Background: The incidence of severe maternal morbidity (SMM) is increasing in high-income countries as a consequence of increased obstetric intervention and increasingly complex medical needs of women who become pregnant. The most commonly reported SMM in the UK includes postpartum haemorrhage and hypertensive disorders. Access to emergency obstetric care means that for the majority of UK women, SMM is unlikely to result in loss of life. However, little was known about the impact on postnatal morbidity. Aim: To assess the impact of SMM (defined as major obstetric haemorrhage, severe hypertensive disorders, critical care unit admission) on maternal health, focusing particularly on post-traumatic stress disorder (PTSD) symptoms at 6-8 weeks postpartum. Method: A prospective cohort study was undertaken of women who gave birth over six months in 2010 in one inner city maternity unit in England. Data on health outcomes were collected on 1824 women using self-administered questionnaires at 6 – 8 weeks postpartum (response rate=53%). The questionnaire included several validated measures to assess aspects of postnatal health and well-being. Multivariable logistic regression analysis examined the relationship between SMM and PTSD adjusting for potential confounders and differences in other postnatal outcomes between women with and without SMM. Results: There was a higher risk of PTSD symptoms following SMM (intrusion: OR=2.22, 95%CI=1.26-3.93, p=0.006; avoidance: OR=3.33, 95%CI=2.06-5.40, p<0.001; both intrusion and avoidance: OR=3.22, 95%CI=1.62-6.43, p=0.001). Women’s sense of control during labour and birth and neonatal outcomes contributed to the risk of PTSD symptoms. There were no statistically significant differences in other mental outcomes, however women with SMM had poorer physical health than women without SMM. Associations between SMM, breastfeeding practice and health service use were inconsistent across indicators of SMM. Conclusions: Findings have important implications for women's health, and the content and organisation of maternity services. Women and clinicians should be aware that SMM can trigger symptoms of PTSD, with further work required to promote care to prevent these symptoms.

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Evidence indicates that many women continue to experience significant physical and psychological problems following childbirth. This is a time when midwives have a unique opportunity to assess women's wellbeing. However, there is scant research on the content and process of midwifery care to women in the postnatal period. This exploratory study investigates agreement between midwives' assessment of women's physical, psychological and social wellbeing at home in the postnatal period, with the women's self reports. A questionnaire was completed by women and midwives, in three study sites in Grampian, Scotland. Aspects of wellbeing were compared between individual midwives and women using a combination of approaches to assess agreement. Regression analyses were used to identify the midwives' and women's characteristics that correlated with midwives' assessment of the women's risk of postnatal depression. To account for the different number of cases the midwives had, a random effect model was applied. The total number of eligible matches were 121. Midwives under-estimated the number of physical problems reported by women. There was better agreement for aspects of physical wellbeing than for psychological or social wellbeing. In the regression models, only how well the midwife considered the woman to be prepared for motherhood correlated significantly (P = 0.05), with the midwife's assessment of risk of PND and the woman's EPDS score. Whether the midwife reported knowing the woman well and whether the woman reported that a midwife knew her well also correlated, but were not statistically significant. This thesis contributes in three main areas. It employed a combination of approaches and used one to one comparisons to assess agreement. In this area of health care this approach has not been reported elsewhere. Secondly, it added to what is already known in the neglected area of postnatal care to the small, but growing, body of knowledge. Thirdly, through considering the physical, psychological and social aspects of wellbeing, it recognised that a balance between these interrelated aspects is required.

