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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA,

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR


DISSERTATION

MISS AREZ SAVIOLA ANSIE


1 NAME OF THE CANDIDATE
AND ADDRESS K.L.E.S’ INSTITUTE OF NURSING SCIENCES,

NEHRUNAGAR BELGAUM-10 KARNATAKA

2 NAME OF THE INSTITUTE K.L.E.S’ INSTITUTE OF NURSING SCIENCES,


NEHRUNAGAR BELGAUM-10 KARNATAKA

M.Sc. NURSING
3 COURSE OF THE STUDY
AND SUBJECT 1st YEAR

OBSTETRIC AND GYNAECOLOGICAL


NURSING

4 DATE OF ADMISSION TO MAY 2007


THE COURSE

5 TITLE OF THE TOPIC “EFFECTIVENESS OF A PLANNED


TEACHING PROGRAMME ON
KNOWLEDGE AND SKILL IN USE OF
PARTOGRAPH AMONG NURSES.”

6 BRIEF RESUME OF THE INTENDED WORK.

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6.1 NEED FOR THE STUDY
“The most dangerous journey is the first one which we all undertake i.e. last
ten cms of genital tract which is full of events and two main hazards – asphyxia and
trauma”
Apsley-Cherney-Garrad 1992.
Pregnancy and labour are unpredictable events that, if not monitored properly
can result in a disabled or a fatal state. Though joy and happiness surround these events,
there are risks to health and survival of women and the infant she bears. These risks are
common in every society and every setting.1
Pregnancy and labour are a normal physiological process, which are associated
with certain risks. These risks can be prevented and managed if adequate ante partum
and intra partum care is given to the pregnant and labouring women by skilled birth
attendant. In developed countries, these risks have been largely overcome as every
pregnant women have access to special care during pregnancy and child birth. And the
maternal deaths resulting from pregnancy and child birth are estimated to be less than
1%. But in developing countries, pregnancy, childbirth and their consequences are still
the leading causes of death, disease and disability among women of reproductive age.
Over 300 million women in the developing world suffer from short term or long term
illness brought by pregnancy and child birth and 5,29,000 die each year.2
The high rate of maternal and infant mortality in India has become a matter of
concern. The maternal mortality rate in the country continues to be high at 540 per one
lakh live births.3
According to the government of India, maternal deaths related to pregnancy in
Indian scenario are as follows.4

Prolonged and obstructed labour significantly contributes to maternal, fetal


morbidity and mortality. Hence early detection and referral can not only reduce but

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prevent the occurrence of both these and their complications.4
To prevent prolonged labour and its complications, we need a tool which not
only prevents prolonged labour, but also identifies the deviation of labour process from
normal at the earliest. The partograph is a simple, inexpensive tool to provide a
continuous pictorial over view of labour, detect prolong labour and identify deviation of
labour process from normal.4
The first obstetrician to provide a tool for the assessment of individual labour
was Friedman. He used a graph paper to record the progress of labour in centimeters of
dilatation of cervix per hour. This came to be known as cervicograph.5
Philpott and Castles formulated a practical tool- The Partograph with an “alert
line” and “action line”, for midwives and assistants to record all intra partum details and
not just cervical dilatation.5
The World Health Organization (WHO) developed a partograph formulated by
Philpott and Castle. To test whether the use of WHO partograph improved labour
management and reduced maternal and fetal morbidity and mortality, a prospective
study of 35,484 women was carried out in tertiary level hospitals in South East Asia.
During the first five months, the hospital collected intra partum data. And the next five
months, WHO partograph was introduced in each of the hospitals. This was also
accompanied by several days of intensive teaching of the midwifery and medical staff.
The outcome showed significant improvement, fewer prolonged labour(>18hrs), fewer
augmented labour and less post partum sepsis.5
The partograph has been tested in a multicentre trial in South East Asia,
involving 35,484 women. Introduction of WHO partograph with agreed labour
management protocol reduced both prolonged labour from 6.4% to 3.4% and the
proportion of labour requiring augmentation from 20.7% to 9.1%. Emergency caesarean
sections fell from 9.9% to 8.3% and intra partum still births from 0.5% to 0.3%.6
Use of partograph during labour can prevent suffering and loss of life. The
partograph records the progress of labour, especially the rate of cervical dilatation. Use
of WHO partogarph in 8 hospitals in Indonesia, Thailand and Malaysia reduced post
partum infections (by 59%), the number of still births, the amount of oxytocin
augmentation and unnecessary caesarean section. Thus the WHO partograph was able to
differentiate labours requiring intervention from those not requiring intervention. WHO
calls for health personnel to use its partograph and its management protocol , both in

