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Pregnancy and childbirth presents both rare and critical events for which healthcare professionals are required to acquire and maintain competent clinical skills. In theory, a skill demonstrated using simulation will transfer into practice competently and confidently; the strength of simulation appears to lie in its validity with clinical context. Evidence shows that some professionals have difficulty responding appropriately to unexpected critical events and, therefore, there were two main aims: 1) to learn more about how healthcare practitioners develop skills in order to prepare for and respond to rare, critical and emergency events (RCEE) during childbearing, 2) to uncover healthcare practitioners’ experiences of simulated practice. An explanatory sequential mixed methods approach consisted of a quantitative systematic review combined with a framework analysis of curricula documentation. Subsequently, a conceptual framework of simulation was explored through qualitative inquiry with twenty five healthcare professionals who care for childbearing women. Attribution theory proved useful in analysing these experiences. Findings illustrated the multifaceted and complex nature of preparation for RCEE. Simulation is useful when clinical exposure is reduced, has the potential for practice in a safe environment and can result in increased confidence, initially. In addition, teamwork, the development of expertise with experience, debriefing and governance procedures were motivational factors in preparedness. Realism of scenarios affected engagement if they were not associated with ‘real life’; with obstetric focus, simulation fidelity was less important and, when related to play, this negatively influenced the value placed on simulation. The value of simulation is positioned in the ability to ‘practise’ within ‘safe’ parameters and there is contradiction between this assumption and observed reality. Paradoxically, confidence in responding to RCEE was linked to clinical exposure and not simulation and was felt to decay over time, although the timeframe for diminution was unclear. Overwhelmingly, simulation was perceived as anxiety provoking and this affected engagement and learning. Data highlights ambiguity between the theoretical principles of simulation and the practical application.

Current policy (DoH 2004a), in response to critiques of the biomedical model of pregnancy, advocates choice and control for women within maternity care and promotes women as active childbirth consumers and decision-makers. This model equates choice to increased quality of experience, in the recognition that pregnancy and childbirth are both a physical and psychological experience. However to date the assumed psychological benefit of offering women choice remains unproven. The aim of this thesis is to explore women's psychology and experiences of pregnancy, and early motherhood, within the context of choice in contemporary maternity care. This will be achieved by assessing the impact of women's pregnancy and childbirth management choices on psychological well-being in the antenatal and postnatal periods and examining the ways in which women perceive and relate their experiences of pregnancy and childbirth and early motherhood in the context of their choice. This thesis argues that understanding of women's maternity experiences necessitates a need to go beyond traditional accounts. Whilst it is important to assess how women respond emotionally to pregnancy, childbirth and new motherhood, there is further a need to comprehend the meanings and understandings that women attach to their maternity experience. Hence, in an attempt to address its own critique, this study adopts a mixed methodology design and uses both a prospective cohort research design and a narrative approach within a single study. In doing so, it addresses the conflict inherent in the use of traditionally opposing methodological stances and argues for a pragmatic approach which aims to understand women's psychology and experiences through a multi-dimensional and integrated frame. Results revealed that no one care option revealed psychological benefit. The statistically significant differences observed occurred over time and exposed largely corresponding profiles across the groups. The mixed method approach promoted a powerful and illuminating interpretation of the concept of choice in maternity care. Women's narratives revealed the strong and powerful role that maternity influences and discourses play in constructing idealised identities, for women, across their maternity experience. These influences underpin and inform how women represent their psychological status and both facilitate and/or constrain maternity choices.

For the past two decades, English health policy has proposed that women should have a choice of place of birth, but despite this, almost all births still take place in hospital. The policy context is one of contested evidence about birth outcomes in relation to place of birth, and of international debate about the safety of birth in non-hospital settings; partly as a consequence of this, 'birth place decisions' have become morally and politically charged. Given the perceived lack of consensus about birth place safety, this study sought to explore the experience of making birth place decisions from the perspectives of women and their partners, in the context of contemporary NHS maternity care. -- Longitudinal narrative interviews were conducted with 41 women and 15 birth partners recruited from three English NHS trusts, each of which provided different birth place options. Initial interviews were conducted during pregnancy, and follow up interviews took place at the end of pregnancy and again up to three months after the birth. Altogether, 141 interviews were conducted and analysed using a thematic narrative approach. -- This research contributes new knowledge about how birth place decisions are undertaken and negotiated, and about the extent to which some are excluded from these choices. Participants' beliefs about birth place risk originated in upbringing and drew upon normative discourses which positioned hospital as an appropriate setting for birth. Individual worldviews informed conceptualisations of birth place risk, and these were premised upon prioritisation of medical risks of birth, perceived quality of the maternity service or the likelihood that medical intervention would interfere with birth.

Aims: The aims of this thesis were to investigate the risk of severe maternal morbidity amongst women from different socioeconomic groups in the UK, explore why these differences exist and compare these findings to the setting in Australia. Methods: Three separate analyses were conducted. The first used UK Obstetric Surveillance System (UKOSS) data to assess the incidence and independent odds of severe maternal morbidity by socioeconomic group in the UK. The second analysis used quantitative and qualitative data from the 2010 UK National Maternity Survey (NMS) to explore the possible reasons for the difference in odds of morbidity between socioeconomic groups in the UK. The third analysis used data from the Victorian Perinatal Data Collection (VPDC) unit in Austra lia to assess the incidence and odds of severe maternal morbidity by socioeconomic group in Victoria. Results: The UKOSS analysis showed that compared with women from the highest socioeconomic group, women in the lowest 'unemployed' group had 1.22 (95%CI: 0.92 - 1.61) times greater odds associated with severe maternal morbidity. The NMS analysis demonstrated that independent of ethnicity, age and parity, women from the lowest socioeconomic quintiJe were 60% less likely to have had any antenatal care (aOR 0.40; 95%CI 0.18 - 0.87), 40% less likely to have been seen by a health professional prior to 12 weeks gestation (aOR 0.62; 95%CI 0.45 - 0.85) and 45% less likely to have had a postnatal check with their doctor (aOR 0.55; 95%CI 0.42 - 0.70) compared to women from the highest quintile. The Victorian analysis showed that women from the lowest socioeconomic group were 21% (aOR 1.21 ; 95% CI 1.00 - 1.47) more likely and that Aboriginal and Torres Strait Islander women were twice (aOR 2.02; 95%CI 1.32 - 3.09) as likely to experience severe morbidity. Discussion: The resu lts suggest that women from the lowest socioeconomic group in the UK and in Victoria have increased odds of severe maternal morbidity. Further research is needed into why these differences exist and efforts must be made to ensure that these women are appropriately prioritised in the future planning of maternity services provisio n in the UK and Australia.