Thesis (M.S.)--Boston University

Newborn morbidity and mortality remains high despite a remarkable decline in the infant mortality and under five mortality rates in Nepal over the last decade (1996-2006). Research shows that newborns’ health outcome is associated with maternal and other factors. This study was designed to understand the factors that have an impact on three good newborn care practices: safe cord cutting, early breastfeeding and delayed bathing. The study used the interview data of 815 married women aged 15-49 years who delivered a live baby between February 2008 and February 2009, collected for the baseline survey of the Community-Based Maternal and Newborn Health program implemented in the Sindhuli district of Nepal. The mean age of the sample women was 26 years. Two-thirds of them were from disadvantaged indigenous caste/ethnicity groups, about 70% were uneducated and the majority were poor. Safe cord cutting, early breastfeeding and delayed bathing practices were studied for 803, 810 and 812 women respectively and 70.7%, 46.7%, and 16.6% of the eligible samples demonstrated the practices respectively. The logistic regression method was used to examine the association of independent factors with the outcome variables. Social gradient was found to be associated with all three practices. Rich women were more likely to demonstrate good practices and bearing a child at the prime age (20-34 years) was likely to result in safe cord cutting. Disadvantaged indigenous and ‘other’ caste/ethnicity women demonstrated unsafe cord cutting practices and dalit caste/ethnicity women demonstrated poor bathing practices. Maternal knowledge also emerged as a strong predictor of early breastfeeding and delayed bathing practices. Antenatal care from a SBA determined good breastfeeding and advice from a FCHV determined good bathing practices. The results showed that the uptake of antenatal and delivery services from a skilled birth attendant is unacceptably low in rural Nepal, which is a challenge for meeting the millennium development goals. The study recommends programmes for improving economic status as a key to improving newborn care practices. As the vast majority of the deliveries are still assisted by traditional birth attendants; including them in maternal health programmes is crucial. Increasing women’s access to a skilled birth attendant and boosting the spirit of the FCHVs to increase their efficiency is also recommended. Future research on newborn health should focus on identifying other determinants of newborn care practices and survival. Qualitative studies to understand the cultural perspectives of newborn care practices are also recommended.

M.Cur. / 28-week premature infants are usually born with Respiratory Distress and need ventilator support in order to survive. However, because of all the associated complications of ventilation of premature infants, it is the practice in the NICU's in this studies to extubate these infants as soon as possible to either nasal continuous positive airway pressure (nCPAP) or nasal cannula (nc). For this study the choice of ventilation was High-Frequency Oscillation (HFO). It is known that during HFOV, Fi02 and MAP constitute the oxygenation needed to ventilate these infants. During weaning the Fi02 is reduced to :s 30% and the MAP gradually to :s 8-10 cm H20 to enable extubation. There are not enough guidelines as to the ideal MAP at which to extubate a HFOV 28-week premature infant to nCPAP or nco The purpose of this study was, firstly, to determine the recommended optimal MAP to successfully extubate a 28-week HFOV premature infant to either nCPAP or nc and, secondly, to formulate guidelines and recommendations for use by the attending neonatal nursing staff, doctors and clinicians for optimal nursing and management of the HFOV premature infant. This is a non-experimental quantitative study with a retrospective, descriptive survey, case study design. All 28-week premature infants that were initially ventilated on a HFOV during the period May 2000 to September 2002 in two private Neonatal Intensive Care Units in Gauteng and extubated to nCPAP or nc were incorporated into this study. The study was done in 3 phases. The first involved an in-depth literature survey in which the physiological and biographical variables that were included in the data collection instrument were identified. The second phase involved collecting the data from the infant's medical files, analysing the data and identifying any correlation of the data. In the third phase guidelines and recommendations for neonatal nursing staff, doctors and any attending clinicians were formulated. The initial settings of the HFOV, as well as the settings at a MAP of 8 cm H20, and the settings of the HFOV prior to extubation were recorded and analysed. The premature infant's initial blood gas and peripheral saturation after commencement of ventilation, as well as at a MAP of 8 cm H20 and prior extubation were recorded and analysed. The physiological stability of the premature infants, 12 hours after extubation, formed the criteria of successful extubation and any need for re-intubations was considered failure criteria. There are a lack of protocols and guidelines for neonatal nurses, doctors and clinicians as to guide them in the nursing of HFOV 28-week premature infants. The analysed data assists in drawing up guidelines for nursing the 28-week premature HFOV infant.

