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Background and aim: Globally there are two million stillbirths annually, 98% of which occur in low-income settings (LICs). Although the majority of data exist in high-income countries (HICs). Stillbirth may be associated with the maternal perception of reduced fetal movements (RFM) in LICs. However, little is known about maternal experiences of RFM and subsequent engagement with health services in LICs. Zimbabwe has a high stillbirth rate of 21/1 000 births. The study aimed to explore views and experiences of pregnant women, partners, and clinicians of RFM in Zimbabwe, and to develop a theory to influence practice, education, policy, and research in maternity care. Methodology and methods: A qualitative study informed by the constructivist grounded theory methodology was conducted. Data were collected using in-depth interviews from fifteen women, three partners, and ten clinicians. A total of ten non-participant observations were conducted through observing clinicians as they attended to women and partners. Data analysis followed the constant comparative analysis by Charmaz. Results: Three major categories were found. The first category, 'Fetal movements as a unique experience' comprised three subcategories, 'Communicating through fetal movements' 'Learning individual normal patterns and recognising abnormal patterns', and 'Catalyst to family bonding'. The second category, 'Factors that impact on RFM' comprised two subcategories, 'Socio-cultural factors' and 'Knowledge of RFM'. The third category, 'Support rendered for RFM' comprised two subcategories, 'Inconsistent health care' and 'Influence of family support'. The Core category 'Being interactive' underpinned the three major categories. The grounded theory combined elements of the Health Belief Model and Ecological Systems model to help understand the women's health-seeking behaviour for RFM. Conclusion: RFM is a concerning symptom and needs to be treated promptly. Women need to be encouraged to listen to their instincts when perceiving RFM and to seek health care early to avoid unnecessary delays. In Zimbabwe, there is a need for formulating national and local practice guidelines to standardise care for women to avoid management inconsistencies. The Ministry of Health and Child Care should institute a policy for immediate investigating and management of a woman with RFM to reduce perinatal mortality and morbidity. Further qualitative research should be conducted in various high and low-resource maternity settings to substantiate the findings.

Background: Mother-to-child transmission of HIV (MTCT) remains the primary source of HIV infection in children. With the use of prevention of mother-to-child transmission (PMTCT), the risk of HIV transmission can be reduced to 5%. Option B+ is a PMTCT intervention that initiates all HIV positive pregnant and breastfeeding mothers on a lifelong antiretroviral therapy (ART) regardless of their clinical staging. Despite Option B+ contributing significantly to the reduction of new HIV infection in children, disengagement in Option B+ is a major challenge. Literature reveals that young mothers (13-24 years) are at an increased risk of disengagement in the Option B+ programme. The thesis reports findings of a study that sought to construct an understanding of the processes disenabling young mothers to engage in Option B+ in Malawi. Method: Intensive interviews were conducted with ten young mothers who disengaged from option B+, nine young mothers who were still practising PMTCT, eight spouses to disengaged young mothers, one family member and seven health workers between November 2018 to August 2019. Additionally, ten non-participant observations were carried out in antenatal and ART clinics. A constant comparison method was used to construct an understanding of the psycho-social processes that disenabled young mothers to engage in the programme. Data analysis followed the Constructivist grounded theory analysis, which included initial coding, focused coding and theoretical coding. Findings: Aided by memo writing, theoretical sampling, theoretical saturation and theoretical sensitivity, a core category - the journey towards reconciliation following HIV diagnosis among young mothers - was constructed. The core category consisted of three main categories, including learning about HIV, reacting and acting and adapting and adjusting. The core category represented a change process that young mothers enacted as they went through the different stages to reach the reconciliation stage. The findings indicate that disengaging from option B+ among young mothers does not entail a refusal of treatment; rather, it is a response to their social world following their HIV diagnosis. The first category provided an explanation of the processes young mother are exposed to as they learn more regarding their diagnosis. Reacting and acting, represents the psycho-social and cognitive responses young mothers engage in due to their exposure to the intrinsic and extrinsic social-economic challenge associated with living with HIV. The third category reflects the processes that enable young mothers to come to terms with their diagnosis cognitively; hence, preparing themselves for lifelong engagement. Conclusion: The study demonstrates that young HIV positive mothers have the potential of maintaining PMTCT engagement when they have successfully reconciled with their HIV diagnosis. Early identification of HIV positive young mothers, provision of age-appropriate sexual and reproductive health education, psycho-social support, empowerment activities and stigma mitigating activities are critical considerations when designing HIV tailored programs for young mothers.

