The South African Medical Journal (SAMJ) - first published in 1884 - is a monthly, peer reviewed, general medical journal publishing leading research impacting clinical care in southern Africa.
Licensing Information The SAMJ is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited. Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository. Publishing Rights Authors grant the Publisher the exclusive right to publish, display, reproduce and/or distribute the Work in print and electronic format and in any medium known or hereafter developed, including for commercial use. The Author also agrees that the Publisher may retain in print or electronic format more than one copy of the Work for the purpose of preservation, security and back-up.
Reminding ourselves of the ethico-regulatory framework for health research
Copyright (c) 2026 Ames Dhai https://creativecommons.org/licenses/by-nc/4.0
Yackoob Kassim Seedat (7 February 1934 - 2 January 2026)
Copyright (c) 2026 S Naicker, I P Naicker, Y Veriava, M W Makgoba https://creativecommons.org/licenses/by-nc/4.0
A unified medical response to gender-based violence
Copyright (c) 2026 N Marques, N Wayne, N Govender, U Subramaney https://creativecommons.org/licenses/by-nc/4.0
Regarding a call to action on the prevention of fetal alcohol spectrum disorder
Copyright (c) 2026 H J Odendaal, H J Kinney https://creativecommons.org/licenses/by-nc/4.0
Pregnancy-related pulmonary embolism: Clinical characteristics, management and outcomes in a South African academic hospital
Background. Pulmonary embolism (PE) is a leading cause of death in pregnant and postpartum women. Objective. To evaluate the clinical presentation, management and outcomes of pregnancy-related PE managed by a multidisciplinary team. Methods. A retrospective review was conducted of pregnant and postpartum women diagnosed with PE between 2018 and 2024 at a tertiary hospital in Johannesburg, South Africa. Pretest probability scores (pregnancy-adapted YEARS and Geneva) were applied in a subgroup with D-dimers available. Results. Seventy-seven women were included: 33 with antepartum and 44 with postpartum PE. The median (interquartile range) age was 29 (9) years, and most were of black African ethnicity. PE risk factors were present in 85% of antepartum and 96% of postpartum cases. Women with antepartum PE more frequently presented with chest pain, shortness of breath and palpitations (p<0.05). Pretest probability scores were assessed in a subgroup with D-dimers available. Based on the pregnancy-adapted YEARS and Geneva scores, imaging would have been required to rule out PE in 87.8% and 73.5% of cases, respectively. Computed tomography pulmonary angiography was the preferred diagnostic modality in 74.0%. Most women (97.4%) were treated as inpatients, and 57% required management in the intensive care and/or high care units. The median length of hospital stay was 14 (8) days. Low-molecular-weight heparin was the most frequently prescribed anticoagulant, with a median treatment duration of 3 (1) months. The live birth rate was 84.4%. One maternal death occurred due to sepsis, unrelated to venous thromboembolism. Antepartum/secondary postpartum major bleeding and primary postpartum major bleeding occurred in 6.5% and 3.9%, respectively. Conclusion. Pregnancy-associated PE managed by a multidisciplinary team was associated with favourable maternal and fetal outcomes.
pregnancy, pulmonary embolism, South Africa, low molecular weight heparin
Copyright (c) 2026 N Zulu , J Zamparini, H Rhemtula, E Schapkaitz https://creativecommons.org/licenses/by-nc/4.0
Copyright (c) 2026 A Dhai https://creativecommons.org/licenses/by-nc/4.0
Criminalising compassion: Why Baby Saver Boxes must be protected, not punished
South Africa (SA) faces a silent crisis of infant abandonment, often in unsafe environments, driven by poverty, stigma and limited access to abortion. Baby Saver Boxes – secure, monitored drop-off points – offer a humane alternative aligned with constitutional imperatives of life, dignity, healthcare and the best interests of the child. However, proposed amendments to the Children’s Act risk criminalising compassion, reframing safe relinquishment as abandonment and undermining harm-reduction strategies. This punitive approach causes increased cases of neonaticide and maternal desperation, deters healthcare engagement, and places healthcare professionals in ethically fraught positions. Evidence from global best practice – including Germany’s Babyklappe and US safe haven laws – demonstrates that legal recognition of safe relinquishment reduces mortality and promotes maternal health. A rights-based approach, informed by trauma-sensitive policy and intersectoral collaboration, is essential to protect vulnerable mothers and infants. SA must choose compassion over control, integrating Baby Saver Boxes into public health systems to uphold human rights and prevent avoidable deaths.
