Magister Public Health - MPH / Background: Maternal mortality is a significant public health problem world-wide,as it is an important indicator for the functioning of the health system. The maternal mortality ratio for Botswana is higher than other countries with comparable economic growth, despite impressive access to health services. In order to develop relevant programs and policies to reduce maternal mortality, the factors associated with maternal mortality were studied. The study aimed to describe the maternal and health services factors associated with maternal mortality in South East Botswana. Methodology: A quantitative case-control study was used to retrospectively review medical records for 71 cases of maternal deaths and 284 controls randomly selected from mothers who delivered in the same year and at the same health facility, in South East Botswana from 2007 to 2009. Information was collected on the maternal and health services characteristics of the cases and controls including age, level of education, marital status, parity, utilization of health facilities that consist of antenatal care (ANC), type of delivery, complications during pregnancy, type of health facility and ANC provider. Data was analyzed using Predictive Analysis Software (PASW) Version 18.Two-sample t- test, Pearson’s Chi-square test and the Fisher’s exact test were used to test the difference between the proportions of the various categories of variables in cases and controls. Univariate logistic regression analysis was applied to identify the risk factors associated with maternal deaths. A multivariate logistic regression model was estimated to see the joint effects of the identified risk factors for maternal mortality. Hosmer and Lemeshow test was used to test the goodness of fit of the model. Results: The mean age of the maternal deaths was 28.0 ± 5.3 years and they had taken place at a hospital (100%). A large number of deaths occurred before delivery(59.0%). The causes of maternal death included both direct (73%) and indirect causes (27%). Direct causes were the leading causes of death and they were abortion(22.5%) and haemorrhage (18.3%). The maternal characteristics associated with maternal mortality were having complications at delivery (OR=20.91), not receiving ANC (OR=6.31) and delivering by caesarean section (OR= 2.66). The health facility characteristics associated with maternal mortality were delivering outside the health facility (OR=14.78), having been referred from another facility (OR=8.62) and delivering at a general hospital (OR=5.91). The data produced a model with good fit that included one maternal risk factor and three health facility risk factors. These were being admitted with preterm labour, delivering at a general hospital or before arrival at the health facility and having been referred from another health facility. Conclusion: Maternal mortality was associated with both maternal and health facility risk factors. The model developed may be used to identify and manage highrisk women to reduce the number of maternal deaths. It was recommended that, the current system should continue to be monitored and evaluated through the Maternal Mortality Monitoring System (MMMS). Furthermore, the referral and management of complications needs to be strengthened through a multi-sectoral approach.

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) 14 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 pre-intervention 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 15 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.

Background A major factor contributing to continued high under-five mortality in sub-Saharan Africa (SSA), is maternal HIV infection, which is associated with adverse birth outcomes such as preterm delivery (PTD), small-for-gestational age (SGA) and low birthweight (LBW) infants. Introduction of antiretroviral therapy (ART) during pregnancy has been a successful intervention for promotion of maternal and infant health, however it has also been linked to an increased risk of adverse birth outcomes. Consequently, the association between maternal ART use and these adverse outcomes is an important area of research in SSA which has the majority of pregnant women living with HIVand the highest rates of PTD, SGA and LBW infants. However, the current state of epidemiologic knowledge remains limited because most evidence on this association comes from observational studies, which have previously given inconsistent findings. Accordingly, the overarching aim of this PhD was to reliably quantify the relationship between maternal ART use and adverse birth outcomes, by addressing the role of methodological factors inherent in observational research in this association. Methods This research included pregnant women (aged ≥18 years) seeking antenatal care at a public sector midwife obstetric unit in Gugulethu (GMOU), Cape Town, enrolled into two separate dedicated research cohort studies. Enrolled women were followed-up during pregnancy and postpartum with their infants, with data obtained from study questionnaires, physical examinations and abstraction of clinical and obstetric records. In parallel, routine electronic data, linked across clinics and data sources were obtained for all pregnant women at the GMOU (pregnancy exposure registry (PER)) and across the Western Cape province (PHDC). Findings The incidence of gestational age (GA) based birth outcomes and the association between maternal ART use and these outcomes, was found to be substantially influenced by method of GA assessment used. While GA based on both last menstrual period (LMP) and measurement of symphysis fundal height (SFH) led to under and over estimation (relative to ultrasound), only LMP-based GA gave rise to a biased measure of association. Across data sources used in this research, an overall PTD incidence of 17% was observed which was lower than incidences observed in the pre-universal ART era. In the cohort studies, there was no significantly increased PTD risk in women living with HIV (compared to living without HIV), predominantly on the tenofovir + emtricitabine + efavirenz regimen. However, when assessed in the significantly larger population of pregnant women (PHDC), an increased PTD risk in women living with HIV was observed. There did not appear to be differences in PTD risk by ART status in the cohort studies or PER. However, across the province those initiating ART preconception were at increased PTD risk compared to those initiating during pregnancy. Blood pressure, particularly when assessed longitudinally played an important role in the association between maternal ART use and PTD, high normal and abnormal blood pressure trajectories associated with increased PTD risk. There did not appear to be any effect modification in the trajectory groups by HIV status for PTD. In the cohort study the overall incidence of SGA infants was 9%, with an increased SGA risk observed in women living with HIV compared to living without HIV. While no differences were observed in SGA risk by ART status, the highest risk was observed among women initiating in the second trimester. An overall LBW incidence of 13% was observed in the cohort study, with no differences observed in risk by HIV status or ART status. Blood pressure also played a role in the occurrence of LBW infants, with abnormal trajectories associated with increased LBW infant risk. Additionally, effect modification among women with abnormal trajectory groups, with women living without HIV at increased risk of LBW infants compared to women living HIV was observed. Finally, investigating this association using both cohort studies and population based electronic health care data proved to be valuable. The three data sources gave similar effect estimates, with varying levels of precision, and each with distinct but complementary benefits. The cohort studies and PER included smaller select groups of women and provided detailed investigation of risk factors that could impact the overall association. In contrast the provincial dataset, had limited risk factor data, but provided overall associations with the ability to detect subtle differences. Conclusion Reassuringly, the magnitude of difference in PTD risk by HIV status under policies of universal maternal ART use, appears to be smaller than in the past. Of concern, however, was the finding of increased SGA risk. Taken together, these findings highlight the need to improve mechanistic understanding of ART-mediated adverse birth outcomes, in order to ensure optimal maternal and infant outcomes. The methodological findings underscore the importance of considering the potential for bias related to selection and measurement when designing and/or evaluating findings from studies investigating this association and by extension other medications in pregnancy.

