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0Disability and Health Journal
"They must understand we are people": Pregnancy and maternity service use among signing Deaf women in Cape Town
Margaret W. Gichane, MSPH, Marion Heap, PhD, Mayara Fontes, MA, Leslie London, MD.
PII: S1936-6574(17)30066-3
DOI: 10.1016/j.dhjo.2017.03.016
Reference: DHJO 598
To appear in: Disability and Health Journal
Received Date: 4 February 2017 Revised Date: 26 March 2017 Accepted Date: 31 March 2017
Accepted Manuscript
Please cite this article as: Gichane MW, Heap M, Fontes M, London L, "They must understand we are people": Pregnancy and maternity service use among signing Deaf women in Cape Town, Disability and Health Journal (2017), doi: 10.1016/j.dhjo.2017.03.016.
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Title: "They must understand we are people": Pregnancy and maternity service use among signing Deaf women in Cape Town
Authors: Margaret W. Gichane, MSPH,a Marion Heap, PhD,b Mayara Fontes, MA,b Leslie London, MD.b
Affiliations:
a. Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, 302 Rosenau Hall, CB #7440 Chapel Hill, NC 27599, USA
b. Health and Human Rights Programme, School of Public Health and Family Medicine, University of Cape Town, Observatory 7925, South Africa
Corresponding author: Margaret W. Gichane
Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, 302 Rosenau Hall, CB #7440 Chapel Hill, NC 27599, USA; warugich@live.unc.edu; phone: +1-315-529-2670
Conflicts of interest: The authors declare no conflicts of interest. Acknowledgements
We would like to thank Professor Tom Moultrie, Director and Demography Programme Convenor, Centre for Actuarial Research University of Cape Town for conducting estimates on fertility among Deaf women in Western Cape for the preparation of this manuscript. We would like to acknowledge the contributions of the University of Cape Town interpreters, research assistants, and students who contributed in data collection.
Disclosure:
This work was supported in part by grant MD 001452 from the National Center on Minority Health and Health Disparities of the National Institutes of Health, Dr. Luz Claudio, Principal Investigator, and by funding from the South African National Research Foundation. Funders had no input on the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
Abstract word count: 250 Manuscript word count: 3998 Number of references: 47 Number of tables: 1 Number of figures: 1
Keywords: Deaf, pregnancy, maternity, disability, access barriers
Abstract
Background: Women with disabilities are at disproportionate risk for adverse pregnancy outcomes, however, there is limited information on their pregnancy histories. This mixed-methods study focuses on signing Deaf women whose access to health care may be compromised by language barriers related to their disability.
Objective: To describe and compare the pregnancy outcomes and maternity service use of a sample of signing Deaf women of child-bearing age in Cape Town to the population of the Western Cape of South Africa.
Methods: We interviewed 42 Deaf women selected by non-probability snowball sampling, using a structured questionnaire in South African Sign Language in Cape Town in July 2016. Results: Average parity of the sample was similar to that of the Western Cape population. Most women had one or two children (74%). Thirty-one percent of women had experienced a miscarriage and 19% had terminated a pregnancy. Almost all women (96%) attended at least one antenatal appointment during their pregnancies, and all deliveries occurred at a health facility. Women primarily relied on writing to communicate during antenatal visits and labor/delivery. The majority of women reported communication issues due to limited interpretation services, and some reported experiencing mistreatment from hospital staff.
Conclusion: This study provides novel information on the pregnancy histories of Deaf women. While maternal service usage was high, the quality of services were inadequate with reports of linguistic barriers and mistreatment. Findings suggest the need to improve maternity care for Deaf women through implementing interpretation services and providing sensitivity training to health care providers.
