Introduction: This thesis investigates abortion service providers' adequacy to facilitate women's choices to have either a medical or surgical abortion. Both the medical and surgical methods of abortion are effective procedures to terminate unwanted pregnancies in early gestation. Provided there is no medical contraindication, women can make the choice about which method of abortion to have. The role of health professionals is to provide complete and accurate information that encourages women to make informed choices between treatment options. This thesis describes three studies which a) assess the adequacy of written information to support choices about abortion methods across service providers in England and Wales, b) describe the quality of verbal information provided by health professionals to women choosing to have an abortion type in routine consultations, and c) evaluate a leaflet designed to facilitate women's choices to have either a medical or surgical abortion. Methods: Two studies employ a cross-sectional survey design with qualitative and quantitative methods, the third a randomised controlled trial. The samples include: service provider's leaflets from across England and Wales (n=44); the content of doctors' consultations in a regional abortion service in Leeds (n=23); women undertaking abortions for unwanted pregnancies in a regional abortion service in Leeds (n=313). Measures assess the accuracy and quality of information provided, and the degree to which the leaflet facilitated women's decisions about abortion method. Results: The analysis of written and verbal information routinely provided by abortion service providers found that the procedures on having the abortion types were adequately described. However,information about the risks and benefits of each method were described less accurately and/or consistently. The findings from the trial indicate that a leaflet can enable women to make more informed decisions without increasing anxiety but does not impact on the type of abortion method chosen. Conclusions: Most information about types of abortion method routinely provided by abortion service providers is not sufficient to enable women to make informed choices. However, services can meet policy objectives on informed patient decision making with minimal resource implications as the decision aid leaflet enabled women to evaluate more information about the risks and benefits of the abortion methods in accord with their own beliefs.

Background: Amniocentesis is the most common prenatal diagnostic procedure undertaken in the United Kingdom, usually performed after 15 completed weeks of pregnancy. The procedure is reported to have a 1 % risk of miscarriage and the results of the chromosome tests may require further decision making about whether to continue with the pregnancy. Deciding about amniocentesis is a complex and emotionally charged decision, often undertaken in a short period of time and, under current practice, with little systematic decision support. Decision Support Interventions, also known as Patient Decision Aids, have been developed to help individuals leam about the features and implications of their treatment or screening options while improving communication with their health professionals. Those interventions are specifically targeted at preference-sensitive decisions with significant harms, benefits and uncertainty, where no screening or treatment option is objectively better than the other. This thesis proposed to assess information and decision support needs of pregnant women undertaking amniocentesis testing and to design and field-test, in collaboration with pregnant women and health professionals, a theory-based Decision Support Intervention for amniocentesis testing (amnioDex). Methods: A multi-method approach was adopted that included a systematic review, theoretical review, and qualitative analysis to develop and pilot a theory-based intervention intended for pregnant women facing a decision to undertake amniocentesis testing. The content areas and themes to be covered in the intervention were determined by a literature review and needs assessment conducted with pregnant women and health professionals. The prototype development of amnioDex (amniocentesis decision explorer) was guided by theory and included heuristic-based deliberation tools. Incremental prototypes of amnioDex and embedded deliberation tools were field-tested with lay users, health professionals and pregnant women facing a decision to undertake amniocentesis, using the "think-aloud" technique. Results: The amnioDex intervention was developed over a period of two years and field-tested for eight months. Conclusion: Findings from this thesis showed that it was feasible to use theory to generate a Decision Support Intervention acceptable to women facing amniocentesis testing and to health professionals counselling them. Future research needs to evaluate the effectiveness of amnioDex in a randomised controlled trial and to examine methods for effectively transferring theory into practice.

