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ABSTRACT Background: About 90% of women in Kenya report at least one antenatal care (ANC) visit yet maternal mortality rate remains high at 414 per 100,000 live births. Only 40% of childbirths occur in health facilities. A previous study of Nairobi slums in 2000 indicated that only 10.3% of women initiated ANC visits in the first trimester. High incidence of maternal deaths in Kenya especially among the very poor has been attributed to inadequate emergency obstetrical care. Decreasing numbers of women are initiating ANC within the first trimester and this may be affecting the ability of the health system to identify and cater for women whose health conditions can be effectively managed through ANC. This study aimed to determine the proportion of women initiating ANC in the first and last trimesters and the background characteristics associated with these women in two slums of Nairobi, Kenya. It also sought to determine if timing of initial ANC visit was associated with number of visits and choice of place of delivery in a slum setting. Materials and methods: This research report is a secondary data analysis of the World Bank funded Maternal Health Project conducted between 1st April and 30th June, 2006 by the African Population and Health Research Center. Participants were women 12 to 54 years, enumerated in the Nairobi Urban Health Demographic Surveillance System living in two slums of Nairobi, who had a pregnancy outcome between January 2004 and December 2005. Women 15 to 49 years were included in this analysis. Analysis of the data was done using STATA 9.2. Findings: Only 7.3% of women initiated ANC in the first trimester, with 52% making four or more visits. In the third trimester 22% of women initiated ANC. Although 97% of women reported receiving their first ANC from a skilled health professional, only 48.4% delivered in well equipped health care facilities. The median number of months pregnant at first ANC was six and median number of visits was four. Women who were most likely to initiate early ANC had secondary school or higher level of education (p=0.055) and were in a union (p=0.008). The least likely to initiate care in the first trimester were of minority ethnicity (0.011) and high parity (p=0.019). As educational level and wealth status rise, the likelihood of late ANC initiation declines. Women living with unemployed partners were less likely to initiate care in the first trimester compared to those living with employed partners (OR 0.2, p=0.046). Only women with educated partners initiated care during the first trimester. Women who initiated ANC in the first trimester were more likely to have 4 visits and more likely to deliver in appropriate facilities than those who initiated care in the third trimester. Those who initiated care to obtain an ANC card were less likely to have 4 visits than those who initiated care to verify that pregnancy was normal (OR 0.5, p=0.000). Women who initiated care in first trimester were 1.5 and 5.0 times more likely to deliver in good health facilities than those who initiated care in third trimester (p=0.040) and those who had no ANC (p=0.000), respectively. Conclusion: Women in Korogocho and Viwandani may have better chances of delivering in appropriate facilities if they have low parity and secondary level education. The presence of a partner with a means of steady income may also make it easier for women to access delivery care in good facilities. Interventions to improve the level of educational attainment among women and provide affordable family planning are necessary to increase early ANC attendance and subsequently delivery in well equipped facilities.

Thesis (M Med (Family Medicine))--University of Limpopo (Medunsa Campus),2010. / BACKGROUND: Common preventable causes of maternal and perinatal mortality such as HIV, anaemia, gestational proteinuric hypertension, syphilis and Rhesus disorders can be identified early with simple antenatal screening, however this screening is not always efficiently and effectively done. It is critical to identify challenges and possible solutions to ensure effective implementation of the national antenatal screening guidelines for these conditions. Even within existing inadequate resources, there is always room for improved efficiency. METHODS: The aim of this study was to evaluate the implementation of the national guidelines for antenatal screening in the Acornhoek district, Mpumalanga. It was a prospective, cross-sectional study of the antenatal screening programme in the Acornhoek district. Data was collected from an analysis of antenatal and medical records of all women who received antenatal care in the Acornhoek district and ultimately delivered at Tintswalo Hospital, Acornhoek, during the study period of one calendar month. Standardised questionnaires were administered at each of the 15 antenatal clinics referring to Tintswalo Hospital to identify the challenges preventing the effective implementation of the national guidelines for antenatal screening that were experienced by the nurses at the clinics. RESULTS: 428 women were interviewed post partum. 335 were included in the study (87 had received antenatal care out of the district and 6 were unbooked). 85.7% of women had been tested for syphilis antenatally, 84.8% had been tested for anaemia, 72.8% had had blood taken for Rhesus factor and only 64.2% had had pre-test counselling for HIV. 14.3% of women did not have their blood pressure checked at every visit and over 31.4% did not have urine dipstick tests done at every visit. 27% of women booked before 20 weeks, however only 18% had their antenatal bloods taken before 20 weeks. Of the women who had had antenatal blood screening tests done, 18% had not received results by the time of delivery. There was considerable variation between the clinics. Challenges preventing the effective implementation of antenatal screening included variation in knowledge of antenatal screening requirements by clinic staff, barriers to HIV testing, poor infrastructure, equipment and supply problems, laboratory support issues, onsite testing challenges, poor support from the district and passive response to problem solving by clinic staff. CONCLUSIONS: Not all women receiving antenatal care in the Acornhoek district are being screened for HIV, anaemia, GPH, syphilis and Rhesus disorders. From the reasons identified above, interventions such as in-service training of clinic staff in antenatal screening, removing barriers to HIV testing such as appointing lay counsellors at every clinic and offering provider driven or opt-out testing for HIV, improving infrastructure such as installing telephones at every clinic, increasing the laboratory courier service to 5 days a week, introducing on site testing of syphilis, anaemia and Rhesus factor and a rapid pro-active approach to problem solving by district and clinic staff to manage barriers to antenatal screening such as broken equipment and out of stock supplies.

