A research report submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Public Health in the field of Health Systems and Policy / Introduction: The maternal mortality ratio in Sedibeng District, Gauteng Province, from 2002 – 2004 was 220/100000. For the past decade HIV has been identified as a factor that has slowed the decline in maternal deaths in South Africa. The purpose of this study was to describe personal and service level factors contributing to maternal mortality of HIV positive women. It is hoped that the results of this study will be useful in developing interventions that will assist to curb the maternal mortality ratio. Methodology: Maternal death records were reviewed for the period 2004-2009. Data was collected on antenatal care, hospital care after admission and access to HIV services. The data were analysed using Stata 10. The results were compared with the national guidelines for the care of HIV positive pregnant women so as to identify discrepancies between the two. Results: One hundred and twenty five maternal death records were reviewed. Of these, 90% booked late for antenatal care i.e. beyond 20 weeks gestation. The majority (60.8%) of the women were HIV positive. Of the HIV positive women, 37.5% had CD 4 counts less than 200, which made them eligible for antiretroviral therapy. Of those that were eligible for antiretroviral therapy, 50.0% did not access the antiretrovirals due to late booking and loss to follow-up. Another main finding was that 36% died during the postnatal period. Conclusion: The antenatal bookings occurred after 12 weeks gestation which limited the time for starting patients on antiretroviral therapy. The high number of deaths during the postnatal period may indicate poor postnatal care and follow-up; as antiretroviral therapy could have been started during the postnatal period. Recommendations: Early antenatal booking and early HIV testing should be encouraged in communities. Antenatal services should be integrated so that HIV positive pregnant women are treated comprehensively and that the focus is not only on HIV, but also on other conditions such as TB, pneumonia, anaemia and hypertension. All pregnant HIV positive women must be done CD 4 counts; and all those found to be eligible for antiretroviral therapy should be given antiretrovirals timeously. Such women should be followed up and monitored closely. Postnatal check-up at 3 days should be strengthened for the mother-and-baby pair.

A thesis submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy April 2017. / Introduction The number of maternal deaths from bleeding during and after caesarean section (BDACS) has increased dramatically in South Africa in recent years. Four studies were conducted to gain insight on measures to reduce maternal deaths from BDACS. The aim was to identify clinical and health system factors associated with near-miss and maternal death from BDACS. Methods A systematic review was done on near-miss from postpartum haemorrhage, with a sub-analysis on BDACS. The field research, done in southern Gauteng, included: 1) a six-month prospective near-miss audit of women with BDACS in 13 hospitals; 2) a two-year retrospective maternal death audit in seven hospitals; and 3) a health systems audit in 15 hospitals. Results The systematic review on near-miss from PPH found two studies that described near-miss from BDACS, with a mortality index of 0-11%. In the near-miss and maternal death audits, the main risk factors for BDACS were pre-operative anaemia and previous caesarean section. Atonic uterus was the main cause of haemorrhage, with associated failure to use second line uterotonic drugs. Failure to diagnose and treat shock was the main reason why women died. Most maternal deaths from BDACS occurred in regional hospitals. The hospital systems audit identified shortages of second line uterotonic drugs and surgical skills availability as contributors to near-miss and maternal death from BDACS. Conclusion Although bleeding may be arrested through obstetric surgical techniques and easily available drugs, severe BDACS is a complex disease that requires a multi-disciplinary approach in a functional health system, especially regarding the detection and management of hypovolaemic shock. Measures to reduce maternal morbidity and mortality from BDACS include health system strengthening, with high care and critical care facilities, and improving the availability of drugs and surgical skills at district and regional hospitals / MT2017

