The UK has a relatively large and increasing Black and Minority Ethnic (BME) population. It is acknowledged that this group has, until now, experienced poorer health, and that there have been barriers for them accessing certain services. There are an increasing number of women from Palestine currently living in the UK. Their access to, and use of, maternal and child healthcare (MCH) services have not been investigated before. From an initial review of the literature there does not appear to be any research which has examined Palestinian women’s access to and use of MCH services. This study will address these gaps and explore the access and use of MCH services by Palestinian women in the UK. The overall aim of the study is to investigate the access to, and use of, MCH in the UK by Palestinian women. The specific objectives are: to explore facilitators and barriers to care for Palestinian women in in the UK; to determine what provisions exist which are intended to facilitate access to healthcare services; to explore factors that may demonstrate effective and positive change to health services and to make recommendations for improving the health service provision for Palestinian women in the UK. The study was designed to use a sequential, exploratory, mixed-method, pragmatic approach. In phase one - twenty-two, in-depth, face-to-face, semi-structured interviews were conducted. In phase two - survey questionnaires were distributed through the Palestinian organisations to generalise the qualitative findings and 243 questionnaires were returned from responders. Four themes emerged from the findings of the qualitative interview, which were: ‘cultural variations’; ‘knowledge of the NHS and the UK healthcare system’; ‘healthcare services and their utilisation, focusing on maternal and child healthcare services,’ and ‘communication, information provision and needs’. The quantitative findings focused on issues specific to Palestinian women, although they might resonate with other BME groups. These include: cultural variations, such as the use of herbal medicine; self-prescribed medication (antibiotics); termination of pregnancy (fatalism); circumcision for male babies; breastfeeding practice and preference for a female GP and caregiver; knowledge of the UK health system; confidence in using the English language; interpreter services; late booking of pregnancy; not attending antenatal classes; duration of visit time and information needs. This study strives to reduce inequalities in MCH among Palestinian women in the UK by highlighting the issue surrounding Palestinian women’s access to, and use of, MCH services. It is important to have a culturally sensitive MCH service that is flexible, adequate and accessible. The study concludes with the following recommendations:  Having cultural competence care and adaptive services for Palestinian and all minority ethnic groups are crucial to have equitable services.  Culturally appropriate care could be satisfactorily achieved through effective and continuous training programmes based on culture, ethnicity and religion for all health professionals, in order to understand patient needs.  Interpretation services should be provided to Palestinian women who have the need. Midwives or nurses should provide oral explanations as well as leaflets to allow patients a full choice when making a decision.  An important implication for midwifery-nursing practice is that, when developing education interventions for this population, it may not be appropriate to implement a “One Size Fits All” programme.  Another practical suggestion is to have a videotape/podcast provided explaining all the required information in English and Arabic languages. This could increase the patients’ knowledge about using and accessing healthcare services.

This PhD examines the impact of policies introduced to improve outcomes in health care in England in the first decade of the 21st century, focusing on their impact on outcomes in maternity care. It uses data from the primary hospital discharge data set for English National Health Service hospitals, known as Hospital Episode Statistics (HES). Chapter 1 examines the impact of a "payment by results" policy aimed at improving care outcomes in hospitals. This scheme was known as the Commissioning Quality and Innovation (CQUIN) payment framework. I examine the impact of this policy on csection rates in England. My focus is on the scheme as used in the financial year 2010/11. I investigate whether there are any reductions attributable to the CQUIN scheme in c-sections. [ find that the scheme does not have any statistically significant impact on c-section rates. Chapter 2 investigates the effect of being born on a weekend on the probability of dying among babies born at English NHS acute hospitals. The "weekend effect" has been documented in a range of hospital settings. We examine whether this is still present in maternity care after large increases in hospital staffing during the mid-2000s. We use 2009/10 Hospital Episode Statistics maternity data and control for a wide range of baby's and mother's characteristics. We find that being born on a weekend is not associated with any statistically significant increase in the odds of dying. Chapter 3 examines the use of the hospital (as distinct from the individual) as the unit of analysis in a difference-in-difference analysis. We provide evidence for our theoretical framework with an empirical application of the evaluation of Payment by Results (PbR) scheme, started in 2005/2006 in maternity care. We find that there is no statistically significant association of this scheme on the outcomes. However, we find modest evidence for the fact that NHS acute trusts game the scheme by increasing the amount of antenatal admissions not related to a delivery event. Chapter 4 examines the impact of Maternity Matters Agenda (2009) on maternal outcomes. The policy introduced choice of place of birth among women. This followed the introduction of competition across English NHS acute trusts. I investigate the impact of competition on the quality of maternity services. I find that although the market competition has increased over the 7 year period, this is not associated with any improvements in the level of quality of maternity services.

