Estima-se que aproximadamente 40 por cento das mulheres experimentam alguma forma de morbidade durante a gestação, parto ou puerpério. Algumas delas aproximam-se da morte - evento conhecido como near-miss materno. Vivenciar tal condição significa compartilhar fatores patológicos e circunstanciais diversos com mulheres que morrem por causas obstétricas. Assim, o relato da experiência de near-miss materno pode ajudar na compreensão dos eventos obstétricos graves, tal como a morte materna, evitável em quase 100 por cento dos casos. A experiência das pessoas é autêntica e representativa do todo por meio da construção de uma identidade comum. Esta identidade confere qualidade à memória de um grupo. Portanto, cada memória é um fenômeno social. Com isto, foram analisadas as experiências de doze mulheres que quase morreram em função do estado gravídico-puerperal, após seleção pela Internet e entrevistas presenciais. O método qualitativo utilizado foi o da História Oral de vida e o referencial teórico de análise baseou-se nos conceitos de Necessidades de Saúde e dos Direitos Humanos. Oito memórias coletivas compuseram os discursos: necessidades de saúde não atendidas; deficiências na assistência recebida; a assistência contribuindo com o quadro de near-miss; outras explicações para a vivência do near-miss; privação do contato com o filho; violação de direitos; ausência de reivindicação dos direitos; e caminhos percorridos para atenuar o sentimento de direitos e necessidades não atendidos. Em algumas memórias, a morbidade grave não permitiu que as necessidades de saúde das mães fossem atendidas. Noutras, o agravamento à saúde teria decorrido do não atendimento às suas necessidades. Em Saúde Materna, uma via comum de violação dos direitos humanos é transitada pelas práticas assistenciais. O uso de intervenções dolorosas, potencialmente arriscadas e sem uma indicação clínica justificável compuseram a maior parte das histórias narradas para esse estudo. Como consequência, mães e bebês tiveram sua condição de pessoa desrespeitada, bem como sua integridade física e emocional ameaçada. Compreender as necessidades de saúde dessas mulheres é reconhecê-las como sujeitos de direitos; é individualizar a assistência, respeitando sua autonomia, garantindo o pronto acesso às tecnologias, estabelecendo vínculo (a)efetivo com a equipe de saúde e preservando suas vidas. / It is estimated that approximately 40 per cent of women experience some form of morbidity during pregnancy, childbirth or the postpartum period. Some of these have even approached death - an event known as a maternal near-miss. To experience such a condition means sharing the pathological and environmental factors of women who died from obstetric causes. Thus, the accounting of maternal near-miss experiences can help in the understanding of severe obstetric events, such as maternal, preventable death in almost 100 per cent of cases. The experiences of the people involved are authentic and representative of all through the construction of a common identity. This identity confers quality to the memory of a group. Therefore, each memory is a social phenomenon. With this, the experiences of twelve women, who almost died due to pregnancy and childbirth problems, were analyzed after selection via Internet and in-person interviews. The qualitative method used was the oral life history and the theoretical analysis was based on the concepts of Health Needs and Human Rights. Eight collective memories composed of speeches: unmet health needs; deficiencies in care received; assistance contributing to the occurrence of the near-miss; other explanations for the experience of near-miss; deprivation of contact with the child; violation of rights; absence of rights of claim; and other paths taken to alleviate the sense of rights and needs not met. In some memories, severe morbidity prevented the health needs of mothers to be met. In some others, worsening health had elapsed due to not meeting their needs. In Maternal Health, a common way of human rights violation is transited through the care practices. The use of painful interventions, potentially risky and without a justifiable clinical indication composed most of the narrated stories of this study. As a result, mothers and babies had their personal condition disrespected as well as their physical and emotional integrity threatened. To understand the health needs of these women is to recognize them as subjects with rights; with individualized care, respecting their autonomy, ensuring ready access to technologies, establishing links (a)effective with the health team and preserving their lives.

Submitted by Rosivalda Pereira (mrs.pereira@ufma.br) on 2017-10-31T17:39:20Z No. of bitstreams: 1 DaniellePintoLima.pdf: 4421246 bytes, checksum: 8f5854008c9b4538576f57e58e82c249 (MD5) / Made available in DSpace on 2017-10-31T17:39:20Z (GMT). No. of bitstreams: 1 DaniellePintoLima.pdf: 4421246 bytes, checksum: 8f5854008c9b4538576f57e58e82c249 (MD5) Previous issue date: 2015-04-30 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This is a qualitative research with an ethnographic approach that aims to study childbearing and giving birth among the Guajajaras in the Arame complex area, in Maranhão State. For this purpose, this study sought to describe the main sociocultural practices and the traditional indigenous care patterns, as well as the therapeutic itinerary of the indigenous pregnant, reports the influence of western medical practices in the universe of Guajajaras women, and identifies the problem-situations of these women in relation to the theme studied. The results show that the process of childbearing and giving birth among the Guajajaras involves sociocultural practices and unique traditional care, with the menarche and the “moqueado feast” as the beginning of this process. The pregnancy is a period of no rituals or specific care. Child birth that in less than three decades ago, in its great majority, was performed in the village, in squatting position, surrounded by people who the pregnant trusted, nowadays is performed mainly in hospitals with the pregnant alone or just with restricted company, in a lithotomy position, and having medical or surgical interventions. In the post-natal period special care is experienced and a series of food and physical restriction happens in 30 to 40 days immediately after the postpartum. The therapeutic itinerary of these women is complex and influenced by many factors like: age, prior personal and/or family experience, difficulties in transportation and communication, precarity in health assistance t o the villages, as well as the incentive to the hospital birth given by the professionals. Among the factors that appear to influence most in the changing occurred in the process of childbearing and giving birth Guajajara over time are: the