The effect of an antenatal exercise programme including diaphragmatic breathing with co-contraction of abdominal and pelvic floor muscles on stress urinary incontinence postpartum

This dissertation is submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Physiotherapy (dissertation)Background: Stress urinary incontinence is a common problem during and after pregnancy. Pelvic floor muscle exercises have been shown to be an effective means to prevent and treat stress urinary incontinence. The literature has shown that abdominal muscles and the diaphragm work in tandem with pelvic floor muscles and co-contraction of all these muscles results in a stronger pelvic floor muscle contraction. However, this has not been tested in pregnant women with stress urinary incontinence and this relationship will be further investigated in this study. Therefore the overall aim of the study is to determine the effect of an antenatal exercise programme including diaphragmatic breathing with co-contraction of abdominal and pelvic floor muscles on stress urinary incontinence postpartum. The following objectives will be addressed: 1. To determine the influence of urinary incontinence on the prepartum quality of life (QOL) of pregnant women. 2. To establish the effect of antenatal co-contraction of pelvic floor and abdominal muscle exercises with diaphragmatic breathing on the amount of urine lost under stress. 3. To establish the effect of antenatal pelvic floor muscle exercises without diaphragmatic breathing and abdominal muscle co-contraction on the amount of urine lost under stress. 4. To determine the influence of urinary incontinence on QOL of pregnant women after the intervention. 5. To compare the effects of the two exercise programmes on urinary incontinence and QOL of pregnant women postpartum. Method: The single blind randomised controlled trial was conducted with the help of a research assistant. Once ethical clearance was obtained from the Human Research Ethics Committee, participants were recruited from the antenatal clinic at Rahima Moosa Mother and Child Hospital, Crosby Clinic and Westbury Clinic in Gauteng province, Johannesburg, South Africa. Participants were randomised by computer generated randomisation and concealed allocation into the control group or the intervention group. At baseline all participants were requested to perform a modified 20 minute pad test and complete the King’s Health Questionnaire (KHQ). They received an educational talk which included the method of performing Kegel exercises and were given a home exercise programme. Participants in the intervention group were given an exercise diary and taught diaphragmatic breathing as well as co-contraction of the abdominal muscles while doing pelvic floor exercises. Participants in the intervention group also received telephone calls every two weeks from baseline assessment until follow-up assessment to remind them to do the exercises and record them in their diaries. Re-assessment was conducted at the eight week follow-up assessment where the same questionnaire and pad test was performed again. Telephonic interviews were conducted for those participants who could not attend their follow-up assessments. The significance of the study was set at p=0.05. Two-sample t-tests and the Wilcoxon’s Rank Sum test were used to compare variables between groups and the Kendall’s Tau Correlation Coefficient and the Spearman’s Rank Correlation Coefficient were used to determine correlations between variables. Results: Fifty-two participants were recruited. Most participants were between the ages of 21 and 30 years (59.6%, n=31) in their second trimester of pregnancy (53.9%, n=28) and most (42.3%, n=22) were experiencing symptoms of stress urinary incontinence for 1 to 2 months. No differences in quality of life were observed between groups at baseline for any part of the King’s Health Questionnaire (part one: p=0.31; part two: p= 0.33 and part three: p=0.46). Stress incontinence score and pad test results were used as measures of urinary incontinence. There was no significant difference in the stress incontinence scores between groups at follow-up (p=0.58), there was also no significant difference in the pad test results between the control and the intervention group at follow-up (p=1.00). Correlations between the pad test results and the KHQ scores showed only weak correlations at baseline for both groups, but a non-significant strong correlation at follow-up for the intervention group for part one (Kendall’s tau= 0.83 and p=0.13) and part three (Kendall’s tau= 0.83 and p=0.15) of the KHQ. Correlations between the stress incontinence scores and the KHQ also showed weak non-significant correlations for all parts in both groups at baseline, while at follow-up only the intervention group showed a moderate non-significant correlation with part two of the KHQ (Part one: Spearman’s Rho=0.35, p=0.03; part two: Spearman’s Rho = 0.50, p= 0.25; part three: Spearman’s Rho = 0.36, p=0.01). There were no differences in quality of life between groups at follow-up for any part of the King’s Health Questionnaire (part one: p=0.35; part two: p= 0.09 and part three: p=0.18). There was also no evidence that any of the demographic characteristics could be linked to stress incontinence, pad test scores or quality of life. Conclusion: Although there were improvements in actual scores of the King’s Health Questionnaire and stress incontinence scores, there were no differences between the control group and the intervention group and hence, a combination of diaphragmatic breathing and abdominal co-contraction and pelvic floor muscle exercises was not more effective than pelvic floor muscle exercises alone. Keywords: : “urinary incontinence”; “pregnancy”; “pelvic floor exercises”; “abdominal and respiratory co-activation”; “abdomino-pelvic synergy”; “antenatal” ; “quality of life”MT201