No description available.

The worldwide maternal mortality rate is excessive. Developing countries such as Tanzania experience the highest maternal mortality rates. The continued exploration of issues to create ease of access for women to quality maternal health care is a significant concern. A central strategy for reducing maternal mortality is that every birth be attended by a skilled birth attendant, therefore special attention was placed on motivations and factors that might lead to an increased utilization of health facilities. This qualitative study assessed the perceptions of local population concerning maternal health services and their recommendations for improved quality of care. The study was conducted in the Karatu District of Tanzania and gathered data through 66 in-depth interviews with participants from 20 villages. The following components were identified as essential for perceived quality care: medical professionals that demonstrate a caring attitude and share information about procedures; a supportive and nurturing environment during labor and delivery; meaningful and informative maternal health education for the entire community; promotion of men’s involvement as an essential part of the system of maternal health; knowledgeable, skilled medical staff with supplies and equipment needed for a safe delivery. By providing these elements, the community will gain trust in health facilities and staff. The alignment the maternal health services offered to the perceived expectation of quality care will create an environment for increased attendance at health facilities by the local population.

A research report submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Public Health in the field of Health Systems and Policy / Introduction: The maternal mortality ratio in Sedibeng District, Gauteng Province, from 2002 – 2004 was 220/100000. For the past decade HIV has been identified as a factor that has slowed the decline in maternal deaths in South Africa. The purpose of this study was to describe personal and service level factors contributing to maternal mortality of HIV positive women. It is hoped that the results of this study will be useful in developing interventions that will assist to curb the maternal mortality ratio. Methodology: Maternal death records were reviewed for the period 2004-2009. Data was collected on antenatal care, hospital care after admission and access to HIV services. The data were analysed using Stata 10. The results were compared with the national guidelines for the care of HIV positive pregnant women so as to identify discrepancies between the two. Results: One hundred and twenty five maternal death records were reviewed. Of these, 90% booked late for antenatal care i.e. beyond 20 weeks gestation. The majority (60.8%) of the women were HIV positive. Of the HIV positive women, 37.5% had CD 4 counts less than 200, which made them eligible for antiretroviral therapy. Of those that were eligible for antiretroviral therapy, 50.0% did not access the antiretrovirals due to late booking and loss to follow-up. Another main finding was that 36% died during the postnatal period. Conclusion: The antenatal bookings occurred after 12 weeks gestation which limited the time for starting patients on antiretroviral therapy. The high number of deaths during the postnatal period may indicate poor postnatal care and follow-up; as antiretroviral therapy could have been started during the postnatal period. Recommendations: Early antenatal booking and early HIV testing should be encouraged in communities. Antenatal services should be integrated so that HIV positive pregnant women are treated comprehensively and that the focus is not only on HIV, but also on other conditions such as TB, pneumonia, anaemia and hypertension. All pregnant HIV positive women must be done CD 4 counts; and all those found to be eligible for antiretroviral therapy should be given antiretrovirals timeously. Such women should be followed up and monitored closely. Postnatal check-up at 3 days should be strengthened for the mother-and-baby pair.