Childbirth is associated with considerable change to the mother physically and emotionally. Physically these changes occur as a result of hormonal variations resulting in changes to the biochemical configuration of tissues, pressure effects from the gravid uterus and distortion and disruption during parturition. Until recently assessment of the changes to the pelvic soft tissues has been difficult to investigate. The objective of this thesis was to investigate these changes as a result of childbirth. The hypothesis applied was that childbirth (by whatever mode of delivery) did not cause alteration in the symptoms or ultrasound appearance of the pelvic soft tissues including the urethra. The first part of the thesis relates to validation of the techniques used. Primiparous women were investigated in the third trimester, at six weeks and at six months postnatally with symptom questionnaires, ultrasound scans and neurophysiological assessments. 114 women were recruited with 83 of them completing all visits. 69% had urinary symptoms antenatally. 51% of the women delivered vaginally and 28% of those delivered by caesarean section had symptoms postnatally. The hypothesis was tested by means of systematically analysing the data collected to examine the prevalence of symptoms, and then relate mode of delivery and the presence or absence of symptoms to changes in bladder neck movement, the levator ani complex and the urethral sphincter. Vaginal delivery resulted in bladder neck hypermobility and reduced contractility of the pelvic floor. These changes recovered by 6 months. Caesarean section was associated with a reduction of the levator hiatus, suggesting a pressure effect of the gravid uterus. A comparison of elective with emergency caesarean sections showed a reduction in the ability to distend the pelvic floor in the emergency caesarean group. This difference may give a clue to the reason for Caesarean section and their (reduced) incidence of urinary symptoms. Urinary incontinence and vaginal delivery were accompanied by reductions in the urethral sphincter volume. This appeared to be a separate mechanism for urinary leakage from bladder neck hypermobility. The pressure transmission theory was tested. Loss of pressure transmission occurred with incontinence but was not necessarily present in continent women, suggesting that continence relies on more than bladder neck position alone. From this study it can be concluded that antenatal urinary symptoms are important in the development of postnatal symptoms, and, that vaginal delivery is associated with significant changes to the pelvic floor, which do not occur in women delivered by Caesarean section. This study has also demonstrated that the urethral sphincter is important in maintaining continence. Finally this study suggests that the factors resulting in Caesarean section rather than the Caesarean section itself may be important in whether a woman is at risk of urinary symptoms.

This thesis examines women’s experiences of postnatal care in hospital and on postnatal debriefing. The objectives were to determine what postnatal debriefing is; to understand reasons why some women attend such services; identify the views of women and staff towards this and finally explore women’s feelings about their birth experience to identify possible links between this and the need for women to talk to a professional. A case study utilised secondary data sources to identify women’s experiences of care on the postnatal ward. This was followed by a critical literature review of postnatal debriefing which adopted meta-ethnography to analyse the varied research papers retrieved. The literature review was published in a peer-review journal. Finally the fourth research component followed a sequential mixed methods approach. This included a survey to a convenience sample of 447 women following birth and qualitative interviews with 16 women. The findings of the case study showed that women felt unsupported on the hospital postnatal ward and the environment unconducive to recovery. The critical review of the literature showed that postnatal debriefing enabled women to have their birth experiences validated by talking and being listened to and being provided with information. Results from the main research study show that women with a high Impact of Events Score (IES) are more likely to want to talk following their birth experience and more likely to rate their experience of birth more negatively compared with those with those with a low IES. Five themes were identified in the qualitative analysis that illuminated women’s reasons for needing to talk about their birth experience. Women found the postnatal debriefing service of value. Maternity providers should consider offering a postnatal debriefing service to help meet women’s postnatal support needs in advance of further research in this area.

