Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 109 num. 10 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Clinical associates in South Africa</b>]]> <![CDATA[<b>Legal regulation of psychotropic drugs</b>]]> <![CDATA[<b>Prof. Gboyega Ogunbanjo</b>]]> <![CDATA[<b>Knowledge and Global Power: Making New Sciences in the South</b>]]> <![CDATA[<b>The most difficult of arts</b>]]> <![CDATA[<b>Lymphadenopathy in a tuberculosis-endemic area: Diagnostic pitfalls and suggested approach</b>]]> Lymphadenopathy is a common presenting complaint, or it may be an incidental finding during examination of a patient. This review focuses on the diagnostic difficulty, common misconceptions and tests that can be applied in the investigation of lymphadenopathy. A diagnostic approach is suggested with regard to the most important causes of peripheral, persistent (>3 weeks) and significant (>1 cm) lymphadenopathy, i.e. tuberculosis, lymphoma and disseminated malignancy. <![CDATA[<b>Approach to lymphoma diagnosis and management in South Africa</b>]]> Lymphoma is a cancer of the lymphoid cells, with a hugely variable mode of clinical presentation, which includes constitutional symptoms, lymphadenopathy, superficial or deep-seated masses, effusions, and full blood count abnormalities such as anaemia and lymphocytosis. Lymphoma can infiltrate any organ of the body, although it typically involves lymphoid tissue or bone marrow, or both. In this article an overview is given of the diagnostic pathway and clinical diagnostic subsets that determine treatment. The treatment approach according to these subsets is best understood as: indolent lymphoma, where treatment is not urgent and the disease is not curable; aggressive lymphoma, where rapid diagnosis and treatment are of the utmost importance, with the majority of cases curable; and very aggressive lymphoma, where patients are at high risk of death at presentation, but with rapid diagnosis and treatment there is an excellent chance of long-term cure. The past decade has seen an explosion of targeted (as opposed to classic chemotherapeutic) treatments for lymphoma. These drugs target certain molecules or receptors in the tumour pathway, often with spectacularly beneficial effects that open up new horizons for cure. <![CDATA[<b>Laboratory testing in the evaluation of a monoclonal protein: A practical framework for interpretation</b>]]> Monoclonal proteins are immunoglobulins secreted by identical but abnormal plasma cells that are clones of a parent cell. While routine screening in the absence of signs or symptoms of disease is not recommended, testing is indicated in the diagnostic work-up for multiple myeloma and other plasma cell disorders. When indicated, a serum protein electrophoresis with immunofixation and serum free light-chain assay should be performed to determine the type and quantity of monoclonal protein. Using a case-based approach, we highlight common misconceptions with monoclonal protein investigations, and suggest a practical framework for diagnostic interpretation. <![CDATA[<b>An approach to the diagnosis and management of multiple myeloma</b>]]> Multiple myeloma (MM) is a plasma cell dyscrasia that accounts for ~10% of haematological malignancies. It is a disease of the elderly, with a slight male predominance. Almost all cases of MM are preceded by an asymptomatic, premalignant phase known as monoclonal gammopathy of undetermined significance (MGUS). The clinical presentation of MM may be nonspecific, with the most common presenting symptoms being fatigue, bone pain and anaemia. The diagnostic criteria for MM were revised in 2014 to include 3 specific biomarkers of malignancy that are associated with an increased risk of target organ damage. This has resulted in a paradigm shift in the management of MM. The introduction of immunomodulatory agents and proteasome inhibitors has significantly improved the survival of patients with MM. Autologous stem cell transplantation remains the standard of care in younger, fit patients, where there is also a clear role for maintenance chemotherapy. Transplant-ineligible patients benefit from a prolonged induction therapy, and the role of maintenance therapy in this setting is still unclear. Despite major advances in therapy, MM remains an incurable malignant condition and novel agents such as monoclonal antibodies play an important role, especially in the elderly and patients who have relapsed. <![CDATA[<b>Figures of the dead: A decade of tuberculosis mortality registrations in South Africa</b>]]> South Africa (SA) is committed to reducing tuberculosis (TB) mortality rates in line with the World Health Organization's End TB Strategy and the Sustainable Development Goal (SDG) targets. From mortality reports released by Statistics South Africa, this study analysed reported TB mortality in SA from 2006 to 2016 to inform our understanding of TB mortality and the development of strategies needed to attain the SDG targets. TB mortality includes all deaths reported to the Department of Home Affairs with TB reported as the underlying cause of death based on the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) definition. Although TB remains the leading cause of death, TB mortality rates in SA have fallen substantially in the past