Exploring the Understanding and Triage Practices of Midwives Working in District Hospitals of Mpumalanga Province, South Africa

1. INTRODUCTION

The World Health Organization (WHO) and the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA) envisioned a world where every woman and newborn receives quality care and treatment throughout pregnancy, intrapartum, and puerperium period; a world where no woman dies giving birth [1]. However, maternal and perinatal deaths remain a global concern. Approximately 287,000 maternal deaths and 1.9 million stillbirths were reported in 2020 and 2019, respectively [2, 3]. Some scholars and the WHO highlighted that the main causes of maternal and perinatal mortality and morbidity are delays in receiving adequate and appropriate care upon arrival in the maternity units, along with a lack of knowledge of healthcare providers, especially in low and middle-income countries [4, 5]. The United States Agency for International Development (USAID) [6] says that millions of women die as a result of substandard maternal health care services. The WHO reported that to combat maternal and perinatal morbidities, skilled care should be provided before and during birth to save the lives of women and newborns [3]. Halim et al. [7] state that it is of significance to improve the quality of care provided in health facilities by further focusing on strengthening the skills and practices of healthcare providers in the early detection and treatment of complications.

Existing investigations showed that proper triage systems and timely, appropriate treatment upon arrival at maternity units are pivotal in improving patient care quality and reducing maternal and neonatal mortality. Moudi et al. [4] and Fernandes et al. [8] assert that effective triage enhances clinical decision-making by prioritizing care for mothers and their infants based on the severity of their conditions, thereby ensuring timely allocation of medical resources and necessary interventions. Therefore, proper triage facilitates early identification of high-risk cases, enabling prompt interventions that can prevent complications and adverse outcomes. It also ensures that patients receive the correct level of care based on the severity of their condition. Despite evidence demonstrating the critical role of proper triage systems in improving patient care quality and reducing maternal and neonatal mortality, there remains a significant gap in the lack of standardized triage protocols in many maternity units, particularly in Mpumalanga district hospitals. The lack of a structured triage system may jeopardize prompt interventions, contributing to unfavourable maternal and neonatal outcomes. Obstetric triage has been recognized and implemented in certain healthcare settings as a key intervention to address maternal and neonatal mortality. This approach facilitates the prioritization of care, ensuring that high-risk cases receive timely and appropriate interventions, thereby reducing adverse outcomes. For example, in North America, obstetric triage acuity scales are used for a quicker initial assessment and shorter wait times [9]. Furthermore, data on acuity, volume, and trends enhanced the number of nurses and other staffing in triage units [9]. The findings of a study conducted in the United Kingdom asserted that the triaging of pregnant women in obstetric units is associated with improved safety of women and babies and reduced waiting time for obstetric assessment of pregnant women [10]. In Sub-Saharan Africa, a tertiary hospital in Ghana developed and implemented an obstetric triage system [11]. The implementation of the newly developed obstetric triage system resulted in a 44% reduction in patient waiting times over a 12-month period. However, in South Africa, a study by Tukisi et al. [12] highlighted the use of initial assessment within maternity records of pregnant women. Clearly, this is not practiced nationally. South Africa appears to have relied on emergency department systems, such as the South African Triage Scale (SATS) [13], for obstetric triage rather than developing a standardized system of its own. Although the SATS has been adapted to include the triaging of pregnant women in emergency departments, it lacks comprehensive coverage of obstetric emergencies, particularly within maternity units. It only focuses on abdominal trauma during pregnancy, ectopic pregnancies, and vaginal bleeding [13]. In addition, the first author observed that many labor wards in Mpumalanga province lack a formal triage system, which has led to instances of patients delivering in waiting areas. This contributes to poor maternal and perinatal outcomes and has sparked increased public dissatisfaction with the quality of care provided in maternity units. Sumbane et al. [14] assert that these incidents contribute to the rise in intrapartum malpractices in maternity units. Moodley et al. [15] findings agree that lack of triage is associated with late recognition and management of obstetric emergencies by physicians and midwives, resulting in poor maternal and perinatal outcomes.

