In developing countries, hundreds of thousands of women still die shortly after giving birth and thousands who make it to survive suffer with short-term or longterm health problems related to pregnancy and childbirth that impact their quality of life. However, empirical evidence shows that the majority of these women did not receive any care after delivery. Unlike antenatal and obstetric care, relatively little is known about the factors that explain levels of postpartum care use. This thesis examines the utilisation of postpartum care services in the context of Thailand, which is best known among the developing countries for its success on maternal and child healthcare improvement. Thailand's maternal mortality rate is low (12 deaths per 100,000 live births) and 92 per cent of women have at least four antenatal visits and 97 per cent of women deliver in hospitals. However, rates of postpartum service use remain low at 61.2 per cent. The thesis considers the explanations for low levels of postpartum service use observed in Thailand from a range of perspectives: women, health providers, policy actors and interrelationships among them. Using sequential mixed methods, the study first examines quantitatively the contemporary context of postpartum services and the individual-level factors influencing the use of postpartum services. This is followed by a qualitative analysis which explores the attitudes and perceptions of women, health providers and policy actors towards postpartum care services. Analyses reveal interacting influences that facilitate and impede women's use of postpartum care service. Whilst the quantitative study reveals several demographic, socio-economic and motivating factors, the qualitative study shows that women's perception of the content of postpartum care services and healthcare systems, as well as their experience of encounters with health providers, have significant impact on decisions whether to use postpartum services. The health service delivery system has some significant negative impacts on women's use of postpartum services. Although Thailand has had postpartum care policies in place since the 1960s, the significance of postpartum care for the mother's health has been neglected. The study finds that there is a complex array of individual, health system-related and political factors that influence the utilisation of postpartum care services. Unless adequate attention is given to these factors and their interrelation, it is unlikely that women's use of postpartum care services will be improved.

Background: Postnatal depression is a global health problem with lasting effects on the family. Government policy is focussed on early intervention and increasing access to psychological therapies. There is a growing evidence base for the use of computerised CBT packages and this study investigated the feasibility of a CBT-based self-help internet intervention for new mothers. Objective: To assess the ability to recruit mothers, deliver an internet course, obtain follow-up data and evaluate what mothers think of the course. Design: A feasibility randomised control design was used to compare a waiting list control group (delayed access= DA) to the Enjoy Your Baby course (immediate access= IA). Measures were administered at baseline and 8 week follow-up. Methods: Adverts were placed in the Metro freesheet, on charity web pages, on social media, posters were put up in the community, and leaflets were handed out at mother and baby groups. Participants had to be 18 years old or over with a child less than 18 months old. The IA arm was given access to the course straight away. After 8 weeks all participants were asked to recomplete the original measures and those in the IA arm also gave feedback on the course. Participants in the DA arm were given access after recompleting the questionnaires. Due to a lack of follow-up data a small discussion group was conducted. Intervention: The course contains 4 core modules including helping mothers understand why they feel the way they do and helping them build closeness to their babies. Additional modules, worksheets and homework tasks were available. The DA group were given a list of additional support resources and services, and encouraged to seek additional help if required. All participants received weekly automated emails for 12 weeks as they worked through the course. It was not possible to deliver individualised support. 34 Results: Despite using a number of recruitment strategies, recruitment was lower and slower than anticipated, and attrition was high. 41 women, primarily recruited via the internet, were randomised (IA n=21, DA n=20). No significant differences were observed between participants in either arm at baseline and no statistically significant differences were identified when the demographics and baseline measures of participants who logged-on to the course were compared to those who did not, or when participants who completed follow-up measures were compared to those who did not. Pre and post intervention scores on the EPDS approached statistical significance (P=.059, r=.444) favouring the intervention arm. The discussion group suggested strengths of the course and recommended areas for improvement, including making the course more mobile friendly. Conclusion: Internet interventions show promise; however it is difficult to recruit mothers, engagement is low and attrition high. A number of recommendations are made and a further pilot or an internal pilot of a larger substantive study should be conducted to confirm recruitment and retention. Trial ID: ISRCTN90927910.

