Chapter one systematically reviews the literature on the psychological impact of breastfeeding on mothers. Whilst breastfeeding is indicated as the superior feeding choice for infants, the full impact on mothers is under-reported. Results show that breastfeeding and weaning have a varied psychological impact on maternal wellbeing, identity and perceptions of role. Where incompatibilities between mothers‟ expectations and lived experiences occur, or where disagreement between self and others is perceived, dissonance, distress and division result. Discussion is made of the implications of these findings for clinical service provision, training and research. Chapter two presents a grounded theory analysis of fathers‟ experiences of attending traumatic childbirth. Despite an increasing trend over recent decades for fathers to attend their children‟s births, relatively little is still known about the potential impact of having been present during a traumatic labour or delivery upon them. In response to this gap in the literature, the current study reports theoretical concepts generated from interviews with fathers. A model of the experiences recounted is also presented, showing that, within the context of their past experiences, antenatal preparation and confidence in the care provided, fathers cycled between seeking control, passive observing, and helplessness. Findings are discussed in relation to the existing literature and the implications of this novel contribution to the subject area for future research and service provision are highlighted. Chapter three discusses the candidate‟s personal observations and reflections on the research process. The impact of parenthood and gender upon research into the perinatal period is considered and effects are noted on the researcher, participants and the research itself. Reflections are discussed with reference to previous research into gender and motherhood in qualitative research, and a call is made for researchers to acknowledge their epistemological positions within their subject fields as a matter of routine.

Pregnancy; a natural insulin resistant state; becomes exaggerated when complicated by obesity and gestational diabetes (GDM). Both obesity and GDM are associated with severe maternal and fetal complications as well as with increased risks of obesity in the offspring later in life. Little work has been performed on the levels of adipokines in lean, obese and diabetic pregnancy. This study aimed to explore the roles of three adipokines; namely, Adipsin, Acylation stimulating protein and Fibroblast Growth Factor-21, all of which are involved in insulin resistant and dysmetabolic states such as obesity and type 2 DM. We hypothesized that these adipokines might play a role in pregnancy. A cohort of Caucasian pregnant women undergoing elective caesarean section was studied. Clinical parameters were assayed as well as circulating maternal and fetal levels of adipsin, ASP and FGF21. Paired samples of fat and placental tissue were taken for explant studies to measure secreted Adipsin, ASP and FGF21 levels. Cord levels of adipsin and ASP were significantly elevated in the offspring of obese and diabetic mothers compared to their lean controls. Plasma FGF21 levels were significantly higher in GDM compared to lean controls. FGF21 levels in cerebrospinal fluid (CSF) were also measured and a CSF/Plasma ratio calculated. I have identified the human placenta as a source of adipsin, ASP and FGF21. More specifically, I have shown that placental Hofbauer cells (macrophages) produce adipsin and ASP. This is the first time secretion of adipsin and ASP by Hofbauer cells has been demonstrated. I conjecture a role of these macrophages in lipid metabolism at the materno-fetal interface. Also, I describe that GDM mothers have higher CSF FGF21 as compared to controls but the CSF:plasma ratio of FGF21 was lower in GDM mothers, potentially suggesting an alternative reason for and contributing to hyperglycaemia in GDM.

