EDUCATION

Da"id L Woods, MD, FRCp, OCR
Di'i.;ision of l\"«maral MedUinc, School of Child and AdokJant Health, Univerriry afCape TOL."1T

A NOVEL APPROACH TO PERINATAL
HIV/AIDS TRAINING FOR DOCTORS AND

NURSES IN SOUTH AFRICA

m SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE

The standard PEP course consists of two training manuals,

one on maternal and the other on newborn care. Each

manual has 15 units, addressing important or common
clinical problems. A manual usually requires a year to

complete. Groups of 5 - 10 students study the Programme

together. They elect a group leader who manages the

course and arranges a meeting of participants every 3
weeks. A formal tutor is not required. The course material

from one unit at a time is studied by each participant at

home and then discussed at the group meetings, thus

introducing the concept of peer tuition. Group members

encourage, support and teach each other in a spirit of co-

operative learning. Participants complete and mark their

own multiple choice tests, enabling them to monitor their

own progress through the course. The responsibility of

learning is therefore placed squarely on the shoulders of

question is asked and then the appropriate answer is given.

Utilising this method, participants are led from the most

basic facts to more complex concepts. Case studies are also
used to place the information into clinical context.

Participants find this method of outreach education simple,

easy and enjoyable. Flow diagrams are used to summarise
diagnostic and management protocols while a multiple

choice test, before and after each unit, allows the

participants to monitor their own progress. Skills

workshops include simple line drawings and step-by-step
instructions to master clinical skills. Widespread

consultation with colleagues and comment by course

participants has transformed PEP into a consensus

statement of maternal and newborn care that has helped

to standardise the provision of perinatal care in South

Africa.

The large number of children presenting with AIDS in South Africa is a wake-up call for urgent attention to be paid to

reducing the risk of mother-to-child transmission of HIV. This requires an innovative method of training the thousands
of nurses and doctors who provide perinatal care, especially in rural areas with limited opportunities for ongoing

education. The Perinatal Education Programme is a self-help method of learning which has been very successful in

enabling nurses and doctors to take responsibility for their own distance training. A recent Perinatal HIV/AIDS
supplement to the Programme provides a novel and appropriate means of meeting this training need.

As the HIV epidemic sweeps across South Africa, many of

the AIDS victims are young children infected by their

mothers in the perinatal period. While these children
unfortunately bear the brunt of the early epidemic, many of

them could have been spared the horrors of AIDS if more

attention had been paid to reducing the risk of vertical
transmission. Screening during pregnancy, short-course

antiretroviral prophylaxis, modification of the management

of labour and delivery, and exclusive breast- or formula-

feeding promise to significantly reduce the rate of mother-
to-child transmission of HIV and therefore the incidence of

childhood AIDS. However, to introduce these essential

changes in management large numbers of nurses and

doctors will require additional training. This is problematic

due to the lack of funding, few available tutors and the

impracticality of moving staff to regional centres for

training courses. Traditional methods of centralised
teaching with tutors training small groups of students in

teaching hospitals are expensive and no longer appropriate

or applicable. What is required is an innovative method of

enabling nurses and doctors to manage their own

continuing education. This need is particularly urgent with

staff caring for pregnant women who are HIV-infected and

their HIV-exposed infants.

The Perinatal Education Programme (PEP) offers a cheap

and practical means of addressing the problem.' PEP is a

self-help distance learning course that aims at improving

the care of pregnant women and their newborn infants,

especially in rural areas. It is presented in the form of

training manuals that use a problem-orientated, patient-

based approach. A question-and-answer method of

problem solving is used as the basic learning model: first a

FEBRUARY 2003 -----------



each participant. The group leader invites an appropriate

medical or nursing colleague to attend the PEP meeting in

order to demonstrate the clinical skills attached to the unit

being studied. In this way local resource personnel are
encouraged to share their clinical abilities, and solve the

seemingly insurmountable problem of skills instruction in

rural areas.

A formal multiple-choice examination is offered to

participants on completion of each manual. Regional

health care services manage their own examination.

Certificates are awarded to successful candidates and a

graduation ceremony is arranged that acknowledges the

considerable effort of the participants, and encourages

other colleagues to join a PEP group. Participants buy their

own manuals from the Perinatal Education Trust at R1S0

each. This payment allows the Trust, which produces the

Programme, to be financially self-sufficient. Through the

generosity of a private donor, nurses from the public sector

who pass the PEP examination may apply for a

retrospective bursary that repays the cost of their course.

This system rewards success and enables most practising

midwives in South Africa to join the project. Because each

group takes ownership of their course, the pride and sense

of achievement is theirs.

To date more than 30 000 PEP manuals have been

distributed and over 10000 certificates awarded to nurses

and medical practitioners, as well as undergraduate

nursing and medical students, who have successfully

completed the course in southern Africa. A field study and

two prospective controlled trials of the Maternal Care and

Newborn Care PEP manuals have documented a significant

improvement in cognitive knowledge, clinical skills,

attitudes and patient care practices of midwives in South

Africa.'" In the prospective trials, either the maternal or

newborn care manual was introduced into a district

hospital and its primary care clinic while the PEP was

withheld from the neighbouring district, which was used as

a control. Midwives in both the intervention and control

districts were objectively assessed at the start and again at

the end of the study. The midwives using PEP managed

their own course over 12 months without a trainer. This is

the first study to have documented that groups of

midwives can be empowered to enhance their own clinical

knowledge and skills and improve their attitudes and

standard of patient care without the infrastructure of a

formal training institution. Midwives using PEP reported

that they felt more confident in their clinical abilities,

experienced less stress at work, and achieved a greater

degree of job satisfaction. Perhaps the awareness and

appreciation of self-growth is one of the most important

achievements of this method of distance education.