Maternal and child-health and health education are three major concerns of public health organisations and researchers throughout the world. Health education for mothers is a strategy many countries have adopted to improve maternal and child-health. The present study was carried out in Uganda with the objective of exploring the factors influencing the utilisation of postnatal services at Mulago and Mengo hospitals, a government and private hospital. Both hospitals are located in Kampala district in Uganda. The survey, was completed by 330 women who responded to a structured questionnaire that was given to them six to eight weeks after delivery. Questions that were asked generated demographic information about the mothers / mothers&rsquo / knowledge about postnatal services / mothers&rsquo / socio-economic status and barriers to utilisation of the postnatal services. The participants included all women who delivered in Mulago and Mengo hospitals in November 2003 except for those who had had a neonatal death. The data was analysed using descriptive and inferential statistics. Some of the key findings of the study were that most women lacked awareness about postnatal services and those who knew about these services only knew about immunisation and family planning services. The majority of the mothers did not know about other services, such as physiotherapy, counselling, growth monitoring, and physical examination. Lack of money for transport or service costs, distance from the health care facility, not being aware of the services, lack of somebody to take care of the child at home were some of the main barriers to utilisation of postnatal services. Others included, lack of education, lack of employment, lack of decision-making powers, and lack of time to go back for the service. The ministry of health should educate women and communities about the importance of postnatal care, its availability, and the importance of women having decision-making power over their own health. The health service organization should improve on the quality of care by ensuring that services are provided at convenient hours with privacy, confidentiality and respect and it should evaluate the services periodically from the users perspective to maintain the quality of service.

Este estudo qualitativo foi motivado pela carência de pesquisas com enfoque na maternidade na adolescência e no período puerperal. Teve como objetivo compreender a vivência da puérpera-adolescente sobre o cuidado do recém-nascido, em domicílio. Adotou-se o conceito de Maternidade como referencial de análise e o método do Discurso do Sujeito Coletivo (DSC) no tratamento dos dados. O projeto foi aprovado pela Comissão de Ensino e Pesquisa, e pelo Comitê de Ética em Pesquisa do Hospital Universitário da USP. Participaram do estudo 15 puérperas-adolescentes, primíparas, que ficaram internadas na unidade de Alojamento Conjunto do HU-USP, juntamente com o recém-nascido. Os dados foram coletados em 2006, por meio de entrevista realizada com as puérperas após o mínimo de 30 e o máximo de 40 dias, no domicílio. As respostas da questão aberta, “conte-me como está sendo em casa com seu bebê ?" possibilitaram a elaboração de 17 DSC apresentados em dois blocos, segundo os temas centrais que emergiram: “cuidados do recém-nascido" e “contexto sociocultural das puérperas-adolescentes". Em relação ao primeiro bloco, os discursos mostraram uma construção diária do ser mãe-adolescente e o desejo da puérpera pela maternidade e pela maternagem, pois assumiam integralmente as tarefas de mãe-cuidadora. A princípio considerada de difícil adaptação, a maternidade gerou na jovem a necessidade de aprender a conviver com as abdicações e ambivalências inerentes ao novo status. O suporte familiar, as orientações recebidas na unidade de Alojamento Conjunto e a experiência anterior no cuidado de recém-nascidos favoreceram a adaptação à maternidade e a superação de suas limitações iniciais. Quanto ao segundo bloco (contexto sociocultural), os dados mostraram a expressão de vivências e de mudanças nas relações sociais, com abandono de projetos de vida imediatos e de atividades de lazer. Verificou-se, ainda, que a puérpera-adolescente vivencia o cuidado do recém-nascido com erros e acertos, e, a cada dia, constrói o próprio modelo de ser mãe, vencendo medos e dificuldades, e despertando para sua capacidade de atender às necessidades de higiene, de alimentação e de afeto do recém-nascido. Diante dos dados, creio que o profissional deve repensar como abordar essas jovens mães nas unidades de saúde, priorizando o atendimento de situações geradoras de conflitos no cuidado do bebê e na relação com familiares. Além disso, deve estar disponível para compartilhar e possibilitar o esclarecimento de suas dúvidas de modo a facilitar a superação de dificuldades. Portanto, oferecer-lhe a chance de uma vivência da maternidade-adolescente com base em cuidados construídos diariamente, com superação / This is a qualitative study that was motivated by the lack of researches related to the maternity during the adolescence and the