Magister Public Health - MPH / Although the Kenyan government implemented safe motherhood programme two decades ago, available data indicate that prevalence of home delivery is still high among women in Garissa District. The aim of this thesis was to investigate the factors influencing the choice of place of childbirth. Methodology: A descriptive cross-sectional study was carried out among 224 women who delivered babies two years prior to December 2010. Using a statcalc program in Epi Info 3.3.2, with expected frequency of home delivery at 83% +5% and a 95% confidence level, the calculated sample size was 215. Furthermore, with a 95% response rate the adjusted minimum sample size was 226.There were two none-responses hence 224 women were interviewed. Stratified sampling was used. Data were collected using pre-tested structured questionnaires and analyzed using SPSS. Descriptive, bivariate and multivariate analysis was performed. A binary logistic regression analysis using the Enter method was performed to determine independent predictors for use or non-use of healthcare services for childbirth. The threshold for statistical significance was set at 0.05. Results: The result was presented in text and tables. The study found 67% (n=224) women delivered at home and 33% delivered in hospital. The study found low level of education, poverty, none-attendance of ANC, distance, cost of services, poor quality services, negative attitude towards midwives, experience of previous obstetric complications and decision-making to be significant predictors in home delivery at the bivariate level (p<0.05). The study did not find relationship between age, marital status, religion and place of childbirth (p>0.05). At multivariate level, the following variables were still found to be significant predictors of home delivery: no education OR=8.36 (95% CI; 4.12-17.17), no occupation OR=1.43(95% CI; 1.08–5.49) experience of obstetric complications OR=1.38 (95% CI; 1.15-2.12), none-attendance of antenatal clinic OR=1.11 (95% CI; 1.03–1.51), Rude midwives OR=5.60 (95% CI; 2.66-11.96). Conclusions: high prevalence of home delivery was noted due to lack of education, poverty and inaccessible maternity services hence the need to empower women in education and economy to enhance hospital delivery.

Background Globally, about 800 women die daily from complications arising during labor or within 42 days of childbirth. These deaths can be prevented by ensuring that women give birth in a safe environment in the presence of Skilled Birth Attendants (SBAs). SBAs are efficient to manage pregnancy, child birth and postnatal complications or refer in very complicated cases. Only about half of the women use SBAs in Kakamega County, Kenya. The study aim was to describe the determinants of utilization of SBA in Kakamega County. Method A cross sectional design was used. Data was obtained from Multiple Indicator Cluster Survey (MICS) conducted in the year 2014. A sample of 295 women were selected through two-stage cluster sampling. Standardized questionnaire was used to collect data from women who had given birth two years prior to the survey. Univariate and multivariate analysis was used to analyze the data. Results There was an association for use of SBAs with lower parity Odds Ratio (OR) 3.11(95% CI,1.82-5.52), early Antenatal Care (ANC) attendance OR 0.49(95% CI,0.27-0.88), secondary education OR 1.89(95% CI, 1.16-3.05) and high wealth index OR 2.87(95% CI,1.76-4.69). There was no association with ANC visits OR 1.3 (95% CI, 0.80-2.24) and place of residence OR 1.50 (95% CI,0.93-2.41). Conclusion Being in higher quartile, exposure to secondary education and low parity were key influencers of SBA use while place of residence did not show any association. There is an association between use of SBA and timely ANC attendance but not with number of ANC visits.

Magister Philosophiae - MPhil / Skilled birth attendance at childbirth is vital for decreasing maternal and child mortality in Zimbabwe. Infant mortality and maternal mortality in Zimbabwe are quite high due to low- use of skilled birth attendance. Based on different study sources, home delivery with complications are high, with many socio-economic and demographic associated factors including lack or no use of skilled birth attendance at childbirth in Zimbabwe. Therefore, the study looked at "preventive" which refers to an action taken to reduce or eliminate the probability of specific undesirable events or dangers from happening in the future and the present time in Zimbabwe. The objective of the study was to highlight the significance of the crucial function within the health systems of saving both the lives of a mother and the child. Furthermore to determine the frequent use of maternal health care services (skilled birth attendant) and identify factors affecting them. The data that was used was nationally represented large scale secondary data ZDHS of Zimbabwe with sample population n = 9,171. It was a secondary data that included all the provinces of Zimbabwe, simple random sampling was used that had questionnaires of both man, women and household questionnaires, these questionnaires helped in examining the socio-economic factors and determinants that leads to low-use of skilled birth attendants at childbirth. The prosed statistics analysis that were used were univariate, bivariate and multivariate techniques. The statistical analysis showed that demographic variables such age, place of delivery and socio-economic factors such as level of education of a mother and wealth index (occupation of a parent) and region has a significant effect on the use of skilled birth attendant during birth. Women with higher level of education were found to have high use rate of maternal health care services (Skilled birth attendants), while women with primary and secondary education were found to have high use rate of less ( traditional birth attendant) or no use of skilled birth attendant. Therefore, the female age at birth, place of delivery, level of education and wealth index played a major role in decision making about the importance of having a skilled birth attendant when giving birth. The access to skilled birth attendance was found to be a significant factor in reducing maternal and child mortality in Zimbabwe. Furthermore women need to be educated about the importance of maternal health care services use and postnatal care and the department of health in Zimbabwe can implement mobile clinics for those who are residing far from health facilities.