Reducing substandard care and improving healthcare quality is an NHS priority. Maternity care is a key area where improvements can be made. Through risk management strategies multiple quality-monitoring tools exist, including the clinical dashboard. Maternity dashboards were nationally recommended for use by all UK maternity units in 2008. However, it is unclear to what extent units have implemented dashboards or any associated issues with their use and quality monitoring as a whole.

Limited and inequitable access to skilled maternal and newborn healthcare has been identified as a major contributory factor to poor maternal and newborn health in sub-Saharan African countries, including Ghana. To address the problem of access, the government of Ghana, in 2003, pioneered and is implementing a new maternal healthcare policy that provides free maternity care at the point of delivery in all public and mission health facilities to ensure increased and equitable access and use of skilled maternal and newborn healthcare services. The aim of this doctoral study is to explore how the introduction of the free maternal health policy in Ghana affects access, equity of access, and to investigate barriers to accessibility and utilization of skilled maternal and newborn health services. It does this using data from the Ghana Maternal Health Survey 2007, in combination with qualitative data generated from ethnographic style in-depth interviews and focus group discussions that the author originally conducted with a total of 185 expectant and lactating mothers, and 20 health care providers and policy-makers in six communities in Ghana between November 2011 and June 2012. Survey data suggest that accessibility to, and utilization of skilled antenatal care, delivery in a health facility, delivery with a skilled birth attendant, as well as other post-natal care services have increased by an average of 8% since the introduction of the policy (i.e. between 2003 and 2007).

Although considerable progress has been made in the reduction of maternal mortality in Sub-Saharan Africa in recent years, mortality rates, especially in rural districts, remain critically high, while uptake of family planning and maternal health services is low. International approaches to maternal health have historically focused on low-cost, technical interventions which have failed to address the social barriers to health care experienced by women. International agencies are now calling for the integration of social initiatives with the provision of clinical services in order to address uptake issues and empower women with greater control over their health and bodies. Through an ethnographic examination of the health systems of the Kati district in Mali and the Shai-Osudoku district in Ghana, this thesis investigates the impact of integrating a social component into formal health service delivery on maternal health care. Taking an actor-oriented approach, I focus on the strategies and community networks generated by the health workers whose actions produce the health care relationships which are central to improving the uptake of services. I conclude by suggesting that the patterns generated by health worker strategies indicate the gaps inherent in the health systems in which they operate, and provide insight into how the integration of social and clinical components might be improved to benefit maternal outcomes.

Despite significant recent improvements, maternal mortality remains high in Malawi. To address this, the Government prioritised strategies promoting skilled birth attendance. However, in a country where 80% of the population resides in rural areas, there are tremendous barriers to institutional deliveries. Historically rural women have been supported in childbirth by Traditional Birth Attendants (TBAs), and by skilled birth attendants (SBAs) at the health facility. In the past, TBAs were trained to help bridge the gaps in provision and accessibility of care but in the 1990’s, the WHO recommended halting their training because it was perceived as ineffective for maternal mortality reduction. In 2007, the Government of Malawi issued Community Guidelines to promote skilled birth attendance and banned TBA utilization for routine deliveries. This grounded theory qualitative study used interviews and focus groups to explore community actors’ perceptions of the 2007 Policy Guidelines and their implementation, and how the Policy affected the decisions and actions of rural women regarding their delivery care. Findings from this study indicate that although all actors may agree that delivering at facilities is safest when complications occur, this does not necessarily ensure their compliance. Women, men and TBAs particularly, perceived the Policy as prescriptive. Furthermore, the implementation of the policy aggravated some of the barriers women already faced. Issues of disrespectful and neglectful care at facilities also partly led women towards non-compliance. Furthermore, a view from the ground demonstrated that the Policy had led to a rupture of linkages between TBAs and SBAs, which have had a detrimental effect on the continuum of care. This study helps fill an important gap in research concerning maternal health policy implementation analysis in LICs, by focusing on the perceptions of those at the receiving end of policy change, and on their needs, and aspirations.

People often behave in ways that are not in their best long term interest. Financial incentives are increasingly being used by governments to persuade individuals to improve health-related behaviours. In developing countries, financial incentives have been shown to increase uptake of preventive health interventions, but it is not well understood whether financial incentives are effective when targeted towards more complex types of care or when implemented at scale in low-income countries. This thesis explores the impact of financial incentives on health seeking behaviour, in the context of the Safe Delivery Incentive Programme (SDIP) in Nepal. Launched nationwide in 2005, the SDIP seeks to encourage greater use of professional care at childbirth by providing cash to women after they give birth in a health facility, as well as an exemption from user fees for those residing in the least developed districts. The thesis develops a theoretical model of the programme's causal pathway and draws on consumer choice theory to derive a set of predictions. These are tested empirically using a variety of econometric methods applied to household data (from a secondary data source and a primary data source). The analysis comprises three main parts. First, it estimates the demand for maternity care using discrete choice models to understand the most important factors influencing a household's decision of where to give birth. By focusing on the role of price, this analysis serves as an ex-ante evaluation of the SDIP. Second, it investigates implementation of the SDIP. The analysis uses a number of key process indicators that emerge from the conceptual framework to explore what factors may have constrained the implementation process. Third, it estimates the impact of the SDIP on health seeking behaviour at childbirth in two areas of Nepal using propensity score matching and longitudinal methods of analysis. It finds that the programme had a modest impact on utilisation of women who had heard of the SDIP, but because programme uptake was low, it has led to only a small increase in skilled birth attendance across the entire population. Implications for financial incentive programmes and maternal health care in low- income countries are explored.

