Thesis (PhD)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: When estimating the covariance matrices of two or more populations, the covariance matrices are often assumed to be either equal or completely unrelated. The common principal components (CPC) model provides an alternative which is situated between these two extreme assumptions: The assumption is made that the population covariance matrices share the same set of eigenvectors, but have di erent sets of eigenvalues. An important question in the application of the CPC model is to determine whether it is appropriate for the data under consideration. Flury (1988) proposed two methods, based on likelihood estimation, to address this question. However, the assumption of multivariate normality is untenable for many real data sets, making the application of these parametric methods questionable. A number of non-parametric methods, based on bootstrap replications of eigenvectors, is proposed to select an appropriate common eigenvector model for two population covariance matrices. Using simulation experiments, it is shown that the proposed selection methods outperform the existing parametric selection methods. If appropriate, the CPC model can provide covariance matrix estimators that are less biased than when assuming equality of the covariance matrices, and of which the elements have smaller standard errors than the elements of the ordinary unbiased covariance matrix estimators. A regularised covariance matrix estimator under the CPC model is proposed, and Monte Carlo simulation results show that it provides more accurate estimates of the population covariance matrices than the competing covariance matrix estimators. Covariance matrix estimation forms an integral part of many multivariate statistical methods. Applications of the CPC model in discriminant analysis, biplots and regression analysis are investigated. It is shown that, in cases where the CPC model is appropriate, CPC discriminant analysis provides signi cantly smaller misclassi cation error rates than both ordinary quadratic discriminant analysis and linear discriminant analysis. A framework for the comparison of di erent types of biplots for data with distinct groups is developed, and CPC biplots constructed from common eigenvectors are compared to other types of principal component biplots using this framework. A subset of data from the Vermont Oxford Network (VON), of infants admitted to participating neonatal intensive care units in South Africa and Namibia during 2009, is analysed using the CPC model. It is shown that the proposed non-parametric methodology o ers an improvement over the known parametric methods in the analysis of this data set which originated from a non-normally distributed multivariate population. CPC regression is compared to principal component regression and partial least squares regression in the tting of models to predict neonatal mortality and length of stay for infants in the VON data set. The tted regression models, using readily available day-of-admission data, can be used by medical sta and hospital administrators to counsel parents and improve the allocation of medical care resources. Predicted values from these models can also be used in benchmarking exercises to assess the performance of neonatal intensive care units in the Southern African context, as part of larger quality improvement programmes. / AFRIKAANSE OPSOMMING: Wanneer die kovariansiematrikse van twee of meer populasies beraam word, word dikwels aanvaar dat die kovariansiematrikse of gelyk, of heeltemal onverwant is. Die gemeenskaplike hoofkomponente (GHK) model verskaf 'n alternatief wat tussen hierdie twee ekstreme aannames gele e is: Die aanname word gemaak dat die populasie kovariansiematrikse dieselfde versameling eievektore deel, maar verskillende versamelings eiewaardes het. 'n Belangrike vraag in die toepassing van die GHK model is om te bepaal of dit geskik is vir die data wat beskou word. Flury (1988) het twee metodes, gebaseer op aanneemlikheidsberaming, voorgestel om hierdie vraag aan te spreek. Die aanname van meerveranderlike normaliteit is egter ongeldig vir baie werklike datastelle, wat die toepassing van hierdie metodes bevraagteken. 'n Aantal nie-parametriese metodes, gebaseer op skoenlus-herhalings van eievektore, word voorgestel om 'n geskikte gemeenskaplike eievektor model te kies vir twee populasie kovariansiematrikse. Met die gebruik van simulasie eksperimente word aangetoon dat die voorgestelde seleksiemetodes beter vaar as die bestaande parametriese seleksiemetodes. Indien toepaslik, kan die GHK model kovariansiematriks beramers verskaf wat minder sydig is as wanneer aanvaar word dat die kovariansiematrikse gelyk is, en waarvan die elemente kleiner standaardfoute het as die elemente van die gewone onsydige kovariansiematriks beramers. 