This study considers the reproductive experiences of women in Sheffield between 1870 and 1939, encompassing the development of concepts of maternal and infant welfare, and debates over birth control and abortion. It focuses on the impact of state and voluntary enterprise, on the development of health professions and hospitals, and on the position of mothers. The study shows that high infant mortality was caused primarily by poor sanitation. Unlike other areas, Sheffield had low rates of both maternal employment and bottle feeding, suggesting that these were not significant factors. The decline in infant mortality was due to a combination of factors; the removal of privy middens and slum areas, and the development of welfare clinics and health visiting services. High maternal mortality was prevalent mainly in areas of skilled working class employment; not middle class areas as in other cities. There was no inverse correlation between infant and maternal mortality in Sheffield. Maternal mortality was caused by high rates of sepsis following illegal abortion. The reduction in mortality was due to a cyclical decline in the virulence of the causative bacteria, and the application of sulphonamide drugs to control it. The development of antenatal and birth control clinics had little impact. Despite early action to train midwives in Sheffield, midwifery remained a largely part time, low status occupation throughout the period. The hospitalisation of normal childbirth occurred early in Sheffield, and demand for beds outstripped supply, demonstrating that women were able to shape the development of services. Local authority and voluntary groups generally co-operated in the delivery of services, which were developed along pragmatic lines with little reference to debates about eugenics or national deterioration. The growth of welfare schemes was circumscribed by the available resources. Central government provided enabling legislation, but schemes were planned and implemented at the local level.

Orientador: Iracema Mattos Paranhos Calderon / Coorientador: Maria Rita Garbi Novaes / Banca: Roseli Mieko Yamamoto Nomura / Banca: José Guilherme Cecatti / Resumo: Realizar uma revisão da literatura mundial e nacional sobre mortalidade materna, descrevendo a população vulnerável, os fatores de risco, as causas, as difi culdades para obtenção dos dados e as medidas de prevenção, de forma a subsidiar as ações de saúde. A coleta dos dados foi realizada por meio de pesquisa de artigos nas bases eletrônicas, SCIELLO, PUBMED, LILACS e MEDLINE, além de materiais publicados por organizações mundiais e nacionais. Foram selecionados estudos publicados no periodo de janeiro de 2000 a maio de 2011, utilizando-se os seguintes descritores: "maternal mortality"[MeSH Terms] OR ("maternal"[All Fields] AND "mortality"[All Fields]) OR "maternal mortality"[All Fields], nos idiomas português, inglês e espanhol. Foram selecionados 36 artigos que atendiam aos critérios de inclusão. O óbito materno está diretamente relacionado com as condições de vida da população e apresenta elevada disparidade entre as diversas regiões sócio-econômicas. Embora a mortalidade materna seja o melhor indicador de saúde da população feminina, seus números muitas vezes são apresentados de forma irreal, pela difi culdade da identifi cação dos casos nos registros de óbito. Medidas de prevenção associadas a diagnóstico e tratamento precoces e adequados são fatores benéfi cos na redução desses óbitos maternos. Apesar da tecnologia avançada e do reconhecimento de algumas medidas de prevenção, um grande número de mulheres morre diariamente por complicações no ciclo gravídico-puerperal. É evidente que para a redução desta tragédia é necessário o comprometimento político, social e econômico com a saúde, para promover as reformas necessárias na assistência ao ciclo gravídico-puerperal / Abstract: Accomplishing a review of worldwide and Brazilian literature on maternal mortality, describing the vulnerable population, risk factors, causes, and difficulties in obtaining the data and preventive measures, in order to subsidize health actions. The data collection was accomplished through a search for articles in the electronic data basis SCIELLO, PUBMED, LILACS and MEDLINE, in addition to published materials from worldwide and Brazilian organizations. Studies published between January 2000 and May 2011 have been selected using the following reference: "maternal mortality" [MeSH Terms] OR ("maternal"[All Fields] AND "mortality" [All Fields]) OR "maternal mortality" [All Fields], in Portuguese, English and Spanish languages. 36 articles that fi tted the criteria for inclusion have been selected.. Maternal death is directly related to the quality of life of the population and presents high disparity among the diverse social-economic regions. Even though maternal mortality is the most accurate health indicator for the female population, its numbers many a time are presented in unreal manners, due to the diffi culties in identifying the cases based on obit registries. Preventing measures associated to early diagnosis and proper treatment are benefi cial factors to the decrease of such maternal deaths. In spite of advanced technology and the recognition of some preventive measures, a large number of women decease daily out of complications through the pregnant and puerperal cycle. It is evident that in order to reduce such tragedy, political, social and economical commitment to Health is necessary to promote the needed reforms in the pregnant and puerperal cycle assistance / Mestre

