Maternal health services (MHS) provide primary, secondary, and tertiary levels of prevention to achieve better pregnancy outcomes. However, use of prenatal and natal services among Nigerian women has been ranked among the lowest in the world and, consequently, the country is among the 10 countries with the highest maternal mortality ratio. Moreover, nationwide community-based studies on the use of maternal health services in Nigeria are limited. To address this gap, this quantitative, cross-sectional study analyzed the 2008 Nigerian Demographic and Health Survey (NDHS) data to identify whether Nigerian women's biological, cultural, and socioeconomic characteristics are associated with their use of MHS and pregnancy outcome as measured by number of antenatal visits, place of delivery, and fetal outcome. The Anderson's health behavior model was used as the theoretical framework for this study. Respondents were women aged 15 - 49 years (N= 31,985), who had given birth between January 2003 and December 2008. Bivariate and multiple logistic regressions were conducted. The results indicated that religion, education, income, and availability of skilled health workers showed consistent significant statistical association with both the number of ante natal care (ANC) visits and place of delivery even after controlling for covariates. Overall, these findings have potential for social change on the choice of public health interventions with collaboration with social services such as education, community, and labor sectors. Further, a systematic involvement of local communities is needed to drive specific culturally-sensitive interventions.

Context Current care guidelines recommend that pregnant women receive advice about the important health behaviours which may influence pregnancy outcomes. These behaviours are associated with pregnancy-related and long-term health outcomes for both the mother and infant. Poor pregnancy outcomes can result in increased costs of health care delivery through longer hospital admissions and intensive care admissions. Although provision of behavioural advice to pregnant women is recommended, most educational materials provide limited and inconsistent information. There is a clear need for widespread delivery of evidence-based information and skill-development strategies to influence pregnancy health behaviours. One avenue of information is via the pregnancy health records (PHRs) provided by maternity health services that women carry for the duration of their pregnancy. Objective My research sought to develop, implement, and evaluate a handheld health record for use in pregnancy (the “Pregnancy Pocketbook”) in an urban population of women with a high proportion of disadvantaged women. Study Overview My research comprised two phases, a development phase, and an implementation and evaluation phase. I identified specific behaviours (cigarette smoking, fruit and vegetable intake, and physical activity) requiring intervention and reviewed evidence-based frameworks, behaviour change theories, and guidelines for the presentation of written information to support behaviour change. I developed and refined the Pregnancy Pocketbook through a number of studies. Studies 1, 2, and 3 The Pregnancy Pocketbook was refined through a qualitative evaluation of a PHR enhanced with behaviour change tools (Study 1), focus groups held with women from the target group to investigate PHR preferences (Study 2), and strategy testing of the Pregnancy Pocketbook activities with women from the target group (Study 3). The focus group results combined with those from the qualitative evaluation suggested the Pregnancy Pocketbook should be a women-held, woman-focussed resource providing essential and comprehensive information on recommended pregnancy health behaviours. It should include tools to facilitate appropriate behaviour changes and tools for women to monitor pregnancy progress and record questions and notes to facilitate communication with their health carers. Strategy testing demonstrated that the Pregnancy Pocketbook content, screening questions and activities were well received by a small sample of women, with minor changes made following testing to improve the understanding and usability of the various sections of the Pregnancy Pocketbook. The final intervention (Study 4) The final version of the Pregnancy Pocketbook was a 73-page interactive resource, designed to be used according to the 5As self-management framework (Assess, Advise, Agree, Assist, Arrange), with screening tools, information, goal setting and self-monitoring activities with information for further referral for greater support when required. It was presented in an A5 plastic ring-bound folder, with dividers, labelled ‘Your health goals’, ‘Tracking your health goals’, ‘Your first antenatal visit’, ‘Pregnancy progress’, ‘Birth summary’, ‘Glossary’, and ‘Emergency contacts and general numbers’. The Pocketbook was evaluated using a quasi-experimental two-group design. Women were recruited from two antenatal clinics within the same health service district. Women received the PP during their first antenatal clinic appointment in one clinic (PP:n = 163) and women in the other clinic received usual care (UC: n = 141). Smoking, fruit and vegetable intake, and physical activity were assessed at baseline (service entry), 12-weeks post-service-entry and 24 weeks post-service-entry. Behaviour-specific self-efficacy was also measured during pregnancy. I also assessed the PP implementation process through adherence of the staff and organisation to planned implementation processes. Results At 12-weeks post-service-entry, a significantly greater proportion of women in the Pregnancy Pocketbook (PP) group had stopped smoking (7.6% vs 2.1%), compared with the Usual Care (UC) group, p <0.05. There was a net (non-significant) increase of 5% more women meeting physical activity guidelines (PP: 1.2% increase vs. UC: 3.5% decrease) and a net 20 minute difference in median minutes of physical activity (PP: 10 minute increase vs. UC: 10 minute decrease). Both groups increased their fruit and vegetable intake. Approximately two-thirds of women reported receiving the Pregnancy Pocketbook, many without introduction or explanation. Few women completed sections of the Pregnancy Pocketbook that required health professional assistance, suggesting minimal interaction about the resource between health staff and the women in their care. Conclusion and future recommendations There were low levels of adherence to health behaviour recommendations for pregnancy in this sample. The Pregnancy Pocketbook produced significant effects on smoking cessation, even under limited delivery conditions. A refocus of antenatal care towards primary prevention is required to more consistently provide essential health information and behaviour change tools for improved maternal and infant pregnancy health outcomes. Future studies must include process evaluations and apply the theory of dissemination to enhance uptake of the interventions.

