Indiana University-Purdue University Indianapolis (IUPUI) / The benefits of breastfeeding are widely known and documented, yet breastfeeding rates at six months have remained well below desired levels. In order to fully understand the breastfeeding experience in the early postpartum period and all the intricacies involved, researchers need to provide mothers with the opportunity to talk about their experiences during the time when there are the most difficulties and when they are most likely to discontinue, the first four weeks postpartum. The purpose of this study was to more fully understand, in their own words, the experiences of mothers who began breastfeeding their infant after birth and may or may not have been breasting at four weeks postpartum. A single research question guided this study: What are the lived experiences of breastfeeding mothers during the first four weeks postpartum? Eight mothers who delivered in the past four to six weeks were interviewed. Data were analyzed using a Heideggerian hermeneutic phenomenological approach. This method was chosen because it allowed the researcher to conduct interviews and explore the lived experience of breastfeeding mothers and to uncover the concealed meaning within the phenomena. This methodology provided a richness that might not be possible through description alone. The narratives shared by the mothers demonstrated that initiating breastfeeding and sustaining it in the early postpartum period was a complex process. Each mother’s breastfeeding experience was unique to her but also similar to someone else’s. The overall constitutive pattern of Getting the Hang of It was selected and consisted of four themes and nine subthemes. The four themes included: Physical Experiences, Emotional Complexities, Infant Involvement in Breastfeeding Process, and Support. These themes and their subsequent subthemes provide insight into the complexities experienced by mothers in order to acquire the skills they needed to breastfeed their infants. Breastfeeding mothers, who have had favorable and unfavorable experiences, are willing to share a wealth of information. Health professionals should encourage mothers to talk about their experiences and listen to what they are saying. Through listening they can provide mothers with the resources and support needed to meet their breastfeeding goals.

Diplomatic summits serve as critical opportunities for national leaders to interact and mobilize the political will needed to address the world’s greatest challenges. Yet, summits have a checkered past with both successes and failures. Consequently, summit diplomacy has been equated with highly publicized photo opportunities for heads of government and grandiose communiqués with vague commitments that are never fully realized. Due to concerns about their effectiveness, legitimacy, and representation, summits are in a period of transition. These trends and challenges are especially evident in the G8, and scholars have recognized that the G8 summit has evolved to include more actors than the past. Although acknowledged as a potential site of networked governance, empirical evidence of such activity is limited. Research has yet to identify the actors involved, the structures of the relationships, and the impact of networked approaches on the preparatory process. This research specifically explores the question of how a global level network affects the priorities adopted by the G8. Using the 2010 G8 Summit as a case to examine the increased prevalence of networked activity, this study focuses on the Summit’s signature initiative: maternal, newborn and child health (MNCH). MNCH is a longstanding global problem and despite efforts such as the Millennium Development Goals, poor health outcomes persist in regions throughout the world. But to understand the selection and shaping of MNCH as the signature initiative of the 2010 G8 Summit, a mixed method approach is used. Social network analysis provides a detailed description of the actors involved in networked governance in summit diplomacy for the G8, and the structure of their relationships with one another. Qualitative data analysis of 63 in depth interviews of network members illuminates the rich and varied perspectives of the participants, which yields insight about why and how actors engage each other in order to achieve individual and collective goals. The study demonstrated that networked governance contributed to the political prioritization and substantive policy content of summit agenda items, determined during the 2010 G8 Summit preparatory process. In the case of MNCH, while the network was found to include of a diverse range of state and non-state actors, a core group of bureaucratic, political, and NGO actors played a prominent role in the selection and shaping of the MNCH initiative. Yet, the role, values and contributions of actors within the network were contested by network members during the preparatory process, demonstrating that shared goals and norms were not a dominant feature of the network. Moreover, the networked governance process has not entirely escaped the confines of geographical boundaries, given the most central actors in the network met face-to-face on a regular basis and were located in close geographical proximity. Actors from regions where MNCH problems persist most severely remained marginalized in the networked approach. While financial capital is an essential ingredient for the MNCH programs and interventions proposed for the G8 initiative, social capital was a neglected factor that is critical for building the capacity to generate new ideas and solutions. Actors within the 2010 G8 preparatory network for MNCH adopted various strategies to build and mobilize social capital. Specifically, a group of Canadian-based NGOs and an international organization formed a coalition in order to strategically advance the MNCH issue on the summit agenda. Conversely, government actors did not invest in developing and mobilizing social capital. Ultimately, informal strategies proved more valuable for breaking down hierarchical barriers and exerting influence than formal processes designed by