A lack of contraception use and contraceptive method discontinuation are common causes of unintended pregnancy in the Eastern Cape. The most common reason for method discontinuation among childbearing women is the unacceptable side effects of their contraceptive choices. Both depression and sexual dysfunction are given as side effects of contraceptive use; however, there is little evidence to support these effects. This randomised, single-blind controlled trial conducted in East London, South Africa, Investigated the effects of the initiation of a long-acting injectable contraceptive, Depot Medroxyprogesterone Acetate (DMP A), compared with the initiation of a copper Intrauterine Contraceptive Device (Cu-IUD) after childbirth on depression and sexual functioning. After counselling, 242consenting pregnant women were randomised to receive DMP A or a Cu IUD within 48 hours of childbirth, in a ratio of 1:1. Primary outcome measures were depression and sexual dysfunction evaluated by validated instruments. Questionnaires were administered at baseline, and telephonically at one month and three months after randomisation. The telephonic interviewer was blinded to the participants' group allocation. English and Xhosa versions of the Beck Depression Inventory and the Edinburgh Postnatal Depression Scale were used to assess depression. The Arizona Sexual Functioning Scale was used to assess sexual functioning. For these primary outcomes, median scores between the intervention groups were compared, as well as the number of events (dichotomous data) in each intervention group. There relative effects of these interventions were summarised by calculating risk ratios, with 95% confidence intervals. Statistical tests used included the Shapiro-Wilk test, T-test, and Wilcoxon test. There were not consistently statistically significant differences in the risk of depression or sexual dysfunction between the intervention groups in this study. However, there was a trend towards more depression in the DMPA group which was statistically significant for mean EPDS score at the one month and for the BDI score three month assessments compared with the IUD group. There was also a trend to more sexual dysfunction with DMPA, but the only statistically significant difference was that fewer women in the DMPA group resumed sexual intercourse within the first month of treatment than in the IUD group. The author's recommendations from the study are that, firstly, family planning providers should inform women during contraceptive counselling that there is no certainty that DMPA causes depression and/or sexual dysfunction; however, it may do so in the postpartum period. Secondly, contraceptive users can continue to use DMPA with confidence as a convenient and effective method of preventing unintended pregnancy. Thirdly, the trend towards postpartum depression and sexual dysfunction in the DMPA group of this study justifies further research with a larger sample size, to include women from various social settings, and for a longer period of follow-up. Lastly, the Cu-IUD is a good alternative to DMPA in women who experience intolerable effects with the latter.

The republic of South Africa has a “health for all” policy, regardless of nationality and residence status. However, challenges still exist for non-nationals and little is known regarding migrants’ maternal healthcare experiences. This study explores the maternal healthcare experiences of migrant Zimbabwean women living in Johannesburg, South Africa. It focuses on the lived experiences of women aged 18years and above, who engaged with the public healthcare system in Johannesburg during pregnancy and childbirth. A desk review of the literature was undertaken. The theoretical framework in this study draws from three concepts (1) the Social determinants of health framework (WHO 2010), (2) the Access to healthcare framework (McIntyre, Thiede and Brich 2009) and (3) the “three-delays (Nour 2008). Primary data was collected through the use of open-ended semi-structured interviews with a sample of 15 migrant Zimbabwean women who have been in Johannesburg for a minimum of 2 years, and have attended and given birth or are currently attending antenatal care in inner city Johannesburg. Thematic content analysis was used to analyse data since it helps to extract descriptive information concerning the experiences of Zimbabwean women in Johannesburg and to construct meaning in order to understand their perceptions and opinions about the healthcare system in the city. Although the findings indicate that documentation status is not a key issue affecting access to healthcare during pregnancy and delivery, a range of other healthcare barriers were found to dominate, including the nature of their employment, power relations, language, and discrimination(generally) among others. Language was singled out as the major challenge that runs throughout the other barriers. More interestingly the participants raised their desire of returning home or changing facilities within the Public sector or to private institutions in case of any further pregnancy. This study concludes that the bone of contention is on belongingness, deservingness and not being able to speak any local language, that runs through the public health care institutions and this impact on professionalism and discharge of duties.

