Thesis (M.Tech.: Nursing)-Durban Institute of Technology, 2005 1 v. : ill. ; 30 cm / An exploratory descriptive research design was used for this study which investigated the underutilisation of a rural clinic’s labour ward by low risk pregnant women (LRPW). The study took place in Maputaland, Northern KwaZulu-Natal. Rosenstock’s health belief model (HBM) modified by Becker et al, in 1977 was adapted as a framework for this study.

Pregnancy can have important effects on oral health and pregnant women are a population group requiring special attention with regard to their oral health and their babies? health. International research shows that oral health care for pregnant women has been inadequate, especially in relation to education and health promotion and there is some evidence of disparities by SES and ethnicity. Improving oral health is one of the health priorities in the New Zealand Health Strategy (Ministry of Health, 2000) and the Ministry of Health (Ministry of Health, 2006a) has recently identified a need for more information on the oral health and behaviour of pre-natal women. The aims of this study were to gain an understanding of pregnant women?s oral health care practices, access to oral health care information and use of dental care services and to identify any difference by ethnicity and socio-economic position. A self-reported questionnaire was completed by 405 pregnant women (55% response rate) who attended antenatal classes in the Wellington region. The questionnaire was broadly divided into four parts: (1) care of the teeth when the woman was not pregnant; (2) care of the teeth and diet during the pregnancy; (3) sources of oral health information during pregnancy and; (4) demographic information . Data were analysed by age, ethnicity, education and income and odds ratios (OR) and 95% confidence intervals (95%CI) were calculated using logistic regression. The majority of women in this survey were pakeha (80.2%), compared to 19.7% „Others? (8.8% Maori, 1.9% Pacific, 8.6% other). Most of the subjects were aged 31-35 years (34.5%), of high SES (household income and education level). Half of the women reported having regular visits to the dentist previous pregnancy while a significant percentage of women saw a dentist basically when they had problems. The usual dental hygiene habits were maintained during pregnancy. However, during pregnancy more than 60% of women reported bleeding gums. Just 32% of women went to see the dentist during pregnancy and less than half had access to oral health information related to pregnancy. „Others? (OR 0.38, 95% CI 0.15-0.91) and low income (OR 0.27, 95% CI 0.10-0.76) groups were significantly less likely to report access to oral health information compared to pakeha and high income groups (respectively). Women who went to see the dentist during pregnancy were more likely to receive information on dental health. However, low income women were more likely to report the need to see a dentist (OR 2.55, CI 1.08-5.99). Information on dental health and access to oral care should be prioritised to low income women, Maori, Pacific and other ethnic groups. Little attention has previously been given to oral health for pregnant women in New Zealand and there is a need to increase awareness of the importance of this area amongst health practitioners particularly Lead Maternity Carers and Plunket and tamariki ora nurses.

Pregnancy can have important effects on oral health and pregnant women are a population group requiring special attention with regard to their oral health and their babies? health. International research shows that oral health care for pregnant women has been inadequate, especially in relation to education and health promotion and there is some evidence of disparities by SES and ethnicity. Improving oral health is one of the health priorities in the New Zealand Health Strategy (Ministry of Health, 2000) and the Ministry of Health (Ministry of Health, 2006a) has recently identified a need for more information on the oral health and behaviour of pre-natal women. The aims of this study were to gain an understanding of pregnant women?s oral health care practices, access to oral health care information and use of dental care services and to identify any difference by ethnicity and socio-economic position. A self-reported questionnaire was completed by 405 pregnant women (55% response rate) who attended antenatal classes in the Wellington region. The questionnaire was broadly divided into four parts: (1) care of the teeth when the woman was not pregnant; (2) care of the teeth and diet during the pregnancy; (3) sources of oral health information during pregnancy and; (4) demographic information . Data were analysed by age, ethnicity, education and income and odds ratios (OR) and 95% confidence intervals (95%CI) were calculated using logistic regression. The majority of women in this survey were pakeha (80.2%), compared to 19.7% „Others? (8.8% Maori, 1.9% Pacific, 8.6% other). Most of the subjects were aged 31-35 years (34.5%), of high SES (household income and education level). Half of the women reported having regular visits to the dentist previous pregnancy while a significant percentage of women saw a dentist basically when they had problems. The usual dental hygiene habits were maintained during pregnancy. However, during pregnancy more than 60% of women reported bleeding gums. Just 32% of women went to see the dentist during pregnancy and less than half had access to oral health information related to pregnancy. „Others? (OR 0.38, 95% CI 0.15-0.91) and low income (OR 0.27, 95% CI 0.10-0.76) groups were significantly less likely to report access to oral health information compared to pakeha and high income groups (respectively). Women who went to see the dentist during pregnancy were more likely to receive information on dental health. However, low income women were more likely to report the need to see a dentist (OR 2.55, CI 1.08-5.99). Information on dental health and access to oral care should be prioritised to low income women, Maori, Pacific and other ethnic groups. Little attention has previously been given to oral health for pregnant women in New Zealand and there is a need to increase awareness of the importance of this area amongst health practitioners particularly Lead Maternity Carers and Plunket and tamariki ora nurses.

