Background: This study examines the socioeconomic factors associated with infant and postneonatal mortality in Kenya and tries to quantify these associations in order to put those factors in ranked order so as to prioritize them in health policy plans aiming to decrease infant and postneonatal mortality. The study has used wealth index, mother’s highest educational level, mother’s occupation and place of residence as exposures of interest. Methods: The study uses analytical cross-sectional design through secondary data analysis of the 2003 Kenyan Demographic and Health Survey (KDHS) dataset for children. Series of logistic regression models were fitted to select the significant factors both in urban and rural areas and for infant and postneonatal mortality, separately, through the use of backward stepwise technique. Then the magnitude of the significance for each variable was tested using the Wald’s test, and hence the factors were ranked ordered according to their overall P-value. Results: After excluding non-singleton births and children born less than one year before the survey, a sample size of 4 495 live births was analyzed with 458 infants died before the first year of life giving IMR of 79.6 deaths per 1000 live births. After adjusting for all biodemographic and other health outcome determining factors, the analyses show no significant association between socioeconomic factors and infant mortality in both urban and rural Kenya. The exclusion of deaths that occurred in the first month of ages shows that risk of postneonatal (OR 3.09; CI: 1.29 – 7.42) mortality, in urban Kenya, were significantly higher for women working in agricultural sector than nonworking women. While in rural Kenya, the risk of postneonatal (OR 0.42; CI: 0.20 – 0.90) mortality were significantly lower for mothers with secondary school level of education than mothers with no education. Conclusions: There is lack of socioeconomic differentials in infant mortality in both urban and rural Kenya. However, breastfeeding, ethnicity and gender of the child in urban areas on one hand and breastfeeding, ethnicity and fertility factors on the other hand are the main predictors of mortality in this age group. Furthermore, results for postneonatal mortality show that level of maternal education is the single most important socioeconomic determinant of postneonatal mortality in urban Kenya while mother’s occupation is the single most important socioeconomic determinant of postneonatal mortality in rural areas. Other determinants of postneonatal mortality are ethnicity and gender of the child in urban areas, while in rural areas; the other main predictors are ethnicity, breast feeding and fertility factors.

Background: Maternal employment has been highlighted in numerous studies as an important determinant of childhood mortality but in contexts which do not have regional significance to Swaziland. Studies such as those conducted in India (Sivakami, 1997) and China (Short et al. 2002) considered maternal employment as an important predictor of childhood mortality. Childhood mortality is still high in Swaziland and with increasing poverty and disease the under-five mortality rate continues to increase. The aim of this study was to investigate the relationship between maternal employment and childhood mortality in Swaziland. Methodology: the Swaziland Demographic and Household Survey (SDHS) conducted in 2006/7 interviewed 4,987 women. Due to the nature of this study, only women who had given birth to at least one child five years preceding the SDHS 2006/7 interviews were included. The sample size used for the study was of 2,136 mothers. Main conclusions of the study were drawn based on the use of a binary logistic regression model in the multivariate section. With the use of a conceptual framework adapted from the classic theoretical model developed by Mosley and Chen (1984) key variables were identified as determinants of childhood mortality. Use of the STATA 11 software was employed to obtain the results. Results: results showed 58.88 percent unemployment rate amongst mothers in Swaziland. The main results showed mother’s employment as having an adverse impact on childhood mortality. Bivariate results showed that mothers who were employed experienced higher childhood mortality and the adjusted regression model showed mothers who work have a 38 percent increased likelihood of childhood mortality compared to mothers who do not work. Maternal education also showed its importance as a predictor of childhood mortality; the higher the level of maternal education the less chances mothers have of experiencing childhood mortality. Maternal age also demonstrated significance as mothers ages increase so too do the chances of childhood deaths. Other significant factors include number of household members, the number of children born as well as breastfeeding duration. Conclusion: The results confirmed the alternative hypothesis to be true which states that mothers who work experience significantly higher childhood mortality in Swaziland. The study also highlighted that in contemporary society, child rearing and maternal employment are incompatible and need to re-evaluate policy concerning this matter is essential to better childhood survival.