The nexus between existing literature on maternal and perinatal deaths attributable to avoidable factors and the author's observations underscores the detrimental impact of the absence of a triage system in maternity units. This lack of a structured triage process not only compromises the quality of care but also results in significant financial losses for government budgets due to malpractices and preventable maternal deaths. It also affects the midwives' understanding and practices of triage. A study conducted in South Africa exploring midwives' experiences with the obstetric triage tool found that they struggled to understand its processes due to insufficient guidance. Additionally, the low staffing levels hinder effective implementation and practices, resulting in an unfavorable midwife-to-patient ratio [12]. While midwives play a crucial role in maternal care, there is limited research on their understanding and triage practices, particularly in district hospitals in Mpumalanga Province, South Africa. This could impede timely obstetric interventions, exacerbating poor maternal and perinatal outcomes. In light of this, the current paper focuses on exploring and describing the understanding and triage practices of midwives working in the labor wards of a selected district hospital in Mpumalanga province of South Africa.

2. MATERIALS AND METHODS

3. RESULTS

Table 2 shows the demographic characteristics of the participants. The interviews were conducted among midwives working in selected district hospitals. Most of the participants were women (19) between the ages of 40-59. The MPs hold various highest qualifications, with 7 holding postgraduate diplomas/honours in advanced midwifery, 4 having an R425 bachelor’s degree in nursing, 7 have an R425 diploma in nursing and lastly, 2 have an advanced diploma in midwifery. Most of the participants have more than 5 years of experience, and advanced midwives are the most experienced of all participants.

After performing a thematic analysis of the data, it was found that the study yielded two main themes and five subthemes. The themes that emerged reflect the understanding and existing triage practices of midwives in triaging women presenting in the labor ward. Fig. (1) shows the themes and subthemes that emerged below.

3.1. Theme 1: Nuanced Understanding of Triaging in Labor Wards

Triaging was described as the process of evaluating and categorizing patients according to their specific needs to determine whether they are emergencies. In addition, triage was identified as a means to prevent unexpected problems in pregnant patients who arrive at the labor and delivery units. Midwives firmly believed that by using triage, they could identify issues early and take prompt action to prevent complications. As a result, they saw triage as a positive step towards strengthening the quality of care. This was supported by the two emerging sub-themes.

3.1.1. Sub-theme 1.1: Basic Understanding of Triage and Maternal Care Guidelines

Most midwives had a diverse understanding of what triage is. They shared detailed insights into their understanding of triaging. Triage was understood as a technique to keep midwives informed of what was happening with the patients. The fundamental component that helps midwives articulate the understanding of triaging in labor is signalling out the pregnant women's needs and, thereafter, sorting them out in the level of urgency. These were supported by the following assertions;

“I think triage in the labour ward is when we place the patients according to their need of attention” P10

“Triaging is right because you will be able to know what kind of patients are waiting for you even if you are busy inside the ward. So, you will have to know which ones are urgent and which ones are not” P8

“It is the look of patients according to their needs and priorities. Looking at which patient needs to be attended like which one is emergency and which one is not.” P19

3.1.1.1. Another Participant Said,

“Triaging is about prioritizing patients, including risks and categorizing patients in terms of their emergencies and risks. So, you manage accordingly…” P16

On the other hand, midwives voiced that their understanding of triage was informed by their understanding of maternity care guidelines. Because while they triaged the patients, they sought guidance from maternal guidelines to provide them with information on how to manage clinical obstetric conditions. This was supported by the following narrative;

“…Also, the maternity guidelines provide us with the information on how the blood pressure is managed.” P16

Drawing from the extracts, there was an absolute shared understanding among midwives about what triaging is and why it should be implemented. One midwife continued to say she is concerned about the lack of understanding of triaging among community health centres, and it is not properly done. This is evidently drawn to the conclusion of overcapacity by low-risk patients in district hospitals.