Keywords: Deaf, pregnancy, maternity, disability, communication, access barriers
Introduction
Frameworks for the right to sexual and reproductive health for women with disabilities have been established through two significant international human rights documents. Article 12 of the International Covenant on Social, Economic and Cultural Rights (ICSECR), adopted in 1966, sets forth the right to the highest attainable physical and mental health for all (1). In 2016, the Committee on Social, Economic and Cultural Rights published General Comment 22 to Article 12, which specifically addresses the sexual and reproductive health rights of women with disabilities and outlines the obligations of states to: 1) repeal laws, policies, and practices that obstruct health access; 2) ensure universal access to quality sexual and reproductive health care; and 3) provide comprehensive information that is non-discriminatory and evidence-based (2). Secondly, in 2006 the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) established provisions for the human rights of persons with disabilities. Several articles within UNCRPD are relevant to the topic of sexual and reproductive rights including: recognition of the unique rights of women with disabilities (Article 6); the right to accessible information, facilities, and resources (Article 9); the right to make decisions around family planning (Article 23); and the right to health care free of discrimination (Article 25) (3).
Despite widespread ratification of UNCRPD (4) and ICESCR (5), women with disabilities in Sub-Saharan Africa still face numerous barriers to receiving adequate sexual and reproductive health care (6, 7). Common themes reported in qualitative studies with people with disabilities include: expensive and limited transportation to facilities, physical inaccessibility of facilities, communication problems with health staff, and staff inexperience and insensitivity with people with disabilities (6, 7). Even in South Africa, where the constitution specifically protects the rights of people with disabilities and cites access to reproductive rights in the right to
access health care, this population still reports numerous difficulties (8, 9). Inaccessible and inadequate sexual and reproductive health care services can have severe implications for the health of women, especially during pregnancy (10).
Women across a spectrum of disabilities face higher rates of adverse outcomes including pre-term births and low birth weight babies (11-13). Few studies have focused on the pregnancy outcomes of Deaf women (14, 15) and none have been conducted in low and middle income countries (LMIC). We use a capital "D" to refer to those: who are born permanently audiologically disabled or become so in childhood, whose first language is signed, and who identify as a member of the Deaf community (16, 17). According to South Africa's 2011 census, 4% of adults report some form of hearing difficulty ranging from partial to full hearing loss (18). The fertility rate among women with reported hearing difficulty is 2.07, which is about 15% lower than the population rate of 2.40 (T. Moultrie, personal communication, March 18, 2016). However, this aggregate estimate does not give sufficient understanding of specific pregnancy outcomes, nor of the possible mismatches in care that may give rise to differential outcomes.
Studies conducted in the United States (US) and the United Kingdom (UK) have assessed pregnancy outcomes of Deaf women. A population-based US study found that women with hearing loss were more likely to experience a pre-term birth and low birth weight infants (15). Similarily, a study conducted in the UK found that women with sensory disabilities (e.g. visual and hearing impairment) did not have significantly different number of children as compared to women without disabilities, but were more likely to have a pre-term delivery (12). A small US study comparing Deaf and hearing women's pregnancy outcomes did not find any significant differences in pre-term deliveries or babies birth weight (14). While these studies provide essential information about this population, they were conducted in high income countries with
the medical infrastructure to accommodate pregnancies and deliveries for women with disabilities.
When it comes to the experience of maternity services, Deaf women report lower satisfaction with overall quality of antenatal care, fewer antenatal appointments, and poor communication with physicians, but when provided with access to the interpretation services they need, they report higher satisfaction (14). Interpretation services are a key component to the provision of high quality health care for Deaf people. Evidence suggests that communication barriers contribute to lower utilization of health services by Deaf women (19).
Despite the South African constitution's provisions to provide language services to all, this law is rarely actualized (20). There is an inadequate supply of South African Sign Language (SASL) interpreters to serve Deaf people in South Africa. As of 2016, there were only five interpreters in South Africa registered and accredited in SASL by the South African Translators' Institute (21) for the estimated 500,000 to 1.5 million SASL users in the country (22). Those without access to interpreters often rely on friends or family members which can pose many ethical and human rights issues. Deaf women report that this practice risks violating privacy and confidentiality (23). Friends and family members may also lack the vocabulary to interpret complex medical terms. Research indicates that using interpreters without professional training is associated with poor clinical care, interpretation mistakes that could lead to medical errors, and use of unnecessary medical interventions (24).
