Thesis--Catholic University of America. / Includes bibliographical references.

Background: Concerns have been well documented about women either dying or developing severe morbidities from prolonged and obstructed labour. These concerns have noted that maternity care during labour has not been of a sufficient standard to improve the outcome for women giving birth in Malawi. This ‘failure to save’ women remains, despite assertions that obstructed and prolonged labour can be prevented through appropriate decision making during the progress and management of labour. Midwives in Malawi form the majority of maternity healthcare workers and an important aspect of their decision-making role is to assess the progress of labour when caring for women in labour. To date, there has been limited exploration of either midwifery decision making during labour or the contextual factors that influence midwives’ decision making. The aim of this study was to explore how Malawian midwives make decisions during the first stage of labour in a hospital setting and to identify the contextual factors that influence their decision making. Design and Method: Using a qualitative ethnographic research approach, 27 participant observations, 26 follow-up interviews and document reviews comprised the data collection. Nine Malawian nurse-midwives who worked at a tertiary (n=5) and a secondary referral hospital (n=4), with a mixture of qualifications and experiences, participated. Each nurse midwife was observed three times with subsequent follow-up interviews. Interviews were conducted in a vernacular language, audio-taped, transcribed, translated into English and back translated into vernacular language. Qualitative data analysis software, NVivo 10, was used to assist with data management for the analysis. All data was analysed using the principle of theme and category formation. Findings: Three major themes were identified - contextual factors influencing midwifery decision making - the role of cue acquisition - the role of the partograph during care of women in the first stage of labour. Integration of the themes has led to the development of a proposed conceptual model of ‘supporting normality’ during the first stage of labour, which suggests that the midwives strived to make decisions during the care of women in labour with the aim of supporting the normal physiological processes of labour. The first theme illustrates that for Malawian midwives, decision making is a complex and contextually dependent undertaking. In everyday practice, decision making was influenced by multiple and competing factors but the midwives developed strategies to manage and control the context of their practice and facilitate decision making. The role of cue acquisition comprised a six-stage subprocess illustrating the ways in which midwives utilise assessment data to reason and make decisions during the care of women in labour. These processes involved the midwives building a case for each woman’s labour progression by piecing together segments of information they obtained. This process was striking when there was uncertainty in a woman’s progress of labour as they used deductive thinking by cross-checking data obtained across the labour progression span. There was a constant forward and backward moving of thought processes supported by actions that uncovered real case-building evidence for informing decisions about whether to intervene or not. The model further indicates the role of the partograph, which alerted midwives to the presence of progress or non-progress of labour. Although the partograph acted as an adjunct to the midwives’ decision making that could indicate opportunities for early intervention in labour if labour appeared not to be progressing, the midwives were sometimes cautious about its interpretation. This thesis has expanded on current theoretical knowledge of decision making by elaborating on the processes midwives employ to make decisions as they care for women in labour. It also illuminates the impact of contextual factors on decision making, and elucidates various strategies midwives use to advance their professional role. The emerging conceptual model provides implications for future midwifery practice, education and policy both in Malawi and worldwide.