Postnatal depression is detrimental to maternal health and wellbeing, associated with poor developmental outcomes in children, and has prevalence estimates ranging from 13-60%; as such it is of significant public health concern and its origins are of interest from an evolutionary perspective. A growing movement within evolutionary research highlights the utility of evolutionary theory to elucidate the origins of health issues and indicate both novel approaches to treatment and prevention. A relatively longstanding, yet largely untested, existing evolutionary approach to postnatal depression proposes that it is a mechanism facilitating maternal investment decisions. More recently it has also been framed, somewhat complementarily, as the result of an evolutionary mismatch. Using the responses to a retrospective survey study which collected the complete reproductive histories of women and was uniquely designed to capture their experiences of postnatal depression, the first data chapter of this thesis explores whether there is support for adaptationist hypotheses that postnatal depression exhibits good design as a mechanism guiding maternal reproductive trade-offs. The results, combined with critiques put forward here and by other authors, suggest an alternative approach to postnatal depression is warranted. A limitation of both evolutionary and more traditional approaches to postnatal depression is that the commonly recognised risk factors for the condition fail to capture all the women who develop the condition. Recent developments in research into general depression, as opposed to postnatal depression, have highlighted the role of the immune system in symptom aetiology. This has led to a number of evolutionary researchers proposing that depression reflects an evolved inflammatory response to biological and social threat, with perceived social threat acting as an indicator of the likelihood of imminent biological threat. Inflammation then acts as the ultimate risk factor in the causal pathway to depression, and by extension postnatal depression, and suggests more attention needs to be paid to the social perceptions of women during pregnancy and early motherhood. Data chapters 3-6 explore the social pressures surrounding women about motherhood, the role such pressures play in generating feelings of shame (an emotional marker of social threat causally linked to general depression development), and the ability of shame to predict postnatal depression. Particular attention is paid to pressures surrounding socially approved levels of maternal investment, namely in the form of bonding. Bonding is of interest due to the documented association between postnatal depression and poor bonding as well as the pressures placed on women in contemporary, developed populations, highlighted by sociologists and feminist scholars, as a result of the emphasis on the importance bonding for child development. The role of social isolation, another form of social threat linked to general depression, in postnatal depression risk is also assessed. In so doing, a new model for maternal emotional investments is developed based on embodied capital theory and the results of two further data sets are presented - the first is a longitudinal survey study tracking women across the perinatal period assessing their experience of social pressure, shame, and postnatal depression, and the second an experimental priming study designed to assess if social threat can be primed using popular and social media relating to mothering. Results derived from these studies are supportive of the perception of social threat being a largely unrecognised risk factor in postnatal depression and the thesis concludes with a discussion of the public health implications which stem from this novel insight.

Background: Postnatal depression (PND) is a global problem and an important public health issue. It is estimated that approximately 15% of women experience depression during the first postnatal year but there are problems in recognition because its clinical assessment can be complex. The incidence of postnatal depression continues to rise resulting in serious consequences for the mother, her child and the extended family and a risk of suicide (the leading cause of maternal death in England and Wales) and infanticide in some severely depressed mothers. Treatment programmes vary considerably but many studies are suggesting that psychological interventions can be as equally, if not more, clinically effective in the management of depression as routine care from a general practitioner or anti-depressants in the short term – and may be more cost effective. Method: The aim of this exploratory pilot study is to identify whether the support, on a one to one basis, from a Peer Support Worker (PSW) would assist in the reduction of PND in new mothers. Eight PSW’s were recruited. Each PSW had previously suffered from mild to moderate postnatal depression but had recovered and were not currently receiving any form of psychological support or taking any medication. They were employed, on a six month contract, by the local NHS Trust. References and enhanced criminal records clearance were obtained. A confidentiality statement was also signed by the PSW. Thirty mothers were recruited by their own Health Visitor. This was carried out using the Edinburgh Postnatal Depression Scoring documentation (EPDS) alongside a clinical assessment. The cut off score, as agreed by both the lead researcher and the Health Visitors involved in the study, was 11. Fully informed consent was obtained and participant information sheets given. The mothers were allocated into either a Control group or an Intervention group using number alternating. The PSW’s received formal training about child protection procedures/safeguarding children in addition to the relevance and importance of confidentiality. However, apart from this, a structured training programme was not adhered to. The PSW’s strongly felt, as a combined group, that they wanted to provide the intervention simply as a ‘fellow mum who had survived the rollercoaster journey of PND’. Each PSW wanted to identify the nature of the problem, find a possible solution, and design their own proposed ‘support package’ – from the outset of the study. The PSW visited the mother in their home environment, or a location of their choice, for a period of six weeks on a once weekly basis (intervention group). This was then compared to a number of mothers who received support from their family Health Visitor (HV) alone (control group). Data collected was both qualitative and quantitative. The PSW's and the mothers from both the control group and the intervention group were asked to maintain a log book reflecting upon their feelings and thoughts after each visit (either from their PSW or their HV). Individual and group supervisory sessions were also offered by the lead researcher to both the mothers within the intervention group, and the control group, in addition to the PSW’s. A number of the participants were interviewed on a one to one basis when their infant was six months old. Data from the interviews was subsequently