3.1.2. Sub-theme 1.2: Unequivocal Value of Triaging in Maternity Units Outlined

The midwives understood that no matter what challenges occur within the unit, they should always be familiar with the patients’ conditions in the waiting area to prevent the occurrence of complications. The way their emotions were in sync with their understanding of triage, they viewed triage as the epitome of maternity care. Triage was regarded to be indispensable in maternity care as it can prevent unexpected complications and save both the mother and the baby. With enthusiasm, the midwives said,

“The importance of triage is that we get to save lives, yeah, sooner. You know, because if you attend, if you prioritize on admission, yeah, it's easy to first manage the high-risk patients…” P3

3.1.2.1. Other Participants Said,

“If we triage, like, checking the condition of the patient, because it will help us reduce the perinatal mortality rate to below the target because we get to start with the patients who are high risk first and see a low risk last if we do that…” P9

“The importance of triage is that we should be able to identify the high-risk patients quickly and also manage them fast enough before they complicate more than the way they came in, so it is important.” P16

“So, it is important to first sort them according to their problems so that we’re able to attend those who need help like urgent firstly and be able to avoid or prevent cases of Maternal death and also the death of babies as well” P17

Above all, triage was not only seen as a means of prioritizing patients based on the urgency of their needs but also as a practical approach to improve the overall quality of patient care and ensure timely interventions when providing maternal care. Through triage, midwives felt that they could also diagnose and detect problems early and avoid potential complications. This was supported by these quotes;

“When we triage… we improve nursing care and mortalities decrease below the target of she is in labor, so we must have triage. Meaning, even the intervention, it cannot be delayed. You can provide care fast, in time, even the intrapartum management is going to be better, it will improve.” P9

“…When we triage its better because we’re able to diagnose, see the problem and have it solved early.” P5

According to what the midwives said, triaging in the labour wards is simply beyond sorting priority cases; it is pivotal in providing optimal quality maternal care services. In essence, it ensures that these pregnant women receive the right level of attention and the appropriate amount of care at the appropriate time. In closing, it goes without saying that triage is a multidimensional approach that also ensures the well-being of both the mother and the baby; It prevents poor maternal and perinatal outcomes.

4. DISCUSSION

Triage plays a critical role in improving maternal and neonatal outcomes, particularly in labor wards where timely interventions can prevent life-threatening complications. Maternal and child health has consistently been a significant concern, leading to high mortality rates globally. Drawing back to Sustainable Development Goals SDG 3.1, which aims to Reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 and goal 3.2 aims to end preventable deaths of newborns and children under 5 years of age by 2030. Hence, literature emphasizes the importance of triaging in obstetric units, which enables a more rapid response to emergencies, resulting in improved maternal and fetal surveillance [22, 23]. According to Moudi et al. [4], effective triage allows for the early identification of high-risk cases, ensuring that resources and care are allocated efficiently. Despite its importance, midwives’ understanding of triage and its application in maternity units often varies significantly, influenced by both individual knowledge and the availability of clear guidelines [12]. However, as Tukisi et al. [12] point out, midwives often lack a comprehensive understanding of triage processes, particularly when guidelines are unclear or inadequately implemented. The SATS, for example, while adapted for pregnant women, does not thoroughly address obstetric emergencies, leading to inconsistencies in how midwives apply triage in practice. In settings where staffing levels are low, this limited understanding further complicates the ability to deliver timely care, as midwives are often overwhelmed by patient loads and lack sufficient support [8]. This gap between guidelines and practice highlights the need for better training and clearer protocols to ensure that midwives have a solid foundation in triage processes tailored to the specific needs of labor wards. Just like in Tukisi et al. [12], the midwives in the current study appeared to demonstrate a diverse practice understanding of triage in maternity units.

