3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Reducing maternal morbidity and mortality from caesarean section-related haemorrhage in Southern Gauteng(2017) Maswime, Tumishang Mmamalatsi SalomeIntroduction The number of maternal deaths from bleeding during and after caesarean section (BDACS) has increased dramatically in South Africa in recent years. Four studies were conducted to gain insight on measures to reduce maternal deaths from BDACS. The aim was to identify clinical and health system factors associated with near-miss and maternal death from BDACS. Methods A systematic review was done on near-miss from postpartum haemorrhage, with a sub-analysis on BDACS. The field research, done in southern Gauteng, included: 1) a six-month prospective near-miss audit of women with BDACS in 13 hospitals; 2) a two-year retrospective maternal death audit in seven hospitals; and 3) a health systems audit in 15 hospitals. Results The systematic review on near-miss from PPH found two studies that described near-miss from BDACS, with a mortality index of 0-11%. In the near-miss and maternal death audits, the main risk factors for BDACS were pre-operative anaemia and previous caesarean section. Atonic uterus was the main cause of haemorrhage, with associated failure to use second line uterotonic drugs. Failure to diagnose and treat shock was the main reason why women died. Most maternal deaths from BDACS occurred in regional hospitals. The hospital systems audit identified shortages of second line uterotonic drugs and surgical skills availability as contributors to near-miss and maternal death from BDACS. Conclusion Although bleeding may be arrested through obstetric surgical techniques and easily available drugs, severe BDACS is a complex disease that requires a multi-disciplinary approach in a functional health system, especially regarding the detection and management of hypovolaemic shock. Measures to reduce maternal morbidity and mortality from BDACS include health system strengthening, with high care and critical care facilities, and improving the availability of drugs and surgical skills at district and regional hospitalsItem Spatial modelling and mapping of antenatal care service utilization in Ethiopia: an analysis of Ethiopian demographic and health survey, 2011(2016-10-12) Asnake, DumichoBACKGROUND: Adequate antenatal care (ANC) is an important indicator to improve maternal and their infant health in a given region. However, ANC coverage varies markedly within geographical locations due to different social and health determinants. Evaluating and documenting such variations provide useful information to improve ANC uptake. OBJECTIVE: To identify socio-economic and demographic factors associated with ANC service utilization, to investigate spatial clustering in ANC service utilization and to develop maps of spatial variation in ANC service utilization in Ethiopia. METHODS: Data was drawn from the 2011 Ethiopian Demographic and Health Survey (EDHS). The two aspects considered under ANC service utilization include the time of first ANC visit and the number of ANC visits. Time of first ANC visit was coded as late (0) when the first visit took place after 16 weeks of gestation otherwise early (1). Number of ANC visit was ordered and coded as no visit (0), inadequate (1) for one to three visits and adequate (2) for greater than or equal to four visits. Alternatively, number of ANC visit was coded as no visit (0) and at least one visit (1) for mapping of spatial variation in number of ANC visit. Spatial scan statistical analysis was carried out on enumeration areas (EAs) aggregated data by using SaTScan to investigate significant clusters of time of first ANC visit and number of ANC visit. High and low rates of ANC service utilization clusters were detected. For time of first ANC visit, the cluster with relative risk (RR) less than one indicates the early visit is lower than late. The number of ANC visits ordered in to three categories, due to this RR in every cluster is represented by three different numbers: the first one stands for (no visits), second for (inadequate visits) and third for (adequate visits). The clusters with RR decrease from low valued category (no ANC visits) to high valued category (adequate number of ANC visits) indicate the rate of number of ANC visits decreases in the clusters. Ordinal logistic regression used to investigate factors associated with the number of ANC visits. Bayesian hierarchical spatial logistic models were used to investigate factors associated with time of first ANC visit and develop maps of spatial variation in the time of ANC visit and the number of ANC visits across Ethiopia. RESULTS: The overall prevalence of time of first ANC visit and adequate number of ANC visits were 26.38% and 19.14% respectively. The result revealed significant spatial variation in ANC service utilization. Women in the West [RR=0.33, P<0.0001] and South-West [RR=0.52, P<0.0001] of Ethiopia were least likely to start ANC early. Those in North-West [RR=1.26,1.03,0.43; P=0.0001], South-East [RR=1.64,0.46,0.03; P=0.0001], North-East [RR=1.81,0.05,0;P=0.0001] and tip of West [RR=1.46,0.67,0.24;P=0.0001] of Ethiopia had lowest numbers of ANC visits. In these parts of the country the rates of number of ANC visits decreases from low- valued category (no ANC visit) to high-value category (adequate number of ANC visits). Age at birth of last child, place of residence, education, religion, marital status and household-wealth were significantly associated with time of first ANC visit. Age at birth of last child, place of residence, region, education, ethnicity, marital status, household-wealth and party were significantly associated with number of ANC visits. CONCLUSION: The finding of this study has potential to assist government, policy makers and other collaborative organizations on resource allocation and improvement of ANC services.Item Caesarean section deliveried in public sector hospitals in South Africa, 2001-2009.(2013-04-05) Monticelli, FiorenzaIntroduction There is concern that C-section rates are increasing in the public health sector in South Africa and wide variation has been reported between districts, provinces and hospitals. This study is a comprehensive analysis of C-section rates in all public sector hospitals during 2000/01- 2008/09 by facility, district and province. It aims to inform decision makers in maternal health services of the trends and patterns occurring in C-section rates in South African public sector hospitals. Variation in C-section rates is described to highlight the differences in care that pregnant women receive in different parts of the country and to illustrate where inequity of resource allocation is occurring, as well as highlighting possible data quality problems. Methodology This is a descriptive study using quantitative methods of analysis on secondary data obtained from the National Department of Health’s routinely collected data specific to Caesarean sections in the DHIS. C-section averages are weighted by taking the number of deliveries per facility and level into consideration. Results 1. Wide variation is noted between individual facilities, between and within provinces and districts and within the different levels of hospitals in 2008/09. The mean weighted C-section rate ranges from 17.2% in District Hospitals to 40.7% in Specialised Maternity Hospitals. A 3.7 fold difference between the highest and lowest district average C-section rates is seen for District Hospitals. Within provinces, average District Hospital C-section rates vary by as much as 3.5 fold between districts. Interdistrict variation in Regional Hospitals shows a 3.3 fold difference between the lowest and highest average district rates. Among the eight National Central Hospitals there is a 2.5 fold difference between the highest (79.7%) and lowest (31.7%) facility C-section rates. Nationally a total of 23 District Hospitals had C-section rates below 5% and nine hospitals of varying levels had rates of over 50% 2. Caesarean Section rate trends, 2000/01 – 2008/09 are increasing. Nationally the average C-section rate in South Africa increased by 6.3 percentage points from 18.1% in 2000/01 to 24.4% in 2008/09, with an average annual compounded growth rate of 3.8%. Bivariate linear regression analysis confirms there is a positive linear relationship between time (year) and C-section rate (p<0.001). All levels of hospitals showed an increasing trend over the nine years, (p<0.001), with the rate in Provincial Hospitals having increased by the highest amount (1.40%) year on year and District Hospitals, the least (0.48%). Trends within certain districts and individual hospitals however, show a decline. 3. A strong relationship between level of deprivation and C-section rate exists when adjusting data for provincial variation Bivariate linear regression analysis revealed no association between the level of deprivation of the population at district level and the mean C-sections rate per district (p=0.130). Multiple regression analysis adjusted for the effect of province, reveals a significant association (p=0.044). A negative association between the DI (p=0.006) and Csection rate is seen in eight out of nine provinces. 4. Data quality of C-sections and deliveries in the DHIS needs improving Data quality in the DHIS leaves uncertainty in some instances whether C-section rate trends are a true reflection or not. The C-section rate indicator on its own is unable to inform on the full spectrum of emergency obstetric care. The definition of C-section rate for primary health care currently only considers deliveries in District Hospitals. The national C-section rate for primary health care in the country however, reduces from 17.2% to 13.2% when including the deliveries which take place in CHCs. Conclusions The quality of data relating to C-sections (number of births, C-sections and hospital categorisation) in the DHIS needs to be improved in order to enable accurate monitoring and should include deliveries and C-sections which take place in Community Health Centres to allow for a more accurate reflection of C-section rate in primary health care. The