lengthy time of coexistence with the “non-indigenous” population, the evangelization of the population, the ethnocentric practices of the healthy system, and the apparently fragility of FUNAI’s performance. Even with the use of biomedicine knowledge at some time during the pregnant and puerperal cycle, the majority of the Guajajaras is able to articulate their traditional knowledge with the biomedical technicians. It was concluded that, in one hand the inclusion of new therapeutic resources in this process brought possib le benefits, as the capacity of resolution, and the search for minimization of health risks; on the other hand, it has created risks and damage like the childbearing medicalization. This research reveals an urgent necessity to revise the assistance given to this population in order to provide a secure service, of quality, and that not only consider the sociocultural aspects and the parties involved, but also that the two knowledges can be used harmonically so that the provision of health services can be offered in a decent way. / Trata-se de uma pesquisa qualitativa com abordagens etnográficas, que objetiva estudar o processo de gestar e parir entre os Guajajara da área de abrangência do polo base de Arame, no Estado do Maranhão. Para tanto, buscou-se descrever as principais práticas socioculturais e de cuidados tradicionais indígenas, bem como o itinerário terapêutico das gestantes indígenas e relatar a influência das práticas da medicina ocidental no universo das mulheres Guajajara, e identificar as situações-problema das mesmas em relação ao tema estudado. Os resultados apontam que o processo de gestar e parir entre os Guajajara envolve práticas socioculturais e de cuidados tradicionais singulares, com a menarca e a festa do moqueado marcando o início deste processo. A gravidez não apresenta rituais ou cuidados específicos. Os partos, que há menos de três décadas, em sua maioria, eram realizados na aldeia, de cócoras, cercado de pessoas da confiança da gestante, atualmente, ocorrem majoritariamente no hospital, com a gestante sozinha ou com companhia restrita, em posição de litotomia e com utilização de intervenções medicamentosas ou cirúrgicas. No pós-parto são vivenciados rituais específicos e uma série de restrições alimentares e físicas, durante os 30 a 40 dias de resguardo. O itinerário terapêutico destas mulheres é complexo e influenciado por múltiplos fatores como: idade, experiência anterior pessoal e/ou familiar, dificuldades de transporte e comunicação, precariedades na assistência à saúde nas aldeias, assim como o estímulo ao parto hospitalar dados pelos profissionais. Dentre os fatores que aparentam mais influenciar na mudança ocorrida no processo de gestar e parir Guajajajara, ao longo do tempo está: o extenso tempo de convivência com a população “não indígena”, a evangelização da população, a atuação etnocêntrica do sistema de saúde e a aparente fragilidade da atuação da FUNAI. Mesmo se utilizando os conhecimentos da biomedicina, em algum momento do período gravídico puerperal, a maioria dos Guajajara consegue articular seus saberes tradicionais com os biomédicos. Conclui-se que, se por um lado, a inclusão de novos recursos terapêuticos neste processo trouxe possíveis benefícios, como a capacidade resolutiva, e a busca pela minimização de riscos à saúde, por outro, gerou novos riscos e danos como a medicalização do parto. Esta pesquisa revela uma necessidade urgente de rever a assistência prestada a esta população de modo que seja prestado um serviço seguro, de qualidade e que possa não apenas considerar os aspectos socioculturais e atores envolvidos, mas que de fato os dois saberes possam ser usados harmonicamente para a oferta de serviços de saúde dignos.

Submitted by Rosina Valeria Lanzellotti Mattiussi Teixeira (rosina.teixeira@unisantos.br) on 2017-11-06T17:11:54Z No. of bitstreams: 1 Laudeci B. Batista.pdf: 1307965 bytes, checksum: 9bb27e13fa5efbdc825d86a5205e63ee (MD5) / Made available in DSpace on 2017-11-06T17:11:54Z (GMT). No. of bitstreams: 1 Laudeci B. Batista.pdf: 1307965 bytes, checksum: 9bb27e13fa5efbdc825d86a5205e63ee (MD5) Previous issue date: 2017-03-30 / From the second half of the twentieth century Brazilian society presented socio-cultural, economic and family changes which marked the construction of masculinity and parental care and which culminated in the advent of the new paternity, proposing a masculine attention that gives to man a bigger parental presence in domestic space and implies new meaning in the affective dimension of the father in relation to the child. However, this transformation is not exempted of tensions and it includes to the man traditional attributes added to new convictions. In this sense, the new paternity occurs from the inclusion and amplification of the involvement of the man-father in the context of the labor and childbirth and acquires a new meaning. The objective of this study is to comprehend the meanings that man attributes to his perception in the performance of paternity in the context of labor and childbirth in a public maternity hospital of Brazilian Northeast. This is a study with a qualitative approach that used the triangulation of methods: ethnography and in-depth interview done at the Instituto de Saúde Elpídio de Almeida - ISEA in the city of Campina Grande - PB. The data were collected during the months of April to May 2016, which population was determined by intentionality, with the interviews recorded in digital devices and later transcribed in totality, and the number of interviews defined by the criterion of theoretical saturation. As for the analysis of the empirical data, from the study of content, three analytical categories were constructed: 1- Expressions of paternity; 2. Meaning of being a father; 3 - how it is for this man being in the process of labor and childbirth. This study evidenced as main results the differences and similarities in the ways of being a father and of taking care, depending on the sector unit and the stages of laboring experienced, highlighting the support and shelter focused on women, suggesting a perspective of care attribution mediated by the mother considering the corporality of the fetus and the conjugal relationship. Although the man-father expresses availability for the care and the follow-up of the woman in labor, he did in an inconsistently form and putting himself as a support. As for the meaning of being a father, there were parents who as soon as they perceived themselves still in gestation, others from the childbirth and some related to the value and quality of their conjugal relationship. Being present in the labor and childbirth scenario offered openness to the living of paternity assuring the man to live an unique moment in life through the birth of the child and, on the other hand, made a problem of his