Background. Breastfeeding has many health benefits for mothers and their infants. In particular, breastfeeding can reduce the risk of obesity and obesity-related diseases. As women with a BMI BMI ≥ 30kg/m² and their infants are at an increased risk of these conditions, breastfeeding can offer substantial benefits to this population's health and well-being. Reports of breastfeeding behaviours show a consistent, global trend of lower rates in women with a BMI ≥ 30kg/m² when compared to their healthy-weight counterparts (BMI 18-25kg/m2). Few interventions have been designed to support women with a BMI ≥ 30kg/m² to plan or begin and continue breastfeeding, and the majority have been unsuccessful; this may be because psychological factors have yet to be considered and addressed. Therefore, this programme of research aimed to utilise evidence and theory to design and assess the acceptability of a psychological intervention to increase breastfeeding initiation and duration in women with a BMI ≥ 30kg/m² who intended to breastfeed. A Patient and Public Involvement (PPI) group of women with a BMI ≥ 30kg/m² was established and consulted at all stages. Methods. Four studies were conducted. The first two studies performed separate systematic searches to identify relevant quantitative and qualitative studies which had investigated the influence of psychological factors on breastfeeding behaviours in women with a BMI ≥ 30kg/m². A narrative analysis (quantitative studies) and meta-ethnography (qualitative studies) was conducted. A third study used deductive thematic analysis to further investigate the influence of psychological factors on breastfeeding in women with a BMI ≥ 30kg/m² in previously collected qualitative interview data. Qualitative interviews were conducted to assess its acceptability in a fourth study. Findings. The first study found 16 psychological factors had been investigated, and that five were associated with breastfeeding. The second found that women with a BMI ≥ 30kg/m² experience common breastfeeding difficulties to a greater degree because of their weight. Both reviews highlighted psychological factors which had potential for intervention development, but firm conclusions could not be drawn due to the relative paucity of research in this area. The third study found that all psychological factors were part of breastfeeding experiences in women with a BMI ≥ 30kg/m². The findings of all three studies were presented to a stakeholder meeting of health professionals and PPI group members, consensus was gained on the intervention content, format and delivery. Both psychological theory and behaviour change techniques were applied to create 'The Breastfeeding Workbook'. The fourth study findings suggest the intervention was acceptable to women with a BMI ≥ 30kg/m² and showed promise for increasing initiation and duration. Conclusions. The key message from this research is that psychological factors have an important influence on breastfeeding behaviours in women with a BMI ≥ 30kg/m², and can be targeted acceptably in an intervention to support initiation and duration. Increasing psychological factors in this way and incorporating the recommendations into current care should improve breastfeeding behaviours in women with a BMI ≥ 30kg/m², and ultimately the health of these women and their infants.

Background: Wireless fetal heart rate monitoring (telemetry) is increasingly being used by maternity units in the UK. Guidelines from the National Institute for Health and Care and Excellence recommend that telemetry is offered to any woman who needs continuous monitoring of the fetal heart in labour. There is no contemporary evidence on the use of telemetry in the UK. Aims: To gather in-depth knowledge about the experiences of women and midwives using telemetry to monitor the fetal heart in labour and to assess any impact that the use of telemetry may have on clinical outcomes, mobility in labour or control and satisfaction. Study design: A convergent parallel mixed methods design was chosen. Methods: Qualitative methods included in-depth interviews with 10 women, 2 partners, 12 midwives and one student midwife from two NHS Trusts in the Northwest of England. A constructivist grounded theory methodology was employed for this phase and used both purposive and theoretical sampling. All interviews were audio-recorded and transcribed verbatim. The quantitative phase recruited 161 women from both sites and compared clinical outcome and mobility data from 74 women who used telemetry during labour and 87 women who had conventional wired monitoring. Women also were asked to complete a questionnaire in the postnatal period on control and satisfaction during labour and birth. Questionnaire data was analysed from 128 women, 64 who used telemetry and 64 who had conventional wired monitoring. Both sets of data were integrated to give an overall broad understanding of telemetry use. Findings: The grounded theory core category was 'Telemetry: A Sense of Normality' and was described by three sub-categories. 'Being Free' described women being more mobile when using telemetry in labour and experiencing greater feelings of control, normality, and support. Telemetry also increased dignity for women as they were able to use the bathroom independently and with ease. 'Enabling and facilitating' described midwives facilitating the use of telemetry, encouraging mobility and using midwifery skills including caring for women in a birth pool. 'Culture and Change' described the different maternity unit cultures and how this impacted on the use of telemetry. Telemetry was viewed as increasing choice and equity for women with more complex pregnancies. Within the quantitative phase there was no difference in the aggregate scores for either the Perceived Control in Childbirth (PCCh) scale or the Satisfaction with Childbirth (SWCh) scale. Sub-group analysis found that women who used telemetry for the majority of the time the fetus was continuously monitored in labour scored a higher aggregate score for perceived control during labour (mean ± SD; 5.3 ±0.8 telemetry vs. 4.9 ± 0.9 wired, p = 0.047). Mobility data found that women using telemetry spent more time off the bed in labour and adopted more upright positions for birth. Conclusions: Both qualitative and quantitative findings confirmed that women were more mobile in labour when using telemetry to monitor the fetal heart and integrated findings also found that telemetry increased feelings of control in labour. The use of telemetry had a positive impact on women who required continuous monitoring in labour and engendered a sense of normality for both women and midwives. The use of telemetry contributes to humanising birth for women requiring more complex care in labour and birth.

