Magister Public Health - MPH / This study explores the challenges faced by nurse counselors in the implementation of HIV and Infant Feeding Policy in Amathole District of the Eastern Cape. Objectives: (i) To describe the demographic characteristics of the study population; (ii) To explore the challenges faced by nurse counselors in the implementation of current HIV and infant feeding policy and guidelines; (iii) To establish the nurse counselors perspectives on the infant feeding policy and guidelines for HIV positive mothers; (iv) To examine the support system available to the nurse counselors who give infant feeding advice to HIV positive mothers. / South Africa

Philosophiae Doctor - PhD / The HIV/AIDS epidemic remains an unbeaten challenge that affects all parts of the global population. Since the identification of the epidemic in the early 1980s, nearly 58 million people have become infected with the virus and 25 million people have died of HIV-related complications. This study aimed to elucidate individual and community level factors associated with the uptake of antenatal care (ANC), health facility delivery, HIV Counselling and Testing (HCT), and Prevention of Mother-to-Child Transmission of HIV (PMTCT) services by implementing a hierarchical (multilevel) methodological approach. This study used a cross-sectional, multistage sampling design in which health facilities were first selected (stage 1), followed by recruitment of post-partum women who came for child immunization from each health facility (stage 2), in Tigray region. Structured interview guides were developed for interviews. Four-fifths (80.0%) of mothers used antenatal services at least once during their most recent pregnancy and of these 74.6% of women accessed HCT. Sixty nine percent of women had delivered at a health facility, 79% of mothers and 55.7% of their children had received PMTCT services. Place of residence was significantly associated with ANC attendance and place of delivery, with women living in urban areas almost 2 times (OR=1.75, 95% CI 1.06, 2.92) more likely to deliver at a health facility. With the addition of one health facility per 25000 people, the likelihood of delivering at a health facility increased by 2.45 fold (OR=2.45, 95% CI 1.04, 5.78). Attending ANC (OR=4.54; 95%CI 2.82,7.33) and getting support from husband (OR=1.97; 95%CI 1.25,3.10) were significantly associated with HCT, at the individual level. At the community-level, for the addition iii of one health facility and HCT site for every 25000 people increase the likelihood of HCT utilization by 2.1 and 2.4 fold respectively. Mothers who delivered at a health facility were 18 times (OR=18.21; 95%CI 4.37,75.91) and children born at a health facility were 5 times (OR=4.77; 95%CI 1.21,18.83) more likely to receive PMTCT services, compared to mothers delivering at home. With the addition of one nurse per 1500 people, the likelihood of getting PMTCT services for a mother increases by 7.22 fold (OR=7.22; 95% CI 1.02,51.26). Community-level random-effects were also significant and there was confirmation of nesting at the community-level even after controlling for individual and communitylevel variables. Findings also showed that HCT utilization was nested according to district of residence, contributing 11.3% of the variance. In addition, the variation of mothers getting PMTCT services between districts was only 0.6%, but was 27.2% for children. Conclusion: Factors influencing utilization of maternal health services work at different levels, individual and community. Hierarchical models reveal these differences in ways that single-level (individual or community) models do not. Interventions are needed to increase spouse involvement in ANC utilization, and explore effective ways of increasing health facility delivery among poor women with little formal education in rural areas and increasing the number of health facility per people are important. The government should focus on increasing ANC access, educating couples on the importance of health services utilization, increasing the number of health facilities and HCT sites per population to improve HCT utilization. In addition to these, programmes should focus on increasing health facility delivery, training traditional birth attendants to understand the need for PMTCT and increasing iv HCT coverage to advance getting PMTCT services for mothers at the individual level and for children at both individual and community level. Permission to conduct the study was granted from the Ethics Committee of the University of the Western Cape and from Tigray Region Health Bureau. Verbal informed consent was obtained from each participant in the health facility based interview.