presence, since there are still barriers of man himself, professionally and institutionally which separate the father from the birth scene, interfering with the father and child relationship. Thereby, the new paternity in the maternity scenario permits the expressions of the different modalities of being a father and that is why it becomes a relevant theme for the field of collective health. / A partir da segunda metade do século XX a sociedade brasileira apresentou alterações socioculturais, econômicas e familiares que marcaram a construção da masculinidade e o cuidado parental e que culminou no advento da nova paternidade propondo uma atenção masculina que confere ao homem maior presença paterna no espaço doméstico e imprime novo significado na dimensão afetiva do pai em relação ao filho. Porém, essa transformação não é isenta de tensões e agrega ao homem atributos tradicionais somados a novas convicções. Neste sentido, a nova paternidade dar-se a partir da inclusão e ampliação da participação do homem-pai no contexto do parto e nascimento e adquire nova significação. O objetivo desse estudo é compreender os significados que o homem atribui a sua vivência no exercício da paternidade no contexto do parto e nascimento em uma maternidade pública do nordeste brasileiro. Trata-se de um estudo com abordagem qualitativa que utilizou a triangulação de métodos: etnografia e entrevista em profundidade feito no Instituto de Saúde Elpídio de Almeida ¿ ISEA no município de Campina Grande ¿ PB. Os dados foram coletados durante os meses de abril a maio de 2016 cuja população foi determinada por intencionalidade sendo as entrevistas gravadas em aparelho digital e posteriormente transcritas na íntegra e o número de entrevistas definidos por critério de saturação teórica. Quanto à análise dos dados empíricos, a partir da análise de conteúdo, foram construídas três categorias analíticas: 1- Expressões da paternidade; 2- Significado de ser pai; 3 - Como é para este homem está no processo do parto e nascimento. Este estudo evidenciou como principais resultados diferenças e semelhanças nos modos de ser pai e de cuidar, dependendo da unidade setorial e das etapas do trabalho de parto vivenciadas, com destaque para apoio e amparo direcionado à mulher sugerindo uma perspectiva de atribuição de cuidado mediado através da mãe considerando a corporalidade do feto e a relação conjugal. Embora o homem-pai expresse disponibilidade para o cuidado e para o acompanhamento da mulher em trabalho de parto, ele o fez de modo inconsistente e posicionando-se como coadjuvante. Quanto ao significado de ser pai, houveram pais que assim perceberam-se ainda na gestação, outros a partir do nascimento e alguns relacionaram ao valor e qualidade da sua relação conjugal. Estar presente no cenário do parto e nascimento, por um lado, ofereceu abertura para vivência da paternidade garantindo ao homem viver um momento único na vida através do nascimento do filho e, por outro, problematizou a sua presença, haja vista ainda existirem barreiras do próprio homem, profissionais e institucionais que afastaram o pai da cena do parto interferindo na relação pai-filho. Deste modo, a nova paternidade no cenário da maternidade permite as expressões das modalidades diversas de ser pai e por isso torna-se uma temática relevante para o campo da saúde coletiva.

Bakgrund: Kontinuerlig barnmorskeledd vårdmodell för kvinnor under graviditet, förlossning och eftervård tillämpas i flera länder runtom i världen. Modellen har visat sig positiv både ur medicinska och ekonomiska aspekter. Kvinnor i Sverige uttrycker en önskan om att kontinuiteten i vården kring graviditet, förlossning och eftervård ska öka. Trots detta tillämpas inte kontinuerlig barnmorskeledd vårdmodell i Sverige idag, bortsett från enstaka nyligen påbörjade projekt. Syfte: Att beskriva kvinnors upplevelser av kontinuerlig barnmorskeledd vårdmodell under graviditet, förlossning och eftervård. Metod: Kvalitativ metasyntes med metaetnografisk innehållsanalys. Femton (15) artiklar inkluderades i resultatet. Resultat: Tre huvudkategorier och sju underkategorier identifierades som centrala och övergripande teman för kvinnors upplevelser av kontinuerlig, barnmorskeledd vårdmodell. De tre huvudkategorierna var personcentrerad vård, relationen till barnmorskan och kommunikationen. Överlag var kvinnornas upplevelser av kontinuerlig, barnmorskeledd vårdmodell positiva. Slutsats: Kvinnor upplever kontinuerlig barnmorskeledd vårdmodell som stödjande, stärkande och personcentrerad. Kontinuerlig barnmorskeledd vårdmodell är en personcentrerad vårdform som stödjer och stärker kvinnorna genom graviditet, förlossning och eftervård. De positiva upplevelserna av kontinuerlig barnmorskeledd vårdmodell verkar minska när vården under graviditeten bedrivs i gruppform istället för individuellt. Klinisk tillämpbarhet: Resultatet av denna studie kan vara till stöd för att utveckla mödrahälsovården och förlossningsvården i Sverige. Den här studien kan inspirera till förändring för att uppnå personcentrerad vård för kvinnor under graviditet, förlossning och eftervård. / Background: Midwife-led continuity of care model for women during pregnancy, childbirth and postpartum care is applied in several countries around the world. The model has proved positive both from medical and economic aspects. Women in Sweden express the wish that the continuity of care regarding pregnancy, childbirth and aftercare should increase. Despite this, midwife-led continuity of care model is not applied in Sweden today, apart from single recently initiated projects. Aim: To describe women's experiences of midwife-led continuity of care model during pregnancy, childbirth and aftercare. Method: Qualitative meta-synthesis with etnographic content analysis. Fifteen (15) items were included in the result. Results: Three main categories and seven subcategories were identified as central and overarching themes for women's experiences of midwife-led continuity of care model. The three main categories were person-centered care, the relation to the midwife and the communication. Overall, women's experiences of midwife-led continuity of care model were positive. Conclusion: Women experience midwife-led continuity of care model as supportive, strengthening and person-centred. Midwife-led continuity of care model is a person-centered form of care that supports and strengthens the women through pregnancy, childbirth and postpartum care. The positive experiences of midwife-led continuity of care model seem to decrease when the care is given in group form during pregnancy instead of individually. Clinical implications: The result of this study can be of value for developing maternity care in Sweden. This study can inspire to create new ways to achieve person-centered care for women during pregnancy, childbirth and postpartum care.

