Despite its status as a middle income country, Peru has one of the highest maternal mortality rates in the Americas. In the Andes region, poor, rural indigenous women are more likely to die from pregnancy related complications than their urban counterparts because they are denied the same level of maternal health services other women in the country receive. Barriers to care include geographic isolation, health staff members who do not speak indigenous languages, and cultural and ethnic discrimination. As a result, indigenous Andean women in need of maternal health services face a significant degree of social exclusion and institutionalized racism which hinders the accessibility, acceptability, and quality of maternal health services offered to them. One approach to improving access to health services has been through the use of Community Health Worker (CHW) programs. Although CHWs are recognized as an important frontline health source, there is a significant lack of literature concerning their role as community level providers of maternal health services. Using a combined grounded theory and case study methodology, this qualitative study investigates the experiences of CHWs working in Andean communities and their relationships with other community members and health and social service professionals. Findings from this study suggest that CHWs can be enabled to bring care directly to their communities in a way that community members can relate to and feel comfortable with while also forming part of the wider health system. Focusing on participants’ reports of challenging cultural and ethnic boundaries through a process of ethnic bargaining and adopting professional affiliation, this study identifies CHWs as a potentially vital link between rural community members and other providers of these services. If the right factors are met, such as finding ways to navigate the tensions between traditional and biomedical health care models, CHWs can be considered critical community level health providers who can communicate the value of both models, thereby improving the accessibility, acceptability and quality of maternal health services. However, the root causes leading to social, structural and institutional boundaries to care still need to be addressed. As such, this study aims to fill a significant gap in current research on the role of CHWs in Peru, specifically in the ways they are enabled to negotiate ethnic discrimination within the health system.

Breastfeeding practices in Lebanon fall short of international recommendations: despite high breastfeeding initiation, exclusive breastfeeding (EBF) rates are almost nil at 4-5 months. In the Lebanese context, health services are expected to have a large contributing role on early breastfeeding practices. This research aimed at identifying Lebanese stakeholders’ perceptions of barriers to recommended early breastfeeding initiation and EBF till 6 months in the context of health services as well as the political dynamics around existing policies that if implemented would address these health system barriers. A review of systematic reviews of the effectiveness of health services interventions to promote and support breastfeeding initiation and exclusivity revealed that a package of complementary interventions would be most effective. It would include applying maternity ward changes according to the Baby-Friendly Hospital Initiative, facilitating the formation of lay support groups, and tailoring education and support to the setting and needs of the population. Semi-structured interviews were conducted with a purposeful sample of 59 Lebanese stakeholders in early breastfeeding. The framework approach was used for analysing data. Health services barriers included suboptimal antenatal preparedness to breastfeeding, detrimental hospital practices, medicalisation of childbirth, health professionals’ knowledge and attitudes towards breastfeeding and aggressive marketing by breast milk substitutes companies. The socio-cultural context was depreciative of breastfeeding. Using the principles of stakeholder analysis, implementation of key policies endorsed by the Lebanese government was found to be hindered by the Ministry of Public Health’s weak governance and commitment, the weak engagement of key international organisations and professional associations compounded by the financial interests of strong stakeholders in the health care system offered by breast milk substitute companies. Key recommendations include the need for further commitment from government, grassroots advocacy to shift the culture towards demanding appropriate early breastfeeding practices, and implementation of several health services related programmes.

Female Afghan healthcare providers are vital to reduce the number of women dying in labour. Since 2001 the numbers of female providers have been substantially increased. Ensuring quality care for women in childbirth, however, remains a more elusive goal. The aim of this qualitative ethnographic study was to analyse the culture of care of a Kabul maternity hospital and explore the barriers and facilitators to quality care. My particular focus was the experiences, thoughts, feelings, and values of the doctors, midwives and care assistants. Six weeks of participant observation, 23 semi-structured interviews with hospital staff, 41 background interviews and 2 focus group discussions with women in the community, between 2010 and 2012, were used to gather diverse perspectives on childbirth and care in Kabul maternity hospitals. A thematic approach was used to analyse the data. Five themes were identified: the culture of care; motivation; fear, power and vulnerability; challenges of care; family and social influences. Three themes are explored in depth in this thesis. They are discussed in the following order: the culture of care, challenges of care, and fear, power and vulnerability. The influence of family and social norms on healthcare providers was integral to understanding hospital life; it therefore contributes to each chapter. Women in childbirth laboured alone with minimal monitoring, kindness or support. For staff, the high workload was physically and emotionally demanding, resident doctors struggled to acquire clinical skills, midwives were discouraged from using their skills. Family expectations and social pressures influenced staff priorities. A climate of fear, vulnerability and horizontal violence fractured staff relationships. ‘Powerful’ hospital staff determined the behavioural agenda. This study offers multiple insights into healthcare provider behaviour. It reveals complex interrelated issues that affect care in this Afghan setting but its relevance is far broader. It is one of few international studies that explore care from the perspective of healthcare providers in their cultural and social environment. It reveals that understanding the context of healthcare is pivotal to understanding behaviour and the underlying obstacles to quality care. Furthermore, it challenges conventional assumptions about individual staff agency, motivation, and common strategies to improve the quality of care.