Introduction Maternal mental health during pregnancy and its effects on offspring outcomes have received increased attention as a public health concern. Recent policies have highlighted the need for better universal perinatal services and to routinely incorporate attention to mental health into antenatal care. This thesis aimed to examine and evaluate current research into the effects of maternal antenatal depression on child psychological, development and developmental psychopathology. A research study was carried out with the aim of understanding the subjective experiences of women with antenatal depression during pregnancy and their transition to motherhood. Method Quantitative studies, exploring the relationship between antenatal depression and early child development were reviewed systematically. The empirical study employed Interpretative Phenomenological Analysis to investigate the experience of antenatal depression in pregnant women. Semi-structured interviews were conducted with six participants who were pregnant and recruited from a perinatal mental health service. Results The small number of papers considered suitable for this review highlights the lack of good quality research in this field. Twelve studies met inclusion criteria for the systematic review, demonstrating mixed results regarding whether antenatal depression effects early child development. Studies were predominantly of poor methodological quality, with inconsistent results and limited by the use of differing antenatal depression and infant development outcomes, making cross study comparisons difficult and weakening any conclusions that could be drawn. In the empirical study one super-ordinate theme, ‘The Lost Self’, and four main themes emerged. Conclusions Findings were inconsistent and of poor quality, and so we cannot say for sure whether antenatal depression itself is associated with adverse outcomes for young children. Further rigorous research on antenatal depression and adverse early child outcomes is needed in order to try and disentangle the effects of both antenatal and postnatal depression on each other and on child development. The findings from the empirical study contribute to an increased understanding of the experiences and challenges faced by women experiencing depression during pregnancy. The study highlights the need for improved awareness of depression during pregnancy to improve understanding of this disorder during the antenatal period.

