This study is a longitudinal exploration of women’s eating behaviours and weight status during motherhood starting from pre-conception, through pregnancy and into the early postpartum period. The study aimed to explore how women negotiate pregnancy in the context of food and weight status using IPA. The rationale was to capture from the diverse voices of different women what is important to them at these different time points and collectively how this informs behaviour in the motherhood journey. The participants consisted of three different, randomly selected sample sets of women 20- 40 years. Focus groups were carried out with 10 never pregnant women, followed by serial individual interviews with five currently pregnant women, and five women who had recently given birth, interviewed at 2 different time points. The findings highlight a change in women’s priorities described in superordinate themes along the motherhood cycle. Women’s priorities changed starting in pre-conception with a strong sense of self and realisation of limited time for childbearing, to focussing on the baby at the expense of the self, during and after pregnancy. The findings strongly show that women’s eating has emotional, biological and gendered meanings during the transition to motherhood. Socialisation, social events, expectations and peer support also strongly influenced how women negotiated conflict in this continuum. There are tensions in the postpartum period between the new focus on the baby (emerging during pregnancy), which prescribes healthful eating, and the stresses of a new motherhood lifestyle which reverts women to emotional eating (present preconceptually). In negotiating these tensions, women adopt the digital discourse as part of self-support behaviours in addition to trust and desire for the support of HCPs and significant others. The findings have implications for lifestyle interventions that acknowledge these tensions, women’s priorities and their coping strategies.

Delivery of ultrasound training remains a challenge. This thesis presents a series of projects that investigated a new approach in acquiring transvaginal ultrasound skills (TVS) in obstetrics and gynaecology using a novel virtual reality simulator (ScanTrainer®, Medaphor plc, Cardiff, Wales). Aims and objectives:(1) To evaluate the validity and reliability of the simulator,(2)to assess the learning curves of trainees’ competence in performing TVS, and (3) to define potential benefits and limitations of simulation training from the trainee’s perspective. These were achieved by undertaking the following studies (1) face, content and construct validity of the simulator, (2) reliability of scoring systems developed for the assessment of ultrasound in obstetrics and gynaecology, (3) validation of simulation scoring system against experts, and (4) evaluating the role of simulation on TVUS skill acquisition (learning curve) in the clinical training environment. Methods: The projects included observational, comparative and semi-qualitative studies and randomised controlled trial (RCT) comparing conventional with simulation supported training. Results: (1) Face and content validity study demonstrated high acceptability of the simulator. (2) Construct validity study showed significant differences between inovices and experts’ performances, p < 0.05. (3) Validation studies showed excellent agreement (i) between two observers in assessing simulated TVUS performances and(ii) between the observer and the simulator scoring system (intra-class correlation coefficient > 0.75). (4) In the RCT, the overall analysis according to the randomisation arm showed no statistically significant difference between the intervention and control groups. (5) Fifty-seven percent of trainees agreed that simulation was a flexible learning platform in practicing TVUS as an adjunct to clinical training. Conclusion: The ScanTrainer® simulator has high face, content and constructs' validity that support the research hypotheses. It also has a potential role in the assessment of clinical skills. However, the impact of simulation on the learning curves requires further evaluation.