government. Networked governance was a key factor that contributed to the political prioritization and shaping of the MNCH signature initiative for the 2010 G8 Summit and increased the inclusiveness of the summit’s preparatory process. However, while important, networked governance was not sufficient to fully explain the final outcomes – other factors such as domestic and global political contexts and the characteristics of the MNCH issue influenced the process and outcomes. Moreover, G8 summit diplomacy moved beyond being solely a state-based process in the case of MNCH, but the presence of a network of interconnected actors did not equate to better problem-solving. Although scholars and practitioners agree that integrated horizontal and vertical approaches are required for addressing the complexity of MNCH challenges, the networked approach failed to enable a move beyond conventional solutions to address the systemic nature of MNCH challenges. The findings of the study have important implications for policy and governance processes, where widespread cooperation among a network of state and non-state actors will be required for resolving intractable global problems.

Diplomatic summits serve as critical opportunities for national leaders to interact and mobilize the political will needed to address the world’s greatest challenges. Yet, summits have a checkered past with both successes and failures. Consequently, summit diplomacy has been equated with highly publicized photo opportunities for heads of government and grandiose communiqués with vague commitments that are never fully realized. Due to concerns about their effectiveness, legitimacy, and representation, summits are in a period of transition. These trends and challenges are especially evident in the G8, and scholars have recognized that the G8 summit has evolved to include more actors than the past. Although acknowledged as a potential site of networked governance, empirical evidence of such activity is limited. Research has yet to identify the actors involved, the structures of the relationships, and the impact of networked approaches on the preparatory process. This research specifically explores the question of how a global level network affects the priorities adopted by the G8. Using the 2010 G8 Summit as a case to examine the increased prevalence of networked activity, this study focuses on the Summit’s signature initiative: maternal, newborn and child health (MNCH). MNCH is a longstanding global problem and despite efforts such as the Millennium Development Goals, poor health outcomes persist in regions throughout the world. But to understand the selection and shaping of MNCH as the signature initiative of the 2010 G8 Summit, a mixed method approach is used. Social network analysis provides a detailed description of the actors involved in networked governance in summit diplomacy for the G8, and the structure of their relationships with one another. Qualitative data analysis of 63 in depth interviews of network members illuminates the rich and varied perspectives of the participants, which yields insight about why and how actors engage each other in order to achieve individual and collective goals. The study demonstrated that networked governance contributed to the political prioritization and substantive policy content of summit agenda items, determined during the 2010 G8 Summit preparatory process. In the case of MNCH, while the network was found to include of a diverse range of state and non-state actors, a core group of bureaucratic, political, and NGO actors played a prominent role in the selection and shaping of the MNCH initiative. Yet, the role, values and contributions of actors within the network were contested by network members during the preparatory process, demonstrating that shared goals and norms were not a dominant feature of the network. Moreover, the networked governance process has not entirely escaped the confines of geographical boundaries, given the most central actors in the network met face-to-face on a regular basis and were located in close geographical proximity. Actors from regions where MNCH problems persist most severely remained marginalized in the networked approach. While financial capital is an essential ingredient for the MNCH programs and interventions proposed for the G8 initiative, social capital was a neglected factor that is critical for building the capacity to generate new ideas and solutions. Actors within the 2010 G8 preparatory network for MNCH adopted various strategies to build and mobilize social capital. Specifically, a group of Canadian-based NGOs and an international organization formed a coalition in order to strategically advance the MNCH issue on the summit agenda. Conversely, government actors did not invest in developing and mobilizing social capital. Ultimately, informal strategies proved more valuable for breaking down hierarchical barriers and exerting influence than formal processes designed by government. Networked governance was a key factor that contributed to the political prioritization and shaping of the MNCH signature initiative for the 2010 G8 Summit and increased the inclusiveness of the summit’s preparatory process. However, while important, networked governance was not sufficient to fully explain the final outcomes – other factors such as domestic and global political contexts and the characteristics of the MNCH issue influenced the process and outcomes. Moreover, G8 summit diplomacy moved beyond being solely a state-based process in the case of MNCH, but the presence of a network of interconnected actors did not equate to better problem-solving. Although scholars and practitioners agree that integrated horizontal and vertical approaches are required for addressing the complexity of MNCH challenges, the networked approach failed to enable a move beyond conventional solutions to address the systemic nature of MNCH challenges. The findings of the study have important implications for policy and governance processes, where widespread cooperation among a network of state and non-state actors will be required for resolving intractable global problems.