Most midwives firmly believe that triage is a process of prioritizing patients in terms of their urgency and need. The unequivocal value of triage in maternity units is supported by numerous studies, which demonstrate that triage improves patient outcomes by enabling midwives to prioritize care based on urgency. For example, Fernandes et al. [8] assert that well-structured triage systems enhance clinical decision-making and streamline resource allocation, reducing both waiting times and the risk of adverse outcomes. Furthermore, Moudi et al. [4] highlight that triaging ensures mothers and newborns receive appropriate care at critical moments, particularly in overcrowded or under-resourced settings. Similarly, the understanding of triage by midwives is strongly related to the study of Christian [22] and Moudi et al. [4], who expanded that triage involves prioritization of patients for patient care and allocation of scarce resources to optimize maternal and neonatal outcomes. Despite these benefits, midwives often face significant challenges in implementing triage effectively. A study by Tukisi et al. [12] revealed that inadequate staff numbers and a lack of clear triage guidelines prevent midwives from fully utilizing triage tools, leading to imbalances in the midwife-patient ratio and compromising the quality of care. This underscores the urgent need for healthcare systems to invest in both human resources and the development of triage protocols that are not only easy to understand but also practical for use in the fast-paced environment of maternity units. A nuanced understanding of triage in labor wards is therefore crucial for improving decision-making and ensuring appropriate care is provided to mothers and newborns based on clinical need. While triage is a valuable tool in maternity care, its successful implementation requires a nuanced understanding of both the guidelines and the contextual factors influencing midwives’ ability to apply it effectively.

Although triage in South African obstetric departments is still a relatively new concept, midwives in this study associated their meanings of triage with their triage experiences in emergency and maternity departments. This was because most of the midwives have more than five years’ experience and hold a speciality in midwifery. Moreover, with their level of experience within the maternity units, their triage skills in the labor wards were seemingly enhanced by frequent consultation with South African Maternal Guidelines. As such, midwives viewed triage to be of significant value in patient care, and its implementation within the maternity units helps prevent unforeseen complications for pregnant women and reduces maternal and perinatal mortality. The study by Floyd et al. [23] conceded with the study findings that triaging in maternity units improves maternity quality of care and reduces care delays. Thus improving patient satisfaction. It seems that the unequivocal value of triage by midwives and other studies is related to the South African National core standards and the World Health Organisation in reducing delays in patient care and waiting times through the provision of timely care [24, 25].

Despite the understanding of triaging in maternity units by midwives, midwives were quite saddened by the lack of standardized triage systems within the labor wards. As they expressed that they lacked a triage system, instead they had to rely on an alternative practical approach. Others stated that they relied on their experiences and consultation with the South African maternal guidelines, which only inform midwives about how to manage emergency obstetric conditions, not about how to prioritize. The practices described by the participants in the current study highlight key approaches midwives use in the absence of standardized or formalized triage systems. These approaches, while pragmatic, may be insufficient to ensure the most efficient care prioritization, especially in resource-limited settings. Seemingly, before the 2020s, the lack of triage systems in maternity units was a global issue. This was supported by several studies conducted in Ghana, Iran, Uganda, and Sierra Leone that indicated that before the authors developed effective triage systems, maternity units lacked a formal triage system; instead, they used informal triage systems [4, 23, 26, 27]. In contrast to this study, Tukisi et al.’s study [12] disparage the lack of a standardized triage system in maternity units in South Africa, as it highlighted the use of a nationalized initial assessment of a patient in labor as an obstetric triage tool, seemingly this is not nationally practiced as evidenced by the voices of the midwives in lack of a standardized triage system.

However, due to the lack of a triage system, the midwives said that they normally do not prioritize; instead, they use the first-come, first-serve technique services. Naz et al. [28] conceded that adopting the first-come-first-serve technique services is commonly inappropriate in obstetric care. According to Tukisi et al. [12], midwives in Bojanala district settings resort to this approach due to high patient loads and a lack of clear triage guidelines. While first-come, first-serve technique services may seem equitable, they overlook the clinical urgency of cases, often delaying care for women with critical conditions. Moudi et al. [4] criticize the first-come, first-serve method for its potential to exacerbate adverse outcomes, as it prioritizes arrival time over medical needs. In labor wards, where conditions can rapidly deteriorate, this approach poses significant risks, particularly in cases where early intervention is necessary to prevent maternal and neonatal complications. Thus, while the first-come, first-serve technique may offer simplicity in an overburdened system, it is a suboptimal triage practice that requires re-evaluation in favor of more structured, need-based methods.

