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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.

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.

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.

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.