A research project submitted to the School of Public Health in partial fulfilment of the requirement for the Degree of Master of Public Health, in the field of Social and Behaviour Change Communication. Date: June 2017 / Globally, access to maternal and child healthcare remains a fundamental human right for all, regardless of an individual’s migration status (1). People migrate for a variety of reasons, and this mobility brings forth implications for health provision, health care experiences and human rights, both for the migrants and their host population (2, 3). An increasing number of cross-border or international migrant women globally report difficulties in access to and use of healthcare services, including maternal and child health (4, 5). Little evidence in South Africa on these issues proposes that there is a need for deeper knowledge in this regard. South Africa is a signatory to a range of international commitments that place emphasis on the non-discriminatory provision of health services and a progressive health policy assuring health for all, including free access to antenatal care (ANC) (1). Despite this, South Africa’s maternal and child health outcomes continue to be poor - including that of migrants (6, 7). The increased number of migrants from neighbouring countries is perceived to have placed a burden on the South African healthcare system (4). The aim of this study was to explore the experiences and perceptions of Zimbabwean cross-border migrant mothers in accessing routine antenatal care, obstetric care and infant/child immunisation in public healthcare facilities in, Gauteng, South Africa (2015-2016). Through a qualitative study design, the researcher gathered data by means of 13 face-to-face interviews with a purposive and snowball sample of participants. Few participants gave positive reports on the quality of ANC and immunization services they had received. It is therefore important to ensure that this positive care is maintained across all public health facilities in order to instill confidence among health recipients. However, most of the study participants experienced barriers in accessing quality routine ANC and infant immunisation in the country’s public health facilities. These challenges include language barriers, discrimination and poor nurse-patient relationships. Based on these findings and conclusions, the researcher recommends that the South African National Department of Health addresses some of the challenges affecting cross-border migrant vi women in accessing maternal health care in public facilities nationally through the formulation, implementation and follow-up of policies. Furthermore, health care providers need to be continuously educated and motivated to respect the rights of all patients, regardless of an individual’s migration status, in order to instil positive attitudes and quality care. There is also a need to conduct further research in other provinces of the country, preferably with cross-border migrant women from other countries, and draw comparisons with South African women in order to take appropriate steps to address the challenges. / MT2017

Thesis (M.S.)--Wisconsin. / Includes bibliographical references (leaf 38).

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Antenatal care (ANC) has been recognised as a way to improve health outcomes for pregnant women and their babies. Only 29% of pregnant women receive the recommended four antenatal visits in Nepal and reasons for such low utilisation of ANC are poorly understood. The main aim of this thesis is to explore opportunities and barriers in ANC uptake and the family’s role in decision-making in Nepal. In-depth interviews were conducted with 30 purposively selected prenatal or postnatal mothers (half users, half non-users of ANC), 10 husbands and 10 mothers-in-law in two communities (one semi-urban, one rural). There is no single factor that determines the use of ANC in the study area. Use of ANC is influenced by cultural norms and values. Culturally women have low status in the household and this contributes to the low uptake of ANC. Heavy workloads (inside and outside the home) are expected of all young women and challenge ANC uptake in rural areas. The findings suggest that husbands and mothers-in-law have a strong influence in the use of ANC. Mostly the mothers-in-law are pivotal family members who make decisions about ANC for their daughters-in-law. Educated husbands are reported to be positive towards ANC. Husbands’ lack of support in ANC is mostly related to alcoholic habit. Education had a positive effect on ANC uptake due to improved knowledge of its function. Perceptions regarding the need for ANC are shaped by previous experiences and severity of the condition of pregnancy. Some women did not go for ANC as pregnancy was seen as a normal condition. Similarly, perceived quality of care such as satisfaction towards the services, privacy and confidentiality, communication skills of the health worker are highlighted as important issues in ANC uptake. Factors related to affordability of care such as poverty and cost of the services are discouraging to some, especially poor families. Similarly, availability and accessibility of the services were highlighted as important issues in ANC uptake. Comprehensive health promotion and educational interventions could be positive actions but should target both women and their family members, particularly mothers-in-law and husbands.

