Introdução: a anemia ferropriva na gestação caracteriza-se como um importante problema de Saúde Pública. A partir de junho de 2004, o governo brasileiro tornou obrigatória a fortificação das farinhas com ferro, atendendo às recomendações internacionais e com intuito de minimizar a anemia na população em geral. Objetivo: estudar a prevalência de anemia em gestantes atendidas em um serviço de pré-natal de uma maternidade social da cidade de São Paulo, antes e após a fortificação das farinhas com ferro. Método: estudo transversal retrospectivo com dados coletados de prontuários de atendimento de pré-natal de 2003 (Grupo Não Fortificado) e 2006 (Grupo Fortificado), de janeiro a maio de 2008. Das 931 gestantes selecionadas, 458 eram do Grupo Não Fortificado (Grupo NF) e 473 do Grupo Fortificado (Grupo F). A anemia foi definida pela concentração de hemoglobina (Hb) menor do que 11g/dL, segundo o critério da Organização Mundial da Saúde. Os dados foram armazenados em duas planilhas de Excel Microsoft 2003 e analisados pelos softwares EpiInfo for Windows e Statistical Package for Social Sciences 16.0. Para o tratamento estatístico, foram utilizados o teste do Qui-quadrado para as comparações entre as variáveis dos dois grupos estudados e a associação da anemia e as suas variáveis relacionadas; e a análise de variância, para a comparação entre as médias da concentração de Hb. O nível de significância adotado foi de 5% (p=0,05). Resultados: dentre aquelas variáveis que se apresentaram semelhantes em ambos os grupos, observou-se que a média da idade das gestantes foi 24 anos, um pouco mais de metade delas vivia com companheiro, menos de 40% exerciam ocupação remunerada. Houve diferença estatística significativa no nível de escolaridade (p<0,001) e na inserção precoce no cuidado de pré-natal (p<0,001), em 2006 (Grupo F). A prevalência de anemia no Grupo NF foi de 29,5% e no Grupo F, 20,9%, diferença estatística significativa (p=0,003). Em relação à época da coleta do exame de Hb, os grupos apresentaram diferença estatística significativa (p<0,001), 42,5% das gestantes do Grupo F e somente 15,9% do Grupo NF realizaram a coleta no primeiro trimestre da gestação, o que provavelmente corroborou para a diminuição de prevalência de anemia do Grupo F, além de melhor escolaridade e início precoce da assistência de pré-natal. A análise de variância mostrou que as médias de Hb não apresentaram diferença estatística significativa (p>0,05), constatando que, aparentemente, não houve efeito da fortificação na concentração de Hb entre os grupos estudados. Conclusão: a prevalência de anemia foi menor no grupo fortificado, mas não foi possível comprovar o efeito da fortificação nos níveis da concentração de hemoglobina das gestantes estudadas / Introduction: iron deficiency anemia during pregnancy is characterized as a major public health problem. Since June 2004, the Brazilian government established that flour was fortified with iron following the international recommendations in order to minimize the anemia in the general population. Objective: To study the prevalence of anemia in pregnant women in an antenatal care service in the city of São Paulo, before and after fortification of flour with iron. Method: A cross sectional study with retrospective data collection from medical records of pregnant women attended in an antenatal care service in 2003 (non-fortified group) and 2006 (fortified group). Data were collected from January to May, 2008. The sample was composed by 931 pregnant women, 458 women were from non-fortified group (Group NF) and the other 473 from fortified group (Group F). It was adopted the anemia definition of World Health Organization, hemoglobin concentration (Hb) < 11g/dl. Data were storaged in two Microsoft Excel spreadsheets, 2003 and analysed by Epi Info and Statistical Package for Social Science 16.0. For statistical treatment it was used the Chi-square test for comparisons between variables of two groups and the association of anemia and its related variables, and analysis of variance for comparison between the average concentration of Hb. The significance level was 5% (p = 0.05). Results: Among those variables that showed similar in both groups, it was observed that the average age of women was 24 years, just over half of them lived with a partner, and less than 40% had paid occupation. The difference was statistically significant higher level of education (p <0001) and greater proportion of women with early inclusion in prenatal care (p <0001) in 2006 (Group F). The prevalence of anemia in the Group NF was 29.5% and in Group F was 20.9%, statistically significant difference (p = 0003). Regarding the time of blood collection to verify the Hb, the groups showed statistically significant difference (p <0001), with 42.5% of pregnant women in Group F and only 15.9% of Group NF performed the collection in the first trimester of pregnancy, which probably confirmed for the lower prevalence of anemia in Group F, in addition to better education and early pre-natal. The analysis of variance showed that the mean Hb do not show a statistically significant difference (p> 0.05), noting that, apparently, there was no effect of fortification on the concentration of Hb between the groups. Conclusion: The prevalence of anemia was lower in the fortified group, but was unable to demonstrate the effect of fortification on hemoglobin levels in pregnant women who were recruited in the study

