This dissertation examines three health insurance eligibility policies and their impact on reproductive health outcomes for low-income women of reproductive age. The first paper examines the effects of expanded eligibility for Medicaid under the Affordable Care Act (ACA), on fertility among low-income women of childbearing age. The second paper explores the effect of presumptive eligibility policies in Medicaid for pregnant women on access to prenatal care and health insurance coverage. Finally, the third paper exploits state-level differences in eligibility for public versus private insurance under the ACA, and the effects on perinatal coverage patterns, childbirth outcomes, and access to care.

In addition to fetal alcohol syndrome and fetal alcohol spectrum disorders, prenatal alcohol exposure is associated with many other adverse pregnancy and birth outcomes. Research suggests that alcohol use during pregnancy may increase the risk of miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome. This research has some inherent difficulties, such as the collection of accurate information about alcohol consumption during pregnancy and controlling for comorbid exposures and conditions. Consequently, attributing poor birth outcomes to prenatal alcohol exposure is a complicated and ongoing task, requiring continued attention to validated methodology and to identifying specific biological mechanisms.

Thesis (M. A. (Nursing)) -- University of Limpopo, 2021 / Indigenous practices are performances that occur naturally in a region or a growing living environment. Most women believe in indigenous practices because of their cultures and social structure. In South Africa regardless of the availability and accessibility of maternal and child health services, 50% of women were found that they still consult traditional birth attendants as their first choice during pregnancy, labour, delivery, and postnatal care. The purpose of the study was to determine the indigenous practices of women during pregnancy, labour and puerperium amongst cultural groupings at selected hospitals in Limpopo Province, South Africa. A Convergent parallel mixed method design was used in the study to collect both qualitative and quantitative data at the same time. Non-probability purposive sampling was used to select 15 participants and Probability simple random sampling was used to select 125 women who were pregnant, in labour and puerperium using slovin’s formula. Data were collected through a semi-structured interview with a guide for qualitative strand and a self-administered structured questionnaire for quantitative srtand. Data were analysed qualitatively using tech’s open coding method and quantitatively using Statistical Package for the Social Sciences (SPSS) Version 25 with the assistance of the University of Limpopo’s Bio-statistician. The results of the study showed that most women use indigeneous practices for protection against witchcraft, fear of giving birth in caesarian section and many other reasons.THPs and church leaders are regarded as the most principled people in their community. Indigenous women are aware of the sign and symptoms during pregnancy, labour, and puerperium which may determine consultation to healthcare practitioners, but they choose THPs and church leaders. Most women still rely on their religious beliefs to assist during their labour. Pregnant women, those in labour and puerperium should be supported to practice their religious beliefs and practices. THPs and church leaders are obliged to teach their clients and ensure that they know the names and components of the traditional medicines and church rituals they use.The nursing education should include indigenous practices in the curriculum so, that healthcare practitioners know about the indigenous practices and can serve as assistance in the training and development of health practitioners who continuously care for women during pregnancy, labour, and puerperium and as a result, may reduce maternal and child morbidity and mortality in Limpopo Province, South Africa.

