Magister Curationis - MCur / The use of health education during antenatal care of pregnant women has been a commonly used strategy in improving maternal health worldwide. However the health education strategy sometimes does not prove to be effective in promoting maternal health, especially in Sub-Sahara Africa.

Magister Public Health - MPH / Common perinatal mental disorders (CPMDs) are increasingly being recognised as an important public health issue including depression and anxiety. In low and middle income countries such as Rwanda, CPMDs are prevalent among women in perinatal period. In Africa, the estimated prevalence rates of depression are 11.3% and 18.3% during ante-postnatal respectively, while ante-postnatal anxiety rates are 14.8% and 14% respectively. However, in Rwanda there is limited literature on CPMDs. This study was aimed at determining the occurrence of CPMDs in a selected district hospital of the Eastern Province in Rwanda as well as the factors associated with CPMDs in the selected study area. A descriptive quantitative cross-sectional survey was conducted with a sample of one hundred and sixty five mothers in perinatal period, who were selected systematically. Demographic data and factors associated with CPMDs were determined using structured questionnaire and combined screening tools such as Zungu Self-rating anxiety scale (SAS) and Edinburgh Postnatal Depression Scale (EPDS). The Cronbach alpha values were 0.87 and 0.89 for SAS and EPDS respectively. SPSS Version 21 was utilized to analyse data. Univariate, bivariate correlational and multivariate analyses were performed. Most of the respondents (38.2%) were aged 25-29 years; Protestants (77.6%); married (44.8%); unemployed (77%) and had a primary school level of education (60.6%). With respect to participants in antenatal period (51.5%); 14.5% had a clinical level of anxiety and 19.4% had depression. In terms of participants in postnatal period (46.7%); 22.5% had a clinical level of anxiety and 29.7% had depression. However, participants in both periods (1.8%) all had a normal level of anxiety and 1.2% had depression.

Attachment refers to a strong emotional bond with special people in a person?s life, in whose presence the person experiences pleasure, joy and comfort in times of stress. The first attachment in life is commonly formed between an infant and primary caregiver, which is usually the mother. The caregiving provided by the mother or caregiver will determine whether a secure or insecure attachment pattern is formed. Attachment theory indicates that this first attachment forms the basis for a cognitive representation, the so-called internal working model, which becomes part of the person?s personality and forms the foundation of the person?s perception of the self and the world as well as of all future interpersonal relationships. As infancy is a sensitive period for the development of attachment, the prenatal period could be an appropriate time to educate expecting mothers about the importance of secure attachment and their role in the development thereof. The researcher therefore wished to explore whether antenatal programmes could be used as a platform for teaching expecting mothers about attachment. As a starting point, the goal of this study was to explore the perceptions of antenatal programme presenters on including training on attachment into antenatal programmes. The study was based on a qualitative research approach, and applied research as the type of research. A collective case study research design was adopted and data was collected by means of semi-structured interviews that were conducted with a sample of ten presenters of antenatal programmes in the Tshwane district. The participants were selected by means of purposive sampling. Data was analysed according to methods for qualitative data analysis, and relevant ethical considerations were followed during the study. The research findings indicate that the participants were aware of the importance and benefits of secure attachment and that they had a positive attitude towards the inclusion of training on attachment into antenatal programmes. They were eager to receive training on attachment and to adapt their programmes to include training on attachment. The researcher concludes that it would be feasible and beneficial to include training on attachment into antenatal programmes, and to train antenatal programme presenters for this purpose. The provision of training on attachment to nurses and raising awareness of attachment in the private and public health care sectors could facilitate greater knowledge of attachment for expecting mothers. Further research in diverse settings, such as in private and public clinics and hospitals in different geographical areas, is recommended. / Mini Dissertation (MA)--University of Pretoria, 2016. / Social Work and Criminology / MA / Unrestricted