Understanding the Nature and Impact of Early Pregnancy Loss Through Women\u27s Stories

Guided by Harter’s narrative framework for health communication this thematic narrative analysis sought to understand women’s experiences of early pregnancy loss with focus on sense making and communication by gathering stories from women who lost a wanted or accepted pregnancy at or prior to at twenty weeks in utero. Ten women ranging in age from twenty-six to seventy years old participated. Time since loss experience ranged from two months to forty years prior to the interview. Ellingson’s crystallization technique was employed with focus given to creating two related texts. Analysis of both individual core narratives at the time of loss and sub-stories located across the entire interview data strengthened early pregnancy loss understanding. Three core narrative summaries provide commonalities of experience within the following convergent core narratives: (a) conceptualization (what was lost?) (b) secret motherhood (disenfranchised grief), and (c) anchoring emotions (talking helps). Two sub-stories occur throughout the data, lost at sea and processing EPL. Lost at sea consists of three themes: (a) blindsided by the unexpected, (b) lack of acknowledgment within interpersonal interactions, and (c) EPL as marginalized by society. Processing EPL consists of: (d) cause of EPL, (e) emotional anchors, and (f) “time heals…it doesn’t erase.” The six themes indicate participants’ shared reactions from the first moments of experiencing loss to current understandings of the EPL experience. The three core narratives symbiotically interact with the six themes to provide a coherent picture of the participants’ early pregnancy loss experiences. Stories gathered provide a depth of understanding early pregnancy loss experiences and communication surrounding the topic both closer to the time of incident and how women understand the experience at the time of interview. Results contribute support for and extension of existing knowledge of disenfranchised grief and the power of the story in the context of early pregnancy loss. Results suggest that in situations of disenfranchised grief of early pregnancy loss, the first step in moving toward working with and/or living in one’s new normal is the ability to speak of the early pregnancy loss. The results provide a deep understanding of the emotional turmoil women experience at time of early pregnancy loss and how the emotions may resurface many years after the event. The new normal exists on a continuum. Women often continue to understand, live into, and with the unexpected early pregnancy loss years beyond the occurrence. As demonstrated through participant’s stories, even though the pain remains the ability to create an alternative option to the original family plan exists. As the data demonstrates, women experience communicative interactions that fail to acknowledge EPL and that acknowledge EPL. Often communication regarding early pregnancy loss is described as societally and interpersonally disenfranchised, silenced, dismissed, and not talked about. Apparent in the stories, the inability to acknowledge and talk about EPL within interpersonal and societal contexts detracts from a woman’s ability to work through the emotions that accompany such a blindsiding event. However, when interactions involve the acknowledgment of EPL, communication is described as anchoring, supportive, and assisting with coping with the pain of loss. Particularly salient to participants’ adjustment to the situation, or new normal, were the memorable moments where practitioners said or did things that positively impacted the participants’ EPL experience. Participants’ stories indicate women benefit from telling stories of early pregnancy loss. The stories remain present long beyond the loss occurrence, highlighting the potential need for more discussions to occur both with women recently experiencing early pregnancy loss and women carrying the secret motherhood story years beyond the occurrence. Understanding “time heals…it doesn’t erase” may warrant further investigation of stories from women experiencing early pregnancy loss and the need to provide discussion with an avid, empathic listener. Women may benefit from anchoring conversations whether the loss occurred recently or long ago