Magister Public Health - MPH / Background: Early HIV testing is a crucial step for pregnant women in preventing mother-to-child transmission of HIV. In the public sector nearly all pregnant women presenting at antenatal clinics are screened for HIV. However, according to a large medical-aid administrator in South Africa, only 21.96% of pregnant women on their medical aid claimed for an HIV test as part of their antenatal care in 2012. Despite having frequent opportunities when consulting with pregnant women, general practitioners tend to be reluctant to offer HIV screening to these privately insured patients. In South Africa, private sector general practitioners are reimbursed for their services at pre-determined, negotiated rates. Previous studies indicate that monetary incentives over and above the negotiated rate may motivate health providers to promote screening to patients, and this may lead to increases in the uptake of testing. Due to limited resources within the public health sector, general practitioners are seen as key resources in a public private partnership to assist government achieve strategic health outcomes such as improved access to quality healthcare and improved compliance to treatment plans. Methodology: A quasi-experimental, ‘before and after’ study design, was conducted among 2,934 Metropolitan Health network general practitioners in South Africa who managed a pregnant woman on a medical aid. The same populations of general practitioners were used in the pre and post analysis with the general practitioners receiving information about the benefits of HIV testing in pregnant women before and after. The only difference was with the intervention related to a new HIV Counselling and Testing incentive process. Data was extracted from the billing system of a private medical insurance company in South Africa>. Quantitative data and stratification was analysed using the Statistical Package for the Social Science software, version 16.0 and Epi Info version 7.1.0.6. The effectiveness of the intervention was assessed by comparing the pre intervention period between April 2011 and September 2012, and post intervention period between March 2013 and August 2014. A subgroup analysis was done to determine variations in the name it, by general practitioners and patient characteristics. Results: There was no significant difference in HIV testing by general practitioners in this network preand post the intervention (21.99% vs. 21.96%, p=0.939). Compared to general practitioners aged 25-44 years, general practitioners older than 65 years old were 13% less likely to test (OR 0.87, CI: 0.74-1.01) and general practitioners between 45 and 65 years were 9% less likely to do an HIV test (OR 0.91, CI: 0.85-0.98). This study found that as patients’ age increased, they were more likely to be tested: beneficiaries aged 35- 44 years were 15% more likely to be tested compared to beneficiaries aged 15-24 years (OR 1.15, CI: 1.1-1.21). Beneficiaries who had a vaginal delivery were less likely to be tested compared to women who chose caesarean as a delivery method (OR 0.87, CI: 0.84-0.9). Medium income beneficiaries were more likely to be tested compared to low income beneficiaries (OR 1.09 CI: 1.03-1.16) and beneficiaries from the “high income” scheme grouping were less likely to be tested (OR 0.87, CI: 0.82-0.92) compared to the low income scheme grouping. The timing and frequency rates of HIV testing, for both caesarean and vaginal deliveries, occurred most between months two and six, peaking at month four. Overall, Eastern Cape and Mpumalanga had the lowest testing rates compared to all the other provinces (OR 0.96 CI: 0.89-1.05). Conclusions: Most general practitioners’ HIV testing rates of pregnant women in the private sector behaviour analysed in this study remained the same, despite the presence of a financial incentive. This study’s findings suggest that healthcare provider behaviour to comply with clinical guidelines and best practice, has no association with the presence of financial incentives, especially with increased administration tasks to access the incentive. These study findings emphasise the need to continue to strive for improved compliance especially by older general practitioners’ to adhere to clinical best practice and national HIV screening guidelines of pregnant women. The aspiration of achieving the highest quality of care in both private and public sector are principles that should continue to be pursued especially where private sector general practitioners’ will be used to offer public health services in the future National Health Insurance.

This thesis frames the transition into motherhood as a rite of passage; proposes a new model for the rite of passage into motherhood based on the four seasons; and highlights the importance of contextual and specific ritual actions or sequences to navigate the transition. Qualitative data from semi-structured interviews with ten western women, from a middle class, Christian background, who had all become mothers through childbirth, are examined under three main headings. Firstly, the women’s experiences of their transition are explored using rites of passage theory as a lens. Although significant differences emerge, particularly from a gender perspective, important themes within the women’s experiences are highlighted, including the nature of relationships; the importance of support; journaling; and the telling of birthing stories. The influences of contemporary cultural aspects such as the medicalization of childbirth and myths about motherhood are also taken into account. Secondly, the field of ritual studies is explored in order to provide a framework in which to situate the women’s ritualizing. Existing rituals associated with motherhood are analysed and gaps are identified in existing Christian liturgical resources for this area, specifically for ritual actions or sequences marking motherhood as a rite of passage, and for the expression of birthing stories. A working definition of ritualizing is also established and the research findings are divided according to time frame, exploring the women’s ritualizing before birth, around birth and after birth. Thirdly, spirituality in relation to childbirth and the transition into motherhood is explored and its place within healthcare and theological literature examined. Nicola Slee’s theory on women’s faith development is used to draw out some of the patterns that emerge from the interviewees’ experiences, and the sacramental nature of birthing is considered. The thesis concludes with a critique of implications and associated suggestions for those within a church or healthcare context with responsibility for the pastoral and spiritual care of women during their transition into motherhood.