Inledning: Antenatal depression är en riskfaktor förknippad med ej fullgången graviditet, anknytningssvårigheter och förlossningsdepression. Ny forskning framhåller att den havande kvinnans psykiska mående kan ha påverkan på fostrets utveckling. Under havandeskapet återkallas i medvetandet känslor, upplevelser och hågkomster från barndomen vilket gör psykoterapi till ett gynnsamt behandlingsalternativ. Det övergripande syftet med denna studie är att undersöka legitimerade psykoterapeuters upplevelser av det psykodynamiska terapiarbetets utmaningar och möjligheter i arbetet med gravida. Frågeställningar: Vad upplever psykoterapeuterna är utmanande i det psykodynamiska arbetet med gravida kvinnor? Vad upplever psykoterapeuterna är gynnsamt innehåll och hjälpsamma interventioner i psykoterapi med gravida? Metod: Fem halvstrukturerade intervjuer med legitimerade psykoterapeuter med psykodynamisk inriktning har genomförts och med hjälp av tematisk analys kondenserats till tre teman. Resultat: De tre temana är Ramen, Innehåll och Terapeutiskt mål. Det psykoterapeutiska arbetets karaktär förändras utifrån var i graviditeten kvinnan befinner sig. Interventioner präglas av lyhördhet och varsamhet och terapeuterna utgår ifrån den blivande mammans komplexa tillstånd: skörhet och styrka. Moderskapandet är det terapeutiska målet och anknytning centralt tema. Diskussion: Resultatet diskuteras utifrån terapeuternas upplevelser av utmaningar och möjligheter i samtalen med gravida kvinnor. Värdefulla komponenter i terapeuternas upplevelser diskuteras utifrån teoretiska begrepp och forskning. Vald metod diskuteras. / Introduction: Antenatal depression is a risk associated with non-full-term pregnancies, difficulties in attaching with the baby and postpartum depression.According to current research, a pregnant woman´s mental state during pregnancy can have a bearing on the development of the foetus. During pregnancy, feelings, experiences and memories from childhood are brought back, making psychotherapy a favourable form of treatment. The overall purpose of this study is to find out about certified psychotherapists experiences of psychodynamic therapy treatment: challenges and possibilities when working with pregnant women. Questions: What do psychotherapists find challenging in the psychodynamic work with pregnant women? What do they experience as successful contents and helpful intervention as regarding psychotherapy with pregnant women? Method: Five qualified psychotherapists practicing psychodynamic psychotherapy were interviewed. The interviews were semi-structured, using thematic analysis condensed into three different themes. Result: The three themes involved are framework, content and therapeutic goal. Depending on the stage of pregnancy, the character of treatment will vary. Interventions are characterized by responsiveness and caution. Therapists will base their treatment on the pregnant woman´s complicated condition: fragility and strength. The therapeutic goal is to prepare the mother-to-be for motherhood; attachment being in focus. Discussion: The result is discussed from the point of view of the psychotherapists´ experiences -challenges and possibilities- in sessions with pregnant women.Valuable factors in therapists experience are discussed on theoretical concepts and research. The reason for selecting the method in question is discussed.

Yes / A Delivery Suite Assessment Unit (DSAU) has been established at a large Northern teaching hospital. This was as a recommendation of ASQUAM (achieving sustainable quality in maternity) to reduce antenatal admissions to delivery suite and provide a more appropriate environment for women attending for antenatal or labour assessment. The DSAU has also provided an effective teaching environment where skills such as effective telephone triage, diagnosis of labour and care of women with pre-labour spontaneous rupture of membranes (SROM) have been developed by junior staff. The first twelve months' audit results indicate that the establishment of the DSAU has been successful in reducing antenatal admissions to delivery suite by increasing the transfers of clients home, rather than to the antenatal wards. This may reflect the confidence of the highly skilled midwives working in this environment and the confidence women feel about their ability to obtain prompt and accurate advice over the telephone.

The important implications of the attachment relationship have led researchers to consider what the precursors to a secure attachment relationship are. Ainsworth, Bell, and Stayton (1971) proposed that maternal sensitivity was the fundamental trait in developing a secure attachment relationship. However, recent research has identified that mind-mindedness; the tendency of a parent to treat their infant as an individual with a mind (Meins, Fernyhough, Fradley & Tuckey, 2001), is a better predictor of parent infant attachment than maternal sensitivity. This study explored the impact of a new antenatal intervention called Baby World on the subsequent mind-mindedness of participants as well as its impact on the parent infant relationship. Participants who had attended the Baby World class and standard NHS antenatal classes (intervention group, N=21) were compared to those who had only attended standard NHS antenatal classes (control group, N=19). The study also explored whether planned pregnancies led to more mind-mindedness than unplanned pregnancies; whether emotional and physical wellbeing in pregnancy predicted mindmindedness and if there was any concordance between couples mind-mindedness. Results showed that participants in the intervention group used significantly more appropriate mind-minded comments than those in the control group. The intervention group also scored significantly higher than the control group on the Absence of Hostility subscale of the Maternal Postnatal Attachment Scale (MPAS, Condon & Corkindale, 1998). There was a non-significant trend of the intervention group scoring higher than the control group on the overall MPAS score as well as the Pleasure in Interaction subscale of the MPAS. The results also illustrated that emotional and physical wellbeing in pregnancy did not predict mind-mindedness and no concordance between couples mind-mindedness was found. Theoretical explanations of these findings are presented and the clinical implications and future research are discussed.