postpartum period. The aim of this study was to understand the adolescent mother’s experience while taking care of the newborn at home. The maternity concept was adopted as the referential for the analysis. For the data treatment the Collective Subject’s Speech was adopted. The project was approved by the Research Committee and also by the Ethic Committee of the School Hospital of University of São Paulo. Fifteen adolescent mothers participated in the research. They were all mothers for the first time and they stayed together with their babies in the rooming-in of the School Hospital of University of São Paulo. The data were collected in 2006 by interviews done with the mothers after the minimum of 30 days and the maximum of 40 days they were in their houses. The answers given to the open question: “Tell me what it is like to be home with your baby", made possible to elaborate 17 Collective Subject’s Speeches that were presented in two parts, according to the following central themes that emerged: “taking care of the newborn" and “social and cultural contexts of the adolescent mothers". In the first part, the speeches showed that everyday, the women were building their role as adolescent mothers as well as their desire for the maternity and care. They totally assumed the tasks related to the caregiver mother. In the beginning, the adolescent mothers considered they had difficult in adapting to the maternity, which forced them to learn how to live with the abdication and ambivalences related to their new status. The support from the family, the orientation given in the hospital and the previous experience taking care of newborns helped the adolescent mother to be adapted to the maternity and also to overcome the first limitations. In the second part of the speeches (social and cultural contexts), the data showed experiences and changes related to their social lives as putting behind some immediate life projects as well as their leisure activities. It was also verified that the adolescent mother experiences the care of the newborn by making the right and wrong things and each day she builds her own model of a mother, overcoming her fears and difficulties. This process makes her understand her capacity to fulfill the newborn’s needs concerning hygiene, feeding and affection. According to the findings, I believe the professional should rethink the way the care is given to these young mothers in the health units and give priority to the situation of conflict in the care of the baby and in the relationship with the members of the family. The professional should also be available to share and clear their doubts in order to make easier for them to overcome their difficulties and give them the opportunity to experience an adolescent maternity based on everyday care built with triumph

Maternal and child-health and health education are three major concerns of public health organisations and researchers throughout the world. Health education for mothers is a strategy many countries have adopted to improve maternal and child-health. The present study was carried out in Uganda with the objective of exploring the factors influencing the utilisation of postnatal services at Mulago and Mengo hospitals, a government and private hospital. Both hospitals are located in Kampala district in Uganda. The survey, was completed by 330 women who responded to a structured questionnaire that was given to them six to eight weeks after delivery. Questions that were asked generated demographic information about the mothers / mothers&rsquo / knowledge about postnatal services / mothers&rsquo / socio-economic status and barriers to utilisation of the postnatal services. The participants included all women who delivered in Mulago and Mengo hospitals in November 2003 except for those who had had a neonatal death. The data was analysed using descriptive and inferential statistics. Some of the key findings of the study were that most women lacked awareness about postnatal services and those who knew about these services only knew about immunisation and family planning services. The majority of the mothers did not know about other services, such as physiotherapy, counselling, growth monitoring, and physical examination. Lack of money for transport or service costs, distance from the health care facility, not being aware of the services, lack of somebody to take care of the child at home were some of the main barriers to utilisation of postnatal services. Others included, lack of education, lack of employment, lack of decision-making powers, and lack of time to go back for the service. The ministry of health should educate women and communities about the importance of postnatal care, its availability, and the importance of women having decision-making power over their own health. The health service organization should improve on the quality of care by ensuring that services are provided at convenient hours with privacy, confidentiality and respect and it should evaluate the services periodically from the users perspective to maintain the quality of service.

