BACKGROUND: Severe maternal morbidity (SMM) is defined as having unexpected outcomes at labor and delivery that result in significant consequences to a woman’s health. The rate of SMM has risen 99% domestically between 1998 and 2015, and has been found to increase postpartum rehospitalizations, but more research needs to be done to understand the impact by race/ethnicity. The postpartum period is a critical time for monitoring the health of women. It is possible that the impact of SMM on postpartum rehospitalizations could be mediated through more effective and frequent follow-up. However, there is a gap in the literature around the experiences of Black women and postpartum care. METHODS: A mixed methods study was conducted to determine 90-day postpartum rehospitalization rates among a population of Black women in the state of Georgia (retrospective cohort study). Additionally, an assessment of the barriers, facilitators, and preferences for postpartum care among low-income Black women in the Atlanta Healthy Start Initiative was conducted (in-depth interviews). The quantitative analysis was based on 317,735 births between 2015-2017, while the qualitative analysis involved 26 in-depth interviews conducted May 2020-August 2020. RESULTS: Black women had a 78% greater likelihood of experiencing SMM (207/10,000 to 116/10,000 deliveries) than White women. The relative risk of SMM was 60% higher for Blacks, compared to Whites, even after adjusting for confounders (1.6: 95% CI 1.4-1.7). The relative risk of 90-day postpartum rehospitalization for women with SMM was 100% higher (RR 2.0, 95% CI: 1.6-2.5) than without SMM, though there was no difference between the likelihood of rehospitalization for Black or White women with SMM. Qualitatively, interviewees reported an array of difficulties in accessing Medicaid, challenges with scheduling appointments, and a lack of coordination of care. Facilitators to care included appointment reminders, consistent childcare, and positive coordination of care. Our study also documents the stigma that some Black women face in healthcare, such as unfair treatment or feeling ignored during their maternal healthcare experience. CONCLUSION: Strategies implemented at hospital discharge and early postpartum should be explored to prevent rehospitalizations in the SMM population. In addition, reducing policy-related and organizational-related barriers are key to improving access to postpartum care for low-income Black women in Atlanta. / 2022-05-14T00:00:00Z

Background The human immunodeficiency virus (HIV) is a leading cause of death among women during pregnancy and the postpartum period, especially in areas of high prevalence. In 2018 there were approximately 1.3 million pregnant women living with HIV globally.Infants born to women living with HIV are at increased risk of contracting HIV as the virus can be transmitted to the foetus/ infant during pregnancy, labour, delivery and breastfeeding, posing a serious risk to their survival and well-being. Viral load (VL) testing of pregnant women living with HIV could contribute to improved care, thereby reducing the risk of vertical transmission of HIV from the mother to her infant. Aim The objective of this study was to describe HIV VL testing amongst pregnant women living with HIV at entry into the prevention-of-mother-to-child-transmission (PMTCT) services at selected health facilities in Mutare district of Manicaland Province, Zimbabwe from January to December 2018. Methods This descriptive cross-sectional mixed methods study evaluated the uptake of HIV VL testing amongst pregnant women living with HIV at entry into the prevention-of-mother-to-child transmission (PMTCT) services at 15 health facilities and explored factors that influence the provision of HIV VL testing services. Results Among 383 pregnant women living with HIV enrolled in antenatal care (ANC) and known to be on antiretroviral therapy (ART), only 121 (32%) had a VL sample collected and 106 (88%) received their results. Among these 106 women, 93 (88%) had a VL< 1, 000 copies/mL and 77 (73%) had a VL< 50 copies/mL. The overall median duration from ANC booking to VL sample collection was 87 (IQR, 7-215) days. The duration was significantly longer among pregnant women newly started on ART [207 (IQR, 99-299) days] compared to those already on ART [50 (IQR, 0-162) days], p< 0.001. The median time interval for the return of VL results from date of sample collection was 14 (IQR, 7-30) days. There was no significant difference when this variable was stratified by time of ART initiation. Viral load samples were significantly less likely to be collected at local authority facilities compared to government facilities [aOR=0.28; 95% CI: 0.16- 0.48]. Barriers for VL testing identified by health care providers included staff shortages, nonavailability of consumables and laboratory forms and weaknesses in sample transportation. Additionally, the turnaround time (TAT) was long as VL testing was centralised at the provincial hospital, and results feedback was not done electronically. High levels of knowledge among health care providers (75%) did not translate into high HIV VL testing coverage amongst pregnant women living with HIV. Conclusions and recommendations The low rate of HIV VL testing among pregnant women living with HIV in Mutare district is a cause of concern and needs to be addressed urgently in the interest of contributing to the eliminating mother to child transmission of HIV. The Ministry of Health should consider disseminating ARV and PMTCT guidelines and other policy documents using electronic platforms as these are more accessible and result in quicker dissemination, which may translate into faster implementation of new policies and policy updates. There is need to conduct regular mentorship and supervision processes and establish quality improvement initiatives for PMTCT services. Interventions like alert systems should be implemented for ease of identifying women who require HIV VL testing. Point of care technology and mHealth could reduce VL result turnaround time. All this should be aimed at ensuring that policies and guidelines are implemented, and targets are reached within agreed timeframes, to ensure that positive outcomes can be experienced by all pregnant women living with HIV.