Telemedicine offers an alternative referral strategy for fetal cardiology but is currently only used for ‘high-risk’ pregnancies. A case-study of a cost-consequences analysis comparing telemedicine to direct referral to a perinatal cardiologist is initially presented, which highlights that for high risk women for whom telemedicine was considered no cardiac anomalies were missed using either referral method. In the light of a review of the literature on the economics of telemedicine, three of the key methodological issues (of selection bias, of patient costs and using quality-adjusted life years (QALYs)) are explored to demonstrate how the case study analysis could be improved. Pregnant women were selected for referral based on their characteristics and risk factors; thus the cost and effects for the two groups may have been biased. Various methods identified in the literature are applied to the case study to reduce selection bias, but the analysis presented is unable to determine which method is best, given a number of limitations including the small sample size. The analysis is extended to include estimated total patient costs. However, when patient costs are added to the total costs of pregnancy, they did not substantially increase the overall cost. The results presented provide a guideline for future researchers and pregnant women of the likely costs during pregnancy. Given that the majority of missed cardiac anomalies were amongst low risk women, a decision analytical model is developed looking at the lifetime costs and QALYs of introducing telemedicine screening for pregnant women whose unborn babies are at a low risk of congenital heart disease. The analysis shows that offering telemedicine to all low risk women is the dominant strategy. The thesis demonstrates, within the constraints of existing data, that it would be cost-effective to provide telemedicine as part of an antenatal screening programme for all low risk women, and this would help prevent future ‘missed anomalies’.

Magister Curationis - MCur / Despite the awareness of the importance of initiating antenatal care in the first trimester of a pregnancy (before 12 weeks gestation), late initiation of antenatal care (on or after 24 weeks of gestation) remains a common trend amongst pregnant women. The late initiation of antenatal care poses such a risk, to both the pregnant women and their unborn babies that it can contribute to maternal and foetal mortality and morbidity. The late initiation of antenatal care, an entirely avoidable occurrence, has an impact on targets set by the United Nations Millennium Development Goals (MDGs), now focusing on the Sustainable Development Goals (SDG‟s) set out by the United Nations. This study aim to investigate the factors which contribute to and cause the late initiation of antenatal care in pregnant women in a region in the Western Cape. Aim: The aim of this study was to investigate the factors that influence pregnant woman and contribute to late initiation of antenatal care (after 24 weeks gestational age) in one health facility/district in Cape Town. The findings of the study identified possible factors that may cause pregnant women to initiate antenatal care late in pregnancy and these findings could facilitate planning and possible interventions targeting the importance of early initiation in the community.

Magister Public Health - MPH / Background: Antenatal Care (ANC) is a key strategy in achieving positive maternal health outcomes. ANC is an important entry point into formal health care services. ANC is very low in cost and among the most effective packages to promote and establish good health before childbirth and the early postnatal period; therefore, it is very feasible for the good results it is proven to have on maternal and child health. South Africa has had free ANC services since 1994. Despite these free services a lot of women still attend the ANC clinics late or do not attend follow-up visits, hindering the quality of care during pregnancy. The first ANC visit should be in the first trimester of pregnancy or as early as possible, because with the first visit underlying conditions must be identified and managed to promote maternal and foetal health. ANC initiation after 20 weeks may increase maternal, foetal and perinatal morbidity and mortality. In the Cape Winelands there are still 27.3% of women that attend ANC after 20 weeks gestation. This may hinder the quality of care during pregnancy and may lead to negative health outcomes for mother and or baby. The purpose of the study is to understand why some women still do not attend ANC before 20 weeks gestation even when it is available.

Magister Public Health - MPH / Background: Antenatal care serves as a key entry point for a pregnant woman to receive a broad range of services and should be initiated at the onset of pregnancy (WHO, 2016). Cameroon has one of the highest maternal mortality ratios in the world (UNICEF, 2016). The majority of pregnant women in Cameroon initiate antenatal care after the first trimester (Njim, 2016). Most studies on initiation of antenatal care in Cameroon have not explored in greater depth the reasons why most of the pregnant women initiate antenatal care late. Methodology: The aim of the study is to understand the reasons why pregnant women initiate antenatal care late in Nkwen Baptist Health Center, North West Region, Cameroon. It is an exploratory study and applied purposive sampling to recruit eighteen pregnant women and three key informants for data collection through individual interviews. Pregnant women who initiated antenatal care after the first trimester were recruited during antenatal care clinics and interviewed in a room at the antenatal care unit. Key informants were midwives working at the antennal care unit. Participation in the study was voluntary. Participants were explained the purpose of the study and signed a consent form if they were willing to participate in the research. Participation in the research did not inhibit the respondent’s access to care. Data was collected using an audio tape and analyzed using Thematic Coding Analysis (TCA) to identify recurring themes that emerged from the data to adequately describe the perceptions of respondents on the reasons for late initiation of antenatal care.