Este estudo qualitativo foi motivado pela carência de pesquisas com enfoque na maternidade na adolescência e no período puerperal. Teve como objetivo compreender a vivência da puérpera-adolescente sobre o cuidado do recém-nascido, em domicílio. Adotou-se o conceito de Maternidade como referencial de análise e o método do Discurso do Sujeito Coletivo (DSC) no tratamento dos dados. O projeto foi aprovado pela Comissão de Ensino e Pesquisa, e pelo Comitê de Ética em Pesquisa do Hospital Universitário da USP. Participaram do estudo 15 puérperas-adolescentes, primíparas, que ficaram internadas na unidade de Alojamento Conjunto do HU-USP, juntamente com o recém-nascido. Os dados foram coletados em 2006, por meio de entrevista realizada com as puérperas após o mínimo de 30 e o máximo de 40 dias, no domicílio. As respostas da questão aberta, “conte-me como está sendo em casa com seu bebê ?” possibilitaram a elaboração de 17 DSC apresentados em dois blocos, segundo os temas centrais que emergiram: “cuidados do recém-nascido” e “contexto sociocultural das puérperas-adolescentes”. Em relação ao primeiro bloco, os discursos mostraram uma construção diária do ser mãe-adolescente e o desejo da puérpera pela maternidade e pela maternagem, pois assumiam integralmente as tarefas de mãe-cuidadora. A princípio considerada de difícil adaptação, a maternidade gerou na jovem a necessidade de aprender a conviver com as abdicações e ambivalências inerentes ao novo status. O suporte familiar, as orientações recebidas na unidade de Alojamento Conjunto e a experiência anterior no cuidado de recém-nascidos favoreceram a adaptação à maternidade e a superação de suas limitações iniciais. Quanto ao segundo bloco (contexto sociocultural), os dados mostraram a expressão de vivências e de mudanças nas relações sociais, com abandono de projetos de vida imediatos e de atividades de lazer. Verificou-se, ainda, que a puérpera-adolescente vivencia o cuidado do recém-nascido com erros e acertos, e, a cada dia, constrói o próprio modelo de ser mãe, vencendo medos e dificuldades, e despertando para sua capacidade de atender às necessidades de higiene, de alimentação e de afeto do recém-nascido. Diante dos dados, creio que o profissional deve repensar como abordar essas jovens mães nas unidades de saúde, priorizando o atendimento de situações geradoras de conflitos no cuidado do bebê e na relação com familiares. Além disso, deve estar disponível para compartilhar e possibilitar o esclarecimento de suas dúvidas de modo a facilitar a superação de dificuldades. Portanto, oferecer-lhe a chance de uma vivência da maternidade-adolescente com base em cuidados construídos diariamente, com superação / This is a qualitative study that was motivated by the lack of researches related to the maternity during the adolescence and the postpartum period. The aim of this study was to understand the adolescent mother’s experience while taking care of the newborn at home. The maternity concept was adopted as the referential for the analysis. For the data treatment the Collective Subject’s Speech was adopted. The project was approved by the Research Committee and also by the Ethic Committee of the School Hospital of University of São Paulo. Fifteen adolescent mothers participated in the research. They were all mothers for the first time and they stayed together with their babies in the rooming-in of the School Hospital of University of São Paulo. The data were collected in 2006 by interviews done with the mothers after the minimum of 30 days and the maximum of 40 days they were in their houses. The answers given to the open question: “Tell me what it is like to be home with your baby”, made possible to elaborate 17 Collective Subject’s Speeches that were presented in two parts, according to the following central themes that emerged: “taking care of the newborn” and “social and cultural contexts of the adolescent mothers”. In the first part, the speeches showed that everyday, the women were building their role as adolescent mothers as well as their desire for the maternity and care. They totally assumed the tasks related to the caregiver mother. In the beginning, the adolescent mothers considered they had difficult in adapting to the maternity, which forced them to learn how to live with the abdication and ambivalences related to their new status. The support from the family, the orientation given in the hospital and the previous experience taking care of newborns helped the adolescent mother to be adapted to the maternity and also to overcome the first limitations. In the second part of the speeches (social and cultural