The lack of information on pregnancy and maternity service use of Deaf women in LMIC means that this population is largely ignored in targeted programs and policies that can improve maternal and child health. This leaves Deaf women and children vulnerable to adverse health outcomes and human rights violations despite a constitutional commitment to protect the most
vulnerable in the South African population (25). The aim of the present mixed-method study is to assess pregnancy experience, utilization of maternity services and pregnancy outcomes amongst signing Deaf women in Cape Town, South Africa and compare findings to the general population of women in the Western Cape and South Africa.
Methods
Recruitment
Participants were recruited via short message service (SMS), Whatsapp, Facebook postings, and announcements at community gatherings at a non-governmental organization that serves the Deaf community of Cape Town and a church service held at school for Deaf children. We were able to gain access to this population due to social connections and longstanding partnerships. Authors MH and LL have previously conducted research, service, and advocacy with Deaf communities in South Africa (20, 26-29). In addition, MH coordinates a research related program that provides free-to-patient interpretation services for general medical and ophthalmology services for the Deaf through the Health and Human Rights Programme of the School of Public Health at the University of Cape Town (UCT).
Whatsapp and SMS messages were sent to a database of Deaf adults in Cape Town. The database was built up from 2009, including cell phone numbers of users of a SASL interpreter service for health care under a linked research project. The cell phone database was expanded using a snowball sampling technique (30) which employed seven Deaf individuals selected on the basis of a diversity of age, gender and geographical area or residential address to be the initial seed participants. They were asked to collect phone numbers from their contacts (no quota was specified) who in turn suggested other contacts. Each person was contacted to explain the purpose of the database and to ask for consent for their phone numbers to be added to the list. The number of contacts collected was 220 - an average of 31 per seed (range 7-35). The final database comprised 407 phone numbers.
To be eligible for the study, women had to be adults of reproductive age (18-49), been pregnant at least once, native SASL users, and self-identify as Deaf.
Procedure
Upon enrollment, participants were taken to a separate room to view recorded videos of the information sheet and consent form in SASL. A member of the research staff was available to answer any questions in SASL. Participants were also given written versions of the information sheet and consent form in their choice of isiXhosa, Afrikaans, or English, the local official written languages of the Western Cape Province of South Africa. After viewing the informed consent video, a trained fieldworker proficient in SASL and research ethics interviewed each participant to ensure they understood the consent form and obtained written consent.
Participant interviews were conducted by accredited SASL interpreters and interviewers trained in survey administration and research ethics. During each interview, the interpreter signed the question and the participant signed their response. The interpreter then voiced the response in English which was captured on an online form by a research assistant. Participants received reimbursement for transport and refreshments upon completion. Interviews took place on two Saturdays in July 2016 at two well-known gathering spaces for the Deaf community of Cape Town. Ethical approval for the study was granted by the UCT Health Science Faculty Human Research Ethics Committee. Instrument
The questionnaire is included in Appendix 1. Items were developed through consultation from medical and public health experts. Questions were first written in English and then professionally translated into isiXhosa and Afrikaans. Written versions were then translated into SASL by an accredited interpreter and recorded. The video was viewed by interpreters, Deaf
staff, and hearing staff. All parties discussed questions and resolved discrepancies in signs. Adjustments were then made to the questionnaire in English.
The questionnaire included 22 questions covering the following: 1) demographics (age, marital status, highest education level achieved, employment status, income; 2) number of pregnancies and outcomes, including numbers of children, miscarriages, stillbirths, loss of a child, and termination of pregnancy; 3) antenatal care usage -timing of initiation, reasons for early or delayed use of antenatal care, and frequency of visits; and 4) delivery location and facility type. Questions about antenatal care usage and delivery location were asked for the participant's most recent pregnancy to reduce recall bias.