Includes bibliographical references. / Background: Intrapartum complications contribute to nearly half of all avoidable maternal and perinatal deaths nationally. Inadequate understanding of the labour process by midwives, poor documentation of labour monitoring and inadequate systemlevel support may lead to wrong diagnosis, incorrect management, and the potential for missed opportunities to prevent mortality. Aim: To evaluate the effect of an intervention package of training and clinical facilitation on the quality of clinical management in labour by registered midwives in primary level public sector health facilities in rural South Africa. Methods: Research design : Pragmatic cluster randomised trial with 12 month follow-up. Setting and participants : Seventeen clusters stratified by geo-political region and size of service; 1020 labour records (60 per cluster / site; systematic random sample); and 154 registered midwives employed in the study sites during the study period. Participants were not blinded. Intervention : A package of clinical faclitation training for selected experienced midwife clinicians / managers, and an intrapartum educational update for midwives. Intervention and control sites continued receiving routine communication, all clinical guidelines and scheduled outreach activities. Main outcome measures : Primary outcome - clinical practice measuring partograph utilisation, using a modified partograph checklist, the testing of which is described in this study. Secondary outcome - midwives’ knowledge and skills, measured by written and clinical tests. Outcomes were analysed at the individual level using regression methods that allowed for clustering. The evaluator was blinded to the study allocation. Findings: The mean scores for the total partograph were not statistically significantly different between arms; the mean difference was 1.55 points out of a possible score 47 (95% CI: -1.18 to 4.28) p= 0.27. At a score of 27 the estimated absolute difference was 13.6% (95% CI : 0.16 to 0.25) p = 0.026. The total score for midwives’ knowledge and skills was 7 points (out of a possible 119) higher in the intervention arm (95% CI : 2.1 to 12.3), p=0.006. Conclusions: Although there was no difference in the quality of the overall completion of the partograph, there was a statistically significant difference in those of better quality completions in the intervention arm. Midwives’ knowledge and skills were higher in the intervention arm and those in the control arm deteriorated over time. This difference was statistically significant. Recommendations and implications for practice: This indicates a critical need to provide continuing professional education to midwives and to arrange midwifery staffing that optimises clinical practice in settings where intrapartum care is offered. In addition to regular, sustainable programmes to enhance partograph utilisation and midwife knowledge and skills, barriers to the utilisation of the partograph need to be investigated and addressed.

Includes bibliographical references (leaves 75-85). / The aim of this study was to determine how Swazi mothers initially respond when their children develop diarrhoea and the factors that could influence their response.

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a progressive form of inherited heart muscle disease characterized by ventricular arrhythmias and sudden cardiac death. Often the pathogenesis is linked to deleterious mutations in the desmosomal gene plakophilin-2 (PKP2). We extended investigations of the pathogenic PKP2 c.1162C>T founder mutation which had previously been reported to occur within four 'unrelated' probands (6.2%) who selfidentified as Afrikaners and who also carried a common haplotype. Common evolutionary history suggests common haplotypes are linked to a common founder and today the Afrikaner populations are a unique ethnic group in South Africa identified with various founder effects for a range of heritable disorders. Aim: This study aimed to identify the common founder using genealogical and molecular methods for the PKP2 c.1162C>T mutation in ARVC families of Afrikaner descent in South Africa. Methods and results: DNA was collected from 46 participants (7 probands and 39 relatives) from the ARVC Registry of South Africa. Probands and relatives were screened for the PKP2 c.1162C>T mutation using High Resolution Melt and Sanger sequencing. The genetic results indicated that 65.2% (30/46) of the family members harbored this mutation. High Resolution Melt, Sanger sequencing and microsatellite typing were used to create a haplotype which encompassed the c.1162C>T mutation and three microsatellite markers (M1, D12S1692 and M2) spanning the PKP2 gene. A common haplotype emerged that segregated amongst all of the affected members of the seven Afrikaner families. Genealogical tracing went back, through multiple generations, into the implicated ancestral lines of the present day Afrikaner families. Four of the seven families attained their 17th century progenitors. Through genealogical analyses of the two largest families, ACM 19 and ACM 38, we identified 116 couples which we reduced to ten candidate South African founder couples who were then subjected to further analyses. After the ACM 12 family was added to the analysis there were five candidate founder couples. Unfortunately, the ACM 71 family did not progress past the 20th century due to tracing difficulties associated with poor record keeping of mixed ancestry data in South Africa and hence, could not be linked back to any other family tree without finding ACM71.5's grandparents. Additionally, ACM 8 and 57 families were recent finds and completion of their genealogical tracing still has to done. Conclusions: Our genetic data showed that not only were 30/46 individuals positive for the PKP2 c.1162C>T mutation but that all 30 individuals also shared the same common haplotype. Our preliminary genealogy tracing data suggests that the PKP2 c.1162C>T mutation segregates at a higher frequency in the Afrikaner population possibly due to a founder effect. The genealogical evidence supports the hypothesis that the PKP2 c.1162C>T mutation is a founder mutation and that descendants of the common founders are at risk of developing ARVC. At least three more families need to be recruited to make a clear conclusion and achieve genealogical evidence based saturation, ideally, a common founder.

