3. Electronic Theses and Dissertations (ETDs) - All submissions
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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.Item Differences in characteristics of women who initiate antenatal care early and late in two slums of Nairobi, Kenya(2009-04-16T08:30:56Z) Ezeh, Nkeonyere FranciscaABSTRACT Background: About 90% of women in Kenya report at least one antenatal care (ANC) visit yet maternal mortality rate remains high at 414 per 100,000 live births. Only 40% of childbirths occur in health facilities. A previous study of Nairobi slums in 2000 indicated that only 10.3% of women initiated ANC visits in the first trimester. High incidence of maternal deaths in Kenya especially among the very poor has been attributed to inadequate emergency obstetrical care. Decreasing numbers of women are initiating ANC within the first trimester and this may be affecting the ability of the health system to identify and cater for women whose health conditions can be effectively managed through ANC. This study aimed to determine the proportion of women initiating ANC in the first and last trimesters and the background characteristics associated with these women in two slums of Nairobi, Kenya. It also sought to determine if timing of initial ANC visit was associated with number of visits and choice of place of delivery in a slum setting. Materials and methods: This research report is a secondary data analysis of the World Bank funded Maternal Health Project conducted between 1st April and 30th June, 2006 by the African Population and Health Research Center. Participants were women 12 to 54 years, enumerated in the Nairobi Urban Health Demographic Surveillance System living in two slums of Nairobi, who had a pregnancy outcome between January 2004 and December 2005. Women 15 to 49 years were included in this analysis. Analysis of the data was done using STATA 9.2. Findings: Only 7.3% of women initiated ANC in the first trimester, with 52% making four or more visits. In the third trimester 22% of women initiated ANC. Although 97% of women reported receiving their first ANC from a skilled health professional, only 48.4% delivered in well equipped health care facilities. The median number of months pregnant at first ANC was six and median number of visits was four. Women who were most likely to initiate early ANC had secondary school or higher level of education (p=0.055) and were in a union (p=0.008). The least likely to initiate care in the first trimester were of minority ethnicity (0.011) and high parity (p=0.019). As educational level and wealth status rise, the likelihood of late ANC initiation declines. Women living with unemployed partners were less likely to initiate care in the first trimester compared to those living with employed partners (OR 0.2, p=0.046). Only women with educated partners initiated care during the first trimester. Women who initiated ANC in the first trimester were more likely to have 4 visits and more likely to deliver in appropriate facilities than those who initiated care in the third trimester. Those who initiated care to obtain an ANC card were less likely to have 4 visits than those who initiated care to verify that pregnancy was normal (OR 0.5, p=0.000). Women who initiated care in first trimester were 1.5 and 5.0 times more likely to deliver in good health facilities than those who initiated care in third trimester (p=0.040) and those who had no ANC (p=0.000), respectively. Conclusion: Women in Korogocho and Viwandani may have better chances of delivering in appropriate facilities if they have low parity and secondary level education. The presence of a partner with a means of steady income may also make it easier for women to access delivery care in good facilities. Interventions to improve the level of educational attainment among women and provide affordable family planning are necessary to increase early ANC attendance and subsequently delivery in well equipped facilities.