comes in contact with maternal blood.
Nursing care of a neonate directly after delivery

Rubbing the baby dry
Directly after delivery of the head the baby's face must be wiped with a soft cloth to rid it o f all maternal secretions.The neonate's entire body must be rubbed well dry to limit exposure to maternal blood and secretions that enhance the chance of HIV/AIDS transmission (Evuan, 2000:220).

Suctioning the airways
Unnecessary suctioning o f the neonate's airways must be avoided as it may cause trauma of the mucosa which will facilitate access to viral infection.Suction is unnecessary in most births.It is only necessary if there is meconium or an excessive amount of amniotic fluid in the neonate's air ways that may result in other infections.
If suction is necessary the tip o f the catheter may be dipped in sterile water as this facilitates access o f the catheter and prevents laceration of the mucous membranes.Sterile w a ter is also indicated to reduce the presence of micro-organisms and to help prevent infection.Deep suction must be avoided as it can damage the mu cous membrane o f the neonate and offer an entry route to the HIV/AIDS virus.The nose may be suctioned with low pressure but the mouth must not be suctioned.Suction must last for less than five seconds (Nichols & Zwelling, 1997:1138).

Bathing the baby
The neonate must be bathed as soon as possible to pre vent prolonged exposure to the HIV/AIDS infected mater nal secretions.The baby must not be washed with m edici nal soap as it is very strong and can damage the skin, pro viding a direct entry route for the HIV/AIDS virus.The baby must be bathed under overhead heating to avoid hy pothermia (MacGillivray, 1996:483).

Administration of injections
Vitamin K injections and BCG immunization must be admin istered after the baby's first bath.There must be no mater nal blood or secretions on the skin as the HIV/AIDS virus can infect the baby through the puncture (Martin, 1990:321 -322).

Breast feeding
The World Health Organisation encourages artificial feed ing for mothers who are HIV/AIDS infected in developing countries only in the following instances: if artificial feeds are readily available over a long period; if there are heating and sterilization facilities, the mother has the training and information to prepare correct feeds and can afford artifi cial feeds and if bottle feeding is acceptable to the mother and the community.In some communities in developing countries there is a stigma attached to artificial feeds as it is an indication that the mother is HIV positive.Because the mother feels rejected by the community she begins to breast feed her baby thereby increasing the hazard of HIV/AIDS transmission (UNAIDS, 1999:10).
If artificial feeds are incorrectly used, for instance if they are mixed with contaminated water or if the instructions are not correctly followed, severe malnutrition or fatal infec tive diseases may result.
Breast feeding is recommended for HIV positive babies.
HIV positive children are twice as prone to diarrhoea and diarrhoea-related diseases and have an eleven times greater chance than healthy children of dying of diarrhoea.The antiviral, antibacterial and antiseptic qualities of breast milk can prevent opportunistic infections.Breast milk also has immuno-modular properties that can retard the effect of the virus on the baby's immune system (Morrison, 1998:4-6).

Caesarean section versus vaginal delivery
The risk o f HIV/AIDS transmission during vaginal delivery is 20% and 14% during caesarean section.(Van Coeveren de Groot, 1995:16).
According to Brocklehurst (1998:2) studies by observation showed that risk factors for the transmission of HIV are halved by elective caesarean section.The operation must be bloodless which means that diathermy must be used for the surgical intervention.
It is within the midwife's power to reduce HIV/AIDS trans mission from mother to baby in the intrapartum period in a cost-effective manner thereby making a unique contribu tion.M idwives must therefore be em pow ered with the knowledge to reduce transmission of the virus from mother to child.

Findings Period within which respondents completed their training
Seven (13.73%) of the respondents completed their train ing before 1985, ten (19.61 %) between 1986-1990, fourteen (27.45%) between 1991 and 1995 and twenty (39.22%) be tween 1996 and 2000.This means that 67% of the respond ents com pleted their training in the past decade during which time HIV/AIDS played a very important role in the media, government and health services.It is, therefore, dis turbing that, as will be shown later, the necessary precau tions are not taken in practice.
Knowledge of the existence of policy regarding the specific management of HIV/AIDS patients Twenty-six (50.98%) of the respondents knew that there was a policy regarding the specific management of HIV/ AIDS patients in their institution while 25 (49.02%) did not know.The inference is that half of the registered midwives did not know about the policy or about its contents.This means that all the patients managed by 49% of the regis tered midwives in the intrapartum period were not given care according to the policy.Furthermore it is alarming that the existing policy does not fully define HIV/AIDS intra partum transmission-reducing interventions.