Poor triage practices seem to be problematic for all departments, including emergency departments. The recent quantitative analysis of Phukubye et al. [29] indicated a high percentage of poor triage practices among nurses in emergency departments, and ineffective triage is likely to lead to poor patient outcomes. The use of this practice could be linked to a lack of triage training and triage experience among healthcare providers [29], including midwives. This appears to contribute to maternal and perinatal mortality, as indicated by several studies that delay in care in admission at birth contributed to avoidable maternal and perinatal mortality [30]. In fact, this negatively affects public perceptions of maternity care services, evidenced by the number of litigation cases reported to the South African Nursing Council. Although some of the sources are not peer-reviewed, stories of negative public dissatisfaction about maternity care in South Africa are covered by newspapers and social networks. The number of cases related to such avoidable causes shows that there is a need to improve government policies and guidelines about triaging in maternity units in South Africa. This underscores an urgent need to involve key stakeholders, policymakers, and midwives to collaborate towards improvement quality plans to optimize the triage practices of the midwives. Therefore, this will further assist in investigating the justification of not having triage systems in South African maternity care and will be able to identify the key challenges to implementing a triage system.

Midwives further highlighted that there were some circumstances in which they overthrew the above-mentioned practice, particularly when a patient was reporting bearing down or came in accompanied by emergency medical personnel or admission through high-risk. Although this is an effective practice in prioritizing other patients, midwives seem to have little background and strategies to prioritize in labor wards. This indicates the need for standardized triage tools for midwives working in the labor wards. On a positive note, other midwives resorted to more practical triage approaches. Among these are the triaging by clinical history and physical inspection. Triage by patient’s clinical history is another method frequently employed by midwives who participated in the current study. In the realm of triaging, midwives simply check the clinical history, like asking the patient what brings them to the labor ward. Midwives said that such triage practices are sometimes accompanied by checking the maternity case records to corroborate the subjective history of the pregnant woman. Drawing from the midwives' narratives of this study, history taking is quite important as it orients the midwives toward what is wrong with the patient and makes a diagnostic assessment. The study by Peart [31] indicated that the subjective history of patients is a common part of patient care and, more importantly, is also important for triaging. This was also noted in the South African triage manual. Fernandes et al. [8] emphasize that midwives often rely on a patient's medical history as a key factor in assessing risk. This approach allows midwives to quickly identify patients who may have pre-existing conditions, complications in previous pregnancies, or other risk factors that require immediate attention. However, Tukisi et al. [12] argue that this method has limitations, particularly in settings where patient records are incomplete or unavailable, which can hinder accurate risk assessment. Additionally, relying solely on clinical history may result in the under-prioritization of women whose current conditions, despite unremarkable histories, require urgent care. Therefore, while triage by clinical history provides a more informed basis for decision-making, it is insufficient as a standalone approach and, needs to be supplemented with real-time clinical assessments and leads to inaccurate diagnoses.