Background: After pregnancy and childbirth the female body goes through changes in both body and mind. Inadequate research has been done in the field of physical activity and exercise in postpartum women. Swedish counties has not formed a cohesive plan of antenatal care which creates variations throughout the country. Purpose: The aim for this study was to investigate how women are being informed about physical activity and exercise postpartum by Swedish healthcare. Method: To complete this study a survey was made and via a snowball sampling distributed throughout social media. Participants; 1023 women whom represented each county of Sweden. Inclusion criteria; to have given birth in Sweden the last 5 years and understand the Swedish language. Results: Women get limited oral and written information about physical activity and exercise. The information is mainly distributed by a midwife and women rarely get to meet a physiotherapist postpartum. Half of the women that did meet with a physiotherapist used the information but was in general not satisfied with its content. Conclusion: Postpartum activity and exercise is an individual process that should be exerted in consultation with a physiotherapist and the field of physiotherapy should be utilized to a greater extent in Swedish antenatal care.

Background: Neonate’s health is intimately linked to maternal health. Yearly approximately 2.8 million neonatal deaths occur worldwide, counting for more than 40 % of all deaths of children less than five years. Over 70 % of these deaths happen during the first week of life (early neonatal mortality), often the first day, and 99% of these deaths occur in low- and middle-income countries with an often low quality of maternal health care services. Aim: To assess societal and household factors, and maternal health care factors delivered in Rwanda, and how these were associated with early neonatal mortality Methods: Cross-sectional data of interviewed mothers to 7726 children between 2010 to 2014, obtained from the 2014–15 Rwanda Demographic and Health Survey, were analyzed in relation to early neonatal mortality using multiple logistic regression. Results: The factors found to be associated with reduced risk of early neonatal mortality were: delivery at a health facility, delivery assisted by a skilled birth attendant, and no low birth weight neonates. After adjustment with socioeconomic and proximate determinants, the same associations were found with delivery at a health facility and no low birth weight neonates. Conclusions: Delivery at a health facility and not to be born of low birth weight were associated with risk reduction of early neonatal mortality. These findings indicate that interventions to strengthen the antenatal health care system and to increase the utilization of already existing health care services are needed, and to educate practicing professional health care workers about early neonatal mortality.

Magister Curationis - MCur / The use of health education during antenatal care of pregnant women has been a commonly used strategy in improving maternal health worldwide. However the health education strategy sometimes does not prove to be effective in promoting maternal health, especially in Sub-Sahara Africa.

Magister Scientiae (Physiotherapy) - MSc(Physio) / Aim: The aim of the study was to to explore women’s awareness and use of antenatal services at Cecilia Makiwane Hospital. Objectives: The specific objectives were to determine the awareness of physiotherapy interventions among pregnant women attending antenatal clinic as well as the health professional’s knowledge about physiotherapy in the antenatal clinic.

