Parenthood is a goal desired by the majority of men and women. People are far more likely to achieve their parenthood goals if they take steps to optimise fertility and pregnancy. Measures to optimise fertility and pregnancy reduce the risk of fertility problems, increase the chance of conceiving and, if a pregnancy is achieved, reduce the risk of pregnancy complications. Such measures include adopting a healthier lifestyle, seeking timely medical help when problems conceiving are encountered, and following medical health recommendations for people who are trying to conceive and/ or are pregnant (e.g., taking folic acid supplements). However, despite the importance placed on becoming parents, many people fail to take steps to safeguard fertility and pregnancy. The set of studies presented in this thesis aimed to examine the role of health-related cognitions in how willing people are to take action to optimise fertility and pregnancy and to identify targets for public health campaigns to promote informed decision-making about fertility and pregnancy. The work presented in this thesis demonstrated that health-related cognitions play a key role in how likely people are to optimise fertility and pregnancy. Knowledge about fertility was poor (51.9% average correct score on fertility knowledge questions), which was associated with being less likely to take action to optimise fertility. However, a common result across studies was that even when people knew about factors that put fertility or pregnancy at risk, they often did not apply these factors to themselves because they had mental models that made them feel insusceptible to risk. Findings suggested that a personalised fertility risk awareness tool was acceptable and feasible among women and health professionals and may help women to understand the personal relevance of risks to fertility. Overall, the findings of the current set of studies imply that timely education about fertility and pregnancy is needed to enable people to make informed decisions about optimising fertility and pregnancy. Further, personalised risk awareness interventions are required to help people understand their own susceptibility to risk and decide whether and what action to take to reduce their risk.

This thesis presents a programme of nine key published works, as well as twelve published supporting works focusing on two areas. Firstly, an investigation of how non-technical skills education in healthcare can be used to enhance outcomes for patients. Secondly, an exploration of how evidence synthesis be used as a tool to direct educational innovation and, in this context, enhance patient safety. Non-technical skills are the interpersonal, communication, team working and decision making skills that support safe patient care. Existing theory was applied to build new conceptual frameworks to understand how non-technical skill learning occurs. Educational innovations were developed, allowing outcomes for patients to be enhanced and the theory to be refined. Ultimately, this has led to the proposal of the SECTORS model, combining three key elements: The generic knowledge and skills in core areas that contribute to and support learning in non-technical skills (Systems and technology use, Error awareness, Communication, Team working), a situated cognition approach to formal and experiential learning that develops these skills (Observation and simulation) and developments in analytical skills that can integrate these and support decision making (Risk assessment and situational awareness). SECTORS can support curricula design, educational innovation and design of assessments. SECTORS will support future scholarly research, allowing the field to move from theory generation to theory testing and refinement. Additionally, synthesis of educational evidence to support the development of this new knowledge has been employed. Building on existing guidance and in response to calls for more theoretical generation in primary educational research, a complete method for health education evidence synthesis has been developed and applied. This method allows clarification of educational questions through generation of conceptual frameworks and new theory within a systematic framework that employs qualitative synthesis techniques such as thematic generation and meta-ethnography, representing a significant contribution to the field.