Giving an HIV positive mother a vaginal douche
Fourteen (27.45%) of the respondents indicated that they do give vaginal douches while 37 (72.55%)stated that they do not do so.About two-thirds of the respondents there fore do not carry out preventive measures to reduce the exposure of the foetus to maternal vaginal secretions.The intrapartum transmission of HIV/AIDS is promoted in this way.

Medications used for vaginal douche
One (7.14%) of the fourteen respondents who stated that they do give douches used saline 0.9%, three (21.43%)used 0.25% chlorhexidine and eight (57.14%)used Savlon.Two respondents did not know which solution they used.It is clear from these figures that only three (5.88%) of the 51 respondents used the recommended solution.Only 5.88% of the babies delivered by registered midwives in these institutions enjoy the benefit of the low cost, non-technological approach of vaginal douching of their mothers be fore and during delivery as recommended by Brocklehurst (1998:2).

Stage at which vaginal douches are given
The 5.88% of babies who benefited from the correct use of solutions for vaginal douches were prejudiced by virtue of the fact that 37.3% of the respondents performed vaginal douches unnecessarily.These include: eight (15.7%) who carried out vaginal douches as a routine on admission to the labour ward and 11 (2 1 .6%) who did so postpartum; w hile only seven (13.7% ) gave vaginal douches after amniotomy/spontaneous rupture of the membranes and five (9.8%) in the second stage of labour as recom mended in the literature (Brocklehurst, 1998:12;Woods, 1998:18).

Performance of amniotomy
Ten respondents (19.61%) indicated that they performed an amniotomy as a routine regardless of the HIV status of the mother.Forty-one (80.39%) stated that they would not perform an amniotomy on HIV positive patients.Accord ing to the personal observations o f the researchers and collegial discussions more than one fifth of the registered midwives perform amniotomies as a routine.This contra diction indicates that the midwives do have the appropri ate knowledge but that they perform amniotomies to has ten the progress of labour at the expense o f foetal w ell being and the reduction of the transmission of the HI virus from mother to child.

Stage at which amniotomies are performed
Four (40%) of the ten respondents who stated that they performed amniotomies as a routine regardless of the HIV status of the mother, did so after the cervix was five centi metres dilated and six (60%) if labour was not progressing strictly according to the partogram.M embranes ruptured for more than four hours before delivery are associated with increased transmission of HIV/AIDS from mother to child.Ruptured membranes provide an access route to as cending infections.Routine artificial rupture of the mem branes must therefore be avoided as far as possible (Evuan, 2000:218;Brocklehurst, 1998:3).

The use of invasive foetal monitoring
Two (3.92%) of the 51 respondents would expose the foe tus to maternal secretions, blood and the risk of further infection by performing invasive foetal monitoring.Both these respondents indicated that they commenced this prac tice as a routine on the patient's admission to the labour ward.The puncture or adherent area of the invasive proce dure serves as a direct access route to the HIV virus and must therefore be avoided (Van Coeveren de Groot: 1995:15).The vast majority, i.e. 96.08% of the respondents did not promote HIV transmission from mother to child because they refrained from performing invasive foetal monitoring techniques.

Type of delivery of choice in singleton pregnancies of HIV positive mothers
Sixteen (31.37%) o f the respondents believed that an elec tive caesarean section is the delivery o f choice for single ton pregnancies of HIV positive mothers; 34 (66.67%)be lieved that a normal vaginal delivery is best, while one (1.96%) was of the opinion that a vacuum extraction should be the delivery o f choice.A ccording to B rocklehurst (1998:2) studies by observation showed that risk factors for the transmission of HIV are halved by elective caesarean section.