This thesis demonstrates the value of an anthropological perspective on informing appropriate breastfeeding support after caesarean section delivery. In contrast to epidemiological research that identifies distinct aspects of mother-infant interactions altered by this birth mode, my research explored the interrelated obstacles to breastfeeding from the mothers’ perspectives as the experiences were unfolding. I apply Trivers’s (1974) parent-offspring conflict model to conceptualise breastfeeding and predict realisation of infant feeding based on the interaction of maternal cost and infant benefit. The work adds the previously unstudied population of caesarean section-delivered breastfeeding dyads to the human life-history theory line of investigation. Postnatal ward and telephone semi-structured interview data were collected in Newcastle, England during 2006-09 with two groups of women. Phase 1 comprised participants who underwent either an unscheduled or scheduled caesarean section delivery (n = 75). Phase 2 involved women who experienced scheduled, non-labour caesarean section delivery and were randomly allocated an intervention or control cot for the entirety of their postnatal ward stay (n = 51). The impact of the infant side-car crib or standalone cot on breastfeeding was tested among the Phase 2 mothers by comparison of 35 overnight postnatal ward video recordings. The various aspects of women’s delivery and infant care were prioritised based on their knowledge of known risks and benefits. Intentions were carried out within the context of the support and opportunities available. Contrary to popular belief, the decision to undergo a caesarean section and deviation from prenatal breastfeeding intentions were undertaken because they seemed like the best or only option in the circumstances. Many women felt frustrated because of their postnatal limitations with caretaking for infants who were described as unexpectedly doing poorly. The absence of labour before the caesarean section was perceived to be beneficial by the mothers due to the intense pain of contractions and the undo “stress” vaginal parturition posed for the infant. However, the participants were surprised by being told by midwives after the delivery that (sub-clinically) poor infant condition was a common consequence of caesarean section. Some breastfeeding difficulty stemmed from “mucous” expulsion that had to occur before the babies could be “interested” in feeding. The peak mother-infant breastfeeding conflict was night-time after visiting hours. Midwifery and maternal concerns over the mothers’ lack of sleep prompted formula supplementation. As predicted, the side-car crib was associated with reduction of the maternal cost of breastfeeding. However, participants in the intervention group were not observed breastfeeding significantly more frequently than the control group as expected. The cost-benefit breastfeeding model suggests that high maternal cost and/or low perceived infant benefit was experienced to such a degree that mothers breastfed minimally despite the “huge difference” in infant access afforded by the side-car crib compared to the standalone cot. Regardless, data support the side-car crib as the better arrangement for mother-infant dyads who underwent a non-labour caesarean section due to the less potential infant risk observed and the benefit to maternal recovery. The utility of the parent-offspring conflict framework for predicting breastfeeding outcomes was supported by the association of reported reasons for breastfeeding intent and of bedsharing with breastfeeding frequency and duration. The thesis suggests that more detailed physiological information may enable families to better understand public health advice for exclusive breastfeeding and low caesarean section delivery rates. Breastfeeding after a caesarean section is affected by interrelated and compounding difficulties, so my single alteration in the postnatal environment did not resolve the impediments. An evolutionary perspective can assist in identifying populations at risk for suboptimal health outcomes and designing support to ameliorate mismatches between coevolved processes and routinely encountered conditions.

There are conflicting reports about the association of maternal caffeine intake with adverse pregnancy outcomes, specifically fetal growth restriction (FGR). Differences in study design and exposure definition have been partly responsible. In order to study the association between maternal caffeine consumption and FGR, I prospectively quantified caffeine intake in pregnancy from all known sources, assessed caffeine metabolism in pregnancy and used serial ultrasound growth scans to identify FGR fetus. In a prospective study of 1340 pregnant women in Leicestershire, UK, I quantified total caffeine intake from 4-weeks prior and throughout pregnancy using a validated caffeine assessment tool. Caffeine half-life (used here as proxy for clearance) was determined by measuring caffeine in saliva after a caffeine challenge. The primary outcome measure was FGR, which was determined by customised birth weight centile calculator and in a subgroup by serial ultrasound growth scan. Mean caffeine consumption decreased in the 1st and then increased in the 3rd trimester. Caffeine consumption throughout pregnancy was associated with an increased risk of FGR: OR = 1.2 (95% CI, 0.9 to 1.6) for 100-199 mg/day, OR = 1.5 (1.1 to 2.1) for 200- 299 mg/day, and OR = 1.4 (1.0 to 2.0) for over 300 mg/day compared to < 100 mg/day (Ptrend< 0.001). There was some evidence that the effect of caffeine on FGR was strongest in women with faster caffeine clearance (P = 0.06). On comparing outcome measure of FGR as defined by serial ultrasound growth scans in pregnancy and customised centile calculator, there was a moderate degree of agreement between the two methods (κ = 0.38, CI 0.26, 0.49). Caffeine consumption during pregnancy is associated with an increased risk of FGR and this effect is continuous throughout pregnancy. This effect was observed from four weeks before pregnancy and was statistically significant in the first trimester. A public health recommendation for pregnant women would be to reduce or limit the caffeine intake to a maximum of 2 cups of tea/coffee per day. Future research is required to study the mechanistic effect of caffeine on trophoblastic tissue.