The questionnaire also included a mix of open and closed-ended questions describing the quality of maternal services received. Participants were first asked to rate their experience at an antenatal clinic as, "good," "bad," or "okay." Then they were asked to explain why they provided that answer. Next, they were asked, to answer "yes" or "no" to the question, "Did you feel like you and the health care staff understood each other?" If participants "yes", they were then asked what communication method was used. Response options included: writing, family member interpreted, friend interpreted, professional interpreter, and fill in the blank. Finally, participants were asked "On the basis of your experiences, how would you suggest it could have all been done better?" The same questions were asked in regards to quality of care at the health facility where they delivered their youngest child. Analysis
Descriptive statistics were calculated to describe participants' demographics, pregnancy outcomes, and responses to questionnaire items. Average parity (an aggregate measure of the average number of pregnancies a woman has carried to term) and average gravidity (the number
of pregnancies a woman has regardless of outcome) were stratified by age compared to the general population of the Western Cape. Proportions for additional pregnancy outcomes including termination and miscarriage were reported. Analysis of open-ended questions on experiences during antenatal care and labor/delivery and recommendations for improvement of maternity services were informed by thematic analysis (31). Responses were read and re-read by authors MG and MH to familiarize themselves with the data. A codebook was developed covering common themes including: communication barriers, interpretation services, discrimination due to disability status, staff demeanor, family support, health of baby, pain, and sensitivity training. MG conducted initial coding. Upon completion, MG met with MH to discuss salient themes. Codes that were not related to experiences with staff or communication were dropped. MG then combined codes into two major categories. Qualitative findings are presented here within the themes of communication in maternal services and staff behavior at health facilities.
Results
Participants
The sample consisted of 42 women ranging in age from 18-49 years (Table 1). The majority of participants were married or lived with a partner (57%) and had between a seventh and twelfth grade education (78%). Over half were unemployed (57%), however, they did receive an income from their monthly disability grant. Seventy-six percent of respondents reported a monthly income less than $282. Most women had one or two pregnancies (62%) and children (74%). Sample average parity, gravidity, and Western Cape population parity (32) are shown in figure one. The sample and Western Cape parity followed similar trends. About a third (31%) of women had experienced a miscarriage and 19% had terminated at least one pregnancy in their lifetime.
Antenatal care use and delivery
Thirty-nine women (93%) in the study received antenatal care when they were pregnant
with their youngest child. Nearly half (49%) of respondents booked at a clinic within the first
trimester as per World Health Organization (WHO) recommendations (33). These participants
recalled that they booked at this time due to the emergence of pregnancy related symptoms and
as a preventative health measure for their baby. Participants who did not book until the third
trimester (18%), cited reasons including: unaware of pregnancy, need for a clinic card during
delivery, and lack of awareness about need for antenatal care. The majority of women (59%)
women had four or more antenatal visits during their most recent pregnancy. All 37 women
whose most recent pregnancy resulted in a live birth had a physician or registered midwife at
delivery and gave birth at a hospital or Midwife Obstetric Unit (MOU). MOUs are health
facilities that are run by nurse midwives and linked to directly to hospitals. They provide
antenatal care and deliveries for low-risk pregnancies and refer women with pregnancy
complications to local hospitals.
Poor communication in maternal services
Participants varied widely in their experiences in antenatal care. While two thirds of women responded that they had a "good" or "okay" experience, their explanations pointed to challenges. Communication was a major determinant of quality. About 38% of participants mentioned language barriers and a lack of interpretation services. Women described issues understanding providers. One participant stated, "They were encouraging but the terminology used was difficult to understand." This sentiment was echoed by another woman who reported, "I didn't understand anything. Mom tried to help me." Fifty-six percent of participants answered that they and the staff did not understand each other during appointments. The communication methods used by those who reported communication difficulties with staff were: writing (23%), family member interpreting (18%), lip-reading (8%), and professional interpreter (5%). Remaining participants reported no form of communication.