Magister Public Health - MPH / Background and Rationale: Antenatal care (ANC) is vital for accessing prevention of mother to child transmission (PMTCT) services. The timing of the first ANC visit is critical for HIV infected pregnant women to access antiretroviral (ARV) prophylaxis as recommended. In addition pregnant women access other interventions like syphilis screening and treatment, provision of ferrous iron supplements, malaria prevention and treatment, health education, identification and management of risk factors. There is however paucity of information on factors associated with the timing and adequate use of ANC services in Chitungwiza Township, Zimbabwe. Aim: This study aimed to determine the factors associated with early access to and adequate use of ANC services among women attending ANC in the four polyclinics in Chitungwiza Township.Method:The study included a retrospective record review of women who registered for ANC in 2010 and a cross sectional study of pregnant women attending ANC clinic for the first time during the current pregnancy during the survey period. Data on gestation age at first ANC visit, number of ANC visits, age, gravidity, parity, tetanus, iron sulphate, rhesus results, HIV test result, WHO clinical stage, CD4 count, cotrimoxazole, PMTCT option accepted, date of initiation of AZT or ART; partner HIV test results; and infant feeding adherence done was abstracted into an MS Excel spreadsheet from the 2010 ANC registers in the four primary health care clinics. Every fourth record was captured. Exit interviews were also conducted on all women attending ANC for the first time during the current pregnancy using a structured questionnaire. Questions on socio-economic status, pregnancy history, reasons for seeking ANC, knowledge and belief about ANC services and their perception of the service received were asked. The outcome variables were gestation age at first ANC visit and the number of ANC visits. The spreadsheet was imported into Epi Info 7.0.9.7 and STATA 11 for analysis. The questionnaires were captured into an Epi Info 7 database exported to STATA 11 for analysis. A sample of 1,236 of first ANC visit records were abstracted from the 2010 ANC registers in the four primary care clinics and 80 women coming for ANC were interviewed in three clinics. The prevalence of pregnant women attending ANC for the first time at gestation age less or equal to 14 weeks and the prevalence of women with less than 4 ANC visits were computed. Pearson Chi-square tests were used to determine the strength of the relationships between the dependent variable (gestation age at the time of the first visit) and independent variables of age, marital status, level of education, parity, gravidity. All statistical tests were performed at 5% significance level and estimates were calculated at 95% confidence interval. Multiple logistic regression analysis was used to investigate the association between the outcome and the independent variables. Model interpretation was done using odds ratios (OR). Levels of knowledge and perception about ANC services as well as service content during the visit were also summarized. Results: Less than 1% of the women who attended ANC in 2010 came for 1st visit at week 14 or less, while of the women interviewed, 2.5% came at similar gestation age. Thirty-nine percent of women attending ANC in 2010 had at least four visits. Lower parity and tetanus immunization were significantly associated with early ANC initiation, while tetanus immunization and syphilis screening were associated with the number of visits.Among the interviewed women (n=80), 72.1% believed that a pregnant women should start ANC at 14 weeks or earlier. Most women (61.7%) cited having no money for booking as the reason for not coming earlier. Need for husband or partners permission, procrastination and not having any health problems with previous pregnancies were also a barrier to access. Uptake of HIV testing was very high at 94.7% of the women. However partner testing was very low at 2.1%. Knowledge of the appropriate time of the first ANC visit was somewhat high but not universal. Conclusions and Recommendations: Timely and adequate uptake of ANC services is very low in Chitungwiza Township. The user-fees appeared to be a major barrier to accessing ANC timely. While correct knowledge about when to go for ANC and the health problems women face during pregnancy and childbirth is prevalent,other factors like the need for permission from spouse or partner and procrastination were barriers to seeking service. Abolishing maternity fees should be seriously considered in order to increase access to timely ANC services. Sustainable means of financing services without reducing quality should be sought. There was variable uptake of various interventions in the ANC package due in part to supplies stock outs. There is need for strengthening the procurement and distribution systems so as to ensure continuous supplies at service delivery level.