Bakgrund: Förlossningen kan upplevas som en positiv livshändelse och har betydelse för framtida hälsa, välbefinnande och relation till partner. Förlossningsupplevelsen påverkas av de blivande föräldrarnas förberedelser inför förlossningen och föräldraskapet. Parrelationen är central under förlossningen där stöd från partnern är viktigt. I nuläget finns dock begränsad forskning kring hur förlossningsupplevelsen påverkas av kvinnors och partners kvalitet i parrelation samt deras tankar och känslor inför förlossningen och föräldraskapet i ett longitudinellt perspektiv, varför det finns behov av att studera detta. Syfte: Syftet med studien är att undersöka faktorer relaterade till förstföderskor och partners förlossningsupplevelse sex månader efter förlossning. Metod: Studien är en kvantitativ longitudinell kohortstudie. Datainsamlingen genomfördes via webbaserade enkäter vid tre tillfällen under graviditet och de första sex månaderna efter förlossning. Enkäterna innehöll frågor kring studiedeltagarnas bakgrund, förlossningsupplevelse (QPP), kvalitet i parrelation (QDR36) och känslor inför förlossning och föräldraskap. Analys av data har skett i SPSS där deskriptiv statistik och multipel logistisk regressionsanalys har genomförts. Resultat: Följande faktorer hade ett samband med en mer positivt skattad förlossningsupplevelse sex månader efter förlossning; Upplevelse av normal förlossning (QPP 5), förstföderska (p=0.001), partner (p=0.003); Upplevelse av kontroll vid förlossning (QPP9), förstföderska (p=0.024); Högre uppfattad kvalitet i parrelation (QDR36-index), partner (p=<0.001). Konklusion: Förlossningsupplevelsen påverkas av upplevelsen av förlossningen som normal, upplevelsen av kontroll under förlossningen samt högre uppfattad kvalitet i parrelation. / Background: Childbirth can be perceived as a positive life event and has a significance for future health, well-being, and relationship with partner. The childbirth experience is influenced by the prospective parent´s preparations for childbirth and parenthood. The couple relationship is central during childbirth where support from the partner is important. At present, however, there is limited research on how the childbirth experience is affected by the quality of couple relationship, as well as thoughts and feelings about childbirth and parenthood, in a longitudinal perspective, why there is a need to study this further. Purpose: The aim of the study is to examine factors related to first-time mothers and partners' childbirth experience six months after childbirth. Method: The study is a quantitative longitudinal cohort study. Data collection was conducted via web-based surveys on three occasions during pregnancy and the first six months after childbirth. The questionnaires contained questions about the study participants' background, childbirth experience (QPP), quality of couple relationship (QDR36) and feelings about childbirth and parenting. Data has been analyzed in SPSS where descriptive statistics and multiple logistic regression analysis have been performed. Results: Following factors were associated with a more positive childbirth experience six months after childbirth; Experience of normal childbirth (QPP 5), first-time mother (p=0.001), partner (p=0.003); Experience of control during childbirth (QPP 9), first-time mother (p=0.024); Higher perceived quality of couple relationship (QDR36 index), partner (p=<0.001). Conclusion: The childbirth experience is affected by the experience of a normal childbirth, feeling of control during childbirth and higher perceived quality of couple relationship.

Background: A lot of women who goes through a vaginal delivery will contract injuries due to the delivery. These injuries are termed as tears, prolapse, dyspareunia, incontinence and the symptoms can affect the women in their daily life. The nurse will get in contact with these women in different contexts when the women seek help for her problems. There is an estimated number of unknown cases that are caused by injuries from the delivery due partly to the normalization in the society. It can also be linked to the ignorance and absence from the health care. Aim: The purpose of the literary survey was to describe how life is affected due to the experiences of injuries from delivery. Method: The literature survey has been based on ten scientific articles of both qualitative and quantitative methods. The authors obtained the articles by searches in the databases Pubmed and Cinahl Complete. Results: From the result three main themes was extracted that was the main findings of how the women experiences their life quality due to the injuries from the delivery. A non-working body, physical, psychological, sexual and social limitations and moving on with life. Summary: Suffering a birth injury can be associated with loss of vital functions, pain, discomfort, worry, anxiety and depression. These can lead to the body being perceived as dysfunctional and entail limitations physically, psychologically, sexually and socially. A good treatment from healthcare is important to get the right diagnosis, treatment and support to be able to move on in life. / Background: A lot of women who goes through a vaginal delivery will contract injuries due to the delivery. These injuries are termed as tears, prolapse, dyspareunia, incontinence and the symptoms can affect the women in their daily life. The nurse will get in contact with these women in different contexts when the women seek help for her problems. There is an estimated number of unknown cases that are caused by injuries from the delivery due partly to the normalization in the society. It can also belinked to ignorance and absence from the health care. Aim: The purpose of the literary survey was to describe how life is affected due to the experiences of injuries from delivery. Method: The literature survey has been based on ten scientific articles of both qualitative and quantitative methods. The authors obtained the articles by searches in the databases Pubmed and Cinahl Complete. Results: From the result three main themes was extracted that was the main findings of how the women experiences their life quality due to the injuries from the delivery. A non-working body, physical, psychological, sexual and social limitations and moving on with life. Summary: Suffering a birth injury can be associated with loss of vital functions, pain, discomfort, worry, anxiety and depression. These can lead to the body being perceived as dysfunctional and entail limitations physically, psychologically, sexually and socially. A good treatment from healthcare is important to get the right diagnosis, treatment and support to be able to move on in life.