Maternal mortality is the leading cause of death among women in Nigeria, especially women aged between 15 and 19 years. This research examines the geography of maternal mortality in Nigeria and the role of cultural and religious practices, socio-economic inequalities, urbanization, access to pre and postnatal care in explaining the spatial pattern. State-level data on maternal mortality rates and predictor variables are presented. Access to healthcare, place of residence and religion explains over 74 percent of the spatial pattern of maternal mortality in Nigeria, especially in the predominantly Muslim region of northern Nigeria where poverty, early marriage and childbirth are at its highest, making them a more vulnerable population. Targeting vulnerable populations in policy-making procedures may be an important strategy for reducing maternal mortality, which would also be more successful if other socio-economic issues such as poverty, religious and health care issues are promptly addressed as well.

No description available.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements of the award of the Masters in Science in Epidemiology in the field of Population-based Field Epidemiology April 2012 / Objective: To determine the causes of death and associated risk factors in women of reproductive age in rural South Africa. . Methods: The study population comprised all female members aged 15-49 years of 11 000 households of a rural South African Health and Demographic Surveillance Site from 2000-2009. Deaths and person-years of observation (pyo) were determined for individuals between 01 January 2000 and 31 December 2009. Cause of death was ascertained by verbal autopsy interviews, based on ICD-10 coding; cause of death were broadly categorized as AIDS/TB causes, Non-communicable causes, Communicable/maternal/perinatal/nutrition causes, Injuries and another category of undetermined (unknown) causes of death. Overall and cause specific mortality rates (MR) with 95% confidence intervals (CI) were calculated. Cox proportional hazard regression (HR, 95% CI) was used to determine risk factors associated with overall and cause-specific mortality. Results: 42703 eligible women were included; 3098 deaths were reported for 212607 person-years (pyo) of observation. Overall MR was 14.57 deaths/1000 pyo (CI;14.07-15.09), increasing from 2000-2003 (2003: MR;18.15, CI;16.41-20.08) and subsequently decreasing (2009: MR; 9.59, CI;8.43-10.91) after introduction of antiretroviral treatment (ART) for HIV in public health system facilities in South Africa in 2004. Mortality was highest for AIDS/TB (MR;10.66, CI;10.23-11.11) and the cause of death for 73.1% of all recorded deaths. Maternal mortality was 0.07 (CI; 0.04-0.11). Women aged 30-34 years had the highest MR due to AIDS/TB (MR; 20.34/1000 pyo), women aged 45-49 years due to other causes (MR; 4.29/ 1000 pyo). v In multivariable analyses, external migration status was associated with increased hazards of all cause mortality (HR; 1.87, CI; 1.56-2.26) and other causes of mortality (HR; 1.782, CI; 1.24-2.57). Self reported poor health was significantly associated with increased hazards of all cause mortality (HR; 11.052, CI; 4.24-28.82) but not with mortality due to other causes. Positive HIV status was associated with increased hazards of all cause mortality (HR; 8.53, CI; 6.81-10.67) and other causes of mortality (HR; 2.84, CI; 1.97- 4.09). Conclusion. AIDS was the main cause of death in the current study, with mortality rates declining since introduction of ART for HIV in public health facilities in the surveillance area in 2004. Further ART roll-out, increased community awareness and sensitisation messages are still needed to reduce the spread of HIV and other sexually transmitted diseases.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Public Health Johannesburg, May 2015 / Worldwide, an estimated 800 women die each day from preventable causes related to pregnancy and childbirth, the majority in low-and middle-income countries (WHO, 2014:1). The Safe Motherhood Initiative (SMI) aims to achieve safe pregnancies and childbirth, but maternal mortality remains a significant problem in Botswana. Aim and Objectives: The aim of this study was to analyse the implementation process of the SMI policy in Botswana, with specific reference to the training component. The specific objectives of the study were to: describe the context of policy implementation; analyse the content of the SMI policy guidelines; describe the process of implementation of the 2005 SMI policy guidelines; describe the key policy actors, their roles and their influence on the implementation of the policy; and describe the factors influencing the implementation of the SMI policy in Botswana. Methods: The study used a contemporary health policy analysis framework. During 2008, key informants were selected purposively in the southern health region of Botswana. Following informed consent, 12 in-depth interviews were conducted with key informants to obtain their views and perceptions of the content, context, process and the actors of the SMI policy implementation process. The data were analysed using thematic content analysis. Results: The study found that there was high level government commitment, with the SMI driven by the Ministry of Health. Key successes of the SMI policy included: the integration of the Prevention of Mother-to-Child Transmission (PMTCT) of HIV component into the SMI policy, the integration of SMI into the midwifery curriculum and the development, standardisation and distribution of reference manuals or protocols. However, legislative and health system barriers, as well as unsustainable funding, insufficient consultation with and support by stakeholders, and inadequate coordination of the policy process hindered the successful implementation of the SMI policy. Conclusion: The findings draw attention to the value of stakeholder involvement in policy formulation and implementation; the importance of addressing policy implementation barriers and resource availability; and the need for effective coordination and communication.