The 2015 global adoption of the United Nations 2030 Agenda for Sustainable Development places the achievement of health equity as a global priority for health and development. Due to the normative nature of the concept of health equity and the multi-level, multi-sectoral approaches required to advance it, interdisciplinary investigations are warranted to demonstrate how health equity as a policy objective is understood and operationalized. This dissertation is a case study of health equity in maternal, newborn and child health (MNCH) in Ethiopia, using qualitative methods to explore how health equity is conceptualized and pursued by stakeholders across levels of the health system. Ethiopia, a low-income country in East Africa, reported improvements in MNCH during the Millennium Development Goal period (1990-2015), largely attributed to the expansion of health services into rural areas; however, achievements were not realized across all geographies and population groups. Health equity is a stated policy objective for the country. Through a series of four articles, this dissertation addresses: community members’ perceptions and experiences related to health inequity and MNCH; barriers and enablers encountered by community-level health workers in implementing an equity-oriented MNCH intervention; subnational health managers’ understandings of health equity, and their roles in promoting it; and the characterization of health equity as a policy problem in national-level health discourses. This work deconstructs health equity into three components (health, distribution of health and characterization of the distribution of health) and compares how stakeholders across levels of the health system attribute meaning to each component and imply responsibility and accountability for health equity. The findings detail how diverse experiences related to health equity in MNCH across community, subnational and national contexts are driven by high-level technocratic framings of health equity, which tend to emphasize the delivery of a narrow package of health services to under-served geographical areas. Providing support and recognition for the role of subnational stakeholders in mediating the adaption of national health equity policies to local contexts, and making prominent the social justice underpinnings of health equity in the implementation of national policies are opportunities to strengthen the advancement of health equity in Ethiopia.

Having a newborn can be a big change for families, especially for first-time parents. At hospital discharge, parents are often provided with a lot of information, which can be difficult to retain. Due to shortened postnatal lengths of stay, nurses typically have less time to educate parents, which often results in families feeling overwhelmed. After hospital discharge, it is recommended for families to see a health care provider (i.e., physician, nurse practitioner, or registered midwife) within 72 hours for a follow-up appointment. This follow-up appointment is meant to assess both the mother and newborn to ensure they are both in good health and to provide any needed support. Unfortunately, completing the appointment within this timeframe may not be possible for every family or they may not be aware of its importance. Depending on the family’s model of care, completing the follow-up appointment within 72 hours after hospital discharge can be challenging. Families that have a physician as their health care provider may experience delays in scheduling the follow-up appointment. This can be due to the physician’s lack of availability, as there is a physician shortage in most communities. Furthermore, some families do not have access to a health care provider and, therefore, do not see a care provider after hospital discharge. Completing the follow-up appointment later than when it is recommended, or not at all, can result in negative health consequences for the mother and newborn and can also increase re-admission hospital rates and related costs (Cargill et al., 2007). At the moment, postnatal lengths of stay are shortening but the service delivery has not changed to accommodate this trend (Lemyre et al., 2018). This means that the services typically provided to families in the hospital now need to be provided in the community. The follow-up appointment after hospital discharge is an opportunity to provide these services; however, timely access to a health care provider, specifically a physician, can be challenging. Thus, this thesis explores the development of a general design methodology for a postpartum nurse practitioner-led clinic. The aim of the clinic is to provide timely access to any family that needs to complete the necessary postpartum services after hospital discharge within a community. An analytical model was developed to explore the characteristics of a postpartum nurse practitioner-led clinic and how it would operate (i.e., what services would be offered, the amount of time needed for these services, what is needed to offer these services, etc.). The model conducts a simulation of the appointment scheduling process based on the input values entered into it and evaluates a number of performance metrics (e.g., number of diversions, patient wait times, resource idle time, clinic overtime, number of appointments provided within 72 hours and number of appointments provided beyond 72 hours). The findings from the model can support the potential implementation of a postpartum nurse practitioner-led clinic in any community. Implementing such clinics could increase awareness, further educate parents and increase access to postpartum services.

