A qualitative study was conducted to identify perceptions of high-risk pregnant Aboriginal women during pregnancy. Five women were interviewed by the researcher who is also Aboriginal. Each woman was a client of the Healthy Mother Healthy Baby pregnancy outreach program in Saskatoon, and was considered to be at high-risk for poor pregnancy outcomes. Interviews were conducted utilizing a phenomenologically-based model of research, from which emerged themes or commonalities of thought between each woman during this time of their lives. The themes were discussed with Aboriginal women elders who worked with Aboriginal families in Saskatoon, for further insight and discussion of the findings. The themes were collated under one general theme called `hopes and dreams.' Each theme included the interest of these women to `want to' move ahead with their lives in the area of improving their relationships with their offspring, their partners, and within themselves. Though each women talked about these areas as being important, all except one did not manifest them in their lives.<p> The implications for the delivery of health care services include the need for health care workers to gain further understanding of the positive motivational factors of high-risk pregnant Aboriginal women that work towards achieving long-term positive behavioural changes, and thus reduce the risks of poor pregnancy outcomes. Other recommendations from this research for health promotion programs include the development of a partnership with the urban Aboriginal community in delivering culturally-based services and teachings to complement the educative and supportive model of program delivery.

A qualitative study was conducted to identify perceptions of high-risk pregnant Aboriginal women during pregnancy. Five women were interviewed by the researcher who is also Aboriginal. Each woman was a client of the Healthy Mother Healthy Baby pregnancy outreach program in Saskatoon, and was considered to be at high-risk for poor pregnancy outcomes. Interviews were conducted utilizing a phenomenologically-based model of research, from which emerged themes or commonalities of thought between each woman during this time of their lives. The themes were discussed with Aboriginal women elders who worked with Aboriginal families in Saskatoon, for further insight and discussion of the findings. The themes were collated under one general theme called `hopes and dreams.' Each theme included the interest of these women to `want to' move ahead with their lives in the area of improving their relationships with their offspring, their partners, and within themselves. Though each women talked about these areas as being important, all except one did not manifest them in their lives.<p> The implications for the delivery of health care services include the need for health care workers to gain further understanding of the positive motivational factors of high-risk pregnant Aboriginal women that work towards achieving long-term positive behavioural changes, and thus reduce the risks of poor pregnancy outcomes. Other recommendations from this research for health promotion programs include the development of a partnership with the urban Aboriginal community in delivering culturally-based services and teachings to complement the educative and supportive model of program delivery.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Die prospektive Studie untersuchte den Verlauf von Hochrisikoschwangerschaften mit zwischen 24/0 und 34/0 Schwangerschaftswochen erstmals diagnostiziertem ARED-Flow in der Arteria umbilicalis hinsichtlich ihres fetal outcome im Vergleich zu einer nach Gestationsalter gematchten Kontrollgruppe. Während der Studiendauer von 1995-1999 wurden 60 Feten aus Einlingsschwangerschaften mit ARED-Flow in der Umbilikalarterie in die Beobachtung einbezogen. Feten mit Malformationen und Chromosomenanomalien wurden ausgeschlossen. Die Beobachtung erfolgte mit wiederholten Doppler-Messungen der arteriellen und venösen Gefäße, mit CTG und mütterlichen Parametern. Eine Entbindung wurde eingeleitet, wenn sich entweder die fetalen Parameter verschlechterten (68%), wie ein Reverse Flow im Ductus venosus oder späte Dezelerationen im CTG oder eine mütterliche Indikation gegeben war (28%), wie das Auftreten einer Präeklampsie. Gemäß Protokoll wurden 50% der Feten mit ARED-Flow 6 Tage nach Erstdiagnose entbunden. Bei mütterlicher Indikation war dies bereits nach 4 Tagen, bei fetaler Indikation nach 7 Tagen der Fall. Im Ergebnis zeigte sich eine Mortalität von 38% mit 23 Verstorbenen (16 intrauteriner Fruchttod und 7 postnataler Tod), die meisten intrauterinen Fruchttode (14) traten bei einem Schwangerschaftsalter unter 29/0 SSW auf. 44 Feten wurden lebend geboren. Die lebendgeborenen Feten wurden in drei Gruppen A, B und C nach dem bei der Entbindung erreichten Schwangerschaftsalter eingeteilt. Zwischen 24/0 und 28/6 SSW (Gruppe A) betrug die Mortalität 36%, zwischen 29/0 und 