3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Antenatal depression screening and perintal depression among women at Rahima Moosa Hospital(2018) Marsay, CarinaIn South Africa, 30-40% of women suffer from perinatal depression. This has devastating consequences for both mother and infant, as depressed mothers are at higher obstetric risk and have diminished capacity to care for the physical and emotional needs of their infants. Without adequate screening, approximately 75% of women with perinatal depression will remain undiagnosed and only 10% of these women will receive treatment. Studies conducted in low, middle and high income settings have shown that it is feasible and acceptable to incorporate mental health screening and depression assessment, with referral, into antenatal clinics. The study reported in this dissertation aimed to investigate whether women attending the antenatal clinic at Rahima Moosa Hospital would benefit from antenatal screening for perinatal depression. This would be achieved by determining whether antenatal screening for depression lead to reduced symptoms of depression. In addition, the study was designed to compare the specificity and sensitivity of the Whooley screening questions with the Edinburgh Postnatal Depression Scale (EPDS) in detecting major depression during pregnancy. Lastly, the study aimed to explore the lived experiences, and barriers to care, of women identified as suffering from perinatal depression who were referred for further management. A mixed-method, explanatory design, involving three phases, was used. In the first phase, data were collected using quantitative measures, including a standardised biographical interview, the EPDS, the Whooley screening questions and the Structured Clinical Interview of DSM5. During the second and third phases, quantitative measures were used again to identify changes from phase one. Data were also collected using qualitative indepth interviews to explain results in greater depth. Perinatal depression is a significant public health problem that needs to be addressed in order to improve maternal and child health. Only by listening to the needs of women experiencing perinatal depression can mental health care be improved within obstetric services. Welldesigned research studies which use an explanatory, transformative design can be used to guide effective screening programmes, improve treatment and inform national policy.Item An integrated approach to training of healthcare providers to improve the administration of intermittent preventive therapy for malaria in pregnancy in Kaduna State, Nigeria(2018) Nuhu, Simbiat SophiaBackground Intermittent Preventive Therapy using sulfadoxine pyrimethamine (IPTp-SP) is a malaria control strategy to reduce cases of malaria in malaria endemic countries. However, the administration of the recommended three doses of IPTp throughout the stages of pregnancy still remains low in Nigeria even though, Nigeria is a malaria endemic country. Quality improvement approach has been demonstrated to improve practice among healthcare providers. This study therefore used a quality improvement approach to train and coach healthcare providers in order to improve the administration of the recommended doses of IPTp to pregnant women receiving antenatal care (ANC) services. Methods A quasi-experimental study design was carried out to evaluate the effect of quality improvement approach consisting of training and coaching of healthcare providers to improve the administration of IPTp during ANC service. Primary Healthcare Centre (PHC) Samaru was purposively selected and twelve healthcare providers participated in the study. ANC daily register was reviewed pre-intervention, intervention and post-intervention period of the study. Data were analysed using line graphs and run charts. Results A total of 36 ANC visit weeks were observed between 21st November 2016 and 27th July 2017. The mean level for IPTp1 administration pre-intervention was 105.85% (SD: 29.28) and 75.20% (SD: 16.89) for IPTp2+. The levels of IPTp1 administration were relatively stable from Week 1 to Week 10 although, there was overestimation of IPTp1 as 8 of the 16 Weeks in the pre-intervention period i.e. Weeks 3, 5, 7, 8, 11, 13, 15 and 16 all had more than 100% of eligible women administered IPTp1. The patterns of IPTp2+ administrations shows the levels of IPTp2+ administration were erratic. There was evidence indicating the process of IPTp1 was relatively stable post-intervention as the data crosses the median line only six times i.e. 7 runs. This indicates that the process of IPTp1 was within normal variation over the post-intervention period. There was an upward shift showing immediate improvement of the administration of IPTp2+ post-intervention although, there was a non-random variation in the administration of IPTp2+. The iv improvements of IPTp were not sustainable due to stock-outs. The quality of the ANC daily register was poor. Conclusion The integrated training and coaching intervention approach improved the administration of the recommended three doses of IPTp within the context of a PHC. These findings should be interpreted with caution as the impact of the intervention may not have reached its full impact due to the short post-intervention assessment. Stock-outs remains a huge barrier to the administration of IPTp under DOT during ANC services. The data quality of the ANC daily register improved post-intervention however, there were still slight errors thus, indicating that healthcare providers need constant coaching. It is important to integrate training and coaching of healthcare providers in order to have desired and sustained outcomes. Keywords: Malaria in pregnancy, IPTp, IPTp-SP, SP, ANC, Pregnant women, Healthcare providers, administration, QI, integrated training and coaching.Item Inequalities in utilisation