This masters thesis presents the stories of Doña Eugdocia and Doña Carmen: two parteras empíricas living and working in the area of Estelí, Nicaragua. The stories were constructed from interviews with the parteras empíricas and are influenced by testimonial life history research methods. The stories, complemented by interviews with Traditional Birth Attendant (TBA) trainers, locally available training manuals, and interviews with other parteras empíricas function as a counter-narrative to global (TBA) discourse revealing the important but little understood contributions these women make to their respective communities and health care systems. The stories demonstrate important parallels between the parteras empíricas narrowing role in Nicaragua and global TBA discourse regarding their practices. The stories also dispel the notion of the traditional as signifying incapable of change. Instead, considering the parteras empíricas story within a postcolonial framework using Jordans (an anthropologist) conceptualization of authoritative knowledge demonstrates that the parteras empíricas positioning of biomedicine as authoritative is a survival mechanism and not a devaluation of their own epistemological orientations.

This masters thesis presents the stories of Doña Eugdocia and Doña Carmen: two parteras empíricas living and working in the area of Estelí, Nicaragua. The stories were constructed from interviews with the parteras empíricas and are influenced by testimonial life history research methods. The stories, complemented by interviews with Traditional Birth Attendant (TBA) trainers, locally available training manuals, and interviews with other parteras empíricas function as a counter-narrative to global (TBA) discourse revealing the important but little understood contributions these women make to their respective communities and health care systems. The stories demonstrate important parallels between the parteras empíricas narrowing role in Nicaragua and global TBA discourse regarding their practices. The stories also dispel the notion of the traditional as signifying incapable of change. Instead, considering the parteras empíricas story within a postcolonial framework using Jordans (an anthropologist) conceptualization of authoritative knowledge demonstrates that the parteras empíricas positioning of biomedicine as authoritative is a survival mechanism and not a devaluation of their own epistemological orientations.

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Nearly one in three women in the United States undergoes major abdominal surgery in childbirth. According to the World Health Organization, in industrialized countries, the cesarean operation provides no health benefits when rates surpass one in six. In fact, the reverse applies; as a result of cesareans both women and their babies suffer disproportionate morbidity and mortality compared to cases of vaginal births. Furthermore, the decision to perform a cesarean relies mostly on subjective physiological indicators and varies according to the sociodemographic characteristics of the birthing woman. By regressing multiple clinical and sociodemographic factors against the method of birth, this research determines the risk factors of undergoing surgery in childbirth in the U.S. Results reveal medicalized childbirth to be a capricious system where sociodemographic factors determine a woman’s chance of major abdominal surgery.

In this thesis, I describe how women who are forced to migrate from Burma into Thailand manage their fertility, unwanted pregnancy and pregnancy loss. The study was initiated by Dr Cynthia Maung, a Burmese medical doctor, herself a stateless person who coordinates a refugee-led primary health service five kilometres inside Thailand. Unsafe abortion is a common problem and much time and resources are taken with the care of women suffering haemorrhage, infection and pain after self-induced abortion in both Thai and Burmese-led health facilities. The thesis examines the characteristics of Burmese women admitted to health facilities with post-abortion complications and their chosen methods of self-induced abortion. Local meanings of abortion and post-abortion care are explored. Lay midwives play a central role in fertility management and some are abortionists. Men’s role in the management of fertility is also presented. The women are generally married with children. Considered illegal migrants, they are employed and work in Thailand without work permits. Many women have a history of escaping human rights abuses and entrenched poverty in Burma. At least a third of women admitted into care with post-abortion complications had induced their abortion with oral herbal preparations, pummelling manipulations or stick abortions. Most of the abortion services were provided by Burmese lay midwives. Reasons for terminating the pregnancy include: poverty, gender-based violence and the local illness of ‘weakness’. In addition, low sexual health knowledge, and difficult access to reproductive health services play a part in mistimed pregnancy. / There is no commonly agreed definition of abortion between formal, informal health workers or women. Most people considered it against cultural lore and in some cases judicial law but still felt it was necessary. Women’s perceptions of the viability of their pregnancy and its outcome prevailed. Men played a limited role in fertility management. I argue that a lack of rights to work and earn a fair wage; to move without fear, a lack of sexual health information, and the ability to safely control fertility increases women’s risk of unsafe abortion. Furthermore, violence perpetrated at the individual and state level contributes to unsafe abortion. Burmese women’s mortality and morbidity associated with unsafe abortion is largely unrecorded by Thai processes and unknown to the Burmese military government. Unwanted and mistimed pregnancy can be avoided through reproductive technologies, education programmes, and access to modern contraceptives. To safely terminate unwanted pregnancies and to treat the complications of pregnancy loss is not only possible but a woman’s right as delineated in the international treaty CEDAW, to which Burma and Thailand are signatories. Yet Burmese women continue to suffer: become sterile, socially vilified, unemployed or repatriated against their will due to their reproductive status. Their sickness and deaths are secondary to the economic imperatives of Burma and Thailand and their human rights continue to be violated.....