contexts), the data showed experiences and changes related to their social lives as putting behind some immediate life projects as well as their leisure activities. It was also verified that the adolescent mother experiences the care of the newborn by making the right and wrong things and each day she builds her own model of a mother, overcoming her fears and difficulties. This process makes her understand her capacity to fulfill the newborn’s needs concerning hygiene, feeding and affection. According to the findings, I believe the professional should rethink the way the care is given to these young mothers in the health units and give priority to the situation of conflict in the care of the baby and in the relationship with the members of the family. The professional should also be available to share and clear their doubts in order to make easier for them to overcome their difficulties and give them the opportunity to experience an adolescent maternity based on everyday care built with triumph

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23781号 / 医博第4827号 / 新制||医||1057(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 石見 拓, 教授 近藤 尚己, 教授 万代 昌紀 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Made available in DSpace on 2016-06-02T19:35:46Z (GMT). No. of bitstreams: 1 4706.pdf: 1390580 bytes, checksum: ac62535fd24adf8500e80618b6f01ac9 (MD5) Previous issue date: 2012-11-05 / To increase the awareness of breastfeeding practices, one must bear in mind that this is a complex act, permeated by the influence of several factors, including the family members. In order to better understand the family context of pregnant/lactating women and identify what they learn with their mothers and mothers-in-law we developed the following research question: What are the existing educational processes in the dialogue between two generations of women about breastfeeding practices and newborn care practices? The objective of this study was to understand what women of different generations learn and teach about breastfeeding practices and newborn care practices, seeking to reveal the type of support and influence that mothers and mothers-in-law may exert on breastfeeding practices. This was a qualitative study, which had the participation of eight women residing in a low socioeconomic neighborhood, and the following techniques were used for data collection: semi-structured interviews and informal conversations. For data analysis we adopted the assumptions of the hermeneutic-dialectic analysis, which led to the development of categories that enabled us to understand: the diversity of motherhood and breastfeeding experiences, the grandmothers knowledge on breastfeeding, the educational processes in the dialogue between women of different generations and the grandmothers potential for encouraging and supporting breastfeeding. We conclude that grandmothers are reference persons in the family, that they have various forms of knowledge about breastfeeding and about caring for newborn babies and who transmit this knowledge to their daughters and daughters-in-law. Thus, when developing actions to promote, protect and support breastfeeding, health professionals need to acknowledge and value the knowledge that women bring from their own child rearing experiences, in addition to building a dialogical relationship that enables to consider and expand this knowledge, enhancing the role of grandmothers as supporters of breastfeeding. / Para ampliar a compreensão sobre a prática do aleitamento materno é preciso considerar sua complexidade. Essa é permeada pela influência de diversos fatores, entre eles as pessoas da família. Foi com o intuito de compreender melhor o contexto familiar das mulheres gestantes/lactantes e identificar o que elas aprendem com suas mães e sogras que elaboramos a seguinte questão de pesquisa: Quais os processos educativos existentes no diálogo entre mulheres de duas gerações sobre a prática de amamentar e os cuidados com o bebê? . O presente trabalho teve como objetivo compreender o que mulheres de diferentes gerações aprendem e ensinam sobre a prática de amamentar e os cuidados com o bebê, buscando desvelar o tipo de apoio e a influência que mães e sogras podem exercer sobre a prática da amamentação. Tratou-se de uma pesquisa qualitativa, da qual participaram oito mulheres de um bairro de classe econômica baixa. Para a coleta de dados foram utilizadas as seguintes técnicas: entrevista semiestruturada e roda de conversas. Para a análise dos dados adotamos os pressupostos da análise hermenêutica-dialética, que levou a elaboração de categorias que nos