Melbourne School of Population and Global Health - Theses
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ItemThe epidemiology of pelvic inflammatory disease diagnosed in Australia( 2018)Pelvic inflammatory disease (PID) is a serious reproductive health issue for women that occurs when infection ascends from the lower to the upper genital tract. Possible sequalae include infertility, ectopic pregnancy and chronic pelvic pain. The sexually transmitted infections (STIs) Chlamydia trachomatis (chlamydia) and Neisseria gonorrhoeae (gonorrhoea) are commonly implicated, however the microbial aetiology is often unknown. PID diagnosis is imprecise due to its many possible clinical features and absence of an objective reliable non-invasive diagnostic test. As PID epidemiology varies between countries and population groups due to different STI prevalence and healthcare systems, country specific estimates are critical. This thesis aims to improve understanding of the epidemiology of PID diagnosed in Australia, particularly with reference to chlamydia infection as this is the most frequently diagnosed STI in Australia. Chapters 1 and 2 discuss the evidence and describe what is known about the aetiology and epidemiology and PID, providing the rationale for this PhD program of research. Chapter 3 involved an analysis of data for 15,690 women aged 16-49 attending a sexual health clinic, to examine the microbial characteristics of PID. At a population level, chlamydia was the more commonly identified microbial organism, with 8.2% (95% Confidence Interval (CI) 7.7, 8.6) of women chlamydia positive, 2.8% (95%CI 2.5, 3.0) diagnosed with PID, and, the adjusted population attributable fraction (aPAF) of PID associated with chlamydia was 14.1% (95%CI 9.9, 18.0). Among a subset (n=8,839) of women, 0.3% (95%CI 0.2, 0.5) were gonorrhoea positive only, 0.2% (95%CI 0.2, 0.4) were gonorrhoea and chlamydia positive, 4.7% (95%CI 4.3, 5.2) were diagnosed with PID, and the aPAF for gonorrhoea was 1%. There was a higher odds of PID for women with gonorrhoea or chlamydia (4.4-fold vs 3-fold, respectively) compared with no infection. A sub-analysis for asymptomatic women showed that 28% of PID was associated with chlamydia but only 0.6% of asymptomatic women were diagnosed with PID. Chapter 4 involved a separate comprehensive analysis of the same dataset as in Chapter 3, to investigate the characteristics of clinically diagnosed PID where no infection was identified (pathogen-negative PID). Among 330 women with PID who were tested for chlamydia, gonorrhoea, Mycoplasma genitalium and bacterial vaginosis, 62% had no infection diagnosed. Multivariable logistic regression showed that women with pathogen-negative PID were more likely to be aged >30 years (Adjusted Odds Ratio (AOR) 1.7, 95%CI 1.0, 3.0) and less likely to have evidence of vaginal inflammation (AOR 0.5, 95%CI 0.3, 0.9) or report recent unprotected sex (AOR 0.6, 95%CI 0.4, 1.0) than women with pathogen-positive PID. Chapter 5 investigated PID diagnosis characteristics and time trends at a large sexual health clinic, before and after clinical audit feedback. The study found that between 2002 and 2016, the yearly PID diagnosis rate increased from 0.8% (37/4836) to 2.9% (209/7088) and an increasing proportion of women reported any symptoms (35.7% to 56.6%) or were diagnosed with an STI or bacterial vaginosis (9.4% to 21.4%). Univariable generalised linear models showed PID rates increased after audit feedback in 2007 by 8% yearly (incidence rate ratio (IRR) 1.08, 95%CI 1.06, 1.11), but were unchanged (aIRR 1.01, 95%CI 0.98, 1.03) when patient characteristics were included in multivariable analysis. Since audit feedback, the clinic has reoriented services to increase capacity for high risk patients that appear to have had a greater impact on PID diagnosis rates than audit feedback. Chapter 6 estimated yearly (2009-2014) population rates of PID diagnosis using hospital admissions and emergency department data from three Australian states (Victoria, New South Wales, Queensland). Zero inflated Poisson regression models were used to