This research has determined which specific keratin molecular species are upregulated when comparing the chorionic villous trophoblast (CVT) to the extravillous trophoblast (EVT) in the basal plate tissues of placentae from healthy and pre-eclamptic mothers at term. Indirect immunofluorescence Confocal Laser Scanning Microscopy (CLSM) revealed that at least 5 keratin proteins are expressed in villous trophoblast and the same 5 in extravillous trophoblast. A further 15 keratin proteins tested were undetectable in these tissues. All the specific keratins identified (K5, 7, 8, 18 and 19) in trophoblast were upregulated by over 20-fold in the EVT “percentage of pixels with high intensity”, a reflection of increased specific immunofluorescence. The statistically significant difference (P < 0.0001) of K5 for example, showed an increase from a median pixel value of 0.14% in CVT to 2.88% in the EVT whereas in the pre-eclamptic there was an increase from 0.06% in the CVT to 2.97% in the EVT. Similar patterns were obtained for K7, 8, 18, and 19. The reduction in the ratio of 4.8:1 of the percentage median pixel intensity from the healthy to pre-eclamptic CVT keratin related immunofluorescence expression was statistically significant in all 5 keratins (p < 0.0001). There were no significant differences in immunofluorescence pixel intensity for the EVTs at the CLSM level. At the electron microscopy level, immunogold labelling technique using anti-K7 and anti-K18 antibodies which were representatives of the two major keratin families TYPE II and TYPE I respectively, were down regulated in the CVT and EVT in pre-eclamptic compared with the healthy. On the basis of the results of these investigations the villous trophoblast in pre-eclamptic placentae may be cytoskeletally weaker through deficiency of these keratin filaments. This could be a reason why, in pre-eclampsia, trophoblast is deported in greater quantity than in healthy placenta.

The exact aetiology and pathogenesis of uterine adenomyosis are not clear. Increased endometrial invasiveness has been proposed in the literature, but without conclusive evidence. This thesis was undertaken to examine the pathogenesis of adenomyosis and the differences between affected and unaffected uteri, testing two possibilities with adenomyosis: (i) that the myometrium is permissive to invasion by a normal basal endometrium, or (ii) that the basal endometrium has a higher invasive potential and penetrates a normal myometrium. To examine the early phases of development of adenomyosis, a mouse model was used, where adenomyosis was induced by dosing female pups with tamoxifen. The same experiment was used on C57/BL6J strain to examine strain differences in response to tamoxifen and predisposition to adenomyosis. Adenomyosis in the human uterus was characterised, examining the immunohistochemical, light and electron microscopy structure, and RNA microarrays of affected and unaffected uteri. The invasive properties of the stroma and its interaction with the underlying myometrium were further studied in a co-culture model. Adenomyosis was successfully induced in the CD1 mice, with abnormal development and disruption of the inner circular myometrium. However, the C57/BL6J did not develop adenomyosis inspite of the presence of inner myometrial abnormalities comparable to the CD1 mice. Affected human uteri showed distinct myometrial features such as reduced myometrial cellular density and enlarged nuclei with hypertrophy and hyperplasia seen on light microscopy. Electron microscopy revealed ultrastructural features (e.g. reduced caveolae and increased myelin bodies, intermediate filaments and dense bands) in adenomyotic uteri. A large number of dysregulated genes were detected between affected and unaffected uteri, with Wnt5a being a key downregulated gene. Steroid reception expression was equally altered in cases of adenomyosis (e.g. reduced progesterone receptors and increased estrogen receptor beta). Increased vimentin immunostaining was equally observed in the inner myometrium of diseased uteri. An increased adenomyotic stromal invasiveness and increased myometrial permissiveness was observed in the co-culture model. The thesis demonstrates that the endometrial – myometrial interface behaves differently in uteri with adenomyosis, concluding that adenomyosis is a uterine disease characterized by both increased endometrial invasiveness and myometrial defects that play a facilitative role for this invasion. Both the myometrium and endometrial stroma of diseased uteri show a unique phenotype, gene expression and protein expression profiles.