Pregnancy can have important effects on oral health and pregnant women are a population group requiring special attention with regard to their oral health and their babies? health. International research shows that oral health care for pregnant women has been inadequate, especially in relation to education and health promotion and there is some evidence of disparities by SES and ethnicity. Improving oral health is one of the health priorities in the New Zealand Health Strategy (Ministry of Health, 2000) and the Ministry of Health (Ministry of Health, 2006a) has recently identified a need for more information on the oral health and behaviour of pre-natal women. The aims of this study were to gain an understanding of pregnant women?s oral health care practices, access to oral health care information and use of dental care services and to identify any difference by ethnicity and socio-economic position. A self-reported questionnaire was completed by 405 pregnant women (55% response rate) who attended antenatal classes in the Wellington region. The questionnaire was broadly divided into four parts: (1) care of the teeth when the woman was not pregnant; (2) care of the teeth and diet during the pregnancy; (3) sources of oral health information during pregnancy and; (4) demographic information . Data were analysed by age, ethnicity, education and income and odds ratios (OR) and 95% confidence intervals (95%CI) were calculated using logistic regression. The majority of women in this survey were pakeha (80.2%), compared to 19.7% „Others? (8.8% Maori, 1.9% Pacific, 8.6% other). Most of the subjects were aged 31-35 years (34.5%), of high SES (household income and education level). Half of the women reported having regular visits to the dentist previous pregnancy while a significant percentage of women saw a dentist basically when they had problems. The usual dental hygiene habits were maintained during pregnancy. However, during pregnancy more than 60% of women reported bleeding gums. Just 32% of women went to see the dentist during pregnancy and less than half had access to oral health information related to pregnancy. „Others? (OR 0.38, 95% CI 0.15-0.91) and low income (OR 0.27, 95% CI 0.10-0.76) groups were significantly less likely to report access to oral health information compared to pakeha and high income groups (respectively). Women who went to see the dentist during pregnancy were more likely to receive information on dental health. However, low income women were more likely to report the need to see a dentist (OR 2.55, CI 1.08-5.99). Information on dental health and access to oral care should be prioritised to low income women, Maori, Pacific and other ethnic groups. Little attention has previously been given to oral health for pregnant women in New Zealand and there is a need to increase awareness of the importance of this area amongst health practitioners particularly Lead Maternity Carers and Plunket and tamariki ora nurses.

Pregnancy challenges the health care system in a unique way in that it involves at least two individuals – the woman and the fetus. The death rates of both pregnant women (maternal mortality) and newborns (perinatal mortality) are often used to indicate the quality of care the health system is providing. In terms of maternal and perinatal outcomes South Africa scores poorly compared to other upper-middle income countries (Penn-Kekana & Blaauw, 2002:14). The high stillbirth rate compared to the neonatal death rate reflects poor quality of antenatal care. Maternal and perinatal mortality is recognised as a problem and as a priority for action in the Millennium Development Goals (Thieren & Beusenberg, 2005:11). The Saving Mothers (Pattinson, 2002: 37-135) and Saving Babies (Pattinson, 2004:4-35) reports describe the causes and avoidable factors of these deaths with recommendations on how to improve care. The quality of care during the antenatal period may impact on the health of the pregnant woman and the outcome of the pregnancy, in particular on the still birth rate. In primary health care services there are many factors which may impact on and influence the quality of antenatal care. For example with the implementation of the comprehensive primary health care services package (Department of Health, 2001a:21-35) changes at clinic level resulted in a large number of primary health care professional nurses having to provide antenatal care, who previously may only have worked with one aspect of the primary health care package such as minor ailments or childcare. Because skills of midwifery or antenatal care, had not been practiced by some of these professional nurses, perhaps since completion of basic training, their level of competence has declined, and they have not been exposed to new developments in the field of midwifery. The practice of primary health care nurses is also influenced by the impact of diseases not specifically related to pregnancy like HIV/AIDS and tuberculosis. The principles of quality antenatal care are known (Chalmers et al. 2001:203) but despite the knowledge about these principles the maternal and perinatal mortality remains high. The Basic Antenatal Care quality improvement package is designed to assist clinical management and decision making in antenatal care. The implementation of the BANC package may influence the quality of antenatal care positively, which in turn may impact on the outcome of pregnancy for the mother and her baby. The aim of this study was to evaluate the effectiveness of the Basic antenatal care (BANC) package to improve the quality of antenatal care at primary health care clinics.

