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Objectives: Self-compassion has been shown to improve emotional wellbeing and act as a buffer against psychological issues. First-time mothers, who are at high risk of developing distress and psychological issues in the transition to motherhood, particularly in the first year after childbirth, could benefit greatly from this skill. Research into self-compassion among new mothers is currently very limited, however, the existing studies have shown the benefits of this skill and recommended self-compassion to be used in intervention and prevention strategies for perinatal mental health issues. This research aimed to explore how self-compassion is practised by first-time mothers in the transition to motherhood in order to learn from this group and implement practical strategies for new mothers who may struggle with self-compassion. Design: Data from eleven first-time mothers, who identified as practising self-compassion, was collected through individual semi-structured interviews. The participants' ages were between 32 and 40 years and reported no symptoms of current psychological issues. The age of the participants' babies ranged from 6-24 months. Methods: Thematic Analysis was used to analyse the transcribed interview data and critical realist epistemology was used. Findings: Three themes that emerged from the data were: 'the building blocks of self-compassion', 'sudden changes and initial difficulties of maternity could block self-compassion' and 'becoming self-compassionate while embracing motherhood'. The subthemes are discussed under each theme, explaining the use of self-compassion by the participants. Conclusions: The findings clearly indicate that first-time mothers are likely to struggle with self-compassion in early motherhood due to several practical and emotional barriers. However, changing their perspective about motherhood, the babies' growth and other people's support appeared to allow the participants to become more self-compassionate. This study has a strong potential to be a guide to enhance interventions in Counselling Psychology, as well as improve services working with new and expectant mothers, as recommended in the implications.

I conducted an ethnography of the humanised birth movement in São Paulo, Brazil between 2015 and 2018. In this thesis I examine the strategies used by the movement to address the two-fold problem in maternal healthcare in Brazil: excessive clinical interventions in childbirth (particularly caesarean sections), and "obstetric violence": the disrespectful and/or abusive treatment of women during childbirth. Movement activists work towards a shared goal of promoting a woman-centred, normalised model of care through changes to policy and clinical practice. I took an ethnographic approach to "studying through" policies across sites and over time in order to examine how they are formed, implemented and contested. Interviews and focus groups with movement members (including mothers, doulas, midwives, obstetricians, politicians and programme leads), and observations in health facilities, participatory policy spaces, online, and in "everyday" social settings, led me to identify a range of strategies used by the movement to achieve their goals. These include: the strategic use of scientific evidence to support claims about the benefits of humanised birth; driving up demand for private humanised birth services; and the advocacy role of doulas, who "multiply" the movement's messages. My findings contribute to debates around the medicalisation and humanisation of childbirth, questioning their dichotomisation, and instead provide evidence that what "matters" are women's perceptions of care. I also found that there is potential in the humanised birth movement as a space for political action and successful health policymaking based around a shared feminine experience of sororidade (sisterhood), which encourages women to work collaboratively in a male-dominated socio-political context. Lessons might be drawn that have wider relevance in settings where policymakers are trying to reduce iatrogenic harm from unnecessary interventions in childbirth, and for supporters of normal birth working to reduce barriers to accessing midwifery-led, woman-centred care.

Background: Health promotion programmes in maternal health are increasingly reaching out to men as partners, husbands and community leaders in a bid to improve women`s uptake of health facilities and or skilled care at birth. Aim: To explore the contribution of male spousal involvement in facilitating uptake for maternal health services. Four main objectives: 1) conduct a scoping review on the rationale for male involvement in maternal health in Low and Middle Income Countries; 2) conduct a literature review on the use of board games with non-health professionals; 3) conduct a pilot study on the use of board games with men in maternal health; and 4) establish the feasibility of using board games as an educational strategy with men in maternal health in Uganda. Methods: The main study used a mixed-methods approach with face-to-face questionnaires (quantitative) and focus group discussions (qualitative) to collect data in Uganda. Completed questionnaires were entered into EPI DATA software and exported into STATA version 13 for analysis. Qualitative data were thematically analysed. The pilot study comprised focus group discussions Results: Quantitative findings showed a 26% increase in men`s ability to identify danger signs during pregnancy/childbirth (p < 0.001), a 26% increase in their knowledge of complication during delivery (p<0.005), and a 22% increase in joint decision making regarding maternal health (p < 0.01) following the Whose Shoes? board game. The likelihood of choosing facility births for women was increased but this was not statistically significant (p = 0.218). The key themes in the qualitative part of the study were; 1) perceptions regarding Whose Shoes?; 2) proposed new behaviour after engaging with the game; 3) perceptions and barriers to male involvement in maternity services. Conclusion: Involving men in maternal health facilitates access to maternal health services through joint decision making, financial support, nutrition in pregnancy and help with care-giving roles at home. This enables women to seek appropriate maternity care and have adequate rest during pregnancy and after childbirth. Maternal health programmes need to target men to increase uptake of maternity services for women. Educational games are a useful strategy to engage men in maternal health. The Whose Shoes? board game was acceptable to a group of Ugandan men living in London and effective in its ability to engage men on topics regarding pregnancy/childbirth complications, health facility birth and nutrition. This was the first-time maternal health messages were packaged through the medium of a board game targeting male spouses in Uganda.

Traditionally, clinical guidelines rely on objective evidence from quantitative research, largely derived from Randomized Controlled Trials (RCTs) of specific interventions in a defined healthcare area. Findings from qualitative research tend to be under-represented or overlooked because qualitative studies are more subjective, relatively small in scale and contextually bound. They may, however, contain important information about how a particular intervention works or doesn't work as well as relevant insights concerning the experiences, values and beliefs of key stakeholders with regard to the intervention or healthcare area. In recent years some novel approaches have been developed to address the lack of qualitative data within clinical guidelines. The most popular of these approaches is 'qualitative synthesis', a method that brings together the findings from isolated qualitative studies exploring the same or similar phenomena with a view to eliciting new, more abstract findings such that the whole is greater than the sum of the parts. More recently, techniques derived from qualitative synthesis have been adapted and used to inform global guidelines in the field of maternity care. Recognition that the findings from qualitative synthesis constitute a form of 'evidence' represents a major breakthrough for qualitative research generally but the newly emerging field is a highly contested area. There are internal tensions relating to the nature of qualitative synthesis itself, including the methodological and philosophical basis of the approach, as well as wider tensions relating to the incorporation of interpretive findings into the positivist frameworks associated with clinical guidelines. By referring to eight publications I have either authored or co-authored I will explore the qualitative synthesis landscape from its roots in the interpretive paradigm to its current application in guideline development. I will start by placing qualitative synthesis within the wider context of qualitative research and introduce the most commonly used synthesis technique, meta-ethnography. I will go on to examine some of the methodological, terminological and philosophical tensions that continue to challenge the credibility of this approach and highlight how I have addressed some of these issues by referring to several qualitative syntheses I have published. I will explain how the findings from these syntheses have been incorporated into clinical guidelines in maternity care and highlight some of the compromises that have been made to accommodate this endeavour within the wider context of Evidence Based Medicine (EBM). I will draw on some of the writings of the German philosopher, Jürgen Habermas, and explore how Habermas' concept of colonization might be applied in this context to illuminate some of the areas of contestation. By developing some of Habermas' theoretical discourse I will suggest that the method of qualitative synthesis is evolving in an 'interference zone' where competing claims for integrity strive for priority. I will juxtapose this position with a more utilitarian view of qualitative research and suggest that the findings from qualitative synthesis reflect a wide range of views, beliefs and experiences and represent a collective voice that can be utilized by guideline panels and policy makers. Finally, I will draw on the work of Carl Rogers, psychotherapist and pioneer of the 'person centred care' model, to illustrate how a patient led approach to guideline development, using qualitative-synthesis as a method, might represent a shift in global healthcare strategy towards more authentic and inclusive guidelines.

Background: Geographic access to hospitals is a key determinant of health outcomes and is critical in achieving Universal Health Coverage. Hospitals are the entry points for provision of comprehensive emergency obstetric and neonatal care. In sub-Saharan Africa where maternal and newborn deaths are disproportionately higher than anywhere else, defining those who are marginalised from these services is critical in in efforts to reduce these deaths. This thesis aimed to define geographic access to Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) at a regional level in sub-Saharan Africa (SSA) and at a national level in Kenya and relate these access quotients to maternal and neonatal mortality. Methods: A spatial database of public hospitals covering 48 countries and islands in SSA, was assembled using a range of sources from both national and international organizations. Based on a review of minimum essential services at first level referral hospitals, the assembled hospitals were assumed to provide CEmONC. These were then used in a cost distance algorithm that adjusted for proximity to roads, to estimate the proportion of women of childbearing age (WoCBA) living within two hours of the nearest public hospital. The accessibility algorithm accounted for complexity in transportation derived from a review of transport speeds to hospitals and different modes of transportation. The derived access quotients were then used to define the relationship between access to hospitals and modelled estimates of both neonatal mortality rate per 1,000 livebirths (NMR) and maternal mortality rate per 100,000 livebirths (MMR) while controlling for other confounding factors. Confounders chosen were physician workforce density, poverty, adolescent-specific fertility, risk of catastrophic expenditure for surgery, the proportion of urban population and fragility. A country case study was then chosen to undertake a more exhaustive analysis of geographic accessibility and its impact on the two outcomes. Using Kenya as an example, service availability assessment was carried out using different datasets to map hospitals that provide services for caesarean section (CS) and very low birthweight (VLBW) newborns. These were chosen as tracer services for provision of CEmONC. A cost distance algorithm that adjusted for the proximity to roads, road condition, land use, elevation and rainfall patterns was developed to define geographic accessibility to both services in Kenya. Lastly, an assessment of the relationship between access to CS and VLBW hospitals in Kenya with maternal and neonatal mortality respectively was undertaken. Relationships were evaluated using maternal mortality data from the 2009 census while the Equitable Strategies Save Lives Tool (EQUIST) tool was used to generate both maternal and neonatal mortality. Results: 4908 public hospitals were mapped for the 48 countries. Accessibility results showed that 704 million (71%) people and 164 million (72%) WoCBA were living within 2 hours of the nearest public hospital across, which varied from 22.8 in South Sudan to 97.4 in Zanzibar. Only seventeen countries had more than 80% of their respective populations within 2 hours of a public hospital. In the continental level regression model, a 1% increase in WoCBA within 2 hours was associated with a reduction of MMR by -2.75 (p=0.039) but was not significantly associated with a reduction in NMR, with a coefficient of -0.01 (p=0.717). In the Kenya accessibility analysis, 228 and 293 hospitals were determined to provide VLBW and CS services respectively, out of a total 431 possible hospitals. Overall, 82% and 80% of the births needing CS and VLBW services respectively occurred within 2 hours of the nearest hospital. Access to CS and VLBW services was heterogenous and varied from 25.7 and 21.8% in Turkana to 100% in Nairobi and Vihiga. Regression models that accounted for confounders showed a 1% increase in access to CS hospitals was associated with are reduction of MMR by -11.92 (p=0.018) using census MMR and -3.81 (p=0.000) using the EQUIST MMR. Finally, using NMR output from the EQUIST model, increasing access to VLBW hospitals was associated with a reduction of NMR by -0.24 (p=0.050). Thus, using the census outcome as an example suggests that MMR in high burden counties of Mandera, Marsabit, Turkana and Wajir would reduce by 457, 452, 647 and 540 per 100,000 livebirths respectively by ensuring all their livebirths use hospitals within 2 hours. On the other hand, Samburu, Turkana and West Pokot counties can reduce their NMRs by approximately 12 deaths per 1,000 livebirths by ensuring all births are within two hours of a VLBW hospital. Conclusion: Understanding the distribution of hospitals and geographic access to these services is critical in estimating the underserved. At the continental level, geographic access is significantly associated with variation in MMR but not NMR. Using Kenya as an example shows that accessibility models can be improved by evaluating the services available in hospitals in addition to using improved data on covariates, thus allowing for better assessment of how access relates to mortality. As such, Kenya can reduce MMR by 240.7 per 100,000 livebirths and NMR by 5.2 per 1,000 livebirths by ensuring universal access to CS and VLBW hospitals. This highlights the importance of implementing interventions that bridge geographic accessibility gaps, especially in the marginalized populations across Africa. However, there are still challenges with availability and quality of hospital services data in addition to reliable data on outcomes such as mortality and ultimately, improving the quantification of impact geographic access to hospitals on health outcomes will be dependent on improving data collection tools.

