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In Afghanistan, the majority of women continue to give birth at home because of poverty, difficult access to health facilities, or gender-based restrictions. Women are often brought into hospitals in moribund conditions after the onset of complications at home. A detailed understanding of the determinants of health care seeking delays is necessary in order to help identify strategies which could reduce the incidence of very severe complications and maternal deaths and improve foetal outcomes in complicated pregnancies. Areview of existing studies of care-seeking delays indicated that durations of care-seeking time had not been well explained because of various methodological limitations. The large majority of previous studies were descriptive and fell short in identifying contributing factors that could be eliminated by interventions while analytical studies lacked methodological rigour largely due to sample size limitations associated with rarity of maternal deaths. In this thesis, data from a hospital-based cross-sectional survey conducted among 472 women with severe obstetric complications in Afghanistan were analysed using a refined version of the conceptual framework developed by Thaddeus and Maine (1994). Three types of care-seeking delays were considered: the duration oftime from onset of symptoms to decision to seek care (or 'decision delay'), the duration from the decision to departure for health care facilities, (or 'departure delay') and variation in self-reported travel time from GIS-modelled travel time (or 'travel delay'). The study posited that delayed care-seeking would be best explained by a combination of factors including a woman's health care practice during pregnancy, her family's financial and social resources, geographical accessibility to healthcare and the types of symptoms and signs associated with each complication. It was also postulated that care-seeking delay would be among important determinants of foetal death. Regression techniques were used to identify determinants of the three types of delays, and logistic regression techniques were employed to assess the role of delays on foetal mortality. This study showed that failure to use antenatal care ('ANC') service during pregnancy was associated with an increase in decision delay. Lack of birth plans and absence of a midwife in the locality were also associated with an increased decision delay for ante- and intra-partum women. Awoman's weak relationship with her birth family was associated with an increased decision delay for complication types which did not have clear symptoms while a woman from an impoverished household appeared to experience a long decision delay when she suffered a complication with dramatic symptoms. In addition to seasonal effects, difficult geographical access to healthcare and lack of social capital were found to be positively associated with delay in departure for healthcare facilities. Multi-referrals, low household economic status, lack of community cohesion, and lack of access to vehicle were associated with an increase in travel delay. Finally, decision delay contributed to an increased risk of foetal death. The main conclusion from this work is that ANCinterventions have a significant role to play in facilitating rapid uptake of emergency care, once a complication occurs, in a setting where access to routine and emergency care is socially and geographically difficult. This in turn has implications not only for maternal but also for foetal outcomes. Future research and programmatic efforts should be directed towards understanding and exploiting the roles that social resources could play in facilitating access to emergency obstetric care.