Background: The literature review reveals information about what makes a good midwife from several perspectives. However, there is a dearth of knowledge around women’s perceptions of a good midwife in different birthplaces. Aim. The aim of the study was to explore and explain first-time mothers’ expectations and experiences of a good midwife during childbirth in the context of different places of birth. Methods: A qualitative grounded theory methodology was undertaken. Fourteen first-time mothers planning to birth in different settings in England (Home, Freestanding Midwifery Unit, Obstetric Unit) were recruited. Data were collected through two semi-structured interviews for each participant (before and after birth). Data analysis included the processes of coding and conceptualising data, with constant comparison between data, literature and memos. Ethical approval was gained. Informed consent was obtained from participants and women were free to decline participation or to withdraw at any time. Confidentiality was guaranteed. Findings: The model named ‘The kaleidoscopic midwife: a conceptual metaphor illustrating first-time mothers’ perspectives of a good midwife’ was developed. The model is dynamic and woman-centred, operationalised as the midwife’s characteristics that should adapt to each woman’s individual needs in the context of each specific labour, irrespective of the birth setting. Four pillars of care are encompassed in the care provided by a good midwife in the labour continuum: promoting individuality; supporting embodied limbo; helping to go with the flow; providing information and guidance. As a kaleidoscopic figure, a good midwife should be multi-coloured and ever changing in the light of the woman’s individual needs, expectations and labour journey (e.g. stage of labour and events occurring during childbirth), in order to create an environment that enables her to move forward despite the uncertainty and the expectations-experiences gap. The following elements are harmonised by the kaleidoscopic midwife: relationship-mediated being; knowledgeable doing; physical presence; immediately available presence. Conclusion: The model presented has relevance to contemporary debates about quality of care and place of birth and can be used by midwives to pursue excellence in caring for labouring mothers. Independently from the place of birth, when the woman is cared for by a midwife demonstrating the above characteristics, she is more likely to have an optimum experience of birth.

The effect of maternal nutrition on fetal and offspring growth and risk of disease in later life is well established. Animal models have shown that the small intestine can be preferentially affected by growth restriction compared with other organs, yet the effect of maternal diet on gastrointestinal (GI) development has not been well studied. Furthermore, both the maternal GI tract and microbiome undergo significant adaptations during pregnancy in response to the increased nutritional demands of the growing fetus, which may be further modulated by the maternal diet. Inadequate development of the GI tract may result in an increase in intestinal permeability, as demonstrated in inflammatory bowel diseases. Compromised gut barrier function has been linked to the development of obesity through the passage of endotoxin on Gram-negative bacteria leading to low-level inflammation of the liver and adipose tissue. The aim of this thesis was to use two animal models of maternal dietary manipulation that are representative of suboptimal nutrition characterised by the nutritional excess of macronutrients found in many Western diets. The effect of either fat in the form of palm oil and carbohydrate in the form of fructose were therefore examined with particular focus on the gut. This was undertaken in a pig model to examine the effects around the time of birth and in the juvenile offspring, whilst in a rat model both the mothers and offspring were studied. Addition of 10% fructose to drinking water in two generations of pregnant Wistar rats induced impaired glucose tolerance and raised serum triglycerides, but only in the second generation. Sequencing of the maternal microbiome in first generation dams through pregnancy revealed significant changes in microbial diversity from pre-mating to late pregnancy, both between and within dams. Consumption of the fructose diet led to further changes in microbial diversity. Offspring of fructose-fed mothers were growth restricted and had significantly shorter small intestines compared to controls. Changes in gene expression in the ileum and jejunum were indicative of raised intestinal permeability in second-generation dams, and included the epithelial tight junction genes occludin (OCLN), claudin (CLDN) and junctional adhesion molecule (JAM). In both generations the fructose diet significantly upregulated glucose transporters 2 and 5, and sodium-glucose linked transporter 1 in the ileum and jejunum suggesting that a relatively low level supplementation of fructose gradually increases the absorptive capacity of the small intestine for both glucose and fructose. This may explain the significantly impaired glucose tolerance and insulin resistance observed in second-generation offspring. To study maternal fat supplementation, sows were fed a standard commercial diet supplemented with palm oil (6.6% added to commercial feed) throughout gestation. Median birth weight offspring born to fat supplemented mothers sampled at 7 days demonstrated no growth restriction, but significant downregulation in OCLN, CLDN and JAMA expression, suggesting increased intestinal permeability. No changes in offspring body composition were observed at either time point, and effects on gene expression did not persist up to 6 months of age. In conclusion, a suboptimal diet through pregnancy in which macronutrient composition is raised has the potential to compromise gut function in the mother and offspring. The magnitude of effect can however be temporary and dependent on the animal model used as well as the macronutrient targeted.

