Magister Curationis - MCur / Background and Problem Statement: Maternal mortality is a global health issue, which mostly affects the developing countries. The United Nations (UN) member states have made a commitment to reduce maternal mortality by 75% by 2015. However, one of the biggest challenges in monitoring maternal deaths in Sub-Sahara Africa including Ghana, is the lack of adequate information for the accurate estimation of the maternal mortality rate (MMRate), and to identify causes of death. The World Health Organization (WHO) developed strategies and guidelines to assist countries to generate accurate information regarding maternal deaths. Maternal death review is one such strategy that was implemented in Ghana. Midwives are among the health workers who participate in the implementation of this strategy in different health facilities.However, what is not well understood is the role that midwives play in the implementation of Maternal Death Review (MDR).The purpose of the study: To explore and describe the roles that midwives play in the implementation of MDR in selected health facilities in Ghana‟s Ashanti Region.Methodology: A qualitative descriptive design was used to guide the research.Purposive sampling was conducted to select midwives who have been involved in maternal death review from the teaching, regional and district referral hospitals. Data was collected by conducting semi-structured individual interviews. Data saturation was reached after twenty interviews. Thematic Content Analysis was used to manage and analyse data. The Facility-based maternal death review model was used to assist the researcher to identify and organize the emerged themes. Ethical clearance was obtained from the University, as well as approval from the management of the health facilities prior to approaching the informants.Main findings: The results of this study indicate that midwives in Ghana‟s Ashanti Region are undertaking various activities and duties in all the stages of the Facilitybased maternal review model. The type of activities and duties undertaken by midwives varied according to their seniority and the level of the health facilities.Conclusion and recommendation: The findings of this study bring insight into the roles played by midwives in the implementation of the Facility-based maternal death review process in the health facilities in Ghana‟s Ashanti Region. These findings have a direct implication for the training and education of midwives. It is recommended that issues related to maternal death review methods and processes be included in the formal and continuing training and education of midwives. However, further research considering the training and practice development needs of midwives in respect of implementation of maternal death review is required.

Magister Public Health - MPH / Background: Maternal mortality is a significant public health problem world-wide,as it is an important indicator for the functioning of the health system. The maternal mortality ratio for Botswana is higher than other countries with comparable economic growth, despite impressive access to health services. In order to develop relevant programs and policies to reduce maternal mortality, the factors associated with maternal mortality were studied. The study aimed to describe the maternal and health services factors associated with maternal mortality in South East Botswana. Methodology: A quantitative case-control study was used to retrospectively review medical records for 71 cases of maternal deaths and 284 controls randomly selected from mothers who delivered in the same year and at the same health facility, in South East Botswana from 2007 to 2009. Information was collected on the maternal and health services characteristics of the cases and controls including age, level of education, marital status, parity, utilization of health facilities that consist of antenatal care (ANC), type of delivery, complications during pregnancy, type of health facility and ANC provider. Data was analyzed using Predictive Analysis Software (PASW) Version 18.Two-sample t- test, Pearson’s Chi-square test and the Fisher’s exact test were used to test the difference between the proportions of the various categories of variables in cases and controls. Univariate logistic regression analysis was applied to identify the risk factors associated with maternal deaths. A multivariate logistic regression model was estimated to see the joint effects of the identified risk factors for maternal mortality. Hosmer and Lemeshow test was used to test the goodness of fit of the model. Results: The mean age of the maternal deaths was 28.0 ± 5.3 years and they had taken place at a hospital (100%). A large number of deaths occurred before delivery(59.0%). The causes of maternal death included both direct (73%) and indirect causes (27%). Direct causes were the leading causes of death and they were abortion(22.5%) and haemorrhage (18.3%). The maternal characteristics associated with maternal mortality were having complications at delivery (OR=20.91), not receiving ANC (OR=6.31) and delivering by caesarean section (OR= 2.66). The health facility characteristics associated with maternal mortality were delivering outside the health facility (OR=14.78), having been referred from another facility (OR=8.62) and delivering at a general hospital (OR=5.91). The data produced a model with good fit that included one maternal risk factor and three health facility risk factors. These were being admitted with preterm labour, delivering at a general hospital or before arrival at the health facility and having been referred from another health facility. Conclusion: Maternal mortality was associated with both maternal and health facility risk factors. The model developed may be used to identify and manage highrisk women to reduce the number of maternal deaths. It was recommended that, the current system should continue to be monitored and evaluated through the Maternal Mortality Monitoring System (MMMS). Furthermore, the referral and management of complications needs to be strengthened through a multi-sectoral approach.