Communication barriers were also present during labor and delivery. About 65% of participants answered that they did not feel that they and the staff understood each other. Women expressed they were unable to communicate the pain they felt:
"I was struggling. I was in labor for 3 hours it was not easy. Also, while I was in labor the nurse was speaking with me but I could not understand. So I keep the pain to myself. I gave them the UCT number for an interpreter but they never called." Two women reported that the family members they had interpreting for them were restricted to visiting hours which meant their communication was limited at night and during non-visiting
hours. During labor and delivery, communication methods used included: writing (32%), family member interpreting (19%), and professional interpreter (14%). Staff behavior at health facilities
Another theme that determined quality of antenatal care experience was staff attitudes and behavior. A third of participants stated that they experienced kindness and helpfulness from health care staff. A few women discussed how providers were aware of their Deafness and made accommodations. A participant reported, "They were giving me a lot of support because they found out I was Deaf. One of the staff could do SASL a little." However, 15% of participants disclosed very negative experiences with staff. They described issues such as: rudeness from nurses, neglect, and yelling. Experiences varied across providers as one women noted, "Some people were rude some were nice. They have a bad attitude toward Deaf people."
Participants described similar experiences with health care staff during labor and delivery as compared to antenatal care. Only 19% described positive staff attitudes and behavior, as in staff being "helpful", "patient", "nice", and "supportive." Acknowledgement of Deafness resulted in better treatment for one woman, "They knew I was Deaf. Each nurse when come in saw in the folder that I was Deaf so they were nice to me." Additionally, 16% recalled negative experiences including unkind nurses and waiting long periods in pain. Recommendations
When asked how to improve maternity services, the resounding response was increased access to interpretation services. About 76% of participants suggested that health care facilities hire interpreters and/or that health staff receive training in basic sign language in order to improve communication. One participant stated, "They need to have interpreters. A child could die because you don't understand." Participants explained that when doctors wrote messages to
them they used medical terms that they could not understand. Some commented that they had limited reading and writing ability. An additional recommendation given by 16% of participants was for doctors and nurses to provide better treatment and respect to Deaf people. In regards to nurses, a participant said,
"They need to be patient with Deaf people and don't scream. They can't just come and think we are nothing. They must understand we are people."
Discussion
This study describes results from a project assessing pregnancy outcomes and maternity service use in a sample of signing Deaf women in Cape Town, South Africa. To our knowledge this is the first study exploring these topics in Africa. The average parity in our sample was similar to the regional rate for the Western Cape (32), which is consistent with findings that women with sensory disabilities do not have fewer children than non-disabled women (12). The proportion of women who experienced a miscarriage (31%), is higher than the 16% found in a population based study in South Africa (34). Due to the limitations of our sample, it is not clear whether this trend would be seen in a nationally representative sample of Deaf women. However, it does suggest that adverse outcomes should be the subject of more careful investigation with more representative samples.
Findings from this study indicate that Deaf women in Cape Town readily access antenatal care. Nearly all women in the sample (96%) reported attending an antenatal clinic, and close to half (49%) did so within the first trimester. These findings are consistent with other studies of antenatal care initiation in South Africa which indicate that almost all women receive antenatal care during pregnancy (35), but a significant proportion delay seeking care beyond the first trimester (36-38) which increases the risk of adverse pregnancy outcomes (39). Most women in the sample attended more than four antenatal visits during their most recent pregnancy which is similar to the Western Cape average of 4.7 visits (35) and WHO guidelines (33).
Even though the sample had high attendance at antenatal visits, the women's narratives suggest that the quality of provider-patient interactions was potentially problematic. The numerous complaints about poor communication with health care staff are consistent with other studies conducted with Deaf populations using health care services (9, 14, 19, 23, 40). Only 28%
of participants had an interpreter during antenatal visits and 33% had an interpreter during labor and delivery. Furthermore, these interpreters were primarily family members which is unethical. Having a family member present without a patient's consent violates patient-provider confidentiality, a right established by the South African government's National Health Act of 2003 (41). Deaf patients report that having a family member interpret for them is concerning because it inhibits them from sharing information (23), which could have negative implications on the pregnancy outcome. The exploratory nature of our study did not allow us to assess whether communication issues had a direct impact on pregnancy outcomes, future studies with representative samples should examine associations between quality of care and adverse pregnancy outcomes for Deaf women.