This study was undertaken to assess HIV-prevalence, uptake of HIV-care, general clinical characteristics and risk factors among a population visiting a mental health clinic in a rural Malawian district hospital.

Includes bibliographical references. / TB was declared a priority disease in South Africa ten years ago. Despite efforts to manage this illness, South Africa ranks as one of 22 high burden countries globally. TB is an important cause of childhood morbidity and mortality, but much of the emphasis of the NTP is on smear positive (adult) TB, as this is perceived to be the greater public health problem. The presence of HIV infection exacerbates both the incidence of TB, and the progress of TB from infection to the development of disease in both children and adults. The diagnosis of childhood TB has proved to be difficult and continues to challenge clinicians, despite technological advances in various spheres of medicine. Several guidelines and recommendations are available for diagnosing TB in children, including combinations of clinical criteria, special investigations, laboratory methods and score systems, but no gold standard exists.It is not clear how well the SANTCP guidelines for diagnosis of childhood TB are being implemented at Emmaus Hospital, or whether these guidelines are still appropriate within the context of high HIV prevalence. Not enough is known about the epidemiology of childhood TB in the Okhahlamba local municipal area surrounding Emmaus hospital to guide optimal management of children. Given the likely magnitude of the problem of childhood TB in this rural area and the difficulties of diagnosis, research into the epidemiology and diagnosis of childhood TB in this context is necessary.

Includes bibliographical references. / ith the advances made in the management of cardiac conditions, much importance has been placed on the maternal outcome in pregnancies complicated by heart disease. However, to enable attending clinicians to provide suitable counseling and manage the pregnancy appropriately, the potential complications arising in the fetus and neonate also require attention. Adverse neonatal and perinatal outcome is more common in pregnant women with cardiac disease. Analysis of the available data pertaining to the South African population is important, as this population’s profile, like that of Africa, differs from that of industrialized countries. The relevance of maternal heart disease is highlighted by the National Committee for the Confidential Enquiries into Maternal Deaths (NCCEMD) in South Africa ( http://www.doh.gov.za/docs/reports/2012/Report_on_Confidential_Enquiries_into_ Maternal_Deaths_in_South_Africa ). Objectives To describe the perinatal outcome in women with heart disease and to determine whether there is an associated adverse outcome related to babies born to mothers with heart disease. Methods 82 patients were collected serially over 18 months. Neonatal outcome was recorded. Adverse neonatal outcome was defined as perinatal mortality, admission to NICU and the need for delivery room resuscitation. Results Perinatal mortality rate in this cohort was good, and better than the rate in the general population from whence this cohort came, but was linked to a high rate of obstetric intervention. The rate of adverse neonatal outcome is better than the rate in industrialized countries. Conclusion Perinatal outcome is good when mothers with heart disease are managed in a multidisciplinary clinic.