This study explored the ways in which community midwives negotiate competing discourses when supporting choice in pregnancy and birth. The ways in which choice was presented to pregnant women by NHS Trusts providing maternity services, via their information leaflets and the websites that host them, offered an indication of how such organisations conceptualised pregnancy and birth, providing the context in which the community midwives practised. Foucauldian discourse analysis was undertaken of the leaflets and websites, illustrating the discursive structures in which community midwives worked. Interviews with community midwives explored the ways in which they negotiated competing discourses when supporting women to make choices in their pregnancy and birth. In Leaflet 1 and its host website, a dominant medical discourse was identified. The power/knowledge of this discourse could be traced to a medical philosophy that believed that pregnancy and birth are risk laden activities, that women’s bodies are likely to fail and therefore require medical input to manage. In this discourse women are discursively constructed as patients, which repeats and renews medical dominance. Leaflet 2 and the associated website demonstrated a midwifery discourse, which recognised pregnancy and birth as a social as well as a biological construct. In this discourse, the community midwife is discursively constructed as one who understands and supports physiologically normal pregnancy and birth and takes responsibility for recognising any departure from the norm and advising and referring on as required. Crucially in this discourse the woman’s autonomy is recognised and her choices, based on her perceptions of risk, respected. The discursive construction of the leaflet and website place the midwife in the community, not just the spaces of the home, but the wider geographical community. The interviews with the community midwives illustrated the challenges and barriers they encountered in providing information to support truly informed choice and at the same time working with competing discourses. The midwives valued working in the community, believing that this gave them greater insights into the women’s lives and more freedom to practice midwifery. The close proximity to the lived experiences of women enabled them to appreciate that choices were often limited by the socio-economic circumstances. This insight however could also lead the midwife to shape options based on her perception of what women might find acceptable. Choices were also influenced by what the midwives knew was possible from an organisational perspective. Through the application of clinical guidelines, the community becomes a disciplinary space where activity can be measured and managed. The midwives wanted to support women to choose care that was right for them but felt personally and professionally vulnerable when women made choices that they were not comfortable with. The woman’s hand-held notes became an object of disciplinary control as they recorded consultations with women in order to create an auditable account in the event of an adverse outcome. Their relative isolation from the Trust was viewed positively by the midwives but also resulted in the loss of their professional voice. This was seen in the ways they did not advocate for women’s choices or did not articulate the community midwifery contribution to care. A discursive transformation from a midwifery discourse to a medical discourse was located, identifying a community midwifery risk discourse. The power/knowledge of the discourse is located in a midwifery discourse with a codicil of risk. The midwives are constituted as practitioners who perceive themselves to have a degree of autonomy but whose practice, and therefore their ability to offer and support women’s choices, is constrained by a risk discourse which governs their thoughts and conduct. This risk discourse is amplified by their location in the community, and where the medical discourse identifies a disciplinary space.

An estimated 2.5 million neonates die every year, with preterm birth being the leading cause. Sub-Saharan Africa and southern Asia account for 78% of neonatal deaths. The WHO recommends kangaroo mother care (KMC) for stabilised newborns ≤2000g; however, most deaths occur before stabilisation. An evidence gap exists regarding KMC for this population. The overall aim of this PhD was to inform the design of a trial of KMC initiated before stabilisation in a sub-Saharan African context. The first part focused on assessing facility readiness and quantifying neonatal mortality risk. Cascade models were developed and used to assess 23 East African facilities. A logistic model was derived and validated using data from 187 UK hospitals and one Gambian hospital. The final model, including three parameters, demonstrated very good performance. The score requires further validation in low-resource contexts, but has potential to improve neonatal resource allocation. The second part of this PhD focused on evaluating the feasibility of initiating KMC before stabilisation and designing the trial. This study showed it was feasible to monitor and provide care in the KMC position, and found the intervention was acceptable to parents and providers. Launched in 2020, the OMWaNA trial will determine the mortality impact of this intervention within 7 days relative to standard care at four Ugandan hospitals. Process and economic evaluations will explore causal pathways for clinical effects, estimate incremental cost and costeffectiveness, and examine barriers and facilitators to inform uptake and sustainability. This PhD has developed a cascade model to assess facility readiness, validated a score to assess individual risk, and demonstrated the feasibility of initiating KMC before stabilisation. These studies have informed the design of a trial evaluating the mortality impact of this intervention in Uganda. The findings are expected to have broad applicability to low-resource hospitals and important policy implications.

Introduction: The World Bank is one of the biggest external funders for maternal and child health in India and the world. Despite being a major actor in the global landscape for maternal and child health, there is no comprehensive analysis of the Bank’s historical involvement and influence in this area. This study thus documents the contributions and limitations of the Bank’s involvement in maternal and child health globally over the last five decades, and examines its influence nationally through the case study of a Bank-funded flagship project in India. Methods: I used a mixed methods research design for this study, consulting primary and secondary sources of data. For analysing the Bank’s historical involvement in maternal and child health over the last five decades, I consulted and analysed documents, archival records, and financial datasets from the World Bank, as well as relevant published literature and grey reports. For the case study of the Bank’s influence in maternal and child health at the national-level in in India, I conducted 30 key informant interviews, and reviewed project documents, archival records, and published literature. I analysed the India case study using a conceptual framework of donor influence developed based on theoretical and empirical literature. Results: Globally, the Bank contributed $24.6 billion for 484 maternal and child health projects in low-and-middle-income countries from 1970 to 2018, $1.4 billion in trust funds from 2005 to 2015, and $106 million in special health programmes from 1987 to 2014. The Bank solidified its role for maternal and child health through its cooperation with donors, UN agencies, and NGOs, to form partnerships and global health initiatives. The Bank’s conceptualisation of maternal and child health has evolved from being purely instrumental to now being considered for its intrinsic value albeit along with the economic case of improving productivity and economic growth by saving lives of women and children. Over the years, the Bank has moved from employing a selective programmatic approach towards a more comprehensive agenda as demonstrated by the increase in its lending for projects on health systems strengthening and multi-sectoral issues. This study also found a shift in the Bank’s focus on public sector provision of maternal and child health services from the 1970s until the mid-1980s, to its promotion of private sector involvement, and its current support of publicprivate partnerships. The limitations of the Bank’s involvement in this health area primarily revolved around its promotion of privatisation and the reduced role of the state in financing and service provision, which undermined the access, availability and quality of health services for women and children, especially from socio-economically vulnerable communities. In India, the Bank used a range of resources and mechanisms to exert its influence over the Ministry of Health and Family Welfare to achieve six policy outcomes for maternal and child health viz. target-free policy for family planning, priority for reproductive and maternal health, decentralised planning, financial monitoring system, strengthened procurement system, and increased domestic financing. Contextual issues including political, economic, social, and organisational factors shaped the India-Bank interactions and subsequently, the process of donor influence. Ultimately, despite the influence of the Bank, the sustainability of the policy outcomes lies within the remit of the domestic agency. Conclusion: In order to be more responsive in this area, leaders within the Bank will need to consider reforms: such as framing maternal and child as a basic human right with intrinsic value, aligning its financing with countries that have the highest burden of maternal and child mortality, supporting countries with sustainable strategies for domestic resource mobilisation, increasing its support for health systems strengthening, and most importantly, including local voices and perspectives to inform its programmes.

Birth is an important time in a woman’s life. While the journey into motherhood can be a transformational and liminal experience, unfortunately, this is not the case for every woman. It is estimated that approximately 30 % of women experience childbirth as a traumatic event, with up to 4% of women in community samples developing Post Traumatic Stress Disorder (PTSD) following childbirth. It is also highlighted that women who are vulnerable and disadvantaged, due to complex life situations such as poor mental health, poverty and social isolation, are more likely to experience birth trauma and PTSD onset. Recent research highlights that women’s subjective experience of birth is one of the most important factors in determining birth trauma, and that negative interactions with health care professionals are a key contributor to its development. The aim of this study was to develop and evaluate a training programme for maternity care providers to raise awareness of birth trauma amongst disadvantaged and vulnerable women. A critical pedagogical approach was adopted so that the design of the programme would aid reflection, critical thinking and conscientization. This study includes a meta-ethnographic review, empirical interviews and the design and delivery of a tailored educational programme within an NHS Trust. Firstly, a meta-ethnography was undertaken to explore disadvantaged and vulnerable women’s negative experiences of maternity care in high income countries. Noblit & Hare’s (1988) meta- ethnographic approach was used and four themes were identified through the synthesis of eighteen studies; ‘Depersonalisation’ ‘Dehumanisation’, ‘Them & us’ and ‘No care in the care’. Secondly, ten local disadvantaged and vulnerable women in North West of England were recruited and interviewed, exploring their negative experiences of birth. A framework analysis was used to interpret the data, identifying key triggers for birth trauma, focused on interpersonal interactions with maternity healthcare professionals. These findings were then compared against studies included in the meta-ethnography. Following these stages an innovative educational programme focused on birth trauma and PTSD was developed and evaluated. Key findings from the meta- ethnography and the empirical interviews informed the content of a filmed childbirth scenario that was embedded within a critical pedagogical framework. The scenario was delivered to participants’ using virtual reality (VR) technology, forming part of a 90- minute educational programme, in which maternity professionals view the scenario from a first-person perspective. Other elements of the education programme involved providing statistical evidence on birth trauma and PTSD, a presentation of qualitative data collected during empirical phases, critical reflections and the development of actionable practice points to change/influence care practice, for self and others. Ten maternity professionals participated in the evaluation, with pre/post questionnaires and a follow-up session used to assess participants attitudes, knowledge and experiences prior, during and following attendance. Findings suggest the immersive educational programme increased participants understanding and knowledge of birth trauma and PTSD, with the use of VR as a tool for knowledge translation found to enhance critical reflection and facilitate praxis. While further research to test the efficacy of the educational programme on women’s birth experiences is needed, simulated first person realities, embedded within a critical pedagogical framework, offer a unique and innovative approach to addressing interpersonal care in maternity and wider health-related contexts of care.

Background/Rationale: Although influenza (flu) does not normally cause serious health consequences, pregnant women are at increased risk of flu, and consequences amongst this population can be more severe. Physiological and immunological changes that occur during pregnancy, make pregnant women five times more likely to be hospitalised as a result of flu. During 2009-2012, one in 11 maternal deaths were attributable to flu, making it a considerable public health concern. Despite the increased risk that flu poses to pregnant women, uptake of the flu vaccination is suboptimal. Since the recommendation in 2010 that all pregnant women receive free flu vaccination, uptake in the UK has not exceeded 45% despite a target uptake of 75%. Aims: This thesis has four main aims: 1.) To examine the influence that interventions that aim to change risk and efficacy appraisals have on the intentions and uptake of vaccination, 2.) To explore the beliefs that pregnant women hold about flu and the flu vaccination, 3.) To design and develop an appropriate intervention, aiming to increase the uptake of flu vaccination amongst pregnant women, and 4.) Explore the acceptability and potential impact of the intervention. Method: This thesis describes a systematic review involving a systematic search to identify randomised controlled trials of interventions presenting a risk message and measuring risk appraisal and intentions and uptake post-intervention. Random effects meta-analyses investigated the size of the effect that interventions had on vaccination risk appraisal, and on vaccination behaviour or intention to vaccinate, and the size of the relationship between vaccination risk appraisal and vaccination intentions. A qualitative study, involving semi-structured interviews was conducted to explore pregnant women’s beliefs about flu and the flu vaccination, and to explore how well the data fits the Illness Risk Representation framework. Data was analysed using thematic analysis. Findings of the qualitative study were used alongside relevant theory to inform the design of an animation, guided by Intervention Mapping, and shaped by collaboration with pregnant women, midwives, Public Health professionals and clinicians. A further qualitative study involved think aloud methods and semi-structured interviews with pregnant and recently pregnant women to explore the acceptability and potential impact of the animation, analysed using content analysis. Results: Searches for the systematic review resulted in 18 studies that met the inclusion criteria (16 of which were eligible for inclusion in the meta-analysis). Interventions overall had small significant effects on risk appraisal (d= 0.161, p= .047) and perceptions of susceptibility (d= 0.195, p= .025), but no effect on perceptions of severity (d= -0.036, p= .828). Interventions showed no effect on intention to vaccinate (d= 0.138, p= .195) and no effect on vaccination behaviour (d= 0.043, p= .826). The qualitative study highlighted a number of beliefs, based on incorrect knowledge, that may have been having an unhelpful effect on vaccination decisions. These included the belief that pregnancy did not increase the severity of flu, that flu would not have any severe consequences on either pregnant woman or their unborn baby, and that the vaccination involved the administering of a live vaccine. The Illness Risk Representation framework was an adequate fit to the data. Following the application of Intervention Mapping techniques, perceived severity, perceived susceptibility, self-efficacy and response-efficacy were selected as appropriate determinants for the animation to target. The Performance Objective (the aim of the animation) was defined as ‘decide to have the flu vaccination.’ The completed animation contained information about the risks and consequences of flu during pregnancy, how the vaccination works to protect both the pregnant woman and the unborn baby, and provided information about the ingredients of the flu vaccine. Results of the think aloud study showed that the majority of participants felt that the length and the level of information provided was appropriate, and felt happy to recommend the animation to other pregnant women, which was considered to be helpful in helping them make the decision whether to vaccinate or not. Discussion: The systematic review was not able to answer whether interventions that contain a risk message are successful in increasing risk appraisal and vaccination uptake. It did however, highlight a number of methodological shortcomings of experimental studies that currently exist on this topic. The qualitative study identified a number of areas of incorrect knowledge that pregnant women held about flu and the flu vaccination, that appeared to be influencing their beliefs. Providing accurate information may help to shape vaccination decisions favourably. The animation is the first known animation, based on theory that aims to increase pregnant women’s acceptable of the flu vaccination, by targeting a change in risk and efficacy appraisals. Initial testing suggests that it is an acceptable intervention that has the potential to be useful in providing information to pregnant women which may help them make an informed decision about vaccinating against flu. Local Public Health departments have agreed to include the animation in local seasonal flu campaigns in the 2018/19 flu season, potentially reaching a large number of pregnant women.

