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This investigation aimed to determine factors that influence women's utilisation of maternal health services, with specific focus on the quality of care and services available to disadvantaged communities in South Africa. It used the women's perspectives to assess the quality of maternal healthcare services in peri-urban commercial farming and rural areas with the purpose of understanding why women utilise maternal services the way they do.

Unacceptably high rates of maternal morbidity and mortality affect the Global North and the Global South. Among many challenges, policy-makers and researchers cite concerns about quality of care, respectful maternity care, and implementation of evidence-based strategies and national guidelines at the frontlines of the health system. Informal payments are one concern that cut across these three challenges; they represent poor quality care; they are often experienced as disrespect by patients; and, health care worker demands for such payments by definition conflict with national policy. Social accountability and legal empowerment are two approaches that are increasingly used to address quality of care concerns in maternal health and poor implementation at the frontlines of the health system. This dissertation is comprised of three chapters (papers), all of which focus on these challenges in maternal health in low and middle income countries (LMICs). They apply concepts and methods from health policy and systems research (HPSR) to undertake theoretically-informed analyses that straddle two fields: (1) accountability, and, (2) global maternal health. The first chapter is a critical interpretive synthesis that summarizes the evidence base on the prevalence, drivers, and impact of informal payments in maternal health care; critically interrogates the paradigms that are used to describe informal payments; and, finally, synthesizes the policy and funding debates directly related to informal payments. The paper finds that though assessing the true prevalence of informal payments is difficult given measurement challenges, quantitative and qualitative studies have identified widespread informal payments in health care in many low and middle income countries in Asia, Africa, and Latin America. Studies and conceptual papers identified both proximate, immediate drivers of informal payments, as well as broader systemic causes. These causes include norms of gift giving, health workforce scarcity, inadequate health systems financing, the extent of formal user fees, structural adjustment and the marketization of health care, and patient willingness to pay for better care. Similarly, there are both proximate and distal impacts, including on household finances, patient satisfaction and demand for health care, and provider morale. Despite the ground level relevance of informal payments, they are generally not adequately addressed in global policy frameworks and strategies, or in standard metrics of health system performance. Though this absence does not necessarily imply lack of financial or other attention to informal payments, it makes inattention more likely, and regardless, represents a notable silence. Informal payments have been studied and addressed from a variety of different perspectives, including anti-corruption, ethnographic and other in-depth qualitative approaches, and econometric modeling. Synthesizing data from these and other paradigms illustrates the value of an inter-disciplinary approach. Each lens adds value and has blind spots. These attributes in turn affect the solutions proposed. The paper concludes that the same tacit, hidden attributes that make informal payments hard to measure also make them hard to discuss and address. A multi-disciplinary health systems approach that leverages and integrates positivist, interpretivist, and constructivist tools of social science research can lead to better insight and policy critiques. The second chapter is a descriptive case study of a social accountability project seeking to decrease health provider demands that women make informal payments in Uttar Pradesh (UP), India. Women in UP are often asked to make informal payments for maternal health care services that the central or state government has mandated to be free. The chapter is a descriptive, contextualized case study of a social accountability project undertaken by SAHAYOG, an NGO based in UP. The study methods included document review; interviews and focus group discussions of program implementers, governmental stakeholders, and community activists; and participant observation in health facilities. The study found that SAHAYOG adapted their strategy over time to engender greater empowerment and satisfaction among program participants, as well as greater impact on the health system. Participants gained resources and agency; they learned about their entitlements, had access to mechanisms for complaints, and, despite risk of retaliation, many felt capable of demanding their rights in a variety of fora. However, only program participants seemed able to avoid making informal payments to the health sector; they largely were unable to effect this change for women in the community at large. Several features of the micro and macro context shaped the trajectory of SAHAYOG’s efforts, including caste dynamics, provider commitment to ending informal payments, the embeddedness of informal payments in the health system, human resource scarcity, the overlapping private interests of pharmaceutical companies and providers, and the level of regional development. Though changes were manifest in certain health facilities, as a group, providers did not necessarily embraced the notion of low caste, tribal, or Muslim women as citizens with entitlements, especially in the context of free government services for childbirth. SAHAYOG assumed a supremely difficult task. Project strategy changes may have made the task somewhat less difficult, but given the population making the rights claims and the rights they were claiming, widespread changes in demands for informal payments may require a much larger and stronger coalition. The third paper is an explanatory case study of a hybrid legal empowerment and social accountability effort led by the Mozambican NGO, Namati Moçambique. Established in 2013, Namati Moçambique runs a multi—pronged health paralegal and policy advocacy program that employs community paralegals as Health Advocates and trains Village Health Committees (VHCs). The study sought to uncover how the program affected the relationship between citizens and the health sector, how the health sector and citizens responded, and what role contextual factors played. The case study had two components: 1) a retrospective review of 24 cases 2) qualitative investigation of the Namati program and program context. The cases came from a total of 6 sites in 3 districts. Program implementers, clients, Village Health Committee (VHC) members, and health providers were interviewed or participated in focus groups as part of the research. The study found that though they are unable to address some deeply embedded national challenges, Health Advocates successfully solved a variety of cases affecting poor Mozambicans in both urban and rural areas. Health Advocates took a variety of steps to resolve these cases, some of which entailed interactions with multiple levels of the government. We identified three key mechanisms, or underlying processes of change that Namati’s work engendered, including: bolstered administrative capacity within the health sector, reduced transaction and political costs for health providers, and provider fear of administrative sanction. In addition to case resolution, stakeholders highlighted individual satisfaction at having one’s complaint remedied and individual empowerment among clients and Health Advocates as stemming from the project. Health Advocates and VHCs developed functional working relationships with providers, in part because they addressed issues that providers felt were important, and engendered community satisfaction with the Health Advocate, and ultimately, trust in the health system. The case resolution focus of legal empowerment brought procedural teeth, helping to ensure that new relationships result in immediate improvements, thus instigating a circle of relationship building and health system improvements.

Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 1982. / MICROFICHE COPY AVAILABLE IN ARCHIVES AND ROTCH / Vita. / Includes bibliographical references. / by Oscar Ruiz Villarroel. / M.C.P.

An epidemic of staphylococcal infections occurred in New Zealand hospitals and communities from 1955-1963. The 'H', or 'Hospital Bug', a strain of Staphylococcus aureus characteristic of the epidemic, was resistant to the most commonly used antibiotics. Post-operative patients, the frail elderly and mothers and babies were particularly vulnerable to staphylococcal colonization and infection. This thesis places the H-Bug epidemic in its historical context, discussing the ways in which the government and health professionals responded to the rising incidence of staphylococcal infection, and the major effects of the epidemic on medical and hospital practice. It also examines the impact of persistent staphylococcal infection on women and families in the community. Primary sources provided the basis for this thesis. The H-Bug epidemic has gone largely unrecorded except in contemporary documents. Health Department files and Auckland Hospital Board records as well as newspaper clippings were important sources. The New Zealand epidemic was clearly linked to the global pandemic of antibiotic resistant staphylococcal infection, 1946-1966, through medical literature and archival documents. International medical journals, including the New Zealand Medical Journal, published numerous articles on the epidemiology of antibiotic-resistant staphylococcal infection, providing an excellent record of research, case studies, current opinion, and recommended practice. The most valuable contribution to an understanding of the impact and experience of the H-Bug epidemic was, however, provided by the nineteen people who agreed to be interviewed for the study. Interviewees included a wide variety of health professionals and women and their children, all of whom had personal experience or association with the epidemic. In this thesis it is argued that the main focus of the medical response was the prevention and control of hospital cross-infection, both to protect patients and to preserve the public perception of the hospital as a safe venue for care. Although the emergence of resistant strains of staphylococci was widely attributed to the misuse of antibiotics, this thesis contends that the Health Department was reluctant to impose restrictions on medical prescribing and that Health Department official and senior clinicians chose instead to modify hospital environments and clinical practice. Rooming-in was widely introduced to counter the epidemic despite the fact that a trial in 1959, at National Women's Hospital, did not demonstrate a reduction in infection rates among neonates. The concept endured, however, as it held strong appeal for hospital administrators hard pressed to keep wards adequately staffed with trained personnel. It was also supported by women and health professionals who were convinced of the benefits of a close mother-baby relationship from birth. The H-Bug epidemic was eventually resolved by the introduction of the methicillin antibiotics in the early 1960s. As a consequence, confidence in a pharmaceutical solution to infectious disease remained intact until the emergence of multiple antibiotic resistant organisms in the 1980s. The lessons of the H-Bug epidemic had been largely forgotten in the intervening years, ignored until New Zealand clinicians were reminded once again that antimicrobial resistance would inevitably accompany the indiscriminate use of antibiotics and inadequate attention to infection prevention and control.