Globally, contraceptive technologies have been critical to improving the reproductive lives of women. This thesis examined the decision-making processes among couples in Kwara State, Nigeria. It began with the premise that contraceptive decision-making is a complex process that involves an array of actors and structural forces that operate and intersect at different levels to influence decision-making. Using a mixed method qualitative approach, this thesis used interviews (semi-structured and Key informant), Focus Group Discussions and participant observation as research tools to provide a nuanced exploration of contraceptive decision-making. The promotion of smaller families by the State served as a precondition for contraceptive discussions collectively within the population and individually within the household. Contraceptive knowledge proved insufficient in guaranteeing use, as the decision to use contraception is not a rational process. Decision-making is gendered and this thesis argued that spousal communication is critical to the use of contraception and involved a series of non-linear conversations that occur at different stages in the reproductive life course of a couple. These conversations stressed the role of external influences and highlights the effect friends and family have on the decision making process. Economic and sexual triggers were identified as life events necessary to move spousal communication from the household to the public domain of service provision. Making informed choices on the method of contraception used highlighted some of the challenges faced in providing quality contraceptive services and how women’s bodies are differentiated and ‘modernised’ based on location. This thesis suggests that in order to make improvements to women’s reproductive lives, bodies need to be understood more broadly in relation to the gender dynamics between couples, the community (family/friends and service providers) and service provision (the State, service providers and the international community).

No description available.

Background: In Tanzania, maternal and newborn health outcomes have been slow to improve. The Expanded Quality Management Using Information Power (EQUIP) project was carried out in Tandahimba district from November 2011–April 2014. EQUIP engaged village volunteers in quality improvement processes in which they problem-solved around key issues related to maternal and newborn health in their communities. Examples of community-level quality improvement are rare and there is little documentation of these. Aim: To explore the implementation of community-level quality improvement in-depth, identifying its facilitators and barriers; to analyse community-level quality improvement within the context of community participation; to determine influencers of birth preparedness and health facility delivery; and to evaluate user perspectives around perceived quality of maternal and newborn health care. Methods: A mixed-methods process evaluation in four villages (November 2012– November 2013). A continuous household survey provided quantitative data around household behaviours and perceived quality of care. Results: Mentoring and coaching were required to strengthen volunteer capacities to do quality improvement. Support from village leaders, regular volunteer education, and use of local data were key facilitators of the intervention. Community participation was high with some indication of empowering processes. Volunteer-targeted practices like birth preparedness and health facility deliveries were carried out by a majority of women (95% and 68% respectively). Common reasons for these practices included education around their importance from multiple sources; feeling that making birth preparations would positively impact care received; and male involvement. Qualitative data highlighted instances of disrespectful or abusive care, suggesting improvements in quality of care are still needed. Conclusion: Village volunteers readily participated in EQUIP. With support, volunteers were able to use quality improvement to contribute positively to changing care-seeking and other behaviours around maternal and newborn health. However, improvements in care-seeking must be accompanied by improvements in quality of care.

This thesis examines the complexities of delivering high quality pro-poor maternal child healthcare. The research recognises that good maternal child health (MCH) is a fundamental development imperative in which initiatives are not achieving targets. There is a chronic deficit of well trained healthcare workers and increasing reports of abuse being suffered by poor patients. The research suggests that current mechanistic results orientated approaches to healthcare should be foregone in favour of an appreciation of the fundamentally fluid and social nature of health and healthcare delivery. It is also suggested that whilst current literature focus on either a patient or a healthcare provider perspective, a complete picture of the healthcare transaction is generated by examining the relationship between the two. This research aims to unpack the realities of delivering high quality, pro-poor MCH in the chronically poor district of Kibaale, mid-western rural Uganda. Standing at a disjuncture between policy, conceptual theory and empirical research, this thesis presents the conceptual tool of ‘healthscapes’. It is suggested that healthscapes are an effective approach to read the hegemonic social values of power, gender and care operating in place. Taking a relational view of space and place, it is suggested that individuals plot routes to achieve health aims through a ‘terrain’ constructed by their health knowledge embedded in place. This constructs a knowledge base for individuals which can become authoritative, potentially enabling them to construct informal spaces of health within the formal setting. In the informal spaces, individuals can adapt their behaviour to overcome barriers to the healthcare transaction and ultimately achieve their health goals. By contemplating the healthcare transaction from both the health-seekers’ and the healthcare providers’ perspectives, the post-structural approach challenges conventional understandings of power in health. This nuanced social insight into health-systems could thus be used to inform policy. Based on 18 months of ethnographic fieldwork, the healthscape concept was used to unpack MCH transactions within Bunyoro as a whole, the Antenatal Clinic and the Maternity Ward. The research discovered that despite the prevailing negative perceptions of the government institution, over 60 women attended antenatal a week whilst only five delivered within the maternity ward. The research suggests that within the antenatal clinic, women were able to use their extensive place-based authoritative knowledge to construct informal spaces in which they could influence the healthcare transaction to achieve their antenatal aim. Due to cultural constructions of childbirth, if women presented at the maternity clinic it was ordinarily for emergency reasons. Their lack of experience and need for care meant they had little place-based authoritative knowledge to influence the healthcare transaction and were subjected to the biomedical gaze.

