MSc (Med), Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand / Background: The knowledge of contraceptive use is high among men and women in South Africa. However, contraceptive prevalence rate is moderate and unplanned pregnancies are common. Understanding the determinants of contraceptive use and unplanned pregnancy will inform future interventions that aim to maintain consistent contraceptive use and reduce unplanned pregnancies. Aim: The study aims to describe factors associated with contraceptive use and unplanned pregnancy in the South African population. Methods: A secondary data analysis was carried out on data collected in a cross–sectional survey conducted in Potchefstroom, South Africa between August 2007 and March 2008.Results: Contraceptive prevalence was 69.5% and unplanned pregnancy was 59.7%. The risk factors for contraceptive use included woman’s employment status at the last pregnancy, woman’s partner employment status at the last pregnancy and number of miscarriages a woman had experienced. The risk factors for unplanned pregnancy included race, woman’s age , education level and employment status at last pregnancy, number of miscarriages, contraceptive use and partner’s employment status at last pregnancy. Conclusion: If the prevalence of unplanned pregnancies is to be reduced, policies and programmes need to address economic factors which were associated with both contraceptive use and unplanned pregnancy. Further study needs to be carried out as to the reasons behind why a woman with a previous history of a miscarriage is less likely to have an unplanned pregnancy yet she is less likely to be on contraception.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Science in Epidemiology & Biostatistics. Johannesburg, February 2015 / Background Anaemia in pregnancy is a major public health and economic problem worldwide, that contributes to both maternal and fetal morbidity and mortality. Clinical manifestations of anaemia in pregnancy include fetal growth restriction, preterm delivery, low birth weight, impaired lactation, poor maternal/infant behavioural interactions and post partum depression. Objective The aim of the study was to calculate the prevalence of anaemia in early pregnancy in a cohort of ‘low risk’ women participating in a large international multicentre prospective study (n = 5 609), to identify the modifiable risk factors for anaemia in pregnancy in this cohort, and to compare the birth outcomes between pregnancies with and without anaemia in early gestation. Methods The study is an analysis of data that were collected prospectively during the Screening for Pregnancy Endpoints (SCOPE) study. Anaemia was defined according to the World Health Organization’s definition of anaemia in pregnancy (haemoglobin < 11g/dL). Binary logistic regression with adjustment for potential confounders (country, maternal age, having a marital partner, ethnic origin, years of schooling, and having paid work) was the main method of analysis. Results The hallmark findings were the low prevalence of anaemia (2.2%), that having no marital partner was an independent risk factor for having anaemia (OR 1.34, 95% CI 1.01-1.78), and that there was no statistically significant effect of anaemia on adverse pregnancy outcomes (small for gestational age, pre-tem birth, mode of delivery, low birth weight, APGAR score < 7 at one and five minutes). Adverse pregnancy outcomes were however more common in those with anaemia than in those without. Conclusion The absence of a marital partner is an important non-modifiable factor that should be added to the conceptual framework of anaemia’s determinants. Although not statistically significant, clinically, a trend towards a higher risk of adverse pregnancy outcomes was observed in women that were anaemic in early pregnancy.

A research report submitted to the faculty of health science, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of MSC MED pharmaceutical affairs / MT2017

by To King-Hon. / Thesis (M.B.A.)--Chinese University of Hong Kong, 1989. / Bibliography: leaf 58.