Orientador: Cristina Maria Garcia de Lima Parada / Resumo: Introdução: Atualmente, o parto é visto como procedimento hospitalar, que quando humanizado, visa proporcionar processo de parturição seguro e confortável para a mãe e o bebê. Objetivo: Apreender as percepções, experiências e expectativas de gestantes quanto ao tipo de parto, no início e término da gestação e desenvolver estratégia educativa que favoreça a promoção do parto vaginal. Método: Utilizou-se abordagem qualitativa, adotando-se, como referencial teórico de análise de dados, os pressupostos da Humanização da Assistência Obstétrica, e o referencial metodológico do Discurso do Sujeito Coletivo. A coleta de dados foi realizada entre outubro de 2015 e maio de 2016, por meio de entrevistas semiestruturadas, com 15 gestantes, em dois momentos: o primeiro, antes da 20ª semana de gestação e o segundo, após a 35ª semana. A questão norteadora utilizada foi: Fale sobre o tipo de parto que você deseja (na primeira entrevista) e, para a segunda entrevista repetiu-se esta e foram incluídas outras duas questões: Você mudou de ideia? Por quê? Resultados: As 15 participantes tinham média de idade de 27,5 anos, variando entre 18 e 37 anos; nove mulheres eram primigestas, três haviam sofrido um aborto e três realizaram cesárea em gestação anterior. Com relação à gestação atual, 13 gestantes realizaram atendimento pré-natal no serviço público, em unidades básicas de saúde e duas, no setor de saúde suplementar, em consultórios médicos privados. Todas as gestantes tinham companheiro e mais... (Resumo completo, clicar acesso eletrônico abaixo) / Mestre

As questões relativas ao parto e sua assistência apresentam-se como problemas relevantes de saúde pública. O enfrentamento das adversidades presentes na assistência à saúde materna tem envolvido diversas iniciativas resultando em avanços em várias direções. Os estudos sobre as práticas assistenciais em saúde vêm tematizando questões como a influência considerável da dimensão relacional na qualidade dos cuidados prestados. Este trabalho aborda tal dimensão no contexto da assistência ao parto. Objetivo: Descrever e analisar pontos de conexão entre as vivências das parturientes durante o trabalho de parto e parto e o suporte oferecido. Aspectos metodológicos: Estudo descritivo, qualitativo, utilizando técnica de entrevista semi-estruturada com parturientes e provedoras de cuidados (doulas) e observação de rotinas em maternidade de São Paulo, em 2004. Resultados: Verificou-se a relevância e a valorização das relações interpessoais no processo da parturição. Processo este referido pelas parturientes como experiência de elevado grau de estresse com vivências de dor, medo, angústia e ansiedade. Identificou-se também disposições subjetivas, entre as doulas, de solicitude, acolhimento e diálogo no exercício de provimento dos cuidados. / Issues related to childbirth and its appropriate care represent a relevant part of the public health concerns. When dealing with the various adversities that appear in the practice of the maternal health care, professionals of the area have launched many initiatives that resulted in advancements in various directions. Studies carried out on health care practices have been focusing questions such as the considerable influence of the dimension of interpersonal relationships on the quality of the services rendered. This paper approaches such dimension in the context of the childbirth care. Hypothesis: the beneficial effects coming from the emotional/psychological support provided for women during labor and birth depend on the quality of the interpersonal relationships established among the agents involved in the situation. Objective: The target of the present study is to describe and analyze the existing connecting points between the childbearing women\' s experiences during labor and birth and the suport they are provided for. Methodological aspects: This paper comprehends a qualitative/descriptive study that uses semi-structured interview techniques among with childbearing women and caregivers (doulas), besides observation of routine practices in maternity hospitals of São Paulo city. Results: Both the relevance and valorization concerning interpersonal relationships during the process of parturition were verified, such process being described by childbearing women as an experience that brings about a high degree of stress, with pain, fear, anguish, and anxiety playing important roles. During the provision of care, subjective dispositions of solicitude, acceptance, and dialogue were also detected among doulas. Final considerations: Data analysis enabled us to consider the intersubjective space of relationships as the point where interlocutions take place, being marked by the listening of the childbearing women\' s demands and the acceptance and reassurance of the processes they are experiencing, thus characterizing it as a resource equivalent to those prescribed as technologies appropriate to the birth care.

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.

Background: Little is known about the experience and psychological outcomes for women who experience emergency peripartum hysterectomy (EPH). The objective of this study was to explore women's experiences of EPH and to determine if women who experience EPH were more likely to experience mental health sequelae. Methods: This mixed method design involved a quantitative and a qualitative phase. The quantitative phase used a retrospective cohort design. Women were sampled through on-line communities, including an EPH support group, and a larger website for mothers. Women completed on-line surveys covering sociodemographic, obstetric/gynecological/ and psychiatric information, including screens for depression and Post-Traumatic Stress Disorder (PTSD). Logistic regression was used to calculate the independent risk that exposure to EPH has on screening positive for PTSD. Participants from the EPH support group who completed the on-line interview were then selected to participate in the second phase. In-depth telephone interviews were conducted and analyzed using Constant Comparative Analysis. Results: 74 exposed women and 355 non-exposed women completed the survey. In the adjusted logistic regression model, women who experienced EPH were over 6 times more likely to screen positive for current PTSD compared to women who did not experience EPH (adjusted Relative Risk (aRR): 6.76; 95% CI: 4.24, 8.88). When women recalled their psychological state at 6 months postpartum, exposed women were 11 times more likely to screen positive for current PTSD (aRR: 11.35; 95% CI: 8.43, 12.95). In the qualitative phase, 15 women participated and 7 major themes were identified: fear, pain, death and dying, numbness or delay in emotional reaction, bonding with baby, communication and the need for information. A major finding is the need for additional follow-up visits to address the emotional after-effects and to fill in gaps in women's understanding and memory of what had occurred. Conclusion: Understanding women's experiences and sequelae can help providers address not only women's initial complications but provide needed long-term support.