This phenomenological study was designed to explore the privacy needs of gynecological patients, as perceived by the clients during hospitalization, for the purpose of adding to knowledge and understanding of patients' privacy. Data were collected through sixteen in-depth interviews with eight recently hospitalized patients. The interviews were tape-recorded and transcribed verbatim for each participant. Data were analyzed using Giorgi's (1975) procedure. Analysis of participants' accounts revealed that privacy was important to participants' maintenance of their self-identity. Characteristics of privacy that participants identified as helping to maintain their self-identity included providing time alone for contemplation and helping to control interactions with others. Participants reported that privacy was important for their comfort during situations involving nursing care, basic needs and social interactions with others. Participants suggested that even though they reduced their expectations of privacy during the hospital stay, their privacy needs in hospital were at times still not met. Factors within the hospital setting that contributed or detracted from participants' hospital privacy included behavior of the nurses, doctors, roommates and the physical environment of the hospital. Participants indicated that nurses were the main factor in meeting privacy needs especially while caring for participants and participants' roommates. The findings of this study indicated that participants were willing to trade some privacy for health care. However, participants still valued privacy and considered it important during their hospital stay. There is a lack of research on privacy and acute care hospitalization. Recommendations for further nursing research, nursing practice, nursing education and nursing administration, based on the findings of this study, are presented in the final chapter of the study. / Applied Science, Faculty of / Nursing, School of / Graduate