Essa tese trata da prática de parteiras na cidade de Melgaço, na região marajoara e fluvial do estado do Pará, no contexto globalizado entre 2004 e 2006. Seguindo uma abordagem antropológica, minha proposta foi me aproximar da “visão nativa”, integrando a prática de parteiras dentro da análise do modo de vida “local”. Optei por centrar a discussão na etnografia pormenorizada da vida cotidiana (práticas e conhecimentos) das parteiras, sem, no entanto, cair no erro de monografias anteriores, isto é, sem me limitar a uma “história natural” do grupo, como se fosse “exótico” e “isolado”. A importância que estas mulheres conferem à atenção da saúde gineco-obstétrica envolveu analisar elementos tão diversos quanto a massagem abdominal empregada (conhecida localmente como puxação), as relações conjugais e de parentesco, a interação com o sistema de saúde institucional e os cursos de treinamento organizados por ONGs. A originalidade dessa pesquisa é pretender suplantar as dicotomias usuais (tradição/modernidade, biológico/cultural etc.), além da preocupação funcionalista (como modificar as práticas locais), para ressaltar a dimensão social (redes familiares etc.) e simbólica (saberes locais, hierarquias de prestígio) que englobam os elementos que vêm “de fora”, conferindo um sentido à prática atual das parteiras. / This thesis addresses the practice of midwives in the city of Melgaço, in the fluvial region of the Marajó, State of Pará, in the globalized context from 2004 to 2006. Following an anthropological approach, my intention was to become closer to the “native view”, integrating midwives’ practice within the analysis of the “local” way of life. I chose to center this discussion on a detailed ethnography of the midwives’ daily life (practices and knowledge) without, although, committing the mistake of previous monographies, that is, without limiting myself to a “natural history” of the group, as if they were “exotic” and “isolated”. The importance that these women confer to gynecological and obstetrical health issues involved the analysis of elements as diverse as the abdominal massage (known locally as puxação), the kinship and marital relations, the interaction with the institutional health system and the training courses organized by NGOs. The originality of this research is to intend to overcome usual dichotomies (e.g. tradition/modernity, biological/cultural etc.), beyond the functionalist worries (how to modify the local practices), in order to enhance the social (family networks etc.) and symbolic (local knowledge, prestige hierarchies etc.) dimensions that involve the elements coming “from outside” and that confer a meaning to the current practice of these midwives.

Made available in DSpace on 2013-01-07T15:55:01Z (GMT). No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) 42.pdf: 2008415 bytes, checksum: 22d7d7586f7b80e825588788e7b54bac (MD5) Previous issue date: 2004 / O objeto do estudo consiste nas relações entre parteiras tradicionais, profissionais de saúde e a população assistida por ambos os grupos, a partir do ponto de vista das parteiras, ao longo do período no qual ocorreram os programas de treinamento para parteiras tradicionais promovidos pela 17ª Regional de Saúde do Estado do Paraná, sediada em Londrina, entre os anos de 1975 a 1978. Contudo, o recorte temporal abrange um período maior, inicia-se em 1929, com a formação do primeiro núcleo populacional de Londrina e atinge o ano de 1978. O referencial teórico utilizado no estudo está baseado nas proposições de micro-história italiana. O trabalho de Susan L. Smith, Sick and tired of being sick and tired: black women's health in America atuou aqui como referncial historiográfico. Dele, aproveitou-se a 'idéia do elo'. Esta elaboração teórica consiste na percepção, por parte dos funcionários do Estado, do potencial de iniciativa, aconselhamento e liderença que as parteiras tinham dentro de suas comunidades. A percepção desse potencial é a idéia fundamental dos trabalhos de Saúde Pública com essas mulheres pelo mundo. A dificuldade de se acessar a documentação sobre treinamento de parteiras levou-nos à opção pelo método de entrevistas e à exploração intensiva das fontes. Os resultados desta pesquisa dão conta de que existiam diferenças entre os significados inferidos à prática da parturição pelas parteiras urbanas e rurais. As parteiras rurais inferiam, quase que exclusivamente, valores religiosos e humanitários à prática. As parteiras urbanas, percebendo o potencial econômico da parturição, acabaram por se apropriar da lógica profissional de médicos e obstetrizes, tomando como exemplo a conduta destes sujeitos. Sendo assim, as parteiras conjugaram os valores de solidariedade, servir e cuidar do próximo com a prática profissional, sem significar, necessariamente, um conflito de valores. Os treinamentos não garantiram a continuação dos serviços realizados por elas, ao terem reconhecidas suas contribuições para a Saúde Pública. Este trabalho que contribuir para o conhecimento acerca do tema das parteiras e a parturição exercida por elas, no que diz respeito pensar nas maneiras pelas quais as mudanças de práticas tradicioanis se dão no cotidiano das pessoas.