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labour wards with the capabilities to manage labour complications and in health centers
without these capabilities can refer women with labour complications to specialist.7
Having so many benefits attached to the use of partograph, the investigator
observed that there is an evident necessity to evaluate the use of partograph among
nurses working in maternity unit of KLES Prabhakar Kore Hospital & MRC, Belgaum
and District Hospital, Belgaum. The investigator observed that there is a need to
improve skills of nurses working in maternity unit in recording the progress of labour
and motivate them to maintain partograph for a woman in labour as a routine practice.
The rationale for advocating such a tool- The Partograph, is to reduce the time midwives
spent on note taking, while enabling them to keep detailed and accurate records so as to
permit them to provide emotional support to labouring women. The introduction of
partograph is an important component in the National Rural Health Mission (NRHM)
programme. KLES Prabhakar Kore Hospital and medical college has been
recognized as one of the Nodal Centre by WHO for implementing NRHM
programme and its components for Medical Officers, Midwives and ANM’s. Hence
the investigator feels that it is very essential to train the nurses working in maternity unit
with knowledge and skill in the use of partograph which will help the nurses to provide
a comprehensive intra partum care to the labouring mothers with early identification and
prevention of complication, thereby playing an important role in reducing the maternal
mortality and morbidity.

6.2 REVIEW OF LITERATURE


A Comparative study of the two world health organization (WHO) Partographs
in a cross over trial was undertaken at Christian Medical College, Vellore. The objective
of the study was solely to compare two WHO partographs - a composite partograph
including latent phase with a simplified one without the latent phase. The sample for the
study consisted of Eighteen Physician. The mean (SD) user friendliness score was lower
for the composite partograph [6.2 (0.9 vs 8.6 (1.0); p=0.002] 84% of the participants
experienced difficulty “sometimes” with composite partograph, but no participants
reported difficulty with the simplified partograph. The labour values crossed the action
line significantly more often when the composite partograph was used and women were
more likely to undergo cesarean deliveries. The outcome of the study showed that the
simplified WHO partograph was more user friendly, was more completed than the

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composite partograph and was associated with better labour outcomes.8
A Quasi experimental study was conducted to examine the effect of partograph
on the first stage of delivery in Al-Zahra Educational Hospital in 1999-2000. The
participants included 218 pregnant women on whom the partograph was used in labour.
Data analysis indicated that using partograph decreased the number of cesareans. In
order to examine the relationship between the number of cesarean with using partograph
and without it, statistical test was used. The results indicated that there was significant
relationship between those two variables (p<0.05). With using partograph the average
length of the first stage of delivery was 3/89  2.8 hrs in experimental group and 3/85 
3/6 hrs in control group. Based on findings researcher recommended that using
partograph decreased the number of cesarean.9
A survey study using a structured questionnaire was conducted on the labour
partograph in Yaounde, Cameroon with the main purpose to evaluate the knowledge,
attitude and practice of the labour partograph among birth attendants of the primary and
secondary care level hospitals of Yaounde, Cameroon. The sample size included 200
doctors and 220 midwives. The results of the study showed that 92.5 percent of doctors
and 95 percent of midwives agreed that partograph is an important tool during labour
but did not use it routinely. 46.5% of doctors and 88.2% nurses showed a desire to be
trained in the use of partograph to have a better outcome of mothers in labour state.10
An interventional study was conducted on evaluation of WHO partograph
implementation by midwives for maternity home birth in Indonesia, with the objective
to asses the effectiveness of promoting the use of WHO partograph by midwives for
labour in a maternity home by comparing outcomes after birth 20 midwives who
regularly conducted births were randomly allocated into two equal groups by cluster
randomized – control trial. There were 304 eligible women with vertex presentation
among 358 labouring women in intervention group and 322 among 363 in control
group. The study showed that in the intervention group 92.4% partographs were
correctly completed and introducing the partograph significantly reduced the number of
vaginal examination, oxytocin use and obstructed labour. The study recommended that a
training programm with follow up supervision and monitoring may be of use when
introducing the WHO partograph in other similar settings11