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The work in this thesis describes a series of studies utilising diverse data sources which were analysed using a number of regression methods (logistic, linear, Cox, Poisson), to address the factors associated with normal and abnormal pregnancy outcome. A series of maternal characteristics were related to adverse pregnancy outcome. Teenage pregnancy was not associated with an increased risk of any adverse outcome among first births, but was strongly associated with adverse outcome among second births [8]. Parity also interacted with body mass index: maternal obesity was associated with an increased risk of preterm birth among nulliparous but not multiparous women. This was explained by higher rates of elective preterm deliveries among obese nullipara [31]. There was a linear relationship between maternal age and the duration of labour, and the risk of operative vaginal and caesarean delivery [37]. It was hypothesised that age-related deterioration in obstetric performance was due to prolonged hormonal stimulation prior to the first birth. This hypothesis was supported by the observation that later menarche was independently associated with a decreased risk of operative delivery [38]. A short inter-pregnancy interval was associated with an increased risk of spontaneous preterm birth, but not stillbirth or intra-uterine growth restriction [16]. The risk of unexplained stillbirth at term was increased among nulliparous women [5] and nulliparous women also had slightly longer pregnancies [7]. A U-shaped relationship between birth weight and caesarean risk was observed at term. There was an interaction between fetal sex and caesarean risk: small boys were at increased risk of emergency caesarean [3]. The same interaction was observed for antepartum stillbirth [4]. Previous pregnancy outcome was predictive of the outcome of subsequent pregnancies. Women who were delivered by caesarean section in their first pregnancy had an increased risk of unexplained stillbirth in their second [17]. This finding was confirmed in a separate cohort and associations were also observed between previous complicated livebirths and the subsequent risk of unexplained stillbirth [32]. Some specific situations were also studied (vaginal birth after caesarean section (VBAC) and twins). Among women attempting VBAC, the absolute risk of delivery-related perinatal death was comparable to primiparous women but was significantly higher than women delivered by elective caesarean section [11]. The risk of perinatal death associated with uterine rupture was increased in low throughput obstetric units and among women induced with prostaglandins [19]. Using simple maternal characteristics, approximately 50% of women attempting VBAC could be classified into having a high (>40%) or low (<10%) risk of emergency caesarean [24]. This was better discrimination than could be achieved using similar characteristics among nulliparous women being induced at term [21]. The risk of delivery related perinatal death was increased among second twins, although this was only evident among births at term [13]. The association was observed among sex discordant twins, but was not observed among twins delivered by elective caesarean section [23]. The association between birth order and the risk of death due to anoxia was confirmed in data from England and Wales [33]. Ultrasonic measurements of the fetus were related to eventual birth weight. The range of error associated with such estimates was quantified and abdominal circumference on its own was as predictive as models using abdominal circumference and femur length [1]. Estimating fetal weight using ultrasound was not found to be a better measure of human fetal blood volume than simply using gestational age [10]. A series of ultrasonic measurements in the first and second trimester were predictive of pregnancy outcome, including smaller than expected crown rump length and intra-uterine growth restriction, preterm birth and low birth weight [2]; a long cervix in mid gestation and caesarean section [36]; and, high resistance patterns of uterine artery Doppler flow velocimetry and stillbirth [30]. Biochemical measurements performed in early pregnancy were also predictive of later adverse outcome: low maternal levels of pregnancy-associated plasma protein A (PAPP-A) were associated with an increased of pre-eclampsia, preterm birth and growth restriction [9]; low PAPP-A prior to 13 weeks was associated with birth weight at term in healthy pregnancies [12] and with a dramatically increased risk of stillbirth due to placental dysfunction [22]. Low first trimester levels of placenta growth factor were associated with increased risks of pre-eclampsia and growth restriction, whereas there was no association between elevated levels of the soluble fms-like receptor and adverse outcome [35]. Measurements of biochemical variables in the second trimester were also predictive of outcome, with elevated maternal serum alphafetoprotein (AFP) being associated with an increased risk of stillbirth [34] and spontaneous preterm birth [29]. Women with the combination of low first trimester PAPP-A and high second trimester AFP were at particularly high risk of complications, reflecting the synergistic predictive ability of the two measures [27]. Given proposed similarities between stillbirth and sudden infant death syndrome (SIDS), this outcome was also studied. Elevated second trimester levels of AFP were also associated with an increased subsequent risk of SIDS [20]. Women with a pregnancy resulting ultimately in SIDS were found to be more likely to have had complications in past and future pregnancies [25]. The risk of SIDS declined with advancing gestational age at term following spontaneous, but not elective birth [15]. Obstetric characteristics were used to generate a predictive model for SIDS [26]. Pregnancy outcome was also predictive of other aspects of child health, specifically, respiratory morbidity following birth at term was associated with an increased risk of hospital admission for asthma [18]. Pregnancy complications were also related to long term maternal health. Elective caesarean delivery for breech presentation did not appear to have an independent effect on fertility [28]. However, pregnancy complications were associated with the mother’s subsequent experience of cardiovascular disease. Women experiencing growth restriction, preterm birth or pre-eclampsia were at increased risk of subsequent ischaemic heart disease (IHD) [6] and the risk of this was also related to the number of miscarriages experienced prior to the first birth [14]. The parents of women who had experienced pregnancy complications or recurrent miscarriage had an increased incidence of IHD [39 & 40, respectively].