Se presenta el caso de una mujer de 19 años con 29 semanas de gestación, procedente de Llumpe (Ancash) con antecedentes de viajes a las localidades de Chanchamayo (Junín) y Rinconada (Ancash). Ingresó al Hospital de Chacas (Ancash) por presentar mal estado general, deshidratación, dificultad respiratoria, ictericia, sensación de alza térmica y dolor abdominal, tuvo reporte de: hemoparásitos 60% en frotis sanguíneo. Fue transferida al Hospital Ramos Guardia (Huaraz) donde presentó mayor dificultad respiratoria, coluria, hematuria, disminución del débito urinario y reporte de Plasmodium (+), luego fue transferida al Hospital Cayetano Heredia (Lima) donde ingresó a la Unidad de Cuidados Intensivos (UCI), con evolución a falla multiorgánica, óbito fetal y muerte. Recibió indicación de ventilación mecánica, tratamiento con clindamicina y quinina, que no recibió por falta de disponibilidad. La evolución de la enfermedad fue tórpida, cursando con falla orgánica múltiple y muerte. Se confirmó infección por Plasmodium vivax. Destacamos la importancia de mejorar nuestras capacidades de diagnóstico y manejo para brindar un tratamiento adecuado y oportuno. / This is the case of a 19-year-old woman, with 29 weeks of pregnancy, from Llumpe (Ancash, Peru) with a history of traveling to the towns of Chanchamayo (Junín, Peru) and Rinconada (Ancash, Peru). She was admitted to the Chacas Hospital (Chacas, Ancash, Peru) with a general poor condition, dehydration, respiratory distress, jaundice, apparent elevation of body temperature, and abdominal pain. A microscopic examination of blood films revealed a 60% of hemoparasites. She was transferred to the Ramos Guardia Hospital (Huaraz, Peru) where presented more difficulty to breath, choluria, haematuria and decreased urine output, also a positive test for Malaria parasites (Plasmodium). Then, she was transferred to the Cayetano Heredia Hospital (Lima, Peru), admitted to the intensive care unit (ICU) where she suffered multiple organ failure and death. The product was stillborn. She had indication of mechanical ventilation, and antibiotic treatment with clindamycin and quinine which did not received by unavailability. The disease evolution was torpid. Plasmodium vivax infection was confirmed. We emphasize the importance of improving our diagnostic capabilities and management to provide adequate and timely treatment.

After decades of decrease, maternal mortality rates have shown a slight increase in Europe. Immigrants, especially Africans, have shown to be at higher risk than native women. This could not be explained solely by well-known obstetric and socio-economic risk factors. The aim of this thesis was to study incidence, classification and quality of care of maternal deaths in Sweden, with focus on the foreign-born population. The study population was identified through linkage of the Cause of Death Register, Medical Birth Register, and National Patient Register, and medical records obtained from hospitals. Data from registers, death certificates, and medical records were reviewed. Suboptimal care was studied by structured implicit review of medical records. Differences between foreign- and Swedish-born women were analysed by relative risks, Chi2- and Fisher’s exact test. Underreporting of maternal mortality was shown to be substantial: as compared to the official statistics, 64% more maternal deaths were identified. Women born in low-income countries were identified as being at highest risk of dying during reproductive age in Sweden. The relative risk of dying from diseases related to pregnancy was 6.6 (95% confidence interval 2.6–16.5) for women born in low-income countries, as compared to Swedish-born women. Major and minor suboptimal factors related to care-seeking, accessibility, and quality of care were found to be associated with a majority of maternal deaths and significantly more often to foreign-born women. Suboptimal factors identified included non-compliance, communication barriers, and inadequate care. The rate of suicides during pregnancy or within one year after delivery did not change during the last three decades, and was higher for foreign-born women. A majority of women who committed suicide had been under psychiatric care, but such documentation at antenatal care was inconsistent, and planning for follow-up postpartum was generally lacking. The conclusion of this thesis is that foreign-born women are a high-risk group for maternal death and morbidity that calls for clinical awareness with respect to their somatic and psychiatric history, care-seeking behaviour, and communication barriers. Cross-disciplinary care is necessary, both in obstetric emergencies and in cases of maternal psychiatric illness, to avert maternal death and suicide.

