Background Midwifery units (MUs) provide midwife-led care for women at low risk of complications. They may be located on the same site as an obstetric unit (OU), in a hospital without obstetric services or separate from any hospital. In MUs, if unforeseen complications arise, transfer to an OU may be necessary. Aim To provide evidence to contribute to the improvement of the transfer process, help make transfer safer and less distressing for women, thereby improving the care and experience of women planning to give birth in MUs. Methods A structured literature review of existing evidence was followed by three integrated component studies using different methods. The content and quality of local NHS transfer guidelines were evaluated. Data from the Birthplace national prospective cohort study were analysed to estimate transfer rates, describe the transfer process and identify factors associated with transfer. The experiences of women transferred were explored in qualitative interviews. Findings Transfer is a common event, affecting around 25% of women planning birth in MUs, although rates in different units vary. Primiparous women are more likely to be transferred than women having a second or subsequent baby. The risk of transfer for primiparous women increases with increasing age; around 50% of women having their first baby aged 40 years or over are transferred. Local NHS transfer guidelines are generally of poor quality and pay little attention to women’s experience. Women interviewed after transfer report feeling unprepared for transfer. Sensitive care and clear communication from midwives during labour facilitate feelings of control in women and help women accept transfer as the right decision and not a 'negative' event. Transfer that is perceived by women as “too late” can have potentially serious and long-lasting negative effects. Women’s experience of the transfer journey could be improved by the offer of choice in a number of areas which would help women feel 'cared for' rather than 'transported'. Having the MU midwife continue to care for the woman after transfer should be considered 'best practice'; where this is not possible a good handover is essential. Women who have experienced transfer should be offered the opportunity to talk to a midwife about their experience.

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.

Objectives: The purpose of this study was to examine rural women s access to maternal health information and its impact on levels of skilled healthcare utilization. Method: A qualitative study involving twenty five (25) pregnant women,five (5) Skilled healthcare providers and five (5) Traditional Birth Attendants (TBAs) was conducted in Chamwino District in Dodoma Region, Tanzania for a period of six months. Due to time and resource limitation the researcher selected two (2) of the 32 wards in the district where the problem of maternal mortality and non-utilization of skilled healthcare was most prominent. The two selected wards were Msanga and Buigiri wards. The researcher used The Health Belief Model and Theory of Planned Behaviour to develop interview questions and focus group guides as well as the interpretation of the findings. The researcher examined how variable factors e.g. maternal health literacy, individual perceptions, local knowledge and care provider-related factors affect pregnant women s health behaviours and utilization of skilled maternal services. The Data was analysed thematically using the 6-stage guide to thematic data analysis with the help of NVIvo Software. Results: The inadequate conditions of the health facilities and the poor working conditions of the care providers affected the provision of quality of maternal services and health information to pregnant women in the study area. The limited access to skilled maternal health information from skilled healthcare providers and lack of alternative sources of reliable health information led pregnant women to seek health information from their Mothers-in-laws, TBAs and other women in the society. However, there was a shortcoming of information inaccuracy as their health advice was not based on previous expert advice but rather on the personal opinion and attitude towards skilled maternal services. The limited access to maternal health information caused majority of pregnant women to underestimate the risks of pregnancy related complications and how they responded to pregnancy danger signs and other ill-health conditions that raised during pregnancy. The majority of pregnant women reported not to seek and kind of care when experienced a health problem. It was also found that during labour some would go to the TBA for childbirth and later go to the dispensary when the TBA failed while others would just go for TBAs opinion and confirmation that it was real labour then go to the health facility. This delayed women s timely access to obstetric care which is essential for positive outcome when a pregnant woman experiences a pregnancy or childbirth complications. Conclusion: The improvement of the quality of skilled healthcare services in rural areas is a prerequisite for achieving desired outcomes in maternal mortality reduction efforts in Tanzania. However, improvement of quality itself is not a panacea if pregnant women are not aware of the services, hence the healthcare providers should also focus in increasing provision of maternal health information to pregnant women. The findings show that the limited access to skilled maternal health information from healthcare providers and lack of alternative sources for reliable health information has constrained majority of these women from becoming maternal health literate hence affecting their levels of utilization of skilled maternal services. The healthcare providers and policy makers should focus on meeting the health information needs of general rural populations and enable them to become well-informed and knowledgeable to make better and well-informed maternal health decisions.