transcribed, coded and categorised, and key themes identified. Quantitative data was collated in the form of an Edinburgh Postnatal Depression Score (EPDS) – an assessment tool which is routinely used to identify mothers at risk or suffering from postnatal depression. The EPDS score was recorded prior to the support commencing by either a PSW or the Health Visitor, after completion of all six visits, and when the infant was six months old. Analysis: The EPDS scores recorded at 6 weeks, 12 weeks, and again when the infant was six months old, were analysed and summarised using graphs and charts. Non parametric analysis using Friedman’s Anova and the Wilcoxon paired test was carried out. A Mann Whitney test, Kolmogorov-Smirrov test and a Shapiro-Wilk test were also performed. A constant comparative method was used as a means of analysing the qualitative data collected from both log books and interview transcript (Denscombe 2008). The lead researcher consistently read and re-read text data, compared new codes and categories as they emerged and repeatedly compared them against existing versions. This process enabled the researcher to refine and improve the explanatory power of the concepts and theories generated from the data. Similarities and differences were highlighted and categories and codes were identified. On completion of this analysis, all participants were contacted to ensure validity of the findings and that each participant agreed with the researchers interpretation of the data collected. Results: Qualitative and quantitative findings from this study suggest that the input from a PSW does assist in the reduction of PND in new mothers. This is demonstrated in both the analysis of the quantitative data and the qualitative. The EPDS scores demonstrated little difference between the participants at 6 weeks but the statistics started to diverge at 12 weeks – the mean at 12 weeks for the control group is recorded at 12.46 and the intervention group is 10.33 – a difference of 2.13. The EPDS at six months demonstrates a difference between the two scores as 2.67 (the control group mean recording is 11.60 compared with the intervention mean which is 8.93). The key themes identified were the immeasurable value of ‘social support’ and ‘shared experiences’. The resounding factor that appears repeatedly throughout the analysis of data is the fact that the mothers could ‘truly relate to their Worker.’ Their PSW gave them ‘hope’, made them feel as if they were ‘not a failure’ and gave them an overwhelming ‘sense of normality’. This, in turn, increased their self-esteem, their positivity towards their parenting role, and their ability to therefore be ‘a good mother.’ A major strength of the work was the involvement of the PSW’s in both the planning and the implementing of the intervention. It was their design, their creation, and their feelings about what may really help their mother. A number of other themes were also identified that were, interestingly, commonalities across the entire data set (participants and PSW’s). These included recognition of their own changing perspective – a realisation that there simply is no ‘quick fix’ solution, that both time and support are required. The PSW’s described feelings of ‘personal benefit’, ‘self-awareness’ and the ‘provision of closure’ for themselves. The intervention group also talked, at length, about their ‘personal benefit’ from the PSW, and their own self-awareness about how they truly felt, their emotions and, in some instances, why they felt this way. The control group recognised the huge advantage from talking to other mothers and, although they did not have the formal support sessions from a PSW, they embraced the opportunity of sharing their thoughts and feelings with ‘fellow mums’. Each participant, and PSW, discussed the sharing of experiences, empathy, the feeling of ‘release’ and, particularly on the mothers’ part, the importance of knowing that, actually, they are not ‘alone’. Conclusion: The aim of this study was to provide early intervention to mothers who were classed as ‘at risk’ of suffering from PND, and, indeed, the support from the PSW’s did appear to have a positive impact upon the mothers’ mental health and wellbeing. However, this was a small scale, pilot study over a relatively short period of time. Larger, more longitudinal studies are certainly required. The importance of the pilot study presented here lies in its usefulness in shaping research to investigate and explore further whether there are indeed beneficial factors to post-natally depressed mothers who receive one to one support from a PSW. The positive results from this study can, potentially, have a huge impact within practice and, most importantly, upon the lives of those affected by postnatal depression.

Background: Postnatal depression (PND) is one of the most common maternal mental health problems for women worldwide. Yet the wide range of reported rates of PND in different countries raises questions about how PND is experienced by women in different cultures and whether interventions developed in western cultures are appropriate in very different settings. It is important to establish how PND is defined, experienced and managed in different cultures in order to create culturally relevant interventions. No previous studies of experience of PND and its management have been conducted in Malaysia. The aim of this study was to explore women’s experiences and healthcare practitioners’ (HCPs) perspectives of PND in a multicultural country, Malaysia. Methods: This was a qualitative study informed by a critical realist approach. Semi-structured interviews were carried out with 33 women (from three different cultural backgrounds) attending for child or postnatal care and 18 HCPs in six purposively selected maternal and child health (MCH) clinics and a female psychiatric ward in Kuala Lumpur, Malaysia. Data were analysed using framework analysis. Findings: There were some differences in the women’s perceptions of PND experience across three different cultural backgrounds in Malaysia. Malay women were more likely to describe the symptoms of PND based on a combination of emotional and behavioural changes, whereas Chinese and Indian women talked more about emotional changes. Traditional postnatal practices were described as contributing to PND by some Malay women but were accepted as promoting maternal and infant well-being by the majority of Indian women. Religious activities were reported as an effective strategy for the Malay women but were not seen as helpful by the majority of Chinese women. Considering HCPs, it appeared that the absence of a clear and specific policy and guideline in the management of PND within the Malaysian healthcare system has resulted in a lack of professional ownership in the management of PND, especially among HCPs in MCH clinics. Conclusion: The women and the HCPs had distinct ways of conceptualising PND experiences, although they agreed on several symptoms and causal explanations. This study calls for a system-based enhanced PND care with an initiation of culturally appropriate care for PND within the healthcare system.