Since 2004, the Government of Nepal has sought to increase availability of comprehensive emergency obstetric and neonatal care (CEONC) services at district hospitals. However, significant and persistent bottlenecks exist in the health system which prevent effective scale-up. A “quick fix” strategy to address bottlenecks and ensure that hospitals had resources to deliver CEONC 24/7 was the creation of a “CEONC Fund” to “top-up” routine hospital budgets. The intention was the CEONC fund should only be used for CEONC services, not for any other hospital purpose. In 2015, the government decided to include the fund as a long-term policy and expand its availability to all district hospitals. However, routine data on fund utilisation and service data is limited. What is available indicates that utilisation varies substantially by hospital and actual provision of CEONC services also varies widely. This study aimed to understand why some district hospitals achieve a better provision of CEONC services than others. It employed a multiple case study design, purposefully selecting four district hospitals using an extreme case selection framework. It triangulated data from the districts with semi-structured interviews from central level key informants. The study results show provision of the fund to hospitals has limited impact on CEONC availability. Several other factors in hospitals and the health system have greater influence on uptake of funding and service availability. The conclusion is, not only is a CEONC fund grant alone insufficient to ensure service availability, several other critical factors need to be taken into consideration to ensure that CEONC services are consistently and universally available. CEONC availability is heavily influenced by the quality of leadership and management of the hospitals and their capacity to maintain or develop the service as financial resources permit. Therefore, the fund’s utility as a sole mechanism to improve CEONC services is limited.

Background: Existing research on poor perinatal mental health largely focuses on recognition and treatment of postnatal depression. Consequently, there is a need to explore antenatal mental health. Aim: To assess poor mental health prevalence in pregnancy, its relationship to sociodemographic characteristics, self-efficacy and perceived support networks. To understand experiences and barriers preventing women with mental health problems from receiving help and explore midwives’ understanding of their role. Method: Questionnaires were completed by women in early pregnancy. A subset identified to have mental health problems, were interviewed in late pregnancy to explore their experiences and barriers to receiving care. Midwives completed questionnaires exploring their experiences of supporting women with mental health problems and focus groups further discussed the issues raised. Results: Amongst participants (n=302), the Edinburgh Postnatal Depression Scale (EPDS) identified 8.6%, and the Generalised Anxiety Disorder Assessment (GAD-7) 8.3%, with symptoms of depression or anxiety respectively. Low self-efficacy (p=0.01) and history of previous mental health problems (p<0.01) were most strongly associated with anxiety or depression. Thematic analysis of interviews with women (n=20) identified three themes: ‘past present and future’; ‘expectations and control’; and ‘knowledge and conversations’. Questionnaires were completed by 145 midwives. The three themes identified from the focus groups with midwives were: ‘conversations’; ‘it’s immensely complex’; and ‘there’s another gap in their care’. Conclusion: Prevalence rates of anxiety and depression amongst women in early pregnancy were found to be similar to those reported in the literature. Low self-efficacy and previous poor mental health were significant predictors of anxiety and depression. Continuity and more time at appointments were suggested by midwives and women to improve discussions regarding mental health. Midwives were keen to support women but lacked knowledge and confidence. Consistent reference was made to the need for training regarding the practical aspects of supporting women’s mental health.

Considerable advances have been made in medical sociology and other population health- related subject areas to understand structural sources of disparities in health outcomes. We know that structural factors are the ‘fundamental causes’ of disease and illness. However, few studies focusing on structural conditions have considered maternal healthcare especially in sub-Saharan Africa. There is a dearth of knowledge regarding the effects of wider structural factors on maternal healthcare utilisation. Specifically, it is not well-known as to which dimension of the social structure is strongly associated with maternal healthcare and what specific combinations of factors influence adequate use of maternal healthcare in sub- Saharan Africa. This study was conceived to fill this gap in literature. The study focuses on community and country-level inequalities in gender relations, human rights violations and globalisation as the three dimensions of structural violence that are consequential to maternal healthcare in sub-Saharan Africa. I also consider individual level maternal characteristics that are associated with maternal healthcare utilisation. The analysis pools data of 245,955 respondents from the most recent Demographic and Health Surveys (DHS) and several other international datasets. I apply separate three-level Bayesian multilevel models on women who have had births five years prior to the recent DHS, nested in 17,000 communities, which are nested in 35 sub-Saharan African countries. On each aspect of structural violence, I estimate four models predicting the odds of having four or more antenatal care visits, institutional delivery and postnatal care based on a set of individual, community and country-level variables. Overall, the results indicate that inequalities in gender relations and disrespect for human rights are negatively associated with adequate use of maternal healthcare in sub-Saharan Africa. The relationship between globalisation and maternal healthcare is conditional on the specific dimension of globalisation. In comparison with other dimensions of globalisation, social globalisation is the most significant predictor of adequate maternal healthcare. These results help to underscore the importance of contextual factors in understanding women’s utilisation of maternal healthcare in sub-Saharan Africa.

This thesis assesses the effects of having pluralistic systems of health financing and service provision on universal healthcare coverage with a case study on maternal health in Kenya. Through five research papers using a mix of systematic literature review, qualitative, and quasi-experimental quantitative methods, this thesis answers three primary research questions. First, how do researchers measure the contribution of the private sector to maternal health and family planning service provision and how much care does the private sector provide in sub-Saharan Africa (SSA)? Second, how did Kenya's pluralistic financing policies and public-private engagement strategies for health arise and evolve over time? Finally, what are the impacts of user fee removals and subsidized vouchers on use, sector, quality, continuity, and equity of maternal care in Kenya? The findings from the systematic review suggest that there is substantial heterogeneity in the way that the private health sector is defined in scientific literature, making it difficult to compare estimates of private sector health provision. The qualitative study reveals that Kenya's pluralistic health system results from the confluence of many historical, social, political, and economic factors and effective lobbying by the private for-profit sector. Finally, the three quasi-experimental studies highlight a complex set of outcomes resulting from user fee removal policies and the safe motherhood voucher program in Kenya. The 10/20 policy was associated with positive effects on the timing and number of ANC visits; however, these improvements were unrelated to use of the public primary care facilities that the policy targeted. The voucher program increased use of facility-based delivery care among poor women; however, it had no impact on use of four or more ANC visits or postnatal care. After the free maternity services policy was introduced, the voucher program no longer improved use of facility-based delivery among the poor; however, use of the private sector remained much higher in voucher counties. Both the voucher program and insurance coverage had positive impacts on continuity of maternal care for poor women, while introduction of the free maternity services policy did not. Many factors affect women's use of maternal health services beyond the cost of care. Making services free in the public sector is not sufficient to eliminate disparities in access to health services; policymakers must therefore simultaneously address both financial and nonfinancial barriers to service use. Health financing strategies involving private providers have the potential to equitably increase service use and continuity, provided that the cost of care is subsidized for users with the lowest ability to pay.

To enter pregnancy whilst obese carries risk for both mother and baby but obesity rates continue to rise. Community midwives are now the lead carers for all pregnant women and will inevitably encounter women whose health is at risk due to being obese. This qualitative study has explored how midwives construct their practice when delivering care and advice to women who live with a raised BMI≥30kg/m2 and what it means for them to do so. Thirteen in-depth interviews were conducted with practicing community midwives in South East Scotland. Participants were invited to complete reflective diaries. Interviews took place between January and May 2018. Interviews were audio recorded and then transcribed verbatim. Data were analysed thematically using a stepwise approach, the software package NVivo 10 was used to assist in this process. Three main themes emerged – ‘The situational context of practice’, ‘Constructing relationships and partnerships with women’ and ‘Midwives as public health agents’. Findings suggest that both the situational context and the role of community midwives is complex. Midwives appear to construct a unique approach to antenatal care as they provide care to women structures that do not appear to be flexible. They appear to ‘move’ between the paradigms of traditional midwifery practice and that of obstetric medicine and simultaneously promote normality and manage risk, in so doing they construct a unique pattern of practice. The public health agenda competes for time during appointments with midwives being expected to deliver voluminous information to women leaving little time to develop woman-focused care. Midwives rely on clinical protocols to open dialogue pertaining to obesity and its risks. Midwives could develop more personalised care schedules in partnership with women, ensuring that the woman’s voice is heard and that her needs are met. Practice may be strengthened by equipping midwives with enhanced consultation skills, enabling them to raise sensitive issues. Exploring alternative ways to address public health components may also facilitate better use of time, allowing midwives to ensure the antenatal appointment is woman-focused.

Decisions about health and care are rarely uncomplicated, and in maternity, they are no less so. In England, choice is at the forefront of maternal health policy, which maintains that women with straightforward pregnancies should have a choice of place of birth. A growing body of evidence shows that midwifery-led settings, such as midwifery units and home birth, are as safe as obstetric units (OUs), and that women planning their births in these settings have better outcomes with reduced chances of medical interventions and caesarean sections. However, a majority of those eligible for midwifery-led care are still giving birth in OUs. Policymakers, clinicians and stakeholders are now focused on augmenting 'informed' choice about place of birth among parents as a means for improving services and uptake, zeroing in on decision-making as the crucial point in which it is initiated and formed. What delineates an informed choice, and how does decision-making during pregnancy engender such a choice? Creating decisions aids or rolling out models of 'shared decision-making' are popular solutions for augmenting informed choice, with the intention of easing the burden of decision-making for parents. Researchers commonly approach each from a disembodied standpoint, assuming rationality in complex, lived phenomena that are in actuality neither linear nor uniform. This thesis, instead, explores decision-making and choice as a process, building an ethnographic account of parents' place of birth decision-making experiences in East London and investigating the feasibility of research related to decision aids and informed choice. To achieve this, I conducted two studies over nearly two years: a community based study situated in the boroughs of Newham, Tower Hamlets and Waltham Forest; and a feasibility study based in Barts Health NHS Trust, which offers all four birthplace options for women with straightforward pregnancies. I argue, contrary to long-held decision theory, that decision-making about place of birth is an embodied practice, one that has corporeal, temporal and affective modalities and involves enskilment built up before, during and after pregnancy. Modern English maternity continues to be a nexus of biomedical and obstetric dominance, uncertainty in terms of risk and safety and notions of good motherhood, all of which are layered through women's decision-making and reified by the frameworks that shape it. My analysis illuminated that informed choice, in the context of place of birth decision-making, is a culmination of skilled practice, a phenomenological and embodied event. Its establishment, in maternity policy and care, is marked by silences concerning knowledge and services. Current conceptions of choice in English maternity are built on a market ideology, which places the onus of improvements to services on women and their families; however, in seeing parental decisionmaking and informed choice as embodied, we can begin to envision future policy and practice based on a platform of human rights.

