Introduction There is concern that C-section rates are increasing in the public health sector in South Africa and wide variation has been reported between districts, provinces and hospitals. This study is a comprehensive analysis of C-section rates in all public sector hospitals during 2000/01- 2008/09 by facility, district and province. It aims to inform decision makers in maternal health services of the trends and patterns occurring in C-section rates in South African public sector hospitals. Variation in C-section rates is described to highlight the differences in care that pregnant women receive in different parts of the country and to illustrate where inequity of resource allocation is occurring, as well as highlighting possible data quality problems. Methodology This is a descriptive study using quantitative methods of analysis on secondary data obtained from the National Department of Health’s routinely collected data specific to Caesarean sections in the DHIS. C-section averages are weighted by taking the number of deliveries per facility and level into consideration. Results 1. Wide variation is noted between individual facilities, between and within provinces and districts and within the different levels of hospitals in 2008/09. The mean weighted C-section rate ranges from 17.2% in District Hospitals to 40.7% in Specialised Maternity Hospitals. A 3.7 fold difference between the highest and lowest district average C-section rates is seen for District Hospitals. Within provinces, average District Hospital C-section rates vary by as much as 3.5 fold between districts. Interdistrict variation in Regional Hospitals shows a 3.3 fold difference between the lowest and highest average district rates. Among the eight National Central Hospitals there is a 2.5 fold difference between the highest (79.7%) and lowest (31.7%) facility C-section rates. Nationally a total of 23 District Hospitals had C-section rates below 5% and nine hospitals of varying levels had rates of over 50% 2. Caesarean Section rate trends, 2000/01 – 2008/09 are increasing. Nationally the average C-section rate in South Africa increased by 6.3 percentage points from 18.1% in 2000/01 to 24.4% in 2008/09, with an average annual compounded growth rate of 3.8%. Bivariate linear regression analysis confirms there is a positive linear relationship between time (year) and C-section rate (p<0.001). All levels of hospitals showed an increasing trend over the nine years, (p<0.001), with the rate in Provincial Hospitals having increased by the highest amount (1.40%) year on year and District Hospitals, the least (0.48%). Trends within certain districts and individual hospitals however, show a decline. 3. A strong relationship between level of deprivation and C-section rate exists when adjusting data for provincial variation Bivariate linear regression analysis revealed no association between the level of deprivation of the population at district level and the mean C-sections rate per district (p=0.130). Multiple regression analysis adjusted for the effect of province, reveals a significant association (p=0.044). A negative association between the DI (p=0.006) and Csection rate is seen in eight out of nine provinces. 4. Data quality of C-sections and deliveries in the DHIS needs improving Data quality in the DHIS leaves uncertainty in some instances whether C-section rate trends are a true reflection or not. The C-section rate indicator on its own is unable to inform on the full spectrum of emergency obstetric care. The definition of C-section rate for primary health care currently only considers deliveries in District Hospitals. The national C-section rate for primary health care in the country however, reduces from 17.2% to 13.2% when including the deliveries which take place in CHCs. Conclusions The quality of data relating to C-sections (number of births, C-sections and hospital categorisation) in the DHIS needs to be improved in order to enable accurate monitoring and should include deliveries and C-sections which take place in Community Health Centres to allow for a more accurate reflection of C-section rate in primary health care. The C-section rate indicator on its own is insufficient to adequately inform on the full spectrum and quality of the provision of emergency obstetric care in South Africa. Including additional indicators to the DHIS, such as the UN process indicators, could improve on the current knowledge and monitoring of the provision of emergency obstetric care in South Africa. The wide variation in C-section rates seen among District Hospitals and the C-section rates between and within districts and provinces, suggest inequity in resource allocation and irregular service delivery patterns. Reasons and solutions for these wide differences need to be found, which are likely to be unique to each district and province. Further studies are needed to investigate the access of poorer women, especially those in remote rural areas to emergency obstetric care services.

Background: South Africa has a high Maternal Mortality Ratio (MMR) and is not on track to meet Millennium Development Goal (MDG) 5, target 5A (to reduce by three quarters between 1990 and 2015 the MMR). Along with gathering crucial information about maternal deaths, it is also important to understand the experiences and opinions of those who have almost died during their pregnancy or delivery - termed near-misses in maternal health services - to recommend relevant interventions aimed at bringing down South Africa's MMR. Aim: The overall aim of the study was to explore patient experiences and perspectives of maternal near-misses and their opinions of how these could have been prevented. Methods: Using a case study design, where the case was women who had experienced severe acute maternal morbidity (a near-miss event), in-depth interviews were conducted with nearmisses until a point of saturation was reached after the ninth woman. Each woman was interviewed twice on two separate occasions between 1st April and 30th September 2009 about their experiences and opinions of the near-miss event, and access to reproductive health services and the health system more broadly. Their social and economic circumstances were also explored.MAXqda was used for data management and a thematic analysis was carried out on the interview data. Results: Bureaucracy in accessing reproductive health services, lengthy referral processes, lack of transport and resources in clinics were seen as major health system barriers that contributed in women being near-misses. Inadequate knowledge about reproductive health and warning signs of serious morbidity; although seen as patient factors, were also be attributed to health system factors. The desire to or not to fall pregnant was not the only factor that influenced contraceptive use. Power relations between women and their partners affected most women who were in lower positions of power. Cessation of menstruation as a side effect of contraception resulted in failure to recognize absence of menstruation during pregnancy. Lack of service integration affected women irrespective of their demographic characteristics. Patients are at risk of abuse in health facilities although this is not the norm. Little attention was given to postnatal care of women. Conclusion: Health systems' issue which according to the AAAQ framework were not satisfactory contributed in women being near-misses. Women's limited knowledge on reproductive health issues which might be as a result of inadequate information offered at the clinic affected use of reproductive health services. Educating women and their families about obstetric emergencies may result in early recognition of warning signs of obstetric emergencies and prevention of near-misses.