In a Quasi experimental study on evaluation of an adapted model of WHO

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partograph used by Angolan midwives was conducted by Halmstad University, Sweden.
50 partographs plotted with an initial dilatation <8 cm were randomly selected from the
first period of 6 month to form sample I and another 50 from second 6 month period to
form sample II. In service education (theory and practice) performed by a team of
midwives and an obstetrician was done as an intervention. The findings of showed that
when comparing sample II with sample I, statistically significant improvement were
found in 7 of 10 measured variables. This indicated a positive effect of the educational
intervention on proper use of partograph. The implication for practice of this study
revealed that in-service educational programme may be used when introducing WHO
partograph.12
A questionnaire base survey study was conducted on the knowledge and use of
the partograph among health care personnel at the peripheral maternity centres in
Nigeria. The sample size of the study included 396 maternity care providers from
randomly selected 66 peripheral delivery units in Ogun state, Nigeria over a 2 months
period. The objective was to evaluate the knowledge and use of partograph of the health
care personnel. The findings of the study showed that 216 (54.5%) personnel were
aware of partograph, out of which 36 (16.7%), 61 (28.2%) and 119 (55.5%)
demonstrated poor, fair and good levels of knowledge respectively. 39 (9.8%) of all the
personnel routinely employed the partograph for labour management and almost half of
these individuals had a poor level of knowledge. The study concludes that to limit the
frequency of referred cases of established obstructed labour, hospital should include
training of care providers in effective use of partograph.13
An experimental study was conducted to assess the impact of training on the use
of partograph on maternal and perinatal outcome in peripheral health centres in Nigeria.
The objective of the study was to assess the impact of training health workers at the
primary health care level in partograph use on maternal and perinatal outcome in
peripheral health units. Data on labour outcome on 242 labouring women were collected
priorly and past training of fifty six health care workers in use of WHO partograph. The
findings of study showed that, there was increase in transfer in labour (p=0.013), but
reduction in the duration of labour (p=0.0001), obstructed labour (p=0.0001), post
partum hemorrhage (p=0.0001), genital sepsis (p=0.0001), perinatal mortality
(p=0.0040) and better neonatal Apgar scores at 1 and 5 minutes (p=0.0001) after
introduction of partograph. There was one uterine rupture and 2 maternal deaths before

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introduction of partograph but none after a prtograph introduction. The study concluded
that introduction of partograph reduced labour complication with resultant reduction in
maternal and perinatal mortality and morbidity.14
An interventional study was conducted in South East Asia on impact of Breech
labour on the WHO partograph. The objective was to assess the impact of breech labour
management using the WHO partogrpah on fetal and maternal outcome of labour. A
sample of 1,740 breech presentation was considered for the study. The partograph was
introduced into each of the hospital during the study and before and after analysis of
various labour outcome was conducted. The outcome of study showed that there were
923 breech presentation prior to implementation of partograph and 817 after.
Introducing the partograph reduced cesarean section for multigravida from 27.1% to
19.3%, for primigravida 38.5% to 38.7%. prolonged labour (>18 hrs) was reduced
significantly among multigravida and primaigravida (p<0.05). Fetal outcome as
measured by intrapartum deaths and Apgar scores <7 at 1 min was significantly better
(p<0.05). The conclusion of this study is that the use of WHO partograph in
management of breech labour reduces prolonged labour, cesarean section and improves
fetal outcome.15
6.3 STATEMENT OF THE PROBLEM
“A study to evaluate the effectiveness of a planned teaching programme on
knowledge and skill in the use of partograph among nurses working in maternity
unit of selected hospitals of Belgaum, Karnataka”.
6.4 OBJECTIVES OF THE STUDY
1. To assess the knowledge of nurses in the use of partograph in maternity unit.
2. To assess the skills of nurses in the use of partograph in maternity unit.
3. To prepare and administer a planned teaching programme on knowledge and
skills in the use of partograph .
4. To evaluate the effectiveness of planned teaching programme on the knowledge
and skills in the use of partograph among nurses working in maternity unit.
5. To find an association between knowledge in the use of partograph among
nurses working in maternity unit and selected demographic variables.
6. To find an association between skills in the use of partograph among nurses
working in maternity unit and selected demographic variables.
6.5 OPERATIONAL DEFINITIONS :-