Objective: To determine the effectiveness of ANC birth plans (birth preparedness and complication readiness) in increasing skilled care at delivery and after delivery Rationale: Although birth plans are key elements of focused ANC in many developing countries including Tanzania that aim to increase skilled care utilization at delivery, after delivery and during emergency obstetric complications, robust empirical evidence is lacking on their effectiveness. Methods The study was a cluster randomized controlled trial (RCT) that was conducted in Ngorongoro district, rural northern Tanzania. The primary outcome was the proportion of women who delivered at the available health units and the secondary outcomes were the proportion of women who sought postnatal care within one month of delivery and women's and providers' satisfaction with ANC. The study was implemented in three phases: the formative qualitative study that aimed to understand contextual factors for the high ANC care coverage but low utilization of health facilities for delivery and how the intervention could be implemented in the study district, a RCT to determine the effectiveness of the intervention in increasing skilled attendance at delivery and postpartum, and a process evaluation of the intervention and control arms' ANC. The qualitative study involved 15 focus group discussions, 12 key informant interviews and participant observation of the ANC and delivery care at randomly selected health units. Eight health units were randomly assigned to the intervention (antenatal care with an emphasis on birth plans by care providers) and an equal number to the control group (care as provided currently). A total of 905 consenting pregnant women (404 in the intervention arm and 501 in the control) at 24 weeks of gestation and above were recruited and followed up to the initial postnatal care clinic attendance or during the postnatal interview at home depending on which occurred first. Results Both demand and supply sides factors prevented women from utilizing health units for delivery and immediate postnatal care, despite the high level of ANC uptake. Notably, women's lack of planning for accessing delivery care at health units, norms and traditions dictating that home delivery is equally safe and health system deficiencies (structural, process and outcome) were the key barriers identified. 2 Unpaired t-test statistic was used to assess the effectiveness of the intervention on the primary and secondary outcomes taking into account the clustering effect. Overall, 34.8% of women in the intervention arm and 20.3% in the control delivered in the health facilities (difference in proportion: 14.5% [-9.4-38.3] p=0.2138 for the crude analysis and 16.8% [2.6-31.0] p=0.0248 for the adjusted analysis). Postnatal care utilization was 62.1% in the intervention and 32.1% in the control group (difference in proportion for the crude and adjusted analysis 30.0% [11.3-48.7] p=0.0040 and 31.3% [15.4-47.2] p=0.0009 respectively). Altogether, 96.8% of women in the intervention and 84.7% in the control units were satisfied with the ANC they received (difference in proportion: 12.1% [-6.3-30.5] p=0.1668 for the crude and 12.6% [-5.4-30.5] p=0.1454 adjusted analysis). Similarly, 97.9% and 91.0% of providers in the intervention and control arms were satisfied with the ANC they provided (difference in proportion: crude analysis 6.9% [-3.2-17.1] p=0.1547 and adjusted analysis 7.8% [-0.7-16.3] p=0.0688). Overall, the intervention was implemented as per study protocol. The average time for initial ANC consultation in the intervention arm of the study was 40.1 minutes (range 33-47 minutes) compared to 19.9 minutes (range 12-32 minutes) in the control arm p<0.0001. The average time for consultation during follow-up ANC visits was 23.3 minutes (rangel5-31) for the intervention units versus 10.3 minutes (range 6-17)in the control p=0.0001. Likewise, providers in the intervention units spent more time for counselling/health education or promotion than in the control units at both initial ANC attendance and during subsequent visits (average time at initial attendance 24.5 minutes, range 19-32 in the intervention vs 10.5 minutes, range 5-18 in the control arm) p<0.0001 ). The respective time for follow-up visits was 13.8 minutes (range 6-17) vs 4.5 minutes (range 0-10) p=0.0001. Nevertheless, the improvement was largely on the discussion on birth plans and PMTCT, and not on the other topics in the national focused ANC guidelines. Conclusion and implication for practice A well-implemented antenatal birth plan intervention improved women's utilization of health units for delivery, and post delivery without substantially affecting the women's and providers' satisfaction with ANC. Implementation of birth plans in health care settings in low resource settings like Ngorongoro is feasible and should be promoted as an effective strategy to increase skilled delivery and postnatal uptake.

Observational studies on the association between birth weight and adult blood pressure provide suggestive evidence that exposures during fetal development can have lasting impacts on health. The effect of maternal nutrition during pregnancy on offspring blood pressure has been demonstrated in animal models, but data from cohort studies in humans have proven inconclusive. The follow-up of randomised controlled trials of nutritional supplementation during pregnancy can add high quality data to this research field; this thesis focuses on the effects in three separate trials. Protein energy supplementation provided to pregnant women in rural Gambia was unrelated to offspring blood pressure at 11-17 years old (n=1267). Again in The Gambia, maternal calcium supplementation compared to placebo was also unrelated to offspring blood pressure at 5-10 years old (n=350). In rural Bangladesh there was no effect of maternal food or multiple micronutrient supplementation on offspring systolic blood pressure at 4.5 years old (n=2335). The micronutrient intervention was also unrelated to offspring diastolic blood pressure, but there was evidence that an early invitation to enter a governmental food supplementation programme was associated with marginally lower diastolic blood pressure: 0.58mmHg (95% Cl: 0.06,1.11; P: 0.03). In this setting, randomisation to receive counselling to promote exclusive breast feeding was not associated with offspring blood pressure at 4.5 years of age and none of the interventions were associated with offspring kidney function, assessed as ultrasound-obtained volume and glomerular filtration rate calculated from plasma Cystatin C. These data suggest that the maternal diet during pregnancy, at least those aspects of intake that can be altered during supplementation trials, may not be directly relevant for the determination of offspring blood pressure. Nutritional exposures during other stages of the life course may prove to be more important