Several factors may affect the choice of place of delivery among expectant mothers in Ghana and few studies have examined the choice of place of delivery with a focus on differences between rural and urban areas. In this study, the factors that influence the choice of place of delivery among expectant mothers in both rural (Tolon District) and urban (Tamale) settings in the northern part of Ghana were identified and compared using the conceptual framework provided by Thaddeus and Maine. A mixed-method study was used to examine expectant mothers and their responses related to factors that affect their choice of place of delivery through a concurrent triangulation using health professional interviews and a detailed participant survey.. The sample consisted of 552 expectant mothers between the ages of 15 and 49 years. Individual interviews were held with 8 health professionals (4 each from rural and urban areas) with a minimum of 5 years of work experience and a focus group discussion with randomly selected pregnant women and lactating mothers. Themes were generated through open coding of the interview data, while multiple regression was performed to identify the factors associated with choice of place of delivery, rural area, preference (60.1%) was for home delivery compared to 20.7% for urban participants. Statistically significant variables affecting the choice of place of delivery among study participants were found to be educational background, the experience of previous deliveries, the attitude of hospital staff toward pregnant women during labor, and frequency of accessing antenatal care. The study's implications may lead to positive change where stakeholders develop and implement policies to promote health facility delivery for expectant mothers in both rural and urban areas of Ghana.

The central concern of this study is the social, cultural and political position of traditional birth attendants (TBA), known as yiey maap (grandmother midwives) in Chup Commune (pseudonym). In particular, this study explores strategies yiey maap use to negotiate or bypass Western model health services in an attempt to maintain their personal integrity and cultural capital as birth attendants, and to ensure the physical, emotional, economic and cultural safety of the woman they care for. / This thesis explores traditional maternity knowledges and practices using ethnographic methods to investigate the central issues, concerns and barriers confronting rural woman as they make choices to adapt, resist or negotiate Western maternity care. It is vital to consider historical, political, cultural and economic factors that influence women's decisions in order to understand how and why women hold onto or surrender their traditional childbirth knowledges and practices, including the preservation of yiey maap, their favoured birth attendant. / Safe Motherhood initiatives were introduced into resource-poor countries by the World Health Organization in 1987 with the goal of reducing maternal mortality rates. They were based on the premise that pregnancy, childbirth and postpartum care were safer when provided by skilled birth attendants in a modern health facility. TBAs were not considered skilled birth attendants by Safe Motherhood partner agencies, as training and utilizing TBAs in Safe Motherhood initiatives did not have a measurable impact on maternal mortality rates. Instead, TBAs' roles have been recast, and TBAs are expected to be health promoters and educators, referral agents and information gatherers. / I argue that Khmer women do not engage with the modern health system because it is unfamiliar and expensive, and health personnel provide poor quality care. Instead, in times of obstetric emergencies, women attempt to negotiate their own and their family's safety through personal autonomy and agency. / I conclude by proposing alternative approaches and strategies, including the increased utilisation of yiey maap in Cambodian Safe Motherhood programs. A central question is whether the Ministry of Health, supported by bilateral and multilateral agencies, should train and utilize yiey maap or midwives in maternity care. I argue that both are of equal importance. Until yiey maap are valued for their contribution to, and enjoy equitable inclusion in midwifery care, initiatives that involve yiey maap as program "extras", who undertake peripheral tasks, will not reduce maternal mortality rates.

