Introduction In sub-Saharan Africa the unmet need for contraception for married couples is estimated to be 24%, with rural, uneducated, poor women generally experiencing a greater risk for unplanned, unwanted pregnancies compared to their urban, educated, well informed counterparts. Recommendations for addressing unmet contraceptive need are inclined to emphasise family planning programmatic efforts. The role of men in contraceptive decisions tends to receive less attention, the perception being that men are often uninvolved and unsupportive of the contraceptive needs of their female partners. This study reviewed the attitudes and perceptions of men about contraceptive services in Engela District of the Ohangwena Region, Namibia. Methods A qualitative study was conducted using Focus Group Discussions (FGD) and Key Informant Interviews (KII) with men and women aged between 18-60 years residing in the Engela district of the Ohangwena Region. Men and women were purposively selected and participated in four and two focus group discussions respectively to explore the subject. Interviews with six influential and respected key informants, including government officials and community leaders were conducted. Data generated from the interviews were transcribed, coded, and content analysis conducted. Based on the research domain, themes and subthemes were generated. Purposive sampling was done. Many people were contacted to participate as participants in the research, some declined from participating due to lack of interest, and it was only those that were keen on participating that were enlisted by the research assistants. Influential leaders, respected in the community were also selected as KII. Results The findings revealed that specific reproductive health issues are common in the community, with a high level of awareness of family planning and contraceptives among men and women, many women having access to contraceptives Yet men held negative views about women’s decision to use contraceptives without their consideration and approval by them. The results indicated that community-level information was not ideal, and should be improved. Conclusion The study showed that most of the men who participated in the study are well informed about family planning and available contraceptive options for both men and women. It also revealed the attitudes and perceptions of men to FP and contraception use of women. However, there is little male involvement in contraceptive decisions.

Introduction: Malawi has one of the highest maternal mortality ratio (MMR) in sub-Saharan Africa (SSA). Despite investments in family planning and emergency obstetric care (EmOC), Malawi’s Millennium Development Goal (MDG) target of reducing maternal deaths to 155 deaths per 100,000 live births was not met by the end of 2015. Between 2010 and 2015, Malawi was only able to reduce the MMR from 675 to 439 per 100,000 live births. Inadequate utilisation of perinatal services is the contributing factor to the MMR target not being achieved. One approach for improving the utilisation of perinatal services is to invest in community health workers (CHWs). CHWs can be trained to: identify women of child bearing age (WCBA) who need perinatal services; provide community education; encourage timely referral of clients to the nearest health facility; and undertake community follow up for WCBA who are pregnant and/or have recently given birth. We evaluated changes in utilisation of antenatal care (ANC), facility based births, and postnatal care (PNC) after CHW deployment to conduct monthly home visits to WCBA for pregnancy identification and escorting women to ANC, labour and facility birth and PNC clinics in Neno district, Malawi. The CHW programme was implemented in two catchment areas from March 2015 to June 2016. Methodology: We employed a retrospective quasi-experimental study design to evaluate the impact of CHWs on changes in the utilisation of ANC, facility based births, and PNC in Neno district, Malawi between March 2014 and June 2016 (pre-intervention period: March 2014 to February 2015, and post- intervention period: March 2015 to June 2016). Monthly outcomes were compared between a combined CHW intervention area and its synthetic control area using the synthetic control method. The synthetic control area (or synthetic counterfactual of the CHW) was the control area that was created from multiple available control sites where the CHW programme was not implemented to allow the comparison of outcomes between the sites where CHWs were implemented and the sites where CHWs was not implemented. Two hundred and eleven CHWs (128 existing CHWs plus 83 new CHWs from the community) were trained in maternal health and deployed to cover an estimated 5,132 WCBA living in a catchment area of about 20,530 people. The primary focus of the CHWs was to conduct monthly household visits to identify pregnant women, and then escort pregnant women to their initial and subsequent ANC appointments, facility births, and to PNC check-ups. As part of package of care, community mobilisation and improvements in services to achieve a minimum package of services at the local health centres were also added. Using the synthetic control method, as developed by Abadie and Gardeazabal (2003) and Abadie, Diamond and Hainmueller (2010) and a Bayesian approach of synthetic control developed by Brodersen (2015), a synthetic counterfactual of the CHW intervention was created based on six available public control facilities. The synthetic counterfactual trend was created to have similar preintervention characteristics as the CHW intervention trend. The impact of the CHW intervention was the difference between the CHW intervention site and its synthetic counterfactual Results: CHWs in the intervention areas visited an average of 3,147 (range 3,036 – 3,218) of WCBA monthly, covering 61.0% of WCBA. During these visit 3.6% (97 women per month) of WCBA were suspected to be pregnant every month. Of those women suspected to be pregnant, 67.8% (66 women per month) were escorted to health facilities immediately every month. CHWs visited an average of 254 pregnant women enrolled in ANC and 64 women in postpartum period monthly. ANC and facility births utilisation in the CHW intervention site increased in comparison to the control site. Firstly, the number of new pregnant women enrolled in ANC per month increased by 18.0 % (95% Credible Interval (CrI) 8.0%, 28.0%), from 83 to 98 per pregnant women. Secondly, the proportion of women starting ANC in first trimester increased by 200.0% (95% CrI 162.0%, 234.0%), from 9.5% to 29.0% per month. Thirdly, the number of women attending four or more ANC visits increased by 37.0% (95% CrI 31.0%, 43.0%), from to 28.0% to 39.0%. Lastly, the number of facility births increases by 20% (CrI 13.0%, 28.0%), from 85 women to 102 per month. However, there was no net difference on PNC visits between the CHW intervention site and its counterfactual unit (-37.0%, 95% CrI -224.0%, 170.0%). Conclusions: CHW intervention significantly increased the utilisation of ANC and facility based births in Neno, Malawi. However, CHWs had no net difference on PNC utilisation.