The endocannabinoid N-arachidonoylethanolamine (anandamide; AEA) adversely affects early pregnancy initiation and maintenance in both animals and humans. Anandamide acting through the cannabinoid receptors CB1 and CB2 affects many aspects of reproduction and is formed on demand by the hydrolysis of N-arachidonoyl-phosphatidylethanolamine (NAPE), by a specific phospholipase D (PLD) NAPE-PLD. Furthermore, AEA is catabolised by Fatty Acid Amide Hydrolase (FAAH). The aim of this thesis was to investigate how variations in the various components of the endocannabinoid system might lead to different early pregnancy outcomes. Using a newly developed UPLC-MS/MS method, plasma AEA levels were measured in women throughout pregnancy, compared to previous data and shown to be comparable. Moreover, women presenting with a viable pregnancy (on USS) with a threatened miscarriage (bleeding), who went on to miscarry and women presenting with a confirmed miscarriage (on USS) when compared with women with a viable pregnancy at the time of USS in whom there were no symptoms of miscarriage or those that went to term, all had increased plasma AEA levels. Median plasma AEA levels in the miscarriage group were 3-fold (p<0.001) higher than the levels in the live birth group. Using an AEA level of 2.0nM as cut-off for predicting subsequent miscarriage gave a sensitivity of 100% and a specificity of 94%, (negative predictive value 100%; positive predictive value 82%). Although other markers of pregnancy success (progesterone, hCG and PAPP-A) all gave the expected concentrations in on-going, failed and failing pregnancies, there was no statistically significant correlation between these factors and plasma AEA levels. Immunohistochemical evaluation of CB1, CB2, FAAH and NAPE-PLD expression in first trimester pregnancy tissues (trophoblast and decidua) showed that FAAH staining in the miscarriage/non-viable group was significantly lower than that in the surgical termination of pregnancy group. In women undergoing medical termination of pregnancy, using an anti-progesterone (mifepristone), FAAH staining was actually increased compared with that from the surgical termination of pregnancy group; whilst CB2 had increased staining and CB1 had reduced staining in the miscarriage and the medical termination groups when compared with the surgical termination of pregnancy group. There was no significant difference in NAPE-PLD staining between all three groups. These data provide new evidence that the endocannabinoid system plays a significant role in early pregnancy failure/miscarriage and that plasma AEA may be used as a future predictive marker for miscarriage. The lack of correlation between AEA and progesterone and the finding of elevated FAAH in the medical miscarriage (anti-progesterone) group, but low FAAH in spontaneous miscarriage suggest that factors other than progesterone are responsible for increased AEA levels in cases of miscarriage.

Œstrogen replacement therapy in post-menopausal women exerts a protective effect against atherosclerosis, but the mechanism of its action is not clear. One of the early events in the development of atherosclerosis, is the adhesion of mononuclear phagocytes to the endothelial cells of the artery. Therefore, it was proposed that the benefits of œstradiol treatment could be by its action on the monocyte. Hence, it was hypothesised that œstradiol affects monocyte functions, which resulted in four investigations reported in this thesis. One of the effects of œstradiol could be by reducing monocyte hydrogen peroxide production. Studies on monocyte hydrogen peroxide production showed that œstradiol activated human peripheral blood monocytes to produce increased amounts of hydrogen peroxide in vitro. These studies also indicated that monocytes could contain multiple types of binding sites for œstradiol, which was confirmed by œstradiol binding studies. The intracellular effect of œstradiol was investigated by studying the de novo protein synthesis patterns, which showed no difference in the band patterns between control cells and œstradiol-17β-treated cells. The final investigation showed that œstradiol does not contribute to any quantitative changes in the surface receptor expression of CD11 a, CD11 b, CD14 and CD18 but down modulates the adherence and phagocytic functions of CD11 b/CD18 receptors in vitro. With the help of these investigations it is possible to propose a new overall hypothesis of œstradiol action on the monocyte. We hypothesise that œstradiol effects monocyte function in at least two ways. First, œstradiol could activate Monocytes to produce increased amounts of hydrogen peroxide following an appropriate stimulation (probably by cytokines) in vivo, thus causing vasorelaxation of blood vessels. Secondly, œstradiol could reduce the adhesion of monocytes to the arterial endothelium by down modulating the functional activity of some adhesion molecules. Both these effects of œstradiol would help in reducing atherosclerosis and Coronary Artery Disease.