Inequalities in UK breastfeeding initiation and continuation rates exist whereby socio-economically advantaged mothers are most likely to breastfeed. Breastfeeding peer support (BPS) interventions are recommended as a solution, and consequently third sector breastfeeding organisations are commissioned to deliver UK BPS services in areas of socio-economic deprivation. BPS interventions have a mixed evidence base, and a key evidential gap concerns understanding interaction between context and intervention. This study explored how and why these organisations have developed BPS services within socio-economically deprived contexts. The study was completed in two phases. During phase one an exercise was undertaken to establish background information about the four main UK breastfeeding organisations. Semi-structured interviews with BPS organisation strategists and representatives (n=7) were undertaken, complemented by a meta-synthesis of published literature. Phase two constituted case studies of two BPS services in different areas of deprivation in England. Semi-structured interviews were undertaken with: mothers who had (n=10) and had not engaged (n=9) with the BPS services, peer supporters (PSs) (n=9), community health professionals (n=5), infant feeding co-ordinators (n=2), third sector organisation managers (n=3), and public health commissioners (n=2). Inductive grounded theory analytic techniques of open coding and constant comparisons, followed by cross case comparisons, were used to analyse data. One over-arching theme and four main themes were constructed. The over-arching theme ‘the transcending influence of society’ explains how the combination of funding availability and data sharing arrangements, determined service operation and PSs access to women. Although commissioners required that more support be given to the target group of women, this was not always achieved. The acceptability of the peer support role, operating at the individual, social group, and community levels was captured by ‘the role’ main theme. The second main theme, ‘access,’ concerns developments to improve the access of target women. The third main theme, ‘embedding’ describes the community-professional connections for supporting access. The final main theme, ‘service management’ captures issues of funding and the relationship with time, communication, and reporting. Findings suggest that organisational practices do not facilitate the discussion, collection, and use of contextual knowledge to inform ongoing development of BPS services. Recommendations include development of a theoretical tool to facilitate the use of contextual knowledge.

Background: Smoking during pregnancy is a global public health issue and one of the most modifiable risk factors for adverse pregnancy outcomes. Complications from continued smoking include miscarriage, preterm birth, low birth-weight and still-birth. In Warwickshire, rates of smoking in pregnancy vary from above the national average in the north of the region, to below the national average in the south. The Warwickshire Stop Smoking in Pregnancy Service (SSiPS) has good quit rates but has problems with low engagement. Behavioural science research can provide theoretical understanding of why behaviour occurs, in order to implement strategies to elicit positive behaviour change. Methods: The aim of this thesis was to design an intervention which addressed rates of smoking in pregnancy in Warwickshire. As a complete behaviour system and framework for intervention design, the Behaviour Change Wheel(BCW), the COM-B model (Capability, Opportunity, Motivation –Behaviour), Theoretical Domains Framework (TDF) and Behaviour Change Technique (BCT) v1 taxonomy (BCTTv1) were chosen for guiding intervention development. Three parallel studies were carried out to inform decision-making about the target behaviours of the intervention. These included a systematic review and meta-analysis, to explore the effectiveness of digital interventions for increasing smoking cessation in pregnancy, and two qualitative needs analysis studies, which were structured around the TDF and COM-B. The first investigated the barriers and facilitators to supporting pregnant women to stop smoking. The second explored the barriers to, and facilitators of, stopping smoking in pregnancy and engaging with cessation support from the viewpoint of women who had smoked during their pregnancy, midwives and Stop Smoking in Pregnancy advisors. Data from face-to-face and telephone interviews were analysed using thematic analysis to underpin intervention development. Steps of the BCW were followed to design the intervention, which was tested in an acceptability study implementing think aloud methodology. Results: The systematic review and meta-analysis found that digital interventions are effective for increasing smoking cessation in pregnancy, particularly computer-based and text message programmes. Seven behaviour change techniques (BCTs) were associated with intervention effectiveness, including ‘Information about antecedents’ and ‘Action planning’, with interventions implementing larger numbers of BCTs appearing to produce the greatest effects. From the needs analyses, a list of possible behaviours for the intervention to address were rated for capacity for change and likely impact on other behaviours, particularly for pregnancy smoking cessation. The behaviours offering the most promise for the intervention were selected as engaging with the Stop Smoking in Pregnancy Service (SSiPS) after referral and continuing to engage with the service. Key barriers to accessing support were found to include a lack of awareness of the service, pressure to quit smoking completely, change of intentions to quit, and considerable social influences and misconceptions about smoking in pregnancy. The BCW was used to map analysed data to intervention functions, policy categories and BCTs. Intervention content was then developed in collaboration with key stakeholders, to produce a multi-component intervention. A script was provided for midwives to help them broach the subject of smoking and to promote the SSiPS. Alongside the script, midwives would also provide women being referred to the SSiPS with a lip balm, to encourage pregnant smokers to engage with the service and to use the service website. The existing SSiPS website was extensively improved to address barriers to smoking cessation and engaging with cessation support. Existing SSiPS text messages were amended and added to, in order to further encourage access to the service and provide support between appointments. In addition, advisors are to ask women at the end of their first SSiPS appointment if they feel ready to quit and to commit to attending another session with their advisor. The acceptability study found that service-users and SSiPS advisors held generally positive views of the intervention components, suggesting areas for improvement which were fed back into the intervention design. Discussion: This thesis has identified that digital interventions are effective for smoking cessation in pregnancy, isolating specific components associated with effectiveness. The research has produced an innovative, evidence-based intervention, which aims to improve the existing care pathway for pregnant smokers by increasing engagement with an already effective service. This intervention addresses uniquely identified barriers, including change of intentions to quit smoking and to engaging with cessation support. Involving stakeholders and service-users at each step of the design has helped to ensure optimal engagement with the intervention, enabling a smooth transition into routine care.

Background: Disrespect and abuse (D&A) in maternity care facilities is a major public health issue affecting women worldwide. There are reports of high prevalence of D&A during facility-based childbirth in Nigeria; however, studies that explore the issue in-depth from women’s and maternity care professionals’ perspectives are sparse. This study provides an understanding of women’s experiences of and healthcare providers’ perspectives on D&A during maternity care in health facilities in Benue State, Nigeria. Methods: This is a qualitative phenomenological study conducted in two phases. Using purposive sampling, focus group discussions were conducted with women (n=32) in the first phase, and in the second, semi-structured interviews with women (n=14) and healthcare providers (n=16) from various professional backgrounds, working in two maternity care facilities. All the women received maternity care in facilities and had experienced at least one incident of D&A. The sample size was determined based on data saturation. All data collected were transcribed and analysed in NVivo version 11 using a six-stage thematic analysis. Findings: Women perceived incidents such as being shouted at and the use of abusive language as a common practice and described these incidents as devaluing and dehumanising to their sense of dignity. They also highlighted the importance of accessing facilities for safe childbirth and expressed that the experiences of D&A may not impact negatively on their intended use of but the choice of maternity facilities. However, their accounts reflected a lack of choice and the adverse effect of D&A on their emotional wellbeing. Healthcare providers recognised D&A as a violation of the human rights of women accessing maternity facilities, but usually highlighted components of respectful care with a good awareness about what it encompasses. They often considered the experiences of D&A as subjective to the women and based on their expectations of care. Their views also reflected underlying gender-related notions and societal perceptions of women being considered weaker than men. The professionals recognised several adverse effects of D&A, including its impact on women, newborns and on their own job satisfaction. Both women and professionals perceived some of the disrespectful and abusive actions were not intended to cause harm but to ensure the health and safety of the mother and her child. Additionally, they reported several factors associated with service users, health professionals and the facilities perceived to contribute to the D&A of women. Conclusion: The participants’ accounts showed that the application of respectful care in everyday maternity practice is inadequate in Nigeria. The findings reveal the need for policy and practice interventions to address the issue urgently through preventive measures such as empowering women through education to reinforce their right to respectful care. It reflects the need for sensitising and training health professionals on the importance of providing respectful care and how its elements can be incorporated into everyday practice. The underlying gender-related notion highlights the need for interventions at wider socio-political and community levels including the importance of educating family members about their right to respectful care and empowering them to report disrespectful practices.

This portfolio thesis consists of three parts: Part one- Systematic Literature Review The systematic literature review integrates the findings of future health care professionals' attitudes towards terminations. A systematic search of the literature generated fifteen studies and a narrative synthesis was conducted. The methodological quality of the studies was also assessed. Subsequent conclusions are discussed and suggestions for future research are made. Part two-Empirical Paper The empirical paper explored the narratives constructed and contextual factors involved in young women's decisions to end a pregnancy. A qualitative narrative approach was used to analyse the stories. Holistic form analysis identified two plot themes and categorical content analysis identified four major and eight minor categories. The findings and implications of the research are subsequently discussed and future research is explored. Part three- Appendices The appendices provide additional information supporting the systematic literature review and empirical paper. Included is an epistemological and reflective statement.

The aim of this project was to identify how cultural differences influence maternity care and knowledge acquisition about movement in labour. A Focused Ethnographic (FE) approach was used. FE is a research method employed to investigate cultural dimensions of specific aspects of contemporary society, an approach different in scale and intensity to conventional ethnography (Knoblauch, 2005). The data were collected from one to one interviews, one group interview and field observations. Data were collected from three groups of participants: 9 women, 10 midwives and 6 obstetricians. The data gathered from the three groups were analysed by thematic analysis to develop an in depth understanding of ideological and cultural differences that influence maternity care and knowledge acquisition about maternal movement in labour. Feminist thought informed the project, acknowledging women and midwives as knowers of equal standing within maternity care services. The main findings showed a binary in cultures of maternity care provision. Where the basic underlying assumptions of a culture are love, compassion and empathy, then relationship-based care and women’s empowerment are espoused and valued. This leads to openly shared knowledge and learning around movement in labour. Where the basic underlying assumptions of a culture are lack of empathy, dignity and choice, rigid boundaries are set, medical practice maintains control and dichotomies in care provision around movement are prevalent. However, these binaries are fluid and nuanced and are not static to an area or individual. Barriers and facilitators to implementing care that supports maternal movement are presented. This requires a shift in the way that birth is presented and learned about in obstetric practice and wider society. This will require leadership, valuing women and midwives and the knowledge they share, and a collaborative approach to birth involving women, midwives and obstetricians.

Aim: The aim of the study was to explore midwifery practice during the second-stage of labour to understand how midwives make decisions at this time. Background: Whilst there is much discussion within the literature about the various care issues that may present themselves as dilemmas for midwives throughout the second-stage, little information is available about how midwives make decisions during this time. Methods: A qualitative single instrumental case study methodology has been applied to facilitate an in-depth understanding of midwives decision-making in the second-stage and the use of observation and interview to gather a rich data set to examine the case. Key Findings: Midwives employed fast thinking using pattern-matching to make rapid decisions during the second-stage which was supported by a slower more focused assessment of cues using the principles of the Hypothetico-deductive model. Within the Alongside Midwifery Unit (AMU) midwives used observation, interpretational and interpersonal skills to assess labour and inform their decision-making. This skill-set did not appear to transfer to the Obstetric Unit (OU) where the focus of care shifted to the completion of tasks and was influenced by midwives perceptions of surveillance and the introduction of technology. Conclusion: Decision-making during the second-stage was influenced by context and midwives used their skills to assess labour progress holistically paying attention to physiological and behavioural cues exhibited by women on the AMU. Implications for Practice: The skill-set used by midwives on the AMU did not transfer to the OU where midwives perceived that their ability to make autonomous decisions was reduced and the focus of care shifted from being woman-centred to task-centred.

Supporting women's psychological needs during pregnancy is an important aspect of providing good quality maternity care. In an attempt to support women's psychological wellbeing during pregnancy, a local National Health Service Trust, developed Confident Birthing Workshops. These workshops aimed to try and increase pregnant women's confidence for birth. Research exploring childbirth self-efficacy, fear of birth and childbirth expectations suggests that women's confidence for birth is likely to affect their long-term psychological wellbeing. However, there has not been any research exploring women's confidence for birth. This PhD therefore aimed to develop a theoretical understanding of the factors that women perceive to influence their confidence for birth, during pregnancy. It is then hoped that the local National Health Service Trust can use this understanding to support the Confident Birthing Workshops. In order to develop a theoretical understanding of women's confidence for birth, a constructivist grounded theory approach, using interviews and internet discussion forum data was taken. This data was subjected to grounded theory analysis and led to the development of a substantive 'Journeying through confidence' theory. The social processes within the theory are divided in to the following five categories: 'Gathering and interpreting information while journeying through pregnancy', 'Relationship with pregnancy and baby', 'Preparing', 'Communicating' and 'Evaluating previous experiences'. The 'Journeying through confidence' theory, is the first theory to provide an understanding of the factors that women perceive to influence their confidence for birth, during pregnancy. This theory has resulted in several suggestions to improve clinical practice, such as, changing the approach that maternity services currently adopt when creating birth plans with women. Further research is needed to explore what factors women perceive to influence their confidence for birth during labour and the postnatal period.

