Reducing maternal and child mortality has been a top global health priority for the past two decades. Through this thesis, I underline some of the strategies, barriers and determinants to optimal maternal and child health (MCH) in three specific districts of Jimma Zone in the southwest of Ethiopia. My first paper has a particular focus on the quality of MCH data collected within the health management information system (HMIS), while the second paper focuses on the utilization of antenatal care (ANC) services, assessments of malaria in pregnancy, and women’s access to malaria preventive measures using data from a cross-sectional survey conducted in the three study districts. The quality of MCH data collected within the HMIS from July 2014 to June 2015 for the 26 primary health care units (PHCUs) located within the three districts was evaluated using the World Health Organization’s Data Quality Report Card (DQRC). To complement the methods recommended in the DQRC, Pearson correlation coefficients, intraclass correlation coefficients, and Bland-Altman analysis were used to determine the agreement between MCH indicator coverage estimates derived from the HMIS and a population-based survey conducted with 3,784 women who had a birth outcome within the same time frame. The quality of MCH data collected within the HMIS was determined to be unsatisfactory, with many health facilities located in the three districts not reporting completely, consistently, or accurately MCH key indicators relating specifically to ANC, skilled birth attendance at delivery, and postnatal care. This finding is important since poor data quality can compromise effective decision-making and resource allocation processes aimed at contributing to better health outcomes in mothers and newborns. vi To address the objectives set in the second chapter, analysis of cross-sectional survey data from 3,784 women who had a birth outcome in the year preceding the survey was performed through logistic regression models adjusting for clustering of the participants by PHCU. While close to 85% of the women attended at least one ANC visit, less than 50% of the participants received four or more ANC visits. Lack of necessity, distance to health facility and unavailability of transportation were determined as key reasons for not attending ANC. Women who completed secondary or higher education, were from the richest households, were exposed to different media sources, and were able to make decisions about their healthcare by themselves or jointly with their husband were more likely to attend ANC services. Frequent visits by a health extension worker and pregnancy intendedness also influenced ANC attendance. Bed net ownership and utilization during last pregnancy were also relatively low (52% and 26%, respectively). The results also showed that the odds of owning and always using a mosquito net were higher in participants that attended ANC, with odds ratios of 1.98 (95% CI: 1.55-2.53) and 1.62 (95% CI: 1.23 – 2.13), respectively. The prevalence of malaria infection during pregnancy was low in our recruited sample, with 1.45% of the participants reporting suffering from malaria during their last pregnancy. We determined significant negative relationships between malaria infection and maternal age and education level. This work emphasizes the importance of improving the quality of MCH data within the HMIS in Ethiopia as well as addressing the inequities relating to ANC attendance in Jimma Zone. Given the adverse effects that malaria can have on the progress and outcomes of a pregnancy, the importance of promoting mosquito net ownership and use as part of ANC services is also highlighted.

The aim of the study is to explore aspects of child safety in registered day care centres situated in a lower socio-economic area of the Cape Town Metropole. This can be achieved by: a) describing the physical environment in day care centres b) assessing the infrastructure of day care centres to deal with potential injurjes c) reviewing injury reporting systems already in place d) highlighting the issue of child safety in the course of conducting the study.

A cross-sectional, descriptive study combining with open-ended (qualitative) interview questions with quantitative component was conducted to explore disclosure experiences of mothers and caregivers of HIV-infected children. The study was conducted with 102 parents and caregivers at a tertiary hospital in Cape Town delivering care to 303 HIV-infected paediatric patients. The study sample included 102 participants, ranging in age from 16 years to 71 years. The sample included 73 mothers (72%), six fathers (6%), 11 foster-mothers (11%), and 12 caregivers or grandmothers (12%). The median age of participants’ children was 4 (IQR 2-8) years and ranged from five months to 16 years. Only 48 (47%) were old enough for disclosure to be possible. Disclosure or disclosure delay was associated with several factors, including the child’s age or ability to understand, anxiety and guilt about being blamed for infecting the child, fear of exposing the child to stigma, discrimination and social exclusion related to the child disclosing to others, and the hope that the child would be adherent if they understood their illness and the way in which the medication could improve their health outcomes. Only 16 (33%) of 48 participants actually disclosed the child’s HIV status. The results indicate that HIV-disclosure remains a challenging, emotionally-charged experience for mothers and caregivers. The findings of this research, and similar studies, point to the value of integrating disclosure support and planning into routine care for children and adolescents, as well as their parents and caregivers.