This thesis presents the results of a qualitative study of self-care in pregnancy, birth and lactation within a non-random sample of 27 women in British Columbia, Canada. The women were interviewed in the third trimester of pregnancy, and 23 of the participants were re-interviewed post-partum. Interviews were tape recorded, transcribed, and subjected to thematic analysis. Results were discussed in the context of the social science literature on the medicalization of pregnancy and childbirth. All but one woman used herbal medicine while pregnant. In the post-partum interviews, nearly half reported using galactagogue herbs. The safety and efficacy of each herbal remedy are discussed here. Most of the herbs are considered safe and effective according to the herbal literature, but clinical reports are largely lacking. While many of the women were cautious about using herbs during pregnancy, as a general rule, they considered them to be safer than pharmaceutical drugs. In choosing to self-medicate with herbs, the women said they were guided by prior knowledge (32%), trusted sources of advice (56%), and intuition (12%). Trusted sources of advice included books, friends, family members, maternity care providers, herbalists, herbal shops, and internet. The majority of herbal advice (69%) was received by word-of-mouth. Prolonged pregnancy also proved to be an interesting situation. Many women said they were opposed to labour induction at the time of the first interview, yet all but one woman who went beyond 40 weeks gestation used self-help measures to stimulate labour. This appeared to be a response to pressure from maternity care providers, friends, and family members. Though the medical definition of prolonged pregnancy is 42+ weeks gestation, in the social context, 40+ weeks was cause for concern. Health care professionals, partners, family members, friends, and co-workers all affected self-care behaviour, and their influence could be positive or negative. After an overwhelmingly negative experience with a maternity care provider, over half of the women went to another care provider, or forewent formal maternity care entirely. These findings did not support the hypothesis that childbearing is almost completely medicalized, at least for the sample population. Rather, women negotiated their maternity care within several frameworks, including the medical, midwifery, and self-care models. Medical language was used to describe birth stories, but only by women in physician care. There was an almost universal effort among the women to normalize the childbearing experience. The findings of this study point to a need for: (1) clinical investigation of herbal medicines used in pregnancy, birth and lactation; (2) public and care-provider education regarding social and psychological aspects of prolonged pregnancy; (3) broad-scale inquiry into the phenomena of medicalization/normalization of the childbearing experience, and (4) further investigation into women’s preferences for empowering styles of maternity care. / Graduate

This research situated antenatal education within a health promotion framework to determine a consumer-based approach to improving antenatal and postnatal education purported to prepare for parenthood. Research, both published and unpublished, criticises current structured educational programs and first time parents are reported to experience high levels of stress and unhappiness. Stage One of this study was a multiple source, multiple methods needs assessment conducted at two large, metropolitan hospitals in Sydney. The aim of the needs assessment was to explore the needs, interests and concerns of first time expectant and new parents, their changing nature during the childbearing year, ascertain learning processes that best suited their needs, and plan effective antenatal education around the results. Repeated in-depth interviews, focus groups, participant observation and surveys were used to collect data from expectant and new parents. Focus groups, surveys and participant observation were used to collect complementary data from educators, midwives and Child and Family Health Nurses who work with expectant and new parents. The third source of data analysed was documentary, that is program outlines and session plans of three comparable hospitals. The needs assessment demonstrated that to effectively prepare women and men for their childbearing experience, a range of strategies, programs and learning activities were required. This resulted in the design of a ‘menu’1 approach to antenatal and postnatal education with an emphasis placed on ‘life as a mum and a dad’, and the ‘world’ of their baby. The results also demonstrated a significant difference existed between the actual learning needs and priorities of expectant and new parents and those perceived to be their needs by the professionals. Expectant and new parents questioned the group facilitation skills of educators and identified methods to improve practice. Three strategies identified by these expectant and new parents as priorities were designed, implemented and an evaluation of each was undertaken in Stage Two of this study. The strategies were: 1. Seven session Having a Baby program for first time parents. 2. Group skills training program for antenatal and postnatal educators. 3. Breastfeeding resource package for antenatal educators. Stage Three of this research was an empirical study. A repeated measures randomised control trial was undertaken to test the effectiveness of the new Having a Baby program. In particular whether women and men who attended this program had improved perceived parenting self-efficacy, knowledge, and decreased worry about the baby eight weeks after birth compared with those who attended the conventional antenatal education program. The new program placed the labour and birth experience as a microcosm of the childbearing experience, and incorporated learning activities designed to enhance the confidence of pregnant women and their partners during their adjustment to parenthood. Perceived parenting self-efficacy2 was the measure by which parenting confidence, and therefore adjustment to parenthood, was measured The randomised control trial demonstrated that the perceived parenting self-efficacy of women and men in the experimental group was higher than those of control group participants at approximately eight weeks after the birth, with the difference being statically significant. The labour and birth outcomes of both groups, and their demographic details, were similar. Evaluation of the group skills training program for antenatal and postnatal educators and the breastfeeding resource package for antenatal educators were undertaken. Data collected from focus groups, interviews and surveys demonstrated the effectiveness of these strategies. The findings of this research question the validity of conventional antenatal classes and confirm the need for training and mentoring of antenatal educators. Effective, high quality antenatal education operating within budget allocation, facilitated by group skills trained educators, can produce superior postnatal outcomes.

Thesis.

Thesis (Ph. D.)--University of Texas at Austin, 2002. / Vita. Includes bibliographical references. Available also from UMI Company.