decade. From 2006 to 2016, the number of deaths due to TB plummeted from 76 881 to 29 399 and the proportion of all-cause mortality due to TB more than halved from 13% to <6%. Furthermore, the profile of people dying from TB has changed, with a decrease in the proportion of children aged <15 years, adults of reproductive age (15 - 49) and women, and an increase in the proportion aged &gt;50. This change has largely mirrored the overall pattern of deaths in SA, with large decreases in deaths in adults aged 15 - 49, especially women, thought to be because of the scale-up of the antiretroviral treatment programme for HIV. The End TB Strategy target of a 95% reduction in TB mortality by 2035 is achievable in SA. However, sustained effort in high-risk groups together with improved vital registration data are needed to ensure attainment of the target. <![CDATA[<b>Appointment cancellations and no shows: To charge or not to charge?</b>]]> Every day patients make appointments with doctors in order for both to be able to schedule their time accordingly. All is well unless one of the parties cancels the appointment. In the case of a cancellation that is within 2 hours of a general practitioner visit or 24 hours of a specialist visit, the patient is usually charged for either the full consultation or part thereof. Doctors may also have reasons to cancel and rearrange their appointments with patients, yet there is no penalty placed on the doctor for such behaviour. There appears to be a mismatch between the disincentives for the patient not to cancel v. those of the doctor not to cancel. In this article, the legal and ethical aspects of charging for a missed appointment will be dealt with in order to determine the current situation in South Africa. Furthermore, research into missed appointments will be discussed to ascertain the major causes and provide recommendations to prevent missed appointments from occurring. <![CDATA[<b>Spitting cobra <i>(Naja nigricincta nigricincta) </i>bites complicated by rhabdomyolysis, possible intravascular haemolysis, and coagulopathy</b>]]> Zebra snake (Naja nigricincta nigricincta) bite is a significant health problem in Namibia. Although fatalities are thought to be rare, the severe cytotoxic effects and debilitating consequences of neglected bites are well documented. The focus of our treatment has always been the urgent treatment of necrosis. Although there have been a few reports of infant fatalities, acute renal failure and mild coagulation problems, systemic effects after envenomation were not well documented. Three case reports of patients with rhabdomyolysis, intravascular haemolysis and coagulopathy following N. n. nigricincta bites are presented. <![CDATA[<b>Patient abandonment in primary healthcare settings: What duty is owed to medical students?</b>]]> Much of the literature on patient abandonment focuses on legal implications as an outcome of a unilateral premature termination of a health service without the consent of the patient. The plight of medical students is seldom considered in such instances. Two cases are presented that highlight the issue of patient abandonment during clinical rotations in primary healthcare settings and the impact on the emotional wellbeing of students. Systemic challenges are flagged for consideration, taking into account the projected annual increase in the number of medical students who must be integrated and trained to respond to the needs of South African patients. <![CDATA[<b>What should private-sector doctors do when relatives of deceased patients pressurise them to prevent medicolegal autopsies in cases of unnatural death?</b>]]> This article deals with what doctors in the private sector should do if relatives of deceased patients refuse to consent to medicolegal autopsies and demand that the bodies be handed over to them. The law does not require consent by relatives for medicolegal autopsies, because the State has a compelling interest in ensuring that such deaths are properly investigated. Relatives of patients who have died an unnatural death may be criminally prosecuted if they attempt to obstruct doctors from carrying out their duties under the Inquests Act 58 of 1959 and the regulations regarding the rendering of forensic pathology services. <![CDATA[<b>De-escalation of biological therapy in inflammatory bowel disease: Benefits and risks</b>]]> The treatment of inflammatory bowel disease (IBD) is often challenging. It has a vexing and waning course with frequent relapses, despite adequate maintenance therapy. Biological agents have been available for the treatment of IBD for the last two decades, with impressive results. However, these drugs are costly and often have significant side-effects. Therefore, the benefit of aggressive treatment must be carefully balanced against the risk of serious adverse events. Despite good clinical outcomes, patients often request to discontinue the drugs because of cost and detrimental effects, especially the risk of malignancy. This review focuses on the benefits of biological treatment, strategies to de-escalate therapy, risk of relapse when these agents are discontinued and success with retreatment with the same or a similar biological agent. <![CDATA[<b>Reasons for requesting removal of the hormonal