Socioeconomically deprived women are at greater risk of adverse pregnancy outcomes. To counteract this, attention tends to focus around access (equality) of services. Yet access may not equate with the meaningfulness (equity) of services for women from different socioeconomic backgrounds. Without understanding equity we are not in a position to plan appropriate and equitable care. This study aimed to determine pregnant women's perceptions of the current antenatal provision and to determine if women from the extremes of socioeconomic background perceived their antenatal care differently. Longitudinal interviews were undertaken with multiple, comparative antenatal case studies between January 2007 and April 2009. Cases were primigravida women from ‘least deprived’ (n=9) and ‘most deprived’ (n=12) geographical areas as identified by the Scottish Index of Multiple Deprivation (SIMD 2006). The data were analysed using case study replication analysis. Analysis of categorical data from the sample groups indicated they were less diverse than might have been expected in terms of age and education. However in the key variables of housing tenure, potential income and socioeconomic status based on area of residence, the groups were indicative of the SIMD target populations. The preliminary analysis showed that the sample groups considered the initial General Practitioner contact to be less than adequate and the subsequent utility of antenatal education to be based on self perceived relevance. The substantive analysis showed little difference in access to antenatal services between the ‘least’ and ‘most’ deprived groups but perception of care differed. A key difference concerned the level of ‘engagement’ (defined as personalisation and active involvement in care, power and relationships and health literacy). Using these concepts, engagement was present in most of the ‘least deprived’ group and almost none of the ‘most deprived’ group. In comparison with women from affluent areas, more deprived women described less evidence of: personal connection to their own care; shared decision making; and perceived value in relation to the written educational aspects of antenatal care. In terms of the preliminary analysis, the results suggest that utility of educational material may need to be reviewed to ensure it is relevant to specific needs. Without this relevance, key information may be missed. The substantive analysis suggests that for women from socioeconomically deprived areas, access may be a less useful indicator than engagement when assessing quality of antenatal services. The lack of engagement perceived by those who are most deprived suggests that equity of service has yet to be attained for those who are most in need. Future research needs to be directed to the potential reasons that may undermine equity and engagement in women from lower socioeconomic areas.

The purpose of this study was to propose women-centered guidelines to enhance the utilization of health facility-based delivery among attendees of FANC in Addis Ababa, Ethiopia. A qualitative exploratory and descriptive research design was used to achieve the aims and objectives of the study. The design was contextual in nature.The study was conducted in three phases, using purposively selected attendees of FANC who participated in individual and focus group interviews in phases I and II respectively. Data were analyzed by means of thematic analysis. In phase III of the study, the findings of the first two phases and literature were used as the basis for the development of guidelines to enhance the utilization of health facility-based delivery services among attendees of FANC in Addis Ababa, Ethiopia. From the analysis of individual interview data, four (4) themes emerged, namely, perceived benefits of home delivery, knowledge deficit about health facility-based delivery, poor access to health care facilities and inadequate resources. These themes were identified as rich and detailed account of the perspectives of facility-based and home delivery among attendees of FANC in Addis Ababa, Ethiopia. Two (2) themes emerged from the analysis of focus group interviews data, namely provision of quality, respectful and dignified midwifery care and increased awareness of FANC. These themes were identified as the rich and detailed account of the views of, and recommendations made by attendees of FANC on measures needed to enhance the development of women-centred guidelines to enhance the utilization of health facility-based delivery services. The recommended measures addressed the negative perceptions of health facility-based delivery among attendees of FANC, with the aim of decreasing home deliveries and increasing the number of institutional deliveries. The study recommends that the Ministry of Health, Addis Ababa Health Bureau and the health facilities use the proposed guidelines to enhance the utilization of health facility-based delivery. / Health Studies / D. Litt. et Phil. (Health Studies)