examine variation in rates by year, age-group and residential area. In 2014 the overall PID rate per 100,000 women aged 15-44 years, was 63.3 (95%CI 60.8, 65.9) for admissions and 97.0 (95%CI 93.9, 100.2) for emergency department presentations. Comparing 2014 with 2009, the overall PID rate in admissions did not change, but when examined by type of PID, admission rates increased for chlamydial and/or gonorrhoeal PID (aIRR 1.73, 95%CI 1.31, 2.28) and unspecified PID (aIRR 1.09, 95%CI 1.00, 1.19) but declined for chronic PID (aIRR 0.83, 95%CI 0.73, 0.95). PID rates in emergency departments were higher (aIRR 1.34, 95%CI 1.24, 1.45) in 2014 than 2009 and substantially higher for women aged 15-24 (aIRR 2.78, 95%CI 2.62, 2.94) than 35-44 years. In conclusion, this thesis provided the first Australian estimates of the population level risk of PID associated with chlamydia and gonorrhoea. This new information based on the PAF suggests that eliminating chlamydia in a high prevalence population might only reduce PID by 14% and around 1% if gonorrhoea were eliminated. For low chlamydia prevalence populations, the PAF findings suggest that only a small number of PID cases might be avoided by widespread chlamydia screening. This thesis provided updated evidence for the frequency of PID pathogens in Australia, and, the many cases without an identified pathogen highlighted the need for non-invasive bio-markers for upper genital tract inflammation. In the absence of bio-markers the decision to commence PID treatment should continue to be based on clinical features and sexual risk. This thesis found that PID remains a substantial cause of attendances at sexual health clinics and hospitalisations for reproductive related health issues for women in Australia. Analyses of sexual health clinic data demonstrated the importance of adjustment for patient characteristics in interpreting time trends, and, investigation of hospital data showed how ecological analyses of data from health settings where women with PID are managed can be used to measure PID trends. Evidence was provided for an increase in PID diagnosed in Australian emergency departments that could reflect increasing PID incidence, shifting healthcare usage from primary care, or, inadequacies in PID diagnosis and management in primary care. Primary care data and systems to monitor PID incidence are needed to better understand PID epidemiology, healthcare usage, and the impact of chlamydia and STI control policies.
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ItemMarkers of midlife: interrogating health, illness and ageing in rural Australia( 2007-06)The aim of this thesis is to explore rural women’s midlife experiences and interrogate the roles of health, social and community factors in these. In the cultural imagination, midlife signifies the onset of ageing and is thus framed in a discourse of decline. For women, it is often considered in terms of menopause and the end of fecundity and fertility. I propose that women’s experience of midlife is much broader than this; instead, it is characterised by transformation in multiple domains and health status is important. I suggest that the continuity theory of ageing is useful when conceptualising the life course. The concept of habitus enables exploration of how identity is re/constructed during the ageing process in response to changing bodily circumstances, such as health problems. (For complete abstract open document)
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ItemPleasure and poison: the meanings and practices of alcohol use in women's everyday lives( 1997-04)Within Australia, research on women and alcohol has been predominantly focussed on either large scale surveys of women’s consumption or on alcohol problems studies within treatment populations. Such research mainly draws upon the biomedical understandings of the body and the disease model of alcoholism. In contrast, this study examines the meanings and practices of alcohol use within the social contexts of women’s everyday lives. Alcohol is viewed as a part of life rather than as an excess or problem.