permitiram compreender: 1) a diversidade de vivências frente a maternidade e a amamentação, 2) os saberes das avós relacionados à prática da amamentação, 3) os processos educativos presentes no diálogo entre mulheres de diferentes gerações e 4) o potencial das avós para o incentivo e apoio à prática da amamentação. As avós são pessoas de referência na família, possuem diversos saberes sobre a prática da amamentação, os cuidados com o bebê e transmitem estes saberes para suas filhas e noras. Dessa forma, ao desenvolver ações de promoção, proteção e apoio ao aleitamento materno, os profissionais de saúde precisam reconhecer e valorizar os saberes que as mulheres trazem da experiência com a criação do (as) filhos (as), além de estabelecer uma relação dialógica que permita a reflexão e ampliação destes saberes, potencializando o papel das avós como apoiadoras do aleitamento materno.

Maternal and newborn health is one of the main indicators of a good health system. The study wished to develop a strategy to improve the referral system for maternal and newborn care. To identify issues for improvement, the researcher explored the appropriateness of referrals, referral pathways and challenges, and provider costs for maternal and newborn care at health centres and hospitals levels. The researcher selected a sequential explanatory mixed method research design. Two primary hospitals and six health centres were purposively selected for participation. The first phase collected quantitative data by reviewing the health facilities’ medical records for services provided and health service costing, respectively. Data collection covered one Ethiopian fiscal year (8 July 2017 to 7 July 2018). Based on the existing human resource arrangement and care needs, the health service costing found that a single midwife at health centre level spent half of the expected time for delivery care. The cost estimates of various types of care delivery care indicated that delivery care at health centre and hospital levels cost $27.5 to $30.2, and $34.7 to $37.8, respectively. The primary hospitals incurred four times the cost for newborn intensive care units and Caesarean sections compared to normal delivery care. In the second phase, the researcher collected qualitative data from 26 purposively selected key informants in interviews. The findings indicated that the selected hospitals and health centres had a referral system, but several factors impeded its effective implementation. Knowledge of referral pathways determined the referral practices at the lower level of the system. The number of inappropriate referrals to primary hospitals indicated a need to mobilize and educate the community on the services available and protocols of care. In general, most referrals could have been managed at health centre level. Emergency medical transportation is a critical component of the referral system; delays in transportation determine the outcome of care at hospital level. Ambulance management was generally poor, lacked a tracking system, and was negatively affected by confusion and lack of coordination between facilities. The available ambulances were not well equipped or well-staffed for emergency management. Moreover, there were frequent breakdowns due to limited budget for maintenance and running costs. The quality of maternal care depends on the quality of the labour monitoring. However, partograph utilization was not consistently practised. Admitted cases were not properly monitored because of the high caseload and limited supervision support. In many cases, healthcare professionals tended to “treat charts” rather than promote evidencebased practice while providing care. The quality of practice was challenged by insecurity in the working environment but strengthened by good teamwork and available consultation support. The implementation of the existing referral system depended on the people involved; the use of performance indicators; follow up by management, and an accountability framework. The findings of the two phases of the study and review of other countries’ experiences on the identified problems, led to the development of draft strategy and then a consultation with relevant experts produced the final strategy. The strategy includes interventions to improve the practices at the sending and receiving facilities as well as suggestions to improve the communication, transportation and overall governance system. Then, taking into consideration all the phases of the study, the researcher makes recommendations for practice and further research. / Health Studies / D. Litt. et Phil. (Healht Studies)