Healthcare Professionals’ Ethical Burden
Global Best Practice (Babyklappe, Safe Haven Laws)
Rights-Based Approach and Intersectoral Collaboration
Copyright (c) 2026 S Bhamjee, S Biyela, A Marais https://creativecommons.org/licenses/by-nc/4.0
Copyright (c) 2026 Claudia https://creativecommons.org/licenses/by-nc/4.0
When will South Africa take the prevention of chronic HBV infection seriously?
South Africa (SA) bears a significant burden of hepatitis B virus (HBV) infection, with a significant prevalence of hepatitis B surface antigen (HBsAg) among pregnant women. In response, the National Department of Health has recommended targeted birth-dose vaccination for infants born to HBsAg-positive mothers. While we commend the move towards antenatal HBsAg screening to identify infected pregnant women, we reiterate that a universal HBV birth-dose vaccination strategy would be a simpler, more equitable and more effective approach to preventing vertical transmission and reducing the overall HBV burden in SA.
Copyright (c) 2026 T G Maponga, M I Andersson, W Preiser https://creativecommons.org/licenses/by-nc/4.0
Enhancing cervical cancer screening coverage in selected primary healthcare sites using Lean thinking: The CerviScreen programme
Background. Cervical cancer is the most common malignancy among South African (SA) women of reproductive age, with women living with HIV (WLWH) facing a six-fold higher susceptibility. The National Department of Health recommends baseline cervical cancer screening (CCS) for WLWH upon HIV diagnosis. SA’s reported CCS rate is 19.3%, despite the World Health Organization (WHO)’s recommended 2030 target of 70%. AIDS Healthcare Foundation initiated the CerviScreen programme to improve CCS rates using Lean thinking. Objectives. To evaluate the effect of the programme on CCS coverage over a 7-month period at selected sites in the Eastern Cape and KwaZulu-Natal provinces of SA. Methods. This quantitative, controlled before-and-after study retrospectively evaluated changes in CCS coverage at purposively selected quality improvement programme (QIP) sites, compared with matched control sites. Key CCS indicator data from Lean A3 tools were analysed. Repeated analysis of variance measures tested changes in CCS proportions over time, at a p<0.05 significance level. Results. Nine CerviScreen and nine control sites per province were assessed. Significant increases in CCS mean proportions were observed at QIP sites in KwaZulu-Natal (5% - 62.9%; F=8.336, p<0.001) and Eastern Cape (21.2% - 82.4%; F=15.525, p<0.001) provinces. Differences in the change of mean proportions between CerviScreen and control sites were not statistically significant in KwaZulu-Natal (F=0.022, p=0.884) and Eastern Cape (F=0.882, p=0.362). Clinically significant improvements were observed, with the estimated marginal mean at KwaZulu-Natal QIP sites consistently surpassing control sites from month 3 onwards. Eastern Cape sites maintained over 80% coverage from month 4. Screening coverage trends differed significantly between provinces (F=11.12, p=0.004). Conclusion. Lean thinking, through the CerviScreen programme, has potential to enhance and accelerate CCS among SA WLWH toward attaining the WHO target. The findings underscore the importance of adopting systematic quality improvement approaches, highlighting the need for scale-up of Lean thinking in primary healthcare settings to address underperforming indicators.
Copyright (c) 2026 L Naidoo, S Nxele, T Yusuf-Saka https://creativecommons.org/licenses/by-nc/4.0
Response to correspondence regarding a call to action on the prevention of fetal alcohol spectrum disorder
Copyright (c) 2026 F Patel, R Pittrof, N Naidoo, V Lebese, S Mullick https://creativecommons.org/licenses/by-nc/4.0
National Health Insurance in South Africa: A critical perspective on policy misalignment and constitutional constraints
South Africa (SA)’s National Health Insurance (NHI) Act, signed into law in May 2024, represents an ambitious attempt at healthcare transformation through universal health coverage (UHC). However, this perspective argues that despite laudable intentions, the NHI faces fundamental deployment obstacles rooted in systemic policy misalignment, fragmented governance structures and legal constraints. We present a critical analysis of five major constitutional violations, multi-departmental co-ordination failures and financial sustainability concerns that threaten the NHI’s transformative potential. Our perspective challenges current execution strategies, and proposes that without comprehensive organisational reforms addressing constitutional alignment, inter-departmental co-ordination and fiscal realities, the NHI risks becoming an aspirational policy rather than an operational reality. This analysis aims to promote scientific discourse about the need for systemic reform as a prerequisite for successful UHC deployment in SA.