[pt] Partindo da lente dos direitos humanos para compreender a temática dos direitos sexuais e reprodutivos, o presente trabalho se debruça sobre os limites e o alcance das diretrizes humanísticas diante das mulheres vítimas de violência e morte no âmbito do sistema de saúde. O ensaio tem como foco principal o tema da mortalidade materna, identificada como importante indicador das condições de vida e saúde das mulheres e suscitada enquanto grave violação de direitos humanos e busca, por meio de uma abordagem interseccional, conceder luz aos diversos eixos de opressão presentes na abordagem a partir das contribuições de autoras como Kimberlé Crenshaw, Patricia Hill Collins e Jurema Werneck. Com a constatação de que mais de noventa por cento das mortes maternas são evitáveis, bem como com a convivência de altos índices de mortalidade materna anuais no país, o trabalho aborda o tema enquanto parte de um projeto político firmado a partir da imposição de sofrimento, da precarização de vidas e da estigmatização de corpos, considerando os direcionamentos políticos que parecem convergir para um cenário de intensificação de violação de direitos. Articulando conceitos de Judith Butler, o ensaio atenta à mortalidade materna a partir da perspectiva da morte digna ou não de lamento, buscando formas de reafirmação dos direitos humanos a partir de seu comprometimento concreto com as mulheres que vivenciam formas de violência no sistema de saúde nacional. / [en] Based on the lens of human rights to understand the theme of sexual and reproductive rights, the present paper focuses on the limits and the scope of the humanistic guidelines before women victims of violence and death within the health system. The main focus of the essay is the issue of maternal mortality, identified as an important indicator of women s living conditions and health, and raised as a serious violation of human rights, and seeks, through an intersectional approach, to give light to the various categories of social inequality present in the analysis from the contributions of authors such as Kimberlé Crenshaw, Patricia Hill Collins and Jurema Werneck. With the observation that more than ninety percent of maternal deaths are preventable, as well as with the coexistence of high annual maternal mortality rates in the country, the study addresses this issue as part of a political project based on the imposition of suffering, the precariousness of lives and the stigmatization of bodies, taking into account the political orientations that seem to converge to a scenario of intensification of violation of rights. Articulating concepts by Judith Butler, the essay focuses on maternal mortality from the perspective of death qualifying or not as grievable, seeking ways to reaffirm human rights based on its concrete commitment to women experiencing forms of violence in the national health system.

Unsafe abortion is a worldwide reproductive health issue and a contributing factor of high numbers of maternal death in the developing world. Many international conferences and assemblies acknowledge the issue and urge governments to take action. Abortion is a phenomenon surrounded by strong opinions, many times regulated by restrictive laws as well as socio-ethical, religious and cultural norms. Factors often active in making abortion a clandestine procedure which take place under unsafe conditions.The Philippines have one of the most restrictive laws on abortion in the world, but it does not diminish the occurrence of abortion in the country. There is unmet need for family planning that in turn makes way for unwanted pregnancies ending in unsafe abortion. Attempts in congress aiming at providing universal reproductive health service are being opposed and the issue of abortion is surrounded by its criminal ban and a great social stigma. The Roman Catholic Church is very present in the Philippine society and also offers a powerful voice against abortion and equally rejects modern contraception.This study look into how the issue of abortion – under its criminal ban – is being dealt with and if there are any actors/groups/organisations of social work, within the reproductive health sector or women’s organisations acting upon this, making abortion an issue and a part of their work. It asks if there is any advocacy for abortion in the Philippines and any interventions for the women concerned. If so, how is abortion spoken about and understood and how is that notion put into action? Groups are identified as either anti-abortion or pro-abortion, two discourses addressing abortion as a public health issue in fundamentally different ways.There are groups that might not be public about their opinion being pro-abortion, as they do not wish to get on the wrong side of the general opinion or negatively affect their reputation. Some pro-abortion groups are found acting against the law by providing safe abortions for these women. Trough social constructivist glasses this study look at the structure surrounding abortion in the Philippines, analysing how these discourses are being reconstructed and transferred under different postulations as anti-abortion or pro-abortion.