The thyroid gland utilises iodine for the production of the thyroid hormones thyroxine (T4) and triiodothyronine (T3). During pregnancy demand for iodine increases as the need for maternal T4 increases. A lack of iodine leading to hypothyroidism may be associated with cretinism, mental retardation and neurological and thyroid damage. Maternal hypothyroidism is known to be associated with a lower IQ in offspring. In 2002, a study of 400 pregnant women in Tayside demonstrated a deficiency of iodine intake in 40 % of women. The aim of the current study was to establish the trend in iodine status of the pregnant population over a ten year period, examining the factors in the monitoring of iodine and thyroid hormone levels; and the causes and strategies for correction of iodine deficiency during pregnancy. The ranges and distributions of several thyroid biomarkers were established and the relationships between them and between iodine deficiency and specific adverse pregnancy outcomes were explored. A dietary questionnaire was used to collect information on diet, supplement intake and frequency of consumption of different food types. Retrospective study: Urine and matching blood samples collected between 39 and 112 days of gestation from 3500 women and stored frozen for 10 years were analysed for iodine and thyroid hormone levels. Median urinary iodine excretion (UIE) level in 3326 women with normal pregnancy outcome was 107.00 μg/l: significantly below the WHO recommended median for pregnancy of 150.00 μg/l. Just over 65.0 % of women were categorised as having insufficient dietary iodine intake. These results confirm and extend the findings of the 2002 Dundee study. UIE levels adjusted for creatinine (UCr) to correct for urine concentration variation were also investigated. A matching serum sample was available for thyroid hormone analysis in 3240 (97.0 %) of the urine samples with iodine measurements. Median concentrations of each marker in the retrospective normal pregnancy outcome group were: 1.36 μU/ml (TSH), 13.48 μg/dl (T4), 15.05 pmol/l (fT4), 2.17 ng/ml (T3), 6.13 pmol/l (fT3) and 14.21ng/ml (Tg). Linear regression analysis in the normal pregnancy outcome group showed that geographical area was a significant predictor (p < 0.0001) of UIE and UIE/UCr levels and all 6 thyroid markers. Maternal age was the only other significant predictor of UIE levels. Other significant associations were for UIE/UCr: BMI and maternal age; for TSH: BMI, UIE/UCr, ethnicity and hCG; for T4: maternal age and TSH; for fT4: parity, smoking status and TSH; for T3: BMI, maternal age, parity and TSH; for fT3: BMI and TSH, and for Tg: smoking and TSH. ANOVA testing showed that women who smoked had significantly lower fT4 and Tg (p < 0.0001) than non-smokers. Women from Southeast Asia had lower UIE/UCr and TSH (p = 0.04) and higher T4 and T3 compared with Caucasian women (p < 0.0001). Women in Glasgow tended to have higher UIE, T4 and T3 and lower TSH (p < 0.0001) compared to other geographical areas (p < 0.0001). A subset of 971 serum samples from pregnancies with adverse outcome including pre-eclampsia, small for gestation, extreme or moderate preterm delivery, or a still birth was also available for analysis. Binary Logistic Regression showed that for UIE/UCr, TSH, BMI smoking status and maternal age, the only statistically significant variable was smoking which was associated with a lower incidence of pre-eclampsia and a higher incidence of low birth weight. Prospective study: Urinary iodine excretion (UIE) levels were measured in 1106 pregnant women recruited prospectively. The median UIE value was 81.40 μg/l; - lower than the WHO recommended UIE level of 150.00 μg/l, and lower than the median found in the retrospective study group of 107.00 μg/l. Just over 80.0 % of pregnant women were categorised as having insufficient dietary iodine intake according to WHO criteria. These results point to a decline in iodine intake over a 10 year period. UCr measurements showed that 16.8% of samples had levels below the minimum WHO defined limit of 30 mg/dl. The median TSH concentration value in the matching serum samples was 1.25 μU/ml. Maternal TSH levels correlated positively with newborn TSH levels in patients for whom data was available (p < 0.0001). The median value of fT4 within the prospective pregnancy group was 11.41 pmol/l. A subset of 145 serum samples from the prospective pregnancy group selected using UIE levels as a cut-off parameter had a median Tg value of 12.30 ng/ml. Seventy one percent of participants completed a questionnaire on diet. Sixty eight percent were unaware that iodine was important in their diet during pregnancy and had a lower median UIE (79.87 μg/l) compared to those who were aware of the importance of iodine (86.23 μg/l) although this was not statistically significant. Using UIE, UIE/UCr, nTSH, mTSH, fT4, and Tg in turn as the dependent variable in a general linear regression model with up to 15 different predictors (including intake of fish, meat, yoghurt, cheese, milk, cereals, bread, vitamin supplements, iodinated salt usage and maternal age, smoking status, geographic area and the other biomarkers tested) showed no dietary factors and only geographic area and smoking status as significant predictors for UIE. When UIE/UCr was used as the dependent variable, significant associations were maternal age, and intake of bread, cheese, cereals, and iodine supplements. The UIE/UCr ratio gave more significant associations than UIE alone. For nTSH significant predictors were maternal TSH, geographic area and maternal age. For mTSH significant predictors were smoking status and fT4. For fT4, significant predictors were geographic area, TSH and smoking status. For Birth weight, the only significant predictor was smoking status. For Tg, the only significant predictor was UIE/UCr. Ninety two (11.24 %) participants reported that they were aware of the availability of iodised salt but only 11 (1.22 %) women used it. Drinking water samples were collected from 21 sites across the West of Scotland. Only one water sample from 21 collected had an iodine concentration > 10 μg/l. Conclusion: In summary this study has shown a significant trend of decreasing iodine intake in Scottish pregnant women over the last 10 years.