Syfte: att undersöka hur gravida kvinnor sökte och fick information om amning under graviditeten och hur vårdrutiner gällande amning upplevdes av kvinnorna under mödravårdsbesök samt utfallet av det första amningstillfället. Metod: en retrospektiv, deskriptiv studie med kvantitativ ansats där data samlades in genom ett bekvämlighetsurval. Besvarade frågeformulär uppgick till 52 stycken och delades ut av barnmorskor på BB på vägs återbesöksmottagning vid Akademiska Sjukhuset. Resultat: Internet var den vanligaste sökvägen för att få information om amning både av först- och omföderskor men förstföderskorna sökte i större utsträckning information om amning. Knappt hälften av kvinnorna ansåg att barnmorskorna de mötte under sin graviditet inom mödravården var kunniga inom amningsfrågor. Endast omföderskorna uppgav att de inte fick någon information alls om amning under den gångna graviditeten. Konklusion: barnmorskor behöver hålla sig bättre uppdaterade om vilken information som finns på Internet samt att de behöver ha bättre kunskap i att kunna hänvisa blivande mödrar till internetsidor med evidensbaserad information om amning. / Aim: was to investigate how pregnant women searched and received information about breastfeeding during pregnancy, how care routines concerning breastfeeding were perceived by women during antenatal check-ups and the outcome of the first breastfeeding session. Method: a retrospective, descriptive study with a quantitative approach where the data was collected by convenience sampling. Answered questionnaires amounted to 52 forms and were handed out by the midwives at Akademiska Hospital´s nursing return reception. Results: Internet was the most common source of information regarding breastfeeding among both primiparas and multiparas but primiparas searched for information about breastfeeding to a higher extent. Almost one-half of the women reported that antenatal midwives they met during pregnancy had knowledge about breastfeeding. Multiparas reported that they had not received any antenatal information about breastfeeding at all. Conclusion: midwives needs to be better updated concerning information available on the Internet as well as be able to refer mothers to Internet sites containing evidence-based information about breastfeeding.

The purpose of this thesis was to explore a collaborative project between Sweden and India, a project that is working with improving maternal health care in India. I focused on investigating how the project worked in practice, how they worked for improving the situation for Indian midwives and for pregnant women. This investigation was performed during a two month fieldwork in India where I got the opportunity to meet and interview several people connected to the project. The focus has been primarily on the “Master Trainers”, i.e. Indian midwives who have taken part in a training program in Sweden and in India, and who will function as teachers to other Indian midwives, regarding their perceptions about the project and its achievements. / Syftet med denna uppsats var att undersöka ett samarbetsprojekt mellan Sverige och Indien, ett projekt som arbetar med att förbättra mödrahälsovården i Indien. Jag fokuserade på att undersöka hur projektet fungerat i praktiken, hur de arbetar för att förbättra situationen för indiska barnmorskor och för gravida kvinnor. Denna undersökning utfördes under ett två månaders fältarbete i Indien där jag fick tillfället att träffa och intervjua flera personer knutna till projektet. Fokus har främst varit på "Master Trainers”, dvs indiska barnmorskor som har deltagit i ett utbildningsprogram i Sverige och i Indien och som kommer att fungera som lärare till andra indiska barnmorskor, om deras uppfattningar kring projektet och dess insatser.

Objectives: The purpose of this study was to examine rural women s access to maternal health information and its impact on levels of skilled healthcare utilization. Method: A qualitative study involving twenty five (25) pregnant women,five (5) Skilled healthcare providers and five (5) Traditional Birth Attendants (TBAs) was conducted in Chamwino District in Dodoma Region, Tanzania for a period of six months. Due to time and resource limitation the researcher selected two (2) of the 32 wards in the district where the problem of maternal mortality and non-utilization of skilled healthcare was most prominent. The two selected wards were Msanga and Buigiri wards. The researcher used The Health Belief Model and Theory of Planned Behaviour to develop interview questions and focus group guides as well as the interpretation of the findings. The researcher examined how variable factors e.g. maternal health literacy, individual perceptions, local knowledge and care provider-related factors affect pregnant women s health behaviours and utilization of skilled maternal services. The Data was analysed thematically using the 6-stage guide to thematic data analysis with the help of NVIvo Software. Results: The inadequate conditions of the health facilities and the poor working conditions of the care providers affected the provision of quality of maternal services and health information to pregnant women in the study area. The limited access to skilled maternal health information from skilled healthcare providers and lack of alternative sources of reliable health information led pregnant women to seek health information from their Mothers-in-laws, TBAs and other women in the society. However, there was a shortcoming of information inaccuracy as their health advice was not based on previous expert advice but rather on the personal opinion and attitude towards skilled maternal services. The limited access to maternal health information caused majority of pregnant women to underestimate the risks of pregnancy related complications and how they responded to pregnancy danger signs and other ill-health conditions that raised during pregnancy. The majority of pregnant women reported not to seek and kind of care when experienced a health problem. It was also found that during labour some would go to the TBA for childbirth and later go to the dispensary when the TBA failed while others would just go for TBAs opinion and confirmation that it was real labour then go to the health facility. This delayed women s timely access to obstetric care which is essential for positive outcome when a pregnant woman experiences a pregnancy or childbirth complications. Conclusion: The improvement of the quality of skilled healthcare services in rural areas is a prerequisite for achieving desired outcomes in maternal mortality reduction efforts in Tanzania. However, improvement of quality itself is not a panacea if pregnant women are not aware of the services, hence the healthcare providers should also focus in increasing provision of maternal health information to pregnant women. The findings show that the limited access to skilled maternal health information from healthcare providers and lack of alternative sources for reliable health information has constrained majority of these women from becoming maternal health literate hence affecting their levels of utilization of skilled maternal services. The healthcare providers and policy makers should focus on meeting the health information needs of general rural populations and enable them to become well-informed and knowledgeable to make better and well-informed maternal health decisions.

