Background: The professional development of midwifery in China has been challenged by its marginalised professional status and the medical dominance within midwifery practice in the contemporary maternity care system. There has been growing confusion about, ‘Who the midwife is and what does the midwife do?’ within and outside the profession. The sense of identity crisis for the profession has become particularly salient when Chinese midwifery becomes a sub-branch of the nursing profession during the contemporary period. If, however, we consider the International Confederation of Midwives (ICM) Mission Statement (2008: 32) that midwives are the ‘most appropriate professionals for childbearing women in keeping childbirth normal’, then the focus on a greater understanding of midwives is needed. It is the aim of this research to facilitate this understanding by exploring how hospital-based Chinese midwives construct their professional identity in the contemporary maternity care system and the factors that significantly influence the process. Design and Method: A Constructivist Grounded Theory (CGT) study was conducted to achieve the research aim. A sample of 15 midwives and 5 women participants was recruited between October 2010 and May 2011 from a capital city in one province of China. The accounts from the participants in the form of in-depth individual interviews were digitally recorded and three work journals from midwife participants were also included to facilitate the exploration of the study subject. NVivo 8 was used to assist with data management for the analysis. Findings: Six principle categories were identified: ‘institutional position’; ‘organisational management’; ‘professional discourse’; ‘compromising strategies’; ‘engaging strategies’; and ‘hybrid identity’. The integration of the principle categories has developed the theoretical model ‘navigating the self in maternity care’, which suggests that professional identity construction in midwives is a dynamic process, involving a constant structural and attitudinal interplay between the external (‘obstetric nurse’) and internal (‘professional midwife’) definitions of the midwife. The model indicates that the midwives’ professional identity construction was contextualised in their ‘institutional position’ in the contemporary maternity care system. In everyday practice, midwives experienced identity dissonance in relation to two competing identities: the ‘obstetric nurse’, bound up to the ‘organisational management’ in hospital settings; and the ‘professional midwife’, associated with the ‘professional discourse’ in the midwifery profession. Two types of strategies were identified to reduce the identity dissonance – ‘compromising strategies’ and ‘engaging strategies’ – which resulted in a ‘hybrid identity’, as the construction of professional identity in individual midwives is navigating along an identity continuum with ‘obstetric nurse’ and ‘professional midwife’ at opposing ends. This thesis has expanded on the current theoretical knowledge of identity work by elaborating on the discursive practices professionals employ to legitimate their professional identity and the various strategies individuals use to negotiate their identities at work. It has also extended attention to the influence of institutional forces on professional identity construction. With specific regard to Chinese midwifery, this emerging theoretical model provides a number of possible implications for midwifery practice, education and policy which would facilitate the exploration of effective operational processes for midwives in China to develop professionally.

Regulation of the growth and differentiation of trophoblast cells is critical for successful embryo implantation and placentation. Cytokines are key players in these processes, as well as modulating the maternal immune response to prevent rejection of the conceptus. This thesis focused on the investigation of the cytokine interleukin (IL) - 33 and its receptor, ST2. ST2 has two isoforms, a functional cell surface receptor (ST2L) and a soluble decoy receptor (sST2). Previous work in this laboratory had shown that the human placenta expresses both IL-33 and sST2 at term. The aim of this thesis was to investigate IL-33 and ST2 in early pregnancy, the time when trophoblast is at its most active, with a view to better understanding their role. IL-33 and ST2 mRNA and protein were examined in 14 first trimester placentas from 6-12 weeks of gestation. IL-33 was localized to cells in the villous stroma, whereas ST2 was present in the syncytiotrophoblast, villous cytotrophoblast and the invasive extravillous cytotrophoblast of the cell columns. Secretion of sST2, but not IL-33, by the placenta was found. Investigation of pre-implantation embryos showed the presence of ST2, but not IL-33 protein. Decidualized endometrium was investigated as a potential source of IL-33 and sST2 at the maternal-fetal interface and, although mRNA for both was present, no protein could be found. The key finding was that sST2, rather than ST2L, was the predominant isoform in the placenta. This led us to reconsider the hypothesis that IL-33/ST2 interactions in the placenta are important for successful pregnancy and raised the possibility that they may have independent roles. Using trophoblast cell lines as a model, it was shown that sST2 binds to trophoblast cells, significantly inhibits their proliferation and stimulates their invasion in vitro. This is the first report of this novel role for sST2 in pregnancy. Thus these studies have shown that sST2 may play an important role in implantation and placentation through controlling trophoblast invasion.