implant, Implanon NXT, at an urban reproductive health clinic in KwaZulu-Natal, South Africa</b>]]> BACKGROUND. The contraceptive implant, Implanon NXT, was introduced in South Africa (SA) in 2014 and, although it offers multiple advantages, users may request to have it removed early for several reasons. The number of insertions of Implanon NXT has declined in SA and there have been concerns about early removals. OBJECTIVES. To gain an understanding of patterns of Implanon NXT use, reasons for requesting removal and duration of use at the time of requesting removal. METHODS. This was a cross-sectional study conducted at an urban public-sector reproductive health clinic in the eThekwini District of KwaZulu-Natal, SA. A total of 120 women >18 years of age requesting removal of Implanon NXT completed an interviewer-administered questionnaire that probed experiences of use and reasons for removal. Data were collected electronically on Wits REDCap (Research Electronic Data Capture) and analysed using Stata 14 (StataCorp, USA). The study was conducted from 2017 to 2018. RESULTS. A total of 120 women were interviewed. Their mean age was 28 (range 19 - 44) years and most women (n=103; 85.8%) had completed secondary school. The majority were black (n=115; 95.8%) and unmarried (n=102; 85%). Implants had been inserted primarily by nurses (n=110; 91.7%) at public-sector clinics (n=91; 75.8%). Three-quarters of the women (n=91; 75.8%) requested removal of Implanon NXT because it had reached the intended 3-year duration. Reasons for early removal were mainly due to side-effects, e.g. bleeding problems (n=19; 15.8%), weight gain (n=7; 5.8%), loss of libido (n=2; 1.7%), headaches (n=5; 4.2%), dizziness (n=4; 3.3%) and pain/numbness in the arm (n=2; 1.7%). Just more than half (57.1%) of the women who had received the implant for the intended 3-year duration had requested reinsertion of Implanon NXT. CONCLUSIONS. The main reason for requesting removal was that Implanon NXT had reached its intended 3-year duration, and more than half of the women requested reinsertion of the device following removal. Implanon NXT is a highly effective, safe, acceptable, long-acting contraceptive and important in the SA contraceptive method mix. <![CDATA[<b>Projecting the fiscal impact of South Africa's contraceptive needs: Scaling up family planning post 2020</b>]]> BACKGROUND. Evidence-informed priority setting is vital to improved investment in public health interventions. This is particularly important as South Africa (SA) makes the shift to universal health coverage and institution of National Health Insurance. OBJECTIVES. To measure the financial impact of increasing the demand for modern contraceptive methods in the SA public health sector. We estimated the total cost of providing contraceptives, and specifically the budgetary impact of premature removals of long-acting reversible contraceptives. METHODS. We created a deterministic model in Microsoft Excel to estimate the costs of contraception provision over a 5-year time horizon (2018 - 2023) from a healthcare provider perspective. Only direct costs of service provision were considered, including drugs, supplies and personnel time. Costs were not discounted owing to the short time horizon. Scenario analyses were conducted to test uncertainty. RESULTS. The base-case cost of current contraceptive use in 2018 was estimated to be ZAR1.64 billion (ZAR29 per capita). Injectable contraceptives accounted for ~47% of total costs. To meet the total demand for family planning, SA would have to spend ~30% more than the estimate for current contraceptive use. In the year 2023, the 'current use' of modern contraceptives would increase to ZAR2.2 billion, and fulfilling the total demand for family planning would require ZAR2.9 billion. The base-case cost of implantable contraceptives was estimated at ZAR54 million. Assuming a normal removal rate, the use of implants is projected to increase by 20% during the 5-year period between 2019 and 2023, with an estimated 46% increase in costs. The cost of early removal of Implanon NXT is estimated at ZAR75 million, with total contraception costs estimated at ZAR102 million in 2019, compared with ZAR56 million when a normal removal rate is applied. CONCLUSIONS. The costs of scaling up modern contraceptives in SA are substantial. Early and premature removals of implantable contraceptives are costly to the nation and must be minimised. The government should consider conducting appropriate health technology assessments to inform the introduction of new public health interventions as SA makes the shift to universal health coverage by means of National Health Insurance. <![CDATA[<b>Practice choices of clinical associates: Policy realisation or practical reality?