Early life experiences impose long lasting effects on health and wellbeing. The early development of eating habits and flavour preferences associated with a healthy diet can help to extend and improve the quality of life. A variety of factors contribute to this process and the resulting early feeding choices have an impact on parents and infants alike. Initially, nutritional factors provide the key influence, with maternal diet affecting the flavour profile of amniotic fluid and breast milk. In doing so, these factors shape the type of flavours recognised as “familiar” and “safe” by the infant. Later parental behavioural inputs interact at different levels, and with an increasing influence, to further mould infants’ and toddlers’ eating related behaviours. This thesis aims to explore elements of the nutrition and behavioural inputs during early life by employing a bi-directional focus. In a small-scale laboratory study comparing vegetable acceptance between breast-fed and formula-fed infants it was found, contrary to hypotheses that the intake of vegetable puree did not vary with milk feeding type. Maternal ratings of their infant’s enjoyment of the vegetables were also comparable between the two groups. With the recognition that mothers likely use multiple means of assessing vegetable preference, the rationale for the enjoyment ratings applied was further explored. Two main categories of cues were derived ‘explicit cues’ and ‘implicit cues, with the first most commonly applied. Finally, the potential for mother-infant interactions to provide insight into vegetable acceptance was explored. Results suggested that mothers might adjust their interactions with their baby during feeding depending on the food familiarity. However, outcomes should be considered with caution due to various methodological limitations and the small sample size. The focus of subsequent research was guided by the methodological limitations identified in the laboratory based. The final online survey was targeted at weaning practices. Specifically, it demonstrated positive associations between the baby-led weaning approach and the use of health promoting parental feeding practices to achieve positive eating behaviour outcomes in toddlers. Although results were encouraging, as BLW is relatively contemporary in the literature, further research is required to explore the long-term benefits of this weaning method.

The topic of termination of pregnancy continues to attract extensive debate in both the public arena and in the academy. Debates about termination of pregnancy for fetal anomaly (TOPFA) in particular take place against this backdrop. Social science analyses of the views of medical professional providers of TOPFA are underdeveloped, and social care professionals (who care for those living with disability) are an under represented group in research more generally. In this contentious area of public policy, the insights could make an important contribution to the on-going policy debates. Using a mixed methods approach, this thesis explores the views about the acceptability of TOPFA from the perspective of two professional groups: medical professionals and social care professionals. Four case studies were used to form a basis for the exploration, and these were selected for intrinsic exploratory value. An epidemiological overview of TOPFA acceptance rates from six areas of the UK was used to help inform the case study selection process. Data collection from professionals by questionnaires and semi-structured interviews followed. The questionnaire data suggest that the views between the professional groups were not radically different. The thematic analysis of the interview data generated two themes: theme one conceptualises the imagined child; theme two conceptualises the predicted experiences of the imagined child. When comparing the accounts given by the two professional groups, the data suggest that social care professionals also look at the wider social context of a person with an impairment when discussing their views regarding TOPFA. Medical professionals focus more on the individual impairment when discussing their views on TOPFA. Whether an anomaly can be ‘fixed’, what pain is associated with the particular anomaly, whether a normal life experience will be had were all considered against what professionals deemed a ‘morally acceptable’ outcome. Acceptable TOPFA was based on what was morally acceptable to professionals both in their professional roles, and within a personal capacity. These findings show professionals are able to negotiate acceptable TOPFA in at least some instances while maintaining a sense of moral self. This research adds support to existing arguments on the extent to which the personal views of medical professionals influence their practices. It also offers insight into a previously under researched group, social care professionals. The mixed methods and interdisciplinary approach has been crucial in providing a productive framework within which to explore the concept of acceptable TOPFA from the perspectives of professionals.

Point of care (POC) is a powerful tool as a diagnostic test because of its advantage of being small, portable device and rapid results obtained. One major class of POC is the lateral flow assay (LFA), which is widely used for protein determinations. A home pregnancy test is the most successful example of the LFAs. A limitation of being quantitative or at best semi quantitative assay leads to improve the assay performance and to enhance its sensitivity. Hence, for this project, a switch from visual detections to electrochemical measurements is the primary goal, which occurred by developing the assay’ concept with keeping the ease and robustness of the traditional LF assay. The integration of streptavidin lateral flow with electrochemical measurements (in particular voltammetric techniques) is the key element to introduce an electrochemical lateral flow assay (ELFA). This concept was based on the amplification of the polymer nanoparticles. A pH responsive eudragit S- 100 was synthesized by nanoprecipitation process. These PNPs are encapsulated with redox active probe such as hydroxylmethyl ferrocene. Eudragit S-100 is dissolved at pH > 7 and it is insoluble in an acidic condition. This dissolution mechanism is preferable since the release of entrapped probe can be controlled until it is being detectable at the test line. Our findings summarized as follows; nanoprecipitation process is able to synthesis PNPs encapsulated both hydroxylmethyl ferrocene and methylene blue. These small-sized particles (~200 nm and ~300 nm) have a highly value negative zeta potentials (-34 mV and -29 mV). These two proprieties respectively, are important in enhancing the probe loading efficiency and in efficient adsorption with the antibody. From our data, it was found that more than 50% of the probes were encapsulated. Further characterizations were performed to investigate the probes’ electroactivity as well as their electrochemical behavior. These voltammetric techniques include cyclic voltammetry and square wave voltammetry, the results suggested good electrochemical behaviors of both probes in respect of their release form the PNPs in immobilized format as well as in the aqueous phase. Importantly, an electrochemical lateral flow assay (ELFA) was investigated the FcMeOH-PNPs and was successfully demonstrated in the presence of varied concentrations of hCG compared to the control (absence of hCG). This indicates that the applied approach was proven. However, further improvements are needed. This led to move toward the screen-printed technology to realize a point of care device.