INTRODUCTION. The perinatal mortality rate is of concern worldwide. In South Africa at the time of the study, 2000, it was estimated to be of the order of 40/1000 live births. However in the setting in which this study took place, namely Tembisa, (Ekhuruleni, Gauteng, South Africa) it was said to be 50/1000 live births. One of the patient- related avoidable factors that has been found to be associated with perinatal and to a lesser extent maternal mortality, is either no, or late initiation of antenatal care. It has been found in an area which, is in many respects similar to Tembisa that 50% of women go the private general practitioner (PGP) for confirmation of pregnancy but, due of lack of funds, do not continue care with the private practitioner but, initiate care in the public sector and in a proportion of these women, this is at an advanced gestational age, making it difficult to prevent or intervene if there are problems in the pregnancy. As (PGP’s) are well placed in the district to render antenatal care, it was decided to perform a study looking at the effect of involving them in the antenatal care of women who presented to them for confirmation of pregnancy. METHODS Sixteen general practitioners agreed to be part of the study. The women who confirmed their pregnancy and who were going to deliver in Tembisa hospital were included in the study after giving written informed consent. They comprised the intervention group, the first antenatal visit was performed, the findings were recorded on the antenatal card which is used in the public sector and which was introduced to the private practitioner at 2 workshops held by the Department of Obstetrics and Gynaecology, University of Pretoria prior to the study. The woman was then to attend antenatal care with the private practitioner until delivery. The private general practitioners waived the costs normally associated with this care for the period of the study. The control group consisted of the women who confirmed their pregnancies in the public health care sector known as the public service health care workers group (PSHCWG). Data collection took place in the postnatal ward of Tembisa hospital over the period of 3 months. By means of systematic sampling, 100 cards from the PGPG and 100 cards from the PSHCWG were obtained. The 2 groups were compared with respect to gestational age at initiation of care and a modified version of the Quality Check for Antenatal Records Score (MQCARS), an audit score which, when applied to the antenatal card, gives a measure of the effectiveness of record keeping, and whether problems in the antenatal period are detected and appropriately managed. RESULTS. There was a statistically significant difference between the two groups in terms of gestational age at initiation of care [PGPG mean gestational age -19.96 (5.86), PSHCW 25.96(5.98,) p<0.0001]. The majority of women in the PGPG initiated care in the 2nd trimester (79%) while the majority of the women in the PSHCWG (53%) confirmed their pregnancies in the third trimester. Six per cent of PGPG confirmed their pregnancies in the first trimester compared to the PSHCWG (3%). The two groups differ significantly with respect to the total MQCARS with the PGPG group performing better [(8.16 (1.55) vs. 16.34(2.58), p<0.0001]. The associated sub- scores are statistically different [History score 5.99 (0.10) vs.7 (0.96), Examination score 9.59(1.29) vs.8.03 (1.85) Interpretation Score 2.55(0.50) vs.2.80 (0.49)]. CONCLUSION Despite the limitations of the study it is felt that if private general practitioners in Tembisa are involved in the antenatal care of those women who confirm their pregnancies with them, there is a reduction in the gestational age at initiation of care. There is a small difference between the two groups in record keeping, detection and management of problems. / Dissertation (MCur)--University of Pretoria, 2011. / Nursing Science / unrestricted

MPH / Department of Public Health / See the attached abstract below

Maternal deaths in Ethiopia are mainly due to complications of pregnancy and delivery. The socio-cultural contexts under which these pregnancies and deliveries occur that pave the way for these complications and mortality. In Ethiopia, the maternal mortality ratio had been 353/100,000 live births in 2015. Therefore, the purposes of this study were to examine, and describe the socio-cultural determinants and missed opportunities of maternal health care in Eastern Ethiopia. The study was conducted in selected districts of Grawa, Chelenko and Haramaya Woreda, East Hararghe, Oromia National Regional State, Ethiopia. A community-based survey involving pregnant women in their third trimester and women who gave birth in the last five years, husbands, mothers-in-law, sisters-in-law, health workers, religious and community leaders were conducted between September up to December 2017. A systematic sampling technique was used to get a total of 422 study participants for quantitative and 24 FGD participants to qualitative study were adopted using triangulation of data collection. Pre-tested and structured questionnaire was used to collect relevant data. The main instrument used for quantitative data collection was the structured questionnaire, specifically in-depth interview methods. Bivariate and Multivariate data analysis were performed using SPSS version 25.0 and focus group discussion (FGD) was used to collect qualitative information and the information was analysed using thematic analysis method based on Atlas.ti version 8.2 statistical software packages. The study revealed that among 359 (85%) pregnant women who planned for ANC visit, 16 (4.5%) received ANC four or more times during their last pregnancies, the respondents (81.3%) claimed that they were taken care of by skilled delivery attendant during delivery, 18.5% of them said that they delivered at home and 71.1% of them received medical care after delivery (missed opportunity). Women in the age group 15-24 years [AOR: 1.18, 95%CI: 1.18 (0.37, 3.74)], primary school [AOR: 4.09, 95%CI: 4.09(0.96, 15.50)], women intended their last pregnancy [AOR: 3.1, 95% CI: 0.32(0.11, 0.94)], and women living in urban residences [AOR: 1.2, 95%CI: 0.86(0.25, 2.95)] were significant predictors of unplanned home delivery. For optimal and effective interventions of maternal health services utilization, provisions should be made for better women‘s education, family planning, community-based health insurance, health facilities access, job opportunity and women empowerment; provisions should also be made for creating income generating activities to women. Strengthening village women‘s army wing, refreshing and enabling health extension workers and traditional birth attendants. What is more, optimal measures should be taken to discourage traditional practices such as female genital mutilation, polygamy, violence against women and teenage marriage. Finally, free maternal and child health services should be advocated for so that the gap in maternal healthcare services is bridged. / Health Studies / D. Litt. et Phil. (Health Studies)