This thesis is a social history of women’s reproductive health in Ghana. It asks how ‘development’ impacted on women’s reproductive health work, and women’s experiences of healthcare, between 1920 and 1982. It recognises development as a discourse, which is used to legitimise the actions of individuals, organisations and governments. Development is malleable and it is plural, in its meaning. It is a label for something which is practiced and it is an aspiration to be reached. Development discourse was used to justify colonial government spending on maternal and child welfare, but equally to hand these services over to populations in the name of ‘self-help’. It was used to legitimise a pronatalist approach under Nkrumah, and later as a core reason to implement population control. Using a combination of oral and documentary sources, I have mapped changes and continuities in women’s reproductive health work. I argue that development has consistently shaped the availability of women’s reproductive health services, and the way in which it has been carried out. This has meant that women’s health as such has rarely been a core priority in reproductive health programmes. Oral histories have been essential in teasing out women’s experiences of their reproductive health, which development discourses often gloss over. Through looking at implementation over a sixty-year period, we can clearly see the relationship between development and women’s reproductive health both under colonialism, and in Ghana as an independent country. I begin by examining the humanitarian and economic impulses that drove early colonial development, move on to the ‘welfarist’ late colonial state through which imperialists sought to defend their positions, and then examine the (economic) nationalism of independent Ghana: all these phases were characterised through attention to reproduction. This thesis covers six themes: demography and development; developmental humanitarianism; social development; nationalist development; family planning and development; and community development. Each of these themes constitutes a chapter of this thesis, and they run chronologically. Tying them together is the fact that each of these histories is deeply intertwined with women’s reproductive health.

Independent Midwives provide relational continuity of care whilst promoting women's autonomy. They report associated high levels of physiological birth and positive outcomes for women and babies and low levels of interventions (Milan 2004). Since the publication of the Changing Childbirth Report (Department of Health 1993) it has been government policy for these components of care to be incorporated into national maternity services to facilitate higher quality of care, although this policy has as yet to be widely implemented in the United Kingdom (UK). The Better Births report (National Maternity Review 2016) has most recently reiterated the need for the inclusion of these components into maternity care in England as a measure to improve care. In Scotland, The Best Start: five-year plan for maternity and neonatal care (Scottish Government 2017) sets out their strategy for improving maternity care based on a commitment to provide individualised continuity of care to mothers and babies. The Welsh strategic vision for maternity services (Welsh Government 2011) is less specific, broadly describing respectful care in which the mother and family are the focus. Whilst continuity of care and supporting women's choices are commonly known attributes of independent midwifery care there is little knowledge about the full gamut of this type of practice. Aims and objectives: The overall aim of this study was to advance knowledge about the practice of Independent Midwives working in Mainland UK. The objective was to explore Independent Midwives' perceptions and experiences of independent midwifery, through in-depth interviews, and to gain an overarching understanding of what is involved in working independently and providing care for clients. Through this exploration the intention was to identify and understand the essential components of a way of practising midwifery which reportedly work well for both mothers and midwives. Research design: This study took a qualitative approach, drawing on the principles of constructivist grounded theory methodology and used semi-structured, in-depth interviews to generate the data. With the participants' consent each interview was digitally recorded, transcribed and then analysed using a constant comparative method. Participants: Eight Independent Midwives were recruited from across Mainland UK using purposive and then theoretical sampling techniques. Ethical approval was gained from the Bournemouth University Human Ethics Committee. Findings: Five categories were identified as being key components of the independent midwifery model of care: professional autonomy, time, mother-centred care, knowledge, evidence and practice, and midwifery philosophy. Conclusions and key recommendations: Professional autonomy is a vital component of independent midwifery practice, enabling Independent Midwives to practise in ways which best serve their clients. They are free to choose how they can best practice in particular circumstances, and importantly, how they apportion their time. Providing continuity of care through caseloading facilitates the establishment of mother-midwife relationships and results in a sustainable work-life balance for the midwives. Time is a critical factor in providing high-quality care. Independent Midwives allot substantial amounts of time to working with their clients and developing their practice, both of which are associated with safer care and better outcomes. The development of mother-midwife relationships results in individualised care and consequently safer care and better outcomes. Independent Midwives' use of a continuum of evidence enables them to incorporate a range of information into the care they provide which caters to the individual needs of the client, resulting in safer care. The midwives' philosophy of normality guides their practice, enabling them to promote health and physiological processes and avoid interventions. The Independent Midwives' model of care provides mother-centred relational continuity of care in the context of the woman's choices, through a caseloading scheme, as recommended by current government policy for maternity services. This exemplar can be used to assist service providers implement government policy recommendations for maternity care. A systems-level change is required to enable all midwives to move from providing fragmented care, to providing individualised, relational continuity of care. Midwives need to have greater professional autonomy and more time, in order to effectively provide this type of care. Maternity services need to focus on normality throughout the pregnancy continuum because it promotes health and physiological processes and reduces the use of interventions.

Background: United Nations' data indicate that conflict-affected low- and middle-income countries contribute considerably to global maternal deaths. Usage patterns during conflict have not been examined in-depth and a cause-effect analysis is relevant for policy insights. This study assessed the association between the acute Egyptian conflict of 2011-2012 and maternal services usage and quality. Methods: An uncontrolled before-and-after study used data from the 2014 Egypt Demographic and Health Survey. The hierarchical nature of data was addressed using multi-level modelling. The pre-conflict sample included 2,569 births occurring from January 2009 to January 2011 and the peri-conflict had 4,641 births from February 2011 to December 2012. Results: After adjusting for potential socioeconomic confounders, conflict was not associated with antenatal service usage. Compared to pre-conflict births, peri-conflict births had lower odds of at least 24 hours post-delivery stay (8%; OR 0.92), delivery in public institutions (1%; OR 0.99), and institutional postnatal care (PNC) (1%; OR 0.99); and relatively higher odds of doctor-assisted deliveries (2%; OR 1.02), institutional deliveries (2%; OR 1.02), private institutional deliveries (3%; OR 1.03), and doctor-assisted PNC (2%; OR 1.02). During conflict, odds of doctor-assisted delivery increased more for oldest (>35 years) women (3%; OR 1.03); odds of receiving PNC decreased more for women aged 25-29 (8%; OR 0.92); and odds of skilled birth attendance increased more for rural women (2%; OR 1.02), primary-educated (4%; OR 1.04), employed (4%; OR 1.04), less poor (3%; OR 1.03) and middle household wealth quintiles (2%; OR 1.02). Odds of physician-assisted delivery increased more for rural women (3%; OR 1.03), primary-educated (5%; OR 1.05), employed (4%; OR 1.04), less poor and middle household wealth quintiles (3%; OR 1.03 each), and richest household wealth quintiles (2%; OR 1.02). Conclusions: Conflict-associated changes in maternal care were minimal, generally reflecting pre-conflict usage patterns. Association between acute conflict and maternal care indicated vertical equity had changed from recent trends. Policy intervention may help improving post-delivery stay. Maternal policy requires 'specific in-built equity strategies' to address unpredictable effect of conflict.

Background: Health equity is strongly linked with underlying socioeconomic differentials. Maternal education is widely regarded as a core social determinant of child health though there are controversies around its independent beneficial effect. Myanmar has limited evidence regarding social determinants of child health in general and the effect of maternal education. The present thesis examined whether there is an association between maternal education and child health and identified pathways of influence through which maternal education exerts its effects. Method: The nationally representative Demographic Health Survey 2015-2016 of Myanmar was analysed. Stepwise logistic regression was used to assess an independent effect of maternal education on childhood mortality, morbidity and health services utilisation among children under five. Multivariate models were developed adjusting for possible demographic and socioeconomic confounding factors relating to parental socioeconomic circumstances and characteristics of the household and community. Mediation analysis was conducted employing four-step regression method to identify pathways of influence of maternal education. Results: Maternal education had a significant independent effect on infant mortality, under-five mortality and pneumonia treatment. It had some effects on neonatal mortality, child stunting and full vaccination, but the effects were not independent as they were accounted for by household wealth status and geographic residence. Maternal education was not associated with the occurrences of diarrhoea and pneumonia and receiving appropriate treatment for diarrhoea among children. Maternal education channelled its effects on child health through four pathways: maternal health knowledge, income, health-related behaviour, and autonomy. Conclusion: Maternal education is an important social determinant of childhood health in the study context. Government policies should focus on ensuring equitable access to education and health services across different population groups, strengthening health-related knowledge and behaviour of girls and women who do not have formal education and boosting economic status of the country populations.

The prevalence and consequences of perinatal mental ill health has attracted more attention as a public health issue in recent years. Much attention has focused on the deleterious effects that parental mental health problems can have on parents themselves, as well as on the quality of the parent-infant relationship and their infants' wellbeing and development. Parental mental ill health can be one of multiple factors that may contribute to the invocation of child protection processes and ultimately, for some families, child removal into the care system. Psychotherapeutic interventions aimed at ameliorating parental mental health or aspects of the parent-infant relationship are significant in the prevention of harm to children and child removals. A systematic literature review of studies investigating parents' experiences of dyadic parent-infant interventions was conducted, which highlighted the importance of the therapeutic relationship within the work. Research has shown that engaging with families is particularly challenging in edge of care contexts however little is known from the parents' perspectives about how they experience relationships with mental health professionals. The current research thus explored the experience and meaning of therapeutic relationships of mothers who had accessed a parent-infant mental health service for infants at the edge of care. Semi-structured interviews with four mothers were conducted and analysed using Interpretative Phenomenological Analysis. The analysis revealed the weight of complex relational and social trauma and their sequelae on the mothers. The mothers described the complexities they faced in developing a relationship with their therapist, as a result of these traumas. The results suggest the potential for the therapeutic relationship to be powerfully reparative, leading to positive change in the mothers' identity and wider relationships. The findings are discussed in relation to extant literature, and recommendations for clinical practice and future research are suggested.

Introduction: A birthing centre (BC) is a component of maternal health service delivery at local level and provides a midwifery led model of care in a community or hospital setting to healthy women with uncomplicated or low risk pregnancies. In Nepal, Auxiliary Nurse Midwives (ANMs) provide much of the primary care maternity services delivering care especially at BCs. Literature suggests, BCs in Nepal are often bypassed in order to utilise services available at hospitals. There is a need for study which focuses on the role of BCs in providing good quality maternity and childbirth services. This study evaluated the effects of an intervention consisting of supporting BCs and community-based health promotion programme on increasing access and utilisation of perinatal care facilities in community setting. Methods: A longitudinal (cross-sectional) study was undertaken using a mixed methods approach. The quantitative methods consisted of two surveys that were conducted in rural area of a district in Nepal in the year 2012 and 2017 respectively. The qualitative method consisted of interviews and focus group discussion. Survey data were analysed in SPSS and interviews in NVivo. Descriptive analysis along with chi square test for association, Cramer's V for strength of association and multinomial logistic regression were conducted for quantitative survey whereas qualitative data were analysed thematically. Results: The results of quantitative data showed that there was increase in utilisation of perinatal services available from BCs. There was also change in place of childbirth from home to health facilities, mostly the BCs. The results of multinomial logistic regression showed women were significantly more likely to give birth at health facilities, mostly primary care facilities compared to home if decision maker for place of birth were husbands, women and family members; and if women had four or more antenatal care (ANC) visits. Similarly, women were less likely to give birth at primary care facilities if they had only primary level of education. Bearing in mind the small scale of this qualitative component of study, it showed the participants were happy and satisfied with the quality of services and attitude and behaviour of ANMs at the BCs. However, the need for increasing health promotion and awareness among women, need for improving referral services and training needs for health promoters were identified. Conclusion: The main conclusion of this thesis on maternity and childbirth care in Southern Nepal is that trained health promoters have potential to increase the births at BCs and decrease home births. The role of health promoters and female community health volunteers are important in rural Nepal, but the socio-economic factors including women's education, occupation of husbands and decision-making capability of women also affects the access to and utilisation of perinatal services at the health facility, especially the BCs. The importance of four ANC visits cannot be overlooked in understanding the uptake of birth at BCs. Moreover, further training of health promoters along with availability of referral services needs to be ensured.