Writing was the most common form of communication during maternity service use. A common issue described by Deaf patients is that physicians assume that writing is an adequate form of communication (14). This assumption presents several issues. First, it incorrectly assumes that sign language is a direct translation of written languages. SASL has its own distinct structure that does not follow the same rules of syntax as other languages (42). Therefore, learning written languages can be challenging. Second, even though all participants in the study expressed that they were able to read and write in either English, Afrikaans, or isiXhosa, their proficiency level may not have been sufficient to understand some medical terms used. On average, Deaf adults in South Africa read and write at a level below the 4th grade (43). Similar literacy levels are found among Deaf adults in the US (44). Third, using writing to communicate even though written languages are not well understood by Deaf people is a violation of human rights (20, 28). The South African National Health Act explicitly states that, 'The health care provider concerned must, where possible, inform the user ... in a language that the user
understands and in a manner which takes into account the user's level of literacy'(41). Lastly, using written communication during delivery is clearly cumbersome and not optimal under conditions where the woman is experiencing pain and distress during labor.
Even though there were positive reports of provider treatment, there were also an almost equal number of women reporting mistreatment in the form of rudeness and poor attitudes. Reports on abuse in maternity wards has been well documented in South Africa; common themes that have emerged in studies of obstetric violence include neglect, yelling from nursing staff, shaming patients, and insults (45-47). Abuse in maternity wards has been found to delay or dissuade women from seeking antenatal care and to postpone going to a health facility during labor which can lead to negative outcomes for the mother and infant (45, 46). In one study, several women reported that they delivered their babies on their own due to the staff's neglect (46). The generally uncaring attitude found in maternity services towards non-disabled women would be aggravated for Deaf women subject to poor communication and discrimination based on their disability. Not surprisingly, besides interpretation services, the main recommendation made by women in the study was for providers to learn to be more respectful of Deaf women. Limitations
Several limitations must be considered in the interpretation of results. First, quantitative data about number and timing of antenatal visits, clinic and delivery location was self-reported which may be subject to recall bias. Some women's most recent pregnancy was over 10 years ago, thus they may not accurately remember details of their antenatal appointments or delivery. Second, only one author (MG) independently coded the qualitative data and combined themes. However, author (MH) also read through open-ended responses and was intimately familiar with the data. Third, the sample may represent a sub-set of the Deaf who are more likely to access
health care as a result of exposure to previous research. That would likely over-estimate usage of antenatal care. Their recommendations for maternity service improvements may also be biased because the SMS database that was used as the source population for this study was created to advertise interpretation services offered by UCT, thus, this group may be more likely to recommend interpretation services as a way to improve health services. However, the need for interpreters in medical care has been widely cited in other studies with Deaf populations (14, 19, 23). Future studies should consider other rigorous methods of recruiting this hard-to-reach population.
Conclusion
Our study provides unique information about pregnancy and maternity service use in this understudied population. Deaf women in Cape Town are engaging in maternity services, but they face a significant barrier due to poor communication and, for some women, poor staff attitudes. Access to poor quality services is not how the Right to Health frames access to health care. Provision of adequate interpretation services is important for ensuring quality of care and human rights for Deaf women.
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39. National Department of Health. Saving Mothers 2011-2013: Sixth report on confidential enquiries into maternal deaths in South Africa, Short report. Pretoria, South Africa: National Department of Health; 2014.
40. Iezzoni L, O'Day B, Killeen M, Harker H. Communicating about Health Care: Observations from Persons Who Are Deaf or Hard of Hearing. Annals of Internal Medicine. 2004;140:356-62.