national health insurance; health policy; constitutional reform; universal health coverage; South Africa; policy implementation
Copyright (c) 2026 N Mofolo, C Heunis https://creativecommons.org/licenses/by-nc/4.0
Beyond valve replacement: Rethinking prosthetic heart valve care
Copyright (c) 2026 H Morais, F M Caceres-Loriga https://creativecommons.org/licenses/by-nc/4.0
Primary cutaneous malignancies in black African patients with oculocutaneous albinism in KwaZulu-Natal Province, South Africa
Background. Individuals with oculocutaneous albinism (OCA) face a significantly heightened risk of developing skin cancer owing to increased sensitivity to ultraviolet (UV) radiation. Data on the epidemiology and geographical distribution of cutaneous malignancies among persons with albinism (PWA) in KwaZulu-Natal Province (KZN), South Africa, remain limited. Objective. To investigate the demographic and regional patterns of primary cutaneous malignancies within this high-risk population. Methods. We conducted a retrospective descriptive analysis of all PWA diagnosed with histologically confirmed primary cutaneous malignancies treated at a tertiary healthcare centre in KZN between January 2002 and June 2022. Sociodemographic, geographical and tumour characteristics were extracted from electronic medical records. Results. A total of 221 patients (56.6% female, 43.4% male) with a mean (standard deviation) age of 37.9 (12.5) years contributed 618 histologically confirmed malignant lesions. 132/221 patients (59.7%) presented before 40 years of age. Female patients presented slightly earlier (37.1 (12.9 years)) than males (39.0 (12.0 years)). Geographical clustering was observed in eThekwini (43.0%), uMkhanyakude (20.8%) and King Cetshwayo (11.8%) municipalities. Squamous cell carcinoma (SCC) (50.2%) and basal cell carcinoma (BCC) (49.7%) were nearly equally distributed across all the districts; one cutaneous melanoma was identified. Conclusions. In KZN, PWA tended to develop skin cancer at a younger age than the general population. Notably, the proportions of SCC and BCC were roughly equivalent – a finding that contrasts with historical data, which show a predominance of SCC. The high incidence of skin cancer in coastal and rural districts aligns with elevated ambient UV exposure, and highlights disparities in healthcare access within these regions. These findings highlight the urgent need for targeted screening programmes, improved photoprotection strategies and culturally sensitive education initiatives to reduce morbidity and mortality among this vulnerable population.
Copyright (c) 2026 P Burge, A Madaree https://creativecommons.org/licenses/by-nc/4.0
The state of caesarean sections in South Africa: Challenges, unknowns and the way forward
The scarcity of safe and timely caesarean sections in much of Africa contrasts with SA’s paradox of having one of the world’s highest rates of caesarean section in the private sector – approaching 80% – yet persistently high maternal and perinatal mortality in rural public hospitals. This article addresses three challenges: (i) inequitable access to safe caesarean sections; (ii) high and rising caesarean section rates without evidence of better outcomes, raising concerns about overservicing, costs and respectful care; and (iii) research and data gaps. Closing these gaps requires action from all stakeholders to ensure equitable, high-quality and life-saving care for all.
Caesarean section; Maternal health; Perinatal outcomes; Health system equity; Public sector; Private sector; South Africa; National Health Insurance (NHI); Obstetric care; Respectful maternity care
Copyright (c) 2026 M Bhathena, S Maswime, S Fawcus, M Isiagi, M V Kinney https://creativecommons.org/licenses/by-nc/4.0
Response to correspondence: ‘Beyond valve replacement: Rethinking prosthetic heart valve care’
Copyright (c) 2026 R Meel https://creativecommons.org/licenses/by-nc/4.0
Incidence and histological outcomes of appendectomies in a South African regional hospital, 2022 - 2023: A retrospective study
Background. Acute appendicitis is one of the most common surgical emergencies in South Africa (SA), yet local histopathological data on appendectomies remain limited. Objective. To determine the incidence and histological patterns of appendicitis at an SA regional hospital over a 2-year period. Methods. A retrospective review was conducted on all appendectomies performed at Tambo Memorial Hospital (TMH) in Boksburg, SA, from 1 January 2022 to 31 December 2023. Histological data, using Gomes score, which was correlated with microscopy and macroscopy from the SA National Health Laboratory Service, as well as patient demographics, were analysed. Logistic regression and χ2 tests were used to assess associations between variables. Results. A total of 283 appendectomies were reviewed. None was excluded. The cohort was predominantly male (64%), with a mean age of 26.99 years. Histologically normal appendices (grade 0) were found in 25.4% of cases. Grade 4 appendicitis (gangrenous/perforated) was the most prevalent pathological finding (39.9%). Males were significantly more likely to present with appendicitis, particularly advanced grades of appendicitis (p=0.00005; odds ratio (OR) 3.305, 95% confidence interval (CI) 1.869 - 5.915). Lymphoid hyperplasia was significantly associated with grade 0 appendices (p=0.00205; OR 0.282, 95% CI 0.125 - 0.631), suggesting possible alternative diagnoses such as gastroenteritis, mesenteric adenitis or pelvic inflammatory disease. Appendicular neoplasms (2.1%), faecoliths (17.3%) and parasites (1.4%) were not uncommon. No significant monthly variation was observed. The overall negative predictive value of clinician-directed appendectomy at TMH was 25.4%, in keeping with or better than rates reported at various tertiary hospitals – despite TMH lacking afternoon sonography and having no after-hours sonographic or radiological reporting services. Conclusion. Appendicitis at TMH showed a high rate of complicated cases, especially among males. Male sex was a significant predictor of appendicitis, whereas lymphoid hyperplasia was associated with negative histology and may represent an important clinical differential diagnosis. Other findings included benign neoplasms, faecoliths and parasites. These findings highlight clinical acumen in a resource- limited setting and the value of histological confirmation in appendicitis diagnoses.