京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第23119号 / 社医博第115号 / 新制||社医||11(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 近藤 尚己, 教授 万代 昌紀, 教授 川上 浩司 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

京都大学 / 新制・論文博士 / 博士(医学) / 乙第13439号 / 論医博第2238号 / 新制||医||1054(附属図書館) / (主査)教授 万代 昌紀, 教授 小杉 眞司, 教授 稲垣 暢也 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

MCur / Department of Advanced Nursing Science / Antenatal care is the health care that women receive during pregnancy before the delivery of a baby; it aims to detect and treat existing health problems and to screen for complications that may develop in pregnancy. The aim of the study was to explore and describe knowledge and attitudes of pregnant women towards antenatal care services in Mbombela Municipality, Mpumalanga Province, South Africa. A qualitative, explorative, descriptive and contextual approach was used. The sample selected for the study from the population of pregnant women consisted of 18 pregnant women who attended ANC at six PHC facilities in Mbombela Municipality. Non-probability, purposive sampling was used to select the PHC facilities and the participants. Data was collected through in-depth individual interviews. The open coding method was used to analyse the data. To ensure that ethical considerations were taken into consideration, permission to conduct the study was obtained from the University of Venda Ethics Committee and the Mpumalanga Department of Health. Participation in the study was voluntary and the ethically approved protocol of informed consent, anonymity and confidentiality were adhered to. Trustworthiness was ensured by considering the criteria of transferability, credibility, dependability and applicability. The results from the study indicated that pregnant women knew about ANC services, but their knowledge of the best time to initiate ANC, as well as the procedures and importance of ANC was poor. The study found that the participants had favourable and unfavourable attitudes to ANC services. This indicates that there is a need for intensive health education regarding ANC services in the area. Findings from the study led to recommendations that there is a need to review ANC programmes to improve the knowledge of pregnant women and communities and also to address the challenges faced by women when accessing ANC services. / NRF

Includes bibliographical references / BACKGROUND: A viral load monitoring algorithm in the 2013 Western Cape Department of Health PMTCT guidelines include VL measurement in women who are antiretroviral (ART)-experienced at presentation for antenatal care, the timing of subsequent VL measurements and criteria for regimen change. The study evaluates the implementation of the algorithm in women who are virologically nonsuppressed and determines the outcomes of virological resuppression and infant PCR status. METHODS: This retrospective cohort study focused on all ART-experienced women who presented for antenatal care at one of two primary level Maternity Obstetric Units (MOUs) in Khayelitsha, Cape Town between July 2013 and June 2014. The study used routine data from facility registers, clinical records and electronic monitoring systems at the MOU, and referral ART sites and hospitals. Data collected included age, ART clinic, start date and regimen, and maternal VL and infant PCR results. RESULTS: Forty percent of the 1412 HIV-positive pregnant women, were ART-experienced, of whom 14.1 % were VNS. Predictors of being VNS included a duration on ART of more than 4 years (p= 0.04), attending an ART clinic other than that in the facility (p= 0.02), being on a second-line ART regimen (p=0.07) and being younger than 25 years (p= 0.05). The algorithm was correctly followed in up to 87.5% of women identified as VNS. The rate of virological resuppression by three months postpartum was 70.0% to 82.3%. Excluding three neonates who died, all of the 82.2% of infants tested were PCR negative. CONCLUSIONS: Nearly 15% of ART-experienced women were virologically nonsuppressed on presentation for antenatal care. Levels of adherence to the guideline, and virological resuppression rates of up to 82.3% are encouraging. The implementation of the VLM algorithm could be improved by the integration of obstetric and ART care, the adoption of a single electronic monitoring system and the use of standardised integrated clinical stationery.

Includes bibliographical references / Proper implementation of and adherence to antiretroviral therapy (ART) is significantly associated with better health and longer life in HIV-positive individuals. Consistent, adequate adherence has been shown to lead to a suppressed viral load. A low viral load delays the virus's progression and leads to better health outcomes for the individual. Adequate adherence is especially important among HIV-positive pregnant women. How well a woman adheres to her ART can not only improve her health during pregnancy but can protect the infant from HIV by preventing in utero transmission of the virus. Continuing ART protects against transmission via breastmilk later in the infant's life. While the benefits of good adherence are undeniable, the definition of adequate adherence varies widely in the literature. Taking 80 to 100% of pills as prescribed is commonly used as the threshold for adequate adherence levels. Various methods exist for measuring ART adherence, and while some are more reliable than others, there is no gold standard. This ambiguity in ART research extends to pregnant women, with even less known about HIV infected women established already on ART who then become pregnant. Changes in treatment protocols in the Western Cape and improvement of ART delivery throughout South Africa have resulted in this group of long-term users growing in size. Without more research into the barriers of ART adherence in these women, efforts to scale up treatment programs and to end mother to child transmission of HIV will ultimately fail. This dissertation is an exploration of these ideas. It begins to fill the gap in current knowledge related to ART compliance in pregnant women, and gives new insights into how specific barriers to adherence can adversely affect this specific group of established ART users.