L’accouchement et ses conséquences demeurent une des principales causes d’incapacité et de décès pour les femmes dans les pays en développement et comprendre l’utilisation tardive des soins obstétricaux d’urgence au moment d’une complication obstétricale constitue un véritable défi en santé publique. La présente étude qualitative relate l’expérience d’accouchement difficile au Mali, en milieu rural. Dans un contexte de pluralité de systèmes de soins, l’objet de cette étude consiste à déterminer les raisons de l’arrivée tardive des femmes au centre de santé de 1ier ligne, à saisir la compréhension qu’elles ont de l’utilisation des services sanitaires, enfin à reconstruire les processus de prise de décisions de recourir aux soins modernes. Cette étude s’inscrit dans une démarche de type ethnographique. Des entretiens semi dirigés et l’observation des interactions entre les femmes et les professionnels de santé ont constitué le corpus de données. Nous retenons qu’une série de facteurs entrent en jeu pour comprendre le problème de l’utilisation tardive des soins obstétricaux d’urgence. Des contraintes exogènes liées à la distance et l’immédiateté de l’urgence obstétricale c'est-à-dire la mobilisation des ressources et des moyens de transport, accompagnées de contraintes endogènes telles que la subordination des femmes au consentement familial, la perception de la qualité des soins et de la compétence des soignants, influencent systématiquement le choix de recourir aux soins modernes. Le phénomène de gestion collective de la complication obstétricale s’inscrit dans un contexte d’intéractions complexes où l’opinion des femmes est totalement minimisée. / Childbirth and its consequences remain a leading cause of disability and death for women in developing countries and the late use of emergency obstetric care during obstetric complications is a challenge in public health. This qualitative study describes the experience of difficult childbirth in Mali, in rural areas. In a context of multiple systems of care, the purpose of this study is first to determine the reasons for the late arrival of women in the health center, to grasp their understanding of the use of health care services, and finally to reconstruct the decision making process to use modern health care. This study is part of an ethnographic approach. Semi-structured interviews and observation of interactions between women and health professionals were conducted. Numerous factors come into play to understand the problem of late use of emergency obstetric care. Exogenous constraints related to the distance and immediacy of the obstetric emergency that is to say the mobilization of resources and means of transport, influence the choice of women to use modern obstetric cares. In the same way, endogenous constraints such as the subordination of women in the family consent, perception of quality of care and skill of caregivers, systematically influence the choice to use modern health care. Collective management of obstetric complications we have observed, occur in a context where the opinion of women is completely minimized.

No description available.