Impact of a multi-level intervention on facility-based births and skilled birth attendance in Kalomo District, Zambia: a mixed-methods evaluation

Problem: Zambia has one of the highest maternal mortality ratios in the world. Risks of serious complications during childbirth and associated maternal morbidity and mortality can be mitigated by improving access to skilled birth attendants and emergency obstetric and newborn care (EmONC) in facilities when complications arise. In 2012, the Saving Mothers Giving Life (SMGL) initiative was launched in Kalomo District, Zambia, to reduce maternal deaths. Methods: This study assessed the impact of SMGL in Kalomo District on rates of facility delivery, delivery with a skilled birth attendant, and facility-level changes in the provision of maternity and newborn care during the first learning phase, 2012–2013. Changes in neonatal mortality were also assessed. A mixed-methods approach utilized a quasi-experimental pre-post nonequivalent comparison group design using household data (n=21,680 women) and health facility assessments (n=77) including EmONC signal functions. Data were collected from February 2011–October 2013, before and during SMGL program implementation, in the intervention district and a comparison area. A qualitative inquiry with key informants (n=26) was then conducted in September 2014. Results: There was a 49% relative increase in the odds of facility-based birth during SMGL in Kalomo relative to comparison districts (OR 1.49, 95% CI: 1.21–1.77), controlling for covariates. There was no significant change in delivery with a skilled birth attendant. Newborn mortality in Kalomo decreased significantly (4.3% to 2.6%, p<0.01), even when controlling for covariates, with no change in comparison. EmONC signal functions increased from a mean of 2.7 to 3.9 (p=0.003) per facility in Kalomo, with no change in the comparison area. Most facility-level changes related to newborn care. Informants attributed impacts primarily to community mobilization by Safe Motherhood Action Group volunteers and clinical mentorship. Conclusion: SMGL positively influenced demand for facility deliveries. Data indicate a limited measurable change in supply-side indicators of provision of intra-partum maternity care, while improving neonatal survival. Interviews suggested that mentoring existing staff might be responsible for improved care and referrals. Phase 2 should focus on strengthening human resources to increase access to skilled delivery and strategies to improve communication and transport to facilitate timely referral of emergency cases

Days with Dignity: a new adult day services typology to support wellness and rehabilitation

Adult Day Services (ADS) facilities have been shown to enable aging in place through the cost-efficient delivery of senior health-related services. However, the most common ADS typologies often work in opposition to the goals of care delivery. The primary intention of this proposal is to envision an Adult Day Services program that is holistically focused on senior wellness and rehabilitation, and which is articulated and reinforced through facility design. A new programmatic and facility typology is proposed and evaluated against a set of design guidelines based on research findings and best practices found in a literature review. In addition, this study aims to achieve a more thorough understanding of the benefits and limitations of Adult Day Services to reveal health-related service goals that are most appropriate for the aging population. These findings would inform a design that could contribute to a more economical and appropriate delivery of long-term health and wellness care in contemporary society

An investigation into human biowaste management using microwave hydrothermal carbonization for sustainable sanitation

The prolonged challenges and dire consequences of poor sanitation, especially in developing economies, call for the exploration of new sustainable technologies. These need to be: capable of effectively treating human faecal wastes without any health or environmental impacts; scalable to address rapid increases in population and urbanization; capable of meeting environmental regulations and standards for faecal management; and competitive with existing strategies. Further and importantly, despite its noxiousness and pathogenic load, the chemical composition of human biowaste (HBW) indicates that it may be considered to be a potentially valuable, nutrient-rich renewable resource, rather than a problematic waste product. This doctoral study therefore investigated microwave hydrothermal carbonization (M-HTC) as a sanitation technology for processing HBW – to convert it into a safe, pathogen-free material, while also recovering inherent value and providing an economic base to sustain the technology. To this end, the products of M-HTC treatment of sewage sludge, human faecal sludge, synthetic faecal simulant and human faeces were characterized with a suite of techniques and tests to demonstrate pathogenic deactivation, and the intrinsic value of the resultant solid char and liquor. [Continues.