Magister Public Health - MPH / Background: Antenatal Care (ANC) is a key strategy in achieving positive maternal health outcomes. ANC is an important entry point into formal health care services. ANC is very low in cost and among the most effective packages to promote and establish good health before childbirth and the early postnatal period; therefore, it is very feasible for the good results it is proven to have on maternal and child health. South Africa has had free ANC services since 1994. Despite these free services a lot of women still attend the ANC clinics late or do not attend follow-up visits, hindering the quality of care during pregnancy. The first ANC visit should be in the first trimester of pregnancy or as early as possible, because with the first visit underlying conditions must be identified and managed to promote maternal and foetal health. ANC initiation after 20 weeks may increase maternal, foetal and perinatal morbidity and mortality. In the Cape Winelands there are still 27.3% of women that attend ANC after 20 weeks gestation. This may hinder the quality of care during pregnancy and may lead to negative health outcomes for mother and or baby. The purpose of the study is to understand why some women still do not attend ANC before 20 weeks gestation even when it is available.

Magister Public Health - MPH / Background: Antenatal care serves as a key entry point for a pregnant woman to receive a broad range of services and should be initiated at the onset of pregnancy (WHO, 2016). Cameroon has one of the highest maternal mortality ratios in the world (UNICEF, 2016). The majority of pregnant women in Cameroon initiate antenatal care after the first trimester (Njim, 2016). Most studies on initiation of antenatal care in Cameroon have not explored in greater depth the reasons why most of the pregnant women initiate antenatal care late. Methodology: The aim of the study is to understand the reasons why pregnant women initiate antenatal care late in Nkwen Baptist Health Center, North West Region, Cameroon. It is an exploratory study and applied purposive sampling to recruit eighteen pregnant women and three key informants for data collection through individual interviews. Pregnant women who initiated antenatal care after the first trimester were recruited during antenatal care clinics and interviewed in a room at the antenatal care unit. Key informants were midwives working at the antennal care unit. Participation in the study was voluntary. Participants were explained the purpose of the study and signed a consent form if they were willing to participate in the research. Participation in the research did not inhibit the respondent’s access to care. Data was collected using an audio tape and analyzed using Thematic Coding Analysis (TCA) to identify recurring themes that emerged from the data to adequately describe the perceptions of respondents on the reasons for late initiation of antenatal care.

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.

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

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.

The dissertation examines how pregnant women seeking antenatal care at a state facility in the Southern Peninsula of Cape Town conceptualise and experience their pregnancies in relation to the biomedical model that informs state practices of care. I specifically explore the experiences that contribute to the state's definition of 'late' presentation at antenatal clinics (i.e. after the first trimester). The antenatal care model advises that pregnant women report "early", at 12 weeks, and have regular follow up visits up until 40 week period, yet recent public health research showed that women present "late" to the antenatal clinics, with only 40.2% of first antenatal visits occurring in the first trimester in South Africa. The women who were a part of the research were chosen in the clinic space, in waiting rooms, booking rooms and while waiting for ultrasounds. The women were selected based on age (17 upwards), and gestational age at first antenatal booking. I examine the ways biomedicine frames temporality, and the way that health policy enacts this through antenatal care. I contest the brackets of 'lateness' and biomedicalisation of pregnancy, and the state's version of the female reproductive body as I describe the unfolding experiences of a reproductive life, showing how pregnancy and health care seeking are enmeshed in social worlds. The discursive framings of antenatal attendance exhorts women to seek antennal care at 12 weeks gestation, to "be responsible" "good women" managing their sexual and reproductive lives with a mode surveillance that presumes a certain way of knowing and counting the body. I explore the other ways of experiencing, knowing, and counting, showing how pregnancy experiences and healthcare seeking behaviours are influenced by social, economic, political, and historical factors, and by the moral and religious values that shape daily life for women. My thesis is grounded in the growing literature on anthropology of reproduction and the biosocial. In doing so, I examine what it means to have and experience a reproductive body within the unfolding events of everyday life, where moments and 'quasievents' (such as structural inequalities, and the daily bouts of gang violence and domestic violence) become enmeshed, such that they influence temporality, differing perceptions of trust, distrust, risk and testing, and differing social values of testing. I further show how maternal kinship networks of support are valued, yet precarious as are intimate partnerships, which both influence experiences of care, neglect, abuse, punishment and shape antenatal attendance. In contesting temporal boundaries of biomedicine I show how women's bodily and relational experiences, their everyday lives and quasi-events within them are inseparable in shaping antenatal health seeking practices and how pregnancies are imagined.

Yes / Early booking or registration into Antenatal Care (ANC) can be defined as initiation of ANC before 12 weeks of gestation and is important for the best health outcome of the mother and the baby. Delayed initiation of ANC has been linked to increased rate of maternal and fetal mortality. There is international consensus that ANC should begin within first trimester yet pregnant women delay initiation of ANC. Health Care Workers (HCWs) understanding of reasons for this can improve patient provider relationship. Objectives: This study aims to explore the perception of the HCWs in Fiji towards early antenatal booking. Methods: A qualitative study was employed using four Focus-Group Discussions (FGDs)with the HCWs who provide health care service for pregnant women in Ba Mission Hospital (BMH) in 2020. Each group comprised of medical officers, mid-wives and registered nurse who were chosen purposively. A semi-structured open ended questionnaire was used to guide the discussion. Data was transcribed and analyzed manually using thematic content analysis using the following process: familiarization, coding, identifying themes, reviewing and refining, integration and interpretation. Results: There was a total of 18 HCWs for the FGDs. The mean age of the participants was 37.4±11.8years. The three themes identified were: knowledge of HCWs on early booking, their perceived barriers and perceived enabling factors to early antenatal booking. The FGDs identified that the HCWs had adequate knowledge on early initiation of ANC and that there were a range of barriers to early initiation of ANC. The HCWs also suggested factors that could enable women to book early. Conclusion: Based on the study it can be concluded that the HCWs have a positive perception of early antenatal booking, however, there are various factors that contribute to delayed antenatal booking. The barriers to early ANC are both an opportunity and a challenge to strengthen and review the maternal services offered. The enabling factors should be reinforced from an individual level to the health system and the general context. The implications of the barriers and enabling factors identified in this study is to implement evidence-based policies to improve early antenatal booking in Ba, Fiji.

Magister Public Health - MPH / Globally, 1600 women and over 5000 newborn babies die daily of preventable causes and over 90% of these deaths occur in developing world. An estimated 358000 maternal deaths occurred worldwide in 2008 with developing countries accounting for 99%. In Zambia, maternal mortality ratio has been estimated to be 591 deaths per I 00,000 live births underscoring the great challenge posed by maternal and child health problems. At the same time, utilization of antenatal care services by pregnant women, supervision of deliveries by skilled person and postnatal care services is low in most regions of Zambia. Since professional attendance at delivery is assumed to reduce maternal and infant mortality, poor antenatal care (ANC) utilization may lead to increased infant and matern.al mortality and morbidity.This study sought to assess the barriers to utilization of antenatal care services in Kazungula district, Zambia. A qualitative exploratory study was used to uncover participants' experiences and perceptions on barriers to use of ANC.Focus group discussions were used to gather information from primegravidae and multigravidae not attending or irregularly attending ANC services and from traditional birth attendants. In-depth interviews were conducted with key informants namely the health centre in-charge and leader of safe motherhood support group.Data was analyzed through thematic content analysis. From the transcripts, patterns of experiences coming from direct quotes or through paraphrasing common ideas forming part of the themes were listed. Data from all the transcripts relating to the classified patterns were identified and placed under the relevant theme. Thereafter related patterns were combined and listed into sub-themes. The analysis involved drawing together and comparing discussions of similar themes and examining how these relate to the variations between individuals and groups that assisted in understanding the phenomenon of interests. The study revealed that utilization of ANC was impeded by multiple interrelated factors such as low socio economic and educational status of women, influence of the older generation, traditional and cultural practices. Previous negative experiences with health workers such as bad attitude of health workers and perceived poor quality of care were mentioned as factors that negatively affect utilization of ANC services. Other notable barriers were built in confidence resulting from previous safe deliveries, family size and competing priorities, fear of being tested for HJY and physical the accessibility.The study recommends that the district and its partners address the barriers if efforts in safe motherhood will yield meaningful impact. DHMT in the long term plan needs to train and deploy skilled personnel to rural health centres. They should have a deliberate policy on rural incentives to motivate trained staff to remote areas. More health posts need to be built as a way of taking health care services as close to the family as possible. In addition, for the short term plan there is need to provide inservice training for staff on safe motherhood and circulate guidelines. Orient staff on focused antenatal care (FANC).DHMT should ensure continuum of, care by supporting adequate supplies, equipment, drugs and transport to the health facilities.