Introduction: Bihar ranks among the most socio-economically disadvantaged states in India, and its public health system had long suffered from structural deficiencies which contributed to poor health outcomes. In November 2013, the Bihar government, with funding from Gates Foundation and technical support from CARE India, launched the state-wide Bihar Technical Support Program (BTSP) – seeking to address gaps in infrastructure, supply chain, and human resources, as well as the quality of service delivery, so as to improve reproductive, maternal, newborn and child health (RMNCH) and nutrition service provision. BTSP adopted a two-pronged strategy – conducting (i) periodic comprehensive facility assessments (CFAs) to identify and address the structural gaps; and (ii) nurse-mentoring programs to develop competency among nursing cadres in providing basic and comprehensive emergency obstetric and newborn care (BEmONC/ CEmONC) services. Through three inter-linked papers, the dissertation aimed to conduct an evidence-based assessment of this health system strengthening program. “Facility readiness” (structural readiness of public health facilities) was operationalized in terms of infrastructure, essential supplies, and human resources, while “facility performance” was operationalized based on the direct observation of normal vaginal deliveries and newborn care (including management of immediate complications if needed) and infection prevention practices in the labor rooms. The first paper describes the evolution of BTSP, and examines the initial progress made in facility readiness between 2015 and 2016. The second paper: (i) conducts a comparative assessment of facility readiness between 2017 (at end of the first four years of BTSP) and 2019, and describes the continuation of progress or lack thereof; (ii) quantifies facility readiness through a scoring system that reflects the readiness to provide maternal and newborn care (MNC) services; and (3) compares the change in this score over time (2015, 2017 and 2019) across different districts and levels of health facilities in Bihar. Thus, the first and second papers together examine the extent to which Bihar’s public health facilities were structurally strengthened in terms of physical infrastructure, supplies and workforce by utilizing data from all four rounds of CFAs conducted till date. The third paper asks the next logical question in a health system strengthening process – was facility readiness positively and significantly associated with facility performance? This is an important query, as it aims to provide evidence of synergistic progress, as envisioned under BTSP. First, the paper examines whether the facility-level performance changed, by comparing baseline (May-December, 2018) and endline (October-December, 2019) assessment data from the nurse-mentoring program (locally called AMANAT Jyoti). Second, it assesses the association of facility readiness (based on CFA 2019 data) with endline facility performance in providing MNC services. Methods: The first paper utilizes a structured, narrative review of scientific and grey literature to describe evolution of the BTSP since 2014, based on programmatic learnings through prior years (2011-2013) of collaborative vertical interventions. Subsequently, the paper measures the tangible change in select facility-level characteristics, utilizing quantitative data generated through two rounds of CFAs conducted by CARE India in 2015 (n=534 facilities) and 2016 (n=550 facilities). The second paper utilizes quantitative data generated through two rounds of CFAs conducted by CARE India in 2017 (n=550 facilities) and 2019 (n=552 facilities). Each CFAs covered all Level 2 (primary health centers) and Level 3 (higher-level facilities) public health facilities in Bihar that conducted at least 100 deliveries in the preceding year. Subsequently, the paper constructs a “facility-level MNC structural readiness score” – henceforth referred to as facility readiness score, based on a common set of indicators from CFA 2015, 2017 and 2019, to reflect human resources, infrastructure and essential supplies related to delivering MNC services. The paper uses this score to map the change at 2-year intervals, from 2015 to 2019, at both facility and district levels. The third paper utilizes quantitative data generated through two separate assessments conducted by CARE India – the 2019 CFA, and the 2018-2019 assessment of AMANAT Jyoti (nurse-mentoring program), which involved direct observation of normal vaginal deliveries, newborn care, and infection prevention practices in the labor rooms. The paper constructs baseline and endline facility-level MNC performance scores – henceforth referred to as facility performance scores based on data from AMANAT Jyoti assessments, and examines the association between endline facility performance and facility readiness scores. While descriptive statistics was used to present findings from the CFAs and AMANAT Jyoti assessments, paired t tests were used to test the mean change in scores over time and between the different levels of facilities. The association between endline facility performance and facility readiness scores was tested using simple as well as multiple linear and multinomial logistic regression modelling. Results: With a demonstrated intent to improve the ailing public health sector, the Bihar government in 2010 forged a collaboration with Gates Foundation to accelerate progress across RMNCH and nutrition programs. Through the Integrated Family Health Initiative program (IFHI, 2011-2013), outreach-based and facility-based solutions were implemented in eight programmatically-prioritized districts to address the stated goals. However, over this period, it became apparent that long-term success of such initiatives remained critically dependent on strengthening the foundational components of Bihar’s public health system –physical infrastructure, supply chain for drugs, consumables and equipment, and the skilled health workforce. These programmatic learnings motivated a re-think and consequent state-wide launch of the BTSP – characterized by a novel structure of health governance that was deeply embedded within the public health system, and a robust information management system that could generate, analyze and disseminate data on community- and facility-level services to support decision making. The quantitative analyses of CFA data (in first and second papers) provided an assessment of the changes that happened at the level of health facilities, likely supported by the policy-level modifications. There was a clear sense of prioritization of the limited resources – with constant focus on structurally preparing health facilities to deliver basic MNC services, more so at Level 2 (primary health centers). By 2019, at least 99% facilities at either level provided 24x7 delivery services and had designated labor rooms, 97% had designated newborn care corners which were mostly located inside the labor rooms, 70% or more had at least one functional fetal doppler, baby weighing machine, radiant warmer, and AMBU bag with neonatal oxygen masks. The improvement in availability of essential supplies like oxytocin, misoprostol, magnesium sulphate, antibiotics, and reproductive health commodities (condoms, intrauterine contraceptive devices, sanitary napkins, iron-folic acid tablets, contraceptive pills) were particularly notable during the 2017 and 2019 CFAs. However, the supply chain variably faltered for a number of other essential supplies like oral rehydration solutions, functional oxygen cylinders, normal saline and ringer lactate solutions. The data revealed that facility-level inefficiencies in utilizing the electronic inventory management system to accurately reflect actual status of supplies within the facility, likely compromised procurement and distribution. With regards to human resources, while a large number of auxiliary and general nurse midwives were available for service during CFA 2019, the BTSP faced continuing challenges (2015-2019) in recruiting and/or retaining physicians, especially the specialist physician cadres. By CFA 2019, these structural changes were also supported by remarkable improvements in two related services areas –availability of emergency transport, and laboratory services. The comparison of facility readiness scores (second paper) based on CFA 2015, 2017 and 2019 showed that while the mean scores increased sharply for both Level 2 (increase=1.51 (95% confidence interval: 1.39, 1.63)) and Level 3 (1.39 (1.1, 1.69)) facilities between 2015 and 2017, the progress was less pronounced at both levels between 2017 and 2019. 25 of the 38 districts in Bihar demonstrated a continuous increase in mean scores over the 3 CFAs. As for the remaining 13 districts, their 2019 mean scores remained higher than that during 2015. The analysis of AMANAT Jyoti assessment data (third paper) revealed improvements across 36 (80%) of the 45 performance parameters assessed through direct observation of deliveries between the baseline and endline. However, at least 80% compliance was observed for only 11 of 45 (24%) assessed parameters at baseline, and 16 of 45 (36%) at endline. The mean facility performance score increased significantly among both types and levels of facilities – but the increase was higher among Level 3 (mean increase = 1.56, p=0.0005, n=13) and CEmONC (1.82, p=0.0029, n=9) facilities, than among Level 2 (0.32, p =0.0288, n=121) and BEmONC (0.33, p=0.0168, n=125) facilities. The regression analysis failed to identify any linear relationship between facility readiness and performance scores. However, a significant positive association was observed between facility readiness score and the middle tertile of endline facility performance score (vs. lowest tertile as reference) in multiple multinomial logistic regression modeling (n=132 facilities). With increasing facility readiness score, the odds of a facility being in the middle tertile of the endline facility performance score relative to the lowest tertile was 1.68 (95% CI = 1.02, 2.76), after controlling for baseline facility performance score, mean delivery volume, and the facility level. Conclusion: The BTSP can be best described as a diagonal health system strengthening initiative –one that starts with a focus on specific programmatic (RMNCH) outcomes, but strives to achieve these through identifying and addressing bottlenecks across the health system. The efforts made to revamp health governance through creating structures for technical support from the state- to block-levels is particularly laudable, as is the remarkable capacity building in collecting and using facility-level data to inform programs and policies. The dissertation identified that BTSP has made appreciable progress in structurally preparing Bihar’s public health facilities to deliver basic MNC services – with improvements in related infrastructure, essential supplies, and supportive services like referral transport and laboratory facilities, as well as through recruitment of large number of ANM and GNM nurses. However, the process encountered a number of challenges, and it may be worthwhile to adopt a targeted approach to address some of these concerns. For example, it is important that the BTSP works to equip all facilities with electronic inventory management systems, while simultaneously training the personnel using such systems. To circumvent the chronic shortage of specialist physicians, a “task shifting” approach may help maximize utilization of existing health workforce to strengthen service delivery capacity. Further, the overall level of facility performance of MNC service delivery remained low at endline despite improvement from the baseline scores, and there was limited evidence of a significant positive association between facility readiness and performance scores. As these scores reflect the minimum essential requirements for a MNC service delivery setting, the BTSP clearly has challenges ahead. They must continue to address the persistent challenges in facility readiness and facility performance so that these two facility-level interventions will complement each other and influence outcomes. As the onus of this diagonal health system strengthening program incrementally shifts from development partners to the government, it will be important to recognize the significance and complexity of this effort.