</b>]]> BACKGROUND. The Bachelor of Clinical Medical Practice (BCMP) programme was introduced in South Africa as a strategy to fill human resource gaps in both the public sector and rural communities. A previous study explored the practice intentions of BCMP students from one university prior to graduation. OBJECTIVES. To determine whether the actual practice choices of these BCMP graduates reflect their practice intentions. METHODS. A cross-sectional analytical study invited all graduates from the four cohorts of BCMP graduates (N=250) who graduated during the period 2011 - 2014 to complete an online survey. Data were exported and analysed using Stata 13. Chi-square tests of independence were done to explore associations in the data. RESULTS. More than 80% of participants were currently employed in the public sector, with over 50% in rural settings. Factors such as where clinical associates spent most of their lives (i.e. where they were born and raised) and bursary obligations influenced their current practice choices. There was no association between gender and rural practice choice. Intention to emigrate was not associated with origin, gender or race. Almost 90% of participants indicated an interest in furthering their studies; 46% of these intended a change in career, with 65% interested in studying medicine. CONCLUSIONS. The practice choices of the first four cohorts of this degree were similar to their intended practice choices. Although the policy intentions of public sector employment and rural practice have been met, it is not clear what will happen once bursary obligations are fulfilled. The reasons for increased intentions to change career need further research, as a change of career would countermand gains achieved in implementing the policy. <![CDATA[<b>An audit of operating theatre utilisation and day-of-surgery cancellations at a regional hospital in the Durban metropole</b>]]> BACKGROUND. Operating theatres account for a significant proportion of hospital costs. There is a paucity of data evaluating utilisation of South African (SA) state operating theatres. OBJECTIVES. To measure operating theatre utilisation and the rate of day-of-surgery cancellations (DOSCs) in a state hospital theatre complex. METHODS. A prospective audit of a state operating theatre complex at a Durban regional hospital was performed between 26 February and 26 April 2018. Times were collected for each theatre case from the entry of the patient into theatre to their departure to the post-anaesthetic care unit. This was done on weekdays between 08h00 and 16h00. The factors causing any delays and DOSCs were identified and recorded. RESULTS. Over the study period, 125 220 operative minutes were available for both elective and emergency operating theatres; 655 elective cases and 359 emergency cases were performed. Overall theatre utilisation was 55.2%, with actual operating time comprising only 36.9% of all available time. Non-operative time occupied 63.1% of all available time, split between late starts (9.3%), early list finishes (16.1%), changeover times (19.4%) and anaesthetic time (18.3%). The DOSC rate was 26.2%, with 232 cases cancelled on the day of surgery. Just under half of the DOSCs were avoidable. The most common reason for cancellation was lack of operative time. CONCLUSIONS. Measured theatre utilisation was higher than previously quoted figures for SA state hospitals, but below international benchmarks. A significant amount of time was wasted as a result of delayed first-case starts, prolonged changeovers and early terminations of lists, all of which contributed to a high DOSC rate. Before more theatre time can be made available, theatre users must first optimise use of currently available time. Further studies quantifying the effect of staff shortages in state operating theatres on inefficient use of time are required. <![CDATA[<b>Primary healthcare delivery models for uninsured low-income earners during the transition to National Health Insurance: Perspectives of private South African providers</b>]]> BACKGROUND. The proposed National Health Insurance (NHI) system aims to re-engineer primary healthcare (PHC) provision in South Africa, with strategic purchasing of services from both private and public sector providers by the NHI Fund. Currently, while access to the private sector is primarily restricted to high-income insured earners, an important proportion of the low-income segment is choosing to utilise private PHC providers over public sector clinics. In recent years, a number of private providers in SA have established innovative models of PHC delivery that aim to expand access beyond the insured population and provide affordable access to good-quality PHC services. OBJECTIVES. To describe the current landscape of private PHC clinic models targeting low-income, uninsured earners and the role they might play during the transition to NHI. METHODS. Key informant interviews were conducted with representatives of a sample of private PHC provider organisations providing services to low-income, uninsured earners with clinics - beyond the traditional private sector general practitioner model. Organisations were asked to describe their service delivery model, the population it serves, the PHC services offered and the financing model. Written responses were captured in Excel and coded manually, and the results were thematically analysed. RESULTS. Of the eight organisations identified, most have actively engaged strategies to ensure the provision of affordable quality care. Within these strategies, scale is an important pivot in spreading fixed costs across more paying patients as well as task shifting to lower cadres of healthcare workers. Access to government medicines and laboratory tests is an important factor in achieving