The research in this thesis aimed to develop an algorithm to support midwives’ diagnosis of active labour in primiparous women and to compare the effectiveness of the algorithm with standard care in terms of maternal and neonatal outcomes. Four linked studies are presented following the template suggested by the Medical Research Council (MRC 2000) Framework for development and evaluation of randomised controlled trials (RCT) for complex interventions to improve health. Study one Aim: To develop an algorithm for diagnosis of active labour in primiparous women. Methods: An informal telephone survey was conducted with senior midwives to assess the need for a decision support tool for the diagnosis of active labour. A literature review identified the key cues for inclusion in the algorithm which was then drafted. Focus group interviews were conducted with midwives to ascertain the cues used by midwives in diagnosing active labour. Findings: Thirteen midwives took part in focus groups. They described using informational cues which could be separated into two categories: those arising from the woman (Physical signs, Distress and coping, Woman's expectations and Social factors) and those from the institution (Midwifery care, Organisational factors and Justifying actions). Study Two Aim: Preliminary testing of the algorithm Methods: Vignettes and questionnaires were used to test the consistency of midwives’ judgements (inter-rater reliability), the content of the algorithm and its acceptability to midwives (face and content validity). The study was conducted in two stages: the first stage (23 midwives) involved vignettes and questionnaires and the second stage (20 midwives) involved vignettes only. Findings: In the first stage a Kappa score of 0.45 indicated only moderate agreement between midwives using the algorithm. After modifying the algorithm, the Kappa score in stage two was 0.86, indicating a high level of agreement. While the majority of the midwives reported that the algorithm was easy to complete, most were able to identify snags or make suggestions for its improvement. Based on the findings of this study the algorithm was modified and the final version was developed. Study three Aim: To assess the feasibility of carrying out a cluster randomised trial (CRT) of the algorithm, in Scotland. Specifically, to identify maternity units potentially willing to participate in a CRT, to test the implementation strategy for the trial and to collect baseline data to inform the sample size calculation. Methods: A questionnaire and interviews were used. The CRT methods were piloted in two maternity units and the algorithm was used for a three-month period in order to test its acceptability and provide estimates of compliance and consent rates. Results: All maternity units surveyed expressed an interest in the proposed study. Midwives’ compliance with study protocol differed between units, although the consent rate of women was high (89% and 84%). Ultimately, one unit achieved 100% of the required sample and the other 60%. The midwives reported that the algorithm was acceptable and was a useful tool, particularly for teaching inexperienced midwives. Study four Aim: To compare the effectiveness of the algorithm for diagnosis of active labour in primiparous women with standard care in terms of maternal and neonatal outcomes. Method: A cluster randomised trial Participants: Fourteen maternity units in Scotland. Midwives in experimental sites used the algorithm to assist their diagnosis of active labour. Seven experimental units collected data from 1029 women at baseline and 896 post intervention. The seven control units had 1291 women at baseline and 1287 after study implementation. Outcomes: The primary outcome was the percentage use of oxytocin for augmentation of labour. Secondary outcomes were medical interventions in labour, labour admission management, unplanned out of hospital births and clinical outcomes for mothers and babies. Results: There was no significant difference between groups in percentage use of oxytocin for augmentation of labour or for the use of medical interventions in labour. Women in the algorithm group were more likely to be discharged from the labour suite following their first labour assessment and subsequently have more pre-labour admissions. Conclusion The studies presented in this thesis represent the full process of developing and testing a complex healthcare intervention (the algorithm). The final study, a national cluster randomised trial, demonstrated that the use of the algorithm did not result in a reduction in the number of women who received oxytocin for augmentation or the use of medical interventions in labour. The results suggest that misdiagnosis of labour is not the main reason for higher rates of intervention experienced by women admitted to labour wards while not yet in active labour. These studies contribute significantly to the debate on care of women in early labour, the organisation of maternity care and to maternity care research.