Background: Perinatal depression disproportionately affects asylum seeking and refugee (AS&R) women, but they are less likely to receive support than other women. There is no published research which considers the assessment and support for symptoms of perinatal depression provided by midwives for AS&R women navigating England’s maternity services. Aim: To investigate how midwifery practice can be developed to support asylum seeking and refugee women with symptoms of perinatal depression. Methods: A post-colonial feminist inquiry consisting of a scoping survey (study one) and a qualitative research study (study two) using remote interviews with AS&R women and midwives. Qualitative data was analysed using reflexive thematic analysis. Findings: Study one demonstrated that midwives who care for AS&R women work within diverse roles and service structures across England. Study two identified that midwives lack the resources and support structures required to effectively recognise and support symptoms of perinatal depression in AS&R women. These factors were sometimes invisible to AS&R women, but still negatively affected their ability to effectively discuss perinatal depression with a midwife and access help for any symptoms. The lack of appropriate resources was harmful to both AS&R women and midwives. Conclusion: AS&R women and midwives who care for them navigate an inequitable maternity system in England. Midwives do not have the appropriate resources to provide a level of care which is equitable to women in the general maternity population. This leaves AS&R women’s perinatal mental health needs unrecognised and unmet, acting as a barrier to receiving effective support. / Mary Seacole research development scholarship

No / NHS maternity services in England must increase productivity if the NHS is to make efficiency savings by 2014. At the same time, it is expected to maintain or improve patient outcomes such as safety and quality. Given staff costs are 60% of the budget; it is likely that either the number or composition of the workforce will need to be changed to meet these targets. In this article, the authors argue that very little is known about the impact of altering the skill mix on either productivity or patient outcomes. Furthermore, it is unclear whether output and outcomes are themselves trade-offs between increased workload, increased number of deliveries and the increased complexity of demand.

No / The NHS needs to make real term cost savings whilst maintaining and, where possible, enhancing the quality of essential services. The performance of maternity services is seen as a touchstone of whether the NHS is delivering quality health services in general. Recent events in relation to increased infant and maternal mortalities demonstrate the necessity of the benefits of continued improved patient safety. The pressing issues which maternity services face are financial, quality and safety.