Submitted by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-10-03T17:49:42Z No. of bitstreams: 1 TESE Elsa Jacinto. 2014.pdf: 1738962 bytes, checksum: 82ca23f0f1c93d9a758beb2e1f4aec45 (MD5) / Approved for entry into archive by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2014-10-07T14:07:04Z (GMT) No. of bitstreams: 1 TESE Elsa Jacinto. 2014.pdf: 1738962 bytes, checksum: 82ca23f0f1c93d9a758beb2e1f4aec45 (MD5) / Made available in DSpace on 2014-10-07T14:07:04Z (GMT). No. of bitstreams: 1 TESE Elsa Jacinto. 2014.pdf: 1738962 bytes, checksum: 82ca23f0f1c93d9a758beb2e1f4aec45 (MD5) / Introdução: Morbidade Materna Grave (MMG) é um quadro clínico observado em mulheres no ciclo gravídico-puerperal, composto por condições graves a extremamente graves, que ao sobreviverem são conhecidos por near miss materno; estes últimos são identificados por sinais de disfunção orgânica subsequentes a condições ameaçadoras da vida. As evidências vêm mostrando a carga da pandemia do HIV/AIDS sobre as condições clínicas de pacientes portadoras de outras doenças. Objetivos: estimar a incidência da razão de resultado materno grave e investigar os fatores associados à MMG em Maputo. Métodos: estudo caso-controle realizado na Cidade de Maputo, Moçambique, no período de Março a Novembro de 2012. As participantes elegíveis para o grupo de casos foram mulheres residentes em Maputo com MMG, segundo a definição da OMS. Os controles foram pacientes admitidas nos mesmos hospitais e no mesmo período, seguindo os mesmos critérios para a seleção dos casos, à excepção da condição clínica exigida para estes. Para o cálculo do tamanho da amostra utilizou-se o programa Epi Info, considerando-se um poder do estudo de 80%, um alfa=0,05, nível de confiança=0,95, relação caso/controle 1:2 e Odds Ratio (OR) esperada de 1,5, obtendo-se uma amostra com 485 casos e 970 controles. A exposição foi a infeção pelo HIV/AIDS, sendo utilizadas variáveis sócio-demográficas, clínico-assistenciais e comportamentais, como o uso de álcool e fumo. Os dados coletados de morbidade materna grave e near miss materno foram extrapolados para o período de doze meses por Regressão Linear Simples, utilizando-se termos quadrático e cúbico e calculados os indicadores. Para a diferença entre proporções utilizou-se o teste 2 de Pearson. A medida de associação entre HIV/AIDS e MMG (desfecho) foi a OR e seus intervalos de confiança a 95% por Regressão Logistica não condicional. Nas análises foi utilizado o pacote estatístico STATA versão 10.0. Resultados: A Razão de Resultado Materno Grave foi de 1,7/1.000 NV, Razão de NMM 0,4/1.000 NV, Razão near miss/morte materna de 28:100, Indice de Mortalidade de 78,3% e Razão de mortalidade materna de 133/100.000 NV. As principais causas de MMG foram as doenças hipertensivas (69,7%) seguidas das hemorrágicas (19,0%); entre as near miss materno foram as hemorrágicas (64,3%) e entre as mortes maternas foi a AIDS (50,0%). Foram fatores associados a um maior risco da gravidade o antecedente de aborto (OR=2,2; IC=1,4 -3,7); HIV positivo (OR=2,5; IC=1,9 – 3,3), puérpera (OR=2,7; IC=2,1 – 3,6), parto cesáreo (OR=14,9; IC=7,3 – 30,4) e tempo de trajeto entre casa e hospital superior a 30 minutos (OR=2,1; IC=1,4 – 3,2). A procura direta do hospital de referência atuou como fator protetor OR=0,6; IC=0,5 – 0,8. A associação entre a infeção por HIV e morbidade materna grave foi de OR=2,7 (IC=2,1 – 3,5). A Fração Atribuível Populacional ao HIV foi de 21,3% Conclusões: A morbidade materna grave é cerca de três vezes maior nas grávidas ou puérperas infectadas pelo vírus do HIV/AIDS do que nas não infectadas. A Razão de Resultado Materno Grave em Maputo é relativamente elevada, sendo as principais causas as doenças hemorrágicas e a infeção pelo HIV/AIDS. Os fatores associados estão relacionados sobretudo aos antecedentes reprodutivos das mulheres, orientando para uma maior atenção ao grupo de maior risco, pelo uso de normas e procedimentos padronizados. / Introduction: Severe Maternal Morbidity (SMM) is a clinical condition of women in their pregnancy and childbirth, composed of conditions ranging from severe to extreme severity, which are known when survive by maternal near miss (MNM); these cases are identified by signs of organ dysfunction subsequent to life-threatening conditions. Furthermore, surveys have shown evidence of the burden of the HIV / AIDS pandemic on the clinical condition of patients with other diseases. Objectives: To estimate the incidence of Severe Maternal Outcome Ratio (SMOR) and investigate factors associated with SMM in Maputo. Methods: case-control study conducted in Maputo, Mozambique, from March to November 2012. Eligible participants for the group of cases were resident women living with SMM, according to the WHO definition. Controls were patients admitted to the same hospitals during the same period, using the same criteria for selection of cases, with the exception of the clinical condition for these. To calculate the sample size we used the Epi Info program, considering a study power of 80%, an alpha = 0.05, confidence level = 0.95, compared case / control 1:2 and an expected odds ratio (OR) of 1.5. 