Background and Aim: According to the Ministry of Health (MOH) in Oman, 92.1% of women initiate exclusive breastfeeding at birth but this rate reduces sharply to 10.2% when the baby reaches six months of age (MOH, 2016). This decline in breastfeeding suggests a need to explore the breastfeeding experience of Omani women. The aim of this study was to explore women's experiences of exclusive breastfeeding in Oman. Methodology and Methods: An exploratory qualitative design, informed by constructivist grounded theory principles. This study included 11 postnatal women, 5 family members of the same women participants and 7 healthcare professionals. Initially, five women were recruited through purposive sampling and participated in semi-structured interviews. In total, 69 semi-structured interviews and 15 observations were used for all participants in this study. Theoretical sampling was applied when categories appeared during the analysis of the data. A constructivist grounded theory analytical structure of initial, focused and theoretical coding was undertaken to analyse the data gathered. Findings and Discussion: The core category, 'Navigating the Reality of Breastfeeding' developed from the three main categories; namely, breastfeeding expectations, breastfeeding support and breastfeeding journey. The core category reflects the concept of women undertaking the process of breastfeeding with uncertainty because they did not know how to deal with breastfeeding difficulties. The women in the study did not know what to expect when breastfeeding. Navigating the unknowns with uncertainty feeling made the women's experience with breastfeeding difficult. Women recognised that they had unrealistic expectations, lacked the practical components of breastfeeding, did not have theoretical knowledge of breastfeeding challenges and their management and very little support. These unknowns regarding the reality of breastfeeding made the women feel confused, upset, frustrated, disappointed and stressed, which led them to stop breastfeeding. However, three women were able to breastfeed. The core category was central to the emergent theory: 'Resilience: The Power to Breastfeed'. The Theory suggests that women's ability to breastfeed depended on their resilience. The three women continued breastfeeding by using adaptive and problem-solving strategies, gaining knowledge quickly, and learning from their difficulties and experiences. The three women continued breastfeeding until the end of the data collection period (which lasted four months). Conclusion: The findings of this study demonstrated that women's ability to breastfeed depends on their resilience in adapting to breastfeeding difficulties. This study aids understanding of the social processes involved in exclusive breastfeeding. The findings could help in informing plans or programmes for improving the breastfeeding rate in Oman.

Background: Globally, pregnancy among the young/adolescent women is a growing public health issue of concern. This group of women are often socially and economically disadvantaged due to their age and low status, including low level of education. Most young/adolescent women (and/or mothers) are less likely to attend the recommended antenatal and/or postnatal visits. Consequently, this puts them and their babies/infants at a considerable health risk. Evidence suggests that adolescent mothers have exhibited lower self-esteem and more depressive symptoms, including low breastfeeding and general self-efficacy compared to older mothers. Trials and systematic review evidence on telephone support intervention (TSI), however, suggest a promising opportunity to offer supportive maternity care. Aim(s): To explore the feasibility of conducting a main trial comparing telephone support versus no support for young mothers in improving maternal physical, psychological and social wellbeing during the immediate postnatal period. Methods: A pilot randomised-controlled trial of a telephone support intervention was conducted between October 2016 and August 2017 using a mixed-methods approach. A sample of 52 young mothers (12-19years) were recruited in two referral hospitals and randomised into intervention and usual care groups, with n=43 retained in the pilot trial and analysed. The usual care group received standard postnatal care while the intervention group received an additional telephone support (weekly SMS, and telephone call after every 3 weeks) for 10 weeks postpartum. Descriptive statistics were used to analyse data (mean, median, 95%CIs), including Chi-square test, Independent- samples t-test and Mann-Whitney U test. Results: Mothers who received telephone-support appeared to have higher maternal self-esteem (median=25 vs 22, 95%CI for difference in median=0.001 to 4.00), with moderate effect-size=0.54; and less infant-related anxiety (median=1.50 vs 4.00, 95%CI for difference in median= -3.00 to 1.00) respectively; and were less likely to report: being ill (22.7% vs 71.4%, 95%CI=-0.68 to -0.19); experiencing difficulty in breastfeeding (9.1% vs 38.1%, 95%CI=-0.51 to -0.03); and initiating early-weaning (22.7% vs 52.4%, 95%CI=-0.53 to -0.009). The results should, however, be interpreted with caution as this small pilot was not powered for significance. Qualitative results highlighted five main themes: social support needs for young mothers; maternal role modelling in maternal role transition and attainment; social support systems available to young mothers after birth; the (perceived) role of TSI; and the feasibility and acceptability of TSI among young mothers and midwives. Overall, the results suggest that TSI is feasible and acceptable among young/teenage mothers and health care providers (midwives) in Kenya. Discussion: Young/teenage mothers in LMICs settings such as Kenya still lack knowledge and maternal competence as they transit to motherhood. Thus, it is important to understand the social support needs for such a group of mothers so as to meaningfully and effectively meet their needs, including the social support systems available to them. Moreover, innovative/novel strategies such as TSI may provide opportunities for addressing the gaps in maternal and infant care practices in such settings. Conclusions: This pilot trial suggests that it is possible to recruit young/teenage mothers in LMICs such as Kenya for main trials. TSI appears helpful and acceptable to both midwives (and other service providers) and young mothers.

Background: The importance of family planning methods in averting unwanted pregnancies has been acknowledged in Malawi. However, Malawi has registered the highest rates of maternal mortality in sub-Saharan Africa. There is a high unmet need for family planning as well as a low contraceptive prevalence rate. Only 41 percent of women aged 15-49 have used contraception, with substantial differences in use across the different districts of the country. There are knowledge gaps regarding experiences of women, men and healthcare workers for use and non-use of family planning methods in Malawi. Aim: This study aimed to gain an understanding of the experiences of women, men and healthcare workers accessing family planning services in Malawi. Methodology and Methods: A qualitative approach informed by grounded theory methodology (Strauss and Corbin, 1998) was used in this study. The study was conducted at Lumbadzi, Area 25 and Area 18 health centres in Lilongwe district of Malawi from November 2017 to August 2018. Purposive, snowball and theoretical sampling approaches were used to recruit participants. Data were collected using semi-structured in-depth interviews with 20 women, 10 healthcare workers and 10 men. Ten non-participant observations of family planning clinic consultations were conducted. Interviews, field notes and memos were analysed using constant comparative analysis. Methods of open, axial and selective coding were utilised until saturation occurred. Findings: The core category describes women's, men's and healthcare workers' experiences of family planning use and non-use in Malawi: 'Disenabling environment prevents women's family planning needs from being met'. The disenabling environment contributed to shaping women's family planning experiences. The core category was supported by three main categories: 'navigating the processes', 'disempowerment of women' and 'learning by chance'. These major categories represent the complexities that women go through to use or not to use contraception. Access to contraception use was influenced by personal beliefs and motivations, procedures to follow and inadequate resources. Women were disempowered from using contraception due to societal demands and cultural influences. Conclusion: This study offers insights into how women, men and healthcare workers experience family planning use and non-use in Malawi. A multifaceted strategy is required to support a woman's family planning needs. At community level, awareness and education of family planning methods is required to actively inform all people in society so that they support a woman's family planning needs. At national level, laws that would empower women with decision-making ought to be enforced. Furthermore, the study proposes building the capacity of healthcare workers to be able to provide all contraceptive methods available at health centre level. Moreover, there is need for the commitment of the government on budgetary allocation to ensure that family planning resources are readily available at the health centres.