The first half of this thesis addressed the clinical question of whether the phenotype of peripheral immune cells is affected by the normal menstrual cycle and whether there are differences in women with recurrent unexplained miscarriage. In chapter 2, a mid-luteal type 1 shift was demonstrated in NK^dim and cytotoxic T cells in the menstrual cycle. In addition, women with recurrent miscarriage had increased numbers of type 1 (IL-18R+) cytotoxic lymphocytes and an increased number of NK^dim and NK^bright cells in the mid-luteal phase of the cycle. The shift to type 2 immunity seen in normal pregnancy has been previously identified from the second half of the first trimester. In chapter 3 this type 2 shift was seen in NK and T cells as early as 9 days post implantation. ST2L (the ligand for IL-33 and a marker of type 2 cells) was consistently up regulated at this very early stage post implantation in women who were pregnant. The second half of this thesis investigated IL-33 and ST2 in normal and pathological pregnancy. In chapter 4 it was shown that circulating IL-33 did not change over the course of pregnancy but that sST2 (the soluble decoy receptor) increased significantly in the 3rd trimester of normal pregnancy. Both IL-33 and ST2 were variably expressed by the pre-implantation human blastocyst, as well as by the 1st and 3rd trimester placenta. Finally, chapter 5 showed a potential role for ST2 in pre-eclampsia, an inflammatory disease of pregnancy. sST2 was significantly elevated in the third trimester in women who went on to develop pre-eclampsia even prior to the onset of disease. Using an in vitro model of placental perfusion, it was shown that sST2 can be secreted by the placenta, suggesting that sST2 may play a significant role in pregnancies complicated by this disease.

Purpose This dissertation focuses at assessing the efficacy of shorter time intervals in the treatment of medical abortions along with the use of various follow up methods. Methods This initial part of dissertation was carried out as an extensive study of literature, followed by observational study on shorter time intervals and follow up methods for the feasibility of the study. The main dissertation met its research aims through an RCT of 121 women comparing shorter to standard time intervals and assessing the various follow up methods at the end of 2 weeks. The qualitative component of the study was achieved by conducting in-depth interviews of women undergoing medical abortion on various aspects of medical abortions with emphasis on shorter time intervals and follow up. Findings This research produced a number of key findings: the RCT showed that both treatments have equal efficacy and acceptability with minor differences in their side effects however the sample size was small to generalise the findings; the follow up methods showed varied responses with preference to confirmatory investigations at 2 weeks follow up. Conclusions The main conclusions drawn from this research were that shorter time intervals can be offered as an alternative to standard treatment intervals in well informed women, however a larger RCT is needed. In order to provide these treatments as outpatient robust follow up methods will need to be incorporated into the abortion services.

This thesis presents two papers. The first is a systematic review of the literature exploring the relationship between perinatal paternal mental health difficulties and child outcomes in preadolescence. Eighteen papers were reviewed. The review found fairly consistent evidence for internalising and externalising problems and mixed evidence for socio-emotional and cognitive difficulties and child temperament. More research is required regarding mental health in fathers during this period more generally as well as how preadolescent child outcomes may be affected. The second paper is an empirical study exploring whether perfectionism was related to experiences of postnatal distress (depression, anxiety and OCD) in first time mothers and whether this relationship could be explained by antenatal maternal orientation. Furthermore, whether the strength of any relationships were affected by participants’ experience of becoming a mother. Eighty-four women completed questionnaires during their third trimester of pregnancy and fifty-nine six-to-twelve weeks after birth. A relationship between socially prescribed perfectionism and postnatal depression and anxiety was observed. Antenatal maternal orientation did not mediate this relationship. Mental health in pregnancy, the impact of sleep deprivation, feelings of control and powerlessness, perceived relationship with baby and levels of social support predicted depression, anxiety and OCD in the postnatal period.