Summary Background: Previous studies report that women are failing to make informed choices with regard to antenatal screening, due to significant deficits in knowledge. However, current definitions dictate that informed choice occurs not merely as a result of sufficient knowledge, but by acting in line with one’s attitudes despite perceived social pressure (Dormandy et al., 2002). Objective: To investigate whether women are making informed choices with regard to Combined Ultrasound & Biochemical (CUB) screening, using more substantial criteria. Design: Prospective non-experimental. Setting: The Queen Mother’s Maternity Hospital in Glasgow. Sample: 63 women due attend their first antenatal appointment. Outcome measures: responses to a questionnaire constructed for the purposes of the study. Methods: A multidimensional questionnaire measure encompassing demographic factors, areas of knowledge recommended by The Royal College of Obstetricians and Gynaecologists (RCOG, 1993) and all aspects of the Theory of Planned Behaviour (TPB; Ajzen, 1985). Results: Women appeared to be well informed, though there were some worrying misconceptions. Women appeared to intend to act in line with their attitudes, although small numbers of women planning to refuse screening limited findings. Attitude was the strongest predictor of behavioural intention. Conclusions: There appears to be moderate support for the hypothesis that women would make ‘informed choices’, though this is limited by a number of factors which require further investigation.

This thesis consists of a series of studies utilising quantitative ultrasound (Sunlight Omnisense 7000P) to assess bone health of infants. Preterm infants are at risk of osteopenia of prematurity (OP) which can result in fractures in the short term and may have an impact on growth in infancy and childhood. OP has a multifactorial aetiology including factors such as poor mineral intake and immobility. There is an increasing number of ex-preterm survivors therefore morbidity becomes more important. There is also increasing evidence from epidemiological studies that growth in infancy can have an effect on adult diseases such as osteoporosis. The first study was a cross-sectional study of bone quantitative ultrasound measurements in 110 term and preterm infants shortly after birth. Speed of sound (SOS) was measured at the tibial and the radius. This validated the technique showing reproducible measurements with low inter and intra-observer error, and also showed no benefit to measuring multiple sites. Preterm infants were found to have a significantly lower SOS than term infants. There was a positive correlation between tibial SOS and gestation, with birthweight being a less significant factor than gestation. The second study followed 18 preterm infants longitudinally from birth to hospital discharge or term corrected gestational age (CGA). SOS fell significantly with time in all infants. The most preterm infants had the greatest fall in SOS. SOS at the end of the study period was negatively associated with peak serum alkaline phosphatase and severity of illness score. SOS was significantly lower in the infants who required total parenteral nutrition for longer than 3 weeks. These results show that the neonatal course has a significant impact on SOS trajectory. When preterm infants were followed up in the out-patient clinic over the first two years of life the SOS measurements taken as the next part of this study showed a catch up phenomenon. In the majority of infants, but not all infants, SOS moved into the normal range by 6 months CGA. In the subgroup of infants followed longitudinally those with the lowest SOS at hospital discharge/term corrected age had the greatest increase in SOS over time. An interventional study of passive exercise was performed to explore its role in influencing the bone health of preterm infants. Thirty one infants born at less than 33 weeks gestation were randomised to receive range of motion flexion and extension exercises once daily for 5 days each week starting ‘early’(n=15) or ‘late’ (when on 100kcal/kg/day enteral feeds, n=16) and continuing until term corrected gestational age (CGA) or discharge from hospital. Tibial SOS declined significantly from birth to end of physical activity in both ‘early’ and ‘late’ groups, and this was similar to the decrease seen in a group of historical controls from the earlier longitudinal study. Weight gain and head growth did not show a significant difference between groups or between study infants and controls. No infant was reported to have sustained a fracture, and length of hospital stay was not significantly different between groups. There was no significant increase in sepsis rate, retinopathy of prematurity or chronic lung disease in study infants but numbers were small. On longer term follow-up the intervention was not associated with any adverse effects. To investigate the possibility that the maternal environment plays an important role in influencing infants’ bone health we also studied SOS changes in 188 pregnant women and their offspring. Most women had SOS in the normal range antenatally, and there was no significant change in SOS across pregnancy in the group as a whole. There was a significant negative correlation with SOS SDS and BMI in early pregnancy. Women who smoked cigarettes had lower SOS throughout pregnancy and so did their infants. Serum bone biochemistry was measured in the women antenatally and after delivery, and umbilical cord blood was also taken where possible. Vitamin D deficiency was found to be common at the end of pregnancy. Women of Asian origin had significantly lower vitamin D levels at all stages of pregnancy. There was no significant relationship between maternal and infant SOS, or between maternal vitamin D status and infant SOS. The work of this thesis establishes quantitative ultrasound as a useful technique in the assessment of infant bone health. It is a radiation free tool which provides precise and reproducible measurements in both term and preterm infants. In agreement with a small number of other studies we found that preterm infants have a lower speed of sound at birth compared to term infants; speed of sound increases with increasing gestation while in utero. By including infants who were both appropriately grown and small for gestational age we found maturity to be a more important factor in bone strength than birthweight. Despite the apparent self limiting nature of osteopenia of prematurity an intervention to improve neonatal bone health is still desirable, to prevent fractures. Our results do not substantiate conclusions from previous studies that physical activity alone can improve neonatal bone health. .Findings are however limited by the small sample size. Further studies are needed which investigate alternative exercise regimens, taking into account mineral and nutrient supply. Vitamin D deficiency, smoking and obesity may adversely affect bone health of women and their offspring. In the west of Scotland vitamin D deficiency is common in pregnancy: women of south asian origin are at particularly high risk, and should be supplemented with Vitamin D.