Introduction: Ensuring access to universal primary health care is essential to secure a safe and pleasant motherhood and to provide compassionate care for mothers and newborns.However, inequalities in the access to maternal health services still remain a prominent problem in many countries. As part of reducing inequalities, Ethiopia launched the Health Extension Program (HEP) in 2003. The HEP is a community based program designed with a defined package of essential promotive, preventive and basic curative services targeting households, particularly mothers and children. Despite the construction of over 600 health posts and deploying more than 1200 Health Extension Workers (HEWs), preliminary data suggests a low utilization of maternal health care services. This thesis explores the HEP contribution in improving women’s access to maternal health care, and the reasons for the low use of maternal health care services from the perspectives of the involved actors in the Tigray region in Ethiopia. The five dimensions of access were used as a framework to explore the access to maternal health care utilization in this setting. Methods: A total of four districts were included in the study. Both quantitative and qualitative methods were applied. In the first sub-study, we assessed the HEP and its association with change in the utilization of antenatal, delivery and postnatal care services. Retrospective longitudinal data for 10 years was extracted from three selected districts and checked for accuracy. Segmented linear regression technique was used to control the secular trends adjusted for correlation of the data. For the second sub-study, we conducted a cross sectional survey with 1115 women (aged 15-49 years who had given birth within five years prior to the survey period) to determine the prevalence of antenatal care and institutional delivery utilization and explore their determinant factors of low utilization. For the third sub-study, we conducted six focus group discussions (FGDs) with a total of 51 women to explore women’s experiences of childbirth and maternal care. An interview with eight HEWs and four midwives were carried out to capture health workers’ perspective on access to maternal health care services in the fourth sub-study. Grounded theory for the former, and thematic analysis for the latter were used for the analysis. Main findings: The finding of the first sub-study showed a statistically significant upward trend for delivery care (DC) and postnatal care (PNC) in all facilities during the HEP late implementation period (July 2008-June 2012). In addition, a substantial trend of antenatal care (ANC) service use was observed at health centres after the intervention. In the second sub-study, the determinant predictors for ANC utilization were: proximity to health facilities, to be married, ≥5 years of education and having non-farming husbands. The last three factors were also significantly associated with institutional delivery, but also lower parity, previous history of obstructed/prolonged labour and ANC