Over 18 million caesarean sections (CS) are performed around the world each year, with many being planned repeat CS which may lack absolute indications. Abdominal delivery on this scale demands an appreciation of the lasting impact, positive or negative, on the health of women and children. Maternal outcomes of planned CS birth have been extensively investigated, but knowledge of outcomes for offspring is largely limited to those occurring in the neonatal period. Avoiding labour and vaginal birth may protect offspring from birth injuries, but could also adversely affect their later health due to avoidance of physiological processes which aid immunity and gut function. Concern that CS may compromise offspring health has arisen from studies which demonstrate an increased risk of chronic health problems following CS compared with vaginal birth. However, the clinical implications of existing studies are unclear due to high risk of selection bias, confounding and lack of power. Studies which can overcome these issues are required. Studies focusing on offspring of women with a history of CS mean the risk of confounding by indication for CS is minimised, as the majority of repeat CS are planned due to maternal preference rather than medical indications. At present, it is not known whether perceived offspring health outcomes of mode of delivery drive women's birth choices after a previous CS, and if so, whether such beliefs reflect evidence-based information on offspring risks. The existing literature highlights a number of factors that may play a role in shaping these birth choices, but no studies have attempted to identify beliefs which independently predict birth preferences after a CS. Such a study has potential to identify key beliefs to target in future interventions designed to optimise women's birth choices. This project investigated both the health of offspring delivered by planned repeat CS and women's beliefs which predict their preferred mode of delivery after CS. Offspring health was investigated using a population-based cohort study. Pregnant women's beliefs about birth after CS were investigated using a synthesis of qualitative literature and a theory based interview and questionnaire study.

Background: Maternal obesity pre-programme offspring to develop obesity and associated cardiovascular disease later in life. In health, perivascular adipose tissue (PVAT) reduces vascular contractility, an effect lost in obesity and during pregnancy. However, neither the effect of obesity during pregnancy on PVAT function in the mothers nor the possible epigenetic effect in the offspring is known. This study sought to identify detrimental vascular changes in post-partum dams and their offspring resulting from maternal obesity. Methods: Six-eight week old female Sprague-Dawley rats were fed a 10% fat (control) or 45% fat diet (HFD) for 12 weeks before mating, throughout pregnancy and during lactation. Offspring received the control diet until sacrifice at 12 (12wo) or 24 (24wo) weeks of age. PVAT-denuded (with or without exogenous PVAT) and PVAT-intact mesenteric arteries from mothers and pups were mounted on a wire myograph and vascular contractility to thromboxane A2 agonist (U46619) and norepinephrine was assessed in the presence of pharmacological tools. Western blotting, immunoprecipitation and an AMPK activity assay were used to detect any changes in the PVAT environment. Results: Offspring of obese mothers were overweight, mildly hypertensive and insulin resistant. Contractions in PVAT-denuded arteries from HFD dams and their offspring were reduced by a mechanism involving increased protein O-GlcNAcylation. PVAT exerted an anti-contractile effect in vessels from control offspring and their mothers through the release of relaxant factors, which included nitric oxide (NO). The anti-contractile effect of PVAT was lost in HFD offspring due to reduced NO bioavailability and increased O-GlcNAcylation, which lead to decreased AMPK activity within PVAT. However, simultaneous AMPK activation within PVAT partially restored the anti-contractile capability in HFD offspring. Reduced NO bioavailability also lead to PVAT dysfunction in HFD mothers. Conclusions: Elevated insulin levels in the HFD offspring may lead to enhanced glucose uptake and increased protein O-GlcNAcylation, which contributes to the PVAT dysfunction in HFD offspring. The PVAT dysfunction, which is associated with reduced NO bioavailability in HFD mothers and their offspring may be the result of reduced AMPK phosphorylation of nitric oxide synthase within PVAT.