Maternal vitamin A deficiency during pregnancy is associated with fetal and infant mortality and morbidity. The present study investigated the effects of the severity and duration of vitamin A deficiency on fetal growth and neonatal survival in the rat, and identified key organs affected. The efficacy of different supplementation regimens in reversing deficiency induced changes was also investigated. Weanling rats were fed a diet free or marginal in vitamin A for seven or eight weeks prior to and throughout pregnancy. Subgroups of these rats were supplemented with dietary vitamin A from day 7 of pregnancy onwards or by injection on day 10 and compared with control fed rats on day 20 of pregnancy and at birth. Severe maternal vitamin A deficiency reduced pregnancy rate, fetal number and neonatal survival. Less severe deficiency reduced neonatal survival only. Dietary retinol supplementation, but not deficiency or injection, increased leptin levels. Dietary supplementation partially counteracted the effects on neonatal survival but not on pregnancy rate. Vitamin A deficiency increased placental:fetal ratio. Placentas from severely deficient rats exhibited an infiltrate of TNF- and leptin immuno-positive neutrophils. Increased neutrophil-associated apoptosis and a decrease in the bax:bcl-2 ratio in trophoblast giant cells were also detected. Relative fetal lung, heart and liver weights were reduced but only the relative lung weight was reduced in neonates. Fetal lungs were underdeveloped with fewer elastic fibres, and reduced lung elastin and gas6 expression. Neonatal lungs had reduced relative airspace and smaller sacculae. Dietary retinol supplementation, but not injection, partially counteracted the effects on relative fetal organ weights. These data show that maternal vitamin A deficiency retards fetal development and reduces neonatal survival. These effects may be mediated by changes in placental immunity. Vitamin A deficiency may retard fetal lung development by influencing the differentiation of critical cell lines. Appropriate dietary supplementation may be beneficial on its timing and magnitude.

Polycystic ovary syndrome (PCOS) affects up to 10% of women of a reproductive age and is a major cause of infertility. It is characterised by polycystic ovaries, hyperandrogenism and chronic anovulation. The disorder is genetically inherited and possibly of polygenic nature. Two methods were employed in the investigation of the genetic basis of PCOS: DD RT-PCR and mutation screening for association based studies. Application of DD RT-PCR on ovarian granulosa cells cells from affected and control women identified twenty-three differentially expressed sequences (B1-23). Of these, B4 was confirmed to be differentially expressed in A PCOS patient by competitive RT-PCR. Similarity searching identified the B4 sequence as the PHEX gene (99% homology). The corresponding PHEX protein is postulated to act as an endopeptidase in phosphate regulation. Its role in the ovary of PCOS patients remains to be elucidated. An association based study indicated reduced risk of PCOS associated with the AA genotype (OR=0.04; P<0.05) of the FSHR G2039A polymorphism in antenatal controls. No difference was seen between PCOS and blood donor control individuals. The 2039A allele confers a novel glycosylation site in the peptide sequence and this may effect processing of the FSHR protein in the endoplasmic reticulum. In addition, a reduced risk of PCOS was associated with the -1944CC genotype (OD=0.3) of the -1994 novel polymorphic site in CYP11a in blood donor controls. These findings suggest that a number of genetic factors may be involved in pathogenesis of PCOS. Their identification will open the potential for direct treatment of the symptoms associated with the disorder, especially infertility, and prophylactic management of those patients most at risk from cardiac disease or NIDDM.