Essa tese trata da prática de parteiras na cidade de Melgaço, na região marajoara e fluvial do estado do Pará, no contexto globalizado entre 2004 e 2006. Seguindo uma abordagem antropológica, minha proposta foi me aproximar da “visão nativa”, integrando a prática de parteiras dentro da análise do modo de vida “local”. Optei por centrar a discussão na etnografia pormenorizada da vida cotidiana (práticas e conhecimentos) das parteiras, sem, no entanto, cair no erro de monografias anteriores, isto é, sem me limitar a uma “história natural” do grupo, como se fosse “exótico” e “isolado”. A importância que estas mulheres conferem à atenção da saúde gineco-obstétrica envolveu analisar elementos tão diversos quanto a massagem abdominal empregada (conhecida localmente como puxação), as relações conjugais e de parentesco, a interação com o sistema de saúde institucional e os cursos de treinamento organizados por ONGs. A originalidade dessa pesquisa é pretender suplantar as dicotomias usuais (tradição/modernidade, biológico/cultural etc.), além da preocupação funcionalista (como modificar as práticas locais), para ressaltar a dimensão social (redes familiares etc.) e simbólica (saberes locais, hierarquias de prestígio) que englobam os elementos que vêm “de fora”, conferindo um sentido à prática atual das parteiras. / This thesis addresses the practice of midwives in the city of Melgaço, in the fluvial region of the Marajó, State of Pará, in the globalized context from 2004 to 2006. Following an anthropological approach, my intention was to become closer to the “native view”, integrating midwives’ practice within the analysis of the “local” way of life. I chose to center this discussion on a detailed ethnography of the midwives’ daily life (practices and knowledge) without, although, committing the mistake of previous monographies, that is, without limiting myself to a “natural history” of the group, as if they were “exotic” and “isolated”. The importance that these women confer to gynecological and obstetrical health issues involved the analysis of elements as diverse as the abdominal massage (known locally as puxação), the kinship and marital relations, the interaction with the institutional health system and the training courses organized by NGOs. The originality of this research is to intend to overcome usual dichotomies (e.g. tradition/modernity, biological/cultural etc.), beyond the functionalist worries (how to modify the local practices), in order to enhance the social (family networks etc.) and symbolic (local knowledge, prestige hierarchies etc.) dimensions that involve the elements coming “from outside” and that confer a meaning to the current practice of these midwives.

Essa tese trata da prática de parteiras na cidade de Melgaço, na região marajoara e fluvial do estado do Pará, no contexto globalizado entre 2004 e 2006. Seguindo uma abordagem antropológica, minha proposta foi me aproximar da “visão nativa”, integrando a prática de parteiras dentro da análise do modo de vida “local”. Optei por centrar a discussão na etnografia pormenorizada da vida cotidiana (práticas e conhecimentos) das parteiras, sem, no entanto, cair no erro de monografias anteriores, isto é, sem me limitar a uma “história natural” do grupo, como se fosse “exótico” e “isolado”. A importância que estas mulheres conferem à atenção da saúde gineco-obstétrica envolveu analisar elementos tão diversos quanto a massagem abdominal empregada (conhecida localmente como puxação), as relações conjugais e de parentesco, a interação com o sistema de saúde institucional e os cursos de treinamento organizados por ONGs. A originalidade dessa pesquisa é pretender suplantar as dicotomias usuais (tradição/modernidade, biológico/cultural etc.), além da preocupação funcionalista (como modificar as práticas locais), para ressaltar a dimensão social (redes familiares etc.) e simbólica (saberes locais, hierarquias de prestígio) que englobam os elementos que vêm “de fora”, conferindo um sentido à prática atual das parteiras. / This thesis addresses the practice of midwives in the city of Melgaço, in the fluvial region of the Marajó, State of Pará, in the globalized context from 2004 to 2006. Following an anthropological approach, my intention was to become closer to the “native view”, integrating midwives’ practice within the analysis of the “local” way of life. I chose to center this discussion on a detailed ethnography of the midwives’ daily life (practices and knowledge) without, although, committing the mistake of previous monographies, that is, without limiting myself to a “natural history” of the group, as if they were “exotic” and “isolated”. The importance that these women confer to gynecological and obstetrical health issues involved the analysis of elements as diverse as the abdominal massage (known locally as puxação), the kinship and marital relations, the interaction with the institutional health system and the training courses organized by NGOs. The originality of this research is to intend to overcome usual dichotomies (e.g. tradition/modernity, biological/cultural etc.), beyond the functionalist worries (how to modify the local practices), in order to enhance the social (family networks etc.) and symbolic (local knowledge, prestige hierarchies etc.) dimensions that involve the elements coming “from outside” and that confer a meaning to the current practice of these midwives.