Magister Public Health - MPH / Background: Although great strides have been made in reducing mother-to-child transmission of HIV (MTCT) in Namibia, the universal target of less than 5% by 2015 has not yet been achieved. In an effort to scale-up services in the programme, a comprehensive family centred approach which broadens HIV prevention activities and considers HIV as a family disease was instituted. However its success has been affected by low male partner participation in the programme. Study aim: To investigate factors influencing male partner involvement in MTCT-plus programme in Gobabis District, Omaheke Region, Namibia. Study design and data collection: This was a cross sectional descriptive study that wasconducted using a qualitative research methodology. Data was generated through focus group discussions (FGDs) and in-depth interviews. Four same sex FGDs were conducted with men and pregnant women. The study participants were HIV positive pregnant women and HIV positive women in their postnatal period purposefully selected from the PMTCT clients. A few male participants were partners of the female participants and other men conveniently sampled from the community. Seven in-depth interviews were conducted to gather information from key informants who were programme managers and midwives. Thematic analysis was used for the data analysis. Results: Men were generally knowledgeable and appreciated the importance of participating in the MTCT-plus programme but the majority of them did not participate. They cited several barriers to actively supporting their partners. Men‘s participation in the MTCT-plus programme was affected by lack of trust in the health workers and cultural practices that shift the role of taking care of their partners to the biological parents. The other barriers included HIV related stigma, unfriendly environment at the antenatal care clinics, time and work related constraints, having many sexual partners and gender and power imbalances in relationships that affect patterns of communication on HIV related matters. Discussion: Participation in the MTCT-plus programme is well supported by men. However, few men put this into practice because of complexities surrounding their specific role in women reproductive health issues, as well as cultural practices and health facilities organizational structures that preclude men from participation in the MTCT-plus programme. Given the positive attitude by men towards participation in this programme, creating a male friendly space within the MTCT-plus programme and empowering men to participate in them should be prioritized for the programme to achieve its goals.

Magister Public Health - MPH / Background: Point of Care Testing (POCT) refers to qualitative or quantitative tests done in health facilities where the patient is being attended to (on-site), and not in the conventional hospital laboratory setting. As a consequence of many developing countries not having access to conventional laboratory services (with trained laboratory personnel), diagnostic testing often relies on the availability of valid POC tests. All pregnant women attending antenatal care clinics in the Sedibeng District Primary Health Care (PHC) centres should be screened for syphilis, anaemia and HIV. This can be done by means of POC testing, which is easy to perform. These POC tests provide results promptly allowing treatment to be commenced immediately, if required. Despite this highly desirable benefit of POCT, there is circumstantial evidence which suggests that staff is choosing to send specimens to the laboratory for testing, instead of doing POCT themselves. The extent to which this happens and the factors contributing to this practice are not clear. Aim: The aim of this study was to assess the prevalence of screening for syphilis, anaemia, and HIV amongst pregnant women during their first antenatal care visit to PHC facilities in the Sedibeng District, and to establish the factors affecting the prevalence of appropriately using POCT for screening tests. Methodology: Study design: A quantitative, analytical, cross-sectional study was conducted. Study Population and Sample: Patient registers, staff expected to perform POCT and facility managers. 33 District’s health care workers expected to perform POCT on pregnant women during the first ANC visit and 30 facility managers from these facilities; 360 patient records (these were collected from a total of 7 200 patients’ records). The data was collected over a six month period (from 1st July 2012 to 31st December 2012). Data collection: Data was collected from 360 patient records to determine the rate, appropriateness and mechanism of screening for syphilis, anaemia and, HIV in pregnant women on their first antenatal visit. Interviewer-administered closed-ended questions was asked from 30 antenatal care clinic staff tasked with performing POC tests and from 30 PHC facility managers to determine the factors affecting the rate of conducting POCT. Data analysis: Data was analysed using univariate, bivariate and multivariate analyses. Ethical considerations: No harm was anticipated to anyone participating in the study or from the findings of the study. A major benefit of the study was that clarity on the factors affecting the rate of screening and the use of POCT was gained. This will hopefully facilitate the implementation of evidence–based interventions to improve POCT uptake if required.