Background: There are many problems of parenting during infancy for Chinese primiparous women. As an important determinant of good parenting, maternal self-efficacy (MSE) should be paid more attention by researchers. At present, the limitations of previous research examining MSE during infancy are that most studies were related to a homogeneous sample (approximately 90% white) and lacked the consideration of cultural effect; the influencing factors remained poorly explored; and there were few studies related to Chinese women. Therefore, it is necessary to assess MSE and to thoroughly explore the factors influencing MSE among Chinese primiparous women in consideration of the Chinese postnatal culture of “Doing the month” to fill the research gap. Aim: The aim of this study was to describe MSE and to explore factors which may influence MSE in primiparous women in China in the first three months postnatally. Methods: A quantitative longitudinal study using questionnaires was conducted. In total, 420 primiparous women were recruited in obstetric wards at three hospitals in Xiamen City, China. Initial baseline questionnaires to measure socio-demographic and clinical characteristics at three days postnatally were distributed to participants face-to-face by the researcher on the postnatal ward. Participants’ contact details were also collected. Follow-up questionnaires at six and 12 weeks were sent via email by the researcher to participants, including the Self-efficacy in Infant Care Scale (SICS), the Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum Social Support Scale (PSSS) to measure MSE, postnatal depression symptoms and social support, respectively. These were returned by participants via email. Quantitative data were analysed using SPSS. Results: The mean MSE score at six weeks postnatally was 74.92 (SD=11.05), and increased to 77.78 (SD=11.13) at 12 weeks postnatally. The mean social support scores at six and 12 weeks postnatally were 40.99 (SD=9.31) and 43.00 (SD=9.55). The mean EPDS scores decreased from 9.09 (SD=4.33) at six weeks postnatally to 8.63 (SD=4.40) at 12 weeks postnatally; the proportion of women with an EPDS score of ten or more at the two time points declined from 47.4% to 38.3%. The mean score of how satisfied women were with “Doing the month” was 68.73 (SD=17.65) at six weeks postnatally, with most women (91.4%) thinking that “Doing the month” after childbirth was necessary. In the multivariate analysis, the variables: social support scores, women’s satisfaction with “Doing the month” scores, EPDS scores, maternal education, maternal occupation, baby health scores, and baby fussiness scores affected MSE scores during the initial postnatal period. Conclusions: In this study, Chinese primiparous women had a moderate level of MSE and received a moderate level of social support at six and 12 weeks postnatally, and a higher proportion of Chinese women had postnatal depression symptoms than did women in Western countries. From six to 12 weeks postnatally, the mean MSE scores and social support scores had a statistically significant increase; the mean EPDS scores had a statistically significant decrease. “Doing the month” was still popular in Chinese modern society and almost half of the women felt satisfied about their experience of “Doing the month”. Obstetric nurses and women’s family members need to be aware of the significant contribution of social support, women’s satisfaction level with “Doing the month” in positively influencing primiparous women’s MSE, and the significant effect of postnatal depression symptoms in negatively impacting on first-time mothers’ MSE; they should pay more attention to primiparous women with less education, unemployed mothers, women with unskilled occupations, women with an unhealthy baby, and women with a baby with a difficult temperament to improve their comparatively lower MSE levels during the initial postnatal period.

Women's experiences of their perineum following childbirth: expectations, reality and returning to normality The aim of the study was to explore the feelings, perceptions and experiences of women in relation to their perineum following childbirth in the early postnatal period. A grounded theory approach was used for collecting and analysing data from eleven diaries and seven interviews with broad questions about how the perineum, following a vaginal birth, affected the way daily living activities were carried out. Initially purposeful sampling was utilised to recruit women but as important issues emerged recruitment continued through theoretical sampling. Following childbirth women expressed a strong desire to get back to normal reflecting the core theme `striving for normality'. Normality in this context meant doing normal things and feeling like their normal selves. Much of what the women described doing during the early postnatal period was related to achieving that goal and linked to the following categories: `preparing for the unknown', `experiencing the unexpected', `adjusting to reality', `getting back to normal' and `recovery of self'. The main theoretical idea that emerged from this study and derived directly from the data is that: If women are able to successfully adjust to their new and often unexpected reality after the birth of their baby, and begin to reclaim their selves and their world, then they experience a return to their normality. The data demonstrates and clarifies three distinct but related aspects. Firstly, coping with the unexpected consequences of childbirth meant that the women frequently made adjustments to how they carried out essential activities such as walking, sitting and passing urine, in order to try and carry on as normal. The second aspect related to daily activities that were not essential but which women felt necessary to undertake because of social expectations. These included housework and shopping. The third aspect related to how the women felt about their body as a result of the perineal trauma they sustained, and what helped them to feel like their `normal selves' again. These interrelated stages form a framework that reflects Maslow's lower order, hierarchy of needs, within the humanistic psychology paradigm. Implications for practice include the need to improve care in areas of preparing women having their first baby, listening to women as part of the assessment of perineal pain following birth and the need for continuity of care from the same midwife in order for women to appropriately manage their perineal experience.