Background: The underutilization of formal, facility-based maternal care is a major contributor to the high maternal mortality rates among women living in rural Africa. Increasing the use of formal maternal care requires exploration of important maternal health issues affecting community members and comprehension of how they perceive the use of formal and traditional maternal care. This thesis aimed to identify the key factors, challenges, and needs of rural populations for the uptake of formal maternal care. Paper 1 explored rural women's preferred choices for sources of maternal care as well as the factors that contribute to their preferences in Africa. Paper 2 explored elders' perceptions about reasons for the underutilization of maternal healthcare and maternal death, as well as potential solutions to improve formal care use in rural Nigeria. Methods: 1) In paper 1, a systematic search on Ovid Medline, Embase, CINAHL, and Global Health identified 40 qualitative studies that elicited women's preferences for maternal care in rural Africa. Reviewers collated the findings and reported on patterns identified across findings using the narrative synthesis method. 2) Data were collected through 9 community conversations with 158 elders in 9 rural Nigerian communities. The data were analyzed inductively through thematic analysis. Results: 1) A variety of preferences for formal, traditional and both formal and traditional maternal care during antepartum, intrapartum and postpartum periods were identified. The majority of the studies reported preferences for formal antenatal care or a combination of traditional and formal antenatal care. During intrapartum, rural women held a wide range of preferences, including facility-based births, traditional births in a domestic setting, as well as a combination of formal and traditional care depending on the onset of complications. The majority of the studies reported preferences for traditional postnatal care involving traditional attendants, self-care, and cultural rituals that fend off witchcraft. The factors that contributed to these preferences were related to the perceived need of formal or traditional maternal care, accessibility to formal or traditional care, and cultural and religious norms, beliefs and obligations. 2) The perceived reasons for the underuse of formal maternal care included poor qualities of care, physical and financial inaccessibility of facility-based services, and lack of knowledge and awareness. Reasons for women's maternal deaths included malaria and blood displacement, facility-based service deficiencies, uptake of traditional maternal care, and poor community awareness and negligence. Increased access to high-quality care, health promotion and education, community support and supernatural assistance were the proffered solutions. Conclusions: The major areas that need improvement across rural Africa include human and material resources availability, technical and interpersonal quality of care in health facilities, physical accessibility, financial accessibility, sociocultural accessibility, cultural and religious sensitivity, and community knowledge and awareness. Generally, the findings reflect the need for multifaceted interventions that engage target populations and consider local contexts, realities, and related needs in order to develop locally acceptable interventions. Such interventions will increase the likelihood of effective and long-lasting positive changes in healthcare utilization and maternal mortality.

