submitted in fulfillment of the requirements for the Doctoral Degree in Nursing, faculty of Health Sciences, Durban University of Technology, Durban, South Africa, 2016. / Globally antenatal care is advocated as the cornerstone for reducing children’s deaths and improving maternal health. The World Health Organization designed and tested a Focussed Antenatal Care model for the developing countries to improve their quality of antenatal care services. South Africa has not successfully implemented this approach, referred to by South Africa as the Basic Antenatal Care approach. A convergent parallel mixed methods design was used to assess how the Basic Antenatal Care approach was implemented in the eThekwini district. Data were collected from 12 Primary Health Care clinics using observations, retrospective record reviews and semi-structured interviews conducted with pregnant women. The quantitative data was analysed using version 21.0 of the Statistical Package of Social Services and qualitative data was analysed using Tech’s method of data analysis. The Basic Antenatal Care approach was not being successfully implemented in the Primary Health Care clinics. Several aspects of planning, people, processes and performance were not done according to the Basic Antenatal Care Principles of Good Care and Guidelines. Although good communication was observed between the clinic staff members and the referral institutions, communication problems existed between the Primary Health Care clinics and the Emergency Medical Rescue Services and also with the pregnant women. Antenatal care and delivery plans and the midwives’ counter checking of maternity charts were not recorded. Some pregnant women had positive perceptions about the antenatal care services but others had negative perceptions. Recommendations pertaining to institutional management and practice, nursing education and research were made. A tailored practice framework and an implementation guide were developed based on setting and client-specific factors to facilitate the implementation of the Basic Antenatal Care approach. The framework highlights the importance of cooperation between management and administration, in-service education and skills development departments/units and the operational level. Effective implementation of the Basic Antenatal Care approach could help to reduce South Africa’s high maternal and neonatal mortality rates. Thus the tailored practice framework and implementation guide, developed as part of this study, could help to improve maternal and neonatal health-related outcomes in South Africa. / D

The purpose of this study was to investigate the determinants of high neonatal mortality rates in Migori County, Kenya. The neonatal mortality cases were utilised as the target population to the study. A quantitative, descriptive, cross-sectional, non-experimental research design was used. A systematic sampling technique was employed to draw a sample of 201 archived neonatal cases out of 420 neonatal mortality medical records, which constituted the study population. Data were collected by means of a developed questionnaire. The Statistical Package for Social Sciences (SPSS) Version 21 was used to analyse data. The main findings revealed the leading determinants of neonatal mortality were early neonatal period, prematurity, poor 1st Apgar score, low birth weight and neonates with intrapartum complications. Obstetrical haemorrhage and HIV were the main maternal complications associated to neonatal mortalities, while the leading direct causes of death in this study were birth asphyxia and sepsis. Other determinants were gender, rural residence, lowly educated and informally employed mothers. To reduce mortalities, a multifaceted approach is needed to establish quality improvement in neonatal intensive care, reduce preterm birth incidences, and empower mothers socio-economically. / Health Studies / M.A. (Nursing Science)

Sammanfattning Av: Frida Rönnbrink Föräldrar som har förlorat ett barn under perinatalperioden – en kvalitativ studie om föräldrars upplevelser av bemötande, stöd och hjälp Studien syftade till att utifrån sex föräldrars berättelser, nå en ökad förståelse om hur de upplever bemötandet, stödet och hjälpen då de förlorat ett barn under perinatalperioden. Studien hade följande frågeställningar: Hur upplever föräldrar, som har förlorat sina barn under perinatalperioden, det bemötande och det stöd och den hjälp de fått från professionella? Hur upplever de det sociala nätverkets bemötande och stöd? För att besvara frågorna utgick intervjun från tre teman, professionellt bemötande, professionellt stöd och hjälp samt det egna sociala nätverket. Studien gjordes med en fenomenologisk vetenskapsfilosofisk position. Resultatet analyserades manuellt och tolkades hermeneutiskt med hjälp av kristeori, systemteori samt Vaux teori om socialt stöd. Studiens resultat visade att de föräldrar som nyligen förlorat sitt barn var relativt nöjda med den professionella hjälpen. Däremot kunde man se klara brister i det egna sociala nätverkets stöd. Nyckelord: Föräldrars upplevelser, perinatal död, bemötande, professionellt stöd, nätverkets stöd. / Abstract By: Frida Rönnbrink Parents who have lost a child during the perinatal period - a qualitative study of parents' experiences of how they are treated, support and help The purpose of the study was to reach a better understanding of how six parents experience how they were treated, supported and helped when they lost a child during the perinatal period. This can then be used to customize the help offered them. The study had the following questions: How do parents who have lost a child during the perinatal period, experience how they are treated and the support and help they received from professionals? And, how do they experience the social network's treatment and support? In order to answer the questions, the interview was based on three themes, professional treatment, professional support and help and support from the network on their own. The study was conducted using a phenomenological philosophical position. The results were analyzed manually and were interpreted hermeneutic using crisis theory, systems theory and Vaux's theory of social support. The results showed that parents who recently lost their infant were relatively pleased with the professional help. However, you could see deficiencies in their own social network support. Keywords: Parents' experiences, perinatal death, treatment, professional support, network support.