485 cases and 970 controls were obtained. The exposure was the infection with HIV / AIDS; socio-demographic, clinical, healthcare and behaviour variables such as smoking e alcool utilization being used. The data for SMM and MNM were extrapolated to the period of twelve months by Simple Linear Regression with quadratic and cubic terms and calculated indicators. For the difference between proportions used the 2 test of Pearson. The measure of association between HIV / AIDS and SMM (outcome) was the OR and confidence intervals at 95% by unconditional Logistic Regression. For the analysis STATA version 10.0 was used. Results: SMOR was 1,7/1.000 LB, MNM Ratio 0,4/1.000 LB, maternal near miss/maternal death ratio of 28:100, mortality index of 78.3% and maternal mortality ratio of 133/100.000 LB. The main causes of SMM were hypertensive disorders (69,7%) followed by bleeding disorders (19.0%); among maternal near miss were bleeding (64.3%) and among maternal deaths were AIDS (50,0%). Factors associated with an increased risk of severity were history of abortion (OR = 2.2, CI = 1.4 - 3.7), HIV positive (OR = 2,5, CI = 1.9 to 3.3), pospartum period (OR = 2.7, CI = 2.1 to 3.6), caesarean delivery (OR = 14.9, CI = 7.3 to 30.4) and time between home and hospital exceeding 30 minutes (OR = 2.1, CI = 1.4 to 3.2) .The association between HIV infection and severe maternal morbidity was OR = 2.7 CI =( 2.1 to 3.5). The direct search of the reference hospital acted as a protective factor OR = 0.6; CI = 0.5 to 0.8. The Population Attributable Fraction of HIV was 21.3%. Conclusions: Severe maternal morbidity is about three times higher in pregnant or postpartum HIV / AIDS infected women than in uninfected. SMOR is high in Maputo and the main causes are bleeding disorders and infection by HIV / AIDS. Associated factors are mainly related to reproductive history of women, requiring greater attention to the high risk group, by the use of standards and standardized procedures.

Etre mère est une aspiration pour de nombreuses femmes, même si à Douala, elles continuent de payer du lourd tribut de leur vie, l’accouchement. Paradoxalement, la réalité vécue par elles, enceintes et le personnel affecté à leur prise en charge reste méconnue ou ignorée par le grand public. Afin de comprendre ce phénomène, nous avons mené une enquête sur la base d’observation et d’entretiens avec les femmes enceintes, le personnel médical et paramédical et la parentèle de la parturiente de mars 2008 à décembre 2010 dans cinq établissements hospitaliers de la ville de Douala et ses environs. Cette recherche appréhende les éléments du discours pour re-construire le contexte anthropologique qu’il génère et dont il est le produit. Elle a permis de comprendre la contradiction entre la valorisation du statut de la parturiente et l’a-normalité des comportements pendant la parturition. Il en résulte un problème de concordance entre des attitudes culturellement marquées et des normes sanitaires. Les femmes, sans toutefois ignorer leur vulnérabilité et les conditions qui favorisent une fin heureuse de la grossesse, ne commencent que tardivement les consultations prénatales. / Becoming a mother is the yearning of many women, even though in Douala, they continue to heavily pay with their very lives the act of childbirth. Paradoxically, the reality about what they go through while being pregnant, and the personnel assigned to manage them remains unrecognized or ignored by the general public. In order to understand this phenomenon, we carried out an enquiry based on observations and discussions with pregnant women, the medical/paramedical personnel, and the relatives of the parturient from March 2008 to December 2010, in five health institutions in the town of Douala. This research takes into account the various elements of discussion to rebuild the anthropological context generated by it, and of which it is also the product. It enables us to understand the contradiction between the valorisation of the parturient status, and the behavioural abnormalities during parturition. As a result, a concordance problem arises between the culturally marked attitudes, and the health norms. Though being vulnerable and aware of the conditions that favour a happy end of the pregnancy, the women still begin prenatal consultations late.