Bibliography: leaves 112-123. / Cervical cancer is integrally associated with the problems of poverty in the developing world. It is the most common cancer cause of death among women in these regions. In South Africa, the lifetime risk for black African women developing this cancer is 1 in 26. Rates for white women are 1 in 80. Cervical cancer is largely preventable by screening for its precursor stages. However, cervical cancer screening in low-resource settings has only rarely been initiated and sustained. There are many barriers to the establishment of mass, organised screening programmes. This study focuses on one aspect of the screening process: the clients' receiving of their screening results. For the most part, health providers in resource-poor settings rely on the clients themselves to return to the health service to receive their results and consequent arrangements for further care. Understanding those factors that impact upon clients' returning is therefore crucial to the success of the screening. The Khayelitsha Cervical Cancer Screening Project (KCCSP) was established in 1996 to evaluate alternative screening tests to cytology. In addition, the Project has evaluated alternative screening algorithms to the traditional approach of cytology, colposcopy, biopsy and treatment, specifically, a "screen and treat" approach. This approach is expected to overcome some of the many barriers to women participating in screening programmes. This study aims to investigate the phenomenon of the high spontaneous return rate in the setting of the KCCSP. Motivating and deterring factors are sought, both logistical and psychological, in the clients' personal contexts, as well as those related to their experiences of the Project. Exploratory study in the interpretive research paradigm located in a peri-urban informal settlement outside Cape Town, South Africa. Volunteer sample of women enrolled in the KCCSP returning for their first set of screening results. Four focus groups were conducted in Xhosa, facilitated by a Xhosa-speaking social worker from Khayelitsha who has experience in focus group work. Discussion guidelines were followed. The discussions were tape recorded and later transcribed before being translated into English by the facilitator. Analysis of the data draws on elements of both the grounded theory and the systems theory paradigms. The findings reveal that, for the most part, women present to the KCCSP in order to have general gynaecological problems addressed. Returning for results represents an extension of this need. Obstacles to returning include problems with access to the clinic, the need to care for dependents at home and the competing priorities of housework and generating income. Factors that promote the returning for results are the imperative to understand the cause of, and have treatment for pre-existing gynaecological symptoms which cause high levels of anxiety. Related to this, women are motivated to have confirmed or refuted the diagnosis of a fatal disease, including cancer and HIV. Certain qualities and design features of the KCCSP facilitate women returning fOr their results. These include the perceived superior quality of interpersonal communication between Project staff and clients and the efficient manner in which results are made available to clients. Other promotive or obstructive factors that playa role in cervical screening service utilisation include; client attitudes towards traditional healers, a prevalent fear of hysterectomy, concern about privacy and gossip and a suspicious attitude toward caring health workers. Women enrolled in the KCCSP have a personal health agenda with a different focus to that of the Project. Chronic gynaecological problems are frequently experienced and give rise to levels of anxiety about their being signs of serious pathology. Women have not had these fears or the symptoms adequately addressed at other health services. The need to have these issues properly managed represents a large enough motivating force to overcome many of the practical and psychological obstacles to utilisation of the KCCSP. The Project represents for women a general women's health service.

Introduction: At Chris Hani Baragwanath Hospital (CHBH) in Johannesburg overcrowding remains a concern as women who have low-risk pregnancies continue to bypass community-based obstetric facilities to deliver at the tertiary hospital. A significant number of self-referred pregnant women had no obstetric risk factors qualifying them for delivery at CHBH Maternity Unit. The primary concern at CHBH was that the management of low-risk maternity patients in high-risk a setting interfered with the care of patients requiring specialist care. Study Objectives: To determine the socio-demographic characteristics of the women who selfrefer to CHBH; to explore the reasons why low-risk patients present at CHB Maternity Hospital in labour, and to determine obstetric risk factors amongst self- referred pregnant women. Methods: A descriptive, cross-sectional study was conducted focusing on self-referred pregnant women who delivered at CHBH and were in the post-natal ward during the study period (26 October 2013 to 03 November 2013). A structured questionnaire was administered by the researcher to each study participant to establish variables of the key determinants of self-referral. The data were analyzed using SPSS version 18 and all tests for statistical significance between appropriate and inappropriate self-referral were carried out at a p=0.05 level of significance with a 95% confidence interval. Results: The total number of deliveries for the study period 26 October 2013 to 3 November 2013 was 514 of which 112 were self-referrals. Only 108 women consented to participate in the study and were subsequently interviewed. The results indicated that of the pregnant women who self-referred to CHBH for delivery (N=108), 58.33% travelled more than 5km, 14,81% were teenagers, 81.48% were single, only 1.85% had no formal education, while 72.22% were unemployed. The results further showed that 47.22% of the women had a history of obstetric risk factors and were appropriate for delivery at CHBH, while the majority (52.78%) were low-risk pregnancies and should have delivered at local MOUs. Analysis of the results showed that age (p=0.042), transport mode (p=0.030), transport cost (p=0.001), transport ownership (p=0.041), distance (p=0.032) and waiting times (p=0.025) had statistically significant influence on self-referral. 22.22% were of the high-risk age-groups (<20 years and >35 years), 2,78% had previous surgery, and 12.04% had medical conditions for which they were on treatment. Conclusion: This study showed that the referral system for maternity care within the Johannesburg Metro Health District is not fully functional. Most of selfreferrals were inappropriate for CHBH. The age of the pregnant woman, transport, distance and waiting times at the service point are key determinants of self-referral.