Background: Childbirth is popularly considered to be a time of happiness and fulfilment, yet many authors have reported that women express more negative feelings, including anxiety, apprehension, self-doubt and guilt requiring significant emotional and psychological adaptations during pregnancy and postpartum than at other times in their lives. Yet, despite evidence of emotional stresses challenging women in the perinatal period, one largely unexplored factor is how the management of this complex range of emotions impacts on maternal psychological health. If managed inappropriately emotions evoked by stressful events will intrude on the maintenance of everyday behaviour. The Emotional Processing Scale (EPS), a tool developed to measure the management of emotions and validated in a variety of countries worldwide, identifies poor processing. To understand maternal emotions more fully this study has used the EPS to explore relationships between emotional processing during the life-changing events of pregnancy and birth and the emergence of postnatal depression. Aims: The study aimed to examine the relationship between the way women managed their emotions during pregnancy, as measured on the EPS and the development of postnatal depression, as measured on the Edinburgh Postnatal Depression Scale (EPDS). It also investigated the possibility of predicting postnatal depression from scores on the EPS in conjunction with other recognised risk factors. Methods: A cohort of 974 pregnant women, aged 16 to 44, from the South of England were surveyed at 13 and 34 weeks gestation and 6 weeks postpartum. In addition to demographic information, standardised measures included the EPS, the Edinburgh Postnatal Depression Scale, the Short –Form 36 and the Rosenberg Self-Esteem Scale. Data were analysed using a variety of univariate and multivariate techniques to investigate the inter-relationships between these variables. Multiple and logistic regression models were built to determine which variables measured during pregnancy best predicted postnatal depression. Findings: Strong associations were found between poor emotional processing and the likelihood of developing postnatal depression. After adjusting for other recognised and established risk factors for depression, poor emotional processing in early and late pregnancy made a strong unique contribution to the prediction of postnatal depression and the odds of women with a high EPS scores in early and late pregnancy developing depression postpartum were 2.5 and 3.4 times greater than women with low EPS scores. Implications: There is a need for professionals to have a greater understanding of emotional processing. It is easily measured, and integration of emotions assessment together with supportive measures to facilitate women to manage their emotions more effectively into the existing framework of antenatal care could enable the strategy to be undertaken in a resource-efficient way. This could benefit families who might suffer from the detrimental impact of maternal perinatal emotional and psychological disturbances.

