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At its inception in 1902, formal midwifery training developed within hospital midwifery services. With the development of a theoretical base, training became education during the 1980s. During a period of economic and societal changes in the 1990s, midwifery education was incorporated into higher education, separating education from health service practice. There were consequences for midwifery education especially the structure of pedagogical relationships. This thesis looks at key sets of relationships in midwifery education between the three main groups of actors: academics, clinicians and students. In so doing, the inquiry utilises a grounded theory approach and embraces disciplines of education, social sciences, social psychology, management and philosophy. The study confirms the importance of relationships between the key actors as part of a student's learning experiences. However, these relationships have become more problematic as a result of the organisational separation between the academic and professional components. A framework is proposed to describe educational relationships in midwifery. The framework has six dimensions; (i) a core component of personal traits, (ii) a secondary component of social and communication abilities and four subsidiary components of (iii) professional expertise, (iv) personal knowledge, (v) education knowledge and skills and (vi) a vision for practice. Realisation of the components by one person of another within the three groups aids mutuality in understanding. General principles are offered that include notions of encounter, exchange, rules, boundaries, reciprocity and reinforcement that aid in constructions of relationships. Though these conditions, in themselves, aid the formation of learning relationships, two processes occur in these relationships through encounters, that is, complementation (a unity of meanings between actors) and complementarity (a matching of understandings). These require a forum for encounters. A model of education is proposed that offers just such a forum aiding positive encounters to promote learning between the three groups of actors. Features of this model are the development of teachers within clinical practice, accreditation of practitioners as educators and the education of students primarily in clinical situations with interactive learning.

Fetal life and early childhood are periods of rapid growth and development and both serve as important indicators of health in later life. Maternal diet during pregnancy has been recognised as one of the major lifestyle factors influencing both fetal growth and long term health. The link between maternal dietary patterns and fetal growth has been examined to some extent, little however is known on the potential long term effects on child growth. Using data from three large international cohort studies, this thesis aimed to assess the effect of maternal dietary components and patterns during pregnancy on offspring growth. The literature review revealed a heterogeneous body of studies that was generally supportive of a positive association between a health conscious maternal dietary pattern during pregnancy characterised by high intakes of fruit, vegetables, water and wholegrains and offspring size at birth. The evidence relating later child growth to maternal diet in pregnancy was inconclusive mainly due to a lack of research as well as heterogeneity amongst studies. Analyses of the association between maternal alcohol intake and fatty fish consumption prior to and during pregnancy and offspring size at birth was explored; providing further support on the evidence of alcohol as a teratogen, even in low amounts in the first trimester of pregnancy. The evidence for fatty fish intake however was inconclusive. In order to facilitate between study comparisons, a common food grouping system was applied to dietary data from the three cohorts and principal component analysis was performed on energy adjusted dietary data. Two, four and seven components were derived from each cohort. However, the dietary patterns identified from the different cohorts did share some commonalities. In particular, a dietary pattern characterised by high positive correlations with fruit, water and unrefined grains and negative correlations with refined grains and chips, seemed to be present in all three datasets. These were also the components that showed the most convincing associations with offspring growth outcomes at birth and around 7 years of age, even after taking into account known confounders and assessing possible mediation by birth weight and gestational weight gain as well as effect modification by breastfeeding and maternal pre-pregnancy BMI status.

Context: Conception and abortion rates among women aged under-20 in Britain are high compared to those of other European countries. Conception and abortion rates among women aged under-20 are lower in France. In both countries, women from disadvantaged backgrounds are more likely to report a conception before age 20, and less likely to terminate the pregnancy with abortion if they do. A significant body of research has explored conception and abortion among young people in Britain, but fewer studies have capitalised on the potential of cross-national research to increase our understanding of the British situation. The aim of this research is to examine how proximal and contextual factors, particularly disadvantage, shape conception and abortion rates among under-20s by comparing two countries, Britain and France. Methods: Routinely-collected data on births and abortions are used to describe rates, trends, and area-level variation in conception and abortion rates within and between the two countries, and associations between disadvantage and conception and abortion at area-level. Nationally-representative survey data from both countries are used to examine differences between the two countries in behaviours and outcomes at each stage in the pathway to abortion (sexual activity, contraceptive use, pregnancy and recourse to abortion), and the associations with socioeconomic characteristics at each stage. Results: The proportion of young women sexually active is greater in Britain but differences between the two countries in contraceptive use are smaller. There are differences in the timing and circumstances of first sex between Britain and France. Associations between socioeconomic characteristics and each stage in the pathway to abortion in individual level analyses are similar in Britain and France. The correlation between disadvantage and conception and recourse to abortion is stronger in Britain. Discussion: The findings indicate that differences in conception rates between Britain and France are driven proximately by differences in the proportion of young women that is sexually active, and, to a lesser extent, differences in contraceptive use. Motivations to avoid pregnancy may play a key role in shaping behaviours at each stage of the pathway to abortion. A cross-national comparison has enabled the role of country-level social context to be explicitly examined. These empirical findings lend weight to arguments that differences in behaviour are shaped by nation-specific compositional and contextual factors including the level of social inequality and proportion of the population that is disadvantaged, the timing and pace of the transition to adulthood, prevailing norms relating to gender and young people’s sexuality and capacity for parenthood, and the opportunities that are available to, and perceived to be accessible by, young people.