Philosophiae Doctor - PhD / Background: Syphilis transmission remains a global problem with an estimated 12 million people infected each year. Ninety percent of syphilis cases occur in low income countries. Syphilis is a serious source of adverse pregnancy outcomes for both mother and infant. Ideally, syphilis screening should be provided as part of a package of maternal and newborn health-care services. This thesis reports on a pilot intervention study to develop, implement and evaluate a point of care test for syphilis in antenatal care services in rural Burkina Faso. Methods: This study used a pre post intervention mixed methods quasi-experimental design with a group of health facilities offering ANC services (primary health centers in rural area) as the sampling units. This study was conducted in three phases, which consisted of a situational analysis using qualitative methods (Phase 1), selecting an appropriate test through evaluating 4 candidate tests and the participatory design and implementation of an intervention that included onsite training, provision of supplies and medicines, quality control and supervision (Phase 2), and an evaluation combining review of record tools, interviews, time motion study and estimating incremental costs (Phase 3). The conceptual framework draws on multilevel assessment (MLA), policy triangle framework, MRC framework for designing complex interventions and the Normalization Process Model (NPM). Methods included document review, seventy five interviews were conducted with health providers, district managers, facility managers, traditional healers, pregnant women, community health workers, and Non-Governmental Organizations (NGO) managers in phase I and fourteen in phase III, non-participant observation, time-motion study, incremental cost analysis, and sensitivity, specificity and ease of use analysis of four candidate point-of care tests. Data were collected between 2012 and 2014. Qualitative data were analyzed through thematic analysis supported by Nvivo software. Quantitative data were analyzed through descriptive statistics such as frequency, mean and median supported by SPSS. Findings: Phase I identified barriers to implementation and uptake of syphilis testing at health provider and community levels. The most important barriers at provider level included fragmentation of services, poor communication between health workers and clients, failure to prescribe syphilis test, and low awareness of syphilis burden. Cost of testing, distance to laboratory and lack of knowledge about syphilis were identified as barriers at community level. Phase II: Alere DetermineTM Syphilis was the most sensitive of the four point-of-care tests evaluated. The components of the intervention were successfully implemented in the selected health facilities. Overall, phase III showed that it is feasible and acceptable to introduce a point of care test for syphilis in antenatal care services at primary health care level using the available staff. The intervention was reported as acceptable, but of 812 pregnant women who came for their first visit 39% were screened during the study period. Rural facilities had higher coverage (66.8%) than the urban ones (25.6%). Quality control found no discordance between the rapid test and TPHA results. The average cost of ANC per unscreened pregnant woman was 3.11 USD (±0.14) vs 5.06 USD (±0.16) per screened woman. The main cost driver was the material costs notably the test itself. The test’s cost is comparable to HIV test costs, but funder support for integrating this additional test is less readily available than for HIV tests. Conclusions: The findings suggested that an intervention that introduces point of care test for syphilis at antenatal care services is feasible, acceptable, and of comparable costs to HIV screening in pregnancy. Nonetheless, instructions and supervision need to be clearer to achieve optimal levels of screening and quality control, and barriers identified by health workers need to be overcome. The point-of care test for syphilis is likely to be acceptable by health workers as a routine service and incorporated as a normal practice in Burkina Faso context. / This research was made financially possible by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR); and the African Doctoral Dissertation Research Fellowship (ADDRF 2012) award offered by the African Population and Health Research Center (APHRC) in partnership with the International Development Research Centre (IDRC).

Thesis (MPH.) -- University of Limpopo, 2017. / Background: Ante natal care (ANC) service is a very important intervention to track the progress and to identify complications that might arise during pregnancy. The first ANC visit at a health facility is even more important as health providers are able to identify whether there are any risks to the mother and the unborn child and it should be initiated at the 1st trimester of pregnancy. Objectives: The study aim was to establish the knowledge and perceptions about ANC services among pregnant women in the Julesburg Local Area in the Mopani District of Limpopo Province. Methods: A quantitative cross-sectional research approach was used at six primary health care facilities in the Julesburg Local Area of the Mopani District in Limpopo Province. Stratified random sampling was used. Data were collected from 293 pregnant women using a self-administered questionnaire. . Data analysis was done using the International Business Management Statistical Package for Social Sciences 23 (SPSS 23). Results: The results reveal that a high percentage of pregnant women have adequate knowledge with regard to ANC services. The results further show that knowledge level of pregnant women has no association with educational level (P=0.488). With regard to perception, half of the respondents have positive perceptions of ANC services, while a further half have negative perceptions of these services. Conclusion: ANC service is of great importance to further reduce maternal and neonatal deaths as most of these deaths are avoidable. There is a need to strengthen the training programme of staff by providing further training exposure and health information to pregnant women with regard to the important of early ANC initiation and frequency of ANC visit need to be intensified. Keywords: Health care workers, antenatal care, knowledge, perception, initiation, utilization.