Introduction: Tuberculosis is the second leading cause of death from an infectious cause worldwide having claimed approximately 1.5 million lives in 2013. Estimates suggest that children account for about six percent of the total number of TB cases globally, however in South Africa this figure is much higher (15%). Young children are at particularly high risk of mortality and significant morbidity from TB. Despite clear evidence that Isoniazid preventative therapy (IPT) can reduce the risk of progression from TB infection to disease, IPT has been a poorly implemented component of national TB control programmes, especially in high TB-burden areas, including South Africa. This study aims to determine current practices regarding the identification and management of child contacts < 5 years in an area with an extremely high TB incidence rate where little background data exists on the topic. It will also assess the operational aspects of the TB control programme relating to the spread of TB to children. Methodology: A cross-sectional descriptive study was conducted using a retrospective review of clinic records from infectious index patients aged ≥15 years at West End clinic in the Nelson Mandela Bay health district in the Eastern Cape Province. A sample size of 246 child contacts (<5 years) was required to obtain a 95% confidence index with a 5% precision. This is based on 20% of eligible child contacts < 5years receiving IPT, as described by van Wyk, et al. (2010). 491 Index patient records were assessed in order to identify 261 child contacts < 5 years of age. Results: Contacts were generally well recorded with only 12.5% of index patient folders having no contacts documented although only 0.53 child contacts <5years were identified per index patient. A total of 261 child contacts < 5 years were identified and of these 184 (70.5%) were screened for TB. Two contacts were started on TB treatment and 108/184 (58.7%) were initiated on TB prevention therapy. For the remaining 74 (40.2%) children who were screened there was no documentation of further management. Adherence to IPT was extremely poor with only 4 (3.7%) children who started TB prevention completing the 24 week course. Female index patients were more likely to have contacts documented and to bring their contacts for screening. Contacts of index 16 patients who had previous TB were less likely to be screened and initiated on TB prevention therapy. The results of the assessment of programmatic factors relating to childhood TB control showed that patients were diagnosed and were rapidly initiated on treatment (median time of 5 days from sputum collection to commencement of treatment). It took a median of 4 days for children to be screened once the index patient had started treatment and a further 2 days (median) for child contacts < 5 years to be initiated on preventative therapy. Conclusion and recommendations: The results of this study are in keeping with those obtained in other settings with a high burden of TB. Although the documentation of contacts in this setting was relatively good, child contacts < 5 years were poorly identified and the fall-out of children at each step from identification to preventative treatment completion was still unacceptably high. Contacts of men and retreatment index patients are at particularly high risk of poor management. Recommendations are made for interventions at national and local level to improve contact management and the documentation thereof.

Includes bibliographical references (leaves 71-76). / The aim of this study is to implement Perinatal Problem Identification Programme (PPIP) at public health facilities in the Emfuleni Sub-district, this will document the medical conditions that led to perinatal deaths and describe the avoidable factors, missed opportunities and sub-standard care.

Includes bibliographical references. / Mpigi District is a rural district in Uganda with high maternal morbidity and mortality. While most pregnant women in Uganda attend antenatal clinics, few ultimately deliver their babies in a health facility. Interventions have not achieved increased utilisation of maternal services. A review of maternal determinants and factors associated with health facility delivery is the focus of this study. To determine the reasons why women deliver in health facilities; to identify the maternal determinants or factors associated with health facility delivery; and to determine the socio-demographic characteristics of women who deliver in health facilities. This quantitative, descriptive, cross-sectional study of 257 women who delivered in the Mpigi District in 2008/2009 used face-to-face interviews at which a questionnaire was administered. Women delivered in health facilities because they expected a safe delivery. Ten factors were found to be significantly associated with a higher possibility of health facility delivery: eight or more years of education (P=0.002); previous health facility delivery (P<0.0001); first delivery in a health facility (P<0.0001); no history of a non-health facility delivery (P <0.0001); more than 50% of deliveries in a health facility (P=0.007); three or more antenatal care visits (P=0.031); above-average socio-economic status (P=0.016); living in a household of three or fewer individuals (P=0.028); living within 30 minutes? travel time of a health facility (P=0.007); and history of contraceptive use (P=0.046). These are the maternal determinants of health facility delivery in this rural setting. The mothers that delivered in health facilities were 15 and 29 years old (85.2%), either married or cohabiting (77.5%), had completed eight years or more of formal education (53.5%), lived within a radius of up to 30 minutes? journey from a health facility (67.2%) and lived in a household of four or more individuals (76.0%). This study shows that there are specific maternal characteristics (sociodemographic descriptors) that are associated with increased possibility of health facility delivery.

Bibliography: leaves 79-84. / Background: While there is a lot of literature available on the negative effects of orphanhood on children, litle attention has been paid to children in the period before their parents die when they are living with a sick parent. This study seeks to focus on such children to gain greater understanding of their situation. Aim: To describe the problems and coping strategies of children living with and caring for their terminally ill parents. Design: This study is a cross-sectional descriptive survey. Setting: A rural district in a middle-income country. Main outcome measures: Demography of households, symptoms of the sick parent, attributes of child carers, how children deal with specified symptoms of their parent's illness, greatest perceived hardships faced, type and quantity of help from outside sources and extended family. Results: Thirty five households were interviewed using a structured questionnaire. Households were found to be poor with difficulty accessing services. Most parents had symptoms consistent with AIDS and over 30% died within two months of the interview. Pain ranked as the most troublesome symptom. One hundred children aged four to eighteen were involved to some extent in the care of their sick parents. Male children were the main carers in 40% of households. The children generally dealt appropriately with the parents' symptoms and correcdy identified what pills they were taking and what the pills were for. Seventy one percent of carers believed that their parent would get better. The children identified their greatest hardships as hunger (43%), lack of money for school (29%) and parent's illness (19%). Sixty nine percent asked for material support and the same number reguested financial support for schooling. Support frum relatives was mostly provided by grandmothers and aunts. Five provided food, five cared for the sick person and three helped with child care. Ten of the 35 households were never visited by relatives staying outside the homestead. From the wider community, neighbours were the most supportive group practically, helping with food and nursing. Church groups were active in praying with families but most did not help materially or practically. Eight families received support from local non-governmental organisations and only two were visited by the Department of Welfare. Conclusions: Poverty was the overriding issue negatively impacting on the families. It prevented adequate access to health care, nutrition and schooling. Poor infrastructure and government services further compounded these problems as well as preventing access to water, sanitation, education and government grants. Children were often found to be caring for their parents with little external support and would benefit from training as well as supervision and counselling from trained health workers. The children's role as carers frequently interfered with school attendance yet many of their teachers were unaware of their home circumstances and did little to support them. Teachers' awareness of the social problems facing learners needs to be raised. Support by the extended family and community is often superficial and generally targets the sick parent while ignoring the children. Greater attention needs to be paid to the psychological and matenal needs of the children in these vulnerable families.

Includes bibiliographical references. / Mycobacterium bovis Bacille Calmette Guerin (BCG) is the only licensed tuberculosis (TB) vaccine. Despite the immunisation of 3 billion individuals with this vaccine, TB remains a major cause of mortality worldwide. Therefore, there is an urgent need for more effective TB vaccines. BCG is likely to remain central to future TB prevention strategies, which could include a BCG prime at birth, followed by boosts with novel TB vaccines within the first year of life, or at later ages. Therefore, a comprehensive understanding of BCG induced immunity is required for the successful design and implementation of novel TB vaccination strategies. This was addressed in the following two studies.The aim of the first study was to characterise specific T cell immunity following BCG vaccination. These data are critical to determine when to optimally boost BCG induced immunity in infants. We enrolled infants routinely vaccinated with BCG at birth, and determined the frequency of T cells induced by immunisation, at various time points over the first year of life. The T cells were identified by binding of cell surface markers and characterised by cell-specific cytokine production, following 12 hr incubation of infant whole blood with BCG. Multiparameter flow cytometry was used for the analysis. We found that the peak vaccine induced CD4+ T cell response occurred at 10 weeks, followed by a contraction phase. BCG specific CD4+ T cells became more poly functional, and acquired the profile of long-lived T cells (measured by Bcl-2 expression), over the first year of life.

The availability of an effective vaccine against Bordetella pertussis substantially reduced the morbidity and mortality from pertussis, however, in the last decade there appears to have been a substantial increase in pertussis cases as reported mainly in high income countries. Although it is believed that the greatest burden of pertussis, including deaths, is in low- and middle-income countries (LMICs), there seem to be little data available to back this up. This thesis set out to find data that will give some insight into the burden of pertussis in a low- and middle-income setting in infants and children with severe lower respiratory tract infection (LRTI). Given the paucity of data in LMICs, the thesis started by systematically searching for existing data that will give some indication of the possible extent of the pertussis problem in these countries. Secondly, a prospective study was conducted at a children's hospital. As hospital admission is a marker of severe disease, these children were targeted as the appropriate population in which to meaningfully conduct a primary study on the burden of pertussis. In addition to quantifying the burden by describing the prevalence of confirmed pertussis in this group of children, the study set out to look for potential factors that may be associated with increased risk of pertussis. LRTI are now commonly known to be associated with identification of multiple organisms in respiratory samples, this study aimed to also look at organisms that are detected with Bordetella pertussis; and investigate whether this association was in any way associated with severe disease or negative outcomes. Finally, this study hoped to identify clinical features that could be used to develop a more reliable clinical case definition of pertussis. Chapter 1 gives a background that justifies the undertaking of this study. In chapter 2 a systematic review quantifies, using the best available data, the burden of pertussis in LMICs. Chapter 3 clarifies the methods briefly described in the rest of the manuscript. The burden of pertussis due to the two organisms known to cause the disease, Bordetella pertussis and Bordetella parapertussis, is described in some detail. In both this chapter and the earlier mentioned systematic review (chapter 2), the burden of pertussis is stratified by subgroups to identify potential risk factors. The issue of risk is formally and specifically taken up in the chapter that follows (chapter 5) where potential risk factors are analysed, and the independent impact for some of these factors is established. The last two results chapters (chapters 6 and 7) deal respectively with the conundrum of finding other respiratory organism in the same specimen with Bordetella pertussis and failure to find useful clinical criteria that can help with improved diagnosis of pertussis. While there is no established pattern noted between pertussis and most organisms, a few give signals of being independently associated with Bordetella pertussis even if the clinical relevance is not clear at the moment. In the final chapter of the thesis (chapter 8) I conclude the thesis by making an argument that although there are still knowledge gaps, the thesis gives a clear indication that pertussis remains a serious problem in LMICs especially for some groups that show increased risk of the disease or its severe consequences.

Background. There are inconsistent published data describing the influence of anaesthetic type during caesarean section (CS), on outcomes of preterm neonates. Objectives. To describe indications and type of anaesthesia in preterm neonates and to describe short-term outcomes, comparing spinal anaesthesia (SA) to general anaesthesia (GA). Methods. Data were collected retrospectively on preterm babies born at 28 – 35 weeks' gestation by CS, between 1 January and 30 Sep 2014 at Groote Schuur Hospital, Cape Town, South Africa. Babies with missing data were excluded. The largest group of babies with similar indications for delivery were identified from the theatre register. Baseline characteristics and short-term outcomes for this group were extracted from an existing prospective data base, and compared between those delivered under SA and GA. Results. Data were available for 226 deliveries, having excluded 23 with incomplete data. Most babies (75%) were delivered under SA. The most common indication for CS was ‘cardiotocograph abnormalities,' in 139 deliveries. Within this group, SA was more frequent (81.7% vs. 12.9%) while GA was associated with lower Apgar scores (p < 0.001) and more intubation at birth (p = 0.004). There was no difference in mortality when comparing SA with GA. Conclusion. Our data suggest a sedative effect of maternal GA on preterm babies delivered by CS, and the need for staff with advanced resuscitation skills. This study provides novel baseline data in our setting, but these data need to be validated in a prospective study.

The availability of an effective vaccine against Bordetella pertussis substantially reduced the morbidity and mortality from pertussis, however, in the last decade there appears to have been a substantial increase in pertussis cases as reported mainly in high income countries. Although it is believed that the greatest burden of pertussis, including deaths, is in low- and middle-income countries (LMICs), there seem to be little data available to back this up. This thesis set out to find data that will give some insight into the burden of pertussis in a low- and middle-income setting in infants and children with severe lower respiratory tract infection (LRTI). Given the paucity of data in LMICs, the thesis starts by systematically searching for existing data that will give some indication of the possible extent of the pertussis problem in these countries. Secondly, a prospective study was conducted at a children's hospital. As hospital admission is a marker of severe disease, these children were targeted as the appropriate population in which to meaningfully conduct a primary study on the burden of pertussis. In addition to quantifying the burden by describing the prevalence of confirmed pertussis in this group of children, the study set out to look for potential factors that may be associated with increased risk of pertussis. LRTI are now commonly known to be associated with identification of multiple organisms in respiratory samples, this study aimed to also look at organisms that are detected with Bordetella pertussis; and investigate whether this association was in any way associated with severe disease or negative outcomes. Finally, as data has been emerging that in the context of immunisation, the clinical presentation of pertussis may no longer be following a classical pattern, this study hoped to identify clinical features that could be used to develop a more reliable clinical case definition of pertussis. 2 Chapter 1 gives a background that justifies the undertaking of this study as well as give a summary of the methods used to answer the question of the thesis. The chapter also gives an indication of the structure that the thesis follows. In chapter 2 a systematic review quantifies the burden of pertussis in LMICs using the best available data. In chapter 3 the burden of pertussis due to the two organisms known to cause the disease, Bordetella pertussis and Bordetella parapertussis, is described in some detail. In both this chapter and the earlier mentioned systematic review (chapter 2), the burden of pertussis is stratified by subgroups to identify potential risk factors. The issue of risk is formally and specifically taken up in the chapter that follows (chapter 4) where potential risk factors are analysed, and the independent impact for some of these factors is established. The last two results chapters (chapters 5 and 6) deal respectively with the conundrum of finding other respiratory organism in the same specimen with Bordetella pertussis and failure to find useful clinical criteria that can help with improved diagnosis of pertussis, specifically in children presenting with acute severe lower respiratory tract infection. While there is no established pattern noted between pertussis and most organisms, a few give signals of being independently associated with Bordetella pertussis even if the clinical relevance is not clear at the moment. In the final chapter of the thesis (chapter 7) I conclude the thesis by making an argument that although there are still knowledge gaps, the thesis gives a clear indication that pertussis remains a serious problem in LMICs especially for some groups that show increased risk of the disease or its severe consequences.