counselling. Findings from the qualitative studies pointed out that elderly women influenced women’s decision making about where to give birth. Women were mostly positive about giving birth at health facilities, but were concerned about the poor quality of care, inaccessibility and unavailability of transport. From the health workers’ perspective: specialized performance of hospital services, community assistance during referral and an increased awareness among women regarding the benefits of giving birth at a health facility were perceived as facilitators for institutional deliveries. Poor perceived competence of HEWs, poor conditions of health care facilities and inaccessibility of transportation, among others, were perceived as barriers for giving birth at health facilities. Conclusion: Overall, this research revealed a considerable contribution of the HEP in improving the access and coverage of maternal health services (ANC, DC and PNC). However, cultural traditions, scattered localities, mountainous roads without adequate transportation and low quality of care are still the major obstacles to accessing the services. Mechanisms need to be designed to enable health facility access of safe delivery for women in hard to reach areas, improving the proficiency of health workers and introducing a women centered approach that enhances acceptability of the services. / ሽፋን መሰረታዊ ክንክን ጥዕና ምዕባይ ድሕንነት ኣዴታትን ህፃናትን ንኽረጋገፅ ዝለዓለ ተራ ከምዘለዎ ይፍለጥ፡፡ ይኹንደኣምበር ግልጋሎት ጥዕና ኣዴታት ብማዕረ ኣብ ምብፃሕን ብምዕሩይ ኣገባብ ኣብ ምሃብን ብዙሓት ሃገራት እናተፀገማ እየን፡፡ ነዚ ዘይምዕሩይን ማዕረ ዘይኾነን ኣዋህባ ግልጋሎት ጥዕና ንምምሕያሽ ኣብ ሃገርና (ኢትዮጵያ) ብ1994-1995 (ብአቆፃፅራ ግእዝ) ዝተኣታተወ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ቤተሰብ (Health Extension Program/HEP) 10 ዓመታት ኣሕሊፉ ይርከብ፡፡ ፕሮግራም ምግፋሕ ጥሙር ጥዕና (HEP)፣ ሕብረተሰብ መሰረት ዝገበረ-ምክልኻል ሕማማትን ምስጓም ጥዕናን - ምትእትታው ግልጋሎት ሕክምና ቀለልቲ ሕማማትን ብፍላይ ድማ ንኣዴታትን ህፃናትን ትኹረት ብምግባር ስድራ ቤት ብምሕቋፍ ዝንቀሳቐስ ፕሮግራም እዩ፡፡ እዚ ፕሮግራም ንምትግባር ኣብ ክልል ትግራይ ልዕሊ 600 ኬላታት ጥዕና ተሃኒፀን፡፡ ልዕሊ 1200 ሞያተኛታት ጥሙር ጥዕና እውን ሰልጢነን እየን፡፡ ክልተ ሞያተኛታት ኣብ ሓደ ኬላ ጥዕና ተመዲበን ካብ 5000-7000 በዝሒ ንዘለዎ ሕብረተሰብ ግልጋሎት እናሃባ ይርከባ፡፡ እንተኾነ ግን ዝተፈላለዩ መፅናዕታታት ከምዘመላኽትዎ ግልጋሎት ኣዴታት ጥዕና (ወሊድን ድሕሪ ወሊድን) ትሑት ሽፋን ከምዘለዎ ይሕበር፡፡ ዕላማ እዚ ዝገበርናዮ መፅናዕቲ እውን ኩነታት እቲ ግልጋሎት ብኣሃዝ ንምዕቃንን ከምኡ እውን ምኽንያታት እቲ ትሑት ግልጋሎት ንምድህሳስን እዩ፡፡ ኣብዚ መፅናዕቲ እዚ ምኽንያታት ትሑት ሽፋን ግልጋሎት ክንክን ጥንሲ ወሊድን ድሕረ ወሊድን እንታይ ምዃኑ ካብ ሕሉፍ ልምዲ (ተሞክሮ) ኣዴታትን ሰብ ሞያ ጥዕናን ብዝርዝር ብምድህሳስ - ፕሮግራም ምግፋሕ ጥሙር ጥዕና ንቐረብ ግልጋሎት ኣዴታት ጥዕና ንምምሕያሽ ዘለዎ ኣስተዋፅኦ እንታይ ከምዝመስል ተተንቲኑ ቐሪቡ ኣሎ፡፡ እቲ ቀረብ ግልጋሎት ጥዕና ሓሙሽተ መዐቀኒታት ብዘለዎ ፍሬም ዎርክ እዩ ተዳህሲሱ እቶም ሓሙሽተ መመዘኒታት 1. ቅርበት ትካል ጥዕናን ሰብ ሞያ ጥዕናን ንተገልገልቲ 2. ህልውነት ሰብ ሞያ ጥዕናን ናውትን ድሌት ተገልገልትን 3. ሰብ ሞያ ጥዕና ብተገልገልቲ ዘለዎም ተቐባልነት 4. ትካል ጥዕና ንድሌት ተገልገልቲ ንምዕጋብ ዘለዎ ድልውነት 5. ተገልገልቲ ወፃኢታት ሕክምና ንምሽፋን/ንምኽፋል ዘለዎም ድሌትን ዓቕምን እዮም፡፡ እዞም ሓሙሽተ መዐቀኒታት መሰረት ዝገበሩ ኣርባዕተ ዓይነታዊን አሃዛዊን ሜላታት ብምጥቃም ዝተኻየዱ መፅናዕትታት ኣብ ኣብ 4ተ ወረዳታት ትግራይ እዮም ተኻይዶም፡፡ ኣብቲ ቀዳማይ መፅናዕቲ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ቤተሰብ (HEP) ኣብ ምምሕያሽ ክንክን ጥንሲ-ወሊድን-ድሕረ ወሊድን ግልጋሎት ዘምፅኦ ለውጢ ኣብ ሰለስተ ወረዳታት (ጋንታአፈሹም፤ ክልተ ኣውላዕሎ፣ ሕንጣሎ ዋጅራት) ንዝሓለፉ 10 ዓመታት ኣብ ዝተዋህበ ግልጋሎት ብምድራኽ እዩ ዳህሰሳ ተኻይዱ፡፡ ትኽክለኛነት እቲ ፀብፃብ እውን ካብ ትካላት ጥዕና ዝተልኣኸ ወርሓዊ ኣብ ወረዳ ምስ ዘሎ ፀብፃብ ብምንፅፃር ንኽረጋግፅ ተገይሩ እዩ፡፡ እቲ ካልኣይ መፅናዕቲ ኣብ ወረዳ ሰሓርቲ ሳምረ ካብ 19 ጣብያታት ካብ ዝተመረፃ 30 ቑሸታት ዕድሚአን ካብ 15-49 ዓመት ምስ ዝኾና 1115 ደቂኣንስትዮ ኣስታት 30 ደቓይቕ ዝወደአ ቃለ መሕትት ብምኽያድ እዩ ዳህሰሳ ተኻይዱ፡፡ ኣብ ወሊድ ግልጋሎት ዘሎ ልምድን ተሞክሮን ንምድህሳስ 51 ኣዴታት ዝተሳተፋሉ ሽዱሽተ ጉጅላዊ ምይይጥ በቲ ሳልሳይ መፅናዕቲ ምርምር ዝተፈፀመ እንትኾን ምስ ሸሞንተ ሞያተኛታት ጥሙር ጥዕናን ኣርባዕተ ነርስ መዋልዳንን ቃለ መሕትት ብምኽያድ እቲ 4ይ ምርምር/መፅናዕቲ ተፈፂሙ እዩ፡፡ ውፅኢት ቀዳማይ መፅናዕታዊ ፅሑፍ ኣብዚ ቐዳማይ መፅናዕቲ እቶም ዝተአከቡ መረዳእታት ኣብ ሰለስተ ደረጃታት - ቅድመ ፕሮግራም-ፕሮግራም-ድሕረ ፕሮግራም ብዝብል ዝተመቐሉ እዮም፡፡ እቲ ቐንዲ ዕላማ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ድሕሪ ምጅማር ዝተራእየ ለውጢ ንምፍታሽ እዩ፡፡ ኣብ ድሕሪ እቲ ፕሮግራም ካብ 2001-2004 ዓ/ም ብዝተኻየዱ ንጥፈታት ጥዕና ግልጋሎት ወሊድን ድሕረ ወሊድን ኣብ ኩለን ትካላት ጥዕና ካብ ዓመት ናብ ዓመት ልዑል ኣዝማሚያ እናርኣየ ከምዝኸደ ብስታቲስቲካዊ መረዳእታ ንምርግጋፅ ተኻኢሉ እዩ፡፡ ብተመሳሳሊ ኣብዚ ወቕቲ እዚ ኣዝማሚያ ግልጋሎት ክንክን ጥንሲ ኣብ ጥዕና ጣቢያታት ጥራሕ እናለዓለ ከምዝኸደ ውፅኢት እቲ መፅናዕቲ የረድእ፡፡ እቲ መፅናዕቲ ከም ዘረድኦ ሽፋን ክንክን ጥንሲ ብ1995 ካብ ዝነበሮ 28.2% ብ2004 ናብ 46.7 ክምዝለዓለ፤ ግልጋሎት ወሊድ ብ1995 ካብ ዝነበሮ 5% ዝነበረ ናብ 23% ከምዝደየበ ድሕረ ወሊድ ግልጋሎት እውን 11% ዝነበረ ናብ 41% ከምዝለዓለ ንምርዳእ ተኻኢሉ ኣሎ፡፡ ውፅኢት ካልኣይ መፅናዕታዊ ፅሑፍ ኣዴታት ግልጋሎት ክንክን ጥንሲ ኣብ ጥዕና ጣቢያ ንኽጥቀማ ቅርበት ትካላት ጥዕና ንመንበሪ ገዛውቲ፣ ሓዳር ምግባር፣ ልዕሊ 5 ዓመት ስሩዕ ትምህርቲ ምምሃርን ካብ ሕርሻ ወፃኢ ኣብ ካልእ ስራሕቲ ዝተዋፈሩ ሰብ ሓዳር ምህላው ወሰንቲ ኣካላት ምዃኖም በቲ ዝተገብረ ካልኣይ መፅናዕቲ ተረጋጊፁ፡፡ ብተመሳሳሊ ኣብ እዋን ክንክን ጥንሲ ንኣዴታት ምኽሪ ግልጋሎት ምሃብ ቅድመ ታሪኽ ዝንጉዕ ሕርሲ ወይ ሃልኪ ምንባር እውን ኣብ ትካላት ጥዕና ወሊድ ግልጋሎት ንኽመሓየሽ ወሰንቲ ኩነታት ከምዝኾኑ በቲ መፅናዕቲ ተረጋጊፁ፡፡ ብሓፈሻ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ቤተሰብ (HEP) ቀረብ ግልጋሎት ጥዕናን ሽፋን ክንክን ጥንሲ ወሊድን ድሕረ ወሊድ ግልጋሎትን ኣብ ምምሕያሽ ዝተፃወቶ ተራ ትርጉም ዘለዎ ምዃኑ በቲ ዝገበርናዮ መፅናዕቲ ንምርዳእ ተኻኢሉ ኣሎ፡፡ እንተኾነ ግን ባህላዊን ልማዳዊን ኩነታት (ኣብ ገዛ ክትወልድ ምድላይ- ነፍሰፁር ዓይኒሰብ ከይረኽባ ኢልካ ምእማን) - ተበቲኖም ዝሰፈሩ ነበርቲ ምህላው - ኣፀገምቲን ዓቐብ ቁልቁልን ጎቦታትን ዝበዝሖም መንገድታትን እኹል መጉዓዝያ ዘይምህላውን ቀንዲ ሃልኪታትን ዕንቅፋታትን እቲ ዝወሃብ ግልጋሎት ምዃኖም ኣብዚ መፅናዕቲ ተገሊፁ እዩ፡፡ ብተወሳኺ ኣብ ላዕለዎት ትካላት ጥዕና ዘይብሩህ ገፅን ሰሓባይ ኣቀራርባ ሰብ ሞያ ጥዕና ዘይምህላውን ተቐባልነት ዘይብሎም ባህሪያት ምንፅብራቕን ነቲ ግልጋሎት ዝዓዘዘ ዕንቅፋት ከምዘለዎ በቲ መፅናዕቲ ንምርዳእ ተኻኢሉ እዩ፡፡ ማይን መብራህትን ዝኣመሰሉ ትሕቲ ቕርፂ ኣብ ኬላታት ጥዕና ዘይምህላዉ ኣዴታት ኣብ ቀረበአን ዘሎ ትካል ጥዕና ንኽወልዳ ዘየተባብዕ ከምዝኾነ እውን ተሓቢሩ እዩ፡፡ ውፅኢት ሳልሳይን ራብዓይን መፅናዕታዊ ፅሑፍ ኣብ ሳልሳይ መፅናዕቲ ምስ ኣዴታት ብዝተገበረ ምይይጥ - ኣደ እትወልደሉ ቦታ ባዕላ ንኽትውስን ከምእነሓጎታት ዝመሰላ ዕድመ ዝደፍኣ ኣዴታትን ፀቕጢ (ተፅእኖ) ከምዝግበረላ እቶም መፅናዕቲታት ይሕብሩ፡፡ ዋላ አኳ ኣብ ትካል ጥዕና ብዛዕባ ምውላድ ኣዎንታዊ ኣረኣእያ ኣዴታት ዝዓዘዘ እንተኾነ ብዛዕባ ድኹም ኣዋህባ አገልግሎት ጥዕና ኣዝዩ ከምዘተሓሳስበን እቲ መፅናዕቲ ይገልፅ፡፡ ትካል ጥዕና ናብ መንበሪ ኣዴታት ዘለዎ ርሕቐትን መጓዓዓዚ ዘይምርካብ ዝኣመሰሉ ፀገማት ከምዘገድስወን እውን እቲ መፅናዕቲ ይሕብር፡፡ ኣብቲ ራብዓይ መፅናዕቲ ብወገን ሞያተኛታት ጥሙር ጥዕናን ነርስ መዋልዳንን ብዝተገበረ ምይይጥ - ኣብ ሆስፒታል ዝዋሃቡ ዝሐሹ ግልጋሎት ኣዴታት ካብ ታሕተዋይ ትካል ጥዕና ናብ ሆስፒታላት ሪፈር እንትበሃላ ኣብ ምጉዕዓዝ ብሕብረተሰብ ዝግበር ምትሕግጋዝ ከምኡ እውን እናዓበየ ዝኸይድ ዘሎ ግንዛበ ሕብረተሰብ ኣዴታት ኣብ ትካል ጥዕና ንኽወልዳ መሳለጢ ከምዝኾነ እቲ ፅንዓት የረድእ፡፡ ዓቕሚ ምንኣስ ሞያተኛታት ጥሙር ሞያተኛታት ጥሙር ጥዕናን ነርስ መዋልዳንን - ድኹም ኩነታት ትካል ጥዕናን (ሕፅረት ናውቲ ጥዕና ምህላዉ - ትሕቲ ቅርፂ ዘይምምላእ) ፀገም መጉዓዝያን እውን ኣዴታት ኣብ ትካል ጥዕና ንኸይወልዳ ዕንቅፋታት ከምዝኾነ እቲ ፅንዓት የመላኽት፡፡ መጠቓለሊ እቶም ዝተጠቐሱ ዕንቅፋታትን ፀገማትን ብምንካይ ቀረብ ወሊድ ግልጋሎት ጥዕና ንምዕባይ እዞም ዝስዕቡ ፃዕሪታት ምክያድ ይግባእ፡፡ ኣብ ጎቦታትን ኣዝዩ ርሑቕን ኣፀገምትን ዝሰፈረ ሕብረተሰብ ካብቲ ልሙድ ዝተፈለየ ቀረብ ግልጋሎት ጥዕና ምሃብ (ንኣብነት ካብ ጥዕና ጣቢያ ኣዝየን ዝርሕቓ ኬላታት ጥዕና ክእለት ዘለወን ነርስ መዋልዳን (midwives) ምምዳብ - ኣደ ማእኸል ዝገበረ ግልጋሎት ንኽወሃብ ሰብ ሞያ ጥዕና ብዓቕሚ ንኽዓብዩ ምግባርን ነቶም ሓሙሽተ መዐቀኒታት ቀረብ ግልጋሎት ብምምላእ ኣብቲ ሕብረተሰብ ተቐባልነት እቲ ግልጋሎት ክዓቢ ምግባርን፡፡