Skilled attendance at delivery is crucial for decreasing maternal and neonatal mortality. My literature review showed that epidemiological research on factors influencing whether women receive skilled attendance has so far been hampered by a lack of data on health service availability, and is often restricted to investigating household and individual factors. Distance to health services, however, is likely to play an important role. The availability of geographic coordinates in both national household survey, population census and health facility census in Zambia provides the opportunity to combine user and provider information on a large scale. These datasets were linked to investigate the influence that distance has on place of delivery, while adjusting for other influential factors such as education, wealth and autonomy in a multilevel model. Classifying Zambian health facilities according to their level of delivery care showed that 88% of facilities are not staffed or equipped to provide even Basic Emergency Obstetric Care (EmOC) and therefore cannot save a mother's life in case of complications. Around half of the Zambian population lives further than 15km from a Basic EmOC facility; less than 10% in urban areas and over 70% in rural areas. Using data from over 3000 rural births, I demonstrate that the odds of delivering in a facility are 4 times higher within 1km of a facility as compared to 20km, and additionally 2.5 times higher if that facility offers Comprehensive EmOC rather than substandard care. If all mothers lived within 5km of Basic EmOC, 16% of home deliveries could be avoided, a population attributable fraction of similar magnitude as for education or wealth. Lack of geographical access to EmOC is a key factor explaining why most rural deliveries in Zambia still occur at home without skilled care; this needs to be addressed to lower maternal and neonatal mortality.

Nepal achieved the Millennium Development Goal 5 by reducing its maternal mortality by more than two thirds. This achievement has been credited to Female Community Health Volunteers (FCHVs) delivering basic Maternal Health Service (MHS) to pregnant women and mothers in their communities. This thesis explores the role of FCHVs in MHS provision in two regions (the hill and Terai ), from the perspectives of health workers, service users, and FCHVs themselves. Data were collected between May 2014 and September 2014 using qualitative methods. Semi-structured interviews were conducted with 20 FCHVs, 11 health workers and 26 women in villages. In addition, four focus group discussions were held with 19 FCHVs and field notes were taken throughout the data collection. Data were analysed using thematic analysis. The study found that most participants viewed FCHVs as a valuable resource in improving MHSs. In both regions, the FCHVs raised health awareness among pregnant women or mothers and referred them for check-ups. They shared health messages through mothers' group meetings and the meetings were also used for discussions around budgeting and finance, which sometimes left little time for discussion on health topics. Such activities, combined with the FCHVs’ lack of education, often proved to be counterproductive to their service provision. The roles of FCHVs were crucial in the hill region where there was limited access to professional healthcare. An important area of FCHVs’ work involved accompanying and assisting women during delivery. In addition, they distributed medicines, administered pregnancy tests and informed women about emergency contraception and availability of abortion services. The FCHVs used novel methods to share maternal health information: for example, they sang folk songs which contained health messages or visited new mothers with food hampers. Such services were invaluable for women in the remote hill villages, who otherwise would not have received any healthcare. In terms of their motivations to volunteer, this study found that FCHVs viewed their work as a form of basic human and social responsibility. In addition, they reported feeling empowered as a result of training and socio-economic opportunities. However, a lack of financial and non-financial incentives was the key hindrance for them in delivering their services, followed by their perception of community misunderstanding about their services. In addition, health system factors such as lack of medical supplies and irregular supervision hindered them in carrying out their role effectively. In general, volunteers in the Terai received less support than those in the hill region. Furthermore, FCHVs perceived a lack of respect by some health workers towards them. A lack of coordination between government health centres and non-governmental organisations was also noted. The thesis concludes with several recommendations for policy makers, practitioners and researchers in order to improve the services by FCHVs. These include providing the FCHVs with context specific support - financial and non-financial incentives, access to supplies, educational training, and supportive supervision - to enable them to deliver services more productively. Recommendations are also made for ensuring that FCHVs are recognised and respected for their contribution to MHSs by local health workers and their communities, as well as coordinating activities among local organisations that mobilise FCHVs to ensure that their services flourish in the future.

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.