The appropriate oral intake for labouring women has long been a controversial issue among midwives and anaesthetists. Anaesthetists argue that any type of food and, to some extent, fluid consumption during labour, will increase a woman’s risk of gastric content aspiration if general anaesthesia is required. Many midwives believe that aspiration, being such a rare event with contemporary medical practice, is unlikely in the hands of a skilled obstetric anaesthetist. These midwives believe that labouring without any form of sustenance other than water or clear fluids may be detrimental for the woman, her baby and the progress of labour. To date, research has been unable to provide reliable information to support either side of this debate. This thesis presents a series of studies (three surveys and a comparative trial) designed to enhance the body of knowledge available for decisions about labouring women’s oral requirements. The surveys were conducted to describe the policies of hospitals in New South Wales, Australia, and the views and practices of anaesthetists and midwives regarding the oral intake of labouring women. The main findings of this thesis come from a comparative study conducted to explore the effect of eating or not eating food on labour and birth outcomes of 217 nulliparous women with low risk pregnancies, (Eating group = 123; Non-eating group = 94). The study employed a naturalistic approach to its design in order to capture the actual eating behaviour of labouring women rather than the manipulated approach used in a randomised control trial. The findings from this series of studies suggest women should be informed of the lack of evidence to support any dietary regime for labour, along with the possible risks and benefits, and allowed to make their own decisions about their oral intake needs for labour. Although this thesis has augmented knowledge, it has been unable to demonstrate that eating food during labour improves labour and birth outcomes. However, it did not find this practice to be harmful for mothers or babies. The lack of reliable research evidence on which to base practice decreases the ability of midwives to be assured of the ‘best practice’ for labouring women’s oral intake. Further research is essential to ascertain ‘best practice’ for this aspect of care. / Doctor of Philosophy (PhD)

Immigrant women often lack the social support and help from extended family and other social relationships, which is very significant during the pregnancy, delivery, and postnatal period. This research was conducted among Bangladeshi immigrant women living in the United States, in order to understand their experiences during pregnancy and childbirth: how they coped with the settings of a different country during that period, and how they felt about this situation. While there are several studies on immigrant women and maternal health issues in anthropology, to my knowledge, there have been none that focused specifically on the childbirth experiences of Bangladeshi immigrant women in the US. These women have very specific culturally-based perceptions about the US health care system around issues such as communication with service providers, dealing with the hospital system, the role of health insurance, and so on. This research was conducted among Bangladeshi women in Tampa, Florida, and sought to understand their experiences during pregnancy and childbirth and perceptions of access and quality in the health care system. Fifteen women were selected through purposive and snowball sampling. Data was collected using in-depth interviews. This study examines the experiences of these Bangladeshi immigrant women within their socioeconomic context and immigration status.