INTRODUCTION Preeclampsia, a hypertensive disorder of pregnancy, affects 3% to 7% of women throughout the world. Preeclampsia is a leading cause of maternal and infant mortality worldwide, occurring primarily in nulliparous women. Despite extensive research over the past decade, the underlying pathophysiological mechanisms of the disease are largely unknown. A recent hypothesis has suggested that when a pregnancy is complicated by preeclampsia, it is the result of an inability of the maternal cardiovascular system to fully adapt to the physiologic challenge of pregnancy. This may result when there is an underlying and predisposing prepregnancy maternal cardiovascular state that leads to the pathophysiologic consequences of preeclampsia when pregnancy is superimposed. Despite evidence for familial predisposition and presumed multifactorial genetic inheritance, preeclampsia generally occurs in first pregnancies and does not recur when the interpregnancy interval is short. One explanation for these observations is that pregnancy itself modifies the maternal cardiovascular system in ways that persist postpartum and reduce the risk for preeclampsia recurrence, at least for a limited period of time. It has been demonstrated that the maternal cardiovascular system is remodeled during pregnancy, and these changes extend postpartum. The long lasting reduction in mean arterial pressure postpartum that pregnancy induces, and the cardiovascular remodeling that accounts for this, may allow for easier adaptation to volume expansion in subsequent pregnancies, even when the first pregnancy was complicated by preeclampsia. As the maternal cardiovascular system returns, over time, to the baseline condition, this protective effect diminishes. With this knowledge, we hypothesize that the length of time between pregnancies is negatively correlated to the likelihood of recurrence of preeclampsia, and more narrowly that the length of time between pregnancies is inversely associated with mean arterial pressure differences comparing pregnancies across all trimesters. METHODS This study was a retrospective chart review of existing medical records. We reviewed medical records of women who had been diagnosed with preeclampsia at Fletcher Allen Health Care, during their first advanced pregnancy between 1995 and 2014, who went on to have a subsequent pregnancy within that time period. We aimed to identify factors that could affect the blood pressure and risk of preeclampsia in women who were previously diagnosed, including previous medical history and demographic variables. We collected blood pressures from each pregnancy, across each trimester, marking the recurrence of preeclampsia and other complications. Mean antepartum mean arterial blood pressure, pulse pressure, and systolic and diastolic blood pressures were calculated and compared between pregnancies examining differences as a function of interpregnancy interval. RESULTS One hundred and seventy two subjects were identified for review. Overall, there was evidence of a significant association of interpregnancy interval (IPI) and the difference in mean arterial pressure (MAP) between pregnancies (p=0.04). The mean MAP of pregnancy decreased significantly between first and second pregnancies when the interpregnancy interval was <24 months (p=0.0018) and 24-48 months (p=0.0003), but the change was non-significant at interpregnancy intervals of >48 months (p=0.55). The mean MAP during the third trimester, specifically, decreased significantly between first and second pregnancies across all subject groups (IPI <24 months: p<0.0001; IPI 24-48 months: p<0.0001; IPI >48 months: p=0.03). Preeclampsia recurred in 39 of the second pregnancies. The recurrence rate of preeclampsia did not vary significantly with interpregnancy interval (p=0.21). DISCUSSION/CONCLUSIONS The interval between preeclamptic pregnancies and subsequent pregnancies has an influence on the MAP of the second pregnancy. There is good evidence of a temporal influence, in that the shorter interpregnancy intervals resulted in a greater reduction in MAP when compared to the longer interpregnancy interval. We believe that with additional research on interpregnancy intervals >48 months, there could be more a conclusive association identified between the rate of recurrence of preeclampsia and the length of interpregnancy interval.