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ItemTo have or not to have?: Australian women's childbearing desires, outcomes and expectations( 2010)Although Australia’s fertility rate has recently increased it has been below replacement level since the mid 1970s. There are widespread perceptions that Australia’s fertility rate is too low mainly due to concerns regarding the social and economic implications of low fertility for Australia’s future prosperity. Yet the factors which contribute to Australian women’s childbearing outcomes are not fully understood, and it is not well known whether the low fertility rate is a deliberate or unintended consequence of women’s childbearing behaviour. There have been several investigations into the factors which are salient in Australian women’s childbearing outcomes. A limited number of individual explanatory factors have been identified including women’s level of education, labour force participation, marital status and age. Existing theoretical explanations of fertility decision-making tend to view childbearing as a rational, voluntary process and focus on the ‘costs’ to women of having children. Although this may help explain why women do not have children, it contributes very little to understanding why women do have children. The aims of this study were: to explore the relative importance of a range of psychosocial factors (including attitudes toward women and motherhood, the influence of women’s partners’ fertility preferences and behaviours, women’s education debts, and housing conditions) and women’s health status to women’s childbearing outcomes; to determine any differences in the contributory factors and their relative importance by parity; and to identify women’s childbearing desires and expectations. The study used a cross-sectional survey design in a population based sample of Australian women currently of childbearing age. The sample was drawn from women aged 30-34 years living in Victoria, one Australian state, in 2005 randomly selected from the Australian Electoral Roll by the Australian Electoral Commission. Participation involved the completion of a study specific anonymous self administered postal questionnaire. The questionnaire assessed participants’ sociodemographic characteristics; attitudes toward women and motherhood; previous childbearing experiences, current and future childbearing desires, and future childbearing expectations; the importance of a variety of psychosocial and health factors in childbearing outcomes; and past and present health status. 569 women (47%) completed and returned questionnaires, which is high for an unsolicited postal survey. The participants were broadly representative of women of the same age in the general population. Most participants wanted children and were mothers, and voluntary childlessness was very uncommon. Multiple, complex and interrelated biological, psychological and social factors such as adverse health conditions, attitudes toward women and motherhood, an interest in being a mother, lack of a partner, education debts and housing affordability were associated with women’s childbearing outcomes. The factors and their relative importance varied by parity. Many of the reasons participants identified as salient to their childbearing outcomes were actually obstacles or constraints which prevented them from achieving their childbearing desires. The results indicate that women often have fewer children than they actually desire and many would have (more) children if their circumstances were different. It appears that it is not the ‘costs’ of children that are important in women’s childbearing outcomes but the necessity for women’s circumstances to be optimal before they will consider having (more) children. An innovative conceptual framework highlighting the importance of women’s circumstances in their childbearing behaviour was developed as a result of the findings. The results challenge prevailing views that women’s childbearing outcomes are mostly voluntary, and based mainly on financial or career considerations. The findings have implications for theoretical explanations of fertility decision-making, and policies which aim to address the fertility rate and women’s childbearing behaviour suggesting that such policies need to address the barriers women face in family formation.
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ItemWe're safe and happy already: traditional birth attendants and safe motherhood in a Cambodian rural commune( 2002)The central concern of this study is the social, cultural and political position of traditional birth attendants (TBA), known as yiey maap (grandmother midwives) in Chup Commune (pseudonym). In particular, this study explores strategies yiey maap use to negotiate or bypass Western model health services in an attempt to maintain their personal integrity and cultural capital as birth attendants, and to ensure the physical, emotional, economic and cultural safety of the woman they care for. This thesis explores traditional maternity knowledges and practices using ethnographic methods to investigate the central issues, concerns and barriers confronting rural woman as they make choices to adapt, resist or negotiate Western maternity care. It is vital to consider historical, political, cultural and economic factors that influence women's decisions in order to understand how and why women hold onto or surrender their traditional childbirth knowledges and practices, including the preservation of yiey maap, their favoured birth attendant. Safe Motherhood initiatives were introduced into resource-poor countries by the World Health Organization in 1987 with the goal of reducing maternal mortality rates. They were based on the premise that pregnancy, childbirth and postpartum care were safer when provided by skilled birth attendants in a modern health facility. TBAs were not considered skilled birth attendants by Safe Motherhood partner agencies, as training and utilizing TBAs in Safe Motherhood initiatives did not have a measurable impact on maternal mortality rates. Instead, TBAs' roles have been recast, and TBAs are expected to be health promoters and educators, referral agents and information gatherers. I argue that Khmer women do not engage with the modern health system because it is unfamiliar and expensive, and health personnel provide poor quality care. Instead, in times of obstetric emergencies, women attempt to negotiate their own and their family's safety through personal autonomy and agency. I conclude by proposing alternative approaches and strategies, including the increased utilisation of yiey maap in Cambodian Safe Motherhood programs. A central question is whether the Ministry of Health, supported by bilateral and multilateral agencies, should train and utilize yiey maap or midwives in maternity care. I argue that both are of equal importance. Until yiey maap are valued for their contribution to, and enjoy equitable inclusion in midwifery care, initiatives that involve yiey maap as program "extras", who undertake peripheral tasks, will not reduce maternal mortality rates.