Traditional Birth Attendants (TBAs) are the primary health care providers for women at the time of childbirth in many parts of the world. In India, particularly in remote areas such as Garhwal, these women play a key role in maternal health. Training programmes for TBAs can lead to dramatic reductions in neonatal mortality as well as in maternal morbidity and mortality, due to improved hygienic practices at the time of delivery. Yet training programmes for TBAs often lack sociocultural relevance, and fail to incorporate an understanding of the TBAs' perceptions of the process of pregnancy and delivery. Understanding more about the role of the TBA as a diagnostician and a decision-maker within a given sociocultural context can make such training programmes more culturally congruent. This research report describes the way in which TBAs (dais) in Garhwal interpret obstetrical complications, and how they make decisions regarding the need for cosmopolitan medical care. TBAs in Garhwal interpret obstetrical complications using a variety of explanatory models, arising from an understanding of health and illness which shows influences of Vedic, Ayurvedic, folk and cosmopolitan medical models. These explanatory models often led to a perception of "danger” and the "dangerous case" which is widely divergent from the cosmopolitan medical model. Specific areas are identified where the dais' interpretation of "danger" was particularly divergent from the cosmopolitan medical model. These areas of conceptual conflict result in diagnoses and treatment procedures which can lead to significant delays in the woman receiving needed cosmopolitan medical care. The third stage of action-research process is the development of a participatory training programme, in which the TBA is an active participant. The aim of the training programme is to move towards a shared perception of risk regarding major obstetrical complications. / Thesis / Master of Arts (MA)

<p>This thesis presents perspectives and experiences of different stakeholders and their ways of reasoning around pregnancy and pregnancy care. Data were generated from individual interviews with 25 health care providers, 18 women and 6 traditional birth attendants (TBAs) as well as 11 focus groups discussions with women, men and TBAs. </p><p>The challenges experienced by health care providers in their provision of antenatal care, while attempting to change antenatal care through routines proven to have medical value, are highlighted. Changing some long established routines, such as weighing and timing of visits, proved difficult mostly because of resistance from the users of care, whose reasoning and rationale for using care did not correspond with the professional perspectives of care. </p><p>Women also combined biomedical and traditional care. The women used the clinic to receive professional care and assurance that the pregnancy was progressing well and used TBAs, who are believed to have supernatural powers, for cultural forms of assurance and protection. The health care staff did not appreciate these aspects and discouraged women using TBAs. Midwives had problems to change routines of care because of their stressful working situations and the expectations of the women.</p><p>In addition, they described the paradoxes in providing antenatal care in the context of HIV and AIDS. The caregivers were aware of the magnitude of HIV and AIDS and yet did not have any information on the HIV status of the women they cared for. This also caused fear for occupational transmission. HIV/AIDS is highly stigmatised in this area and women used various strategies to avoid testing.</p><p>The study emphasised the need to broaden the conceptualisation and practice of evidence-based care to incorporate different types of evidence and include realities, knowledge and perspectives of not only the beneficiaries but also those implementing change as well as local knowledge. The necessity of reorganising the health care systems to accommodate the new challenges of the HIV/AIDS epidemic is also emphasised.</p>

This thesis presents perspectives and experiences of different stakeholders and their ways of reasoning around pregnancy and pregnancy care. Data were generated from individual interviews with 25 health care providers, 18 women and 6 traditional birth attendants (TBAs) as well as 11 focus groups discussions with women, men and TBAs. The challenges experienced by health care providers in their provision of antenatal care, while attempting to change antenatal care through routines proven to have medical value, are highlighted. Changing some long established routines, such as weighing and timing of visits, proved difficult mostly because of resistance from the users of care, whose reasoning and rationale for using care did not correspond with the professional perspectives of care. Women also combined biomedical and traditional care. The women used the clinic to receive professional care and assurance that the pregnancy was progressing well and used TBAs, who are believed to have supernatural powers, for cultural forms of assurance and protection. The health care staff did not appreciate these aspects and discouraged women using TBAs. Midwives had problems to change routines of care because of their stressful working situations and the expectations of the women. In addition, they described the paradoxes in providing antenatal care in the context of HIV and AIDS. The caregivers were aware of the magnitude of HIV and AIDS and yet did not have any information on the HIV status of the women they cared for. This also caused fear for occupational transmission. HIV/AIDS is highly stigmatised in this area and women used various strategies to avoid testing. The study emphasised the need to broaden the conceptualisation and practice of evidence-based care to incorporate different types of evidence and include realities, knowledge and perspectives of not only the beneficiaries but also those implementing change as well as local knowledge. The necessity of reorganising the health care systems to accommodate the new challenges of the HIV/AIDS epidemic is also emphasised.