Traditional Birth Attendants (TBAs) are the primary health care providers for women at the time of childbirth in many parts of the world. In India, particularly in remote areas such as Garhwal, these women play a key role in maternal health. Training programmes for TBAs can lead to dramatic reductions in neonatal mortality as well as in maternal morbidity and mortality, due to improved hygienic practices at the time of delivery. Yet training programmes for TBAs often lack sociocultural relevance, and fail to incorporate an understanding of the TBAs' perceptions of the process of pregnancy and delivery. Understanding more about the role of the TBA as a diagnostician and a decision-maker within a given sociocultural context can make such training programmes more culturally congruent. This research report describes the way in which TBAs (dais) in Garhwal interpret obstetrical complications, and how they make decisions regarding the need for cosmopolitan medical care. TBAs in Garhwal interpret obstetrical complications using a variety of explanatory models, arising from an understanding of health and illness which shows influences of Vedic, Ayurvedic, folk and cosmopolitan medical models. These explanatory models often led to a perception of "danger” and the "dangerous case" which is widely divergent from the cosmopolitan medical model. Specific areas are identified where the dais' interpretation of "danger" was particularly divergent from the cosmopolitan medical model. These areas of conceptual conflict result in diagnoses and treatment procedures which can lead to significant delays in the woman receiving needed cosmopolitan medical care. The third stage of action-research process is the development of a participatory training programme, in which the TBA is an active participant. The aim of the training programme is to move towards a shared perception of risk regarding major obstetrical complications. / Thesis / Master of Arts (MA)

Infant mortality (IM) incidence in health facility systems during or after infant delivery is substantially high in Nigeria. In this quantitative, cross-sectional study, the effects of skill birth attendants (SBAs), prenatal care, and providers of prenatal care on IM in health facility delivery centers were examined. The Mosley and Chen theoretical framework informed this study and was used to explain the relationship between SBAs, prenatal care, and providers of prenatal care and IM. One hundred and sixty infant deaths were examined among mothers who used an SBA versus those who did not, mothers who had prenatal care versus those without, and mothers who received prenatal care from a health facility versus traditional providers. The 2014 verbal and social autopsy secondary data set was analyzed using binary logistic regression technique. There was no significant difference in risk of IM between mothers who had SBA during infant delivery in health facility compared to those without SBA during delivery. Mothers who received prenatal care had a significant higher risk of infant death in a health facility compared to those that did not receive prenatal care. Mothers who received prenatal care from traditional providers did not have a statistically significant risk of IM compared to mothers who received prenatal care from a health facility. The findings could have positive social change implications by encouraging multilevel public health stakeholders to support and promote the use of health surveillance in understanding the barriers and challenges of health facility delivery practices, prenatal care, and use of SBA as it relates to IM to facilitate policy change in maternal and infant care practices in Nigeria.