Introduction: Globally, the World Health Organisation (WHO) have reported approximately 16 million adolescent pregnancies per year, of which 95% are reported to occur in low-lower and middle-upper middle income countries. Indonesia, is one of the low-lower and middle-upper middle income countries; and data indicates that during 2012, 48 per 1,000 pregnancies occurred at the aged 15-19, of these 0.02% were aged 15 or less. This study is the first research of its kind in Indonesia to explore, illuminate and understand Indonesian adolescents’ reproductive practices and their experiences during pregnancy and early parenthood. Methods: This is an exploratory qualitative research conducted over a period of three years, consisting of three studies, a qualitative systematic review (study 1), an in-depth study of adolescents during pregnancy (study 2) and an in-depth study of young parents (study 3). Four couples participated in study 2 and twelve young parents participated in study 3 (including eight young mothers and four young fathers). One-to-one in-depth interviews were used for data collection, thematic analysis was used for data analysis and N Vivo was employed for data management. Findings: This study revealed that adolescents engaged in premarital sexual relationship due to a loving relationship, whilst knowledge related to preventing pregnancy and Sexual Reproductive Health (SRH) services was limited and resulted in unplanned pregnancies. When unplanned pregnancy occurred, the couples were forced by their parents to get married to ’fit in’ with cultural and societal norms of not having children outside of marriage. However, it brought life difficulties within adolescents’ marriage relationships i.e. coping with stress, stigma, judgement, social exclusion, education termination, financial difficulties, jobs, role divisions, breastfeeding and children care. Foucault's theory of power is used to interpret findings. Conclusions and recommendations: Power of culture and religion within Indonesian society played a critical role in adolescents’ complex experiences through their unplanned pregnancy, marriage and parenthood. Indonesian adolescents require timely and accessible SRH education and services to increase their knowledge and understanding around SRH practices so that they can make informed decisions about sexual reproductive practices and prevent unplanned pregnancies. Evidence based care pathways are essential to support and empower young parents during their journeys that they can undertake their parenting role effectively. Future research is invaluable which might evaluate service models initiated to meet the health and social needs of the adolescents during pregnancy and early parenthood.

This thesis (comprised of the literature review and empirical paper) aimed to explore the correlation between physical activity and mood in pregnant women. The literature review of this portfolio presents a narrative review of the research exploring the correlation between physical activity and mood in the general pregnant population. The findings of the review suggest that physical activity improves mood in this population. The empirical paper investigates the correlation between physical activity and mood over the duration of pregnancy. The findings suggest that increased physical activity from before pregnancy to the second trimester improves mood. The Summary of Clinical Experience is an outline of my experiences on 4 different clinical placements. The Table of Assessments outlines the titles of all assessments completed whilst on the clinical training programme.

In this thesis, I draw inspiration from Bourdieu’s theory of practice to inform a conceptualisation of birthing women as skilful and knowledgeable agents. The study contributes to geographical knowledge about spaces of birth and about how these represent key sites of learning. Empirical data were collected in 2011/12 through in-depth semi-structured interviews with 26 women living in North-West England (involving 68 childbirth experiences). Two key themes emerged from the women’s narratives: the prevalence of trouble (and how this is accepted as ‘just the way things are’) and routine (and non-medically indicated) diversions from an undisturbed physiological birth process. This thesis argues that rather than representing a space in which women might learn to protect the physiological process of birth, successive experiences of birth seem to represent a space in which many women learn to shut down that possibility. Rather, they prioritise defensive action to protect themselves against emotional and physical harm, with some women learning that a physiological approach to birth is unnecessary, abnormal and dangerous. Whilst there is evidence that some women learn to birth physiologically over their childbearing careers by drawing on their experiential knowledge, the main finding is that being skilful and knowledgeable as a birthing woman frequently works in the opposite direction. The study thus offers new understandings of birthing women as skilful and knowledgeable agents and explores the diversity of women’s learning about birth by drawing a distinction between how women come to master the social practice of birth and how they learn to birth physiologically over their childbearing careers. For the wider academy, this study brings a renewed emphasis on the key role of childbearing women in the social practice of birth.