This portfolio presents a unique and significant body of research which together provides a substantial, original description and analysis of women’s engagement with weight management behaviours and services during pregnancy. This body of research examines this topic from multiple perspectives, concluding with a detailed interpretative study which sheds light on the deep-rooted determinants of women’s weight-related behaviours during pregnancy. All outputs are articles published in peer-reviewed scientific journals: Article one describes an evaluation of the acceptability of an individual, home-based perinatal weight management service, based on a qualitative examination of the experiences of obese women who used the service during pregnancy. The findings showed that women valued the support they received from the service, and highlighted home visits, personalised advice and regular weight monitoring as beneficial, while suggesting that more frequent appointments and practical support with target behaviours would enhance the service. Article two describes a qualitative study of the views and experiences of obese women who had declined or disengaged from the service evaluated in article one. The study identified the referral experience as key to women’s decisions to decline participation, highlighting the need for midwives and other health professionals to have detailed knowledge of the service and training on how to sensitively offer this additional support. Findings also demonstrated that some obese women lacked the confidence or capability to successfully change weight-related behaviours, even with support, leading them to disengage from the service. Article three compares and combines qualitative data obtained from two sets of midwives, each referring women to either a one to one, home-based weight management service, or a group, community-based weight management service, to explore how midwives approach the referral with obese and overweight women, and their views of women’s responses to being offered a referral. Findings highlighted the important role midwives play as gatekeepers to weight management services and raised questions regarding how midwives approach the referral process within the wider context of the maternal obesity issue. The findings also suggest that services might improve uptake through addressing pragmatic and motivational barriers, and through better communication with their referral agents. Article four describes analysis of qualitative data collected from women who declined a referral to a group, community-based weight management service during their pregnancy, specifically exploring their views on being referred to the service by their midwife. In contrast to the findings described in article two, women in this study reported finding the referral acceptable, and that they expected to receive information about such services from their midwife. The more positive response of these women could be attributed to a number of potential factors, including; an increase in women’s awareness of the risks of maternal obesity, an increase in midwives’ confidence and skill to raise the issue of weight in the time elapsed between the two studies, or a different approach to making the referral between the two services. Article five reports the findings of a qualitative study using Interpretive Phenomenological Analysis (IPA) which sought to explore in detail the lived experience of a first pregnancy and the process of making decisions about diet and physical activity during this time. The article aimed to further illuminate the multiple and significant barriers to adopting positive dietary and physical activity behaviours during pregnancy, and to challenge the commonly cited belief that ‘pregnancy is a good time for behaviour change’ by examining women’s experiences with specific reference to the model of ‘Teachable Moments’ (McBride, Emmons, & Lipkus 2003). While partially supporting the model, the results also indicated that women with healthy, uncomplicated conception and pregnancy experiences base their diet and physical activity choices primarily on automatic judgements, physical sensations and perceptions of what pregnant women are supposed to do, which in turn suggests limited opportunity for antenatal health professionals to intervene and subsequently influence behaviour. These accumulated findings suggest that there is much that can be done to increase obese women’s engagement with maternal weight management behaviours and services. Service providers and commissioners could draw on these findings to design services which better meet the needs of many obese women, such as receiving personalised support, at a time and location convenient for them, and providing regular weight monitoring. There are also implications for health professionals’ education and clinical practice, with findings indicating that midwives would benefit from further training and better information about the weight management services they are asked to refer to, in order to make referrals more evidence-based and increase their confidence to advocate for the service to women who might benefit. Finally, the work presented in this portfolio further informs our understanding of the psychosocial determinants of women’s weight-related behaviour during pregnancy. It suggests that researchers and practitioners should consider how to tackle the largely socially learned, sub-optimal behaviour patterns that are often established in early pregnancy and how to activate more reflective decision-making in relation to diet, physical activity and weight management. The portfolio also includes critical reflection on each of the outputs and the contribution of each unique study to the development of the author into an independent and expert researcher, and concludes with suggestions for future research.

This study explores discourses around private three- and four-dimensional (3/4D) ultrasound scans in pregnancy, the experiences of women who have 3/4D scans and what impact these scans may have on pregnant women. A critical discourse analysis of scanning company websites was undertaken to explore the discourses, identities and genres set up on the websites. Longitudinal interviews exploring women’s experiences of 3/4D scans were analysed using interpretative phenomenological analysis. Case studies, using longitudinal questionnaire and interview data, were used to investigate the psychological impact of 3/4D scans on pregnant women. The critical discourse analysis revealed mixed discourses, identities and genres. While 3/4D scans are not overtly medical, they nevertheless contain medical aspects. They are promoted as enhancing bonding and reassurance. In the interview analysis, two superordinate themes emerged: ‘Getting to know the baby’ and ‘Experiences of pregnancy’. While the women’s physical and emotional experiences of pregnancy varied considerably, there were more convergences in the desire to ‘get to know’ the fetus and how women approached this. While routine and 3/4D scans played an important role, fetal movement also emerged as a significant factor. The case studies showed that the psychological impact was not consistent. Scans had no effect on fetal health locus of control, may have reduced anxiety about specific issues for some women and may have had a positive impact on some components of bonding for some women. It is not possible to state categorically that they reduce anxiety or increase bonding. The psychological impact of 3/4D scans appears to be individually mediated and depends on pregnancy experience and individual psychological differences, highlighting the significance of individual factors in both research and practice. Two opposing discourses portray 3/4D scans as either beneficial, by enhancing reassurance and bonding, or problematic, by undermining women’s embodied knowledge and experience and being potentially risky. This study suggests that neither of these two conflicting discourses are reflected in women’s experiences. The women in this study were not motivated primarily by bonding or reassurance when choosing 3/4D scans, but considered them a nice experience; on the other hand, the scans do not seem to have had a detrimental impact either. The interview analysis suggests that women acquire knowledge about the fetus through scans and fetal movement and combine these to make sense of the fetus. This study also provides evidence that the concept and measurement of bonding during pregnancy is problematic and that professional and academic perspectives are not necessarily reflected in women’s experiences.