Since the introduction of coffee to Europe in the early 17th century its popularity has steadily increased and, water apart, is the most widely consumed beverage globally. Being derived from a plant, a cup of coffee represents a complex mixture of naturally occurring chemicals such as caffeine, coffee oils and chlorogenic acid. As the popularity for coffee has grown so too has the interest surrounding its possible biological and pharmacological effects. A small number of studies suggest potential risks and benefits associated with coffee consumption in pregnancy; however these have yet to provide definitive conclusions. Furthermore government advice does not directly address coffee intake during pregnancy and there is no information regarding womens’ and midwives’ views and opinions on this increasingly important issue. This was a mixed-method research study, with both a qualitative and quantitative components. Firstly, I aimed to gain insight into womens’ and midwives’ views and opinions on coffee consumption during pregnancy. Informed written consent was obtained from women attending the hospital for their antenatal care. These women were of varying gestational age, ethnic background, socioeconomic status and age. Informed written consent was also obtained from midwives from varying disciplines and experience levels; those from academia, research and practicing midwives included. I recruited twenty participants in each group. Information and perspectives were gathered through semi-structured face-to-face or telephone interviews. Interviews were analysed with the Framework method of analysis. The second quantitative arm of my study investigated the effect of specific coffee chemicals on placental and myometrial vascular function. Human chorionic plate arteries, isolated from placental biopsies, and maternal myometrial arteries isolated from myometrial biopsies, were assessed by wire myography. Contraction and relaxation were determined to incremental doses of caffeic acid, chlorogenic acid and caffeine. The antioxidative properties of these chemicals were also assessed in response to application of reactive oxygen species. My findings indicated that women and midwives’ were unsure of the information surrounding coffee consumption. Pregnant women and midwives’ discussed the provision of information, sources of information and supplementing information. Findings also indicated that the relationship between health care professional and pregnant women can influence willingness to accept information and womens’ level of pregnancy stress. My laboratory studies indicated that the active coffee chemicals did not significantly impact on placental or myometrial arterial function. The chemicals investigated did not elicit any significant protective antioxidative effects. Combining methods allowed for a more comprehensive primary study to be completed. My literature search indicated that there was a clear gap in the knowledge surrounding coffee and its consumption during pregnancy. There is a clear lack of evidence-based information accessible to women regarding consumption. Midwives feel ill-equipped to provide women with information on coffee but err on the side of caution with their advice. Laboratory studies indicate that the coffee chemicals investigated did not induce an effect and cast doubts on the potential antioxidative effects that have been previously quoted in the literature.

Background: Maternal anxiety in pregnancy has been associated with an increased risk of poor obstetric outcome, including preterm delivery, low birth weight and emergency caesarean delivery. Furthermore, mothers suffering from antenatal anxiety are more likely to experience delivery complications and develop postnatal depression. Consequently, the National Institute of Clinical and Health Excellence (NICE) in the UK have emphasised the need for non-pharmacological interventions to help reduce antenatal anxiety. Yoga may be a suitable intervention as it incorporates relaxation techniques with physical exercise that can be customised for pregnant women. Furthermore, it has been shown to be as effective as cognitive behavioural therapy in reducing anxiety in non-pregnant women. Aim: To develop and pilot a randomised controlled trial that tests a yoga-based relaxation therapy designed to help reduce maternal anxiety in pregnancy. Method: This thesis is divided into two sections. The first details the methodology, results and implications of pilot work conducted to develop the design for the larger RCT. This pilot work entailed (1) a survey of yoga instructors to examine the usual structure of yoga classes and the features of a class that make it beneficial, (2) a pilot study with the preliminary design for the larger RCT applied to women already attending antenatal yoga sessions, (3) a discussion group with yoga instructors who took part in the pilot study and (4) service user feedback on study design. The second section focuses on the implementation and findings of the RCT where pregnant women were recruited through an ultrasound department and community midwives. Pregnant women were subsequently randomised to either treatment-as-usual (TAU) or an 8-week programme of antenatal yoga to test whether a single session of yoga significantly lowered maternal anxiety and levels of the stress hormone cortisol, and whether multiple sessions help to reduce maternal anxiety, specifically fear of childbirth. Results Participants who attended antenatal yoga showed a significant decrease in fear of childbirth compared to at baseline. Furthermore, the decrease in scores was significantly greater than that observed for the control group. In contrast the control group showed significantly elevated depression scores post-intervention when compared to those that received yoga. A single session of yoga was shown to reduce both subjective ratings of anxiety and stress hormone levels. This effect remained at the final session of the intervention. Conclusion: These preliminary data suggest yoga to be a potentially useful intervention, both in the short and long term, in helping to reduce women’s anxieties towards labour and delivery. However further research is required to identify ways to research complementary therapies, which are readily available within the community, to help maintain the fidelity of comparison groups in scientific research.