Bakgrund: Många kvinnor upplever förlossningsrädsla. Föda utan rädsla är en naturlig metod som främjar trygghet och optimerar födandets fysiologi och stärker det positiva i förlossningsupplevelsen. Kvinnans stödperson har en viktig roll under förlossningsarbetet.Syfte: Syftet är att beskriva och undersöka om användandet av metoden Föda utan rädsla (FUR) påverkar den födande kvinnans upplevda vårdkvalitet samt upplevelse och känslor i samband med förlossningen jämfört med tidigare insamlat material.Metod: Mixad metod av fall-kontrollstudie med kvantitativ ansats och en kvalitativ innehållsanalys med induktiv metod. Data samlades in genom QPP-I-enkät och analyserades genom Mann Whitney U-test.Resultat: De kvinnor som upplevde god effekt av FUR upplevde bättre stöd från personal, att partnern fick bättre stöd, uppmuntrades att delta och fick sina fysiska behov tillgodosedda under förlossningen. Kvinnorna upplevde även andra faktorer som påverkade den upplevda vårdkvaliteten.Slutsats: Genom förberedelse i FUR-metoden kan det födande paret upplevaökad trygghet och självförtroende inför förlossning och förlossningsrädsla kan motverkas. FUR kan ge upplevelse av ett bättre bemötande från personal, ökat stöd och respekt. Partnern blir stärkt i sin roll, vågar ta plats och ge stöd till den födande kvinnan.Klinisk tillämpbarhet: FUR-utbildningen är kort och ger en stor vinst tillbaka till både det födande paret samt förlossningspersonalen. / Background: Many women experience fear of childbirth. Confident Birth is a natural method that promotes security and optimizes the physiology of childbirth and strengthens the positive in the birth experience. The woman's support person has an important role during the labor. Aim: The aim is to investigate whether the use of the method Confident Birth affects the woman giving birth's perceived quality of care and delivery experience compared with previously collected material. Method: Mixed method of case-control study with quantitative approach and a qualitative content analysis with inductive method. Data are collected through the QPP-I survey and analyzed by the Mann Whitney U-test. Resultats: Women who experienced good effect of Confident Birth, experienced better support from caregivers, that the partner received better support, was encouraged to participate and had their physical needs met during childbirth. The women also experienced other factors that affected the perceived quality of care. Conclusion: Through preparation in the Confident Birth method, the birthing couple can experience increased security and self-confidence before childbirth and fear of childbirth can be counteracted. Confident Birth can provide an experience of a better response from healthcare personal, increased support and respect. The partner dares to act and provide support to the woman giving birth and the partner´s role is strengthened. Clinical application: Preparation in the Confident Birth method is short and gives a big profit back to both the birth couple and the delivery staff.