M.Cur. / Few South African studies have been done with regard to private midwives and their clients. The practices of these midwives are overloaded, indicating a growing need for their services. An exploratory, contextual and descriptive study was undertaken to investigate some of the issues relating to the practice of the private midwife. This was done from the perspective ofthe women attending these practices. The aims of this study were to explore and describe how women experience the care they receive from their private midwives in Gauteng during antenatal visits, labour and postnatal contacts; to explore and describe the reasons for clients of private midwives in Gauteng to choose an independent midwife as birth attendant and to explore how these clients get to hear about their midwives. Eight women, attending a total of two different midwifery practices, were interviewed. The main categories that emerged from analysing the women's experience of private midwifery care were that the midwives were caring, family orientated, informative, knowledgeable, guiding and unintrusive. Time was both respected and given by the midwives. The midwives saw childbirth as a normal and natural process. The midwives empowered the women and left them in control oftheir childbirth. A mutual, intimate relationship was formed between the women and their midwives, which was based on trust and continuity of care. The women felt they were treated as unique individuals. One woman related some negative aspects ofthe care she received. A variety of reasons were given for choosing a private midwife as birth attendant. Some had specific wishes for their birth, such as a homebirth and knew that private midwives would grant them Other reasons included cost effectiveness, control over childbirth, one on one care, shorter waiting periods, longer consulting times and wanting an experienced birth attendant. Previous negative experience with staff at government hospitals and private gynaecologists; and hearing about positive experiences with private midwives also contributed to women opting for independent midwives. The women got to hear about their private midwives through their general practitioner, obstetrician, antenatal class instructor, friends, family members or health professional that delivered a previous baby. These research findings were supported by existing literature and recommendations were made to midwifery practice, education and research.

D.Cur. / The overall objective of this study was to describe the model and criteria for woman-centered care that will serve as a theoretical framework for implementing the Batho-Pele Principles in order to facilitate mutual participation between mothers and attending midwives during childbirth at one hospital of the Capricorn district in the Limpopo Province. The phases followed in this study were as follows: Phase 1: Concept Identification The concept identification was achieved through the use of a qualitative research approach which was exploratory, descriptive, contextual and inductive. A sample of 24 mothers and 12 attending midwives participated in the study. Different data collection methods were utilized. Data obtained from unstructured in-depth interviews were analyzed according to the protocol by Tesch (1990; cited in Cresswell, 1994:155). Data analysis from participant observation using semistructured observation and VAS were performed quantitatively by using frequency distribution. The results of interviews indicated experiences that foster/promote dependency in midwifery care. Woman-centered care was identified as a core category and as a central approach that would enhance mutual participation during childbirth. To ensure valid results, a model of trustworthiness as proposed by Lincoln and Guba (1985: 301-318) was utilized. Phase 2: Concept Analysis Following the concept identification, the concept analysis of a core category ‘woman-centered care’ was conducted using the framework as described by Walker and Avant (1995). Phase 3: Development of the Model and Criteria This phase dealt with the description of the structure and process of the model. Strategies were proposed, described and recommended to implement the model where there is interaction of a mother (patient) and a midwife (nurse). Evaluation of the model was done by having dialogue with experts and by utilizing Chinn and Kramer’s (1995:134-135) guidelines for evaluating theory. The criteria for womancentered care were formulated. A unique contribution of this study is the concept analysis of woman-centered care, the development and description of the womancentered childbirth model and the formulation of criteria for woman-centered care.