Philosophiae Doctor - PhD / The value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national levels, with little understanding of how accountability is integrated into the routine functioning of local health systems. This PhD explores the forms and functioning of accountability at the district level focusing on MNCH as a programmatic area with long-established institutional mechanisms (structures and processes) in South Africa (SA). The thesis is presented in the form of four empirical papers (published or submitted), exploring different dimensions of accountability, which are embedded in a series of narrative chapters. In this thesis, accountability is understood as a set of relations between an accountholder and ‘accountor’ (or duty bearer), in which the latter provides information or justification for actions or decisions taken, and faces the resulting consequences of his/her actions (reward or sanction). Accountability mechanisms are the means to regulate accountability relationships and include broad strategies, interventions or instruments. These mechanisms can take various forms including performance, financial and public accountability, and operate both vertically (accountability inside bureaucratic hierarchies, or towards external stakeholders and/or the community), or horizontally (between peers, ‘neighbour’ units, departments or ministries in a national health system). Drawing conceptually on the field of governance and considering the complexity of the accountability phenomenon, I adopted a case study approach to the PhD research, using a combination of policy document review, interviews (with managers, providers, community representatives and members of labour unions) and field observations, conducted iteratively over 16 months. The study was conducted in Gert Sibande District, one of the three South African health districts in Mpumalanga Province, with an in-depth focus on two of the seven sub-districts in the District. The research found that frontline health professionals have a clear understanding and conceptualisation of accountability in the SA health policy context, despite the reported inability to define accountability by health professionals described in the literature. Respondents referred to accountability as responsibility, answerability and virtue, and also argued for strengthening accountability mechanisms as critical to addressing maternal and child mortality. While deeming accountability as important, frontline professionals experienced the existing accountability mechanisms as ‘too much’ and indicated the desire for the streamlining of existing mechanisms. In this regard, the study documented numerous mechanisms at district level, almost all related to performance accountability in MNCH. These included a performance management system, quality assessment and accreditation processes, quarterly reviews, and death surveillance and response processes. The existence of multiple and overlapping accountability mechanisms engenders operational confusion and ‘accountability overload’ for frontline providers, encouraging empty bureaucratic compliance, while critical gaps – notably in community accountability – remain. In practice, at their best, some mechanisms operate following a reciprocal1 pathway of capacity building with resource provision (from management) and expectation for better performance (from providers). There were, however, contextual variations in the implementation and practice of the mechanisms between sub-district settings. The fieldwork observations and interviews were also able to document how formal institutionalised mechanisms are embedded within a complex system of informal accountability relationships and social norms (‘accountability ecosystem’) that enables or constrains the ability of frontline professionals to fulfil their tasks. In addition, using a Social Network Analysis approach, the research identified key actors and their involved network, which form the relational backdrop to the functioning of accountability mechanisms for MNCH. By revealing complex relationships and collaboration patterns among frontline health professionals, the study was able to show the multi-level action and multiple actors required to achieve MNCH goals.