This portfolio presents a unique and significant body of research which together provides a substantial, original description and analysis of women’s engagement with weight management behaviours and services during pregnancy. This body of research examines this topic from multiple perspectives, concluding with a detailed interpretative study which sheds light on the deep-rooted determinants of women’s weight-related behaviours during pregnancy. All outputs are articles published in peer-reviewed scientific journals: Article one describes an evaluation of the acceptability of an individual, home-based perinatal weight management service, based on a qualitative examination of the experiences of obese women who used the service during pregnancy. The findings showed that women valued the support they received from the service, and highlighted home visits, personalised advice and regular weight monitoring as beneficial, while suggesting that more frequent appointments and practical support with target behaviours would enhance the service. Article two describes a qualitative study of the views and experiences of obese women who had declined or disengaged from the service evaluated in article one. The study identified the referral experience as key to women’s decisions to decline participation, highlighting the need for midwives and other health professionals to have detailed knowledge of the service and training on how to sensitively offer this additional support. Findings also demonstrated that some obese women lacked the confidence or capability to successfully change weight-related behaviours, even with support, leading them to disengage from the service. Article three compares and combines qualitative data obtained from two sets of midwives, each referring women to either a one to one, home-based weight management service, or a group, community-based weight management service, to explore how midwives approach the referral with obese and overweight women, and their views of women’s responses to being offered a referral. Findings highlighted the important role midwives play as gatekeepers to weight management services and raised questions regarding how midwives approach the referral process within the wider context of the maternal obesity issue. The findings also suggest that services might improve uptake through addressing pragmatic and motivational barriers, and through better communication with their referral agents. Article four describes analysis of qualitative data collected from women who declined a referral to a group, community-based weight management service during their pregnancy, specifically exploring their views on being referred to the service by their midwife. In contrast to the findings described in article two, women in this study reported finding the referral acceptable, and that they expected to receive information about such services from their midwife. The more positive response of these women could be attributed to a number of potential factors, including; an increase in women’s awareness of the risks of maternal obesity, an increase in midwives’ confidence and skill to raise the issue of weight in the time elapsed between the two studies, or a different approach to making the referral between the two services. Article five reports the findings of a qualitative study using Interpretive Phenomenological Analysis (IPA) which sought to explore in detail the lived experience of a first pregnancy and the process of making decisions about diet and physical activity during this time. The article aimed to further illuminate the multiple and significant barriers to adopting positive dietary and physical activity behaviours during pregnancy, and to challenge the commonly cited belief that ‘pregnancy is a good time for behaviour change’ by examining women’s experiences with specific reference to the model of ‘Teachable Moments’ (McBride, Emmons, & Lipkus 2003). While partially supporting the model, the results also indicated that women with healthy, uncomplicated conception and pregnancy experiences base their diet and physical activity choices primarily on automatic judgements, physical sensations and perceptions of what pregnant women are supposed to do, which in turn suggests limited opportunity for antenatal health professionals to intervene and subsequently influence behaviour. These accumulated findings suggest that there is much that can be done to increase obese women’s engagement with maternal weight management behaviours and services. Service providers and commissioners could draw on these findings to design services which better meet the needs of many obese women, such as receiving personalised support, at a time and location convenient for them, and providing regular weight monitoring. There are also implications for health professionals’ education and clinical practice, with findings indicating that midwives would benefit from further training and better information about the weight management services they are asked to refer to, in order to make referrals more evidence-based and increase their confidence to advocate for the service to women who might benefit. Finally, the work presented in this portfolio further informs our understanding of the psychosocial determinants of women’s weight-related behaviour during pregnancy. It suggests that researchers and practitioners should consider how to tackle the largely socially learned, sub-optimal behaviour patterns that are often established in early pregnancy and how to activate more reflective decision-making in relation to diet, physical activity and weight management. The portfolio also includes critical reflection on each of the outputs and the contribution of each unique study to the development of the author into an independent and expert researcher, and concludes with suggestions for future research.

No description available.

