Background: Northern Uganda is recovering from a 23-year civil war that was largely confined to the region. During this period the rest of Uganda enjoyed a rapid GDP growth rate following wide-ranging macroeconomic reforms by the Ugandan government and its development partners. A post-recovery programme was implemented for Northern Uganda; however, the region still has the worst health status. This contributed to the country’s failure to attain MDG five for maternal health. Limited research has been conducted to determine which national and health system governance factors influence performance and affect access and utilisation of health care in countries like Uganda that have witnessed the dual context of conflict and non-conflict. A better understanding of the governance and policy development process in such settings is required if health policy adoption and implementation is to be more appropriate to the needs of the country’s entire population. Methods: A Political Economy Analysis framework was applied to compare governance factors at national and sub-national level in post-conflict Northern Uganda and in non-conflict East Central Uganda that had influenced the provision and utilisation of maternal health care. An analysis of constitutional, economic and health policies determined contextual factors, while data collected through in-depth interviews and focus group discussions with decision-makers, implementers and communities determined the institutional and agency features. The features were used to access power and accountability relationships and incentives that drove the actions of health system stakeholders in central government, health ministry, district local government and civil society as well as in the local communities during the post conflict period in the Northern and East Central Uganda. Findings: The post-conflict period in Northern Uganda coincided with evidence of increased national political commitment to addressing the healthcare needs of Northern Uganda. However, the President, International Funding Institutions and Finance Ministry technocrats who were the dominant governance stakeholders pursued an approach to economic development that prioritised funding for the development of energy, transportation and defence sectors over that for healthcare. Women parliamentarians emerged as maternal healthcare policy champions but played a limited role in highlighting the special health needs of Northern Uganda. The Health Ministry lacked the political and technical capacity to adapt and implement maternal health care policies to specific sub-national needs. NGOs focused on human rights advocacy in Northern Uganda that enhanced the community’s demand for appropriate healthcare while in East Central Uganda they mainly addressed supply-side issues. Political patronage at national and sub-national levels negatively influenced supply and demand for healthcare. In Northern Uganda donor funding, district-based development partner presence, and CSO health system demand-side activities moderated a more positive influence. Conclusion: Decentralisation offers greater opportunities for health system recovery in settings of confined conflict but is prone to elite capture and corruption in peaceful settings within the same national context. Women leaders are critical in the development of a national health system where there is confined conflict, but political and traditional norms limit their role in the promotion of universal healthcare coverage. Despite the presence of factors that portended better maternal healthcare in the post-conflict setting, the limited involvement of the health ministry in the recovery process diminished the impact. CSOs in collaboration with communities play an important role in enhancing the responsiveness of the health system but are prone to political intrusion. The comprehension of policies, economic processes and social institutions of a country recovering from confined conflict enables the identification of variables which, if addressed, will lead to versatile, equitable health systems for all citizens.

Mother and Baby Units (MBUs) are recommended for the treatment of women requiring admission while pregnant or in the first year following childbirth. In this thesis, the experience of such an admission was explored. In the systematic review, the evidence relating to psychological outcomes from a MBU admission was synthesised and critically evaluated. This included outcomes relating to maternal mental health, the mother-child relationship and child development. Further aims focused on evaluating the quality of the available research, the efficacy of specific treatments and the utility of various assessment tools. A total of 23 papers met the inclusion criteria for this review. Overall the findings were highly positive, indicating a beneficial impact on maternal mental health and the mother-child relationship, and the absence of negative effects on child development. However these findings were limited by the relatively poor methodologies employed, with most studies including no comparison group nor any follow-up after discharge. There was insufficient evidence to explore the impact of specific interventions. It was possible however to make recommendations regarding the appropriateness of specific tools for both clinical and research purposes, as well as to identify further research priorities. The impact of one aspect of a MBU admission was explored in the empirical paper: the experience of compassion from nursing staff. Compassion is an increasingly discussed concept in the National Health Service (NHS) and is incorporated into the NHS Constitution, the values statements of various NHS Trusts and the code of ethics for nursing staff. Despite the differences between MBU admissions and admissions to general psychiatric inpatient units, no research had previously explored the experience of compassion by mothers admitted to a MBU. Repertory Grid interviews were completed with 15 mothers regarding their perceptions of both psychiatric and nursery nurses. The findings indicated the central role of compassion as well as its perceived impact on recovery. Additional valued characteristics in nursing staff included the ability to cope in stressful situations without becoming overwhelmed, and a willingness to be flexible in the application of rules and professional boundaries. The implications of these results for both nurses and managers are discussed, as well as future research directions. The final paper consists of a critical reflection of the research and the research process. This includes an evaluation of the decision making processes and discussion of the strengths and weaknesses of this research.