Background: This research explores whether rural Community Maternity Units (CMUs) contribute to NHS Scotland’s Quality Ambitions of safe, effective and person centred care. Currently there is no available recent evidence regarding the quality of this particular model of care in a rural setting. This research makes an important contribution given that most women are encouraged to access local maternity services. Design: An exploratory case study was used with a hermeneutic phenomenological approach to the qualitative data collection and analysis. Quantitiative data were collected and analysed to provide descriptive statistics. Methods: The study was conducted in three phases. In phase one a retrospective medical records review was undertaken to provide quantitative data on the care provided. Phase two was an observation of team meetings, interviews with staff and focus groups with stakeholders in roles aligned to the provision of care at the CMUs. In phase three observations of clinical encounters and interviews with women informed by aide memoire diaries were used. Findings: Maternity services provided by the CMU teams achieved a consistently high standard of safety and effectiveness when measured against national guidelines, standards and other evidence. The stakeholders appreciated the ability within these small teams to provide local, accessible services to women with effective support when required from tertiary services. The women valued person centred and relationship based continuity of antenatal carer, provided by compassionate named midwives, but were disappointed by the discontinuity when complications occurred. Conclusions: The CMUs’ physical position within the community, smallness of scale and the midwifery team’s ethos of normality within a socially based but medically inclusive service facilitated local access for most women to maternity care. This service provision addressed NHS Scotland’s Healthcare Quality Strategy of improving health and reducing inequalities for the people of Scotland. The role of the named midwife was key to providing high quality care by maintaining connections across contextual boundaries for women experiencing normal and complicated pregnancies. This research provides an original contribution to the study of rural maternity service provision in Scotland to help inform future sustainability and service development of rural CMUs.

PURPOSE: The main aim of this study was to systematically assess women’s maternal health care seeking behaviour and its determinants in Addis Ababa, Ethiopia. DESIGN: A quantitative and cross-sectional community based study was the selected methodology for this study. METHOD: Data was collected using structured questionnaire administered to 903 women aged 15-49 years through a stratified two-stage cluster sampling technique. Binary and multinomial logistic regression models were employed to identify predictors of adequacy of antenatal care and delivery care. RESULTS: Most of the women (97.9%) visited health care facilities at least once for antenatal care follow up. About 86.5% of them had at least four visits during their last pregnancy; and only 51.1% started their first antenatal visit early. Further, only about one out of five of the antenatal care attendees received sufficient content of antenatal care services. Consequently, only about one out of ten women received overall adequate antenatal care mainly due to inadequate use of the basic components of antenatal services. Most of the women delivered in public health care institutions (76.3%) despite the general doubts about the quality of services in these facilities. Women of better socioeconomic status preferred to give birth at private health care facilities. Caesarean section delivery rate in Addis Ababa (19.1%) is higher than the maximum WHO recommended rate (15.0%); particularly among the non-slum residents (27.2%); clients of private health care facilities (41.1%); currently married women (20.6%); women with secondary (22.2%) and tertiary (33.6%) level of education; and women who belong to the highest wealth quintile (28.2%). The majority (65.8%) of the caesarean section clients were not informed about the consequences of caesarean section delivery and about 9.0% of the caesarean section births had no medical indication. CONCLUSION: Disparities in maternal health care utilisation between the socio-economic groups was evident, requiring urgent attention from policy makers and other stakeholders to enable Ethiopia to meet its millennium development goal 5. Improving the quality of antenatal care in public health facilities which are the main provider of health care services to the majority of the Ethiopian population is urgent. The increase in the rate of caesarean section beyond the World Health Organization recommended upper limit has to be taken seriously. / Health Studies / D. Litt.. et Phil. (Health Studies)

PURPOSE: The main aim of this study was to systematically assess women’s maternal health care seeking behaviour and its determinants in Addis Ababa, Ethiopia. DESIGN: A quantitative and cross-sectional community based study was the selected methodology for this study. METHOD: Data was collected using structured questionnaire administered to 903 women aged 15-49 years through a stratified two-stage cluster sampling technique. Binary and multinomial logistic regression models were employed to identify predictors of adequacy of antenatal care and delivery care. RESULTS: Most of the women (97.9%) visited health care facilities at least once for antenatal care follow up. About 86.5% of them had at least four visits during their last pregnancy; and only 51.1% started their first antenatal visit early. Further, only about one out of five of the antenatal care attendees received sufficient content of antenatal care services. Consequently, only about one out of ten women received overall adequate antenatal care mainly due to inadequate use of the basic components of antenatal services. Most of the women delivered in public health care institutions (76.3%) despite the general doubts about the quality of services in these facilities. Women of better socioeconomic status preferred to give birth at private health care facilities. Caesarean section delivery rate in Addis Ababa (19.1%) is higher than the maximum WHO recommended rate (15.0%); particularly among the non-slum residents (27.2%); clients of private health care facilities (41.1%); currently married women (20.6%); women with secondary (22.2%) and tertiary (33.6%) level of education; and women who belong to the highest wealth quintile (28.2%). The majority (65.8%) of the caesarean section clients were not informed about the consequences of caesarean section delivery and about 9.0% of the caesarean section births had no medical indication. CONCLUSION: Disparities in maternal health care utilisation between the socio-economic groups was evident, requiring urgent attention from policy makers and other stakeholders to enable Ethiopia to meet its millennium development goal 5. Improving the quality of antenatal care in public health facilities which are the main provider of health care services to the majority of the Ethiopian population is urgent. The increase in the rate of caesarean section beyond the World Health Organization recommended upper limit has to be taken seriously. / Health Studies / D. Litt. et Phil. (Health Studies)