Background: A vesico vaginal fistula (VVF) is an abnormal communication between two epithelial surfaces. In VVF, an abnormal communication may develop between the urinary system and the reproductive system of a woman. Prolonged labour is a major cause of fistula in women: however, fistulas may be caused by rape, malignancies and as a traumatic outcome in abdominal surgeries. The cardinal sign of VVF is continuous urine leakage with offensive smell. Often, these patients are stigmatised and depressed. Objective: The main objectives of the study were to establish predictors of fistula healing and to gain understanding of the first-hand experience of women before and after repair of a vaginal fistula. Design: A mixed method study which employed quantitative and qualitative data collection approaches. Consecutive sampling was used to recruit participants for the quantitative component. A standard tool was developed, pilot tested and used to collect demographic and fistula characteristics. Quantitative data was managed using IBM SPSS and analysed using descriptive and inferential statistics. Purposeful sampling was used to select participants' for in-depth interviews. In-depth guide used to guide interviews. All interviews were recorded and transcribed per verbatim. Aanalysis was done in thematic themes. Results: A total of 1224 women with a confirmed diagnosis of fistula were recruited over a three year period, in East Africa. In all of the countries, literacy levels were low. Overall, most women had only been educated to primary school level 62.9%, 17.0% had no education. Only 4.8% women had been educated to college level or higher and all were from Kenya. Most women were unemployed varying from 92.1% for DR Congo and 76.1% for Southern Sudan 76.1%, to 13.5% for Rwanda and 13.2% for Uganda. The mean fistula size was 2.15 cm in diameter, with most fistulas measuring 1-2 cm from the external urethral orifice (EUO) or urethral meatus. At the time of joining the study, 22.4% of women had undergone a previous surgery to repair the fistula and lived with urine leakage for up to twelve months. Vaginal stenosis/scarring were very common (72.4%). There were few combined fistulas (VVF/RVF) (3.0%). The mean success rate of surgery was 94.1%.Sixteen women were interviewed for the qualitative component of study. Two main themes representing the women's journeys emerged: from social isolation to social reintegration. Women felt euphoric following fistula repair, believing that a ‘miracle' had occurred. However, the 'post-miracle component' demonstrated that the social and psychological impact of fistula leaves scars that are not easily healed, even when fistula repair is successful. Conclusion: Fistula surgery alone is not adequate in restoring women's health. The impact of fistula in women's lives is felt far beyond the surgical period. These findings point to the urgent need for researchers to conduct psychological assessment in the management of women with fistula and design community based programs aimed at social integration and women empowerment.

Background: The World Health Organization (WHO) acknowledges childbirth as a normal physiological process that does not require unnecessary interventions by maternity care providers. However, some maternity settings in Bahrain still continue to intervene during labour and childbirth while providing care to low-risk women. This approach contradicts the WHO's initiatives in implementing Evidence-Based Practices (EBP) of intrapartum care. Aim: to gain an understanding of intrapartum practices in Bahrain. Methods and methodology: A convergent parallel mixed-methods design was used in the study, conducted in two maternity units of governmental and University-affiliated hospitals in Bahrain. Quantitative data were collected by auditing retrospective birth records and a questionnaire on the intrapartum care of 228 postpartum women. Qualitative data were collected using purposive and theoretical sampling guided by grounded theory through 20 semi-structured interviews with maternity care providers and women and six non-participant observations of care providers' practices during labour. Descriptive and inferential statistical analyses were applied for quantitative data using IBM SPSS Statistics 23. Qualitative data were analysed by constant comparative analysis using Microsoft Word 2016. Findings: Integrated findings revealed that current intrapartum practices in the two maternity units in Bahrain contradicted the recommendations of EBP in certain aspects of intrapartum care. There was a routine use of continuous Electronic Fetal Monitoring (EFM) (93.4%), limited fluid intake during labour (77.2%), discouragement of mobility during labour (76.3%), routine vaginal examinations (65.8%) and lack of companionship presence at labour and birth (64.9%). Qualitative findings provided an in-depth understanding about the intrapartum practices in the two settings. The core category 'women as recipient of care' which includes three major categories 'experiencing childbirth', 'knowing the context of childbirth care' and 'moving toward EBP' emerged from qualitative data analysis. Qualitative findings explored the positive attitude of maternity care providers to some intrapartum practices such as the commitment to use the partograph, encouragement of skin-to-skin contact, provision of privacy and midwives' empathetic support. The integrated study findings contributed to the development of a theoretical model: 'Labouring women-from recipients to participants', drawing a path to move current intrapartum care in Bahrain toward women's active participation and involvement in care through adopting the recommendations of EBP. Conclusion: This study offers insights about how low-risk labouring women experience childbirth in maternity settings in Bahrain. Study findings suggest an urgent need to move intrapartum practices in Bahrain towards consistency with the WHO's recommendations for safe childbirth care. Maternity care providers should pay attention to the practices used routinely during labour. Policymakers need to consider the development of a unit policy that acts as a reference for midwives, updating the existing guidelines to align with Evidence based recommendations for care during labour and birth.