Type of delivery of choice in multiple pregnancies of HIV positive mothers
Thirty-one (60.78%) of the respondents believed that an elective caesarean section is the delivery of choice in mul tiple pregnancies of HIV positive mothers; two (3.92%) opted for emergency caesarean section; 15 (29.41 %) for a normal vaginal delivery; one (1.96%) for forceps delivery and two (3.92%) for vacuum extraction.According to the literature F IG U R E 1 : When an episiotomy was performed in H IV positive patients

54.90% PROLONGED SECOND STAGE
elective caesarean section is the delivery o f choice in such cases (Goedert, Duliege, Amos & Felton., 1991:1473).Thirtyone respondents marked this as their choice of delivery, showing that they had adequate knowledge in this regard.
When an episiotomy was performed on HIV positive mothers Fourteen (27.45%) o f the re sp o n d e n ts a n sw e re d c o r rectly according to the litera ture by stating that they would never perform an episiotomy on an HIV positive m other (See Figure 1).This was in contrast to the 72.59% who would expose the foetus un necessarily to maternal blood an d c o n s e q u e n tly to in creased HIV exposure by per forming an episiotomy.Eight o f these (15.69% ) routinely perform ed episiotom ies on prim igravidas, one (1.96% ) routinely performed them on all patients and 28 (54.9%) did so in cases o f a prolonged second stage.In the latter case an episiotom y can be averted by positioning and other alternatives.The m oth e r's perineum must be wellsupported but even if lacera tions should occur the blood loss is less than after an episi otomy.The baby will come in contact with less of the HIV positive blood o f the mother (M aier & M aloni, 1997(M aier & M aloni, :15, Pillitteri, 1999:326):326).

When the neonate was suctioned
Only nine (17.6%) of the respondents suctioned only neonates with ex cessive m econium or aspirated amniotic fluid (See Figure 2).In con tra s t, 18 (3 5 .3% ) suctioned neonates as a routine, 17 (33.3%)respondents suctioned them if they did not cry im m ed iately and six ( 1 1 .8%) did so if they w ere c y a n o tic .Five (9.8%) respondents in dicated that they never su ctio n a n eo nate.T h irty -sev en (7 2 .6 % ) su c tio n ed neonates unnecessarily possiblly causing traum a o f the mucous membranes, facilitating access to viral infection and increasing the risk of mother to child transmission of HIV.Babies of HIV/AIDS mothers should only be suctioned if there is meconium and excessive amniotic fluid aspiration (Nichols & Zwelling, 1997:1138).
F IG U R E 2 : When neonates were suctioned

When the baby was rubbed clean and dry
Forty-nine (96.08%) of the respondents indicated that they rub the neonates of HIV positive mothers clean and dry immediately after birth.This reduces the period of expo sure to maternal secretions and blood (Evuan, 2000:220).Two respondents (3.92%) stated that they first administer oxygen before rubbing the baby.Fory-nine of the midwives therefore have a positive impact on the reduction of HIV/ AIDS transmission from m other to child by immediately rubbing the baby clean and dry.

When intramuscular Konakion was administered
Thirty-three (63.71%) of the respondents stated that they adm inistered Konakion intramuscularly immediately after birth, two (3.92%) after the baby's temperature was above 36.5°Cand sixteen (31.37%) after the first bath.Thirty-five (68.83% ) respondents therefore adm inistered Konakion intramuscularly before the first bath thereby increasing the baby's exposure to HIV/AIDS as the injection provides a direct access route to maternal secretions and blood still present on its skin (Martin, 1990:321-322).

When intradermal BCG was given
Six (11.76% ) of the respondents indicated that they admin istered BCG intradermally directly after birth, two (3.92%) after the baby's temperature was above 36.5°C,40 (78.43%) after the first bath and three (5.88%)stated that they never give BCG intradermally to the baby of an HIV positive m other.F orty o f the respondents adm in istered BCG intradermally after the baby's first bath when all maternal blood and secretions have been rem oved from its skin thereby avoiding a direct access route to the HIV/AIDS virus (Martin, 1990:321-322).

Bathing the neonate
Twenty-eight (56.87%) o f the respondents did not provide for the patient's HIV status and therefore contributed to child mortality by increasing HIV/AIDS infection since 21 (41.18%) of them did not bath the baby until it maintained a tem perature above 36.5°Cand eight (15.79% ) waited six hours after birth to prevent hypothermia.Hypothermia can be avoided by using overhead heating when the baby is bathed directly after birth in order to prevent protracted exposure to maternal HIV/AIDS infected secretions and blood.Neonates must not be bathed with medicinal soap as it can dam age the skin, offering a direct access route to the HIV/AIDS virus (MacGillivray, 1996:483).Twenty-two (43.14%) o f the respondents acted in terms of the literature and bathed the baby im m ediately after birth.