[Truncated abstract] Periodontal disease is a common and underdiagnosed disease in humans that may have adverse effects on pregnancy outcomes. The aim of this thesis was to investigate the effects of periodontal disease in pregnancy by means of two observational human studies and the development of animal models of fetal and uterine exposure to periodontopathic bacteria and lipopolysaccharide. I performed a prospective study examining the rates of preterm birth, small for gestational age neonates and neonatal inflammation in 277 women who had undergone a detailed antenatal periodontal examination and oral health questionnaire. Periodontal disease was associated with small for gestational age neonates, and increased CRP levels in umbilical cord blood, but no effect was seen on the rate of preterm birth. Maternal oral health symptoms predicted both periodontal disease and newborn biometry. In a retrospective case control study, I examined the role of periodontal disease in perinatal mortality. Participants included 53 women who had experienced a perinatal loss for which no cause could be found after thorough investigation, and 111 control women. Women who had experienced a perinatal loss were more than twice as likely as controls to have periodontal disease. The incidence of periodontal disease was even higher in women in whom the perinatal loss was due to extreme prematurity. In contrast to my prospective study, risks to the pregnancy could not be predicted by maternal oral health behaviours or oral health symptoms. In order to better understand the mechanisms regulating the associations described in the human studies, two animal models were developed; one to investigate acute exposure and the second to investigate long-term exposure to periodontal pathogens. The first study examined the effects of administration of a bolus of periodontopathic bacteria and lipopolysaccharide to the pregnant sheep. Injection of bacteria and lipopolysaccharide in the amniotic fluid of the pregnant preterm sheep caused a high rate of fetal lethality, disturbance of fetal acid base status and inflammation of the fetus and membranes. Given the circumstances of exposure to periodontopathic pathogens in human periodontal disease, a model investigating long-term exposure to periodontopathic lipopolysaccharide on pregnancy outcomes was developed. ... Overall, I have demonstrated that maternal periodontal disease is associated with adverse pregnancy outcomes including fetal growth restriction and possibly perinatal loss. Mechanisms regulating these effects are likely to be mediated by fetal adaptations to intrauterine inflammation resulting in altered fetal development, growth or survival. Randomised controlled trials that are currently in progress will provide further information on the effects of periodontal disease in human pregnancy, and the efficacy of treatment to reduce these adverse outcomes.