lower costs per patient. Together, these strategies support the sustainability of these models. CONCLUSIONS. We have provided an exploratory analysis of private PHC service delivery models serving the low-income, uninsured patient population, establishing factors that increase the efficiency of such service delivery, and delineating combinations of strategies that could make these models successful both during the transition to NHI and during full-scale NHI implementation. A clear regulatory framework would act as a catalyst for further innovation and facilitate contracting. These existing models can enhance and complement government provision and could be scaled up to meet the needs of expanding PHC under NHI. Understanding these models and the space and parameters in which they operate is important. <![CDATA[<b>Characteristics and drinking behaviour of patients on antiretroviral therapy who drink and attend HIV clinics in Tshwane, South Africa: Implications for intervention</b>]]> BACKGROUND. Patients on antiretroviral therapy (ART) who drink alcohol are at risk of poor medication adherence and negative health outcomes. OBJECTIVES. To explore the drinking behaviour of patients on ART and assess the associations between drinking, adherence to ART and viral load, and in particular factors associated with binge drinking (>6 drinks per occasion) at least monthly. METHODS. We recruited 623 HIV patients from six hospitals in the Tshwane metropole who scored positive on the Alcohol Use Disorders Identification Test (AUDIT-C) but were 'non-dependent' drinkers into a randomised controlled trial. This article reports on baseline data. RESULTS. Of the patients, 51% reported drinking in the past week, 60% of men and 33% of women consumed >6 standard drinks on a typical drinking day, and 19% of men and 5% of women were identified as drinking at harmful levels. Over a quarter reported having a friend or relative, or a doctor or other healthcare worker, express concern about their drinking or suggest that they cut down. AUDIT total scores were significantly negatively correlated with self-reported adherence to ART and positively correlated with viral load. Number of years on ART was not significantly associated with binge drinking. Persons who were employed part time (odds ratio (OR) 1.474) or were self-employed (OR 2.135) were more likely to binge-drink than unemployed persons. Beer drinkers (OR 1.716) were more at risk for binge drinking than non-beer drinkers, and persons who drank monthly or less (OR 0.053) or 2 - 4 times a month (OR 0.168) were less at risk for bingeing than those who drank >4 times per week. CONCLUSIONS. The high volume of alcohol consumed per occasion by patients on ART, especially beer and spirits drinkers, is a concern. Interventions that address structural drivers of heavy drinking and target HIV patients at risk of heavy drinking are needed. <![CDATA[<b>Medicolegal perspectives of interpersonal violence: A review of first-contact clinical notes</b>]]> BACKGROUND. South Africa has one of the highest rates of interpersonal violence (IPV), in all its forms, in the world. Incidents of assault are largely under-reported and place an immense burden on the healthcare, fiscal and judicial systems. The first contact a victim of IPV has with a medical practitioner may be the only opportunity to identify, record and preserve valuable evidence, as evidence not captured on this occasion may be lost forever. The accuracy and quality of clinical notes taken at the time may be of paramount importance in facilitating the administration of justice. OBJECTIVES. (i) To investigate the adequacy of medicolegal note keeping by doctors in cases where subsequent legal proceedings may ensue; and (ii) to apprise clinicians of their shared responsibility in contributing to the administration of justice through both appropriate patient management and objective and contemporaneous recording of findings from a medicolegal perspective. METHODS. A prospective descriptive study was conducted over a period of 18 months from 2016 to 2018. The investigators reviewed patient files and critically appraised first-contact clinical notes in fatal-outcome cases of IPV admitted to the Pretoria Medico-Legal Laboratory during the study period. The cases were reviewed using rubrics specifically designed by the investigators to critically but consistently assess the adequacy of documentation of the medicolegal aspects applicable to each case. RESULTS. One hundred cases met the defined criteria for inclusion in the study. The victims were predominantly male (98%), and most (79%) were aged <40 years. Blunt-force injuries were the most frequent type of injury (43%), while gunshot wounds accounted for 36% of cases and sharp-force injuries were documented in 11%. Insufficient medicolegal documentation, wound description and evidence collection, by medical practitioners, was identified across all wounding modalities in the study sample. CONCLUSIONS. This study showed that medicolegal documentation in cases of IPV is suboptimal, with many important parameters not being routinely recorded, which is likely to impact negatively on criminal investigations and downstream legal proceedings. Greater emphasis on these issues is required during the undergraduate