Triage based on genuine physical observation is another key practice the midwives currently use to assess the condition of labouring women. This method involves the midwife making a real-time evaluation of the patient’s physical state, looking for visible signs of distress, pain levels, or abnormal vital signs. Physical observation can be a critical factor in determining the urgency of care when formal tools are absent, as noted by Fernandes et al. [8]. However, this approach relies heavily on the clinical judgment and experience of the midwife, which can vary significantly due to the number of years in the maternity units. Moudi et al. [4] argue that while physical observation is an important part of triage, it can be subjective and may not always capture the severity of an underlying condition, especially in less experienced midwives. The study of Rochana et al. [32] and Wolf et al. [33] highlighted that quick inspection was common practice even in emergency departments, as it gives clarity as to whether the patient is sick or not. However, Wolf et al. [32] argued that relying on just a quick inspection predisposes patients to risk, as that patient might lack a comprehensive assessment that might detect problems quite early. Furthermore, as Tukisi et al. [12] highlight, this method can be inadequate in busy maternity units where midwives may not have the time to thoroughly assess every patient, leading to potential misjudgements. Thus, while physical observation is a valuable tool in the triage process, its effectiveness is limited by time constraints, workload, and the individual midwife’s expertise. Drawing from the first author's experience in maternity units, this proves to be true, as not all patients will present with all symptoms or any symptoms. For example, in the case of obstetric conditions such as hypertensive disorders in pregnancy, not all patients will present puffy faces and edema, as indicated by the midwives in this study. Similarly, the study of Wolf et al. [32], recommends that midwives not only rely on quick inspection of patients but also conduct a comprehensive triage assessment, as sometimes, with simple quick inspection, a lot can be missed. This concedes with the midwives that revealed that sometimes patients scream in the waiting room, reporting an urge to bear down only to be one centimeter dilated or reporting vaginal bleeding during pregnancy, only to be blood-stained show. It seems that their skills in triaging pregnant women need sharpening for them to triage effectively as they relied on some practices that might prove to impact patients negatively. These findings suggest that there’s a need for a standardised triage system in maternity units. More efforts should be made towards improving the midwife's ineffective triage practices by developing a standardised triage system for maternity units to improve patient outcomes. This also calls for action to change of the midwifery education curriculum and maternal guidelines to include basic triage courses to optimize the midwives’ skills in triaging. Moreover, clinical institutions should also host triage training courses for midwives to enhance their triage practices.

On the other hand, it is worth considering that with current midwives' triage practices, the Sustainable Development Goal targets 3.1 and 3.2 the United Nations of reducing maternal and child mortality by 2030, and the WHO standards of quality maternal and newborn care of the provision of evidence-based practice for routine and emergency care may seem to be a little bit difficult to attain without a proper triage system in place [25]. As suggested by the WHO quality care framework for maternal and newborn healthcare, an evidence-based triage system needs to be developed in collaboration with end users and, thereafter, midwives should be trained to be competent in triaging and given support to implement the triage system [25]. However, looking at the demographic data of the study, one could conclude that the practices and understanding of triage by the midwives were influenced by the level of experience and the qualifications they hold. Hence, the experienced midwives ensured that they applied the scientific skills to inform their practices in triaging pregnant women.

5. LIMITATIONS OF THE STUDY

The lack of funding limited the study to only two district hospitals; the findings may not be representative of midwives' triage practices across a wider range of healthcare settings in South Africa or other regions, limiting the generalizability of the results. A larger number of district hospitals from different regions could help improve the generalizability of the findings. This would capture a wider variety of triage practices and experiences across diverse healthcare settings, leading to more robust conclusions. Despite some similarities between this current study and other studies conducted in emergency departments, this study's findings only reflect midwives' triage practices and understanding in the labour wards and do not reflect any other clinical department triage practices. Therefore, the study results should not be generalized to any other clinical department except the study setting. Considering that the study is qualitative in nature, it could not quantitatively measure the influence of demographic factors on the practices and understanding of midwives. This study recommends more studies to investigate sociodemographic factors influencing midwives’ prac-tices and understanding.

CONCLUSION

The current study explored the understanding and triage practices of midwives working in district hospitals of Mpumalanga Province, South Africa. The findings underscore the critical need for an effective and standardized triage system in maternity units, particularly in resource-limited settings. The absence of such systems has been shown to contribute to delays in care, poor maternal and neonatal outcomes, and increased healthcare litigation. Midwives' current triage practices, which include first-come, first-serve methods, reliance on clinical history, and physical observation, though pragmatic, are inconsistent and inadequate for addressing the complexities of obstetric emergencies. The findings highlight the importance of formal triage protocols that prioritize care based on medical urgency rather than convenience or subjective judgment. To enhance clinical decision-making and improve outcomes, the implementation of structured triage tools—tailored to obstetric care and supported by adequate staffing and resources—is essential. Furthermore, ongoing training for midwives in triage procedures and the integration of evidence-based guidelines into practice are imperative. Addressing these gaps will not only optimize maternal and perinatal outcomes but also reduce preventable maternal deaths and associated healthcare costs. Future research should focus on co-developing triage systems with midwives as key stakeholders to ensure their practical applicability and widespread adoption in maternity care settings.

REFERENCES