of maternal health services in Zimbabwe(2018) Madzudzo, NyashaBackground: Maternal mortality in developing countries like Zimbabwe is much higher amongst poorer, rural and less educated communities. Poorer or marginalised communities have the highest burden of disease and worst health status, but the least access to health care services. The distribution of health care resources and their use plays a key part in determining health and health outcomes. This study aims to measure inequalities in the utilisation of key maternal health care services in Zimbabwe using the PROGRESS-Plus framework, and to examine how the intersection of these factors create multidimensional advantage and disadvantage. Methodology: Using Data from the 2015 Zimbabwe Demographic and Health Survey (DHS), the Concentration Index, Slope Index of inequality and Relative Index of Inequality were computed for key maternal health care utilisation outcomes. Bivariate and Multiple Logistic Regressions were computed to determine the PROGRESS-Plus factors associated with utilisation of these services. Multiple Correspondence Analysis was used to investigate the interaction of multiple PROGRESS- Plus factors influencing social position. Results: The majority of women (93.3%) in the 2015 Zimbabwean DHS survey had a skilled ANC attendant although few of the women (38.5%) had their first ANC visit before four months gestation. Most women (78.1%) had a skilled birth attendant and delivered at a health facility (77.0%). Inequalities were higher in delivery care than antenatal care. The utilisation of maternal health service was higher amongst socially advantaged groups, although the magnitude of the inequality was small. Higher wealth index, educational attainment and health insurance coverage were significantly associated with higher maternal health service utilisation. These factors were closely inter-related with the same group of women having low wealth, low levels of education and no health insurance. Conclusion: Inequalities in utilisation of maternal health services favour socially advantaged groups. Wealth, education and health insurance where the strongest determinants of use of maternal health care and these factors were interlinked. There is need to consider social protection policies that reduce the vulnerability of disadvantaged groups of women to access education and work opportunities Keywords: Inequality, Maternal Health, ZimbabweItem Patient factors associated with gestational age at first presentation to antenatal clinic at four facilities in the Masquassi hills sub district, North West Province, Republic of South Africa(2017) Manwana, Jean-Paul KipanguBackground Research has shown that women who do not obtain adequate prenatal care significantly reduce their chances of a favourable pregnancy outcome. Despite antenatal care services being provided free of charge in South Africa, only 53.9% of women attend antenatal care before the gestational age of 20 weeks or less as recommended by the World Health Organisation (WHO) and National Department of Health (NDOH).The interventions aimed at reducing unfavourable pregnancy outcomes are most effective during prenatal care, it is crucial to identify factors that prevent pregnant mothers from presenting early. It is believed that the findings of this study will give us an insight into the rate of early ANC attendance and will also be useful to policymakers and facility managers, especially at the Primary Health Care (PHC) level, in optimising patient care and improving healthcare services. Aims and objectives Therefore, the objectives of this study were: 1 To establish the gestational age at which pregnant women present to first antenatal visit in Maquassi Hills sub district. 2 To describe participants’ socio-demographic profile, health status and obstetrical characteristics 3 To explore knowledge and attitudes that affect timing of first presentation. 4 To determine any association between first ANC presentation and socio-demographic, obstetric factors, knowledge and attitudes towards ANC. 5 To determine predictors for first antenatal attendance. Method This was a cross-sectional study conducted in four publicly funded primary health facilities in the Maquassi Hills sub district, between August and October 2015. A total of 127 participants were directly interviewed using a structured questionnaire to obtain information about their socio-economic characteristics, ANC and services rendered. Most of the information required for the study was obtained from the Maternity booklet. This included demographic data, obstetric history, medical history, and gestational age. Data analysis was done using Microsoft Excel 2014. A chi-square test was used to determine associations between time of the first presentation and each variable; and a multiple variable regression was used to determine predictors of early attendance. Results Most participants interviewed were: Tswana speaking (72.4%), with a mean age of 26.5 years (SD = 5.9), had a high school education (84.6%) and were mostly single (70.6%). This study showed that 68.9% of the respondents presented to their first antenatal booking within the recommended time of less than 20 weeks. The average period of presentation was 16.3 weeks (SD = 6.0). No statistically significant association was found between socio- demographic, obstetrical characteristics and the timing of the first antenatal visit. All the participants knew that the right time to book an appointment was before 20 weeks as the best perceived time for initiation of ANC. However, there was a statistically significant difference in the best perceived time between those who booked early (2 months [1.99 months (SD =1.145)]) compared with those who booked later (3 months [2.83months (SD = 1.595)]) (p = 0.006). The multivariate analysis showed that participants who perceived three