MSc (Med), Population-Based Field Epidemiology, Faculty of Health Sciences, University of the Witwatersrand / Background Complications of childbirth and pregnancy are leading causes of death among women of reproductive age. Worldwide, developing countries account for ninety-nine percent of maternal deaths. The United Nations’ fifth millennium development goal (MDG-5) is to reduce maternal mortality ratio by three fourths by 2015. Aim The aim of this study is to explore the levels, trends, causes and risk factors associated with maternal mortality as put forward by World Health Organization (WHO) in rural settings of Tanzania. Specific objectives To establish the trend of maternal mortality ratios in Rufiji health and demographic surveillance system (RHDSS) during the period 2002-2006. To determine the main causes of maternal deaths in RHDSS during the period 2002-2006. To determine the risk factors associated with maternal mortality RHDSS during the period 2002-2006. Method Secondary data analysis based on the longitudinal database from Rufiji Health and Demographic Surveillance System was used to study the risk factors and causes of maternal death. Data for a period of 5 years between 2002-2006 was used. A total of 26 427 women v aged 15-49 years were included in the study; 64 died and there were 15 548 live births. Cox proportional hazards regression was used to assess the risk factors associated with maternal deaths. Results Maternal mortality ratio was 412 per 100 000 live births. The main causes of death were haemorrhage (28%), eclampsia (19%) and puerperal sepsis (8%). Maternal age and marital status were associated with maternal mortality. An increased risk of 154% for maternal death was found for women aged 30-39 versus 15-19 years (HR=2.54, 95% CI=1.001- 6.445). Married women had a protective effect of 62% over unmarried ones (HR=0.38, 95% CI=0.176-0.839). These findings were statistically significant at the 5% level. Conclusion This analysis reinforced previous findings pointing to the fact that haemorrhage and eclampsia are the leading causes of maternal mortality in Tanzania and other developing countries. This indicates the need for better antenatal and obstetric care, particularly for women over thirty years of age, as well as implementing health care delivery strategies according to the regional specific risk factors of maternal deaths and not the global factors.

Maternal mortality is an important public health problem in Mexico. Although the Mexican government has invested many physical and economic resources to strategies specifically created to reduce this problem and reach the Millennium Development Goals, Mexico is not going to achieve this goal on time. Maternal Mortality is a problem of inequality and social injustice. Access to health services is unequally distributed among regions and among population within those regions. Despite a general decline in childbirth deaths worldwide, differences still exist depending on the level of urbanization and size of residence. Because of extreme inequality in Mexico, pregnant women living in rural and highly marginalized areas face the highest risk of dying for maternal causes. The main strategies Mexican government has adopted to reduce maternal mortality target the unsecure, rural and poor population, with the aim of closing the significant gap between geographic regions and social groups. / text