No description available.

This thesis presents findings from a qualitative study of the emergence and early clinical translation of non-invasive prenatal diagnosis (NIPD) in the UK. Drawing from interviews with a range of experts and users I track the enrolment and translation of this new prenatal testing technology across a variety of clinical and social spaces. I show how encounters with NIPD prompt deep critical examination of the moral, social and political implications - not only of the technology - but of the established clinical practices (routine and specialised prenatal testing) and specific policy contexts (prenatal screening programmes) within which NIPD has begun to sediment. I explore how, as NIPD advances at a rapid pace and emerges within a culturally and politically complex context, the technology both aligns with and disrupts routine practices of prenatal screening and diagnosis. I show how, as the technology divides into two major strands - NIPD and NIPT - at an early stage of development, and before becoming naturalised/normalised within the clinic, scientists, clinicians and policy makers attempt to pin down, define and ‘fix’ the technology, drawing upon and engaging in substantive practices of division, categorisation and classification. I explore ambiguities present within such accounts, highlighting dissenting voices and moments of problematisation, and following this, I show how the ‘troubling’ of boundaries prompts much examination of ethical and social concerns. As a location within which interviewees explored more contentious issues, I show how abortion emerged as central to the discussion of NIPD. I proceed to show how institutionalised, professionalised bioethical debate dominates mainstream discourse, and I explain how a particular construction of the informed, individual choice-maker is mobilised in order to locate moral and political responsibility for testing in the hands of individuals, and to distance political/organisational structures from entanglement with problematic concerns. I explore how clinicians and patients respond to this positioning in multiple ways, both assimilating and questioning the mainstream discourse of ‘informed choice’. In conclusion, I highlight the broader (bio)political aspects of NIPD’s emergence and translation within prenatal screening and diagnosis.

Research suggests that the relationship between caregivers and their infants has a significant effect on development and well-being across the lifespan. There is a significant body of research into psychological interventions which focus on this relationship. However, there is only limited research into the impact of antenatal interventions which aim to promote the caregiver-foetus relationship, thus preventing later difficulties in the caregiver-infant relationship. Findings so far suggest that such interventions could be effective, and recommendations have been made for further studies exploring the effect antenatal interventions on the caregiver-foetus relationship. This pilot study explored the impact of a newly developed psychoeducational intervention entitled “Baby World” on the caregiver-foetal relationship. Seventy-nine females and 26 males who were expecting their first child were recruited from an NHS midwife service in London. They were randomly allocated to experimental or control groups. All participants completed questionnaires measuring antenatal attachment, mental health and childhood experiences of caregiving at baseline. Those in the experimental group then attended the Baby World class. All participants then completed the questionnaires for a second time, and then attended the standard antenatal classes. Following attendance at these classes, participants completed the questionnaires for a third time and gave anonymous responses to qualitative questions. Statistical analyses of the quantitative data indicated that the intervention did not have an impact on antenatal attachment. Results did show that antenatal attachment increased over time, whilst anxiety decreased. A significant correlation was found between recollections of maternal caring and antenatal attachment. Qualitative analysis suggested that the intervention did have an impact on aspects of the relationship. In the qualitative responses, the majority of participants wrote that the class had been a positive experience for them, and that it had increased their confidence about being a caregiver. Many of the responses indicated that the class had positively affected their skills in reflective functioning, caregiver sensitivity and attunement, and changed their perspective on how to interact with their infant. The results add to the literature regarding the impact of antenatal interventions on the caregiver-foetus relationship. Further research is needed to explore the impact of the intervention on the relationship more closely, in particular to understand which aspects of the relationship may be affected. There are several limitations of the study, in particular the small sample size and the limited number of expectant fathers who participated. Reasons for these limitations are discussed.