Objective: To identify the epidemiological characteristics of early fetal and neonatal deaths in maternal near miss patients and the associated elements to this outcome. Method: Cross-sectional study including 79 women with features near miss, identified in a one-year period, and their newborns. Semi-structured interviews and the study of patients’ records were conducted. The variables were analyzed through simple frequency and percentage. To evaluate the association between those variables, the Fisher’s Exact Test was used. For the multivariate analysis the perceptual map constructed from the multiple correspondence examination was used, using the variables that were significant to 20%. Results: Amongst the near miss mothers, hypertensive disorders (severe pre-eclampsia, eclampsia, hypertension) totalized 32 cases (40,5%) and, of those, 14 (58,3%) had fetal and neonatal adverse outcome (p 0,046). The highest prevalence of fetal and neonatal adverse outcome was derived from cesarean delivery (20, 83,3%), of women with 2 or 3 children (11, 45,8%), and without previous stillbirths (17, 70,8%), this last variable with significance p 0,038. In the fetal and neonatal adverse outcome analysis significant levels were verified in newborns admitted in Neonatal Intensive Care Unit (17, 70,8%, p < 0,001); children with gestational age < 32 weeks (10, 41,6%, p < 0,001); birth weight < 2500 (16, 66,7%, p 0,001); APGAR score at 5 minutes < 7 (9, 52,9%, p < 0,001); neonatal asphyxia, 9 (50,00%, p < 0,001); and early respiratory distress syndrome, 13 (72,2%, p 0,002). Conclusion: The characteristic of early fetal and neonatal deaths in maternal near miss patients had a close association with fetal and neonatal adverse outcome. Among the mothers with hypertensive disorders the significant characteristics to the outcome in newborns were prematurity, neonatal asphyxia and early respiratory distress syndrome. / Objetivo: Identificar as características epidemiológicas dos óbitos fetais e neonatais precoces em pacientes com near miss materno e os fatores associados a este desfecho. Método: Estudo transversal, cuja população foi composta por 79 mulheres com características de near miss (NM), identificadas no período de um ano, e dos seus respectivos recém-nascidos. Foram realizadas entrevistas semiestruturadas e investigação dos prontuários. As variáveis foram analisadas por meio de frequências simples e percentual. Para avaliar associação entre as variáveis, utilizou-se o teste Exato de Fisher. Para análise multivariada, foi usado o mapa perceptual construído a partir da análise de correspondência múltipla e utilizadas as variáveis que foram significativas a 20%. Resultados: Entre as mães classificadas com NM, as desordens hipertensivas (pré-eclâmpsia grave, eclâmpsia, hipertensão) totalizaram 32 casos (40,5%) e, destes, 14 (58,3%) tiveram desfecho fetal e neonatal adverso (DFNA) com p-valor =0,046. A maior prevalência de DFNA foi proveniente de parto cesáreo (20, 83,3%), de mulheres com dois a três filhos (11, 45,8%) e sem natimortos anteriores (17, 70,8%), verificando-se significância para esta última variável p =0,038. Na análise dos DFNA, foi observada significância estatística para os recém-nascidos admitidos na UTIN (17, 70,8%, p <0,001); crianças com idade gestacional < 32 semanas (10, 41,6%, p <0,001); peso ao nascer < 2500 (16, 66,7%, p =0,001); APGAR de 5 minutos < 7 contabilizaram 9 (52,9%, p <0,001); asfixia neonatal, 9 (50%, p <0,001); e desconforto respiratório precoce, 13 (72,2%, p =0,002). Conclusão: As características dos óbitos fetais e neonatais precoces em pacientes com near miss materno tiveram associação forte com o desfecho fetal e neonatal adverso. Nas mães com desordens hipertensivas, as características estatisticamente significantes para o desfecho entre os recém-nascidos foram a prematuridade, asfixia neonatal e desconforto respiratório precoce.

Dissertation submitted in fulfillment of the requirements for the Degree in Masters of Technology: Nursing, Durban University of Technology, 2011. / Background South Africa is burdened by consistently high maternal and perinatal mortality rates. In a move to alleviate this burden the South African National Department of Health (DoH) instructed the adoption of the Basic Antenatal Care (BANC) approach in all antenatal care (ANC) facilities. Whereas many facilities have begun the implementation of the BANC approach, in the eThekwini district, not all of the facilities have been successful in doing so. The study was conducted in those eThekwini Municipality Primary Health Care (PHC) facilities that have been successful in order to identify the factors influencing their success in implementing BANC. Methods The facilities that had been successful in implementing BANC were identified, followed by a review of the past records of the patients who had completed their ANC and had given birth. This was done in order to establish whether the facilities that were said to be implementing BANC, were in fact, following BANC guidelines. The factors that influenced successful implementation of BANC were identified based on information obtained from the midwives who were working in the ANC facilities that were successfully implementing BANC. The sample size was comprised of 18 PHC facilities that were successfully implementing BANC from which a total of 59 midwives were used as the study participants. Results Several positive factors that influenced successful implementation of BANC were identified. These factors included; availability and accessibility of BANC services: Policies, Guidelines and Protocol; various means of communication; a comprehensive iii package of services and the integration of services; training and in-service education; human and material resources and the support and supervision offered to the midwives by the PHC supervisors. Other factors included BANC programme supervisors’ understanding of the programme and the levels of experience of midwives involved in implementation of BANC. There were, however, certain challenges and negative factors that were identified and these included: shortage of staff; lack of cooperation from referral hospitals; lack of in-service training; problems in transporting specimens to the laboratory; lack of material resources; lack of management support and the unavailability of BANC guidelines.