Over the past 15 years the focus of postnatal care has changed. Contemporary professional guidance no longer directs midwives to undertake specific assessment tasks in relation to women’s genital tract, but advocates an holistic and individualised approach. However more recently some concern has been expressed within the professional literature that women’s physical needs may be overlooked. It is unclear how midwives decide upon their approach to maternal genital tract assessment, the involvement of women in this process, what assessment methods they use and the factors that influence this clinical reasoning process. A constructionist grounded theory methodology was employed to guide the research design and processes, including analysis of the data, the use of theoretical sampling to evolve the emerging research categories and the construction of a grounded theory. Ethical approval was gained from the regional research ethics committee and the research and development committee at the data collection site. Sampling was purposeful and data was collected using narrative style in depth interviews involving fourteen midwives and observations of fifteen postnatal assessments involving five midwives and fifteen postnatal women. Three themes were identified from the data and form the framework of the constructed grounded theory; they are Methods, Motivators and Modifiers. Within each theme are a number of categories and focused codes. The Methods theme summarises a range of assessment methods used by the midwives, including risk assessment, questioning and clinical observations. The Motivators theme incorporates factors which motivated how, when and why the midwives undertook genital tract assessment and includes verification, personal preferences and sensitive care. The Modifiers theme consists of factors and contexts, which facilitated or inhibited the midwives’ ability to negotiate an appropriate approach to assessment and includes the categories therapeutic relationship, care in context and evolving midwifery knowledge. The findings of this study suggest that the midwives are aware of a range of assessment methods, however there was less articulation or demonstration of methods pertaining to assessment of uterine health. The motivating and modifying factors highlight midwife, woman and contextual factors, which may enhance and inhibit the midwives clinical reasoning process. The complexity of contemporary midwifery practice is illuminated as these factors conflict and create practice tensions and contradictions for the midwives. There was limited evidence that the midwives involved women in deciding the approach to genital tract assessment. Implications include the need to ensure midwives have the knowledge regarding uterine health and the skills and affective abilities to engage women in health assessments and practice effectively within the complexity of contemporary practice.