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 Med(Family Medicine)) -- University of Limpopo, 2010. / Abstract AIM The aim of the study was to measure the maternal and foetal outcomes of the deliveries attended to at Emkhuzweni Health Centre, Swaziland. Objectives The objectives of the study were: .:. To determine maternal outcomes of the deliveries attended to at Emkhuzweni Health Centre. .:. To determine foetal outcomes of the deliveries attended to at Emkhuzweni Health Centre. .:. To identify risk factors that affect maternal and foetal outcomes at Emkhuzweni Health Centre Methods A retrospective chart review was performed for all 520 deliveries at Emkhuzweni Health Centre between January 1,2007 and December 31 2007. Labouring mothers were eligible for the study if they met the inclusion criteria. The study was conducted after ethical approvals from the relevant authorities were obtained. Data were obtained from records for the following variables: age, address, gravidity, parity, health service where ANC was attended, risk factor, mode of delivery, maternal condition after delivery and post-delivery maternal hospital stay. For each foetus, the APGAR score at the first and fifth minute, weight and sex of the neonate and condition after delivery were recorded. Results The results revealed that the maternal outcomes after delivery were normal for 89.85% of the mothers; 3.4% of those who delivered at EHC had PPH, 5.4% developed puerperal sepsis, 1 % PIH and 0.2% cases resulted in maternal death. The majority of mothers (61.7%) were discharged from the maternity ward in less than 24 hrs. As far as foetal outcomes were concerned, normal babies accounted for 68% of births, early onset neonatal sepsis for 1.9%, congenital malformation (0.6%), stillbirth (1.5%), low birth weight (9.2%), preterm babies (17.8 %) and neonatal death (0.4%0. Conclusion This study found that the maternal outcomes at Emkhuzweni Health Centre in 2007 were similar to those in Swaziland as a whole and in other developing countries, except that there was a higher rate of pre-term delivery among pregnant women assisted at Emkhuzweni Health Centre. The foetal outcomes of Emkhuzweni Health Centre in 2007 were similar to the data from developing countries. Additionally, however; significant numbers of pre-term babies were delivered and a high incidence of neonatal sepsis was observed at the Health Centre. Some of the risk factors for the observed maternal and foetal outcomes were poor antenatal care attendance, distance of the Health Centre from the home state of the pregnant woman, preterm labour, under age and teenage pregnancies.

Background: The adoption of the Sustainable Development Goals in 2015 has renewed interest in maternal mortality reduction. Indonesia"'s maternal mortality ratio is among the highest in Southeast Asia. While skilled birth attendance (SBA) reduces the risk of maternal death, few studies have been done on SBA utilization in Indonesia using nationally representative data. This study estimated the own-price, cross-price, and income elasticities of demand for SBA in Indonesia. The effects of community and health system factors on SBA were also explored. Methods: Data from the 2004 wave of the Indonesia Family Life Survey, were used as the primary source of information. These data were supplemented with information from reports produced by the Indonesian Ministries of Health and Finance and the World Bank. The polytomous outcome variable was choice of attendance at last birth. Three estimation strategies were used to estimate the elasticities"u2014multinomial logit, multinomial probit, and an instrumental variable multinomial probit model. Statistical significance was determined at the 5% level. Results: The own-price elasticities of the facility-based delivery alternatives were between -1 and 0, indicating that demand is own-price inelastic for those alternatives. Two cross-price elasticities"u2014price of skilled home deliveries on demand for unskilled home deliveries and price of public facility deliveries on demand for skilled home deliveries"u2014indicated that women chose lower priced alternatives as the price of an alternative is increased. Increased income reduced demand for unskilled home deliveries and increased the demand for skilled home and private facility deliveries. Community and health system-level factors had small but significant effects on delivery attendance. Increases in the percentage of women in the community with SBA were associated with higher likelihood of using skilled delivery alternatives over unskilled home deliveries. Health worker density increased likelihood of choosing public facility deliveries over unskilled home deliveries. Finally, government health expenditure was positively associated with choosing skilled home and public facility deliveries over unskilled home deliveries, but was negatively associated with choosing private facility over unskilled home deliveries. Discussion: The elasticities revealed that women substituted for lower-priced alternatives as the price of an alternative increased and that they increased utilization of skilled delivery alternatives as household income increased. These findings can be interpreted as evidence that price is still a barrier to accessing SBA in Indonesia. The findings from the community and health system-level variables suggest extra-individual characteristics also affect individual decision-making on choice of delivery attendance. / 1 / Rieza Hawarina Soelaeman

Thesis (MNursing (Advanced Practice))--University of South Australia, 1996

Thesis (LL. M.)--University of Toronto, 2004. / Adviser: R. Cook.

Thesis (M.S.)--West Virginia University, 2000. / Title from document title page. Document formatted into pages; contains vi, 57 p. Vita. Includes abstract. Includes bibliographical references (p. 38-42).

Thesis (M.S.)--Brigham Young University. Dept. of Sociology, 2008. / Includes bibliographical references (p. 29-35).