This thesis sought to work towards a better understanding of eenagers who have more than one pregnancy within the UK, where there is currently very little literature. To achieve this, there were three distinct strands of research: firstly, a scoping review to identify evidence on the characteristics of young women who have more than one pregnancy and their individual experiences; secondly, a data linkage study bringing together birth registration records with abortion notification records to identify the proportion of teenagers who have more than one pregnancy in England and Wales and the patterns of these according to pregnancy outcome (birth or abortion); and finally, an Interpretive Phenomenological Analysis study to explore young women’s experiences of becoming pregnant following an abortion. The findings revealed that aside from not using long-acting reversible contraception (LARC), there appeared to be few features that characterise a subgroup of young women who are more likely to have more than one pregnancy. As such, perhaps al previously pregnant teenagers should be treated as ‘high risk’ for further pregnancies. Moreover, it was not possible through the data linkage study to more accurately identify the proportion of subsequent teenage pregnancies in England and Wales. This was primarily due to the lack of a unique personal identifier on both datasets. This thesis therefore advocates a change in routine data collection to include NHS number on all abortion notification forms to maximise the use of these data. The qualitative findings highlighted that, while there were some collective narratives, each young woman’s story also had its own unique features. They were faced with a range of choices as they tried to manage their fertile lives following an abortion. However, these choices were situated within broader social contexts and sometimes they had little to tangibly choose from. Pregnancy was often a reassessment point where the young women looked at where their lives were heading, their relationships, and their sexual behaviour, and made changes - but in the unpredictable and changing world of adolescence, these were often not maintained.

This study was initiated following the high maternal mortality ratio in Rivers State, Nigeria, which stands at 889 maternal deaths per 100,000 live births. Approximately two thirds of Nigerian women deliver their babies outside of health facilities and without medically skilled attendants, thereby, indicating the need for a risk communication, thus increasing the chances of potentially avoidable maternal deaths. A mental models approach to developing risk communication was applied to this study to elicit the knowledge of maternal health experts and lay people, in order to achieve a better understanding of factors that lead to maternal death. The intent is to discover better ways of engaging the stakeholders to achieve a better understanding of the risk in order to enable an improved risk communication in the maternal health sector. An expert mental model about maternal mortality has been developed based on literature review, and expert interviews. This model provides a framework of components that influence the high rates of maternal mortality seen in the State. The concepts within the model were used as a guide in developing questions for use in semi-structured interviews with the lay participants (Rivers State women of childbearing age). This led to the derivation of 6 emergent themes (religion, negative perception of government’s health provision/responsibility, compassion and skill of workers, influence of native midwives, lack of maternal health information, folklore, customs and tradition), and a diagram illustrating participant’s mental models. Comparison of the expert’s and women’s mental models revealed vital beliefs, knowledge gaps and misconceptions in the women’s understanding. The prevalence of the emerging information was further tested with a wider sample of women participants through means of a questionnaire survey. Finally, analysis of findings led to the derivation of key risk communication messages for the women. The original one-way mental model approach was adapted to become a two-way model, which includes critical findings from the lay participants for expert attention, potentially encouraging a holistic communication solution. While the mental model approach is established in risk communication research, this is the first known application to the maternal health field. The mental models of experts and participants that emerged identify the diverse ways stakeholders perceive the issue, and components that influence risk attitudes and health care behaviour. On the basis of the findings, key messages have been suggested that may instil behavioural change.

Hyperemesis Gravidarum (HG) is a severe form of nausea and vomiting of pregnancy that is distressing, debilitating and potentially life threatening. This thesis presents qualitative, exploratory data of the experience of HG from the perspective of women with the condition and the health care professionals (hep's) caring for them. The study originated from difficulties identified by hep's managing HG in a hospital setting. The purpose of the study was to provide data to inform the development and improvement of services for women with HG.