'n Geregulariseerde kovariansiematriks beramer onder die GHK model word voorgestel, en Monte Carlo simulasie resultate toon dat dit meer akkurate beramings van die populasie kovariansiematrikse verskaf as ander mededingende kovariansiematriks beramers. Kovariansiematriks beraming vorm 'n integrale deel van baie meerveranderlike statistiese metodes. Toepassings van die GHK model in diskriminantanalise, bi-stippings en regressie-analise word ondersoek. Daar word aangetoon dat, in gevalle waar die GHK model toepaslik is, GHK diskriminantanalise betekenisvol kleiner misklassi kasie foutkoerse lewer as beide gewone kwadratiese diskriminantanalise en line^ere diskriminantanalise. 'n Raamwerk vir die vergelyking van verskillende tipes bi-stippings vir data met verskeie groepe word ontwikkel, en word gebruik om GHK bi-stippings gekonstrueer vanaf gemeenskaplike eievektore met ander tipe hoofkomponent bi-stippings te vergelyk. 'n Deelversameling van data vanaf die Vermont Oxford Network (VON), van babas opgeneem in deelnemende neonatale intensiewe sorg eenhede in Suid-Afrika en Namibi e gedurende 2009, word met behulp van die GHK model ontleed. Daar word getoon dat die voorgestelde nie-parametriese metodiek 'n verbetering op die bekende parametriese metodes bied in die ontleding van hierdie datastel wat afkomstig is uit 'n nie-normaal verdeelde meerveranderlike populasie. GHK regressie word vergelyk met hoofkomponent regressie en parsi ele kleinste kwadrate regressie in die passing van modelle om neonatale mortaliteit en lengte van verblyf te voorspel vir babas in die VON datastel. Die gepasde regressiemodelle, wat maklik bekombare dag-van-toelating data gebruik, kan deur mediese personeel en hospitaaladministrateurs gebruik word om ouers te adviseer en die toewysing van mediese sorg hulpbronne te verbeter. Voorspelde waardes vanaf hierdie modelle kan ook gebruik word in normwaarde oefeninge om die prestasie van neonatale intensiewe sorg eenhede in die Suider-Afrikaanse konteks, as deel van groter gehalteverbeteringprogramme, te evalueer.

Background: Preconception care (PCC) is highly recommended evidence-based intervention to optimize women’s health in particular and in so doing reduce the incidences of adverse pregnancy outcomes (APO). PCC targets modification of risk factors to APO occurring before and just at early weeks of conception. Nevertheless, in Ethiopia, the need to implement PCC as part of the continuums of the comprehensive Maternal, Neonatal and Child Health Care services is not yet studied. Purpose/Aim of the study: This study aimed to develop a guideline to assist the incorporation of PCC in Ethiopian health system thereby reduce the highly incident APOs in the country, which is the purpose of the study. Methodology: This study applied the explanatory sequential mixed method to determine the determinants to the non-implementation PCC in Ethiopia. In addition, a policy document analysis was conducted to identify the existence of policy guiding the implementation of PCC in Ethiopia. Finally, the study applied a Delphi technique to increase the utility and acceptance of the guideline developed. The study was guided by a theory based framework called a Framework for Determinants of Innovation Processes (FDOIP). RESULT: Nearly all (84.7%) of the healthcare providers (HCPs) never ever practiced PCC. Even among those who ever practiced, the majority (74%), practiced it poorly. More than two third (68.6%) had poor PCC knowledge. HCP’s with good PCC knowledge had likely hood of practicing PCC by four times greater than those with poor PCC knowledge (AOR=4.4, 95% CI: 2.5-7.6). The policy document analysis identified the absence of policy guiding the practice of PCC in Ethiopia. The HCP’s curriculums also didn’t include PCC. The determinants to non-implementation of PCC, as perceived by the qualitative study participants include absence of national PCC policy , absence of PCC guideline, lack of institutional PCC plan, presence of other competing demand, lack of laboratory facilities and setup, lack of accountable body, absence of Individual or organization introduced PCC to the country, absence of trained manpower on PCC, absence of known expert in PCC, Poor public awareness about preconception health and PCC, Unplanned Pregnancy and poor health seeking behaviour. CONCLUSION The study revealed the absence of a standard and complete PCC practices by the HCPs. Nearly all HCPs never ever implement PCC. Even those very few practitioners were found practicing PCC poorly that is in a substandard, incidental, and in an inconsistent way. There is no formal policy document guiding the implementation of in Ethiopia. The HCPs training curriculum didn’t include PCC. The guideline developed base on the study findings of the study recommended to incorporating PCC in Ethiopia health system. / Health Studies / D. Litt. et Phil. (Health Studies)