Rationale: High levels of preventable infection still occur among mother and newborns. This burden is concentrated in low and middle-income countries (LMICs) where increasing numbers of women attend facilities for childbirth. Poor quality of care contributes to this burden. Birth attendants' hand hygiene in healthcare facilities is a key infection prevention opportunity. Objectives and methods: To assess existing evidence on birth attendants' hand hygiene compliance in LMIC facilities by systematically reviewing the literature. To describe the enabling environment for hand hygiene in Zanzibar maternity wards (Tanzania) using a mixed-methods cross-sectional survey. To develop a tool to capture the complex patterns of hand hygiene performed by birth attendants using time-&- motion methods. To assess the compliance of Zanzibar birth attendants to hand rubbing/washing, avoiding recontamination and glove use before aseptic procedures using time-&-motion methods and descriptive statistics. To assess the determinants of Zanzibar birth attendants' hand rubbing/washing and of avoiding recontamination before aseptic procedures using time-&-motion, a survey, and analytical methods. Findings: We found only nine studies - often with poor methods and definitions - that quantitatively examine birth attendants' hand hygiene in LMICs facilities; amongst the three with better definitions and sample sizes, compliance ranged from 1-28%. The HANDS at birth tool was developed using time-&-motion software, which allowed all birth attendants' actions to be captured and operationalised. Only 9.6% of Zanzibar birth attendants hand rubbed/washed, donned gloves and avoided recontamination before aseptic procedures. Half of the time when rubbing/washing or glove donning was performed, hands were recontaminated. Analysis of determinants found rubbing/washing was associated with lower workload (Adjusted Odds Ratio= 29.39), and availability of single-use drying material (AOR=2.9). Avoiding glove recontamination was associated with less time elapsed since glove donning (AOR=4.49). Conclusion: Further research should examine the extent to which failure to avoid recontamination contributes to poor hand hygiene and what effective behaviour change strategies could tackle it.

This thesis presents the findings of an original study that explored NHS midwives practice of facilitating women's alternative physiological birthing choices - defined in this study as 'birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth'. The premise for this research relates to dominant sociocultural-political discourses of medicalisation, technocratic, risk-averse and institutionalisation that has shaped childbirth practices in the UK. For midwives working in the NHS, sociocultural-political and institutional constraints can negatively impact their ability to provide care to women making alternative birth choices. A meta-ethnography was carried out, highlighting a paucity of literature in this area. Therefore, the aim of this study was to generate practice-based knowledge to answer the broad research question: 'what are the processes, experiences, and sociocultural-political influences upon NHS midwives' who self-define as facilitative of women's alternative birthing choices'. Underpinned by a feminist pragmatist theoretical framework, a narrative methodology was used to conduct this study. Professional stories of practice were collected via self-written narratives and interviews to understand the processes of facilitation (the what, how, why), their experiences of carrying out facilitative actions (subjective sense-making), and what sociocultural-political factors influenced their practice. Through purposive and snowball sampling, a diverse sample of 45 NHS midwives from across the UK was recruited. A sequential, pluralistic narrative approach to data analysis was carried out, and a theoretical model was developed using the whole dataset. The findings were subjected to three levels of analysis. First, 'Narratives of Doing' highlight how and what midwives did to facilitate women's alternative choices. The sub-themes reflect the temporal nature of a wide range of actions/activities involved when caring for women making alternative birthing decisions. The second analysis; 'Narratives of Experience' - highlighted the midwives polarised experiences captured as 'stories of distress', 'stories of transition,' and 'stories of fulfilment'. For the third level of analysis, a theoretical model of 'stigmatised to normalised practice' was developed using notions of stigma/normal, deviance/positive deviance. A six-domain model was developed that accounted for the midwives sociocultural-political working contexts; micro, meso, and macro. The implications of this research related to a number of identified constraints, protective factors, and enabling factors for midwifery practice. Key barriers included negative organisational cultures that restricted both midwives' and women's autonomy. Disparities between the midwives' philosophy and their workplace culture were highlighted as a key stressor and barrier to delivering woman-centred care. Protective factors related to the benefits of working in supportive, like-minded teams that mitigated against their wider stressful working environments. Facilitating factors included positive organisational cultures characterised by strong leadership where midwives were trusted and women's autonomy was supported. Therefore, this study has captured what has been achieved, and what can be achieved within NHS institutional settings. Through the identification of both challenges and facilitators, the findings can be used to provide maternity professionals and services with insights of how they too can facilitate women's alternative birthing choices.

Escalating maternity litigation costs threaten the stability of any health system and are unsustainable. Improving patient care and reducing preventable harm during childbirth remain crucial in overcoming this litigation crisis. In order to make the widespread improvements in obstetric care required to alleviate this litigation burden, a system- based approach, acknowledging all levels (micro, meso and macro) of a health system, may be needed. This thesis explores the use of a system-based approach to improve maternity care and tackle the increasing cost of litigation in obstetrics. Chapter 1 provides a general introduction to the thesis. Part 1 of the thesis adopts a 'bottom-up' approach and focusses on the health economics of multi-professional simulation training for obstetric emergencies. Chapter 2 demonstrates that adults with obstetric brachial plexus injuries (OBPIs) and caregivers of children with permanent OBPIs have a worse quality of life compared to the general population. Chapter 3 highlights the cost of a multi-professional simulation training programme for obstetric emergencies. Chapter 4 investigates the cost-utility of simulation training for obstetric emergencies with particular regard to its impact on reducing OBPIs. This study demonstrates that national implementation of multi- professional obstetric training can be both cost-effective and cost-saving. Part 2 of the thesis uses a 'top-down' approach and focusses on the role of the state- based medical indemnifier (MI) in influencing and improving patient care. Chapter 5 explores how MIs engage with clinical staff and offers some recommendations for how they could have a more effective role in patient safety. Chapter 6 demonstrates that obstetric simulation training is associated with a reduction in the maternity claim rate and mean monthly litigation cost. Chapter 7 identifies the rate of low 5-minute Apgar scores as a predictor of future litigation. Finally, Chapter 8 provides an overall summary of the thesis and its key messages.

Obesity, as defined as a BMI ≥ 30 (kg/m2) had been established as a risk factor for increased morbidity and mortality during childbearing. There was a need for empirical research to explore the experiences of obese women and midwives during childbearing to stimulate debate and inform the delivery of care to this client group. This thesis provides a justification for a qualitative interpretivist study using semi-structured interviews with a small group of obese women (N=13) and midwives (N=11). This study found that once an obese mother has been placed on the high-risk medicalised pathway, her choices are reduced and the ability to bring a sense of agency and choice to promote and support her own health is limited. The relationship with the midwife, which could have been focused on promoting the health and wellbeing of mother and baby, instead becomes a relationship of managing risk in a reductionist way. This makes it harder for both mothers and midwives to raise the issue of obesity, resulting in a tendency not to deal with the issue. Subsequently, the opportunities for health promotion offered by the midwife-mother relationship sustained over 7 to 8 months are lost, so that encouraging self-understanding and self-help in managing and reducing obesity cannot be achieved. The findings of this study suggest the need to enhance the health promotion role of the midwife. This thesis suggests reviewing the use of BMI, developing discussions about gestational weight gain and healthy lifestyle choices with women during antenatal care, and listening to mother's lay theories, perceptions and concerns around weight. Midwifery care, which uses positive discourses and forward-facing care approaches and supported by continuity of carer schemes and access to midwifery-led care, could enhance the midwife's health promotion role. This could lessen the risk of post-partum weight retention post-birth and enhance a new mother's physical and emotional well-being.

This study has taken a modified action research approach to explore the understanding held by midwives working across four healthcare facilities in the Kabarole district of Uganda about antibiotic resistance and antibiotic stewardship. Antibiotic resistance is fast becoming a threat to the health of the global population. Antibiotic resistance arises when an antibiotic becomes ineffective at treating a bacterial infection which it once could. Antibiotic resistance is a natural phenomenon, but the ineffective use of antibiotics, such as inappropriate prescribing by healthcare professionals and poor adherence to prescribed regimens by patients, is increasing the speed at which resistance is developing. Antibiotic stewardship is the name for a collective group of activities that aim to prolong the effectiveness of antibiotics. In using a modified action research methodology the study has gone through five cycles of action using a mixed methods approach to data collection. Data collected from observational work that was informed by ethnographic approaches, and secondary data analysis were used throughout the five cycles. Interviews with midwives were used in three of the five cycles. Findings from the first two cycles of action found that knowledge held by midwives about antibiotic resistance and antibiotic stewardship was lacking. The remaining three cycles of this study sought to bridge these knowledge gaps. An evidence base for antibiotic stewardship was presented to the midwives in the form of a training session. This session was followed up with monthly feedback for the midwives reporting on their responses to the evidence base in terms of their adherence to antibiotic stewardship practices. Findings have demonstrated that a simple intervention in the shape of a training session combined with monthly feedback and a longitudinal approach to mentorship, have supported the midwives in this study to progressively bring their antibiotic stewardship activities into line with evidence-based guidelines. The extent to which the antibiotic stewardship practices of the midwives in this study changed to align with evidence-based guidelines differed between individuals and healthcare facilities. These findings underline the important role that context plays in behaviour change. Future efforts to modify the practice of midwives should take this factor into consideration when designing interventions aimed at changing behaviours.

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.

This study aimed to explore the personal constructs of mothers in health care, their own role, that of the doctors and how they felt the doctors they consulted construed them in their role. In addition, the study aimed to explore how these construals influenced whether a consultation was considered satisfactory or less than satisfactory. The preferred poles relating to the role of mothers identified by participants across the study included being calm, in control, nurturing, attentive, knowledgeable and confident. How participants felt perceived by doctors was reflected in a number of constructs including whether they were nurturing, calm and were able to balance the needs of the child with the demands of the consultation. Participants in the study overall experienced more satisfaction with doctors they perceived as warm, empathic, compassionate, competent and attentive. Satisfaction also correlated with feeling in control, knowledgeable, calm and being able to attend to the doctor whilst demonstrating care and nurturance to their child. Satisfactory experiences were linked in the study, to feeling validated in their role, accurately anticipating the outcome of the consultation and a greater sense of mutual understanding with the doctors. The study offers an interesting reflection on the influence of both personal agency and societal factors on how the role of mothers is viewed. It also offers recommendations regarding how doctors may consult with mothers to develop a positive and productive interaction and outcome.

This PhD study examines the impact of moderated social media based groups for pregnant women on the provision of information and support. During pregnancy and early motherhood, women need information and support from health professionals, other pregnant women and mothers. Whilst women have access to overwhelming amounts of information they may not have contact with, or support from, other pregnant women and new mothers. Such relationships are fundamental for a supported transition to motherhood. This thesis explores the concept of Communities of Practice as a framework for social learning, and seeks to explore if and how Communities of Practice can develop from online groups to improve information provision and support for pregnant women and new mothers. A qualitative methodology, with a modified action research component, was used to explore women’s experiences, the concept of Communities of Practice and the potential for their emergence from an online group. Two midwife moderated online groups were created with 31 pregnant women (n=17, n=14). Data were collected using focus groups (k=8) every 3 months and individual interviews (k=28) in the early postnatal period. A thematic analysis framework, informed by Communities of Practice theory, was used to interrogate the different data at different points in time. This generated process findings on which to act; and new knowledge to understand whether and how a Communities of Practice approach could be adopted as a new model of support within midwifery. The key findings show that women will engage with midwives and other pregnant women through social media and doing so improves their pregnancy experience. Information and support needs can be met through such groups and, furthermore, midwifery relational continuity can be achieved. Communities of Practice can emerge from online groups but they are not essential for information and support needs to be met, or for relational continuity. However, Communities of Practice can provide greater information convergence and the potential for sustained relationships. Mutual engagement is the key Community of Practice dimension which differentiated the groups and signified that one group had evolved into a Community of Practice. Midwife moderated social media based groups may provide a solution for service providers who thus far have struggled to provide relational continuity which is vital for quality, but so often lacking from traditional models of maternity care.