In May 2002 the National Institute for Clinical Excellence (NICE) made the recommendation that all pregnant women with an RhD negative blood type should be offered routine antenatal anti-D immunoglobulin (Ig) prophylaxis (RAADP). Midwives were the key professional group who would be involved in administration of anti-D Ig and yet they had little input to formation of policy and contributed little to the evidence base that informs policy and practice. A midwifery perspective is however important and relevant, and forms the basis of this work. The thesis comprises three distinct, but related, pieces of research: a survey conducted in 2005 to determine implementation of RAADP at UK maternity units; secondary analysis of anti-D Ig errors involving midwives that were reported to the Serious Hazards of Transfusion (SHOT) scheme in 2007/8; and focus group interviews conducted in 2010 to explore midwives’ views on issues that impact the care provided for women with an RhD negative blood type. The aim of the RAADP survey was to establish current {2005} policy in the United Kingdom in relation to the NICE recommendation for RAADP (NICE, 2002). The survey formed the foundation on which to build the thesis by determining that by 2005 RAADP had become an integral aspect of maternity care within the UK. However it also found that there were significant variations within local policies and among the information that was provided to pregnant women and healthcare professionals. The aim of the survey was to determine implementation of policy and not to explain findings, raising important questions which were used to inform the subsequent research. The second piece of research was secondary analysis of existing anti-D Ig error reports collated by SHOT. The analysis was unique in that it included only those errors involving midwives. The findings highlight both individual and organisational impact on errors, building on the findings of the RAADP survey. The research identified proximal errors, trigger events and fallible practices providing a framework within which the common pathways to error involving anti-D Ig can be understood. This will allow midwives to better understand and improve the care they provide. This piece of research also raised further questions about midwifery practice and those questions informed the focus group research. The focus group research aimed to consolidate the findings of the previous research by gaining direct input from midwives. Two focus group interviews were held, with clinical midwives as participants. The research found that the midwives and the organisations within which they worked provided care in line with policy and procedure at the apparent expense of a woman centred approach. This appeared to be linked to the midwives’ understanding of their responsibility, accountability and the education and information that underpinned the care they provided. The other important finding from the focus group research was that the midwives regarded RAADP as a less important intervention than they did anti-D Ig given following a potentially sensitising event (PSE) during pregnancy or given following delivery. When considered as a whole body of work, this research provides unique and valuable insight to midwifery involvement in the care of women with an RhD negative blood type. The research highlights the challenge of achieving government objectives for individualised, woman centred care within the present framework of clinical governance and evidence based care. In doing so it also raises questions about how individual midwives and the midwifery profession have engaged with medical colleagues and policy makers to maintain a midwifery context to the care they provide. Although the research findings relate to care provided for women with an RhD negative blood type the findings are pertinent to other aspects midwifery practice, particularly those originating within the medical profession that are now a routine part of midwifery care.

The impact of a termination on subsequent pregnancy outcomes has been widely studied. It has been suggested that women who terminate a pregnancy are more likely to have an adverse outcome of a subsequent pregnancy, either miscarriage, or a preterm or low birthweight baby. However, the evidence to date is inconclusive and in some cases contradictory. Hypothesis: It is hypothesised that those who had terminated their first pregnancy are more likely to have an adverse outcome of a subsequent pregnancy, (either miscarriage, preterm delivery (<37 weeks), or low birthweight ((<2500g) as a proxy for gestation). They are also more likely to have shorter gestation at miscarriage, and the gestation at miscarriage is associated with method of termination. Also, women are more likely to show a dose-response in three-pregnancy series, with increasing numbers of consecutive terminations associated with increasingly poorer outcomes. Data and Methodology: Setting and Sample: Aberdeen maternity hospital (AMH) is the level III consultant-led maternity unit for NHS North of Scotland Region. It provides care for pregnant women both with and without complications and for sick neonates. The data were extracted from the Aberdeen Maternity and Neonatal Databank (AMND), with the sample restricted to Aberdeen city women in 1970-1999, and only singleton pregnancy events were included. Outcomes The study group was Termination-Birth (TB) and this group was compared to three comparison pregnancy history groups, Miscarriage-Birth (MB), Birth-Birth (BB) and Birth (B). The outcomes are preterm and low birthweight deliveries and the sub-categories of preterm and low birthweight. In