PhDH / Department of Advanced Nursing Science / Background: The National Committee for the Confidential Enquiries into Maternal Deaths recommend the implementation of “Saving Mothers’ recommendations” as a measure to reduce maternal deaths. However, this objective has not been achieved because the Maternal Mortality Rate in South Africa was standing at 134.33/100 000 live births and Limpopo Province at 165.16/100 000 live births. The national target for reduction of maternal mortality was 20% for all provinces for 2016. Limpopo Province’s reduction was below 12.5% for 2016. Purpose: The purpose of the study was to develop a strategy to enhance the implementation of the Saving Mothers’ recommendations in the maternity units of Limpopo Province. Methods: The convergent parallel design was used in this study. The study was conducted in phases, namely: Phase 1(a) was a qualitative research approach and a non-experimental, descriptive and exploratory design. The population consisted of district managers who were managing the Maternal Health Services and registered midwives who were working in the maternity units of Limpopo Province. Non-probability purposive sampling was used for both the district managers and the registered midwives. Data were collected using a central question for the managers managing Maternal Health services which was “What support are you giving to facilitate the implementation of the recommendations by the Saving Mothers Report?” and the question for the registered midwives was “What challenges are you experiencing when implementing the Saving Mothers’ recommendations.” Tesch’s open-coding technique was used to analyse qualitative data. Trustworthiness was ensured through credibility, confirmability, dependability, transferability and authenticity. Phase 1(b) was a quantitative and a non-experimental descriptive design. The population comprised of 200 patients who were included in the study. Questionnaires were developed and used to collect ABSTRACT vi data. Data was analysed using the Statistical Package for Social Sciences (SPSS, version 24.0) with the assistance of the statistician. Discussion of data were done in an explanatory sequential way where data from Phase 1a was discussed and supported by data from Phase 1b. Findings: The themes that emerged were: Challenges related to implementation of the recommendations of the Saving Mothers Report in maternity units, Description of existing training programmes and in-service education for health care professionals, Knowledge on implementing recommendations for the Saving Mothers Report when providing care in maternity units and Suggestions related to improvement of adherence to recommendations for the Saving Mothers Report in maternity units. Some of the themes were supported by the quantitative results whilst some not supported. Validity and reliability were ensured by giving the questionnaires to experts on the subject, colleagues and promoters to analyse and determine if items adequately represent content in the correct proportion. Ethical considerations were ensured by obtaining ethical approval from the University of Venda Ethics Committee and permission to access the facilities from the Limpopo Province Department of Health. The participants signed informed written consent. Phase 2 entailed strategy development and validation of the developed strategy. Recommendations: The recommendations included that the Department of Health should employ more staff and put operational managers in permanent positions. Sufficient equipment and supplies essential for maternal health care and maternal health infrastructure should be procured and a good plan for the managing thereof implemented. It is also recommended that health care workers should work hand in hand with the community structures and the ‘mosate’. / NRF