Aims : The aims of the study were to describe the experiences of the midwives who were part of the first Australian CenteringPregnancy Pilot Study and to inform the future development of CenteringPregnancy. Background CenteringPregnancy is a model of group antenatal care that has evolved over the past two decades in North America. A pilot study that explored the feasibility of implementing CenteringPregnancy in Australia was undertaken in 2006-2008. I was the research midwife employed to coordinate this study and I explored the experiences of the midwives who were participants as the focus of my Master of Midwifery (Honours) research. Method : An Action Research approach was undertaken to study the implementation of CenteringPregnancy in Australia. This included a qualitative descriptive study to describe and explore the experiences of the midwives who were participants. The study was set in two hospital antenatal clinics and two outreach community health-care centres in southern Sydney. Eight midwives and three research team members formed the Action Research group. Data collected were primarily from focus groups and surveys and were analysed using simple descriptive statistics and thematic content analysis. Findings : CenteringPregnancy enabled midwives to develop relationships with the women in their groups and with their peers in the Action Research group. The group antenatal care model enhanced the development of relationships between midwives and women that were necessary for professional fulfilment and the appreciation of relationship-based care. The use of supportive organisational change, enabled by Action Research methods, facilitated midwives to develop new skills that were appropriate for the group care setting and in line with a strengths-based approach. Issues of low staffing rates, lack of available facilities for groups, time constraints, recruitment difficulties and resistance to change impacted on widespread implementation of CenteringPregnancy. Conclusions : The experience of the midwives who provided CenteringPregnancy care suggests that it is an appropriate model of care for the Australian midwifery context, particularly if organisational support and recruitment strategies and access to appropriate facilities are addressed. The midwives who undertook CenteringPregnancy engaged in a new way of working that enhanced their appreciation of relationship-based care and was positive to their job satisfaction. Implications for practice Effective ways to implement CenteringPregnancy models of care in Australia were identified in this study. These included a system of support for the midwives engaging in facilitating groups for the first time. It is important that organisations also develop other supportive strategies, including the provision of adequate group spaces, effective recruitment plans and positive support systems for change management. In the light of current evidence the development of continuity of care models which enhance the relationship between an individual women and her midwife, it is important to explore the effects of group care on this unique relationship.

Aims : The aims of the study were to describe the experiences of the midwives who were part of the first Australian CenteringPregnancy Pilot Study and to inform the future development of CenteringPregnancy. Background CenteringPregnancy is a model of group antenatal care that has evolved over the past two decades in North America. A pilot study that explored the feasibility of implementing CenteringPregnancy in Australia was undertaken in 2006-2008. I was the research midwife employed to coordinate this study and I explored the experiences of the midwives who were participants as the focus of my Master of Midwifery (Honours) research. Method : An Action Research approach was undertaken to study the implementation of CenteringPregnancy in Australia. This included a qualitative descriptive study to describe and explore the experiences of the midwives who were participants. The study was set in two hospital antenatal clinics and two outreach community health-care centres in southern Sydney. Eight midwives and three research team members formed the Action Research group. Data collected were primarily from focus groups and surveys and were analysed using simple descriptive statistics and thematic content analysis. Findings : CenteringPregnancy enabled midwives to develop relationships with the women in their groups and with their peers in the Action Research group. The group antenatal care model enhanced the development of relationships between midwives and women that were necessary for professional fulfilment and the appreciation of relationship-based care. The use of supportive organisational change, enabled by Action Research methods, facilitated midwives to develop new skills that were appropriate for the group care setting and in line with a strengths-based approach. Issues of low staffing rates, lack of available facilities for groups, time constraints, recruitment difficulties and resistance to change impacted on widespread implementation of CenteringPregnancy. Conclusions : The experience of the midwives who provided CenteringPregnancy care suggests that it is an appropriate model of care for the Australian midwifery context, particularly if organisational support and recruitment strategies and access to appropriate facilities are addressed. The midwives who undertook CenteringPregnancy engaged in a new way of working that enhanced their appreciation of relationship-based care and was positive to their job satisfaction. Implications for practice Effective ways to implement CenteringPregnancy models of care in Australia were identified in this study. These included a system of support for the midwives engaging in facilitating groups for the first time. It is important that organisations also develop other supportive strategies, including the provision of adequate group spaces, effective recruitment plans and positive support systems for change management. In the light of current evidence the development of continuity of care models which enhance the relationship between an individual women and her midwife, it is important to explore the effects of group care on this unique relationship.