Background Each neonatal death counts, as recognised by the Every Newborn Action Plan (ENAP). This is an important aspect in attaining the third Sustainable Development Goal by 2030. Accurate neonatal mortality data as well as an understanding of the causality and context is essential to plan interventions to reduce neonatal deaths and attain the third Sustainable Development Goals (SDG) of a neonatal mortality rate of less than 12 per 1000 livebirths by 2035. Objectives The objectives of this study were: (i) to determine neonatal mortality occurring in and out of health facilities in the Metro West GSA using the three audit programmes; Perinatal Problem Identification Programme (PPIP), Child Healthcare Problem Identification Programme (Child PIP) and Forensic Pathology Services (ii) to ascertain the cause of death specific neonatal mortality (iii) to describe the avoidable factors in each death as coded by the three audit programmes (iv) to make recommendations for the alignment of existing audit databases to obtain accurate neonatal statistics for the Metro West GSA. Methods This was a retrospective descriptive study of neonatal deaths undertaken in the public healthcare setting in the Cape Town Metro West GSA from January 2014 till December 2017. Existing data from PPIP, Child PIP and the CDR/FPS was used. Neonatal deaths were defined as in the first 28 days of life where there had been signs of life at delivery and a birthweight greater than 500g. Neonatal deaths were excluded where birth had occurred outside of the GSA or in the private health care setting. The audit data with regards to cause of death and avoidable or modifiable factors was obtained for each death. Results From a total of 134843 live deliveries, 1243 neonatal deaths were identified: 976(78%) from PPIP, 58(5%) from Child PIP and 209 (17%) from CDR/FPS. Sixteen per cent of the deaths occurred outside of healthcare facilities. The neonatal mortality rate (NMR) for PPIP was 7.2, Child PIP 0.43 and CDR 1,6 per 1000 livebirths. When the audit systems were combined, the annual NMR over the study period varied from 8.05 to 10.1 with a mean of 9.2 per 1000 livebirths over the entire period. Seventy-eight per cent of the deaths occurred in the early neonatal period with a mean early neonatal mortality rate of 7.2 per 1000 livebirths. The mean late NMR was 2 per 1000 livebirths. Where all neonatal deaths were considered for those more than 500g, the main cause of death was immaturity related, then infection related followed by congenital disorders and then hypoxia related. Seventy-four per cent of deaths occurred in those less than 2500g at birth and 41% were less than 1000g and defined as extremely low birthweight. In the group of neonates greater than 1000g, the main cause of death was infection related deaths, closely followed by congenital disorders and then hypoxia, followed by immaturity. Most of infection related deaths were collected by the CDR and Child PIP. A third of Child PIP and PPIP deaths and half of the CDR deaths were coded as avoidable. The prevalence of deaths due to abandonment either by passive or active neonaticide contributed towards the higher proportion of preventable deaths in the CDR group. Conclusions The burden of deaths due to immaturity is high and may be attributed to the finding that 41% of neonatal deaths were in the ELBW group. Current viability criteria that aim at optimum use of resources may improve survival amongst this group. Infection related deaths were shown by this study to have a greater burden than recorded from PPIP data; most of these deaths were derived from Child PIP and CDR data. Also, where 10% of neonatal deaths were sudden unexpected deaths (SUDIs), a better understanding and definition of this group is urgently required as many of these deaths were subsequently found to be secondary to lower respiratory infections. It is further relevant that where 20% of CDR deaths or 3% of all the study deaths were due to active and passive neonaticide, this entity should be monitored and investigated. The study showed that the GSA has achieved the SDG for NMR of less than 12 per 1000 livebirth. However, a mean NMR of 9.2 per 1000 livebirths is not comparable to other upper middle-income countries. As 38% of the deaths were coded as avoidable, appropriate programmes to address these factors could reduce the NMR to 5.7 per 1000 livebirths. A strong recommendation from this study would be to use all three audit systems to calculate the NMR, understand the causes of neonatal deaths and plan programmes to improve neonatal survival in this GSA.

Includes bibliographical references. / The study objectives were to: determine the prevalence of perinatal mortality (PNM) and causes of early neonatal deaths (ENNDs), describe socio-demographic factors of mothers with PNM and assess some of the associations with PNM at Kamuzu Central Hospital.