C-section rate indicator on its own is insufficient to adequately inform on the full spectrum and quality of the provision of emergency obstetric care in South Africa. Including additional indicators to the DHIS, such as the UN process indicators, could improve on the current knowledge and monitoring of the provision of emergency obstetric care in South Africa. The wide variation in C-section rates seen among District Hospitals and the C-section rates between and within districts and provinces, suggest inequity in resource allocation and irregular service delivery patterns. Reasons and solutions for these wide differences need to be found, which are likely to be unique to each district and province. Further studies are needed to investigate the access of poorer women, especially those in remote rural areas to emergency obstetric care services.Item The cost of clinical procedures performed in the maternity ward of Thebe District Hospital(2012-01-10) Maarohanye, Ramaimane Peter GiftyBackground: Maternity services in South Africa like in many developing countries remains a challenge. The high mortality and morbidity rates recorded in the confidential enquiries to maternal death (CEMD) reports in South Africa support a need for more studies to be done to improve maternal health services. Although clinical procedures are an integral part of the maternal health services, little is known about the current-status of clinical procedures performed in the maternity units of district hospitals and related resource utilisation. The apparently “free” maternity services at government hospitals involve substantial hidden and unpredicted costs, which is not quantified. Aims of the study: To describe the cost of the specific clinical procedures performed at the maternity unit of Thebe District Hospital. Methodology: This was a cross-sectional study design involving a retrospective record review of all maternity patient records for a one-month period in 2009. The month of September is mid-month for the financial year and was chosen as it is reflected a stable month in terms of financial performance. The costing aspect of this study was based on the National Health Reference Price List and UPFS. Data was analysed with NCSS software. Results: The study found that NVD was the main clinical procedures, which is in line with the district hospital package. The CS rate was within acceptable norm but a significant number of BBA is of concern and would require further exploration. The majority of the patients who delivered at this unit are black, unemployed and had no medical aid. Most of them arrived by ambulance although it was not clear whether these patients were coming directly from home or were referred by PHC clinics and CHCs. There were no maternal and perinatal mortality and morbidity during the study period. This study documented the direct cost of clinical procedures performed at a district hospital. The Human resources was the main cost driver. The calculated cost for this study was far lower than the costs prescribed in NHRPL for NVD and CS but higher than UPFS. This study highlighted the need for revising the UPFS. Conclusion: The research findings will inform the resource needs for performing specified clinical procedures in maternity section at the Thebe District Hospital and will hopefully be used as a benchmark for maternity sections at all district hospitals in Thabo Mofutsanyana District and elsewhere. It has provided reasonable indications about the costs of each procedure and evidence can be used to determine the costs of each procedure in various district hospitals in the country and worldwide. It can further be utilised to do proper planning for our district hospitals in the province and develop the scientific criteria for resource allocation.Item Evaluation of the quality and management of maternity services in the national district hospital in the Free State Province(2011-11-11) Sesing, Agnes SeatileINTRODUCTION: Maternity services are a priority for all health care services but in most cases there have been serious challenges experienced through service performance. The National District Hospital (NDH)‟s key performance indicator is bed occupancy rate which showed an underutilization of this facility. The maternity services statistics, especially did not give a clear picture of the performance of the unit. Various studies have been conducted to identify management challenges in maternity units of district hospitals, but no formal study has been done to systematically document this problem at the National District Hospital (NDH), although there has been anecdotal evidence of problems in the performance of the unit. It was therefore important to investigate the functioning of the maternity unit of the NDH and identify problems that hinder it from functioning effectively. AIM: To evaluate the performance of maternity services in the maternity unit at the National District Hospital. METHODOLOGY: A cross sectional study design was used comprising of a retrospective record review. The setting of this study was the maternity unit