This thesis presents the results of a qualitative study of self-care in pregnancy, birth and lactation within a non-random sample of 27 women in British Columbia, Canada. The women were interviewed in the third trimester of pregnancy, and 23 of the participants were re-interviewed post-partum. Interviews were tape recorded, transcribed, and subjected to thematic analysis. Results were discussed in the context of the social science literature on the medicalization of pregnancy and childbirth. All but one woman used herbal medicine while pregnant. In the post-partum interviews, nearly half reported using galactagogue herbs. The safety and efficacy of each herbal remedy are discussed here. Most of the herbs are considered safe and effective according to the herbal literature, but clinical reports are largely lacking. While many of the women were cautious about using herbs during pregnancy, as a general rule, they considered them to be safer than pharmaceutical drugs. In choosing to self-medicate with herbs, the women said they were guided by prior knowledge (32%), trusted sources of advice (56%), and intuition (12%). Trusted sources of advice included books, friends, family members, maternity care providers, herbalists, herbal shops, and internet. The majority of herbal advice (69%) was received by word-of-mouth. Prolonged pregnancy also proved to be an interesting situation. Many women said they were opposed to labour induction at the time of the first interview, yet all but one woman who went beyond 40 weeks gestation used self-help measures to stimulate labour. This appeared to be a response to pressure from maternity care providers, friends, and family members. Though the medical definition of prolonged pregnancy is 42+ weeks gestation, in the social context, 40+ weeks was cause for concern. Health care professionals, partners, family members, friends, and co-workers all affected self-care behaviour, and their influence could be positive or negative. After an overwhelmingly negative experience with a maternity care provider, over half of the women went to another care provider, or forewent formal maternity care entirely. These findings did not support the hypothesis that childbearing is almost completely medicalized, at least for the sample population. Rather, women negotiated their maternity care within several frameworks, including the medical, midwifery, and self-care models. Medical language was used to describe birth stories, but only by women in physician care. There was an almost universal effort among the women to normalize the childbearing experience. The findings of this study point to a need for: (1) clinical investigation of herbal medicines used in pregnancy, birth and lactation; (2) public and care-provider education regarding social and psychological aspects of prolonged pregnancy; (3) broad-scale inquiry into the phenomena of medicalization/normalization of the childbearing experience, and (4) further investigation into women’s preferences for empowering styles of maternity care. / Graduate

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Master of Medicine in Obstetrics and Gynaecology MMed(O&G) Johannesburg, April 2015 / Background Pre-eclampsia and its complications remain a significant cause of maternal and perinatal morbidity and mortality on a global level. There are few data regarding the maternal and fetal outcome of pre-eclampsia at term. Studies suggest that poor maternal outcome is more prevalent as one approaches term, while there are conflicting findings regarding the outcomes of the babies born to term pre-eclamptic patients. Objective To determine the prevalence of pre-eclampsia in term pregnancies at Rahima Moosa Mother and Child Hospital (RMMCH), a hospital that provides district and higher level referral services, and to assess the severity of maternal disease in pre-eclampsia at term, as well as fetal outcomes. Methods This was a prospective cross-sectional, descriptive study on women giving birth at term with pre-eclampsia. All women were followed up until delivery. The indication for and mode of delivery, maternal progress and complications, as well as fetal outcome, were recorded. Results Seventy-eight patients were entered into the study, giving a hospital prevalence rate of pre-eclampsia at term of 1.2%. The major maternal complications were those of severe hypertension (75.6%), eclampsia (9%), HELLP syndrome (3.8%), and pulmonary oedema (7.7%). There was one maternal death. Fifty-one patients (65%) delivered by caesarean section. Major fetal complications encountered were respiratory distress (7.5%) and birth asphyxia (3.7%). There was one neonatal death from meconium aspiration.

Gestational diabetes mellitus occurs in up to 10% of pregnancies and often leads to labor and delivery complications for both the mother and the baby. Early identification of gestational diabetes and educational intervention are needed to improve the self-management and knowledge among pregnant women. The purpose of the project was to implement newly established national guidelines to ensure that women with gestational diabetes are identified during the first trimester of pregnancy and begin diabetes education early in gestation. Lewin's planned change theory was selected as the theoretical framework, and the six sigma approach was used to facilitate the change process. The project used a pretest and posttest design in a convenience sample of 35 women with gestational diabetes who were referred for the educational intervention and completed the education and the questionnaires. The anticipated outcomes were for (a) women to be screened during the first trimester of their pregnancy and (b) the post education scores on the self-management questionnaire to demonstrate an increase in knowledge about contacting the provider for abnormal blood sugar results and making appropriate dietary choices. Data were entered into SPSS and were analyzed using descriptive statistics. A t test was used to compare pretest and posttest knowledge scores. During the project, 57% of the participants were screened in the first trimester of pregnancy. The difference in the pretest (M = 75.43) and the posttest scores (M = 91.71) was statistically significant (p < .0001). These findings have important social change implications because early screening and early intervention will help to reduce birth complications and long-term development of Type 2 diabetes.