Background. There are inconsistent published data describing the influence of anaesthetic type during caesarean section (CS), on outcomes of preterm neonates. Objectives. To describe indications and type of anaesthesia in preterm neonates and to describe short-term outcomes, comparing spinal anaesthesia (SA) to general anaesthesia (GA). Methods. Data were collected retrospectively on preterm babies born at 28 – 35 weeks' gestation by CS, between 1 January and 30 Sep 2014 at Groote Schuur Hospital, Cape Town, South Africa. Babies with missing data were excluded. The largest group of babies with similar indications for delivery were identified from the theatre register. Baseline characteristics and short-term outcomes for this group were extracted from an existing prospective data base, and compared between those delivered under SA and GA. Results. Data were available for 226 deliveries, having excluded 23 with incomplete data. Most babies (75%) were delivered under SA. The most common indication for CS was ‘cardiotocograph abnormalities,' in 139 deliveries. Within this group, SA was more frequent (81.7% vs. 12.9%) while GA was associated with lower Apgar scores (p < 0.001) and more intubation at birth (p = 0.004). There was no difference in mortality when comparing SA with GA. Conclusion. Our data suggest a sedative effect of maternal GA on preterm babies delivered by CS, and the need for staff with advanced resuscitation skills. This study provides novel baseline data in our setting, but these data need to be validated in a prospective study.

The availability of an effective vaccine against Bordetella pertussis substantially reduced the morbidity and mortality from pertussis, however, in the last decade there appears to have been a substantial increase in pertussis cases as reported mainly in high income countries. Although it is believed that the greatest burden of pertussis, including deaths, is in low- and middle-income countries (LMICs), there seem to be little data available to back this up. This thesis set out to find data that will give some insight into the burden of pertussis in a low- and middle-income setting in infants and children with severe lower respiratory tract infection (LRTI). Given the paucity of data in LMICs, the thesis starts by systematically searching for existing data that will give some indication of the possible extent of the pertussis problem in these countries. Secondly, a prospective study was conducted at a children's hospital. As hospital admission is a marker of severe disease, these children were targeted as the appropriate population in which to meaningfully conduct a primary study on the burden of pertussis. In addition to quantifying the burden by describing the prevalence of confirmed pertussis in this group of children, the study set out to look for potential factors that may be associated with increased risk of pertussis. LRTI are now commonly known to be associated with identification of multiple organisms in respiratory samples, this study aimed to also look at organisms that are detected with Bordetella pertussis; and investigate whether this association was in any way associated with severe disease or negative outcomes. Finally, as data has been emerging that in the context of immunisation, the clinical presentation of pertussis may no longer be following a classical pattern, this study hoped to identify clinical features that could be used to develop a more reliable clinical case definition of pertussis. 2 Chapter 1 gives a background that justifies the undertaking of this study as well as give a summary of the methods used to answer the question of the thesis. The chapter also gives an indication of the structure that the thesis follows. In chapter 2 a systematic review quantifies the burden of pertussis in LMICs using the best available data. In chapter 3 the burden of pertussis due to the two organisms known to cause the disease, Bordetella pertussis and Bordetella parapertussis, is described in some detail. In both this chapter and the earlier mentioned systematic review (chapter 2), the burden of pertussis is stratified by subgroups to identify potential risk factors. The issue of risk is formally and specifically taken up in the chapter that follows (chapter 4) where potential risk factors are analysed, and the independent impact for some of these factors is established. The last two results chapters (chapters 5 and 6) deal respectively with the conundrum of finding other respiratory organism in the same specimen with Bordetella pertussis and failure to find useful clinical criteria that can help with improved diagnosis of pertussis, specifically in children presenting with acute severe lower respiratory tract infection. While there is no established pattern noted between pertussis and most organisms, a few give signals of being independently associated with Bordetella pertussis even if the clinical relevance is not clear at the moment. In the final chapter of the thesis (chapter 7) I conclude the thesis by making an argument that although there are still knowledge gaps, the thesis gives a clear indication that pertussis remains a serious problem in LMICs especially for some groups that show increased risk of the disease or its severe consequences.

Lesotho, like many other developing countries, has a high incidence of maternal deaths. Minimal research has however been undertaken to establish the actual maternal mortality rate. The result has been a very wide gap between the officially quoted figure (282/100,000 live births) and the various estimates that have been made over the years. It was only in 1997 that a survey based on active case finding revealed a maternal mortality rate of738/100,000 live births. The researchers noted that not all cases of maternal deaths that occurred during the survey period might have been traced. The figure was however an eye opener to the magnitude of the problem in Lesotho. One of the main limitations of the 1997 survey was that no attempt was made to establish the causes of the documented maternal deaths. This was the motivation behind the current research.