Women commonly complain of cognitive impairment during pregnancy; although some research has confirmed impairments using objective tests, the aetiology of this is uncertain. The relationship between disturbed sleep during pregnancy and cognitive functioning has not been specifically investigated. Using a correlational design, the present study aimed to examine the relationship between disturbed sleep and cognitive functioning during pregnancy. Method: Sixty-four women in the third trimester of pregnancy completed the Pittsburgh Sleep Quality Index and the Insomnia Severity Index. A sub-sample also undertook actigraphic monitoring to obtain objective estimates of sleep quality. Cognitive functioning was measured subjectively using the Cognitive Failures Questionnaire and objectively using the IntegNeuro computer package. Results: Women reported significant sleep disturbance, which was confirmed by actigraphic monitoring in a sub-sample. Poorer subjective and objective sleep quality was related to more self-reported cognitive failures. Subjective sleep quality was also significantly correlated with objective measures of delayed verbal recall, but not to other domains of cognitive functioning. Poorer objectively measured sleep was related to decreased vigilance. Women reporting significant sleep disturbance reported significantly more cognitive failures than good sleepers, although this difference was not reflected by performance on objective cognitive tests. Conclusion: Sleep disturbance during pregnancy is related to subjective cognitive impairment and to some domains of cognitive performance using objective cognitive tests.

This thesis examines obstetric practice associated with cephalopelvic disproportion in Glasgow between 1840 and 1900. Disproportion is a complication of labour, which occurs when there is a physical disparity between the size of the fetus and the size of the birth canal. The majority of these cases involved women who had suffered from rickets as a child, and had a deformed pelvis as a result. During this period the number of children affected by rickets appeared to increase, and as a consequence more cases of disproportion were encountered towards the end of the century. Descriptions of these cases found in a wide-range of published and unpublished materials have been used to analyse changes to obstetric practice in Glasgow. The complex nature of medical decision-making in cases of disproportion is shown. Methods available for the treatment of disproportion included caesarean section, craniotomy, forceps, induction of premature labour, symphysiotomy, and turning. Medical practitioners’ decisions were subject to social, medical and scientific factors. Practitioners’ choices were influenced by their experience, reports of successful cases both abroad and at home, the severity of the pelvic deformity, innovations in medical technique, perceptions of the value of the mother compared to her unborn child, location, and the decisions of the women and their friends and family. After the 1870s there was an increase in the number of women who were delivered by one of these forms of intervention at the Glasgow Maternity Hospital. This change can be attributed to an increase in the prevalence of this condition, but it also reflected a shift from women being admitted on social grounds to medical reasons. This change was in response to an acknowledgement that selecting cases earlier improved the chances of a successful outcome, as evidenced by Murdoch Cameron’s work with caesarean section. In addition, as obstetrics emerged as a specialism, obstetric practitioners claimed these difficult cases for themselves. It was stressed that general practitioners and midwives should send women to obstetric physicians as soon as they were aware of complications, and that obstetric specialists were to replace general surgeons as the operator in severe cases of disproportion when caesarean section was required.