The SA National Department of Health made maternal deaths notifiable in 1997. It also commissioned a National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) to confidentially investigate all maternal deaths, to write the "Saving Mothers Report" and to make recommendations based on the findings of the study. The Department of Health in 2003 commissioned an evaluation of the extent to which the 10 recommendations contained in the first "Saving Mother's Report" had been implemented. This rapid appraisal was carried out by Centre for Health and Social Studies (CHESS), University of Natal. A report 'The Progress with the Implementation of the Key Recommendations of the 1998 "Saving Mothers Report" on the Confidential Enquiry into Maternal Deaths in South Africa - A Rapid Appraisal," was published in 2003. The data collected on Recommendation 5 on the use of the obstetric partogram in 46 selected provincial hospitals in all the 9 provinces was only partially analysed in this report. This study reports on a secondary analysis of the 942 questionnaires that were completed on the use and application of the partogram in hospitals in South Africa. In the rapid appraisal experienced field workers evaluated the use of the partogram using a 36-point checklist. Provincial and national averages for each of these variables were calculated and hospitals were evaluated into how they performed according to these averages using Lot Quality Assurance Sampling methodologies. Using national and provincial averages, the hospitals in each province are compared with one another provincially and nationally. In addition, the application and use of partograms in areas and levels of hospitals are described. An attempt is made to show if there is relation between the number of deliveries and the recording of the partogram. The main findings were that, of all the provinces KwaZulu-Natal had the lowest number variables below the national average from the 36 variables used as a checklist. Eastern Cape and Limpopo had the highest number of variables below the national average. The hospital with the highest number below the national average is in the Eastern Cape. In the recording of the chart rural and level one hospitals are low in comparison with urban and level three hospitals. There was no relation in the recording of the chart and the number of deliveries. / Thesis (M.PH.)-University of KwaZulu-Natal, 2004.

The introduction outlines the reasons for the priority of maternal and child health emphasizing the relatively simple resources required. The aims of such programmes must be identified and the results measured so that services can be monitored and evaluated. Categories of measurement are defined and indicators of maternal child health identified within these categories. A chapter is devoted to an outline of the principal non-medical determinants based on material from the Inter-American Investigation of Childhood Mortality. The significance of the principal indicators viz. the perinatal mortality rate, the infant mortality rate, the maternal mortality rate and growth and development data are compared. Chapter lV presents a report of a questionnaire study into local indices viz. Stillbirth rates, Caesarean Section rates and Maternal Mortality rates. The uptake of certain clinic services was also determined. Differences between groups and possible reasons for these are discussed. The final chapter points out the need for accurate birth and death registration and a reliable health information system and suggests methods for achieving this. Recommendations are made for upgrading the collection of data and for improving maternal and child health by research and peripheralization of services. / Thesis (M.Med.)-University of Natal, Durban, 1981.

The uThukela District in the province of Kwazulu-Natal, Republic of South Africa, has been involved in improving Primary Health Care (PHC) in the district through evaluation surveys carried out at regular intervals during the past six years. World Vision's uThukela District Child Survival Project (TDCSP) began in November 16, 1999. This has been made possible by a Child Survival Grants Program from the Unites States Agency for International Development (USAID). In all previous surveys a 30-cluster sampling methodology was used to select individuals from the survey population. This time however, the Lot Quality Assurance Sampling (LQAS) methodology was used. The recent re-organization of the District into municipalities enabled each municipality to function as one Supervision Area (SA) or Lot. Even with a small sample size (in this case 24 per SA), poor health service performance could be identified so that resources are appropriately distributed. Furthermore, people from the community such as Community Health Workers (CHW) were involved in all phases of the study, including the manual analysis of the results, upon being trained appropriate. However, it is questionable as to how accurate and reliable such a manual analysis was. In this dissertation, the manual results of the study were evaluated by doing an electronic analysis. In addition, a more refined analysis of the data has been produced (e.g. population-weighted coverage, graphs and stratified analyses in some cases). From the comparisons made, it was concluded that the manual analysis was very similar to the electronic analysis and that differences obtained were not statistically significant. In addition, due to each municipality varying in population size, it was queried as to whether population-weighted results would produce a marked difference from the un-weighted, manual results. Again, the differences produced were in most cases not statistically significant. This concluded that the manual analysis carried out by the TDCSP team was accurate and that it is appropriate to use such results in determining individual municipality performance and overall District performance so that responsive action can then be taken immediately, without necessarily having to wait for electronic results. / Thesis (M.P.H.)-University of KwaZulu-Natal, 2005.