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Indonesia has one of the highest rates of maternal mortality in Southeast Asia. Community participation has been known to reduce maternal mortality in some areas in Indonesia. However, in Aceh Province, the prevalence remains higher than the general Indonesian maternal mortality rate. The aim of this research was to gain an understanding of pregnancy and childbirth experiences from multiple perspectives, in relation to the use of maternal health services in Aceh, Indonesia. The conceptual framework was based on the importance of community engagement in improving maternal health. A qualitative study design with a grounded theory approach was utilised. This approach was chosen in order to gain an understanding of the social processes and ways in which experiences of pregnancy and childbirth are related to maternal death incidents. The process inherent in the method enabled the emergence of important theoretical concepts. A theoretical sampling strategy was employed. The data collection used multiple methods that involved a series of in-depth interviews, observations and focus group discussions with women, family members, a village leader and health professionals. The sample size was determined by data saturation (19 women, 15 family members, 7 health professionals, 3 kaders, 4 student midwives and 1 village leader participated). Ethical approval was gained and the research setting was in the two villages of Aceh Besar District, Aceh Province, Indonesia. Data were coded and analysed by following a constant comparison process. The emergent core category, entitled “maternal death: the elephant in the room” explains the views of the community about maternal death incidents in the research setting. The research findings highlighted that despite the maternal mortality rate still being high in the region, maternal death was not focused upon, as a problem within the community. The research findings revealed that maternal mortality was a hidden problem within the community, and was related to inadequate maternity practices in the village. The core category “maternal death: the elephant in the room” was found to consist of four interrelated categories. The categories of the value of midwifery in the community, desicion-making of maternity care, social control of the childbearing and distancing of maternal deaths; explain maternity practices in the community. Understanding of social processes related to maternal health can assist in informing strategies to improve the quality of maternal healthcare in Aceh Indonesia.

Americans consume three percent more total daily calories from sugar than current recommendations. Maternal diets high in sugar can cause obesity and diabetes mellitus. Objectives were to compare supplemental dietary sucrose to a protein alternative on maternal health and fetal programming utilizing a sow biomedical model. Pregnant sows (Landrace × Yorkshire, average BW = 222 ± 35 kg, n = 21) were fed a corn-soybean meal-based diet (CSM) at one percent BW at 0700 h daily from d 29 (± 1.47) to 111 (± 0.58) of gestation. Sows were randomly assigned to dietary supplement treatments: 126 g CSM (CON, n = 5), 110 g cooked ground beef (BEEF, n = 6), 85.5 g sucrose (SUCR, n = 5), or the combination of 54.8 g BEEF and 42.7 g SUCR (B+S, n = 5). Dietary supplements were fed three times daily from d 40 to 110 (± 0.58) of gestation. A repeated measures design was modeled using the MIXED procedure of SAS. Dietary treatment did not influence gestational BW (P ≥ 0.99), subcutaneous fat depth (P ≥ 0.09), blood chemistry panel (P ≥ 0.21), or total-, HDL-, or LDL-cholesterol, triglyceride, insulin, or C-reactive protein serum concentrations (P ≥ 0.07). Dietary treatment did not influence sow organ or lean tissue weight (P ≥ 0.42). Compared to CON, BEEF fetuses had increased BW (P = 0.01), crown to rump length (P = 0.01), nose to crown length (P < 0.01), heart girth (P = 0.02), and abdominal girth (P = 0.05). Dietary treatment did not influence fetal growth characteristics of median weight male and female fetuses (P ≥ 0.23). Compared to BEEF, SUCR fetuses had heavier liver weights (P = 0.04). Dietary treatment by sex interaction occurred for fetal kidney weight with BEEF males having heavier kidney weights compared BEEF females (P = 0.03). Dietary treatment did not influence other fetal organ or lean tissue weights (P ≥ 0.09). These results suggest beef or sucrose supplementation at 1.49 or 1.16 grams per kilogram BW per day, respectively, from day 40 to 110 of gestation had minimal impact on maternal health and fetal development. / North Dakota Beef Commission; Topigs Norsvin; and North Dakota State University Agricultural Experiment Station