Thesis (MPH.) -- University of Limpopo, 2021 / Background: Late antenatal care (ANC) booking delays treatment and management of high-risk pregnancies, which may result to maternal deaths. Early ANC booking has been found to be effective in most of the pregnancy related risk factors that can be detected and managed at early stages of pregnancy. Aim: The aim of the study was to investigate the prevalence and factors contributing to late ANC booking amongst pregnant women in primary health care facilities at Dikgale-Mamabolo local area. Methods: Quantitative cross-sectional research approach was used. The study was conducted at Dikgale-Mamabolo local area, which consists of seven clinics at Polokwane, Limpopo province in South Africa. Only three clinics were purposefully selected for the study. The population of the study included pregnant women who were 18 years and above. The sample size consisted of 238 pregnant women who came for ANC services in primary health care facilities during the period of the study. Convenience sampling method was used to select pregnant women from the population. Data was collected using an adapted questionnaire. Data was analysed using Statistical Package for Social Sciences (SPPS) version 25. Results: The results indicated that 86% of pregnant women booked antenatal care before five months gestational age and 14% booked after five months gestational age. Factors contributing to late ANC booking amongst pregnant women were marital status, educational level, employment status, mode of transport to clinic, lack of information, cultural beliefs, long distance to the clinic, long waiting time in the clinic and clinic operating hours. Conclusion: Late ANC booking remains a major public health issue. The study showed that lack of information and cultural beliefs are major contributing factors to late ANC booking. It is recommended that awareness campaigns should be conducted in the community and schools to empower women with knowledge about ANC services.

Health appears as a fundamental right on the Declaration of Human Rights of 1948 onarticle XXV. In humanitarian research, health is often viewed as a secondary theme anddid not have that much relevance. This has changed recently and nowadays health isconsidered an important factor. Social determinants of health are social factors, such ashousing, nutrition, and sanitation, that have a deep influence on one’s health. Thosedeterminants are particular to each individual and the conditions in which it lives and canbe modified by one’s migratory journey. In fact, migration in itself can be seen as a socialdeterminant of health, once the implications of the journey directly affect their health.Health inequity and the disparities caused by it are direct consequences of the socialdeterminants of health.This thesis analyses productions on refugee health in relation to the barriers existent inboth accessing and providing healthcare services to pregnant and postpartum women inGreece. The discussion chapter analyses the data found, discusses social determinants ofhealth, the resulting health disparities, and arguments through an intersectionality lens.The result chapter discusses the most important factors, suggests actions to overcome thebarriers and discusses the responsibility of the global society regarding inequalities.

Fewer rural Congolese women complete 4 antenatal care (ANC) visits than do urban women, despite high maternal and child mortality rates. This quantitative cross-sectional survey applied Andersen's behavioral model of service utilization to examine whether the ANC facility type, provider type, provider gender, time to ANC facility, cost, and number of services can predict ANC compliance among rural women. The study was a secondary analysis of the 2015 Maternal and Child Health (MCH) survey, which comprised 1,280 eligible women selected through stratified random sampling. The analysis included bivariate and multivariate logistic regressions. The findings showed that women seen in private facilities, AOR = 2.220, 95% CI [1.384, 3.561], p < .01; women seen by female providers, AOR = 1.407, 95% CI [1.055, 1.877], p < .05; and women receiving 7 to 9 ANC services, AOR = 1.680, 95% CI [1.142, 2.472], p < .05, were more likely to complete 4 ANC visits. The cost of services and time to the ANC facility had no association with ANC compliance. Further analysis showed that private facilities provided more services (median of 6 vs. 5, p = .000) and had more women attended to by doctors (11% vs. 2%, p = .000) and female providers (72.9% vs. 58.4%, p < .001). These findings suggest that service quality and provider gender play a role in ANC compliance in rural areas. Therefore, Congolese health authorities should establish quality improvement programs and incentives to attract female providers to rural areas. This study contributes to positive social change by identifying ANC access barriers of rural populations and informing future efforts to close the urban-rural gap in MCH outcomes.