Pregnancy is often portrayed as a happy time for the woman and her family. In reality, many women struggle with negative emotions and moods that can have deleterious effects on the mother, the fetus, and the growing family. Depression is an increasing, worldwide problem, with women in their childbearing years and those of low socioeconomic status the most vulnerable. <p>This study explores depression, as determined by the Edinburgh Postnatal Depression Scale (EPDS), in a high-risk sample of pregnant women enrolled in two prenatal programs in Saskatoon, Saskatchewan, Canada. A prevention and population health approach has been used to identify potential determinants and implications of antenatal depression. The data analyzed in this study were from the first cross-sectional portion of a longitudinal, epidemiological study of depression in pregnancy into the postpartum. Women were invited to participate in the study at their first prenatal visit. Data were collected by program staff. <p>The prevalence of depression in this sample of 402 high-risk women was 29.5%, which is similar to other studies of inner-city, low income, and minority women elsewhere in the world. In the final model, antenatal depression was associated with a history of depression, moods going up and down, current smoking status, high levels of stressors, and social support.<p>Factor analysis of the EPDS revealed three underlying factors: Anxiety, Depression, and Self-harm thoughts. The anxiety factor explained most of the variance in the overall EPDS scores in this sample of women. A history of problems with mood fluctuations was significantly associated with anxiety and depression subscales and self-harm. Significantly more women aged 21 and under experienced anxiety, and more Aboriginal women experienced depressive symptoms and self-harm thoughts. Twenty percent of women reported self-harm thoughts in the preceding seven days. Depressed, Aboriginal, and single women, and women who use alcohol were most at risk for self-harm thoughts. <p>The level of depressive symptoms in this sample of women represents a significant public and mental health problem in women already challenged by inequities in their life circumstances. We need to develop public health policy that will support screening and identification of women with depression. Interventions at the primary, secondary, and tertiary levels of prevention can help to improve the health of women struggling with antenatal depression, promote the optimal intrauterine environment for their unborn children, and reduce the intergenerational transmission of depression.

Pregnancy is often portrayed as a happy time for the woman and her family. In reality, many women struggle with negative emotions and moods that can have deleterious effects on the mother, the fetus, and the growing family. Depression is an increasing, worldwide problem, with women in their childbearing years and those of low socioeconomic status the most vulnerable. <p>This study explores depression, as determined by the Edinburgh Postnatal Depression Scale (EPDS), in a high-risk sample of pregnant women enrolled in two prenatal programs in Saskatoon, Saskatchewan, Canada. A prevention and population health approach has been used to identify potential determinants and implications of antenatal depression. The data analyzed in this study were from the first cross-sectional portion of a longitudinal, epidemiological study of depression in pregnancy into the postpartum. Women were invited to participate in the study at their first prenatal visit. Data were collected by program staff. <p>The prevalence of depression in this sample of 402 high-risk women was 29.5%, which is similar to other studies of inner-city, low income, and minority women elsewhere in the world. In the final model, antenatal depression was associated with a history of depression, moods going up and down, current smoking status, high levels of stressors, and social support.<p>Factor analysis of the EPDS revealed three underlying factors: Anxiety, Depression, and Self-harm thoughts. The anxiety factor explained most of the variance in the overall EPDS scores in this sample of women. A history of problems with mood fluctuations was significantly associated with anxiety and depression subscales and self-harm. Significantly more women aged 21 and under experienced anxiety, and more Aboriginal women experienced depressive symptoms and self-harm thoughts. Twenty percent of women reported self-harm thoughts in the preceding seven days. Depressed, Aboriginal, and single women, and women who use alcohol were most at risk for self-harm thoughts. <p>The level of depressive symptoms in this sample of women represents a significant public and mental health problem in women already challenged by inequities in their life circumstances. We need to develop public health policy that will support screening and identification of women with depression. Interventions at the primary, secondary, and tertiary levels of prevention can help to improve the health of women struggling with antenatal depression, promote the optimal intrauterine environment for their unborn children, and reduce the intergenerational transmission of depression.