Includes bibliographical references / This thesis focuses on the use of maternal health services and child health in Tanzania. The main focus is on how these issues relate to social networks and bargaining power within couples. These issues are interrelated and are discussed in three essays. The first essay investigates the impact of information externalities in social networks on the use of antenatal services. Particular emphasis is placed on the extent to which the probability of early antenatal check-up and antenatal completion are affected by social networks. Adopting an econometric technique that minimises the problem of omitted variable bias, the analysis suggests that these network effects increase the probability of antenatal care completion by an additional 6 to 35 percent, and may be as high as 59 percent. The study further finds that without adequate control of omitted variables, the network impact would be understated. It is also evident that failure to control for individual and household observable characteristics overstates the impact of networks. Results from the two approaches used in this study confirm that irrespective of the definition of social network, having a high quality contacts increase the probability of utilising maternal health services. The second essay examines the effect of bargaining power within couples on the probability of delivering in a health facility (public and private), as opposed to a home birth. It further investigates the effect of bargaining on the probability of health care provider choice at childbirth using a multinomial nested logit. Evidence suggests that cooperation within couples in decision-making, female discretion over household resources, and freedom from domestic violence increases the probability of childbirth in a facility, as opposed to home. The study finds that a woman's influence on service use varies if she is better educated than her partner. In addition, while cooperation in household decision and the incidence of domestic violence significantly affect private facility use, female discretion over household resources has a strong effect on public facility choice. Finally, antenatal completion, health knowledge, and maternal specific factors increase the probability of delivering in a public and private facility. ii The third essay empirically explores the contribution of intra-household bargaining, to the rural-urban gap in child nutrition. The study analyses the effect of parental bargaining indicators (cooperation in household decisions, the incidence domestic violence and discretion over household resources) on the probability of child stunting in both rural and urban areas. The essay contributes to the literature by demonstrating empirically that differences in intra-household bargaining increase the rural-urban gap in child health. It further contributes to the literature by correcting for possible sample selection bias. The results suggest that the significant effects of household bargaining indicators on child stunting in Tanzania are mainly from the rural and not the urban population. It provides evidence that weak bargaining power within couples in rural areas account for 5 percent of the rural-urban gap in child nutrition. The contribution reduces to 4 percent after correcting for sample selection bias. The results also suggest that failure to adequately correct for selection bias leads to a substantial underestimation of the overall rural-urban gap in child nutrition by 11 percent.

Collecting and aggregating timely and rigorous data for sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) services and outcomes evaluation in humanitarian settings is essential for accountability and transparency. However, reliable SRMCNAH data are scarce in such settings, and the quality of available data often varies across different humanitarian settings. Establishing a core set of SRMNCAH indicators that are feasible to collect in all humanitarian settings is the first step in developing and implementing a common core framework for monitoring SRMNCAH programs in such settings. Led by the World Health Organization, in 2018 a group of global experts in the SRMNCAH field proposed a core list of indicators for inclusion in routine data collection systems. In 2019-2022, a team at the University of Ottawa in partnership with local investigators led multi-method feasibility assessments in Afghanistan, Bangladesh, the Democratic Republic of Congo, and Jordan to understand the feasibility, relevance, and acceptability of the proposed core indictors. In this thesis I report on the results from the multi-methods assessment in Afghanistan. Based on a desk review, key informant interviews, facility assessments, facility observation sessions, and focus group discussions in three provinces, we explored national stakeholders’ perspectives on SRMNCAH data collection, in general, and the proposed indicator list, in particular. The findings of this assessment and the results from the other three countries will help stakeholders reach a consensus on the final list of SRMNCAH indicators that are feasible for collection in all humanitarian settings.

BACKGROUND: In the United States, racial and income disparities in maternity care outcomes are large and persistent. Research demonstrates that community doulas (specialized community health workers for pregnant, birthing and postpartum people) can improve maternal and infant outcomes. Despite this evidence, doulas have not yet been widely adopted in health services for low-income communities. One barrier to scale-up is understanding the costs and benefits of integrating doula services into maternity care payment systems. METHODS: An exploratory, sequential mixed methods study design was used to understand decision-maker perspectives on doulas in maternity care and apply these priorities to an economic evaluation of a randomized trial of enhanced doula support. 16 in-depth, semi-structured interviews with Medicaid, Accountable Care Organization (ACO) and maternity care decision makers in Massachusetts were conducted. Results from the qualitative study informed the design of an economic analysis of a pragmatic trial of doula support. A return on investment analysis, with a focus on areas of high financial impact and organized by segments of health care services was conducted. Program costs were analyzed using a micro-costing approach. Hospital data on health care costs and payments were used to calculate financial outcomes for both intervention and control groups. Sensitivity and sub-group analyses were developed to understand variations in impact for different populations, settings and doula program models. RESULTS: Decision-maker interviews revealed that health care organizations prioritize investments that promote improved population health, patient experience, cost reduction, and elimination of racial disparities in outcomes. Participants universally expressed interest in an analysis approach that provides information on return-on-investment outcomes, as well as the clinical and cost areas with the largest impact. The time frame of interest was primarily in the pregnancy and newborn episodes of care, with some participants expressing interest in longer term outcomes related to fewer first cesarean deliveries or preterm birth. The economic analysis found an 18% return on investment for the Best Beginnings for Babies doula intervention overall. Sensitivity analyses demonstrated the largest impact was for people with medical and social risk factors and for those who received at least 5 hours of prenatal home visits, as well as labor support. CONCLUSION: Medicaid and maternity care decision-makers are supportive of doula programs if they are affordable and can create cost savings. An economic analysis of the Birth Sisters Best Beginnings for Babies program found a positive return on investment, benefiting both health care payers and families. Community doula programs are a high-value innovation that should be reimbursed by Medicaid agencies. / 2021-09-25T00:00:00Z