With the rising popularity of Mary's mother, St. Anne, Birth of the Virgin images proliferated at the beginning of the sixteenth century. However, these images have not been analyzed in great depth by any previous art historical scholarship. This thesis indicates the broader significance of these images by considering Birth of the Virgin compositions by Jan de Beer, Jacob Cornelisz van Oostsanen, and Adriaen van Overbeke. First, this thesis considers how these artists derived iconography from Robert Campin to connect Mary's nativity to the birth of her son. Thus, the artists invite the viewer to witness the significance and purity of both babies. Next, I argue that the sacrificial imagery of these panels cultivates a sacerdotal space, in which midwives become pseudo-priests and everyday objects are conflated with ritual material culture. These panels, which draw upon Old and New Testament covenants, present Mary as co-sacrifice, indicating a sixteenth-century expansion of the Virgin's co-redemptive role alongside Christ. The paintings emphasize the beginnings of the Virgin's life to explore the life-giving quality of mankind's redemption. Finally, I explore the viewership possibilities of these paintings for a lay audience, who could interpret their own experiences with birth through these images. Many of the objects in the artworks bear similarities not only to priestly objects but also to the material culture associated with birth. Overall, this thesis demonstrates the important role that Birth of the Virgin images played in interpreting the role of the Virgin Mary and her mother Anne in increasingly affective piety. The subject matter was a way to explore the doctrinal implications of Mary's sacrificial, life-giving power even as it invited viewers to frame their own day-to-day experiences with childbirth in more religious terms.

Syfte: Att undersöka kvinnors erfarenhet av könsstympning och vilken påverkan det har på deras hälsa med fokus på den perinatala och sexuella hälsan. Metod: Kvalitativ intervjustudie med induktiv ansats. Tio kvinnor som genomgått könsstympning grad I-III deltog. Intervjuerna var semistrukturerade intervjuer och genomfördes på Zoom. Intervjuerna spelades in med mobiltelefoner och sedan transkriberades och analyserades med innehållsanalys på manifest nivå. Resultat: Det utvecklades fyra kategorier och 10 subkategorier. Könsstympning påverkade perinatala och sexuella hälsan i flera avseende i form av flera olika komplikationer så som smärta vid själva ingreppet, men också vid samlag, problem med menstruation och problem under graviditet och förlossning. Kvinnorna blev ofta dåligt bemötta när de sökte vård och märkte att det fanns kunskapsluckor hos barnmorskor. Psykiska hälsan påverkades då kvinnorna hade en känsla av att vara annorlunda och att de blivit bestulna på en kroppsdel som de sörjde. Flera kvinnor hade genomgått rekonstruktion och rekommenderade andra att genomföra det.  Slutsats: Kvinnornas perinatala och sexuella hälsa påverkades negativt av könsstympningen i form av komplikationer. Smärta vid ingreppet, smärta vid samlag som påverkade samlivet och därmed sexuella hälsan negativt. Komplikationer under graviditet och förlossning med upprepade urinvägsinfektioner, stora bristningar och klipp i underlivet. Det dåliga bemötandet samt kunskapsluckan hos barnmorskorna upplevdes som jobbig.    Nyckelord: Förlossning, graviditet, kvalitativ metod, perinatal hälsa och sexuell hälsa / Aim: To examine women's experience of female genital mutilation and the impact it has on their health with a focus on perinatal and sexual health. Method: Qualitative interview study with an inductive approach. Ten women who underwent genital mutilation grade I-III participated. The interviews were semi-structured interviews and were conducted on Zoom. The interviews were recorded with mobile phones and then transcribed and analyzed using manifest level content analysis. Results: Four categories and 10 subcategories were developed. Female genital mutilation affected perinatal and sexual health in several aspects in the form of several different complications such as pain during the procedure itself, but also during intercourse, problems with menstruation and problems during pregnancy and childbirth. The women were often treated poorly when they sought care and noticed that there were gaps in knowledge among midwives. Mental health was affected as the women had a feeling of being different and that they had been robbed of a body part that they mourned. Several women had undergone reconstruction and recommended others to undergo it. Conclusions: The women's health was negatively affected by female genital mutilation in the form of complications. Pain during the procedure, pain during intercourse that negatively affected marriage life and thus sexual health. Complications during pregnancy and childbirth with repeated urinary tract infections, large ruptures and cuts in the female genital. The poor treatment and lack of knowledge among the midwives was perceived as troublesome   Keywords: Childbirth, pregnancy, perinatal health, qualitative method and sexual health