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1. EVALUATE: Refers to statistical analysis, (descriptive and inferential) of
knowledge and skill in the use of partograph among nurses included in this
study.
2. EFFECTIVENESS : Refers the extent to which the Planned Teaching
Programme, has achieved the desired outcome as measured by nurse’s
knowledge and skill scores.
3. PLANNED TEACHING PROGRAMME: Refers to a written and verbal
material used for teaching which is prepared by the researcher and content
validated by experts. It is designed to provide information/knowledge regarding
use of partograph by nurses with regard to:
 History and Introduction.
 Definition of partograph.
 Components of partograph.
 Use of partograph in clinical situation.
 Plotting on a partograph.
 Advantages of effective use of partograph.
 Conclusion.
4. KNOWLEDGE : Refers to appropriate response received from the subjects to
items of structured knowledge questionnaire.
5. SKILL: Refers to the particular ability or mastery over an art of plotting on the
partograph and to identify any deviation from normal.
6. NURSES: Refers to registered staff nurses with B.Sc Nursing or GNM
qualification, working in maternity unit of selected hospitals of Belgaum,
Karnataka.
7. SELECTED HOSPITALS : Refers to KLES Prabhakar Kore Hospital and
MRC, Belgaum and District Hospital, Belgaum.
8. SELECTED DEMOGRAPHIC VARIABLES: Refers to factors such as age,
parity, professional qualification, total years of experience, experience in
maternity unit and inservice education programme attended.
9. MATERNITY UNIT: Refers to the labour ward, antenatal ward, postnatal
ward and NICU where nurses are working to provide obstetric care.

10. PARTOGRAPH: In this study refers to the graphical representation of progress

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of labour on a graph devised by WHO which monitors the fetal and maternal
condition on a single sheet of paper plotted by nurses.

6.6 HYPOTHESIS :

1. H1  The mean post test knowledge scores of nurses will be significantly higher
than their mean pre-test knowledge scores at 0.05 level of significance.

2. H2  The mean post test skill scores of nurses will be significantly higher than
their mean pre-test skill scores at 0.05 level of significance.

3. H3  There will be a statically significant association between pre-test


knowledge scores and selected demographic variables at 0.05 level of
significance.

4. H4  There will be a statistically significant association between pre-test skill


scores and selected demographic variables at 0.05 level of significance.

5. H5  There will be statistically significant association between knowledge and


skill of nurses regarding the use of partograph at 0.05 level of significance.
6.7 ASSUMPTIONS :

1. Nurses working in maternity unit have some knowledge and skill regarding the
use of partograph.

2. Planned teaching programme is an effective method to improve knowledge and


skill of nurses in the use of partograph.
6.8 DELIMITATIONS:

This study is delimited to the nurses working in maternity unit of KLES


Prabhakar Kore Hospital and MRC, Belgaum and District Hospital, Belgaum.

6.9 PROJECTED OUTCOME :


This study will help nurses to gain knowledge and skill in using the partogarph
effectively during intrapartum care and identify deviations from normal and provide
timely nursing intervention and referral.
7 MATERIALS AND METHOD
7.1 SOURCES OF DATA

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 Primary Source: Nurses working in maternity unit of selected hospitals of
Belgaum, Karnataka.

 Secondary Source : Review of literature collected from various journals,


magazines, newspapers, books and internet.