Introduction and aim: In Zimbabwe, a one-year midwifery-training programme, based on a competency-based curriculum, aims to develop essential competencies for midwifery clinical practice and sound professional judgement, as required by the International Confederation of Midwives (ICM) Global Standards for Midwifery Education. This study aimed to explore midwives’ preparation for practice to the level defined by ICM core competencies in Zimbabwe. Methods: A critical realist mixed-method study included an exploratory correlational approach for the quantitative phase and classical grounded theory for the qualitative phase. In the quantitative phase, complete sampling was used to recruit a cohort of 85 midwives from three midwifery schools (School A, School C and School B; recruitment rate 53.8%) before they received the results of their state final examinations. Confidence and competence data were collected from participants, their ward supervisors/senior midwives, peers and clinical instructors using a 360° assessment tool developed for the study, based on one currently used for assessment at the participating schools. This consisted of a checklist of 20 ICM competencies each scored as a rating scale from 0-10 in six areas of midwifery care. Data were collected at initial recruitment, after the participants had received their examination results and after three months of clinical practice, with 58 from School A and School C providing data at the final time point (68.2% retention rate). The qualitative study used in-depth interviews to explore the knowledge views and practices of midwives regarding ICM core competencies, using theoretical sampling to recruit 36 participants (21 newly qualified midwives, 4 tutors, 5 ward supervisors, 3 clinical instructors, and 3 acting clinical instructors) from School A and School C until data saturation was reached. Data analysis: IBM SPSS Statistics 22 was used to analyse quantitative data. Cronbach’s alpha was used to estimate the internal consistency of subscales and the overall scale of the 360° assessment tool. Most analyses were descriptive, and Pearson’s chi-square, Fisher’s exact and the Mann-Whitney U test was used to compare data by school. Kendall’s correlation and multiple linear regressions were used to explore which variables were associated with total confidence and competence scores. Constant comparative analysis was used on the qualitative data to develop categories to build a grounded theory of social processes facilitating or hindering competence and confidence development in midwives. Results: The 360° assessment tool was reliable although some assessors appeared not to have observed the participant performing an episiotomy or resuscitating a new born. Participants’ confidence scores were generally higher than their assessors’ competence scores. Confidence and competence scores at School C generally increased over time, but confidence scores at School A fell after the midwives had spent three months in clinical practice. The number completing the quantitative phase limited the generalisability and precision of the multiple regressions but the main predictor of confidence and competence was school. The qualitative phase explained the difference between schools in terms of school policies, the way facilitators planned and organised clinical settings to facilitate student learning, and facilitator characteristics. Students at School A were allowed to pass assessments without reaching the required standard while those at School C were marked more harshly, but were subsequently appreciative of this approach, recognising its necessity for competence development. Following transduction, a Competence and Confidence Development Model was proposed to explain how the dualistic nature of an individual and their confidence and competence were related via a student learning typology combining individualism-collectivism and rate of learning with six phases of skill acquisition. Conclusions: Midwifery schools in Zimbabwe must consider policies, the training environment, student learning styles and the teaching processes required for students to acquire the clinical skills and theoretical knowledge necessary to become competent qualified practitioners.