Decisions about marriage and childbearing, and the subsequent interactions between members of a family unit can have important individual and societal impacts on income, well-being, and economic mobility. This is especially true for women in developing countries, given limited female formal labor force participation, the economic significance of marriage markets, and the reliance on kin networks in the absence of formal safety nets. This dissertation consists of three essays that analyze how individuals form families, how those family members interact, and the subsequent impacts on the well-being of the family unit. The first chapter studies the effects of a rapid university expansion on access to education and family formation for women. The second chapter examines the long-term effects of a primary schooling expansion program on the prevalence of child marriage. The final chapter examines the long-term consequences of early life exposure to armed conflict on family formation. In the first essay, I analyze the impact of increased access to higher education on family formation outcomes for women in developing countries. Using a difference-in-differences design that accounts for the staggered nature of university openings, and a combination of household surveys and administrative data, I examine the impact of women’s exposure to a rapid university expansion in Nigeria in the 2000s on three key aspects of the family formation process - the likelihood and timing of first marriage and birth, their spouses’ characteristics, and the quantity and “quality” of any children produced in the marriage. I find that university openings improved years of schooling and educational attainment among school-aged women, and delayed the timing of the first marriage and childbirth of women. Women also had fewer births, and their children were more likely to have better development outcomes. I show suggestive evidence that these outcomes are driven by increased autonomy - women delay sexual activity and are more likely to work, use contraception and have the final say over important decisions. My second essay analyzes the impact of a 1976 universal primary education reform that provided free primary education to all school-aged children in Nigeria on the prevalence of child marriage. Using data from household surveys, I implement a difference-in-difference empirical strategy that exploits variation in exposure to the reform across birth cohorts and localities. I find that women exposed to the reforms acquired more schooling and the probability that women marry before the age of 15 reduces. However, there are no significant effects of exposure to the policy on the overall age of marriage, or the likelihood of marriage before the age of 18 on average. I present evidence on other marriage outcomes - men’s education increases, as does the spousal education gap. Furthermore, women desire and have fewer children, and are also more likely to be engaged in paid work. However, I find no effects on the spousal age gap or the husband’s age. My third and final essay explores the long-term effects of exposure to violent conflict onfamily formation in developing countries. Using a difference-in-differences empirical design that exploits variation in the intensity of war exposure by ethnicity and age, I analyze the long-term impacts of the 1967-1970 Biafran War on the family formation outcomes of men and women who were exposed to the war during their pre-adolescent years. I find that conflict induces men to delay first marriage and first birth, but there are no significant impacts on the timing of these activities for women. Both men and women who are exposed to the war have fewer children, and women also desire fewer children overall. Additionally, women who were exposed to the war have a smaller age difference from their husbands and are less likely to be married to men who have other wives. They are also less likely to experience domestic violence, on average. War exposure has no effect on the education difference between spouses, but women’s educational attainment increases, on average, while that of men decreases. Finally, I find no effects of war exposure on women’s relational empowerment, in terms of their attitudes to domestic violence and intra-household decision-making, but they are less likely to be engaged in paid work. This study contributes new evidence on the long-term impact of armed conflict on family formation in sub-Saharan Africa and shows how these impacts vary by gender and the age and duration of war exposure.

The study highlights the significant role that cultural doulas play in supporting and guiding migrant women during pregnancy, childbirth, and the postpartum period in Sweden. The Swedish healthcare system is understaffed, overburdened, and medically dominated, making it difficult for nurses and midwives to provide continuous and culturally-sensible care to their clients. Cultural doulas can significantly support their clients and the maternal healthcare system. However, improvements must be made in the working conditions of cultural doulas to create a sustainable project that can serve many migrant families in the future. The study emphasizes the need to recognize the significant contribution of cultural doulas to improving equitable maternal healthcare in ethnically diverse Sweden.