According to the concept of perinatal programming environmental factors during fetal development and early postnatal life can influence phenotype in later life by modifying organ and tissue development and the epigenetic information of specific genes which, in turn, induce alteration in gene expression. Global nutrient restriction is a well-established intervention to study fetal programming but choline, a micronutrient essential for tissue growth and development, has not been extensively studied. The aim of this thesis is to investigate long term effects of modifications in maternal macro and micronutrient intake on the offsprings‟ appetite regulation and metabolic health. Twin-pregnant sheep were fed to requirements until 110 days of gestation and then randomised to stay on the same diet (R) or be restricted to 60% of caloric requirements (N) until term (~145 days). Offspring were subsequently subject either to a standard early postnatal growth rate as both twins remained with the mother (S) or to an accelerated growth rate resulting when only one twin remained to be mother fed (A). After weaning, offspring were reared in either a lean (L) or an obesogenic environment (O) until 17 months of age. These interventions gave rise to 4 groups: RAO, NAO, NSO and NSL. There were no differences in body weight, composition or adipocyte size with perinatal nutrient restriction but insulin response to a glucose tolerance test was increased in offspring born to N mothers. Measurement of hypothalamic gene expression in the latter offspring suggested a more orexigenic and cortisol-sensitive regulatory phenotype. During lactation, rats were fed a diet that was either choline-devoid (D), or contained a standard amount of choline either as bitartrate (C) or as phosphatidylcholine (PC). After weaning, female offspring were maintained on a standard choline diet until 11 weeks of age. D mothers had a substantial decrease in food intake and offspring were smaller at weaning but had similar glucose tolerance. Adult offsprings‟ brain phospholipid concentrations were reduced, which may suggest changes in brain development, but food intake and hypothalamic protein expression were unchanged. Intake of different forms of choline, i.e. bitartrate versus PC, during lactation had no long term effects on offspring. Both maternal dietary interventions had long term effects on offspring. Sheep developed the most adverse metabolic phenotype when the offspring were subjected to slow growth in late gestation followed by rapid growth and obesity, with the onset of insulin resistance mediated through changes in peripheral tissues. Maternal choline intake during lactation is essential for the health of the offspring as it alters brain composition. In conclusion, both studies produced results which are consistent with the concept of perinatal programming as adult metabolic health was affected in the sheep study and organ development was affected in a long term manner in the rat study.

Waterbirth practice has the potential to support a midwifery model of care and yet little is known about how the organisation of care can be changed to improve the use of birthing pools. This action research study focused on a group of midwives working on a labour ward in an English obstetric led maternity unit with 3,800 births and 25 recorded waterbirths per year. Interviews and focus groups with labour ward midwives and managers were employed to identify barriers to birthing pool use and inform the change process. Three problem-solving workshops with labour ward coordinators were organised with the aim of influencing other midwives’ use of birthing pools. Data from a newly developed waterbirth questionnaire and maternity records were used to evaluate change in levels of personal knowledge, waterbirth self-efficacy and social support. Foucauldian discourse analysis and One-Way ANOVA with Tukey post hoc tests were used to analyse qualitative and quantitative data. Fourteen midwives took part in focus groups and seventeen in interviews over four research phases. Interventions, developed by workshop attendees, included improvements to the recording and dissemination of waterbirth and water immersion data, target setting and the appointment of a waterbirth champion. By the end of the study the numbers of waterbirth practitioners, recorded waterbirths and social support increased significantly. Discourse analysis revealed the presence of dominant biomedical and subjugated ‘being with woman’ midwifery discourses. The study is the first to describe midwives’ attitudes to waterbirth practice and attempt to improve the use of hospital birthing pools. The findings illustrate that, by co-opting rather than replacing dominant discourses, it is possible to support the delivery of a midwifery model of care in a medicalised environment. As such this study offers a pragmatic approach to organisational change.