Obstructed labour contributes significantly to the morbidity and mortality among both mothers and babies in Ethiopia nationwide, and also in the West-Wollega region where this study was conducted. The researcher used a retrospective hospital based review of maternity files to quantify the problem of obstructed labour in the selected hospital. The findings revealed that maternal and perinatal mortality due to obstructed labour amounted to 1.4% and 7.5% respectively. Most of these complications could be prevented by proper antenatal care and careful attentive monitoring during delivery with proper use of the partogram which will indicate the occurrence of complications in good time when successful and life saving interventions are still available. The findings clearly show that poor documentation in general and very sporadic usage of the partogram in particular contributes significantly to the complications for mother and child. Re-introduction of proper documentation and careful use of the partogram are advocated / Health Studies / M.A. (Public Health)

Grâce à des entretiens non directifs réalisés auprès de 16 sages-femmes et 16 obstétricien(ne)s, cette recherche tente de cerner l’impact que la mort périnatale a sur eux et sur leur travail, au-delà de celui qu’elle a sur les parents avec le deuil périnatal. Face à des progrès médicaux sans précédent, la société, les parents et les soignants eux-mêmes s’attendent peu à la survenue de la mort dans la naissance. Interruption médicale de grossesse ou mort périnatale inattendue confrontent cependant ces soignants à des épreuves au travail susceptibles d’avoir sur eux des répercussions majeures selon le contexte et l’âge de la grossesse. Elles donnent lieu à des déficits de la reconnaissance, qu’elle soit sociale, professionnelle ou personnelle. Leur restauration nécessite le recours actif à l’intersubjectivité engagée auprès des pairs comme auprès des parents afin que les soignants puissent continuer leur travail et y rester. / Through 32 open-ended interviews with midwives and obstetricians, this work attempts to identify, beyond parental mourning, the impact of perinatal death on childbirth professionals and their work. Unprecedented medical advances result in a relative absence of expectation of death in birth for the society, medical professionals and for the parents. Medically motivated induced termination or unexpected perinatal death, however, confronts caregivers at work with an ordeal which can have major repercussions depending on the context and the term of the pregnancy involved. These events cause deficits in social, professional and personal recognition in these caregivers. To be restored, symbolic processing is necessary for all concerned through the implication of subjectivity at work with peers and parents in order for these caregivers to be able to continue to work.

Obstructed labour contributes significantly to the morbidity and mortality among both mothers and babies in Ethiopia nationwide, and also in the West-Wollega region where this study was conducted. The researcher used a retrospective hospital based review of maternity files to quantify the problem of obstructed labour in the selected hospital. The findings revealed that maternal and perinatal mortality due to obstructed labour amounted to 1.4% and 7.5% respectively. Most of these complications could be prevented by proper antenatal care and careful attentive monitoring during delivery with proper use of the partogram which will indicate the occurrence of complications in good time when successful and life saving interventions are still available. The findings clearly show that poor documentation in general and very sporadic usage of the partogram in particular contributes significantly to the complications for mother and child. Re-introduction of proper documentation and careful use of the partogram are advocated / Health Studies / M.A. (Public Health)

The purpose of the study was to determine the causes, of the increased perinatal mortality, identify and describe other factors contributing to the increased perinatal mortality rate in a rural healthcare facility situated in Sekhukhune district in Limpopo province, and to formulate the recommendations that will reduce the perinatal mortality rate based on the results. A quantitative, descriptive, cross-sectional and retrospective design was conducted. The study population was one hundred and sixty two (162) records of babies who died in the perinatal facility from the 1st January 2015 to the 31st December 2015 with a gestational age of about 28 weeks or more. No sampling was done, but a census was used. The sample comprised of one hundred and sixty two (162) of all the records related to perinatal mortality. Data were collected from patients’ records by using a checklist. Analysis of the data was performed by the IBM Statistical Package for Social Sciences (SPSS) version 14 computer software. Frequency tables and pie graphs were used to present the data. The results indicated that 75.3% (n=122) of the records were associated with health personnel as a factor contributing to perinatal mortality. Furthermore, preterm cases accounted for 45.1% (n=73) and prematurity accounted for 37.0% (n=60) of the cases of perinatal mortality. Therefore, preterm births and prematurity are risk factors that should be managed immediately after birth, and all babies should be managed prior to being transferred to the other healthcare institutions. The recommendations are that the education of patients about early antenatal visit, signs of labour and danger signs during pregnancy and training of healthcare workers on record-keeping have to be done on a continuous basis. Managers should conduct quality improvement programmes, benchmarking and implement maternal and neonatal guidelines in the clinical area throughout pregnancy. / Health Studies / M. P. H. (Health Studies)