Includes bibliographical references / Background: In recent years there has been increasing debate about the impact of scaled-up ART and PMTCT programmes on the uptake and outcomes of reproductive health services, in particular the potential detrimental effects of HIV-care on the overall capacity of fragile health systems. The objective of this study was to evaluate changes in the uptake of reproductive health services as well as the main pregnancy outcomes during the scaling up of ART and PMTCT in Thyolo District, Malawi. Methods : Study design: retrospective descriptive district-wide cohort analysis for the period 2005 to 2009. Setting: Thyolo District, an area with around 600,000 inhabitants, an adult HIV-prevalence of 21% and a Total Fertility Rate of 5.7 in 2004. HIV-care including ART and PMTCT was scaled up since 2004 in Thyolo District to reach district-wide coverage in 2007. HIV-care is provided at district hospital, health centre and community health post levels. Outcomes: uptake of antenatal, intrapartum and postpartum care, family planning and treatment of sexually transmitted infections; infrastructural changes, and changes in maternal and perinatal pregnancy outcome. Data collection and analysis: data were collected from facility antenatal, intrapartum and postpartum records, as well as from MoH and MSF databases maintained for routine programme monitoring. Chisquare tests were performed comparing the baseline year (2005) with the year of study end (2009). Results: Uptake of peripartum care had improved markedly by the end of the five-year study period: the percentages of pregnant women who took up antenatal, intrapartum and postpartum care increased by 30%, 25% and 20% respectively. The number of family planning consultations increased by almost 50% and the number of women treated for sexually transmitted infections more than doubled. Interactions between HIV-care and general reproductive health care had positive effects on key health system components, including governance, health financing, human resources and drug supply. Reliable pregnancy outcome indicators for the entire observation period were difficult to obtain due to likely under-reporting of facility-based maternal and perinatal mortality. However, previously documented results from Thyolo show a reduction of facility-based severe maternal complications, including uterine rupture, between 2007 and 2009. Conclusions: Uptake of reproductive health services and facility-based maternal outcomes increased markedly during the period of HIV scale–up. This implies that the scale up of HIV-care did not inhibit, and likely increased, uptake of reproductive health services, while quality improvements in perinatal care could still be successfully implemented. The finding that ART and PMTCT care may be successfully integrated into broader reproductive health services with satisfying outcomes is a strong argument for continued scale up of ART and PMTCT in similar settings.

Includes bibliographical references. / Syphilis is a common sexually transmitted disease in South Africa and infection acquired during pregnancy is associated with an increased rate of miscarriage, stillbirth, preterm labour, intra uterine growth restriction (IUGR), neonatal death and congenital syphilis in the newborn. This study was undertaken in the Potchefstroom and Wolmaranstad Districts of the North West Province and was aimed at contributing to reducing perinatal mortality and morbidity within these districts. The objectives of this study were: + To determine the prevalence of syphilis amongst women attending antenatal and/or delivery care in the two selected districts. + To evaluate the effectiveness of antenatal screening and management of syphilis + To determine the perception of consumers (antenatal attendees) concerning screening for syphilis at antenatal clinics. + To determine the perception and understanding of health workers concerning the provision of antenatal syphilis screening and treatment. + To analyse any inadequacies revealed in the antenatal screening and management of syphilis in the two districts + To make recommendations for guidelines arising from the results of the research in order to improve syphilis screening in service delivery.

Background: Breast milk provides optimal nutrition for infants. Human milk banks allow breast milk feeding for infants who do not have access to their own mother's milk. However, there are variable perceptions and attitudes towards human milk banking. Aim: This study aimed to evaluate community members' and healthcare workers' knowledge, perceptions and attitudes towards breast milk donation and use in Empangeni, KZN. Methodology: The research was conducted at a large regional hospital and an affiliated primary health care centre in the area. There were five focus group discussions held with healthcare workers employed at the two sites which explored the attitudes regarding donating and receiving breast milk. In addition, there were sixteen individual semi-structured interviews held with community members. Content analysis was used to analyse the data. Results and Discussion: Five main themes were found which includes: “Breastfeeding is an optimal feeding choice”, “Infant feeding choice”, “Misperceptions of HIV”, “Knowledge of DHM” and “Acceptance of DHM”. Though most participants were aware of breastfeeding benefits, there are poor breastfeeding rates within the area. Many mothers choose to formula feed their infants due to the fear of HIV transmission. There is also a fear of HIV transmission when using DHM. Acceptance of DHM was largely related to knowledge of DHM and exposure to its use. Conclusion: Healthcare workers need to be given updated, evidence-based information (in accordance with national guidelines and policies) to ensure appropriate counselling of caregivers. Furthermore, community awareness and engagement is required to improve breastfeeding rates and acceptability of DHM.