Introduction The most tragic outcome of a teenage pregnancy is a teenage maternal death. Research from African countries has shown that pregnant teenagers are at increased risk for maternal death when compared with older women, chiefly from complications of hypertension in pregnancy and pregnancy-related sepsis. The objectives of this study were to determine the proportion of maternal deaths accounted for by teenagers, and to describe associated obstetric factors, causes of death and avoidable factors. Setting and methods This was a descriptive retrospective study, using records of all maternal deaths at Chris Hani Baragwanath Hospital (CHBH) from 1997 to 2011. All maternal deaths at CHBH are notified to the national government, and complete patient records have been kept since 1997. All teenage (age less than 20 years) maternal deaths were found by hand-searching all maternal death files for the study period. Demographic and obstetric details were recorded, as well as the primary cause of death and avoidable factors in each case, using the methodology of the Confidential Enquiries into Maternal Deaths in South Africa. Results There were 33 teenage maternal deaths out of a total of 562 deaths (6.1%). Eighteen (54.5%) of the teenagers were 18 or 19 years old. Nine died without having booked for antenatal care.Twenty-six (78.8%) were 28 weeks or more pregnant or postpartum when they died. The most frequent causes of death were hypertensive disorders of pregnancy (n=10; 30.3%), including 9 cases of eclampsia, and non-pregnancy-related infections (n=10; 30.3%), including 6 cases of lower respiratory tract infection and 2 foreign nationals who died of malaria. Among the teenagers who died from non-pregnancy-related infections, 3 were HIV infected, 4 were HIV negative and 3 did not have HIV results. Infrequent causes of death included pregnancy-related sepsis (n=2; 6.1%), and postpartum haemorrhage (n=1; 3.0%). The most frequent avoidable factors were failure to book for antenatal clinic (n=5; 15.2%) and delay in seeking medical help (n=8; 24.2%). Conclusion Maternal deaths in teenagers were infrequent and occurred in a lower proportion of all maternal deaths (6.1%) than expected, based on data suggesting a 13% teenage pregnancy proportion from a study done in 1999 to 2001. This finding differs from those in other African countries. The high frequency of eclampsia is similar to data from other countries, but pregnancy-related sepsis was not frequent. Development and maintenance of adolescent community resources and health services, including improving access to foreign teenagers, may improve health care utilisation by teenagers. Utilisation indicators would include use of contraception, uptake of termination of pregnancy services, and antenatal care attendance for ongoing pregnancies.

ABSTRACT Introduction Under-five mortality is still a major cause of concern in Sub Saharan Africa and among the highest in the world. This is also exacerbated by the high prevalence and episodes of malaria in this age group, which accounts for 90% of all under-five deaths estimated in the region annually. The effect of detecting clustering of all cause and cause specific mortality and underlying factors is crucial for timely public health interventions. This is especially important for health authorities in Tanzania where under-five malaria attributable deaths accounts for 45% of the annual estimated mortality of 100, 000. Study objectives To estimate under-five mortality and analyze clustering of all cause and malaria specific mortality among under five children in Ifakara Demographic Surveillance System from 2002-2005. Methods Data from the Ifakara Health Research and Development Centre (IHRDC) were obtained for all under-five children who lived in 25 villages in the DSS from 2002 – 2005. Analyses for all cause and malaria cause specific under-five mortality were done using data collected from the DSS and verbal autopsy systems. Annual all cause and malaria specific mortality rates were calculated by dividing number of deaths and person years observed. Clustering of deaths for all cause and cause specific (malaria) in the 25 villages were analyzed using SaTScanTM version 7.0 software. A Poisson model was used to detect clusters with high rates in space and in space-time. Household assets and characteristics were used to construct a wealth index using Principal component analysis (PCA) in StataTM version9. The index was used to group households into five equal groups from poorest to least poor. Results Overall infants’ mortality was sixty-three times higher (326 per 1,000 person years) compared to children (5.1 per 1,000 person years) and with mortality rates between girls and boys were very similar, (15.8 and 14.8 per 1,000 person years). Year of death and place of death (village) were found to be significantly associated with malaria deaths. However, socio-economic status of parents in households where deaths occurred was not associated to malaria deaths in the DSS. A number of statistically significant clusters of all cause and cause specific malaria deaths were identified in several locations in the DSS. The located clusters imply that villages within the clusters have an elevated risk of under-five deaths. A space-time cluster of four villages with radius of 15.91 km was discovered with the highest risk (RR 2.71; P-value 0.020) of malaria deaths in 2004. Conclusion These findings demonstrate that there is non-random clustering of both all cause and malaria cause specific mortality in the study area. The high infant mortality results also suggest a careful examination of the data collection procedures in the DSS and require further studies to understand this pattern of mortality among the under-five population. Appropriate health interventions aimed at reducing burden of malaria should be strengthened in this part of rural Tanzania. There is need to replicate this study to other areas in the country.