A descriptive quantitative study was undertaken in the Leribe and Butha-buthe northern districts of Lesotho. Thirty-six trained, twenty-four untrained TBAs and nine nurses involved in training TBAs were recruited. In line with research by Clarke and Lephoto (1989:3) the TBAs were elderly females who had children of their own. In contrast with the MOH (1993: 10) where TBAs were found to be illiterate, most (93%) of the TBAs in this study had at least a primary education. The art of primary midwifery was learned through assisting with a delivery and being taught by mothers or mothers-in-law. The public health nurses conduct formal training ofTBAs in Lesotho over a period of two weeks, where subjects like ante-natal care, delivery of the baby and post- natal care are addressed. The majority (78.8%) provide antenatal care at their homes or the home of the mother. This includes palpation, history taking, and abdominal massage and health education. An important role is identifying women at risk. During labour the progress of labour is monitored and care is given to the mother and baby post-natally. Trained TBAs could identify women at risk more readily than untrained TBAs. Cases referred most frequently were prolonged labour and retained placenta. Trained TBAs practiced hygiene more often and gave less herbs than untrained TBAs. The health care system is providing support to the TBAs through training and supervision, but was found to be inadequate. Community leaders are involved in the selection of TBAs for training. Regular meetings are held with the TB As to discuss problems. Communication is one of the problems the TB As have to face, because of the long distances from health care centres. A lack of infrastructure and supplies is also of concern. It can be concluded that TBAs play an important role in maternal health care in Lesotho and are supported to a lesser degree by the health care system, which causes problems for the TBAs in their practices. It is recommended that the ministry of health becomes more aware of the need for training TBAs and that a programme for training should be more appropriate, taking cultural practices into account. / Advanced Nursing Science / D.Lit. et Phil.

Background: Occupational stress is a global and complex phenomenon, and workers in developing countries can be affected by it (International Labour Organisation 2001). Staff within maternity settings have been identified as being at risk of suffering from stress, resulting in adverse health outcomes (Evenden and Sharpe, 2002). However, MWAs’ perceptions of stress have not been captured and are not reflected in the literature. Purpose: The aim of this study was to explore MWAs’ perceptions of occupational stress, possible cause(s), the impact and support available and the coping methods they adopted within maternity care settings (hospital) in Nigeria. Methodology: This study adopted a qualitative methodology. Husserl’s (1962) phenomenological approach was chosen as it enabled the researcher to collect rich, in-depth, descriptive accounts of the MWAs’ perceptions of the phenomenon under study through the use of semi-structured interviews. Findings: The major sources of stress for MWAs included work overload, long working hours, staff shortages, work exploitation and intensification and lack of support from senior staff. The stress levels MWAs experienced impacted on their health and well-being and resulted in related behavioural and physical reactions. Conclusion: This study confirmed that MWAs were exposed to similar stress factors experienced by other health workers and reported in the research literature. Additionally, it demonstrated the need for more qualitative studies to explore the perceptions of occupational stress among under-represented groups of healthcare workers. Importantly, this study created an opportunity to explore the experience of dedicated women facing challenging employment practices in hospital settings in Nigeria. Equally, it gave a voice to these unrecognised, almost invisible women, who were the MWAs that played a key role within the maternity services.

A descriptive quantitative study was undertaken in the Leribe and Butha-buthe northern districts of Lesotho. Thirty-six trained, twenty-four untrained TBAs and nine nurses involved in training TBAs were recruited. In line with research by Clarke and Lephoto (1989:3) the TBAs were elderly females who had children of their own. In contrast with the MOH (1993: 10) where TBAs were found to be illiterate, most (93%) of the TBAs in this study had at least a primary education. The art of primary midwifery was learned through assisting with a delivery and being taught by mothers or mothers-in-law. The public health nurses conduct formal training ofTBAs in Lesotho over a period of two weeks, where subjects like ante-natal care, delivery of the baby and post- natal care are addressed. The majority (78.8%) provide antenatal care at their homes or the home of the mother. This includes palpation, history taking, and abdominal massage and health education. An important role is identifying women at risk. During labour the progress of labour is monitored and care is given to the mother and baby post-natally. Trained TBAs could identify women at risk more readily than untrained TBAs. Cases referred most frequently were prolonged labour and retained placenta. Trained TBAs practiced hygiene more often and gave less herbs than untrained TBAs. The health care system is providing support to the TBAs through training and supervision, but was found to be inadequate. Community leaders are involved in the selection of TBAs for training. Regular meetings are held with the TB As to discuss problems. Communication is one of the problems the TB As have to face, because of the long distances from health care centres. A lack of infrastructure and supplies is also of concern. It can be concluded that TBAs play an important role in maternal health care in Lesotho and are supported to a lesser degree by the health care system, which causes problems for the TBAs in their practices. It is recommended that the ministry of health becomes more aware of the need for training TBAs and that a programme for training should be more appropriate, taking cultural practices into account. / Advanced Nursing Science / D.Lit. et Phil.