The postnatal period is an important and extremely vulnerable time for new mothers and their infants. Research has outlined the considerable extent of maternal physiological and psychological morbidity following childbirth. The underreporting and undiagnosed aspect of this morbidity has also been highlighted. Newborn infants are totally dependent on their needs being met and are also at risk of newborn conditions particularly if they are undiagnosed, for example neonatal jaundice. There is however, mounting evidence regarding the lack of postnatal support from health professionals, with women continuing to report their dissatisfaction with postnatal care. Research into postnatal care is pre-dominantly quantitative and clinically focused. Few empirical studies have examined the meaning women give to their postnatal care experiences. This research aims to generate a deeper understanding of the meanings, and lived experiences of postnatal care. In addition, it aims to reveal future possibilities to enhance women’s postnatal care experiences. Initially, an in-depth examination of relevant literature is undertaken followed by a presentation of the process and findings from a qualitative meta-synthesis. An in-depth exploration of Martin Heidegger’s biography and explication of his philosophy is then outlined. This research is a Heideggerian hermeneutical phenomenological study of Irish women’s aspirations for, and experiences of, postnatal care. Purposive sampling is utilised in this research, which was undertaken in two phases. Phase one involved group interviews over three different time periods (between 28-38 weeks gestation, 2-8 weeks and 3-4 months postnatally), with a cohort of primigravid women and a cohort of multigravid women. The second phase involved recruiting two further cohorts of primigravid and multigravid women who participated in individual in-depth interviews over the same longitudinal period. In total nineteen women completed the study. Thirty-three interviews were held in total. The data analysis is guided by Crist and Tanner’s (2003) interpretative hermeneutic framework. The women’s aspirations/expectations for their postnatal care are represented through three interpretive themes: ‘Presencing’, ‘Breastfeeding help and support’ and ‘Dispirited perception of postnatal care’. In addition, five main themes emerged from the data and capture the meanings the women gave to their lived experiences of postnatal care: ‘Becoming Family’, ‘Seen or not seen’, ‘Saying what matters’, ‘Checked in but not always checked out’ and ‘The struggle of postnatal fatigue’. The original insights from this research clearly illuminate the vulnerability women face in the days following birth. A further in-depth interpretation and synthesis of the findings was undertaken. This philosophical-based discussion drew from the work of Heidegger (1962) and Arendt (1998). Engaging with these theoretical perspectives contributed to a new understanding about why some women within a similar context, have positive experiences of postnatal care while others do not. As such, the very nature that midwives and other postnatal carers are human beings has an influence on a woman’s experience of her care. These carers, in their exposition of ‘being’ have the ability to demonstrate ‘inauthentic’ or ‘authentic’ caring practices. It is those who choose to be ‘the sparkling gems’ that are the postnatal carers who make a difference and stand out from the others. For the women in this study, their postnatal care experiences mattered. While some new mothers reported positive and meaningful experiences others revealed experiences which impacted unnecessarily. The relevance of these findings, recommendations and suggestions for future research are offered.

Background: Adults benefit from participating in physical activity (PA) for chronic disease prevention and treatment. Postnatal women are encouraged to commence a gradual return to PA 4-6 weeks after giving birth, with participation in line with PA guidelines. The potential benefits of postnatal PA include weight management, improvements in cardiovascular fitness and psychological wellbeing. There has been limited high-quality information about the efficacy, feasibility and acceptability of PA interventions in postnatal women and few studies in the UK. Behavioural counselling interventions informed by behaviour change theory have been shown to successfully increase PA in low-active adults. Physical activity consultations (PACs) use structured and individualised behavioural counselling to enhance individuals’ motivation for change, and improve self-management skills. This approach may support adoption of PA in low-active postnatal women with research demonstrating that modifiable socio-cognitive factors influence PA behaviour. This thesis reports on the efficacy of a postnatal PA intervention, the More Active MuMs in Stirling (MAMMiS) study on change in PA behaviour. Efficacy of the intervention was tested in a randomised controlled trial. The effect on secondary health and wellbeing outcomes and PA cognitions targeted by the intervention and feasibility results are also reported. Methods: The intervention comprised a face-to-face PAC of around 35-45 minutes and 10-week group pramwalking programme. Non-attenders to the pramwalking group received a support telephone call. A follow-up PAC (15-20 minutes) was delivered after three month assessments. The first PAC involved raising awareness about benefits of PA, developing self-efficacy for change, setting goals and action planning PA, developing strategies for overcoming barriers, encouraging self-monitoring, prompting social support and selecting/changing the environment to support PA. The second PAC involved feedback about changes and preventing a return to sedentary habits. The pramwalking group met weekly for 6 walks of 30-55 minutes at a brisk pace, providing opportunities to demonstrate moderate-intensity walking and to encourage and support PA behaviour change. The control group received an NHS leaflet, which encouraged PA after childbirth. Postnatal women (six weeks to 12 months after childbirth) were identified through a variety of NHS-based and community-based strategies plus