addition, miscarriage on the index event is also considered as an outcome. Methods: The distributions of gestation and birthweight were examined between and within study groups for outcomes of preterm and low birthweight deliveries, and logistic and multinomial regression was used to assess the impact of selected potentially confounding socio-demographic and pregnancy related characteristics on the odds of delivering at different levels of preterm and low birthweight by pregnancy history. The gestation at miscarriage of the index subsequent event is also examined between study groups, as is the method of termination for women whose first pregnancy was terminated. In addition, two and three pregnancy sequences are examined to determine if there was a ‘dose-response’ effect of termination of pregnancy. Results: For women from group TB, the overall difference in average adjusted gestation at delivery is approximately 1 day less for women from group TB compared to women from group MB, and only 2 days from women with only a history of births, these results could be considered clinically insignificant. This thesis has shown that compared with women with a previous birth, and after adjusting for possible confounding factors, births after a previous termination were consistently more likely to result in a preterm delivery. Women who terminated a first pregnancy have an increased likelihood of preterm delivery from a public health perspective, with an overall 40% increase in risk for preterm birth for women from group TB when compared to women from group B (OR 1.35 95%CI 1.15, 1.58). These increased odds of preterm delivery for group TB are very similar to those for women from group MB (OR 1.45, 95%CI 1.18, 1.79). Similarly, after adjustment for potential confounding factors, women from group TB were consistently more likely to deliver a low birthweight baby, when compared to women with from group B, (OR 1.18 95%CI 1.00, 1.38). Women from group MB were also significantly more likely to deliver a low birthweight baby after adjustment for possible confounding factors (OR 1.42 95%CI 1.16, 1.72). Few if any of the explanatory variables are directly modifiable, and the PAF associated with women from group TB is relatively small, when compared to other significant potential risk factors. Women who terminated a first pregnancy were significantly more likely, after adjustment for socio-demographic characteristics to miscarry late (OR 1.74, 95%CI 1.07, 2.84), but there was no difference between medical and surgical terminations. Finally, there was no evidence of a dose response of termination for either preterm or low birthweight deliveries, although there was marked evidence of a dose response of miscarriage. Conclusions The results from a clinical and public health point of view may appear to be contradictory, in that there is an approximate 40% increase in relative risk for preterm delivery, but only an adjusted absolute difference of two days lower gestation at birth for women from group TB. PAF findings indicate only a small overall reduction in the number of preterm deliveries if the exposure to the risk factor of a previous termination was eliminated. Women who undergo a termination should therefore receive full information on factors which might have an influence on the outcome of a subsequent pregnancy, and in addition medical information given to the women should cover details about the termination process, including methods of termination, possible complications, post termination follow up and future contraception.

The aim of this study was to use the grounded theory method to discover the main concerns of midwives in relation to their practice with baby feeding, and to identify the processes that are involved in dealing with baby feeding in their day-to-day work. Data were generated from thirty in-depth interviews with midwives who worked in two maternity care Trusts in the North of England. Data were analysed using constant comparative techniques of the grounded theory method. A computer software program (Non-numerical Unstructured Data Indexing Searching and Theorising package) for qualitative data analysis was used to manage and store the analysis. The grounded theory that emerged suggests that baby feeding was not an easy part of these midwives’ work. These midwives were finding ways of dealing with the pressures that were around them, and which they felt, were affecting their practice. Examples of these pressures include the environment where feeding took place, the support and contributions of those around the woman and baby (particularly other midwives), and the beliefs and behaviour of the woman and baby themselves. ‘Surviving’ enabled midwives to feel that they had dealt with baby feeding in their practice and successfully managed their workload. Surviving consists of four main categories: altering proximities of baby feeding, emotionalising baby feeding, struggling with baby feeding, and directing baby feeding. Surviving is not a linear process that is sequential, but cyclical as these categories are inter-related to each other. However, these midwives’ actions created many of the problems that they experienced, therefore the process was perpetuated. The significance of this substantive theory has been explored within the literature related to baby feeding, workers’ functioning in other public service bureaucracies, and research methodology. Implications for midwifery research, practice and policy are discussed. It is suggested that this thesis could contribute to wider health service agendas such as clinical governance, multi-disciplinary working and public health.