31/6 SSW (Gruppe B) 10% und ab 32/0 SSW (Gruppe C) 8%. Signifikante Unterschiede zwischen den drei Gruppen zeigten sich bezüglich des Auftretens von periventrikulärer Leukomalazie (nur A: 36%), von neurologischen Auffälligkeiten (A: 73%, B: 45%, C: 8%), von Atemnotsyndrom (A: 100%, B: 35%, C: 8%) und hinsichtlich der Apgar-Werte nach 5 und 10 Minuten. Die 44 lebendgeborenen Feten mit ARED-Flow wurden einer nach Schwangerschaftswochen gematchten Kontrollgruppe normgewichtiger Frühgeborener gegenübergestellt. Zwischen den Feten mit ARED-Flow und der Kontrollgruppe konnten verschiedene signifikante Unterschiede festgestellt werden: In der ARED-Gruppe fanden sich niedrigere pH-Werte (p=0,001), ein geringeres Geburtsgewicht (p=0.0001), häufigeres Auftreten von bronchopulmonaler Dysplasie (p=0.002) und von Darmkomplikationen (p=0.01). Weitere beobachtete Parameter, wie z.B. peri- und intraventrikuläre Hämorrhagien, neurologische Auffälligkeiten, waren nicht signifikant verschieden. Allerdings war das Risiko postnatal zu versterben in der ARED-Gruppe 8-fach erhöht. Es ergibt sich der Rückschluss, dass die Diagnose ARED-Flow eine Gruppe ernsthaft hypotropher hypoxämischer Feten umschreibt, die eine hohe Mortalitäts- und Morbiditätsrate aufweist. Die Mortalität ist tendenziell bei niedrigem Schwangerschaftsalter bei der Entbindung (vor 29/0 SSW), bei extrem niedrigem Geburtsgewicht (unterhalb der 3. Perzentile), bei Vorliegen von spät auftretenden Dopplerveränderungen (wie Reverse Flow in der Arteria umbilicalis oder pathologischem venösen Doppler) erhöht. Obwohl die Inzidenz peri- und intraventrikulärer Hämorrhagien (16%) und neurologischer Defizite (40%) hoch war, erwies sich dieser Unterschied gegenüber den Frühgeborenen der Kontrollgruppe als nicht signifikant. Es kann angenommen werden, dass eine Verlängerung der Schwangerschaft unter venöser Dopplerkontrolle das fetal outcome verbessert. / The study examined prospectively the progression of high-risk pregnancies in cases of ARED flow in the Arteria umbilicalis detected between 24/0 and 34/0 weeks gestation in respect of their fetal outcome compared with a gestational age-matched control group. During the 1995-99 study period, 60 fetuses from singleton pregnancies with ARED flow in the umbilical artery were included in the study. Fetuses with malformations and anoiploidy were excluded. Surveillance was performed by repeated Doppler measurements of arterial and venous vessels, CTG and maternal parameters. Delivery was induced when either fetal parameters deteriorated (68%), as in the case of reverse flow in the Ductus venosus or late decelerations in CTG, or when maternal indication (28%) was given, as when pre-eclampsia occurred. Following our protocol, 50% of fetuses with ARED flow were delivered 6 days after the first diagnosis. In the event of maternal indication, this took place after 4 days, with fetal indication after 7 days. The results showed a mortality rate of 38% with 23 deaths (16 intrauterine and 7 postnatal). The majority of intrauterine deaths (14) occurred under 29/0 weeks of term. 44 fetuses were born live. The fetuses born live were divided into Groups A, B and C in line with gestational age on delivery. Mortality between 24/0 and 28/6 weeks pregnancy (Group A) was 36%, between 29/0 and 31/6 weeks (Group B) 10%, and 8% from 32/0 weeks onward (Group C). Significant variations between the three groups was indicated in the incidence of periventricular leukomalacia (only A:36%), neurological development (A:73%, B:45%, C:8%), respiratory syndrome (A:100%, B:35%, C:8%), and in relation to the Apgar values after 5 and 10 minutes. The 44 fetuses with ARED flow born live were compared with a control group of preterm neonates of average weight and similar gestational age. Various significant differences could be shown between ARED flow fetuses and the control group: the ARED group showed lower pH values (p=0.001), lower birth weight (p=0.0001), and a higher incidence of broncho-pulmonal dysplasia (p=0.002) and of intestinal complications (p=0.01). Other observed parameters such as peri- and intraventricular haemorrhage and neurological development were not significantly different. Nevertheless, the risk of postnatal death was 8 times higher in the ARED group. It has to be concluded that diagnosis of ARED flow encompasses a group of severely hypotrophic, acidemic fetuses showing high rates of mortality and morbidity. Mortality tends to increase in the case of low gestational age on delivery (up to 29/0 weeks), in cases of extremely low birth weight (less than 3%), and in incidences of late Doppler changes (such as reverse flow in the umbilical artery or pathological venous Doppler). Although the incidence of peri- and intraventricular haemorrhages (16%) and neurological defects (40%) was high, compared with the neonates of the control group it was insignificant; It can be assumed that prolongation of pregnancy using venous Doppler improves the fetal outcome.