training of healthcare workers in a society as severely afflicted by IPV as SA. Although this study focused on fatal-outcome cases, these conclusions are equally applicable to many more cases where investigators, prosecutors and presiding judicial officers may be dependent on findings contemporaneously and objectively recorded by medical professionals. <![CDATA[<b>A multicentre prospective observational study of the prevalence and glycaemic control of diabetes mellitus in adult non-cardiac elective surgical patients in hospitals in Western Cape Province, South Africa</b>]]> BACKGROUND. Diabetes mellitus (DM) is a common condition. The high burden of undiagnosed DM and a lack of large population studies make accurate prevalence estimations difficult, especially in the surgical environment. Furthermore, poorly controlled DM is associated with an increased risk of perioperative complications and mortality. OBJECTIVES. The primary objective was to establish the prevalence of DM in elective adult non-cardiac, non-obstetric surgical patients in hospitals in Western Cape Province, South Africa. The secondary objectives were to assess the glycaemic control and compliance with treatment of known diabetics. METHODS. A 5-day multicentre, prospective observational study was performed at six government-funded hospitals in the Western Cape. Screening for DM was done using finger-prick capillary blood glucose (CBG) testing. Patients found to have a CBG &gt;6.5 mmol/L had their glycated haemoglobin (HbA1c) level measured. DM was diagnosed based on the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) diagnostic criteria. Patients known to have DM had their HbA1c measured and completed a Morisky Medication Adherence Scale (MMAS-4) questionnaire to assess glycaemic control and compliance with treatment. RESULTS. Of the 379 participants, 61 were known diabetics (16.2%; 95% confidence interval (CI) 12.4 - 19.8). After exclusion of 8 patients with incomplete results, a new diagnosis of DM was made in 5/310 patients (1.6%; 95% CI 0.2 - 3.0). The overall prevalence of DM was 17.8% (66/371; 95% CI 13.9 - 21.7). HbA1c results were available for 57 (93.4%) of the 61 known diabetics. Of these, 27 (47.4%; 95% CI 34.4 - 60.3) had an HbA1c level &gt;8.5% and 14 (24.6%; 95% CI 13.4 - 35.8) had a level <7%. Based on positive responses to two or more questions on the MMAS-4 questionnaire, 12/60 participants (20.0%) were deemed non-compliant. CONCLUSIONS. There is a low rate of undiagnosed DM in our elective surgical population, but in a high proportion of patients with DM the condition is poorly controlled. Poorly controlled DM is known to increase postoperative complications and is likely to increase the burden of perioperative care. Resources should be focused on improvement of long-term glycaemic control in patients presenting for elective surgery. <![CDATA[<b>Maternal and neonatal vitamin D status at birth in black South Africans</b>]]> BACKGROUND. Vitamin D deficiency (VDD) in pregnant women has been associated with adverse pregnancy and neonatal outcomes. 25-hydroxyvitamin D (25(OH)D) levels are affected by numerous factors, including vitamin D intake, skin pigmentation, latitude and season of the year; they therefore vary by race and country. Vitamin D status in pregnant women and their offspring in South Africa (SA) is not well established. OBJECTIVES. To assess vitamin D status by measuring serum 25(OH)D in pregnant black SA women and their offspring in Johannesburg (latitude 26°S) and to assess whether vitamin D status is affected by maternal HIV infection. METHODS. We prospectively enrolled pregnant women and their healthy neonates, and measured 25(OH)D in maternal and cord blood at delivery. Pregnant women were stratified by their HIV status. Predictors of maternal and neonatal VDD (levels <30 nmol/L) were assessed using multiple logistic regression analysis. RESULTS. A total of 291 pregnant women and their healthy neonates were enrolled over a 21-month period. Mean (standard deviation) maternal and cord blood 25(OH)D levels were 57.0 (29.7) and 41.9 (21.0) nmol/L and the prevalence of VDD was 15.9% and 32.8%, respectively. On average, concentrations of 25(OH)D in cord blood were ~80% of those in the mother. There was no association between cord 25(OH)D and gestational age, but levels were associated with birth weight (p<0.001). There were no differences in maternal or cord blood 25(OH)D levels between those HIV-infected or uninfected. The predictor of VDD in mothers was giving birth in winter (odds ratio (OR) 2.87, 95% confidence interval (CI) 1.47 - 5.61), and in neonates the predictors were maternal age (OR 16.5, 95% CI 1.82 - 149), being born in winter (OR 3.68, 95% CI 2.05 - 6.61), being born by caesarean section (OR 4.92, 95% CI 1.56 - 15.57) and being of low birth weight (OR 1.99, 95% CI 1.13 - 3.50). CONCLUSIONS. Among black SA women delivering in Johannesburg, about one in six mothers and one in three neonates have 25(OH)D levels indicative of VDD. Maternal HIV status appears not to affect levels of 25(OH)D in either the mother or her neonate. Research on the effects of VDD on the outcomes of pregnancy and the best methods to combat the high prevalence of VDD in women of childbearing age in the SA context is required.