1. Introduction: Obtaining Informed consent is an ethical prerequisite for enrollment in clinical research. There is a perception that Informed consent documents used in biomedical research are lengthy, overly complex and above the reading capability of typical research participants. In South Africa, ethical committees regulating research on human participants (HRECs) are mandated by the Department of Health’s National Health Research Ethics Council’s (NHREC) guidelines to ensure that researchers have made special considerations for vulnerable groups when conducting research. This includes considerations made for populations with low literacy. For example, the Standard Operating Procedure (SOP) of the University of Cape Town’s Human Research Ethics Committee (UCTHREC), requires that the language used in Informed consent documents should be directed at a reading level of grade 6 to 8 and that common, everyday words should be used rather than complex language syntax. The HREC expects researchers to translate the approved English version documents into local languages such as isiXhosa and Afrikaans. Since ethics committee focus approval on the English language consent documents and only acknowledge translated versions, a potential gap in this process is whether the translated versions meet the same required readability levels. This study aims to investigate whether translated versions of English language informed consent documents used at a single busy clinical research site are readable and meet the readability levels specified by UCTHREC. 2. Methodology: A quantitative descriptive statistical design was used to explore readability levels of informed consent documents used at a single clinical research facility based in a semi-rural community. Informed consent documents approved by UCTHREC over the past thirteen years (2004 to 2017) that met the inclusion criteria were analysed for readability. The LIX readability test tool was used to calculate readability scores and the levels of reading difficulty. These scores were then matched to a grade level conversion chart to determine the equivalent number of education years required to be able to easily understand the information. Readability levels were determined for isiXhosa and Afrikaans translations of the documents and compared to the levels of the English document. 3. Results: The results indicate that informed consent documents used at this single clinical research facility, independent of language type, are difficult to read. A total of 259 sub-sections of informed consent documents from 10 different studies were analysed. The analysis showed that informed consent documents were classified as “very difficult to read” according to the LIX readability tool in a large proportion of English, isiXhosa and Afrikaans languages: 41 (16%), 255 (98%), and 85 (33%) of informed consent sections respectively. Of all the subsections of English, isiXhosa and Afrikaans documents respectively, 98 (38%), 0 (0%) and 126 (49%) were classified as “difficult to read”, while 79 (31%), 3 (1%) and 38 (15%) were found to have an “average” readability level. Twenty eight (11%), 1 (0%) and 10 (4%) were found to be “easy to read” and 13 (5%), 0 (0%) and 0 (0%) had a “very easy” readability level. The mean LIX readability scores across English, isiXhosa, and Afrikaans languages were respectively 42.27 (95% CI 41.20 – 43.34) corresponding to a readability level of “average”, 74.64 (95% CI 73.79-75.49), corresponding to “very difficult to read” and 46.73 (95% CI 45.66-47.8) “difficult to read”. These findings suggest a high level of difficulty in reading of the text in the Informed consent documents. 4. Conclusion: Translations of Informed consent documents used at a single busy clinical research site are difficult to read and are written at high school to tertiary reading level. These reading levels are above the recommended level prescribed by the site’s research ethics committee (UCTHREC). Local ethics committees should employ more stringent guidelines and checks to ensure readability of translated informed consent documents. Researchers and Sponsors should include readability outcomes in the design and with submissions of new protocols.

Introduction: In order to better understand the epidemiology and burden of human coronaviruses - NL63, HKU1, OC43 and 229E in South Africa, their role in the aetiology of childhood pneumonia needs to be described. Methods: We used data collected between September 2012 – September 2013 from children aged < 13 years with lower respiratory illness at Red Cross War Memorial Children's Hospital. Respiratory samples including a nasopharyngeal swab (NP) and induced sputum (IS) were taken and tested for the four strains of coronaviruses using FTD33 multiplex realtime PCR. Results: A total of 460 respiratory samples were analysed. Of these, 258 (56.0%) were male and 19 (4.1%) HIV infected. The median age of the children was 8 (IQR 4-18) months. Nasopharyngeal (NP) samples were obtained from 460 children while induced sputum (IS) was not available for six children due to sample loss prior to analysis, leaving 454 available for analysis. A total of 42 (9.1%, 95% CI 6.7- 12.1%) participants tested positive for HCoV in at least one of the two specimens. PCR was able to detect a total of 35 (7.7%) cases from the 454 tested IS specimens compared to 23 (5.0%) detected out of 460 NP samples. The commonest detected HCoVs were coronavirus OC43 with 20 (4.3%) detected from either specimen followed by coronavirus NL63 or coronavirus HKU detected in 14 (3.0%) and 10 (2.2%) of positive test samples, respectively. The least common virus detected HCoV was coronavirus 229E detected in both positive test samples of one participant. Overall HCoVs were detected in 23 (8.9%) of boys compared to 19 (9.1%) of the girls who returned a positive test; p=0.856. The overall age distribution of children with PCR detected HCoVs was similar to that of children with a negative result with median age of 10 (IQR 5- 16) months and median of 8 (IQR 4- 19) months, respectively; p=0.535. Prevalence of HCoV was 11/192 (5.7%), 23/153 (15.0%) and 8/115 (7.0%) in children <6 months old, 6-18 months and over 18 months respectively; p=0.008. Conclusion: Children aged 6 to 18 months had double the risk of other age groups.