Background: When children experience food insecurity, in addition to poverty, their resultant inadequate food intake and disease often leads to the development of proteinenergy malnutrition and ultimately to death. In South Africa, where three out of every four children live in poverty, food insecurity and its multiple negative effects are consequently among the most urgent social issues affecting households and their children. Since household food insecurity is thought to be associated with increased child mortality, it is important to study any such associations amongst South African children to determine additional risk factors for child mortality. Objectives: The main objective of this study was to establish the relationship between household food security and mortality in children under the age of five years in the Agincourt field site, Limpopo Province, in 2004. Methods: An analytical cross-sectional study of secondary data obtained from the 2004 census questionnaire and food security module of the Agincourt Health and Demographic Surveillance System in rural Limpopo Province was conducted, involving a total of 7,790 black children under the age of five years. Certain exposure variables were selected for use as indicators of food security and these were analysed with respect to child mortality using univariate and multivariate logistic regression. Results: Based on the outcome indicators of food consumption, 37% of the study population were found to have experienced household food insecurity in 2004, reporting insufficient food for the entire household in the previous month and year. The limited dietary diversity and insufficient quantities of food experienced by the majority of the population were supplemented by the local growth of food crops and the gathering of food from the bush. Of the 79 children (1%) under the age of five years who died in 2004, the majority (24%) died of HIV-related diseases, in addition to deaths caused by diarrhoea, respiratory infections, and malnutrition. Child mortality was found to be associated with the reporting of “unknown” for several indicators of food security. Additionally, expecting the food availability of the household in the coming year to be less than that of the current year (that is, the prediction of future household food insecurity) was significantly associated with an increased risk of under-five child mortality compared to the expectation of the same amount of food the following year (adjusted odds ratio (OR) 2.0), and with a greatly increased risk of mortality compared to the prediction of more food (future household food security) (adjusted OR 4.4). The latter association was age-specific to infants under the age of one year (adjusted OR 5.6) and cause-specific to HIV deaths (adjusted OR 5.9). Conclusions: Following a significant trend in this study in the rural north-east of South Africa, future household food security was inversely related to, and hence protective over, childhood mortality in 2004, even after controlling for confounding factors. Further research on the associations between household food security and under-five child mortality, conducted following the development of a standard nation-wide food security measurement tool specific to South African household conditions, would confirm household food insecurity as a significant risk factor for under-five child mortality and, consequently, as a target for future policies in the reduction of child mortality in this country.

Background: This study examined the relationship between mothers’ age at first birth and infant mortality in Zimbabwe. Childbearing at a significantly young age has been noted to be a predictor of infant mortality, as children born to young mothers are at a greater risk of early death. Methods: This is a cross-sectional, secondary study which uses the data from the Zimbabwe Demographic and Health Survey 2005-2006. The population of interest in this study are women of reproductive ages in Zimbabwe, who have had children within the last five years prior to the survey. A total of 4074 women are used as the sample in this study. The dependent variable is infant mortality, which is understood as the deaths of infants between the period of birth and their first birthday. The independent variables include demographic, socio-economic and reproductive characteristics of the women. The analysis of data was undertaken at three levels. Univariate analysis, binary logistic regression and multivariate logistic regression were conducted. In addition, stepwise logistic regression was applied to the multivariate analysis to analyse the relationship between the significant variables found in the study in relation to infant mortality. Results: This study confirmed an association between mothers’ age at first birth and infant mortality as infants born to mothers of 18 years and younger suffer higher risk of infant mortality, as they have a 33% increased risk in comparison to infants born to older women. This indicates the need for policy development focused on the issue adolescent childbearing and how childbearing can be delayed in Zimbabwe in order to reduce infant mortality. Furthermore the reproductive characteristics of the mother prove to have great impact on infant mortality within the country. Thus the importance of policies focused on women’s reproductive health care. Conclusions: This study confirms that mothers’ age at first birth is a central influential factor in infant mortality in Zimbabwe. Infant mortality cannot be isolated from the characteristics of mothers, in particular her age at first birth, as they are more often the primary care-givers thus have immense influence on whether the infants survive or not.