 Research Approach: Evaluative.

 Research design : Quasi-experimental One group pretest-posttest control


group design.

 Research setting: The study will be conducted in maternity unit of KLES


Prabhakar Kore Hospital, Belgaum, and District Hospital
Belgaum.

 Population: Nurses working in maternity unit of KLES Prabhakar Kore


Hospital and MRC, Blegaum, and District Hospital,
Belgaum.

 Sample size: 60 nurses (30 experimental and 30 control)

 Inclusion criteria:
Nurses
1. Having completed their BSc Nursing or GNM Nursing qualification.
2. Working in maternity unit of KLES Prabhakar Kore Hospital & MRC,
Belgaum, and District Hospital, Belgaum.
3. Willing to participate.

 Exclusion criteria:
Nurses
1. On managerial post
2. Not present during the time of data collection.

7.2 METHOD OF COLLECTION OF DATA.


Sampling technique: Purposive sampling.
Instrument: 1. Structured knowledge questionnaire to assess the knowledge.

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2. Graphical record worksheet to plot a partograph based on given data.
Section I: Items on selected demographic variables like age, parity, professional
qualification, total years of experience, experience in maternity unit and
inservice education programme attended.
Section II : Items on knowledge and skills of nurses in the use of partograph
Section III: Exercise of plotting the given data on graphical record sheet (WHO
partograph).
Data Collection Method:
STEP I : The investigator will obtain permission from respective authority to
conduct the study.
STEP II: Selection of subjects (Nurses).
STEP III: Investigator introduces herself to the subject and explains about her
aim, objectives and steps of the study and takes written consent to
conduct the study.
STEP IV: Conducts pre test with a structured knowledge questionnaire and
graphical record sheet.
STEP V: Administer planned teaching programme on knowledge and skills in
use of partograph.
STEP VI: Conducts post test by using structured knowledge questionnaire and
graphical record sheet to plot the partograph.
STEP VII: Analysis of collected data and interpretation.

7.3 Does the study require any interventions or investigations to be conducted?


Yes ( Plan teaching programme).
7.4 Has ethical clearance been obtained from your institution?
Yes.
7.5 Permission will be obtained from the authorities of KLES Prabhakar Kore
Hospital and MRC, Belgaum and District Hospital Belgaum.

8 LIST OF REFERENCES

1. Bala k. Iron Deficiency Anemia. Women’s Era. 2005; 1: 149-150

2. Global Picture. The World Health Report 2005. Available from:


URL:http://www.who.int/whr/en/.

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3. Sivanandan TV. High rate of infant, maternal mortality a course for concern. The
Hindu Times. 2005 Jul 08; Available from:
URL:http://www.Hindu.com/2005/07/08/stories/2005070804470300.htm.

4. Dalal A, Metgud MC, Kolli B. The partogarph- Medical Officers Training


Module. Proceedings of the National Rural Health Mission Programme; 2005 ;
Belgaum, Karnataka: 2005. p.1-19.

5. Lavender T. NCT Evidence Based Briefing- Use of the Partogram in Labor.


Reseach. [cited 2007 Nov 12]; 14-19. Availablefrom:
URL:http://www.nct.org.uk/files/info/ebb/use_of_the_partogram_in _labour. pdf

6. World Health Organization partograph in the management of labour.World


Health Organization Maternal Health and Safe Motherhood Programme. J
Lancet [online]. 1994 Jul [cited 2007 Nov 12]; [1screen]. Available from:
URL:http://www.ncbi.nlm.gov/sites/entrez.

7. World Health organization partograph used during labour. Safe Mother [online]
1994 Jul-Oct [cited 2007 Nov 12]; [1 screen]. Available from:
URL:http://www.journalagent.com/z4.

8. Mathew JE, Rajaratnam A, George A, Mathai M. Comparision of two WHO


partogarph. Int J Gynaecol Obstet [serial online] 2007 Jan 24[cited 2007 Nov
12]; 96(2):[147-50]. Available from:
URL:http://www.f1000medicine.com/article/id/1067110.