Recently a supplementary PEP manual on Perinatal

THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE

HIV/AIDS has been developed. It allows groups of

professional health care workers to learn about all aspects

of perinatal HIV infection. The five units address the

following topics:

• A general introduction to HIV infection and AIDS.

• Management of HIV-infected women during pregnancy.

• Management of HIV-infected women during labour and
delivery.

• Management of HIV-exposed infants.

• Counselling HIV-positive women.

The learning material provides the reader with the basic

theoretical knowledge of HIV infection and AIDS, an

approach to diagnosis and management of mother and

infant, and counselling principles to support the mother

and family. Thirteen experts in the field of perinatal HIV in

South Africa contributed to the development of the

training manual. The layout and method of learning is the

same as the two basic PEP manuals. The cost of the

Perinatal HIV/AIDS manual is RSO, inclusive of VAT, postage

and packaging, and the end-of-course examination. A

certificate is awarded to candidates who successfully

complete the 4-month course and pass the final multiple-

choice examination. The course offered by the Perinatal

HIV/AIDS manual is recognised for 10 CPD points provided

the doctor successfully completes the examination. Both

the standard manuals and the supplementary manual on

Perinatal HIV/AIDS are available in either English or

Afrikaans.

In a small field trial in KwaZulu/Natal, midwives studied the

Perinatal HIV/AIDS manual. An assessment of their

knowledge of the subject, before and after they conducted

their own self-help course, showed a significant

improvement from 64% to 94%. This result is similar to

the more exhaustive assessments of the two basic PEP

manuals. Over the past year, 1 000 Perinatal HIV/AIDS

manuals have been distributed and well received by doctors

and nurses working in both hospitals and clinics.

The Perinatal Education Programme offers a cheap and

appropriate means of bringing on-site training to the many

thousands of professional health care workers who are

struggling to provide adequate care to HIV-positive women

and their newborn children, especially in rural areas. The

cost of the course is minimal compared with that of

traditional training methods, and no formal teaching

infrastructure is needed. Provisional results suggest that

the Perinatal HIV/AIDS manual is as effective in providing

appropriate knowledge as the rest of the Perinatal

Education Programme. What is required is a concerted

national and provisional plan to promote this form of

educational opportunity to all who could benefit. With

well-trained midwives and doctors, and a simple,

appropriate protocol of managing pregnant women who

----------- HBRUARY 2003



INDUSTRY NEWS

2. Woods DL Theran Ga The impacr of the Perinatal Education Programmf' on
cognitivt: knowledge in midw~ 5AfrMroJ 1995; 85: 150-153.

3. Theron GB. Improved cognitivt knowledge of midw~ practicing in the E4srern
Ca~ P(ovin~ of the Republic of South Africa through study of Cl self educational
manual. Midwifery 1999; 15: 66-71.

4. Tneron GB. lmprovro practical skills of midw~ praeticing in the Eastern Province
of the Republic of South A'"cc; through me study of a self-tducation manual.
JPmnaro!2lXXJ; 3: 184- 18a

5. Theran GB. The effect of the Maternal Care manual of the Ptrinatal EtiuCdtion
Programml:' on the attitude of midw~ towards Ih~r work. Curorionis 1999;
Dettmber: 63~67.

6. rneron GB. The effe<:t of the Maternal Ci!!:' Manual from the Perinatal Educ;;tion
Programme on the quality of ;nte+ and inuapa/1Um care rendered by miowives.
SAfr M~J 1999; 89: 336-341

7. Gr~nfietd OH. Evaluation of the use of the Neonalal Manual of the PerirLaral
Educ;;tion Programme. In: Proceedings of rh~ 7th World IAMANEH Conf~~nce.
Pretoria: University of Pretoria, 1999: 229-231.

Tllf SOUTHfRN AFRICAN JOURNAL Of HIV MfOICINf

Ms LMackenzie (BMS Anti-Infective Franchise Monoger),
Mr I Strochan (CEO of BMS), Prof. CFeldman.

Or 0 Mwanthembe, Prof. GRichards, Or M Sussmon.

1. Woods DL An innovativl:' programme for training in maternal and newborn care.
~min Neonotol 1999; 4: 209-216.

are HIV-positive, the present high rate of mother-ta-child

transmission can be reduced, with a resultant drop in the
numbers of children suffering from and dying of AIDS in

South Africa.

For further information visit the Perinatal Education
Trust website at www!pepcourse.co.za or contact the
Trust by phone or fax at (021) 671-8030.

REFERENCES

The Castle in Kyalami was the ideal venue for Bristol-Myers

Squibb to introduce the newly formed Anti-Infective

Franchise in both grandeur and style on 3 December 2002.
The sovereign feast and dancing were enjoyed by all until

well into the night

Introduction of the Bristol-Myers Squibb Anti-Infective
Franchise

Bristol-Myers Squibb have a wealth of knowledge in the

anti-infective market with products including Tequin,

Maxipime, Prozef, Fungizone, Cefril, Cefril-A, Cefacidal and

Azactam in their Anti-Infective Franchise.

In addition, Bristol-Myers Squibb has a strong Anti-

Retroviral Franchise in Zerit and Videx, which are supplied

below cost to the South African market

Mrs and Prof. De KSommers, Ms RCoetzee (Prozef Product
Manager), Or A Brink.

HHRUAR 2003-----------