Philosophiae Doctor - PhD / This thesis is about HELLP Syndrome (hemolysis, elevated liver enzymes, low platelet count in pregnancy): a devastating maternal hypertensive complication that results in multi-system changes that can rapidly deteriorate into organ failure and death. Despite rapid advancesin medical technology and medical science this disease continues to take the lives of women and their infants. The only effective intervention for this disorder is immediate termination irrespective of the gestational stage of the pregnancy. The primary objective of this thesis was to explore the subjective experiences and meaningmaking processes of women in and through their high-risk pregnancies. This objective crystallised into the following aims: to facilitate and listen to the voices of women who were HELLP Syndrome survivors; to explore the reported bodily, psychological and emotional experiences of HELLP Syndrome survivors; to understand the role medical intervention and biomedical discourses play in these women’s experiences and finally to explore the subjective experiences of HELLP Syndrome in the context of traditionallyheld notions of motherhood. The study was couched in a feminist poststructuralist epistemology. A material-discursive framework which comprised phenomenological and poststructuralist theorising was usedin an attempt to understand both the lived experiences as well as the discursively constructed nature of those subjective experiences. Thus the analysis encompassed both a broadly phenomenological framework to understand the lived experiences of HELLP Syndrome, and a discourse analysis to explore the meaning-making processes of participants in relation to larger social discourses, in particular the dominant biomedical and motherhood discourses. A qualitative approach using in depth semi-structured interviews was utilisedto gather data. Eleven participants from very diverse backgrounds consented to be part of thisstudy. The findings of the study highlighted the immense trauma, difficulties and challenges participants faced in these high-risk situations. What was evident from the analysis was that their experiences were so diverse and werecompletely shaped by the severity of the disorder and the gestational stage of the pregnancy. Some women ended up in the Intensive Care Units (ICU) and had near-death experiences, some had very premature babies, while some of the participants lost their babies during the process. With regards to the emotional, psychological and corporeal aspects of the disorder,participants described their situations as a disaster, painful and difficult. Due to the rapid deterioration of symptoms, they described the tempo of these events as a whirlwind in which they felt they had no control. Emotions ranged from shock, total disbelief and surprise to anger, helplessness and powerlessness. Lacking knowledge and access to appropriate information further compounded the situation for participants. Theparticipants who had premature babies found the Neonatal Intensive Care Unit experience (NICU) extremely challenging and stressful. A discourse analysis revealed that women’s talk was shaped by the disciplinary frameworks oftechnocratic medicine and patriarchal notions of gender. Participants’ discourses about their encounters inthe medical context werelocated in, and shaped by, the structure of health care in our country. In this regard binaries (like private versus public health care, women versus men and nurses versus doctors) were evident. Furthermore their hospital stay reflected their experiences in the Intensive Care (ICU) and the Neonatal Intensive Care Units (NICU) both of which are highly technologically orientated and managed. Biomedical discourses that filtered through the participants’ talk were: medicine as indisputable truth;mechanistic model of the body as machine; medical doctors as gods and the foetus as ‘super subject’. Discourses of risk were inevitably taken up as participants tried to make sense of both their current pregnancies and the potential ones to follow. The passage into motherhood for these participants was dependent on whether they had live babies or not. For those who had live babies it was a difficult time as they had to contend with their own recovery as well as the prematurity of their infants. The NICU experience was described as tiring, trying and cumbersome. For mothers who lost their babies it was a time of profound sadness and loss coupled to the notion that motherhood itself was lost. This loss of their children symbolised broken dreams, severed connections and a powerful taboo. In addition, discourses in which motherhood was naturalised and normalised saturated their talk and framed their experience in a narrative of deficit and failure. The ideologies of mother blame and the ‘all responsible’ mother were pervasive in their discussions. In conclusion, this high-risk situation represented a time of tremendous uncertainty and unpredictability for all participants and was powerfully shaped by dominant discourses about motherhood and the biomedical discursive and institutional framework in which participants were subjugated. The study thus highlights how the HELLP syndrome experience illuminates the erasure of women’s subjectivities while the foetus/infants’ life takes precedence. This has significant implications for scholarship in general and feminist scholarship in particular and highlights the need for this type of engagement in an area that has remained on the periphery of feminist research. / South Africa