Background: Slow progress of labour (SPL) occurs in 3-37% of all labours. It constitutes the main cause of primary caesarean section (CS) and is associated with operative births, maternal and foetal morbidity, and a negative birthing experience. SPL is also the principal reason for the transfers of women from midwife-led units (MLUs) or their home, to hospitals. The current standard medical management of SPL, including intravenous administration of synthetic oxytocin and artificial rupture of membranes (ARM), has been increasingly questioned and the need for alternatives recommended. A midwifery approach to SPL represents a possible important alternative. However, contemporary literature shows a surprising dearth of research concerning midwives’ approaches to SPL. Birth centres appear ideal settings for exploring a midwifery approach to SPL, given the strong midwifery philosophy and the relevance of SPL reported in these contexts. Aim: To explore midwives’ approaches to SPL in birth centres, focusing in particular on midwives’ understanding of the phenomenon, diagnostic process, clinical management and decision-making. Methods: A qualitative multiple case study, underpinned by a critical realist perspective. Midwives’ approaches to SPL represented the ‘case’ of interest; an Italian alongside- (AMU) and an English freestanding- (FMU) midwifery units were purposively selected as case-sites. Data was collected between November 2012 and July 2013, after obtaining all necessary ethical approvals. An inductive reasoning, and triangulation logic characterised data collection. Multiple methods were adopted including individual semi-structured interviews, focus groups, observations and document reviews. Practising midwives, midwife managers and two lead obstetricians were included as participants after obtaining written informed consent. Data was analysed at two levels, within-case and cross-case, using a thematic analysis. Findings from the cross-case analysis supported the development of assertions and final conceptualisation regarding midwives’ approaches to SPL in birth centres. Findings: At the Italian site, midwives identified SPL as the problem of their care in the AMU. They perceived the process of recognition of this phenomenon as an engaging challenge and attempted to untangle the main cause amongst the many intertwined ones, in order to tailor their approach. Dealing with SPL represented a struggle; midwives adopted several different interventions and their decisions appeared enabled or constrained by numerous factors, especially the problematic relationship with the hospital staff. At the English site, SPL was not considered an issue, midwives were keen in looking at diagnostic and causal factors of SPL within a bigger picture. Midwives’ interventions aimed at giving women the best chance to overcome SPL and give birth in the FMU. The several influential factors were managed by many midwives through experience. Across cases, midwives’ understanding of SPL varied. SPL was acknowledged to result from a complex interaction of causes. Early labour was considered a critical stage for the development of SPL. The process of recognition of SPL appeared a dynamic one and aimed at reaching an objective diagnosis. Distinguishing whether SPL represented a physiological rest or arrest of labour progress represented an emerging dilemma. Midwives tailored interventions to single situations. Some interventions appeared to be fundamental to midwifery care, whilst others depended on various factors. Midwives’ relationships with all factors in the context appeared to be pivotal for both performing interventions and decision-making. Conclusion: This is the first case study exploring midwives’ approaches to SPL in birth centres, in both an English and an Italian context. This research outlines midwives’ approaches to SPL as a result of a complex and dynamic system. Midwives’ understanding, identification, clinical management of SPL and decision-making represents a multifaceted and stratified reality. The individual characteristics of the women, the birth attendants, the midwife, and colleagues, as well as the relationships occurring in this context, represent the main factors whose variable interactions may result in variable manifestations of the midwifery approach. On the basis of the findings of this research, recommendations are made for midwifery practice, education and research.

Women with raised BMIs ≥30kg/m2 have now become the ‘norm’ in maternity practice due to the recent obesity epidemic. To date only very limited research evidence exists highlighting midwives’ experiences of caring for this group of women. This thesis aims to provide original research on what it means to midwives and student midwives on the point of qualification to care for this client group throughout the childbirth continuum.