41. Government of the Republic of South Africa. National Health Act 2003.
42. Morgan R. The linguistic structure of South African Sign Language after apartheid. Sixth International Conference on Theoretical Issues on Sign Language Research; Washington D.C.1988.
43. Glaser M, Lorenzo T. Developing literacy with Deaf adults. In: Watermeyer B, Swartz L, Lorenzo T, Schneider M, Priestly M, editors. Disability and social change: A South African agenda Cape Town, South Africa: HSRC Press; 2006. p. 192-205.
44. Traxler CB. The Stanford Achievement Test, 9th Edition: National Norming and Performance Standards for Deaf and Hard-of-Hearing Students. The Journal of Deaf Studies and Deaf Education. 2000;5(4):337-48.
45. Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients? Reflections from South African obstetric services. Social Science and Medicine. 1998;47(11):1781-95.
46. Abrahams N. Health care-seeking practices of pregnant women and the role of the midwife in Cape Town, South Africa. Journal of Midwifery & Women's Health. 2001;46(4):240-7.
47. Kruger LM, Schoombee C. The other side of caring: abuse in a South African maternity ward. Journal of Reproductive and Infant Psychology. 2009;28(1):84-101.
Table 1. Characteristics of respondents (n = 42).
_n (%)
Age (years)
<20 1 (2)
20-24 6 (14)
25-29 9 (22)
30- 34 9(22)
35-39 6(14)
40-44 5 (12)
45-49 6 (14) Written language3
English 35 (83)
Afrikaans 4 (10)
isiXhosa 6 (14) Marital status
Single/Never married 13 (31)
Married/Living together 24 (57)
Widowed 1 (2)
Divorced 4 (10) Education
< Grade 7 5 (12)
Grade 7-12 33 (78)
Passed matric 2 (5)
Don't know 2 (5) Employment status
Unemployed 24 (57)
Employed 18 (43) Monthly income
<$282 32 (76)
$282-$706 8(19)
Refused 2 (5) Pregnancy Outcomes Number of pregnancies
1-2 26 (62)
> 3 16 (38) Number of children
0 4 (9)
1-2 31 (74)
> 3 7 (17) Miscarriage 13 (31) Stillbirth 1 (2) Abortion_8 (19)
a Participants were allowed to list more than one language
Figure 1. Comparison of Sample and Western Cape Gravidity and Parity
<20 20-24 25-29 30-34 35-39 40-44 44^9
■ Sample Gradivity 1 1.67 1.44 2.33 2.83 2.4 2. S3
—Sample Parity 0 1.17 1.33 1.67 2.17 2 2. S3
• Western Cape Parity 0.14 0.58 1.1 1.62 2.06 2.31 244
Pregnancy Prevalence
*Required 1. Reference number *
2. Consent signed? *
Mark only one oval.
( ) Yes No
3. In which of the following languages do you prefer to read or write? *
Tick all that apply.
| | English
| | Afrikaans
| | isiXhosa
| | Other:
4. What is your current marital status? *
Mark only one oval.
o Married
o Living together like married partners
o Never married
o Widow/widowed
o Separated
o Divorced
5. What is your highest level of schooling/education? *
Mark only one oval.
( ) Below Grade 7/Standard 5
( ) Between Grade 7/Standard 5 and Grade 12/Standard 10
Q ) Passed matric
Q ) No matric but diploma
Q ) Have post-matric qualification
) Don't know
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ACCEPTE Pregnancy Revatenc^IpT
6. What is your employment status? *
Tick all that apply.
| | Employed
| | Unemployed
| | Disability Grant
| | Not looking for employment
| | Never worked
7. Your monthly income? *
Mark only one oval.
( ) None
(" ) Disability Grant
( ) Less than R4000
( ) Between R4000 and R10000
( ) More than R10000
( ) Refused
8. How many times have you been pregnant? Include times in which you were pregnant but the pregnancy did not result in a baby. *
9. How many children do you have? *
10. How old are your children - what are their birth dates?
Sensitive Questions
I am going to ask you some questions that you don't need to are about whether you may have had a miscarriage; you may whether you chose to have a termination of pregnancy.