The subject of this research is a basic demographic and health status survey. The location of the study is an informal settlement within the Municipality of Knysna, a town on the Southern Cape coast of South Africa with a population of approximately 40 000. Maps in Appendix 1 and 2 show the Western Cape and the study area respectively. The delivery of health services in the area has historically been fragmented, with the private sector and the provincial hospital providing curative services and the Municipality taking responsibility for environmental and personal preventive care such as immunisation and family planning. As a consequence of fragmented health care delivery, health information systems and planning have not been geographically integrated. The philosophy of a cohesive, well planned and equitable service provided to all residents of a district is dependent on adequate information for planning. It is hoped that this study will inform such a planning process.

Background: Effective workforce planning requires stakeholders to agree about the desired roles and contributions of advanced and specialist nurses across different tiers of service delivery. Role descriptions can help to reduce role confusion and inform workforce planning if stakeholders use them to establish a shared contextual basis for defining roles within their health service or system. There is a scarcity of rigorously developed role descriptions worldwide, especially role descriptions accurately reflecting the work of advanced and specialist nurses in Africa. Aim: Malawi is one of many African countries investing in establishing a specialist children's nursing workforce as part of globally advocated strategies to improve child health. This study aimed to develop a replicable process to assist stakeholders with specialist nursing workforce planning, informed by understanding the roles and contributions of children's nurses in the context of Malawi's health system. Methods: This study used a multiple methods approach with four phases. Design principles of stakeholder engaged research were incorporated into all research activities, which included: 1) a systematic scoping review to inform stakeholder identification; 2) a situational analysis; and 3) focus groups and interviews with 41 children's nurses in Malawi about their roles. Following qualitative content analysis of interview and focus group data, 4) concept mapping was used to integrate characteristics of the roles of children's nurses in Malawi and published role descriptions of other African specialist and advanced nursing roles with global frameworks for advanced nursing roles. Results: The study generated a framework for systematic identification of nursing HRH stakeholders; a situational analysis; and richly descriptive accounts of the roles of children's nurses in Malawi. The major product of the study was a flexible framework proposing four role domains and associated categories of activity for specialist and advanced practice children's nurses in Malawi, also applicable to other specialisations and other African health systems. Conclusions: The flexible framework is a distinctive response to the needs of African health systems. Advanced and specialist nurses in Africa are establishing their newly introduced roles into health systems in transition, within challenged and challenging practice contexts which demand high levels of adaptability. The framework is positioned to form part of a replicable process for stakeholder engaged nursing workforce planning. It is hoped that it will assist nurses and other stakeholders to manage the development of advanced and specialist roles at the levels of individual nurses, institutions and health systems.

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Mortality and morbidity due to low birth weight and pre-term birth are high, especially in developing countries where resources and qualified neonatal staff are scarce. There is a need to find measures that reduce the cost of care for low birth weight and pre-term babies without sacrificing quality. Conventional methods of care, where infants are exclusively cared for by the nursing staff using incubators, are very costly. In addition~ morbidity and mortality are adversely affected by some conventional low birth weight care procedures and better means of care are needed to avoid these extra risks. It is therefore important to find a substitute for conventional care without putting infants' lives in danger. The Kangaroo Mother Care (KMC) method could be a viable solution, since it addresses many of the problems encountered with the conventional method. KMC is the practice of caring for low birth weight neonates by keeping them in skin-to-skin contact with their mother's chest. The length of time that the infants are placed in this position can vary from a few hours a day, to 24 hours a day. KMC provides warmth and care; it promotes bonding, breastfeeding and early discharge. Published studies of this method also indicate that KMC decreases mortality and costs while improving health outcomes. Much research has been done on the use of KMC with low birth weight children in different settings, but less has been done on its practice from the mother's point of view. This study explores the quality of the mothers' experiences with KMC in the East London Hospital Complex, consisting of the Cecilia Makiwane Hospital (CMH) and the Frere Hospital (FH), where it has been practised since July 1999. The aim of the study was to identify factors that influenced mothers' knowledge, attitudes and opinions regarding the practice of KMC. In order to make recommendations for improving the quality of KMC practice, the study also examines hypotheses that (1) Mothers' receptivity and responsiveness are critical to the implementation and practice of KMC and (2) Mothers receptivity and responsiveness are affected by (a) education and information, (b) nature and levels of support, and (c) general hospital conditions. In-depth interviews were conducted with thirty mothers in the East London Complex. Twenty participants were at CMH and ten at FH. One participant at each hospital was practising intermittent KMC. The findings of this qualitative study demonstrate clear consensus for the questions posed. The findings confirmed that KMC was positively received by mothers in a public hospital setting in South Africa but in order for the practice of KMC to be successful, attention should be paid to the following: (a) information received early and effectively, (b) KMC support in hospital and at home after discharge (c) improvement of hospital conditions. Recommendations based on these findings are included to improve the practice of KMC in hospital and at home after discharge.