M.Cur. / The objective of this study explores and describes the experiences of first-time mothers regarding pain management during the first stage of labour. A qualitative approach involving phenomenology was used. Midwives were also interviewed to determine their assessment and management strategies in this regard in order to get a broader perspective on the focus of interest. The data collected from the mothers revealed three themes and they are: the care rendered, needs/wishes and beliefs/feelings of the mothers regarding the care given. These themes were further subdivided into small headings/categories as specified in the data and elaborated on. Eight categories of care strategies emerged from the data gathered from the midwives. Information from both the mothers and midwives were then extensively discussed and compared to the existing literature. Conclusions were drawn and recommendations formulated, in the form of guidelines, to assist midwives and other health-care professionals to improve their caring modalities in the management of patients with pain during the first stage of labour.

Magister Curationis - MCur / Background: In the South Africa, the number of HIV- positive pregnant women is rising and has resulted in more than 70,000 babies being born with HIV infection annually since the year 2000. In response to the escalating number of HIV-positive pregnant women, the Department of Health of South Africa, decided, in 2002, to implement the Prevention of Mother to Child Transmission (PMTCT) programme at 18 pilot sites in the country. An effective PMTCT programme could reduce the incidences of maternal and child mortalities in the country. An evaluation of the effectiveness of the PMTCT programme that was done in 2010 showed that, although the programme was rendered effectively during pregnancy and labour, there were still irregularities that appeared, especially during the postnatal period. Khayelitsha was the first pilot site in South Africa to provide Antiretroviral Therapy and initiate the Nurse Initiated Management of Antiretroviral Therapy (NIMART) at primary care level in the public sector. Midwives are the health professionals who render the PMTCT services to HIV-positive mothers and their babies until six weeks post-delivery. They have managed to test almost 100% of pregnant women during the antenatal period and the HIV-positive women were started on the PMTCT programme during their first visit. Aim: The aim of this study was to explore the challenges that midwives faced in rendering care to postnatal HIV-positive mothers enrolled in the PMTCT programme at the Khayelitsha Community Health Clinic in the Western Province of South Africa. Method: An exploratory design and qualitative approach was followed. The study population consisted of midwives who were rendering PMTCT services to HIV-positive mothers and their infants during the postnatal period. Purposive sampling was conducted until data saturation was reached. Six participants were included in the sample. The participants were informed about the study by means of an Information Sheet, advised that the study was voluntary and reminded that they could withdraw from the study at any time, without prejudice. In-depth, unstructured individual interviews were conducted with each of the participants. With the permission of participants, an audio tape recorder was used during the interviews to collect data, while the researcher took field notes to supplement and verify the voice recordings, after the interviews. The seven steps of Colaizzi were used to analyse the data. Six themes and sixteen sub-themes emerged during the data analysis. Trustworthinesswas maintained by using the criteria of Guba’s model, i.e. credibility, transferability, conformability and dependability. Permission to conduct the study was obtained from the appropriate ethical committees; the Department of Health, the Khayelitsha Community Health Clinic, as well as, the Senate Research Committee of the University of the Western Cape. Participants were asked to sign Informed Consent forms before participating in the study. The ethical principles of privacy, anonymity, withdrawal, confidentiality and consent were strictly adhered to. Findings: The study found several challenges faced by midwives while implementing the PMTCT programme during the postnatal period. These challenges included: the shortage of NIMART-trained staff attending to the high number of clients per day; the lack of manpower with data base systems to trace mothers who did not come back after delivery; and mothers who did not come back for postnatal appointments because of denial, non-disclosed HIV status and socioeconomic reasons. Furthermore, the participants also reported on midwives experiencing ‘burnout’ as a result of the hectic working environment at the Khayelitsha Community Health Clinic. Recommendations: There is an urgent need for all midwives in the MOU’s to be NIMART-trained. NIMART should be standardize and be the part of the curriculum that taught in all the tertiary institutions and be updated in a yearly basis as part of the in-service training or education for all practising midwives. The South African Government should introduce home visits in the PMTCT programme. Data-bases of all MOU’s and facilities that offer PMTCT services need to be synchronized and these MOU’s and facilities should all follow the same PMTCT guidelines. Further research should be done on the same topic at other clinics and MOU’s that render the PMTCT programme in the Western Cape.