months as the best time for booking were 1.5 times more likely to book later (OR= 1.589, 95% CI 1.227-2.059) compared with those who perceived that the best time was at two months. The most frequent reason given for booking early was to confirm pregnancy (64.0%) and (31.1%) initiated ANC because they were ill. Long waiting times and staff attitude were reported by participants (91.3%) and (5%) respectively as barriers to early ANC visit. Conclusion The findings of this study show that most participants booked antenatal care timely and all participants knew the right time to initiate ANC. However, there is incongruity between knowledge and practice for the 30% who presented late. This could be attributed to the long waiting time and staff attitude mentioned by some of the participants. There is a need therefore to address the demotivating factors such as long waiting time, and staff attitude in order to promote early ANC booking/attendance.Item Experiences and perceptions of Zimbabwean migrant women accessing antenatal and infant/child immunisation in public healthcare services in Gauteng South Africa (2015-2017)(2017) Saburi, SusanGlobally, access to maternal and child healthcare remains a fundamental human right for all, regardless of an individual’s migration status (1). People migrate for a variety of reasons, and this mobility brings forth implications for health provision, health care experiences and human rights, both for the migrants and their host population (2, 3). An increasing number of cross-border or international migrant women globally report difficulties in access to and use of healthcare services, including maternal and child health (4, 5). Little evidence in South Africa on these issues proposes that there is a need for deeper knowledge in this regard. South Africa is a signatory to a range of international commitments that place emphasis on the non-discriminatory provision of health services and a progressive health policy assuring health for all, including free access to antenatal care (ANC) (1). Despite this, South Africa’s maternal and child health outcomes continue to be poor - including that of migrants (6, 7). The increased number of migrants from neighbouring countries is perceived to have placed a burden on the South African healthcare system (4). The aim of this study was to explore the experiences and perceptions of Zimbabwean cross-border migrant mothers in accessing routine antenatal care, obstetric care and infant/child immunisation in public healthcare facilities in, Gauteng, South Africa (2015-2016). Through a qualitative study design, the researcher gathered data by means of 13 face-to-face interviews with a purposive and snowball sample of participants. Few participants gave positive reports on the quality of ANC and immunization services they had received. It is therefore important to ensure that this positive care is maintained across all public health facilities in order to instill confidence among health recipients. However, most of the study participants experienced barriers in accessing quality routine ANC and infant immunisation in the country’s public health facilities. These challenges include language barriers, discrimination and poor nurse-patient relationships. Based on these findings and conclusions, the researcher recommends that the South African National Department of Health addresses some of the challenges affecting cross-border migrant vi women in accessing maternal health care in public facilities nationally through the formulation, implementation and follow-up of policies. Furthermore, health care providers need to be continuously educated and motivated to respect the rights of all patients, regardless of an individual’s migration status, in order to instil positive attitudes and quality care. There is also a need to conduct further research in other provinces of the country, preferably with cross-border migrant women from other countries, and draw comparisons with South African women in order to take appropriate steps to address the challenges.Item 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 Psychosocial risk assessment by midwives during antenatal care: a focus on psychosocial support(2013-03-19) Mathibe-Neke, Johanna MmabojalwaThe rationale of any national screening programme is to recognize the benefits for public health, to test a predominantly healthy population including low risk pregnant women, and to detect risk factors for morbidity in order to provide timely care interventions. The South African health care system faces many challenges that undoubtedly impact on maternal health, resulting in poor quality of care and indirectly causing maternal deaths. The government has embarked on a number of initiatives that address women’s psychosocial wellbeing during pregnancy, for example free maternity care, legalizing abortion, expanding on provider-initiated HIV counseling and testing for antenatal patients. These initiatives imply a re-look at antenatal care screening, in order to identify wider determinants of health that may have an impact on a woman’s psychosocial wellbeing. This includes amongst others, poor socio-economic conditions such as poverty, lack of social support, general health inequalities, domestic violence and a history of either personal or familial mental illness, all of which have the capacity to influence a pregnant woman’s decision to utilize health care services. The intention of this study was therefore to establish the extent of psychosocial risk assessment for pregnant women during antenatal care, with a focus on the psychosocial support.Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee (Protocol no. M081013). A mixed-method approach was applied through combining quantitative and qualitative research techniques, methods and approaches to address psychosocial risk assessment and psychosocial support by midwives during antenatal care. An explanatory sequential design was used. The methodology was aimed at accommodating the diverse population involved in the study, the nature of data being sought and the number of investigations conducted. A fully mixed research approach was implemented interactively through all the stages of the study. The study took place in six phases to meet the purpose of this research. Phase 1 entailed quantitative data collection and analysis; phase 2 qualitative data collection and analysis; phase 3 report writing; phase 4 formulation of guidelines; phase 5 pilot test; phase 6 integration of results and findings, and writing of final report. The philosophical basis of the study is based on the researcher’s values and belief of holism and comprehensive assessment. Much as values are part of the study, the researcher strove to keep values as separate from the research as possible, to minimise researcher bias. The feminist standpoint theory provided the guiding epistemological framework to address the qualitative research questions for this study as the issues regarding reproduction are of central feminist concern. Pragmatism, which is considered a best philosophical basis for mixed-methods as it values both objective and subjective knowledge, was applied in this study. The methodological goal of the study was guided by two paradigms, “constructivist”, which is the basis of qualitative research and “contemporary empiricist” paradigms, which is the basis of empirical analytic research as the study used a mixed-method approach. Although the empiricist lens is the most appropriate for a sequential explanatory design, both paradigms are acknowledged in this study. A quantitative-qualitative data collection and analysis sequence was followed. The sequential explanatory approach was maintained through, for example, collecting and analyzing quantitative data first, followed by obtaining information from midwives through a questionnaire and focus group discussions, and from pregnant women through a questionnaire and focus group discussions, using the same populations. Non-probability purposive sampling was done for all data sources. All data were collected by the researcher.Qualitative data analysis consisted of the identification of themes and relationships through constant comparison of data, which enabled the researcher to establish group and across-group saturation in focus group discussions. Quantitative data was collected through the review of midwifery education regulations, documents and records. Midwives’ questionnaires with a response rate of 46%, questionnaires administered to pregnant women and the review of antenatal cards with a 94% response rate. The data sets provided multiple data sources, a characteristic of the mixed methods approach. Data were analyzed using the Stata Release 10 statistical software package. Data analysis included summary statistics i.e. mean and standard deviation for continuous variables, frequencies and percentages for discrete variables, and Chronbach’s alpha for internal consistency. Confidence intervals of 95% were used to report on discrete variables. Quantitative and qualitative data were initially analyzed separately to develop an understanding of the two data bases before merging the findings and results. The process provided separate and independent results that could be compared for the purposes of corroboration, complementarity and discussion. The results were compared for specific content areas, for example major themes. A tool for psychosocial risk assessment and care was developed in response to the findings from the midwives’ focus group discussions at the three clinics, the expert interviews findings, the cross-sectional survey results from midwives, the self-administered questionnaires for pregnant women, and review of the antenatal cards carried by women during antenatal care. The tool was piloted in the three clinics where data were initially obtained. The general results of the study suggest that depressive and anxiety disorders are common in pregnancy and may be associated with negative experiences during antenatal care. Adequate screening of women and recognition of emotional responses with appropriate interventions are essential to promote a woman’s healthy adjustment to pregnancy. Attempts to minimise high levels of uncertainty, anxiety and depression should be incorporated within routine antenatal care.Midwives should strive to empower women physically and psychosocially in order for women to be able to overcome any barriers to safe motherhood, with emphasis on providing information, in order for them to make informed choices.The findings from the pilot study confirmed that pregnant women experience psychosocial problems which can be identified by the use of a screening tool, howeverthere remains a need to test the tool on a larger sample which might elicit more factors that could hinder or help its implementation. The implication of the findings appears to be that midwives are willing to incorporate the psychosocial assessment tool into routine antenatal care. The findings might be used to advocate for the incorporation of the tool into routine antenatal care. While the use of this antenatal psychosocial pilot tool may increase the midwives’ awareness of psychosocial risks and form a basis for further studies, a bigger sample size and statistical power are required to provide evidence that routine antenatal psychosocial assessment would also lead to improved outcomes for mother and/or child. The final stage of the study, based on research findings, led to the development of guidelines and recommendations for psychosocial care at the midwifery regulation level, midwifery education, clinical practice level and research. Key concepts: Antenatal care; Midwife; Psychosocial risk assessment; Psychosocial support.