9. Effect of partograph on first stage of delivery. Medical Faculty Journal of Gulian


University of medical Sciences [serial online] 2001 autum [cited 2007 Nov 13];
9(35&36):[1 screen]. Available from:
URL:http//:www.gums.ac.in/magazin/abstract79aw_14.htm.

10. Sama J. KAP study of the labor partograph in Yaunde-Cameroon. [online] 2006
[cited 2007 Nov 12]; [22 screens]. Available from:
URL:http://www.gfmer.ch/medical_education_en/PGC_RH_2006/reviews/ pdf/
dohbit_2006.pdf.

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11. Fahdhy M, Chongsuvivatwong V. Evaluation of WHO partograph implemented
by midwives for maternity home birth in Medan, Indonesia. Midwifery [online]
2005 Aug 1][cited 2007 Nov 15]; 21(4):[301-310]. Available from:
URL:http://www.sciencedirect.com/science?ob=article URL&Udi=B6WN9-
4GSC 2N61.

12. Petterson KO, Suensson ML, Christensson K. Evaluation of an adapted model of


the World Health Organization partograph used by Angolan midwives in a
peripheral delivery unit. Midwifery [online] 2000 Jun [cited 2007 Nov 16];
16(2):[82-88]. Available from: URL:http://www.sciencedirect.com/science.

13. Oladapo OT, Daniel Olatunji AO. Knowledge and use of partograph among
health care personnel at the peripheral maternity centers Nigeria. J Obstet
Gynaecol [online] 2 2006 aug [2007 Nov 12]; 26(6):[538-41]. Available
from:URL:http://www.ingentaconnect.com/content/tandf/cjog/2006.

14. Oriji EO, Adeyemi BA, Makinde NO, Fatusi AA, Onwudiegrew U. Impact of
training on the use of partogarph on maternal and perinatal outcome in
peripheral health centers. J Turkish German Gynecol Assoc [serial online]. 2006
Dec 9 [2007 Nov 16]; 8(2):[148-152]. Available from:
URL:http://www.journalagent.com/z4/vi.asp?pdir=jtgga&plng=eng&un=
JIGGA-75046&look4.

15. Lennox CE, Kwast BE, Farley TMM. Breech labor on the WHO partograph. Int.
J. Gynaecol Obstet [online] 1998 [citeed 2007 Nov 16]; 62(2):[117-127]:
Available from: URL:http://cat.inist.fr/2aModele=afficheN&psidt=237893.

9 SIGNATURE OF THE
CANDIDATE

10 REMARKS OF THE GUIDE THE STUDY IS FEASIBLE AND OF


GENUINE INTEREST OF THE
STUDENT.

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Mrs.SUDHA A. RADDI
11 11.1 NAME AND DESIGNATION OF M.Sc(OBG.N) M.Phil
GUIDE PROFESSOR & H.O.D
DEPARTMENT OF OBSTETRICS &
GYNAECOLOGICAL NURSING
KLES INSTITUTE OF NURSING
SCIENCES, NEHRU NAGAR,
BELGAUM.

11.2 SIGNATURE

Mrs. SANGEETA N. KHARDE


11.3 CO-GUIDE MSc(OBG.N)
PROFESSOR
DEPARTMENT OF OBSTETRICS &
GYNAECOLOGICAL NURSING
KLES INSTITUTE OF NURSING
SCIENCES, NEHRU NAGAR
BELGAUM

11.4 SIGNATURE
PROF. Mrs. SUDHA. A. RADDI
11.5 HEAD OF THE DEPARTMENT MSc(OBG.N)
H.O.D OBG NSG
KLES INSTITUTE OF NURSING
SCIENCES, NEHRU NAGAR,
BELGAUM.

11.6 SIGNATURE

12 12.1 REMARKS OF THE THIS TOPIC WAS DISCUSSED WITH


CHAIRMAN & PRINCIPAL THE MEMBERS OF THE RESEARCH
COMMITTEE AND FINALISED. SHE IS
PERMITTED TO CONDUCT THE
STUDY.

12.2 SIGNATURE

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