Background: Fear of birth (FOB) is becoming increasingly recognised as a clinical issue that can have profound effects on the mother and her experience of pregnancy and birth. Failure to identify women with FOB could potentially lead to them feeling isolated and unsupported, and impact on their psychological health and the health of their baby. Aim: The main aim of this study was to gain an understanding of FOB and the associated impact on health professional practice, clinical outcomes and women's experiences of birth. The objectives were to: identify the most effective way of measuring FOB in clinical practice; investigate the most appropriate antenatal intervention to support women who fear childbirth; inform the study design for an RCT to assess the effectiveness of the intervention; and assess the most meaningful outcomes to include in future work. Methods: An explanatory mixed-methods study design was used. The first phase was a two-part online survey sent to Heads of Midwifery at 202 maternity units in the UK via Survey Monkey. Respondents were asked to give details of their unit in part 1 and service provision and evaluation for women with FOB in part 2. The second phase was a prospective cohort study of 148 women who had not experienced childbirth who were consecutively attending the Elisabeth Garrett Anderson and Obstetric Hospital, London or St Mary's Hospital, Manchester. Demographic data and details of sources of information on pregnancy were collected from participants in the first trimester along with their score on the tool chosen to measure FOB, the Fear Of Birth Scale (FOBS), and a saliva sample to measure cortisol level. In the third trimester, a second FOBS score and saliva sample were collected, and the Personal Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) were administered to measure depression and anxiety respectively. Birth outcomes for the participants were collected from clinical records. In the third phase, 15 women participating in the second phase were purposively selected to reflect a range of FOBS scores and interviewed by telephone using a semi-structured interview to find out their experiences of pregnancy, being part of the study and service provision. Results: Response rates for the online survey were 63% for part 1 and 54% for part 2. Consultant obstetricians 25% had the most involvement in the care of women with FOB, followed by consultant midwives 21% and 30% had a designated midwife for dealing with FOB and only 32% provided specialist midwifery-led services for women with FOB, with 16% referring to a consultant obstetrician and 47% providing no specialist provision. No unit provided an evaluation of their services, although 19% had undertaken local audits. In the cohort study, using a cut-off of 54 for the FOBS, 30/148 (20%) had a FOB in the first trimester while 21/80 (26%) had a FOB in the third trimester. Compared with the first trimester, 51/80 women showed an increase in FOBS score, with 14 gaining and 7 losing a FOB. FOBS scores were not correlated with salivary cortisol in either trimester but they were correlated with PQH-9 and GAD-7 scores in the third trimester. They were also associated with a previous history of depression but only in the first trimester (p=0.011). FOBS scores showed considerable variability and a high measurement error, indicating a need for further refinement and psychometric testing. The qualitative interviews identified three themes underlying FOB: fearing the worst (pain, fear for the baby and fear of the unknown and complications), pathways to fear (friend-induced fear, mother-induced fear or reassurance and media-induced fear) and igniting or reducing fear (sources of information, support and communication). Conclusions: The FOBS is a potentially effective way of measuring FOB in clinical practice and research, but it requires enhancement informed by the themes identified by this study and psychometric testing in all three trimesters. An enhanced version of the FOBS could be used as the primary outcome to measure FOB during pregnancy in an RCT assessing the effectiveness of a suitable intervention, with the PHQ-9 and GAD-7 as secondary outcomes to measure depression and anxiety during pregnancy. An intervention to support primiparous women with FOB should be developed informed by the findings of this study, including components such as psychological education, relaxation, social support, reliable information sources and continuity of carer.

Background: Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide. For every woman that dies, 20 or 30 more will experience morbidity. Severe PPH is increasing and is the leading cause of severe maternal morbidity in the UK. Rapid recognition of PPH is essential, but concealed bleeding, underestimation of blood loss and a failure to appreciate the physiological effects of blood loss, lead to delays in recognition and treatment. Experts believe that most deaths from PPH could be avoided by earlier diagnosis, but there is a lack of evidence on how to achieve this. Aims: To explore the experiences of those involved in evaluating blood loss during childbirth; and to develop and test a theory of blood loss evaluation and PPH recognition, as a prerequisite to developing strategies to support earlier diagnosis. Study Design: A sequential, exploratory mixed methods design was used. Methods: Qualitative methods included 8 focus groups and 19 one-to-one semi-structured interviews, conducted with 50 participants. These included: women and their birth partners (recruited from Liverpool Women's Hospital); and health professionals (midwives and obstetricians recruited from Saint Mary's Hospital, Manchester). A purposive sampling strategy was used to recruit women, who had experienced vaginal birth with or without PPH, and health professionals, with varying levels of experience in blood loss evaluation and PPH management. A snowball sampling strategy was used to recruit the birth partners of women participants. Phase one was completed from June to September 2014. All discussions were audio-recorded and transcribed verbatim. Data were managed using NVivo 10 qualitative data analysis software, which also supported the Framework approach to analysis and interpretation. Quantitative methods were used in phase two and involved 10 midwives and 11 obstetricians, recruited from Liverpool Women's Hospital, during February and March 2015. Two scenarios, one of fast and one of slow blood loss, were presented to the sample using clinical simulation with the NOELLE® childbirth simulator, in a pilot, randomised, cross-over study. Participants also completed three questions about the use of the NOELLE® mannequin for these types of scenarios. IBM SPSS Statistics version 23 software was used for quantitative data management and to estimate descriptive statistics. Numerical crossover data were copied into StatsDirect software, to perform the crossover analyses. Results: Women and birth partners were very perceptive to blood loss but felt ill-prepared for the reality of bleeding, with many experiencing negative emotional responses to both PPH and the lochia. Non-verbal communication from staff was used by women and their birth partners to interpret the seriousness of their blood loss. Health professionals: Recognition of PPH mainly occurs as an automatic response to the speed of blood flow. Volume of blood loss is often ascertained and used retrospectively after a PPH diagnosis, to validate the intuitive response and to guide and justify on-going decisions. This was confirmed by the simulation studies, where treatment was initiated at 100ml or less in all blood loss scenarios. Fast blood loss was more likely than slow blood loss to elicit a PPH response, despite volumes in the two groups being similar. Formal quantification of blood loss is not used routinely in practice. When it is used, values are often unofficially normalised to reflect health professionals' perceptions of the woman's clinical condition. Tools introduced to aid diagnosis, such as blood collection bags, routine weighing and the use of early warning scores, are not routinely used in the immediate post-birth period, especially if the woman and her blood loss are perceived to be normal. The tools are again used to validate intuitive feelings about blood loss and maternal condition. When they are used, the values are often modified if they contradict professional judgement. Conclusions: Women and birth partners want more information, open communication, and on-going support, to minimise the emotional impact of blood loss. For health professionals, the speed of blood loss is the crucial factor in PPH recognition rather than an accurate assessment of the volume of blood loss. The amount of visible blood is generally not initially interpreted as a volume, but is used to compare current blood losses to those previously witnessed. Experience therefore plays a crucial role in the decisions of whether blood loss is considered normal or excessive. Formal quantification of blood loss and regular recording of physiological observations do not occur routinely in the immediate post-birth period. Therefore, women with insidious blood loss can have delayed PPH diagnosis because they have a normal blood flow and exhibit minimal physiological changes, due to the compensatory mechanisms of shock. Often such women need to exhibit outward signs of physiological compromise, such as fainting or feeling unwell, before their physiological observations and blood loss are formally re-evaluated. Education of health professionals should highlight the common errors of judgement made during blood loss evaluation and provide feedback on cases of delayed recognition. Future research should examine normal postnatal bleeding in the hours following birth, and create visual aids for women to self-diagnose insidious blood loss. Training should focus on the skills of PPH recognition, particularly those with insidious blood loss and postnatal physiological assessments. Novel tools such as the shock index should be considered and evaluated as tools of assessment.