Labour induction and caesarean section are childbirth interventions experienced by a growing number of women globally each year. These two medical procedures are often linked in maternal health literature through the cascade of interventions, an intervention pathway defined by labour induction at the start of birth and operative delivery at the end. While the maternal indicators of labour induction have been well documented in countries such as the United States, considerably less research has been done into which women have a higher likelihood of labour induction in the United Kingdom, and how the risk of labour induction is associated with operative delivery in the UK. This project examines the maternal risk factors of labour induction in the United Kingdom and how these indicators are related to the likelihood of operative delivery, using data from the Millennium Cohort Study. The thesis first uses logistic regression to explore which maternal characteristics are associated with labour induction in the United Kingdom, and determines that maternal educational qualifications and the deprivation of a woman’s electoral ward have significant associations with likelihood of labour induction. In the second analysis chapter, this project examines health care context by utilizing multilevel logistic regression to analyse if risk of labour induction varies by NHS Trust. Results from these analyses determine that risk of labour induction does vary by NHS Trust, the influence of maternal educational qualifications on labour induction risk varies by NHS Trust, and country of NHS Trust is a significant predictor of labour induction. Finally, in order to better understand how the cascade of intervention operates in the United Kingdom, the third analysis investigates the link between labour induction and type of delivery using multinomial logistic regression and KHB mediation analysis. This analysis finds that women who are induced are more likely to experience operative delivery, and that this relationship is mediated by epidural anaesthesia. Additionally, maternal height moderates the associations between labour induction, epidural, and delivery type, such that women between 1.60 and 1.69 metres tall are more at risk of operative delivery after labour induction and epidural than women at shorter or taller heights. This project finds that maternal demographic and socioeconomic indicators influence the risk of labour induction, and that the association between labour induction and operative delivery can be mediated by epidural anaesthesia and moderated by maternal height, within the health care context of the United Kingdom. Determining which women are more likely to experience labour induction and operative delivery in the UK can allow women to make more informed choices about their health care and can help support efforts to provide women with individualized, patient-centred care during their labours and births.

Background: In Oman, 33.3% of women attended late for publicly funded antenatal care in 2015 and 24% did not attend for the recommended 4-6 visits during their pregnancy. This low attendance suggests a need to explore attendance for antenatal care for low-risk pregnant women in Oman. Methodology: An exploratory qualitative design informed by constructivist grounded theory methodology was used in this research. Methods: In-depth semi-structured interviews were conducted with an initial purposive sample of nine pregnant women. The initial analysis enabled theoretical sampling of thirteen non-participant observations during women's appointments, interviews with ten care providers, and six women who booked late after 12 weeks of gestation. A constructivist grounded theory analytical framework of initial, focused and theoretical coding was followed to analyse all the data collected. Findings: The core category consists of five interrelated sub-categories: perceived benefits and value of antenatal care; timing of the first antenatal visit; woman-carer interactions during antenatal care; experiences with antenatal care delivery; and supplementary use of private healthcare. The integral categories explain the social processes and issues surrounding antenatal care. The emergent core category, Navigating antenatal care, reflects the views of the women and their care providers. The women were unhappy with the organisation and physical environment of care but attended their appointments to ensure optimal pregnancy outcome and to alleviate their fears of developing complications. Thus, they used both private and public healthcare and sourced online information in response to their feelings of obligation to protect their fetus. Conclusion: The women appeared disempowered and to lack control over the care they received. Thus, they accepted conditions such as long waiting times in an uncomfortable environment and the disrespect they encountered during their visits. There was a discrepancy between what the women expected and needed from their antenatal care and the actual care and information they received, which did not satisfy their needs. This could be due to a lack of woman-centred care and limited involvement in the plan of care. Thus, women sought further reassurance by accessing private clinics, using online information, and networking with others, which also resulted in a late booking for public antenatal care.

Evidence synthesis is considered a corner stone of modern health care and clinical practice. Systematic reviews of randomised trials, when undertaken with meta-analysis provide summary estimates on the effectiveness of interventions. However, the findings of meta-analysis are often limited by the selective reporting of primary studies, and the variations in population, intervention and outcomes. Furthermore, difficulties in disentangling the study and individual level associations in meta-analysis make them susceptible to ecological fallacy, and may lead to incorrect conclusions. Meta-analysis using Individual Participant Data (IPD) has the potential to overcome many of the above limitations, by using raw trial data. Access to IPD minimises problems from incomplete or incorrect reporting of trial outcomes, by verifying reported results, and by standardising the definition of outcomes where possible. Importantly, this allows detecting any variation in the effects of interventions according to characteristics of the participants. Amalgamated individual datasets assembled to address the effectiveness question, can be further used to explore secondary objectives such as the relationship between surrogate and clinical outcomes. This maximises the use of available clinical data, and addresses the problem of research waste. In this thesis, I evaluated the effects of diet and physical activity based interventions in pregnancy on maternal and offspring outcomes using both study-level and IPD meta-analyses, and assessed the differential effects of interventions on outcomes according to mother's BMI pre or in early pregnancy. I reviewed the variation in outcomes reported in this field, and developed composite outcomes for IPD meta-analysis. I also evaluated the relationship between weight gain in pregnancy and clinical outcomes in pregnancy using the IPD meta-analysis methodology. Aims The aim of this thesis was to evaluate the effects of diet and physical activity based interventions in pregnancy on clinical outcomes using standard and advance methods of evidence synthesis; assess the variation in outcomes and their clinical importance in a trial with those interventions and examine the relationship between gestational weight gain and important clinical outcomes. Methods Delphi methodology, systematic reviews of literature, and meta-analyses using study-level and individual participant data of randomised controlled trials (RCTs). Results Composite outcomes Developed composite outcomes comprise of four maternal (gestational diabetes, hypertensive disorders in pregnancy, preterm birth, caesarean section) and four offspring outcomes (stillbirth, small for gestational age, large for gestational age, and admission to neonatal intensive care unit). The components to assess maternal composite outcome were available in two-thirds (66.7%, 24/36) and for offspring composite in half (50%, 18/36) of the studies in the IPD meta-analysis. The effect of interventions was not statistically significant neither on the maternal nor on the offspring composite - Odds Ratio (OR) 0.90 (95% CI 0.79, 1.03) and OR 0.94 (95% CI 0.83, 1.08), respectively. The direction of the pooled effect was consistent between the composite and its components for the maternal composite and variable for the offspring outcomes. 6 Effects of diet and physical activity based interventions The IPD meta-analysis of 36 RCTs (>12 500 women) showed a significant effect of diet and physical activity based interventions in pregnancy in reducing gestational weight gain (Mean Difference -0.70 kg, 95% CI -0.92, -0.48) and chance of caesarean section delivery (OR 0.91, 95% CI 0.83, 0.99) in comparison to routine antenatal care. There was no effect of the interventions on any of the offspring complications. Incorporation of outcome data unavailable on study-level returned more modest magnitude of the summary estimates in comparison to effects obtained using study-level data of trials that shared IPD. The addition of study-level data from non-IPD trials changed the magnitude and the statistical significance of the summary effects on GDM - from OR 0.89 with only IPD (95% CI 0.72, 1.10; 27 studies, 9 427 women) to OR 0.76 (95% CI 0.65, 0.89; 59 studies, 16 885 women). It has also changed the funnel plot structure in the meta-analysis for gestational weight gain (Egger's test p = 0.04 with only IPD to p= 0.61). The IPD meta-analysis shows that the effects of diet and physical activity based interventions on the maternal and the offspring outcomes did not differ by women's BMI status. While the study-level meta-regression indicated that the interventions might reduce gestational weight gain stronger for the obese women - coefficient -0.22 (95% CI -0.33, -0.11) for each 10% change in the proportion of women in the obese class. Outcomes in trials with diet and physical activity based interventions 66 primary publications from trials with diet and physical activity based interventions in pregnancy reported 142 outcomes. Half of those outcomes appeared in the publications once (72/142). 'Critically important' outcomes are reported less often in comparison to 'non-critical' ones (15.5%, 22/142 vs 68.3%, 97/142). The overall quality of outcome reporting varied between trials with the least frequently provided information on the methods to improve the quality of outcome measures (33.3%, 22/66 publications). 7 Gestational weight gain and pregnancy outcomes IPD from 4 429 pregnant women randomised to the control arms of RCTs with diet and physical activity based interventions were available for the analysis. Women who most often exceeded the IOM recommendation belonged to the overweight (51.5%, 641/ 1 245 women) and the obese groups (44.5%, 695/ 1 562 women) while women with normal BMI most often gained below the recommended amounts (40%, 649/1 622 women). Each kilogram of gestational weight gain within the IOM ranges was not link with a change in the chances of preterm birth, caesarean section, or birth of LGA and SGA infant. Not achieving of the recommended weight was associated with the decreasing chance of giving birth to LGA infant with each kilogram below the lower limit among the obese women (OR 0.80, 95% CI 0.65, 0.99). Each kilogram of weight gain above the upper limit was associated with an increase in the chance of caesarean section (adjusted 1.04, 95% CI 1.01, 1.08) and delivering LGA infant (adjusted 1.08, 95% CI 1.05, 1.12) regardless on women's BMI status. Conclusions Diet and physical activity based interventions in pregnancy moderately reduced gestational weight gain and decrease the odds of caesarean delivery. Overall, IPD meta-analysis improved the robustness of the evidence synthesis of RCTs with diet and physical activity based interventions. However, more attention is needed for the data-related issues in IPD meta-analysis as the purported benefits of the method are not always practically realised. The use of the composite outcomes was hampered by the variable availability of important clinical outcomes. The introduction of minimal core outcome set would facilitate the comparison of the wide range of the evaluated interventions and improve implementation of the composite outcomes. Gestational weight gain was found to be associated with the odds of delivering LGA infant and caesarean section. Future research should aim to collect and report a minimal set of outcomes, and ensure better reporting of study conduct and its findings.

This is a phenomenological study exploring the experiences of seven birth mothers who relinquished a child for adoption between 1960 and 1990. The aim of the study is to understand the depth and breadth of the experience of relinquishment and to establish whether the impact of relinquishment is long-term. This study explores the relationship between the moral values and social policies that existed during the era of the study and how these factors influenced the birth mothers' decision-making. The objective of the study is to use the findings to develop therapeutic guidance for practitioners working with birth mothers who have lost a child through adoption. The data was gathered through semi-structured interviews and was analysed using Interpretative Phenomenological Analysis. The women provided compelling accounts of lives consisting of secrecy, shame and loss, harsh treatment by family and professionals, and an absence of any emotional support. Additionally, most of their stories had not been heard before. Three master themes emerged from the findings: 1) The power of social stigmatisation; 2) The unique experience of relinquishment; 3) Experiencing psychological distress. The study shows that the impact of the experience of relinquishment is indeed long term, with a diminishing of the intensity of emotions over time. The lack of acknowledgement of the experience was a significant contributory factor in the longevity of the impact. Clinical implications and recommendations for practitioners who support birth mothers in Adoption Support Agencies are presented. It is anticipated that the recommendations will also be useful for practitioners currently supporting birth mothers whose children have been, or are presently being, taken into care and subsequently adopted. Many of the themes identified in this study, such as loss and stigmatisation, have been shown in the literature to be also present for this group. The findings and clinical implications would therefore have some relevance in supporting these birth mothers.

Health professionals and women accessing health care are increasingly recognising the importance of shared decision making (SDM) within pregnancy. Despite recognition, implementing SDM and truly supporting an informed choice is suggested to still be lacking in clinical exchanges. Literature focuses on creating ways and tools to support SDM in health care. One possible way is to incorporate Decision Support Tools (DST) into practice. Evidence within the context of general health care shows they improve knowledge and satisfaction with information, however less is known about DST use in pregnancy. MyBirthplace was developed by a National Health Service (NHS) Trust in response to both a local and national call for information in accessible formats and to enable women to be more informed about their choice regarding place of birth; as hospital birth is still seen as the norm. The primary aim of this thesis was to assess how effective a new DST called MyBirthplace is in helping make this decision. The impact of the DST was assessed using the Stages of Decision Making Scale (SDMS) (O’Connor 2000). Secondary aims were to; identify when women make a decision about place of birth; explore women’s information gathering and decision making behaviours during pregnancy to understand women’s views and opinions about using the DST; and to determine the use of the DST by their midwives. A mixed method, multiphase, sequential exploratory design was conducted with 172 pregnant women within one large urban NHS Trust. The study involved three phases. Phase 1 utilised questionnaires given to the participants’ pre and post the first appointment with the midwife where they had access to the DST. Phase 2 followed up these women via a survey sent at 28 weeks of pregnancy. In phase 3, face to face interviews were conducted with 12 women purposively chosen from the initial two phases. Finally, data were retrieved from the hospital database to identify actual place of birth. This study provides new evidence that the use of MyBirthplace positively affects women’s decision making. The DST resulted in a positive increase in decision making (reduced conflict) and by the 28 week follow up there was a significant shift with greater decision-making. Women’s views showed a division in the level of information they found acceptable, but in general they valued MyBirthplace as a source of information to help make them aware of their choices. Women highlighted the role a midwife plays in supporting them to be proactive in accessing MyBirthplace and the way in which midwives frame information affects women’s choices. Unfortunately, for some women the midwives acted as a barrier, making them rethink their birth options or not providing women with information about MyBirthplace. These findings provide a unique view of both the effectiveness of MyBirthplace and women’s views regarding choice for place of birth. The findings fill the gap highlighted by the recent maternity review that asked for more information to be given to women and to be available in different formats. DSTs have been found to be valuable in aiding women in decision making about place of birth but only when the midwives are engaged, supportive and women are introduced to MyBirthplace at the first appointment.