Postpartum psychiatric disorders include the postpartum blues (PBs), postpartum depression (PPD), and postpartum psychosis (PP). The focus of this thesis will be on PPD. PPD is a commonly unrecognized mood disorder affecting up to 15% of women. Of women with PPD, half may go untreated. Untreated PPD has shown significant potential for adverse effects in both mother and child. The reproductive hormone model attributes PPD to the rapid hormone changes following removal of the placenta at delivery. This is especially true of the withdrawal of the reproductive hormones estrogen and progesterone. A true causal pathway or causal factor in PPD depression, however, is yet to be established. Several factors must be taken into account when considering risk. These risk factors include women of low socioeconomic status (SES), women with a history of depression, women with a higher reported average of recent life stressors, women with neurotic and/or shy personalities, and women who experience past and/or present obstetric complications. Currently, the Edinburgh Postpartum Depression Scale (EPDS), the Postpartum Depression Screening Scale (PDSS), the Patient Health Questionnaire-9 (PHQ-9), as well as several other screening tools are used in clinical practice to diagnose PPD. Each screening tool utilizes its own unique method to obtain depression scores from patients. The EPDS is most commonly used, yet, no statistically significant difference has been found between the use of one screening tool over the other. PPD screening tools are seen across OB/GYN practices, family practices, health centers, and pediatric practices. Routine well-child visits represent the most regular contact that mothers have with the healthcare system postpartum, making pediatric primary care practices ideal settings for PPD screening and management. PPD management within primary care primarily involves non-pharmacological interventions such as counseling, psychoeducation, motivating help seeking, encouraging social support, and referring to others as needed. On the other hand, medication management is integrated into the stepped care treatment approach, which screens for and treats PPD in a step-wise fashion tailored to a woman’s risk assessment and responsiveness to treatment. Treatments for PPD have varying success. They may include selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SSNRIs), gamma aminobutyric acid receptor A positive allosteric modulators (GABAA receptor PAMs), norepinephrine and dopamine reuptake inhibitors (NDRIs), estrogen therapy, omega-3 polyunsaturated fatty acid supplementation (n-3 PUFA), cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), electroconvulsive therapy (ECT), and bright light therapy (BLT). More statistical evidence currently exists on the use of pharmacological and psychotherapeutic treatments, and less on the ECT and BLT clinical treatments. Mothers deciding on which treatment to pursue should consider the potential for psychotropic and estrogen medications to pass into their breast milk and onto their infant. New mothers should also outweigh the risks and benefits of pursuing pharmacological treatment rather than letting their depression go untreated. By conducting a thorough literature review, this thesis serves the purpose of identifying the most effective treatments to be integrated with a modified stepped care pathway, thereby creating a standardized PPD protocol that can be used across pediatric primary care practices. The aim of standardization of protocol using specific treatments in a modified stepped care approach is to effectively detect maternal PPD, minimize the potential for harm to mother and infant, as well as improve the consistency of care provided to mothers diagnosed with PPD. Implemented correctly, the protocol should show increased use of validated PPD screening tools such as the EDPS in practices managing care for postpartum mothers and/or infants up to the age of one, followed by risk assessment, and then treatment escalated from psychotherapy to antidepressants if required.

Yes / Objectives: Recent developments in incremental dentine analysis allowing increased temporal resolution for tissues formed during the first 1000 days of life have cast doubt on the veracity of weaning studies using bone collagen carbon (δ13C) and nitrogen (δ15N) isotope ratio data from infants. Here we compare published bone data from the well-preserved Anglo-Saxon site of Raunds Furnells, England, with co-forming dentine from the same individuals, and investigate the relationship of these with juvenile stature. The high resolution isotope data recorded in dentine allow us to investigate the relationship of diet with juvenile stature during this critical period of life. Materials and methods: We compare incremental dentine collagen δ13C and δ15N data to published bone collagen data for 18 juveniles and 5 female adults from Anglo Saxon Raunds Furnells alongside new data for juvenile skeletal and dental age. An improvement in the method by sampling the first 0.5mm of the sub-cuspal or sub-incisal dentine allows the isotopic measurement of dentine formed in utero. Results and Discussion: δ13C profiles for both dentine and bone are similar and more robust than δ15N for estimating the age at which weaning foods are introduced. Our results suggest δ15N values from dentine can be used to evaluate the maternal/in utero diet and physiology during pregnancy, and that infant dentine profiles may reflect diet PLUS an element of physiological stress. In particular, bone collagen fails to record the same range of δ15N as coforming dentine, especially where growth is stunted, suggesting that infant bone collagen is unreliable for weaning studies. / Funded in part by the NERC standard grant NE/F018096/2; University of Bradford.

Yes / Food insecurity is a determinant of maternal health; however, research on the health impact of food insecurity among mothers of varying ethnicities is under-developed. We assessed the association of food insecurity and health among white British and Pakistani mothers. Data from the Born in Bradford cohort were matched with data on food insecurity and self-reported health from the nested BiB1000 study (N= 1280). Food insecurity was associated with elevated odds of fair/poor health among white British mothers but not Pakistani mothers. Adjusting for financial security, the association between food insecurity and poor health was not significant among either white British or Pakistani mothers.

Thesis (Ph. D.)--State University of New York at Binghamton, School of Nursing, 2006. / Includes bibliographical references.