3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Evaluation of the termination of pregnancy services in South Africa(2011-10-26) Mendes, Jacqueline FariaIntroduction 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.Item Contraceptive study: an assessment of contraceptive use in patients requesting termination of pregnancy at Chris Hani Baragwanath hospital(2009-11-12T11:52:55Z) Nyakoe, Robert BarasaThe aim of this study was to assess the demographic characteristics and contraceptive practices of women requesting termination of pregnancy (TOP) at Chris Hani Baragwanath Hospital (CHBH). The study will provide insight into the reasons for contraceptive „failure‟ or non-use. Methods This is a cross sectional questionnaire survey. Subjects for the study were recruited from clients requesting TOP at the Gynaecology clinic (ward 54), CHBH. They included women between 13 to 49 years, who were referred from their local clinic or General practitioner with a positive pregnancy test or a pregnancy confirmed on sonar, and were less than 20 weeks pregnant. Consenting women completed a self-administered questionnaire which assessed their demographic details, current contraceptive use, past contraceptive experience, future contraceptive plans, knowledge of emergency contraceptive pill, and the current status of the relationship, initial intention with regard to the pregnancy, and the number of sexual partners they had in the last year. The data was analysed using the Epi Info 6 software programme. Results There were 780 requests for TOP during the study period. Two hundred and twenty nine women were approached to participate in the study and 203 questionnaires were analysed, i.e. an 89% analysable response rate. The mean age of the respondents was 25 years (range 13 - 42 years), the mean parity was 1.3 (range 0 to 9), 35% were still in school, 28% were unemployed and 70% were financially dependent on their parents, partners, or other relatives. A total of 56% of the respondents reported that they were using contraception when they conceived. Only 11% of the respondents knew of the emergency contraception pill. Eighty two percent of the respondents knew where to obtain contraceptives and only 7% had experienced actual difficulty in obtaining contraception. However, 46% thought they received „too little‟ information about contraception at their local clinic and 26% said that the contraceptive method they received was the healthcare provider‟s choice. Up to 47% of the respondents were either unsure of the contraceptive method they would use or would not use any contraception following the TOP. However, 43% would use a highly reliable contraceptive method (the oral contraceptive pill, injectable contraceptive, or sterilisation). Regarding the status of the relationship which resulted in the pregnancy, 44% were no longer in a permanent relationship (41% were and 11% never were). Twenty two percent of the respondents initially wanted the pregnancy. Conclusions Twenty two percent of the respondents initially wanted the pregnancy and would not have been helped by better provision of contraception. A large number of respondents reported contraceptive failure. Knowledge of emergency contraception was poor, and its use should be better promoted for cases of contraceptive failure. It is alarming that up to 47% of the clients could not use contraception in the future. Perhaps more time should be spent on contraceptive counselling and initiation of a method on site, with referral and follow-up at primary health clinics to improve uptake of contraception. Only 2.5% of the respondents were having a repeat TOP.