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

ABSTRACT Background: There is a paucity of empirical data on the impact of HIV/AIDS on mortality in the mining industry in the pre-ART era. Such data will provide a baseline against which the efficacy of antiretroviral treatment can be measured into the future. Objectives: To measure all-cause mortality in a population of platinum miners between 1992 and 2002, the impact of HIV/AIDS on mortality in this group and to determine the pattern of other cause-specific mortality. Methods: This was a primary analysis of mortality in an open cohort of male semi- and unskilled workers at a platinum mine. Using Poisson regression, all-cause, HIV/AIDSrelated and other cause-specific mortality rates and rate ratios were calculated by age and calendar year. Results: There were 1986 deaths in the cohort of 29954 subjects who contributed 200657 person years of follow up over the 11 year period of the study. Crude all-cause mortality increased from a base of 5.1 per 1000 person years at risk (pyar) (95% CI 4.2- 6.2) in 1992 to 20.4 per 1000 pyar (95% CI 18.3-22.8) in 2002. Age-adjusted all-cause mortality increased more than three-fold from 1992 to 2002 (RR 3.2, 95% CI 2.5-4.0). The excess mortality was attributed to HIV/AIDS-related deaths which increased from 0% in 1992-1994 to 5.1% of total deaths in 1995 and reached 63.3 % of deaths in 2002. Mortality due to other communicable diseases, non-communicable diseases and injuries remained stable throughout the study period. Conclusion: The impact of the HIV/AIDS epidemic on mortality in this group of platinum mine workers has been profound and comparable to that experienced by the general South African population. The data reported here provide a baseline to measure the impact of antiretroviral treatment on the future course of mortality due to the epidemic.

dissertation submitted to the Faculty of Health Sciences for the degree of Masters in Medicine in the University of the Witwatersrand, Johannesburg. August ,2013 / South Africa is one of the countries in which neonatal mortality has either remained the same or decreased marginally over the past 20 years (1). Resource constraints result in early discharge of well newborns and curtailment of follow up home visits by nurses. This potentially high-risk group of infants may contribute to these neonatal deaths post hospital discharge. In addition, once a neonate has been home, they are no longer admitted to the neonatal unit but to the general paediatric wards that may lack specialized neonatal care. Numerous programs, algorithms, education drives and protocols have been devised in an attempt to improve the quality of healthcare offered to the newborn. These have led to a perceptible decline in the neonatal mortality and morbidity rates respectively. The neonatal mortality and morbidity rates remain unacceptably high however, particularly in resource poor settings. Aim: The aim was to determine the profile and outcome of neonates admitted to the general paediatric wards at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Methodology: Audit of all newborns (<28days) admitted to the general wards from 1 January 2011 to 30 April 2011. Patients transferred from other tertiary hospitals were excluded. Patients with incomplete records were also excluded Results: There were a total of 73 neonates admitted with a mean weight of 3.2kg (SD 0.65). The median age for 0-7 days was 4 days and for 8-28 days was 17 days. The majority of neonates 41/73 (56.2%) were male and 21/73 (28.8%) were HIV exposed. In the HIV exposed group only 16/21 (76%) were on HIV prophylaxis. Although antenatal care (ANC) was received by 76.7% of mothers, this is lower than ANC received by the general population. Lack of ANC could possibly be a risk factor for admission of neonates. Possible risk factors for serious illness included 8 (11%) were ex premature infants and 11 (15.1%) had a low birth weight (<2.5 kg). Individual indicators for severity of illness by World Health Organization (WHO) Integrated Management of Childhood and Neonate Illness (IMCNI) were used. The most frequent indicators were tachypnoea (RR>60) 34 (46.6%), jaundice 30 (41.1%) and only 1 (1%) presented with convulsions. Respiratory distress was very sensitive (100%) and relatively specific (76%) for detecting bronchopneumonia (BRPN) with a LR of 3.98. The other clinical indicators were neither specific nor sensitive in detecting serious illness. Most 45 (61%) were referred from the local clinic. The commonest diagnoses were bronchopneumonia (BRPN) 20 (27.4%), neonatal sepsis (NNS) 22 (30.1%) and jaundice 22 (30.1%). Two patients died (2.7%). Their diagnoses were NNS and BRPN Conclusions: There are a significant number of newborns admitted to the general paediatric wards, although the mortality rate in this group was low. IMCNI guidelines remain the most sensitive indicator of the need for admission, and “routine” blood investigations are often non-contributory Community based care and education programmes as well as targeted neonatal care in hospitals for this group is warranted.