Background: Breastfeeding is globally recognised as a gold standard of nutrition, recommended for the first six months of an infant’s life. Despite its benefits, most women in Ghana do not breastfeed, as recommended by World Health Organization (WHO) and United Nations International Children Emergency Fund (UNICEF). Aim: To gain in-depth understanding of first-time Ghanaian mother lived experience of breastfeeding. Design/Method: A longitudinal qualitative design was adopted, underpinned by the hermeneutic phenomenological approach, as described by van Manen (1990). The study explored the lived experiences of thirty first-time women recruited from antenatal clinic. A series of three semi-structured, in-depth interviews were conducted; the first in late pregnancy, the second in the first week following childbirth and the final one between four and six months postpartum. Findings: Inductive thematic analysis informed by van Manen (1990) and principles of hermeneutic interpretation allowed the emergence of four main themes: the ‘Breastfeeding Assumption,' Breastfeeding as Women’s Business,’ the Postnatal Experience of Breastfeeding and ‘Family as Enabler or Disabler’. Within the context of this study, breastfeeding is expressed as an activity within the family and social environment. The overall phenomenon that emerged was ‘Social Conformity’. This demonstrates an understanding of the breastfeeding experience suffused with emotions as women project an image of themselves as successful breast feeders in order to conform to family and social expectations. Conclusion: Findings from the study demonstrated the multifactorial dimensions of breastfeeding. Most importantly, it was identified that first-time breastfeeding women use emotion work to cope with their experience of breastfeeding, within the social context. It was suggested that midwives play a pivotal role in helping women develop realistic expectations prior to breastfeeding. Furthermore encouraging family centered education that promotes holistic support for women. The findings therefore suggested the need for better antenatal education based on evidence-based practice. Breastfeeding women require individualised support that assesses their emotional needs and offers encouragement. Developing policies that ensure training of midwives and breastfeeding advocates was recommended. Future research could explore the impact of these interventions on breastfeeding practices, helping first time women to breastfeed effectively.

Indonesia has one of the highest rates of maternal mortality in Southeast Asia. Community participation has been known to reduce maternal mortality in some areas in Indonesia. However, in Aceh Province, the prevalence remains higher than the general Indonesian maternal mortality rate. The aim of this research was to gain an understanding of pregnancy and childbirth experiences from multiple perspectives, in relation to the use of maternal health services in Aceh, Indonesia. The conceptual framework was based on the importance of community engagement in improving maternal health. A qualitative study design with a grounded theory approach was utilised. This approach was chosen in order to gain an understanding of the social processes and ways in which experiences of pregnancy and childbirth are related to maternal death incidents. The process inherent in the method enabled the emergence of important theoretical concepts. A theoretical sampling strategy was employed. The data collection used multiple methods that involved a series of in-depth interviews, observations and focus group discussions with women, family members, a village leader and health professionals. The sample size was determined by data saturation (19 women, 15 family members, 7 health professionals, 3 kaders, 4 student midwives and 1 village leader participated). Ethical approval was gained and the research setting was in the two villages of Aceh Besar District, Aceh Province, Indonesia. Data were coded and analysed by following a constant comparison process. The emergent core category, entitled “maternal death: the elephant in the room” explains the views of the community about maternal death incidents in the research setting. The research findings highlighted that despite the maternal mortality rate still being high in the region, maternal death was not focused upon, as a problem within the community. The research findings revealed that maternal mortality was a hidden problem within the community, and was related to inadequate maternity practices in the village. The core category “maternal death: the elephant in the room” was found to consist of four interrelated categories. The categories of the value of midwifery in the community, desicion-making of maternity care, social control of the childbearing and distancing of maternal deaths; explain maternity practices in the community. Understanding of social processes related to maternal health can assist in informing strategies to improve the quality of maternal healthcare in Aceh Indonesia.