Type of feeds recommended
Twenty-one (41.2%) of the respondents stated that they would recommend artificial feeds for neonates of HIV posi tive mothers.Twenty-eight (54.9%) would recommend ex clusive breast-feeding and six ( 1 1 .8%) recommended mixed feeds.Twenty-eight (54.9%) of the midwives promoted the triple protection that breast milk offers.They enhanced mother-child bonding while having a positive impact on child mortality.Exclusive breast milk can, therefore, be rec ommended for the babies of HIV/AIDS infected mothers (UN ADDS, 1998:2).

Factors that influence the recommended type of feeds
Breast feeding is a lifesaver where there is no access to food and clean water.According to the World Health Or O f the rest o f the respondents, two (3.9%) indicated the gravida of the mother and three (5.9%) the birth weight of the neonate.However, these factors are not taken into ac count at all in decision-m aking about the type o f feed (UNAIDS, 1999:10).

Understanding of exclusive breast feeding
O f the 51 respondents 40 (78.43%) had a correct under standing of the concept and 11 (21.57%)provided an incor rect definition.This means that 21.56% of the midwives did not understand the basic term inology of breast feeding and therefore could not provide HIV positive mothers with correct information about feeding their babies.

Conclusions
The findings show that most of the midwives did not apply practices or interventions to lower the transmission of HIV/ AIDS from mother to child in the intrapartum period.It is possible therefore that they did not have a positive impact on child mortality.The researchers conclude that the mid wives did not implement the interventions m entioned in the study because they probably did not have the required knowledge or skills.However, there must be other reasons that were not researched.The research showed that 67% of the midwives completed their training between 1990-2000.Their inadequate knowledge may therefore be due to a de ficiency in the curriculum of training institutions and the lack o f a re ce n t p o licy in p ro v in cia l in stitu tio n s in Bloemfontein.

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The managem ent o f the institutions involved must be made aware of the results of the study and the researchers will present them with a report of the research.This is necessary to motivate the manag ers to make available the resources to em power the registered midwives for the battle against AIDS.

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The simple and affordable interventions identified by the researchers to lower the transm ission rate of intrapartum HIV/AIDS from mother to child, must be incorporated in the existing policy.

Synopsis
Seventy thousand children are infected with the HIV/AIDS virus every year in South Africa (McGeary, 2001:53).Regis tered midwives can, therefore, make a great impact on child mortality as two-thirds of these children are infected in the intrapartum period (Farley, 2000:1).At present the media are giving great prominence to the use of antiviral drugs for reducing the rate of transmission of HIV/AIDS from mother to child.In view of the economic status o f the country there must be a shift in emphasis from expensive complex interventions to simple and affordable practices as dis cussed in the study.M idwives who are empowered with the appropriate knowledge and skills are South A frica's first line o f defence.
D a a r w o rd a a n b e v e e l d a t al d ie b e k o s tig b a re tussentredes in die bestaande beleid geinkorporeer moet word.

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The policy must be made known to all registered m idwives in the institutions.The interventions set out in the policy should be enlarged and exhibited in a prom inent and attractive m anner in the wards and workshops about the interventions should be conducted.■ A video should be compiled incorporating all the interventions m entioned with their scientific expla nations, and dem onstrations of the techniques.Rel evant literature used for the study by the research ers will be made available to the institutions and should be made available to all staff members.The video should be included in the inservice training programme.■ A suggestion will be made to the staff of the inservice training program mes to include the video, relevant literature and the new policy as part o f the induc tion program m e o f the institutions.■ Despite the fact that 67% o f the respondents of this study completed their training in the past ten years, deficiencies were found in their interventions.For this reason the findings of the research should be made known to all training schools in the country for inclusion in their midwifery curricula.■ The study should be repeated after two years to ascertain whether the recom mendations o f the re searchers made an impact.■ The research will be presented at the research fo rum of the medical faculty of the University o f the Free State to expose all the m embers o f the multidisciplinary team to the findings.■ In private practice babies are delivered by doctors and therefore the researchers recomm end that a copy of the research report be handed to the Dean o f the Faculty o f H ealth Sciences of the University o f the Free State in order that the interventions may be included in the curriculum of the medical school. ).
• Avoid deep suctioning of the airways o f the neonate that could cause trauma of the mucosa