Copyright (c) 2026 A H Shulman, L Broderick, J Nel, G Shemesh, N N Tshabalala , M G Mendelow, M J Malapane, Y E Segal, S Raichund, Z F A Peermamode, L Nsakala, A Singh https://creativecommons.org/licenses/by-nc/4.0
Beyond BRCA: Genetic testing for gynaecological cancers in South Africa
Background. Hereditary cancer syndromes, caused by pathogenic variants in specific genes, substantially increase an individual’s risk for cancer, and are estimated to cause 10% of all uterine cancers and 20% of all ovarian cancers. However, these data are primarily based on high-income countries, and to date there are no published data on the known pathogenic variants or testing of cancer predisposition genes associated with gynaecological cancers in South Africa. Objectives. To investigate the uptake and type of molecular testing performed on patients with a suspected hereditary cancer syndrome associated with gynaecological cancer, and to assess whether patient characteristics impacted the detection of pathogenic variants. Methods. A retrospective file review was performed for patients with a confirmed diagnosis or family history of gynaecological cancer, seen by a single clinical genetics centre in Johannesburg between 2003 and 2023. Demographic information, family history and medical information were recorded and analysed. Results. A total of 104 records were included in analysis. The majority (73/104, 70.2%) of patients were seen in the private healthcare system, of whom most (41%) were of European ancestry. Of the remaining 31 public healthcare patients, the majority were of indigenous African ancestry (42%). Most (78/104, 75.0%) underwent diagnostic genetic testing. Of these, 25 (32.1%) were positive for pathogenic variants, 41 (52.6%) were negative and 12 (15.4%) returned a variant of unknown significance. Test results were significantly different between patients of European and non-European ancestry (p<0.05), with those of non-European ancestry 30% less likely to have a pathogenic variant detected (odds ratio 0.7, 95% confidence interval 0.22 - 2.21). Conclusion. A disparity exists not only in genetic testing availability but also clinic attendance between the public and private healthcare systems, which likely limits the ability to diagnose hereditary cancer syndromes associated with gynaecological cancers in public healthcare hospitals.
hereditary breast and ovarian cancer (HBOC)
Copyright (c) 2026 S Barnard, B Rossouw, E Gilfillan https://creativecommons.org/licenses/by-nc/4.0
Supporting doctors’ mental health: Exploring the utility of a life skills programme for interns in rural Eastern Cape Province, South Africa
Background. Occupational stress affecting junior doctors poses a serious risk to mental health, with consequences such as anxiety, burnout, substance misuse and suicide. Objectives. To evaluate the utility of a life skills training programme (LSTP) developed and implemented at Nelson Mandela Academic Hospital in the Eastern Cape Province, South Africa, in improving stress levels and coping abilities among second-year medical interns. Methods. We used a quasi-experimental pre-post quantitative design without a control group. Identical surveys were administered before and after the intervention, including the Perceived Stress Scale (PSS-10) and items on coping behaviours. Descriptive statistics, paired t-tests and Wilcoxon signed-rank tests were used for analysis. Results. Of 56 eligible interns, 45 (80.4%) completed both pre- and post-intervention assessments. Stress scores decreased significantly (from mean 2.92 to 2.51, p<0.001), while coping scores improved (from mean 3.26 to 3.48, p=0.001). Wilcoxon tests confirmed significant gains, with enhanced confidence in ethical reasoning (Z=–5.014, p<0.001), professionalism (Z=–2.673, p=0.008) and teamwork (Z=–2.357, p=0.018). Participants who were single or lived alone showed higher stress levels. Subgroup analysis also revealed that interns who were single or lived alone had lower coping scores. Conclusion. The LSTP improved interns’ mental wellbeing and coping mechanisms. Findings support integrating life skills training into internship programmes.
Copyright (c) 2026 Z Zingela, S van Wyk, Y Thungana, E Abakisi https://creativecommons.org/licenses/by-nc/4.0