local advertisements and word-of-mouth. The primary outcome measure was evaluation of PA behaviour change using the Actigraph GT3X/GT3X+ accelerometer, an objective measure of PA behaviour; self-reported moderate-vigorous physical activity (MVPA) was measured using a recall questionnaire (Seven-Day Physical Activity Recall) and cardiovascular fitness using a submaximal step-test (Chester step-test). Secondary health and wellbeing measures were; anthropometric (i.e. weight and body mass index (BMI)) and body composition (measured using a bioelectrical impedance), psychological wellbeing (measured using the Adapted General Wellbeing Index) and fatigue (measured on a 100-point visual analogue scale). PA cognitions were measured via a questionnaire with constructs adapted from previous studies. All were taken at baseline (prior to randomisation), three and six months follow-up from baseline. Process measures were used to investigate intervention fidelity and feasibility. Acceptability was investigated in a post-trial interviews, conducted by a researcher not involved in the trial. RESULTS: Sixty-five postnatal women (average 33 years old with an infant 24 weeks old) were recruited (77% of those eligible). There was a 91% rate of retention at six months; participants who missed a follow-up assessment were younger (30 versus 34 years old) and had younger infants (21 versus 34 weeks old). Participants were less deprived and older compared with postnatal women in Scotland. Objectively measured PA behaviour did not change in response to the intervention. There was no between-groups difference in change in mean counts/minute from baseline to three months (p=0.35, 95% CI -73.50, 26.17, d=0.22) or three to six months (p=0.57, 95% CI -39.46, 71.18, d=0.13). There was no change in MVPA 7 minutes/day in either group from baseline to three (intervention =-0.70, IQR -9.86, 8.36; control =1.65, IQR -4.79, 8.21) or three to six months (intervention =0, IQR -1.13, 1.10; control =0, IQR -9.86, 8.23), with no between-groups difference baseline to three (p=0.43; r=0.10) or three to six months (p=0.75, r=0.09). Results for relative MVPA were similar. Median steps/day from baseline to three months did not change in the intervention group (0, IQR –1619.44, 1047.94) and increased by 195.95 (IQR -1519.55, 1691.03) among controls. The between-groups difference was non-significant (p=0.37, r=0.18). From three to six month follow-up steps/day increased in the intervention group and not in controls (0, IQR -1147.50, 1303.52), this between-groups difference was also non-significant (p=0.35, r=0.16). From baseline to three months self-reported MVPA declined in the intervention group (15 minutes/week; IQR -111, 15) and increased in the control group (30 minutes/week; IQR –68, 75): a non-significant between-groups difference, with a small effect size (p=0.71, r=0.22). From three to six months a decline in self-reported MVPA was found in controls (53 minutes/week; IQR -41,-101) and no change among the intervention group (0, IQ range -26, 71); a significant between-groups difference with a small effect size (p=0.04, r=0.26). There were no differences between the groups for the change in aerobic capacity from baseline to three months or three to six months with no evidence for change over time in aerobic capacity or fitness category in either group. Change in secondary outcomes did not differ between the groups from baseline to three or three to six months (although fatigue did improve in the intervention group relative to controls from baseline to three months). Considering PA cognitions, outcome expectancies declined in both groups from baseline to three months and continued to decline only in the intervention group from three to six months, a between-groups difference with a small effect size (p=0.03, r=0.26). Self-efficacy increased in the intervention group from baseline to three months and declined in the control group with a small effect size for the between-groups difference (p=0.03, r=-0.27). An increase in action 8 planning was seen among the intervention group but not controls from baseline to three months (p<0.01, r=-0.34). Both groups showed an increase in coping planning and action control; the change was larger among the intervention group relative to controls (i.e. p<0.01, r=0.44, r=0.43, respectively). Increased self-efficacy and action control were maintained from three to six months in the intervention group. Coping planning increased relative to controls (p<0.01, r=0.41) and action planning increased among controls from three to six months (p<0.01, r=0.39). Intervention fidelity and feasibility was good. All intervention participants received the initial PAC and adoption of self-management strategies was high for ‘thinking about the benefits of PA’, ‘action planning’ and ‘self-monitoring’, between baseline and three months. Most participants attended at least one walk (61% attended five or more), 89% of planned walks were conducted with no evidence of poor attendance due to season. Walks were conducted at a brisk pace and met moderate-intensity thresholds. DISCUSSION: MAMMiS aimed to recruit low-active healthy postnatal women to test the efficacy of a PAC and group pramwalking intervention. There was no evidence for an intervention effect on PA or on secondary health and wellbeing outcomes.

The purpose of this study was to evaluate care rendered to HIV positive women and their infants during the first six weeks of postpartum. Quantitative, descriptive, cross sectional and analytic study was conducted to investigate postnatal care services provided to HIV positive mothers. Data collection was done using structured questionnaires. 372 respondents participated in the study. Descriptive data analysis was used; Epi info version 3.5.2 software was used. The study highlighted that the quality of PNC was compromised, in all levels including the critical immediate postnatal care, 3-14 days and 6 weeks postnatal care services. All health facilities that were involved in the study had the basic resources to render quality postnatal care. Negative attitudes of staff and long waiting time (16.7%), were the most deterrents to postnatal care. / Health Studies / M.A. (Health Studies)