Background: Immigrant women are at risk for not receiving the same support and security during childbirth as native-born women. When the woman speaks little or nothing of the language in the country she is in, difficulties may arise in the communication between healthcare staff and the pregnant woman. If the woman has access to a cultural doula, adequate information can be provided and the risk of medical injuries can probably be reduced.  Purpose: The purpose was to describe the importance of a cultural doula for women with other ethnic background during childbirth.  Method: A general literature review. A total of ten original articles published between 2009-2021 were used in the literature review. The databases that were used: PubMed, CINAHL, Scopus and Web of Science. The articles were quality reviewed with SBU:s template.  Results: Three categories emerged in the analysis of the results: 1) Cultural doula - a bridge between two cultures, 2) Feeling safe before a birth and 3) Cultural doula as an opportunity but also an obstacle. The result is based on opinions and experiences from healthcare staff, immigrant women and cultural doulas. The opinion was that cultural doulas contributed to increased communication. The presence and an early contact before delivery were seen as reassuring for the pregnant woman. Healthcare staff, cultural doulas and the woman herself felt that the pregnant woman lacked information about the country's healthcare system and what she could expect during pregnancy and childbirth. Loneliness was considered to decrease with a cultural doula being present. The informants believed that thanks to the support of the cultural doula, the chance for integration also increased. Conclusion: The availability of a cultural doula for women with other ethnic backgrounds was shown to provide several benefits. Among other things, the cultural doula contributed to increased security for women, improved communication between women and healthcare staff, a greater understanding of healthcare and the country, and an increased chance of integration into society. Promoting cultural competence in healthcare can contribute to equal care for all individuals.

This research examined two interrelated issues relevant to maternal and neonatal health in Pakistan, namely, the rising rates of C-section delivery and low rates of exclusive breastfeeding. By using the Andersen's health behavioral model to frame two empirical studies, the data from the Pakistan Demographic and Health Survey (PDHS) 2012-13 was used. The first empirical study examined the correlation between place of delivery and the odds of cesarean section in Pakistan. Not all Pakistani women have an equal chance of delivering at a health facility where C-section delivery takes place; therefore, the study modeled mode of delivery as a two-step process. In the first step, place of delivery was a function of medical indications and various sociodemographic and community factors. Women who delivered at a health facility were included in the second step, where C-section was a function of medical indications and type of facility (private, public). It is found that women who delivered at a private health facility were more likely to have a C-section, even after controlling for the effects of medical/clinical factors, which is concerning. Findings suggest that the private maternal health sector in Pakistan may be over-medicalizing childbirth. The second study examined this paradox of low exclusive breastfeeding in Pakistan, taking into account not only individual-level characteristics of the child and parents, but also place and mode of delivery, sociocultural factors, and community composition. The sample consisted of 1,044 children 0-5 months old, currently living with their mothers. Binary logistic regressions of exclusive and predominant breastfeeding found women who delivered vaginally, whether at home or health care facility were more likely than mothers who delivered via C-section to predominantly breastfeed their infant, and that mothers who delivered vaginally at a health care facility were more likely than their peers who delivered via C-section to exclusively breastfeed their infants. Collectively, the findings of both empirical studies suggest that private maternal health care services in Pakistan may be facilitating medically unnecessary C-sections, either for profit making or time management. An extended and integrated policy regarding medically unnecessary C-section delivery and low rates of exclusive breastfeeding is needed in Pakistan to address both issues together effectively.