Background: Institutional delivery rates in India have improved in the past decade, but maternal mortality remains high. The aim of this study was to describe current referral pathways and transport services for pregnant women in the Indian public health sector to identify strategies for strengthening the referral system for emergency obstetric care. Methods: I conducted three literature reviews; a health provider’s KAP survey of staff in primary level public health facilities from two states; analyses of ‘108’ ambulance service data from six states; and telephone interviews of women who called this service in two states. Results: The reviews found no standard protocols or guidelines for referral of women with obstetric high-risk or complications in India, and over half of pregnant women attending primary level health facilities were referred. There was poor quality institution referral care and no studies on the effectiveness of transport interventions. The KAP study found staff had sub-optimal knowledge and practice for screening common high-risk conditions and complications, and low confidence and resources to manage emergency situations. Less than a quarter of pregnancies and institutional deliveries in the study populations used ‘108’ ambulances. Most women called the service for normal labour: only 4.3% had an obstetric emergency and 5.8% were inter-facility transfers. Of pregnant callers to the ‘108’ service, one third reported a high-risk condition or early complication in pregnancy. Women transported using other means were more likely to use private facilities than those transported by ‘108’. Conclusion: The quality of obstetric care at peripheral health centres is suboptimal and the high proportion of referrals could be avoided. The ‘108’ ambulance service is underused, especially in emergency situations. India’s health systems should improve the provision of obstetric care by standardising services at each level of health care. Strategies are required to increase the use of ‘108’ services for obstetric emergencies.

Normal birth, defined as birth without induction of labour, anaesthetic, instruments or caesarean section conveys significant maternal and neonatal benefits. Currently one-fifth of women in the United Kingdom are obese. There is increasing evidence of the detrimental effects obesity has on intrapartum outcomes. There is a lack of research on how to minimise the associated risks of obesity through non-medicalised interventions and how to support obese women to maximise their opportunity for normal birth. This thesis aims to provide evidence to address this gap and develop an evidence-based intervention to promote normal birth. Using a methodological approach aligned with pragmatism, this research was conducted in four parts and underpinned by the Medical Research Council framework for the development of complex interventions. Part one was a national survey involving 24 maternity units. Part two was a qualitative study of the experiences of 24 health professionals and part three involved 8 obese women. The final part was a multi-disciplinary workshop that used consensus decision-making to design the intervention. Collectively, the findings suggest that intrapartum care of obese women is medicalised. Health professionals face challenges when caring for obese women but many strive to optimise the potential for normal birth by challenging practice and utilising ‘interventions’ to promote normality. The findings also demonstrate that obese women have an intrinsic fear of pregnancy and birth, have a desire for normal birth and ‘obese pregnancy’ presents a window of opportunity for change. The intervention consists of three component parts; an educational aspect (e-learning package), a clinical aspect (intrapartum care pathway) and a leadership aspect (ward champions). Whilst acknowledging the importance of safety, increasing intervention during labour for obese women may further increase the risk of complications, with detrimental effects. Addressing intrapartum management of obese women through non-medicalised interventions is of paramount importance in order to promote normality, maximise the opportunity for normal birth and reduce the associated morbidities.

Over 275,000 women died of pregnancy related causes in 2015. Most occur in resource-poor settings and are preventable. This study aimed to improve the working lives of maternity healthcare workers in Malawi to enable delivery of higher quality care, using Appreciative Inquiry (AI); a positive-focused, participatory action cycle. Following a systematic review and narrative synthesis of AI, an ethnographic study and Interpretative Phenomenological perspective were utilised to understand working lives. Before the intervention was implemented, working lives were assessed through validated questionnaires for staff and patient satisfaction surveys. AI has been used in healthcare, but little empirical evidence for its effectiveness exists. Staff wanted to do a good job, but were confined by a lack of resources, knowledge and support. The longitudinal survey of staff showed significant improvements in general wellbeing and home-work interface, and patient satisfaction improved. AI also improved staff relationships and made work easier and happier. Qualitative work suggested this was because staff were working better together, underpinned by everyone meeting together. From these findings a theory of change was developed. AI showed great promise. However, further research, in the form of a large-scale trial, is needed to empirically demonstrate the effectiveness of AI in healthcare.

Background: There is a need for more studies that analyse evaluation methods in the context of maternal health promotion. These should assess the effectiveness of health promotion interventions on health outcomes, factors contributing to impact, and transferability. This thesis reports on an evaluation of one such intervention in Nepal targeting rural women to promote maternal health. Methods: A mixed-methods approach was used where, first, a Difference-in- Difference (DiD) estimation assessed the effects of the intervention on selected outcome variables while controlling for: 1) a constructed wealth index; and 2) women’s socio-economic characteristics in a five-year controlled, non-randomised, repeated cross-sectional study of a community-based health promotion intervention targeting maternal health in Nepal. Second, the qualitative data were analysed to explore the knowledge, attitudes, and beliefs of women post-intervention. Finally, the financial data were analysed to identify resources needed and estimate the cost of the health promotion intervention. Results: After five years, women in the intervention area were more likely to seek antenatal care at least once, to take iron/folic acid, and to attend postnatal care. The intervention did not influence women’s place of birth or likelihood of receiving care from a skilled birth attendant. However, it did improve attendance for the recommended four antenatal visits for the first two and a half years. The qualitative findings helped explain some of the changes or lack thereof, where in the intervention area women were perceived, by the researcher, as empowered, confident, and the family as supportive. The cost of providing the health promotion intervention per group/woman and the evaluation process consisted of only 10% of the total programme cost. Conclusion: This is the first community-based health promotion intervention that has demonstrated a greater impact during pregnancy (i.e., uptake of antenatal care) than around birth (i.e., changes in delivery care). Other factors, not easily resolved through health promotion interventions, may influence birth outcomes, such as financial liquidity or geographical constraints. The evaluation showed that using mixed methods provided valuable information that would not have been extracted through one method alone. While DiD is a precise tool for measurement, the qualitative research provided insight into why the intervention had an impact in pregnancy but not at birth.

Background/Aim: Historical evidences indicate that maternal health care by a skilled birth attendant is one of the key strategies for maternal survival. However, the rate of maternity care utilisation and reduction of maternal death is very low in Nigeria. This study was designed to investigate factors influencing access to emergency obstetric care with a view to guiding programmatic efforts targeted at overcoming these barriers and also contribute to health reforms in Nigeria. Hence, the need to understand factors influencing access to emergency obstetric care in Nigeria using the Socio-ecological Model (SEM) and Gender and Development (GAD) to identify associated factors operating at different levels. Methods: A mixed method was employed for this study. Data collection used questionnaires and in-depth interviews. Questionnaires were distributed to 330 respondents of which 318 of them were retrieved and qualitative in-depth interviews were conducted for 6 participants. Data collection were done using a sequential approach. The study was conducted in one of the tertiary health facilities in Nigeria from January-April, 2015, amongst mothers aged 15-45 years meeting the study inclusion criteria. Statistical Package for Social Sciences (SPSS) was used in analysing the quantitative data. Bivariate and logistic regressions were conducted for the quantitative data whilst a qualitative content analysis was done for the qualitative data. Results: The study established that education, income level, costs associated with seeking care, distance and time taken to travel were significantly associated with maternity healthcare services utilisation. Quality of service, staff attitude and women's autonomy showed consistent significant association with maternal health care utilisation. Conclusions: The study concludes that; costs of treatment, distance and time, income level, staff attitude and women's autonomy were critical in determining women utilisation of maternity care services. Recommendation: As an outcome of this research, best practice framework has been developed. The framework presents a coherent and systematic approach for achieving sustainable MH by providing a roadmap for instituting measures at the policy, health facility, community and at the individual levels, taking into account factors that are likely to promote or impede the achievement of sustainable MH.

The importance of the pregnant woman’s autonomy and the role of increased choice in decision-making relating to her maternity care have gained widespread recognition. This is borne out in the healthcare and bioethics literature, key initiatives in policy documents and clinical guidelines. Although guidelines are a central feature of maternity care, little is known about how their recommendations are experienced by women and the impact on their autonomy. This thesis addresses that gap in knowledge. The methods I used in this research comprised a literature review and an empirical study consisting of semi-structured interviews with 20 participants in an inner-city teaching hospital. Data collection, transcription and analysis were informed by adaptation of the Constructivist Grounded Theory approach (Charmaz: 2006). My analysis generated two main thematic categories. First, women lack the appropriate in-depth pregnancy and birth knowledge to make decisions independently. Second, interactions with trusted professional carers were highly valued. Analysis suggested new insights, namely that the meaning of autonomy to women is more complex than self- government, a range of options and relational responsibilities can account for. Women felt empowered by being a genuine participant in the decision-making process. They expressed their autonomy by being invited to share their previous experiences, current expectations and concerns and request information in a manner consistent and timely with their own agendas. Women’s responses were also shaped by considered reflection of the impact of their decisions on others. My analysis revealed that some level of interdependence may be a precondition for women to exercise their autonomy. It is a paradox that the recommendation professionals should follow guidelines and be non-directive may result in the unintended consequence of women exercising their autonomy by in part reinstating authority to professional carers. Interpretation of findings led to the development of my grounded theory, ’Choosing when to choose’.

This dissertation outlines the relationship between obstetric violence, and colonial era conditioning. Examining South Africa’s post-1994 public health system, I argue societal norms, political-economic arrangements, health systems, and their policies, have established structural violence which generates and spreads a continuum of violent practices within reproductive health services. The rationalisation and obfuscation of violence against Black women throughout the colonial and apartheid periods, including coercive contraception protocols, indexes more than simply gender-based violence in health services. I propose a theoretical underpinning: obstetric structural violence to explain what I argue is a particular type of violence against women. I interrogate the systematic violation of sexual and reproductive health rights enacted by health systems, resulting in: 1) non-consensual constraint of reproductive autonomy, 2) preventable maternal and neonatal disability, 3) mortality. Part 1 analyses the colonial conditioning that led to health services becoming constitutive of racial, and gendered structural violence. Historical stereotypes of sexuality are linked to rationalisations of contemporary obstetric violence. Examining the political-economy of the democratic period, Part 2, demonstrates how constant reform and limited power undermine low-level managers capacity to ensure the functioning of accountability, thereby propagating obstetric violence. Drawing on extensive qualitative fieldwork within seven primary–tertiary hospitals, I describe how routine, as well as episodic, physical and psychological forms of direct obstetric violence are pervasive. I argue these outcomes prove the connection between obstetric violence, adverse health, and obstetric malpractice, a fact often absent from related literature. Lastly, I argue the resultant case law and individual awards from obstetric malpractice for incurred patient harms, encourages the invisibility of obstetric, and obstetric structural violence.

'Reconceptualising the Birth Process in Eighteenth-Century England' employs a broad range of historical sources to construct a richly detailed account of childbirth. By examining women's life-writings, manuscript recipe books, medical texts, court records, collections of folklore, Anglican prayerbooks and material culture this thesis moves away from an historiographical focus on the delivery of the infant to explore the embodied experience of 'giving birth' in the eighteenth-century from the perspective of the labouring woman, her family and the friends and neighbours that visited her. Birth, it is argued, was a process of four distinct phases that lasted between four and six weeks in total. These phases - confinement, labour, delivery and lying-in - were flexible, highly adaptable and indispensable components of 'giving birth'. In exploring birth as a process, this thesis challenges the dominant historiography of the rapid professionalisation of childbirth during the eighteenth century by tracing high levels of continuity in community practices of childbirth management. By broadening the focus of research to include each phase of the birth process this thesis highlights the wide range of cultural, social and emotional behaviours that constituted the embodied experience of giving birth. In reconceptualising childbirth as a process, the thesis refocuses attention on the woman giving birth and the rich networks of friends, family and neighbours that were so crucial to the management of birth in eighteenth-century England.