The results of this thesis include the following:-.; 54 fetuses were studied, of which 33 were appropriate for gestational age (AGA) and 21 SGA. The mean birthweight of the AGA fetuses (3227 471 g) was significantly higher than that of SGA fetuses (2361 245g).; The overall mean umbilical vein blood flow was 86 24 ml. kg.-1 min.-1. Blood flow was significantly lower in SGA fetuses (66 23 ml. kg.-1 min.-1) compared with AGA fetuses (90 18 ml. kg.-1 min.-1).; Mannitol clearance across the placenta decreased as maternal mannitol concentration increased indicating saturation of a transfer process. Mannitol transfer across the placenta was therefore thought to be carrier mediated rather than passive as had been previously thought and implicitly cannot be used as a good extracellular marker. The mean clearance of mannitol in SGA pregnancies (5.6 2.1 ml. min.-1) was significantly lower than in AGA pregnancies (12.8 1.6 ml. kg.-1 min.-1).; L-leucine transport across the placenta was significantly lower in the SGA fetuses.; Glycine transport and fetal uptake were significantly lower in the SGA group. In addition, neonatal glycine levels were significantly lower in the AGA group.;The transport of D-and L-leucine and glycine across the placenta is defective in SGA pregnancies. In addition, fetal uptake of these amino acids is significantly reduced. D-leucine is actively transported across the placenta and the same transporter may be involved in carrying D- and L-leucine. Glycine metabolism in the SGA neonates is significantly slower than that of AGA neonates.

Background: Oral health is a concern in pregnancy because of local oral effects such as gingivitis and the potential to have an adverse effect on pregnancy outcomes. In Kuwait, evidence suggests that expectant mothers have poor oral health, are fearful of dentistry, have little awareness of oral health and are in need of dental health education (DHE). In order to design an intervention aiming to change the oral health behaviours of pregnant Kuwaiti women, it was important to have contemporary evidence on the relationship between periodontal disease (PD) and adverse birth outcomes (ABOs), and an understanding of the social and cultural context in Kuwait in which oral health behaviours take place. Aim: The aim of the thesis was to design, implement and evaluate a DHE intervention for Kuwaiti pregnant women. In order to achieve the aim of the thesis three studies were undertaken: 1) A systematic review and meta-analysis to assess the association between PD and ABO, and the efficacy and the safety of non-surgical periodontal treatment (NSPT) during pregnancy to prevent ABOs. 2) A qualitative study amongst Kuwaiti women to investigate perceptions, beliefs, attitudes and expectations about oral health and maintaining and improving oral health during pregnancy. The data were also used to identify social cognition constructs which might be helpful to promote oral health behaviour in this group of women. 3) A randomised controlled trial to assess the efficacy of dental health education (DHE) with or without a planning intervention on adherence to dental health related behaviours amongst Kuwaiti pregnant women. Results: Study 1) The majority of individual cohort studies support an association between ABOs and PD, the meta-analyses support the association [(PTB: RR1.63 (95% CI: 1.06, 2.50, P=0.03), LBW: RR 2.35 (95% CI: 1.21-4.57, P=0.01) and PLBW: RR 3.53 (95% CI: 1.51 -8.20, P=0.003)] but are compromised by high levels of heterogeneity associated with the insecurity of definition of periodontal disease. The meta-analyses of 13 RCTs found that NSPT during pregnancy did not prevent PTB and PLBW but may prevent LBW (RR 0.75 (95% CI: 0.56-0.99, P=0.05) and stillbirth (RR 0.48 (95% CI: 0.25-0.90, P=0.02). The meta-analyses for PTB, LBW and PLBW were characterised by high levels of heterogeneity also attributable to uncertainty about definition of periodontal disease. None of the RCTs assessed robustly the safety of the periodontal treatment during pregnancy, though no significant adverse events were reported. There remains uncertainty in relation to the efficacy and safety of NSPT to prevent ABOS. Study 2) The qualitative study found that women had low levels of oral health knowledge and information. They had unhelpful cultural beliefs concerning oral health during pregnancy, and were unaware of the effect of pregnancy on oral health. Pregnant women lacked motivation to seek dental care even when they considered dental treatment safe during pregnancy. Dentists, unhelpful cultural beliefs, and lack of motivation were identified as barriers to accessing oral health care and seeking oral health knowledge. A number of social cognition constructs were identified from the qualitative study: knowledge; attitudes; subjective norms; barriers; and intentions. These together with the findings from the first study were used to frame, inform and design the intervention reported upon in study 3). Study 3) At T1 154 women were eligible and randomly allocated to the three groups respectively: Treatment as Usual (TAU) =53; DHE=53; DHE & Planning=48. At T2 the number of women in each group completing the intervention (N=90) was respectively: TAU=28; DHE=30; DHE&P=32. SCM constructs and self-report of behaviours were assessed at T1 and T2 through a questionnaire assessing knowledge, attitudes, subjective norms, barriers, intentions and self-report of oral health behaviours in relation to oral hygiene. Plaque scores (PI ) and gingival scores (GI) were recorded by a trained and calibrated examiner blind to group allocation. There were no demographic differences between the groups at baseline. The mean age of women was 27.80±SD 5.40, 43% (n=38) had a high school level education and 10% no formal education. Twenty eight per cent were in their first pregnancy, the remainder had 2.06±1.98 or more children. A mixed factor ANOVA analysis demonstrated that all women improved their PI (F=94.343 df=1 p=0.001) and GI (F=73.138 df=1 p=0.001) scores. There were no differences in self-reported oral hygiene and PI and GI by intervention group. The SCM constructs changed over time in all women (N=90) except barriers to attendance (F=1.067 df=1 p=0.305). There were no differences in SCM constructs by intervention group at T2. All women reported increasing the frequency of tooth brushing and flossing. Conclusion: Providing a basic oral hygiene leaflet was sufficient to motivate women to change their behaviour in relation to tooth-brushing and dental flossing resulting in improved PI and GI scores. In this study where women had very limited oral health knowledge, information giving was as efficacious as an intervention underpinned by SCMs in influencing behaviour change, but these results must be interpreted with caution given the high attrition rates and possible influence of a Hawthorne effect.