Background  Maternal health is described as the health a woman experiences during pregnancy, delivery and after the baby is born. Every year an estimation is made that 210 million women are pregnant and 140 million babies are being born. However, the care around pregnant women and during deliveries varies depending on what country a woman is located in. Above all, science shows that pregnant women in Sub-Saharan regions have a 46 times higher risk of suffering from maternal morbidity and mortality compared to women in high-income countries. Tanzania is a country within the Sub-Saharan region with the highest numbers of births, yet with limited access to both hospitals and staff which affects mothers and children. Limitations are caused because of poverty, for instance the majority of Tanzania's population live in rural areas where no healthcare is accessible, if the healthcare does not go to those areas.  Aim  The aim was to describe healthcare workers' experiences of reproductive and maternal health at Nkinga Referral Hospital in Tanzania.  Methods  This study was based on a Minor Field Study [MFS] in Tanzania. The chosen method was a qualitative study design with an inductive approach. The interview questions were of semi structured character and in total eight healthcare workers were interviewed at Nkinga Referral Hospital. The data was analyzed with the help of a manifest content analysis.  Findings  The data analysis resulted in three main categories and eight subcategories that reelected the healthcare workers' experiences. Overall, healthcare workers described the preventive work, experienced difficulties, maternal healthcare in general as well as the wishes regarding possible changes in today's reproductive and maternal health.  Conclusion  The healthcare workers' experiences regarding the provision of care for pregnant women differ. Existing deficiencies that have been discovered within reproductive and maternal health are insufficient economic resources as well as equipment. While this unavailability, the healthcare workers experienced the care provided was remarkably affected and the inability to provide good quality care. Because of this, the provision of resources is essential for the ability of healthcare workers to provide good quality care to pregnant women. / Bakgrund  Mödrars hälsa beskrivs som den hälsa kvinnan upplever sig ha under graviditet, förlossning och efter födseln. Varje år uppskattas det att cirka 210 miljoner kvinnor blir gravida och att 140 miljoner nyfödda föds. Däremot ser vården kring den gravida kvinnan och under förlossningen olika ut beroende på vilket land kvinnan befinner sig i. Framförallt visar forskning att gravida kvinnor i Sub-Sahara Regionen har en 46 gånger så hög risk att drabbas av maternell sjukdom och död jämfört med kvinnor i höginkomstländer. Tanzania är ett land i Sub-Sahara som har höga födelsetal, dock med en begränsad tillgång till både sjukhus och personal vilket påverkar mödrar och barns hälsa. Begränsningen beror bland annat på fattigdom, men också på grund av att större delen av befolkningen lever på landsbygden där ingen hälso- och sjukvård finns att tillgå, om inte hälso- och sjukvården tar sig till dem.  Syfte  Syftet var att beskriva sjukvårdspersonalens upplevelser av reproduktion och mödrahälsovård på Nkinga Referral Hospital i Tanzania.  Metod  Denna studie baserades på en Minor Field Study [MFS] fältstudie i Tanzania. Den valda metoden var en kvalitativ studiedesign med induktiv ansats. Intervjufrågorna var av semistrukturerad karaktär och sammanlagt intervjuades åtta hälso- och sjukvårdspersonal på Nkinga Referral Hospital. Datan analyserades med hjälp av en kvalitativ manifest innehållsanalys.  Resultat  Dataanalysen resulterade i tre huvudkategorier och åtta subkategorier som återspeglade hälso- och sjukvårdspersonalens upplevelser. Sammantaget beskrev hälso- och sjukvårdspersonalen det preventiva arbetet, upplevda svårigheter, den generella mödrahälsovården samt vilka önskningar de upplevde skulle kunna förändra dagens reproduktion och mödrahälsovård.  Slutsats  Hälso- och sjukvårdspersonalens upplevelser av att vårda gravida kvinnor skiljer sig åt. Befintliga brister som uppdagats inom reproduktiv- samt mödrahälsovård är bristfälliga ekonomiska resurser likväl som redskap. När detta var otillgängligt upplevde hälso- och sjukvårdspersonalen att vården som gavs till de gravida kvinnorna påverkas avsevärt då en vård av god kvalitet inte kunde tillhandahållas. Således är det av stor vikt att resurser finns tillgängliga så att hälso- och sjukvårdspersonalen kan erbjuda en kvalitativ vård till de gravida kvinnorna.

This study examines major American maternal and children’s healthcare initiatives in the backdrop of international and national crises from 1917 to 1969. During these crises, maternal and child welfare reformers used the rhetoric of citizenship and democracy to garner support for new maternal and child healthcare policies at the national level. While the dissertation focuses on national policies, it also explores how state public health officials from Alabama, Mississippi, and New York implemented these programs and laws locally. The dissertation chapters study regional similarities and differences in maternal and child healthcare by highlighting how economy, culture, and politics influenced how national programs operated in different states. By utilizing White House Conference on Children and Youth Series sources, state public health records, and newspapers, this dissertation argues that by using rhetoric about protecting mothers, children, and American democracy, the Children’s Bureau (CB) members claimed and maintained control of maternal and child health care for over fifty years. CB leaders used World War I draft anxieties as a rallying call to reduce infant mortality and improve children’s health. In the following decades, maternal and children’s healthcare advocates met at the White House Conference on Children and Youth Series to discuss policies and influence legislation relating to maternal and child hygiene. The Sheppard-Towner Program, Title V or the Maternal and Children’s Health Section of the Social Security Act, and the Emergency Maternity and Infancy Care Program reflect policies debated at these White House conferences. By the 1950s, child welfare advocates associated mental health with a child’s overall health and the CB leaders and other child welfare reformers linked happy personalities to winning the Cold War. In the 1960s, the CB members and child welfare advocates’ attention shifted to focusing on low socio-economic mothers and children or children with intellectual disabilities. By 1969, the Children’s Bureau no longer managed national maternal and child healthcare programs and could not “safeguard the health of mothers and children.”