A thesis submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy April 2017. / Introduction The number of maternal deaths from bleeding during and after caesarean section (BDACS) has increased dramatically in South Africa in recent years. Four studies were conducted to gain insight on measures to reduce maternal deaths from BDACS. The aim was to identify clinical and health system factors associated with near-miss and maternal death from BDACS. Methods A systematic review was done on near-miss from postpartum haemorrhage, with a sub-analysis on BDACS. The field research, done in southern Gauteng, included: 1) a six-month prospective near-miss audit of women with BDACS in 13 hospitals; 2) a two-year retrospective maternal death audit in seven hospitals; and 3) a health systems audit in 15 hospitals. Results The systematic review on near-miss from PPH found two studies that described near-miss from BDACS, with a mortality index of 0-11%. In the near-miss and maternal death audits, the main risk factors for BDACS were pre-operative anaemia and previous caesarean section. Atonic uterus was the main cause of haemorrhage, with associated failure to use second line uterotonic drugs. Failure to diagnose and treat shock was the main reason why women died. Most maternal deaths from BDACS occurred in regional hospitals. The hospital systems audit identified shortages of second line uterotonic drugs and surgical skills availability as contributors to near-miss and maternal death from BDACS. Conclusion Although bleeding may be arrested through obstetric surgical techniques and easily available drugs, severe BDACS is a complex disease that requires a multi-disciplinary approach in a functional health system, especially regarding the detection and management of hypovolaemic shock. Measures to reduce maternal morbidity and mortality from BDACS include health system strengthening, with high care and critical care facilities, and improving the availability of drugs and surgical skills at district and regional hospitals / MT2017

BACKGROUND: The Tokollo/Mafube District (TMD) Hospital Complex located in the rural area of Fezile Dabi District within the Free State Province has reported a high number of adverse events (AE) from the maternity units. Although the information linked to AE occurring in the hospitals is routinely collected and reported to the hospital management in accordance with the Provincial policy, no study has been done to systematically analyse the available information and to explore the current situation. AIM: To describe the patient-related AE in the maternity units of TMD Hospital Complex, related individual and health system factors, and the functioning of the reporting system used for these AE during the two year study period. METHODOLOGY: A descriptive cross-sectional study design was used, based on a retrospective review of routinely collected hospital data from the health records of patients, the AE Committee meeting minutes, and other relevant hospital documents. The study was conducted at the maternity units of TMD Hospital Complex which consists of two hospitals in the Fezile Dabi District within the Free State Province. Data was collected in the following categories of variables: the types of AE (in terms of levels of seriousness), the profiles of patients who experienced such AE (e.g. age, gravidity, marital status, residence, and socio-economic status), the related health system factors identified during the adverse events committees meetings (such as personnel, transport, equipment, environment and management) and reporting of these AE. RESULTS: This study revealed that a total of 88 patients, comprising 0.8% of the total number of admissions to the maternity units, experienced AE. Maternal AE occurred more commonly than perinatal AE. The majority of women experiencing AE were unemployed (93%), between the ages of 19-34 (81%), unmarried (79%) and resided in towns (88.6%). In addition, most of these women belonged to the groups of primigravida and multigravida (85%), attended between one and three antenatal visits (42%), and delivered via normal vaginal deliveries (76%) with a high number of stillborns (77.2%). Overall, the majority of maternal AE occurred during the intrapartum stage. Another significant finding was that majority of AE reported were classified as the most serious being SAC 1, which accounted for 93% of the maternal AE and 84% of perinatal AE. The early perinatal AE accounted for 100% of the reported perinatal AE. Although majority of AE reported at the institution were within the prescribed period, reporting time to the Complex AE Committee (CAEC) and District AE Committee (DAEC) was exceeded in the majority of cases. In addition, all AE that required investigation complied with the provincial policy but exceeded the required investigation period. The findings regarding health systems related factors as determined by root cause analysis performed by the AE committee revealed that clinical governance issues accounted for 43% of both maternal and perinatal AE, followed by patient transport issues as provided by the Emergency Medical Services (EMS) which also accounted for a significant percentage (33%). CONCLUSION: This study has demonstrated that specific health system related factors played a significant role on the occurrence of AE at the maternity units of TMD Hospital Complex and that the majority of the reported AE were very serious (SAC 1). It is important that these preventable, contributory factors are addressed by management at both the complex and district levels. Furthermore the results suggest that patients’ profiles, to a certain extent, do have an influence on the occurrence of AE in maternity units of TMD hospital Complex and it is important that patients’ profiles be taken into consideration when adverse incidents are analysed.

Thesis (M.A.)--University of Wisconsin--Madison, 1966. / eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references.

Maternal mortality is the leading cause of death among women in Nigeria, especially women aged between 15 and 19 years. This research examines the geography of maternal mortality in Nigeria and the role of cultural and religious practices, socio-economic inequalities, urbanization, access to pre and postnatal care in explaining the spatial pattern. State-level data on maternal mortality rates and predictor variables are presented. Access to healthcare, place of residence and religion explains over 74 percent of the spatial pattern of maternal mortality in Nigeria, especially in the predominantly Muslim region of northern Nigeria where poverty, early marriage and childbirth are at its highest, making them a more vulnerable population. Targeting vulnerable populations in policy-making procedures may be an important strategy for reducing maternal mortality, which would also be more successful if other socio-economic issues such as poverty, religious and health care issues are promptly addressed as well.