<p><font size="3"> <p>Namibia has recorded an ascending trend of maternal and neonatal mortality rate from 225 &ndash / 449 per 100 000 women from 1992 to 2006, and 38 &ndash / 46 per 1000 live births from 2000 to 2006 respectively. Kavango Region in Namibia is one among the top seven regions with high maternal and infant mortality rate. Most pregnant women in peri-urban areas of Rundu District in the Kavango region, where this study was conducted, attend ante-natal care services but do not use public health facilities for delivery. The health records from the public health facilities in Rundu, especially from Nkarapamwe clinic and Rundu Hospital maternity section, reveal that although the pregnant women comply with the required standard policy of a minimum of three visits per pregnancy or more, over 40% of women who attend public ante-natal care clinics do not deliver in the public health facility. The aim of this study was to explore the perceptions of women regarding obstetric care in public health facilities in Kehemu settlement, a peri-urban area of Rundu town. The objectives of the study were to explore the perceptions of women on accessibility and acceptability of maternity services in public health facilities. An explorative qualitative study design using focus group discussion as a data collection method was conducted with three groups of women. A purposeful sampling procedure was used to select participants. Ethical approval was obtained from the High Degree Committee of University of the Western Cape and permission to use data from local facilities was obtained from the Ministry of Health and Social Services. Participants were recruited on their own free will and they signed an agreement on confidentiality. A data reduction process was used for analysis. The study findings indicate that women wish to use public health facilities for deliveries due to perceived benefits, in particular, safety for the mother and the baby and that those services are<font size="3"> affordable. However a number of reasons hinder women to access services including the attitudes of health care providers, inability to afford transport at night and cultural influences. The study recommends that delivery services at the local clinic be expanded from eight to twenty-four hours / an information campaign on pregnancy and birth complications as well as the benefits of delivering in a public facility be implemented / refresher training for nurses to improve their caring practices during delivery should be considered and that a similar research be conducted with care providers to ascertain ways to improve maternity services in the public health facility in the area. </font></p> </font></p>

<p><font size="3"> <p>Namibia has recorded an ascending trend of maternal and neonatal mortality rate from 225 &ndash / 449 per 100 000 women from 1992 to 2006, and 38 &ndash / 46 per 1000 live births from 2000 to 2006 respectively. Kavango Region in Namibia is one among the top seven regions with high maternal and infant mortality rate. Most pregnant women in peri-urban areas of Rundu District in the Kavango region, where this study was conducted, attend ante-natal care services but do not use public health facilities for delivery. The health records from the public health facilities in Rundu, especially from Nkarapamwe clinic and Rundu Hospital maternity section, reveal that although the pregnant women comply with the required standard policy of a minimum of three visits per pregnancy or more, over 40% of women who attend public ante-natal care clinics do not deliver in the public health facility. The aim of this study was to explore the perceptions of women regarding obstetric care in public health facilities in Kehemu settlement, a peri-urban area of Rundu town. The objectives of the study were to explore the perceptions of women on accessibility and acceptability of maternity services in public health facilities. An explorative qualitative study design using focus group discussion as a data collection method was conducted with three groups of women. A purposeful sampling procedure was used to select participants. Ethical approval was obtained from the High Degree Committee of University of the Western Cape and permission to use data from local facilities was obtained from the Ministry of Health and Social Services. Participants were recruited on their own free will and they signed an agreement on confidentiality. A data reduction process was used for analysis. The study findings indicate that women wish to use public health facilities for deliveries due to perceived benefits, in particular, safety for the mother and the baby and that those services are<font size="3"> affordable. However a number of reasons hinder women to access services including the attitudes of health care providers, inability to afford transport at night and cultural influences. The study recommends that delivery services at the local clinic be expanded from eight to twenty-four hours / an information campaign on pregnancy and birth complications as well as the benefits of delivering in a public facility be implemented / refresher training for nurses to improve their caring practices during delivery should be considered and that a similar research be conducted with care providers to ascertain ways to improve maternity services in the public health facility in the area. </font></p> </font></p>