Midwives recommend antenatal HIV testing in pregnancy for all women. However,limited information is available on the experience of testing HIV positive in pregnancy.This thesis explored women’s experiences of receiving a positive HIV test resultfollowing antenatal screening in United Kingdom (UK). Black Africa women have highlevels of HIV infection in the UK and notably all participants were African in origin.The theoretical basis for the study was hermeneutic phenomenology, proposed byHeidegger (1962) and further guided by van Manen (1990), exploring essence andmeaning of this lived experience. Thirteen women were recruited and participated in asemi-structured interview. Participants were recruited from two NHS sites, several HIVsupport organisations and a national advert, in order to obtain diversity of this livedexperience.The emergent phenomenon is transition and transformation of “being,” as womenintegrated HIV into their lives. As women transformed with the HIV diagnosis theybalanced major themes. The major themes consisted of shock and disbelief; anger andturmoil; loss of old self; stigma and confidentiality issues and acceptance and resilience.Primary and secondary themes included: extreme reaction on being given a diagnosiswith a cultural belief that they would die; disbelief as the result was unexpected;sadness and loss of their old self; turmoil wanting to terminate the pregnancy; isolationfrom significant others; breakdown of their relationship and considering suicide and selfharm. Most reported the pervasiveness of stigma, and how they managed both thisstigma and HIV in their lives; growing resilience was apparent with time. Copingstrategies included keeping HIV “secret” and their child or children becoming the primefocus of life, with less importance on self.This study gives midwives a unique understanding of the complexities for womentesting HIV positive and supports Bonanno (2009) and Kübler Ross’ (1969 & 2005)findings on personal loss. Additionally this study provides a unique insight into thephenomenon of transition and transformation for women who tested positive inpregnancy and explores the factors and impact of testing HIV positive. The impact of anHIV diagnosis is culturally difficult for African women and had major implications andchallenges for their future life. Midwives are crucial in supporting and improving theexperience of women when they test HIV positive.

Midwives are often the lead providers of maternity care for women. To provide the variety of care required by women, they need to be confident in their role and practice. To date, only limited evidence exists in relation to confidence as experienced by midwives. This thesis aims to explore the phenomena of confidence through the lived experience of midwives. In particular, this will encompass confidence in the context of the intrapartum care setting. The theoretical basis for the study was hermeneutic phenomenology, guided by the work of Heidegger and Gadamer. Midwives were recruited from three clinical settings to obtain a diversity of views and experiences. Rich data from diaries and in-depth interviews, from twelve participants, provided insight into the phenomena of confidence and the factors midwives encountered that affected their confidence. The phenomena of confidence consisted of a dynamic balance, between the cognitive and affective elements of knowledge, experience and emotion. This balance was fragile and easily lost, leading to a loss of confidence. Confidence was viewed as vital to midwifery practice by the participants of the study; however, maintaining their confidence was often likened to a battle. A number of cultural and contextual factors were identified as affecting confidence within the working environment, including trust, collegial relationships and organisational influences. Midwives also described various coping strategies they utilised to maintain their confidence in the workplace environment. This study provides unique insight into the phenomena of confidence for midwives working in intrapartum care, resulting in a number of recommendations. These highlight the importance of leadership, education and support for midwives in the clinical environment in enabling them to develop and maintain confidence in practice.

Background: Kangaroo Mother Care (KMC) is defined as skin-to-skin contact between a mother and her newborn baby, frequent and exclusive or nearly exclusive breastfeeding and early discharge from hospital. This concept was proposed as an alternative to conventional methods of care for low birth weight (LBW) infants, and in response to problems of serious overcrowding in neonatal intensive care units (NICUs). KMC essentially uses the mother as a natural incubator. According to this principle, LBW babies are placed to the mother’s chest in an upright position, where maternal body heat can help control the baby’s body temperature. Although widely used in some parts of the world, this practice is not the norm in the Kingdom of Saudi Arabia (KSA). Aim: The aim was to assess the feasibility and acceptability of running a randomised controlled trial (RCT) to evaluate the effectiveness of KMC in LBW infants in KSA.Study Design: A pilot RCT with supportive qualitative interviews was conducted, underpinned by a post-positivist approach.Methods: This was a mixed methods study. Quantitative methods were used to measure the effectiveness of KMC, and qualitative methods were used to explore women’s and nurses’ experiences of a) KMC and b) trial processes. The study took place in two urban hospitals in Jeddah, KSA. Ethical approval was gained, and data were collected between March and May 2011.The quantitative element comprised a two-group, individually randomised controlled pilot trial with 20 mothers-and-babies per group. The randomisation sequence was computer-generated, and participants were randomised using consecutively numbered, sealed, opaque envelopes. Data were collected using routinely collected case records, specifically designed clinical data sheets and two questionnaires (validated maternal bonding scale and maternal breastfeeding experience questionnaire). For the latter questionnaire, the design was informed by an expectation-fulfilment model. The qualitative element comprised semi-structured interviews, within 48 hours of birth, with a sample of 20 mothers who participated in the pilot RCT and 12 nurses who were attending these mothers. All 40 mothers were also telephoned when their babies were 6 months old to ascertain their feeding method and exclusivity of feeding.Quantitative data were managed using SPSS and analysed descriptively to estimate confidence intervals and effect sizes. Statistical tests and regression models were used to explore associations with potential outcome measures, with findings interpreted with caution as hypothesis-generating rather than hypothesis-confirming, given the small sample size. Qualitative data were analysed manually, using the Framework Approach.Results: The pilot study confirmed that trial processes were efficient, the intervention was acceptable (to mothers and nurses) and that the outcome measures were appropriate; the percentage of women exclusively breastfeeding at 6 months was identified as the most appropriate primary outcome. A large scale trial of KMC would be feasible and acceptable in KSA. However, issues relating to religious and organisational culture would need to be resolved, including improving privacy in the NICU, addressing language issues arising from transcultural nursing and engaging with male partners. A unique finding was the effect of KSA culture on women’s mobility and the impact that this had on their ability to carry out KMC if they were personally discharged but their baby remained in the NICU. Conclusion: A large scale RCT comparing KMC with standard care in KSA is feasible, acceptable and recommended. However, prior to progressing to a large scale study, a thorough planning stage is necessary which considers cultural practices and ward environment. The understandings gained from this research will be transferable to other research within similar settings