ETD Collection

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    Evaluation of the termination of pregnancy services in South Africa
    (2011-10-26) Mendes, Jacqueline Faria
    Introduction Three public health interventions well known to decrease the risks associated with pregnancy and child birth are access to maternity care, family planning and contraception, and safe abortion. Worldwide, the African region has the highest case fatality rate associated with unsafe abortion 750 per 100 000, largely as a result of restrictive abortion laws. South Africa (SA) legalised abortion in 1996 with the “Choice on Termination of Pregnancy” (CTOP) Act. It sought to improve the quality and access to termination of pregnancy (TOP) services in SA. Since its enactment there has been a 91% decrease in deaths due to unsafe abortions. There have been some experienced challenges associated with the implementation of the Act, limited number of functional TOP facilities, prolonged waiting times, and negative attitudes of TOP providers to clients. After more than a decade of liberalised law in SA, what are TOP providers’ perceptions, clients’ experiences and the overall quality of TOP services? Main Aim The evaluation of TOP services in the urban Johannesburg Metropolitan Municipality (JHB), Gauteng Province, and two rural municipalities Bela-Bela Municipality, Limpopo Province and Mangaung Municipality, Free State Province. Methodology A mixed methods approach was adopted; both quantitative and qualitative data were collected in three sections. Included were all primary health care facilities offering first trimester TOPs in the Johannesburg Metropolitan, Mangaung, and Bela-Bela Municipalities. Section I the analysis of district health information management system (DHIS) data for JHB. Section II, TOP providers and TOP clients completed self-administered questionnaires. Section III the TOP clients from JHB were questioned again after eighteen months. Various parametric and non-parametric tests were conducted on the data, based on the data distribution. The statistical software used for quantitative data analyses was Stata release 10.0 and qualitative data MAXQDA release 10.0. Results The DHIS showed a 61% increase in TOP requests from 2006 to 2009 (Chi-square for trend; P=0.08). The number of first trimester procedures performed only addressed 40% of total requests in 2006 and 33% of total requests in 2009. Section II demonstrated that all the TOP providers reported not coping with their duties, only two (15%) providers were comfortable with administering TOPs. One hundred and fifty-two TOP clients were recruited into the study. The mean age was 26.00 (±6.03) years. One hundred and sixteen (76%) women were not using contraception. Clients from JHB had prolonged waiting times 14 days (IQR; 6-28) compared to Bela-Bela clients’ 3 days (IQR; 1-6) (Post-hoc Wilcoxon- Ranksum; P<0.0001). Hence clients from JHB had TOPs at later median gestational ages of 9 weeks (IQR; 8-11) and Bela-Bela clients at 7.5 weeks (IQR;4-8) (Post-hoc Wilcoxon Ranksum; P<0.0001). Knowledge of the CTOP Act exceeded seventy percent across all three municipalities (Pearson Chi-square; P=0.83). Section III identified that 39% (n=9) of interviewed clients experienced a TOP-related complication. The odds of experiencing a complication was decreased if client received a follow-up appointment (OR 0.12; 95% CI 0.02-1.51; P=0.02), if client was aware of the CTOP Act (OR 0.11; 95% CI 0.01-2.08; P=0.06), and clients that had attended Lenasia South CHC had odds of complication 8 times higher than clients who had presented to Bophelong clinic (OR 8.68; 95% CI 3.47 -21.7; P<0.0001). The qualitative analysis identified themes of an association with intra-procedural pain and perceived inadequate counselling with those reporting emotional distress. Discussion The prevalence of contraceptive use during the month of conception was low, and the majority of clients were unaware of the correct gestational age for termination of pregnancy according to the CTOP Act. This suggests that the pre-TOP services required strengthening. The TOP services in the public sector may not to be addressing the number of TOP requests; this affects the availability of the service. TOP providers in different South African settings report similar challenges associated with delivering TOP services. The clients from JHB are waiting longer for the TOP and hence having the abortion at later gestational ages which are associated with increased complications rates. The study estimated a complication rate of approximately 26 per 100 abortion clients, higher than acceptable global rates which approximate 3 per 100. The improvement of pre and post-TOP counselling was highlighted. Conclusion This study introduces the importance of passive surveillance in improving the quality of service delivery. Though this is only achieved when data collected are analysed and used to inform policy and service. The studies conducted in South Africa since the CTOP Act enactment has demonstrated various challenges and areas for improvement. These findings have ensured that issues of public health importance continue to be studied and relevant findings disseminated to stakeholders for and consideration and action where appropriate.
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    The effects of availability of reproductive health services on the contraceptive use and method choice in the city of Tshwane Metropolitan Municipality
    (2009-02-13T10:03:44Z) Tshibangu, Delphin-Cyrille
    ABSTRACT This study is the first of a series of community-based surveys that the City of Tshwane Metropolitan Municipality (CTMM) has planned to conduct in the next 15 years to fulfill its provincial mandate (being the provider of primary health care services) in accordance with the Gauteng District Health Services Act (Act No 8 of 2000)1. The study determined the prevalence rate of contraceptive use and method choice, and the effects of the availability of reproductive health services on contraceptive use and method choice in the CTMM in 2004. The study used a descriptive cross-sectional population-based study design and a sample of 3, 547 women of childbearing age (15-49 years) using a multi-stage cluster sampling with probability proportional to size to determine these effects. A modified 1998 SADHS questionnaire helped to collect information on selected individuals, programmes and district explanatory variables from women living in the four health sub-districts and data were used in three B (4 variables), C (six variables) and D (eight variables) unconditional binary logistic regression models and a multinomial logistic model to estimate their effects (odds ratios and pvalue at 5% level) on contraceptive use and method choice. The selection of these variables is based on the conceptual framework that recognizes that contraceptive use or method choice is the consequence of service utilization, which, in turn, is influenced by individual, service/programme and community factors2,3. The availability of reproductive health services was measured by the presence or absence of the supply source of contraceptive methods in a district. After controlling for the effects of individual (social and demographic) variables, none of the programmatic variables was independently associated with contraceptive use. By contrast, district/place of residence predictor was associated with reduced odds of contraceptive use and with reduced odds of condom, injection and IUD’s choice against pill in all the models and districts, respectively. In terms of the source of first information on contraceptive methods and the differences between IUD and injection, the study shows that nurses (odds ratio, 1.80, p<0.05) are more likely than mothers to be the providers of information on IUD while physicians (odds ratio, 0.65, p<0.05) are shown to be less likely than mothers to be the providers of information on injection as opposed to the pill. The private sector ( odds ratio, 2.12, p<0.01) is shown to be more likely than the public sector to be the supply source of IUD methods rather than the pill, and also more likely (odds ratio, 1.97, p<0.01) than the public sector to be the supply source of IUD instead of injection. Private pharmacies (odds ratio, 2.25, p<0.05) are more likely than the public sector to supply condoms rather than the pill. The presence or absence of reproductive health services in a district was significantly associated with reduced odds of both contraceptive use and choice of condom, injection and IUD methods against pill. This may be attributable to women’s willingness to travel outside their place of residence to get their preferred method. Thus availability of reproductive health services in the district seems not to have an important effect on use and choice of modern contraception in the City of Tshwane in 2004.