at National District Hospital. Data was collected on various variables that are relevant to the performance of maternity services. ANALYSIS: The data collected was analyzed and revealed that the factors contributing to the poor performance of the maternity services were: Poor record keeping, such as incomplete recording of partograms. Non adherence to guidelines and protocols, such as poor management related to HIV and AIDS care and poor management of patients in the advanced labor phase. Failure to make informed decision due to information mismanagement. Poor supervision in the unit. No adherence to objectives of peer review meetings. RECOMMENDATION: The recommendations based on the findings are: - Establish patient centered maternity services - Train and retraining of health care providers in the maternity unit - Review existing strategies to improve quality of care in the maternity unit - Improve information management and functioning of the Maternal Morbidity Review meetings CONCLUSION: The recommendations given can be used to improve maternity services within district hospitals as well as provincial and national maternity services.Item Patient-related adverse events in the maternity units at Tokollo/Mafube district Hospital complex(2011-10-27) Noge, Sesi RoslinaBACKGROUND: The Tokollo/Mafube District (TMD) Hospital Complex located in the rural area of Fezile Dabi District within the Free State Province has reported a high number of adverse events (AE) from the maternity units. Although the information linked to AE occurring in the hospitals is routinely collected and reported to the hospital management in accordance with the Provincial policy, no study has been done to systematically analyse the available information and to explore the current situation. AIM: To describe the patient-related AE in the maternity units of TMD Hospital Complex, related individual and health system factors, and the functioning of the reporting system used for these AE during the two year study period. METHODOLOGY: A descriptive cross-sectional study design was used, based on a retrospective review of routinely collected hospital data from the health records of patients, the AE Committee meeting minutes, and other relevant hospital documents. The study was conducted at the maternity units of TMD Hospital Complex which consists of two hospitals in the Fezile Dabi District within the Free State Province. Data was collected in the following categories of variables: the types of AE (in terms of levels of seriousness), the profiles of patients who experienced such AE (e.g. age, gravidity, marital status, residence, and socio-economic status), the related health system factors identified during the adverse events committees meetings (such as personnel, transport, equipment, environment and management) and reporting of these AE. RESULTS: This study revealed that a total of 88 patients, comprising 0.8% of the total number of admissions to the maternity units, experienced AE. Maternal AE occurred more commonly than perinatal AE. The majority of women experiencing AE were unemployed (93%), between the ages of 19-34 (81%), unmarried (79%) and resided in towns (88.6%). In addition, most of these women belonged to the groups of primigravida and multigravida (85%), attended between one and three antenatal visits (42%), and delivered via normal vaginal deliveries (76%) with a high number of stillborns (77.2%). Overall, the majority of maternal AE occurred during the intrapartum stage. Another significant finding was that majority of AE reported were classified as the most serious being SAC 1, which accounted for 93% of the maternal AE and 84% of perinatal AE. The early perinatal AE accounted for 100% of the reported perinatal AE. Although majority of AE reported at the institution were within the prescribed period, reporting time to the Complex AE Committee (CAEC) and District AE Committee (DAEC) was exceeded in the majority of cases. In addition, all AE that required investigation complied with the provincial policy but exceeded the required investigation period. The findings regarding health systems related factors as determined by root cause analysis performed by the AE committee revealed that clinical governance issues accounted for 43% of both maternal and perinatal AE, followed by patient transport issues as provided by the Emergency Medical Services (EMS) which also accounted for a significant percentage (33%). CONCLUSION: This study has demonstrated that specific health system related factors played a significant role on the occurrence of AE at the maternity units of TMD Hospital Complex and that the majority of the reported AE were very serious (SAC 1). It is important that these preventable, contributory factors are addressed by management at both the complex and district levels. Furthermore the results suggest that patients’ profiles, to a certain extent, do have an influence on the occurrence of AE in maternity units of TMD hospital Complex and it is important that patients’ profiles be taken into consideration when adverse incidents are analysed.