Background Pregnancy and childbirth are normal physiological processes but the internal and external circumstances in which the child is conceived and born affect the life of the mother and child. Every pregnancy is associated with unpredictable risks and complications. Therefore, having a birth preparedness and complication prevention plan including safe motherhood are paramount to reduce maternal and infant mortality rates. Purpose of the study This study aimed to establish the pregnant women’s knowledge, perceptions and practices regarding birth preparedness planning, complication readiness and safe motherhood at Raleigh Fitkin Memorial Hospital to help reduce some of the avoidable causes of maternal and infant mortality rates. Research design and methods An exploratory, descriptive and qualitative research design was used for the study. Women who had delivered within a period of one week were purposively selected from the research site and interviewed using a structured interview guide until saturation of data. Ethical considerations were adhered to and measures of trustworthiness were applied. Giorgi’s analytic method was used for data analysis. Findings The findings revealed that most participants were not well informed about birth preparedness although some had managed to save for baby requirements and hospital fees. Transportation to the hospital for ANC and delivery was a problem to those who ended up delivering their babies at home or on the way to hospital. Knowledge about complications of birth was poor and only a few participants could name bleeding and prolonged labour. Most participants were not sure about safe motherhood, whilst some mentioned contraception and post-natal care. Conclusion Evidence from the study reveal that as much as pregnant women prepare baby’s clothes and money for labour and delivery, psychological preparation and transport preparation seemed poor. Complication readiness was not known by most participants. / Health Studies / M.A. (Health Sciences)

In 2011, African Americans in Tarrant County, Texas experienced an infant mortality rate of 14.3 per 1,000 live births. The leading cause of infant mortality in Tarrant County is prematurity and maternal nutritional status. Both maternal under-nutrition and over-nutrition are known risk factors for premature birth. Improving maternal nutrition, by reducing rates of gestational diabetes and preeclampsia, and by increasing consumption of essential prenatal vitamins and nutrients, is a road to decreasing preterm birth in African Americans. This qualitative study, based on both anthropology and public health theory, of the nutrition behavior of a group of African American expectant mothers and the experience of their health care providers and co-facilitators had a goal to provide a foundation for future development of nutrition behavior research and education for this specific population. The main finding of this study was the substantial gap of lived experience and education between the patients and their providers and co-facilitators, which hinders delivery of care and the patients’ acquiescence to nutrition recommendations. The discrepancies between the authoritative knowledge of the providers and the bodily knowledge of expectant mothers were responsible for the ineffectiveness of nutrition recommendations.

Du fait de son impact sur la morbidité et la mortalité infantile, ainsi que de ses implications sur la santé à l’âge adulte, le petit poids de naissance constitue un problème majeur de santé publique. Le Burkina Faso, pays sahélien enclavé au cœur de l’Afrique occidentale est classé dans le groupe des pays pauvres très endettés et présente une forte prévalence de petit poids de naissance, imputable dans la majorité des cas au retard de croissance intra-utérine. Le contexte de ce travail, réalisé en milieu rural, se caractérise par une situation socioéconomique précaire se traduisant par un faible niveau des indicateurs de l’état de santé et une faible accessibilité aux services sociaux de base.<p><p>Objectifs, hypothèses<p>Ce travail repose sur les hypothèses que les facteurs socioéconomiques influencent la survenue du petit poids de naissance et que le petit poids de naissance a un impact négatif sur la croissance et la survie au cours de la première année de vie. <p>Ce travail s’est fixé pour objectifs de :<p>•connaître l’importance du petit poids de naissance à terme ;<p>•analyser les déterminants du petit poids de naissance ;<p>•proposer un score pour l’identification des femmes enceintes à risque de mise au monde d’un enfant de petit poids ;<p>•identifier les facteurs influençant la croissance des enfants nés de petit poids ;<p>•étudier l'impact du déficit pondéral à la naissance sur la morbidité et la mortalité infantile ;<p>•formuler des recommandations pour la prévention et la prise en charge du petit poids de naissance en milieu défavorisé dans le but d’orienter les stratégies de réduction de la mortalité infantile.