11. Do you feel OK to answer these questions?
Mark only one oval.
( ) Yes
( ) No After the last question in this section, skip to question 20.
answer if you don't want to. The questions have lost a baby at birth or later on; or
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12. If yes, did you ever have a miscarriage?
Mark only one oval.
( ) Yes
13. If yes was it...
Mark only one oval.
( ) Once
f ) Twice
f ) Three times
Q ) More than three times
14. Did you ever lose a baby at birth?
Mark only one oval.
( ) Yes
15. If yes, do you want to tell us about it?
16. Did you ever lose a child later on?
Mark only one oval.
( ) Yes
17. If yes, do you want to tell us about it?
18. Did you ever have a termination of pregnancy?
Mark only one oval.
( ) Yes
19. If yes was it...
Mark only one oval.
(" ) Once
C ) Twice
) Three times
C ) More than three times
Medical care
5 ACCEPTE Pregnancy Prevalence^JpT
20. How many months pregnant were you when you went to book at clinic with your youngest child?
Mark only one oval.
( ) Less than 2 months (less than 8 weeks)
Q ) 3 months (12 weeks)
Q ) 4 months (16 weeks)
Q ) 5 months (20 weeks)
Q ) 6 months (24 weeks)
Q ) 7 months (28 weeks)
( ) 8 months (32 weeks)
f ) Did not book
21. Ask this question if the answer above is < 5 months. What was the reason you booked early at ?
22. Ask this question if the answer above is > 5 months. What was the reason you booked later at ?
23. Which clinic did you attend when you were pregnant with the youngest child?
Mark only one oval.
( ) Michells Plain
( ) Site B
(" ) Town 2
( ) Mfuleni
( ) Delft
( ) Guguletu KTC
( ) Other
24. If other, where?
25. Did you attend a hospital when you were pregnant with the youngest child?
Mark only one oval.
( ) Yes No
C ) Can't remember
26. If you attended hospital, what was its name?
Tick all that apply.
□ Mowbray Maternity
□ Groote Schuur
□ Somerset
□ Tygerberg
□ Other
□ Don't know
27. If other, where?
28. How many times did you attend clinic when you were pregnant with your youngest child?
Mark only one oval.
( ) More than 4 times
Q ) 4 times
Q 3 times
( ) Twice
( ) Once
( ) Did not attend
( ) Other:
29. In which province was your youngest child born?
Mark only one oval.
Q ) Eastern Cape Q ) Western Cape ( ) Other:
30. In which type of health care facility did you deliver the youngest child?
Mark only one oval.
( ) Midwife Obstetric Unit
f ) Hospital
f ) Home
( ) Other
31. What was name of the hospital or clinic?
Antenatal Care
32. Please tell me about your experiences at ante-natal clinic when you were pregnant with the youngest child. How was the experience ?
Mark only one oval.
( ) Good ( ) Bad ( ) Okay
33. Explain why
34. Did you feel like you and the staff understood each other?
Mark only one oval.
o Other:
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ACCEPTE pregnancy preva!ence>JpT
35. If you did understand each other, how did you communicate?
Mark only one oval.
C ) Writing
(" ) Interpreter
f ) Friend interpreted
( ) Family member interpreted
( ) Other:
36. On the basis of your experiences how would you suggest it could all have been done better?
Delivery and Birth
37. Please tell me about your experiences at ante-natal clinic when you were pregnant with the youngest child. How was the experience ?
Mark only one oval.
( ) Good ( ) Bad ( ) Okay
38. Explain why
39. Did you feel like you and the staff understood each other?
Mark only one oval.
o Other:
3 ACCEPTE Pregnancy Prevalence»^
40. If you did understand each other, how did you communicate?
Mark only one oval.
(" ) Writing (" ) Interpreter C ) Friend interpreted ( ) Family member interpreted Other:
41. On the basis of your experiences how would you suggest it could all have been done better?
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