Health inequities are a serious public health concern. Achievements in health equity are particularly challenging to attain in reproductive and maternal health in developing countries. Research exploring this issue is of great relevance, given the extent of such disparities, and as pressure builds to include universal health coverage in the post-­‐ 2015 development goals. This thesis examines equity in reproductive and maternal health services in Cambodia, and two health financing interventions aiming to improve health equity, Vouchers for Reproductive Health Services (VRHS) and Health Equity Funds (HEFs). Study objective 1 was to estimate equity in reproductive and maternal health services in Cambodia over the last decade. Analysis was conducted with Demographic and Health Survey data for six health services between 2000 and 2010, revealing that dramatic improvements have been made in reproductive and maternal health equity since 2000, however inequity remains in use of facility-­‐based deliveries and skilled birth attendance. Objective 2 was to qualitatively explore Cambodia’s poverty identification programme, the ID Poor. Semi-­‐structured interviews were conducted with women, service providers and programme implementers. Extensive targeting errors within the programme were found, with implications for the targeting effectiveness of VRHS and HEFs. Objective 3 was to qualitatively explore low uptake of vouchers in the VRHS project, also using interview data. It was found that vouchers were positively received by beneficiaries and had the potential to influence health-­‐seeking behaviour. However several factors were found to improve future voucher performance. Objective 4 assessed the impact of HEFs on financial protection, service utilisation and health outcomes, using difference-­‐in-­‐differences analysis. Evidence of a financially protective effect of HEFs was found; no effect was found for service use or health outcomes. The thesis contributes to knowledge gaps in the health equity, poverty targeting and demand-­‐side financing literature, and provides practical policy implications based on empirical findings.

The experience of pregnancy loss is difficult and psychologically challenging. Over 14,000 women experience pregnancy loss in Taiwan annually. This thesis set out to understand the journey women travel from pregnancy loss to subsequent pregnancy and eventual motherhood. The design was exploratory, descriptive and action research focused in order to inform practice development. Initially, a phenomenological approach was selected and six Asia women described their experience of birthing a healthy baby following previous pregnancy loss. Interpretative Phenomenological Analysis was used to analyse the transcripts. Subsequently, a structured literature search identified the Stillbirth and Neonatal Death Society (SANDS) information package as an appropriate information resource.

The increasing proportion of teenage girls of West Indian origin presenting for legal NHS abortions at the two teaching hospitals in a district of South London prompted the setting up of this study (1979-81, funded by the DHSS). The study's main aims were to ascertain whether, in fact, the proportion of girls of West Indian origin was higher than would be expected in the district, which has a sizable population of long-settled West Indian immigrants; if so, to identify the most important contributory factors and to make appropriate recommendations for changes or improvements in the services, in order to bring about a reduction in the number of unwanted pregnancies. In all, 550 teenage girls were interviewed: 220 after termination of their pregnancies, and 217 after the birth of their babies; a small comparison group of 113 teenagers who had never been pregnant was recruited in the district's hospital and community family planning clinics. Interviews were conducted using a semi-structured questionnaire and the results compared, where possible, with other similar studies. This survey data, together with systematic and non-systematic observations made throughout the period of the study, were used to give support to the hypotheses. About a third of both groups of pregnant teenagers were of West Indian origin. This was higher than anticipated. Since socio-economic differences did not provide immediate explanations, certain hypotheses were tested which derived from the apparent importance of types of inter-personal relationships (specifically, mother-daughter and boy-girl) as predictors of the risk of a teenage girl experiencing an unplanned and initially unwanted pregnancy. The method of contraception (if any) used by a teenager at the time of her first sexual experience, provided a useful indicator of the type of relationship a young couple had. Girls of West Indian origin appeared to find themselves when they became sexually active, in "segregated" relationships with their partners (as opposed to "integrated" relationships), relationships typified from the study's viewpoint, by the non-use of any form of contraception, at least in the relationship's initial stages. Once having identified what seemed to be a key to the problem (exemplified in the classification of relationship types devised) the question of how best to utilise this knowledge arose. It was suggested that the study's classification of relationship types could provide a useful frame of reference for those health professionals most closely concerned with young women and young men. Recommended changes in the services centred upon changing the attitudes of service workers towards young people, in the hope of improving their image and making them more approachable. It was suggested that a lay visitor on the wards who would also be available to give advice during those family planning clinic sessions directed specifically at young people, would provide invaluable support for teenage girls who had experienced an unplanned pregnancy.