<p><p>Méthodologie<p>Trois types d’études ont été réalisés:<p>•une étude de cohorte rétrospective portant sur 435 enfants dans le but d’explorer les facteurs de risque, la croissance, le statut nutritionnel et la mortalité des enfants nés de petit poids de naissance à terme.<p>•Une étude transversale portant sur 1013 naissances vivantes à terme qui a permis de déterminer la fréquence du petit poids de naissance et d’analyser les facteurs associés qui lui étaient associés.<p>•Une étude de cohorte prospective au cours de laquelle les 1013 enfants enrôlés dans l’étude transversale ont été suivis afin d’analyser leur croissance et leur survie au cours des 12 premiers mois de vie.<p><p>Principaux résultats <p>•Le petit poids de naissance représente 15,8% des naissances à terme. <p>•Le sexe féminin est prédominant chez les enfants de petit poids.<p>•Les facteurs sociodémographiques associés au petit poids de naissance sont essentiellement des caractéristiques sociodémographiques maternelles :le jeune âge de la mère (moins de 20 ans), le faible niveau d’instruction, le mauvais état nutritionnel et la faible accessibilité géographique aux structures de santé.<p>•Les facteurs obstétricaux associés au petit poids sont :la primiparité, la survenue de vomissements gravidiques, l’exécution de travaux champêtres et une charge de travail plus importante en cours de grossesse.<p>•Le score proposé pour l’identification des femmes à risque a un pouvoir de discrimination acceptable et présente une bonne stabilité et une faible marge d’erreur de prédiction.<p>•Indépendamment de la catégorie de poids à la naissance, tous les enfants demeurent en dessous des médianes des courbes de référence internationales pour l’ensemble des indices nutritionnels entre 0 et 12 mois. <p>•Malgré des gains plus importants mais de façon non significative, les enfants de PPN montrent une incapacité à combler leur retard en taille et en poids.<p>•Le PPN est associé à un risque significativement plus élevé de retard de croissance et d’insuffisance pondérale au cours de la première année de vie.<p>•Le petit poids de naissance et la non-complétude de la consultation prénatale étaient associés à un risque deux fois plus important de décès. <p>•L’état nutritionnel à l’âge de 3 mois ainsi qu’à l’âge de 6 mois joue un rôle plus important dans la survie chez les enfants de PPN que chez les enfants nés de poids normal.<p><p> <p>Conclusions<p>Les solutions au problème du petit poids de naissance impliquent un paquet d’interventions intégrant des stratégies avant, pendant et après la grossesse et des programmes de prise en charge ciblant les enfants de petit poids après leur naissance. Il s’agit prioritairement de :<p>•l’information et de la sensibilisation des populations pour un meilleur suivi de la grossesse et une complétude de la consultation prénatale ;<p>•l’adoption de pratiques et d’habitudes en faveur d’une alimentation équilibrée des femmes enceintes ;<p>•un plaidoyer pour un allègement de la charge de travail des femmes enceintes ;<p>•l’utilisation de méthodes opérationnelles pour l’identification des femmes à risque ;<p>•l’amélioration de la qualité des prestations de surveillance de la grossesse ;<p>•la redéfinition du contenu et des protocoles des programmes de suivi et de promotion de la croissance des jeunes enfants avec une attention particulière pour les enfants nés de petit poids ;<p>•la lutte contre certaines pratiques sociales comme les mariages précoces et les grossesses chez les adolescentes et les femmes de moins de 20 ans ;<p>•la promotion de la scolarisation des jeunes filles et l’alphabétisation des mères ;<p>•l’amélioration de l’état nutritionnel de la population ;<p>•la réalisation d’études pour évaluer l’impact de certains déterminants et interventions sur l’incidence du petit poids et le devenir des enfants nés avec un handicap pondéral :rôle de l’infection palustre, interventions nutritionnelles ciblant les enfants de petit poids, apports nutritionnels pendant la grossesse.<p><p>Summary<p><p>Due to its impact on infant morbidity and mortality, and its effects on adult’s health, low birth weight (LBW) is a major issue in the public health sector. Burkina Faso, a Sahelian country land-locked in the heart of West Africa is listed among the heavily indebted poor countries, with a high prevalence of Low Birth Weight, caused in most cases by intra uterine growth retardation. The context of the current study, conducted in urban area, is characterised by a poor socio-economic situation resulting in weak health indicators and difficult access to the basic social services.