The aim of this study was to explore whether professional home postnatal care in n Northern Ireland (NI) and the Republic of Ireland (ROI) meets women's expectations and needs. s. This was the first study of Irish community postnatal services in a Border area. The study site was a hospital tmst located in Northem Ireland in a Border area that serves pregnant women from either side of the Border. In NI midwives care for all women for a period not less than 10 days and longer if necessary. In the ROI. a different model of care exists whereby the public health nurse visits less often initially but provides care for families with infants over a longer period up to and including the school years. Key findings were that some ROI mothers received the minimum of two visits by the public health nurse. ROI mothers valued home visits up to three months after the birth but wanted more visits in the early postoatal peiiod. More advice about maternal health was needed and more help with infant feeding was required.

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This exploratory research study describes a child and adolescent psychotherapeutic clinical service offered to children/adolescents and their families with mothers with a life-threatening illness. The clinical service itself was also exploratory in nature. The research objectives of the study were (i) to explore whether this form of clinical work could be beneficial for such families in relieving distress and supporting their development; (ii) to discover the factors at play within and between the family members using an adaptation of Grounded Theory research methodology; and (iii) to add to the knowledge base for adults – family members and professionals – relating to, and dealing with, such children and adolescents. Descriptions and discussion of the therapeutic input and research study are given. Symptoms, which included emotional, behavioural, psychological, learning, and interpersonal difficulties, decreased in all the children/adolescents who were offered clinical treatment within an outpatient multidisciplinary Tier 3 Child and Adolescent Service (CAMHS). Six Themes were identified across the cases and these were named: Engagement, Parental Concern, Impact of Mother’s Illness, Defences, Sustaining Factors and Feeling Different. These Themes are discussed in the light of relevant published research. A literature review was undertaken and focuses on: epidemiological context; children’s understanding of death; impact of parental bereavement in childhood; the mourning process; anticipatory grief; psychoanalysis: mourning and trauma; children’s play and drawings as communication; and psychosocial therapeutic services. The thesis has particular relevance for child and adolescent psychotherapists and other mental health professionals who work within hospital and hospice settings.

Out of the diversity of possible ways of knowing in maternity and health care, there has emerged a hegemonic emphasis on knowledge that is based on scientific principles. Arguably, there is also a role for intuition in healthcare. Indeed, leading midwives, educationalists and researchers in related fields have hailed the important role of intuition in advancing midwifery practice and education. A review of the literature shows that there is a dearth of research exploring the nature and use of intuition in midwifery practice. This descriptive phenomenological study explores the experiences and use of intuition in a cohort of seven independent midwives across the South and Midlands area of the United Kingdom. The study explores what midwifery intuition is for them and how they incorporate this form of knowing into the complexity of their midwifery practice. The study found that the experience and utilisation of the independent midwives’ intuition is a complex phenomenon that included the reception of subtle cues, own emotions, bodily-felt sensations, images and dreams. Such ways of knowing provided practice-relevant knowledge that can be either specific or non-specific and can serve various levels and kinds of use (for example, from directly increasing generalised alertness to specific directions for treatment). The findings result in a novel typology of the essence of midwifery intuition and the different nuanced ways it comes to be utilised, developed, and confirmed or disconfirmed within the holistic trajectory of practice. The study concludes with a consideration of how the findings contribute to existing scholarship in the area as well as the implications for practice and education. This comprises how the identification of the salient elements of the midwives’ intuition has contributed to the understanding of the phenomenon and may aid other midwives and students in developing and enhancing their own intuition. This will provide assistance in enabling intuition to be recognised as a first person rational form of authoritative knowledge to be utilised, and at times, prioritised alongside other forms of practice knowledge. Recognising intuition as part of a holistic knowing will enhance individualised, safe, maternity care for women and autonomous, transparent decision making for midwives. It is recommended that the provision of reflective workshops and reflection during revalidation will enable clarification of the phenomenon and enable other practitioners to develop this form of artistry. It is also recommended that models of care that promote this intimate way of knowing are utilised in maternity provision.