<p><p>Objectives, assumptions<p><p>The study is based o the assumptions that socio-economic factors have an influence on the occurrence of Low Birth Weight and that Low Birth Weight has a negative impact on growth and survival during the first year of the infant.<p>The study has the following objectives:<p>•To assess the importance of low birth weight a term;<p>•To analyse the determinant factors of low birth weight;<p>•To suggest a classification for the identification of pregnant women at risk of giving birth to low birth weight infants ;<p>•To identify factors which have an impact on the growth of low birth weight children ;<p>•To look at the impact of body weight deficiency at birth on infant morbidity and mortality ;<p>•To give recommendations on the prevention and treatment of low birth weight children from underprivileged background with the aim to orientate strategies for infant mortality reduction.<p><p>Methodology<p>Three types of studies were conducted:<p>•A retrospective cohort study of 435 children aiming at exploring risk factors, growth, nutritional status, and mortality of low birth weight infants in the long run.<p>•A cross-sectional study of 1013 live full-term births, which led to determining the frequency of low birth weight and at analysing associated factors which are linked to low birth weight.<p>•A prospective cohort study during which the 1013 children taken into consideration for the cross-sectional study were followed up so as to analyse their growth and survival all along the first 12 months of their life.<p><p>Main results<p>•Low birth weight represents 15.8% of full-term births.<p>•Female babies are predominant among low birth weight babies.<p>•Socio-demographic factors linked to low birth weight are mainly maternal socio-demographic characteristics: young mother (below 20 years old), low educational level, poor nutritional status and limited geographical access to health infrastructures.<p>•Obstetrical factors linked to low birth weight are the following: primiparity, occurrence of vomiting during pregnancy, field work and a heavier workload during pregnancy.<p>•The suggested classification for the identification of women at risk proves to have an acceptable power of discrimination and shows good stability and limited margin of error for prediction.<p>•Regardless of weight categories at birth, all children remain below medians of international reference curves for all nutritional indicators between 0 and 12 months. <p>•In spite of more important but not significant weight gains, LBW children prove not to be able to catch up on height and weight.<p>•LBW is linked to a significantly higher risk in growth retardation and weight deficiency during the newborn’s first year of life.<p>•LBW and non-complete antenatal visits are linked to a death risk multiplied by two.<p>•The nutritional status at the age of 3 months and 6 months old plays a more important role in the survival in LBW children than in children born with normal weight.<p><p>Conclusions<p>Solutions to LBW imply a package of interventions which should integrate strategies before, during and after pregnancy, together with treatment programmes targeting LBW children after their birth. In priority, these are:<p>•Information and awareness given to population for a better follow-up of pregnancies and complete cycles antenatal visits ;<p>•New practices and habits to be taken on favouring a balanced diet of pregnant women ;<p>•Advocacy actions aiming at reducing the workload of pregnant women ;<p>•The use of operational methods to identify women at risk ;<p>•Improving the quality of monitoring of pregnancy; <p>•Redefined content and procedures of monitoring programs and promoting young children growth, with particular focus on LBW children ;<p>•The fight against some social practices such as early marriages and pregnancies of teenagers and women below 20 years;<p>•The promotion of school education for young girls and literacy for mothers ;<p>•Improving the nutritional status of the population;<p>•The realisation of studies to assess the impact of some determinant factors and interventions on the occurrence of low birth weight and on the future of children born with weight deficiency: role of malaria, nutritional interventions targeting LBW children, nutritional intakes during pregnancy<p> / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished