Severe maternal morbidity generally refers to the most severe complications of pregnancy and includes: hemorrhage, embolism, acute renal failure, stroke, acute myocardial infarction, and other complications. These complications affect more than 50,000 women in the United States every year, with rates significantly increasing from 1998 to 2011. In an effort to reduce these increasing complication rates, clinicians and researchers have emphasized the need to identify potential modifiable risk factors for severe maternal morbidity, and the need to study the relationships between these risk factors and severe maternal morbidity. The overall goal of this study is to improve the understanding of the increasing rates of severe maternal morbidity. The objective of the first study is to examine the association between prepregnancy BMI and severe maternal morbidity in women residing in Florida who had a live birth during 2007-2014. Additionally, the specific association between prepregnancy BMI and the most common individual conditions that comprise the composite measure of severe maternal morbidity will also be examined. We conducted a population-based retrospective cohort study using Florida’s linked birth certificate and maternal hospital discharge data for the years 2007-2014. The risk of severe maternal morbidity associated with BMI was then estimated by odds ratios (OR) and 95% confidence intervals (CI) derived using generalized estimating equations (GEE) for logistic regression. This final model was rerun separately for the most common conditions that comprise severe maternal morbidity as the outcome measure to assess differences by type of condition. Unadjusted rates of severe maternal morbidity increased with increasing BMI; however, after risk adjustment overweight and obese women had slightly protective odds of severe maternal morbidity when compared with normal weight women. The association between prepregnancy BMI and severe maternal morbidity differs by types of severe maternal morbidity. A protective dose-response relationship was seen for blood transfusion and disseminated intravascular coagulation, with the odds of morbidity decreasing with increasing BMI. The odds of heart failure, adult respiratory distress syndrome, and ventilation all increased with increasing BMI. This study shows that severe maternal morbidity is a complex measure and not just a single condition. In future studies, it will be imperative to analyze severe maternal morbidity as a composite measure and as individual conditions to identify modifiable risk factors to focus on for interventions. The objective of the second study is to identify potential determinants of the increase in the rate of severe maternal morbidity among women residing in Florida who had a live birth during 2005-2014. We examined severe maternal morbidity rates and related risk factors in live births to Florida women between 2005 and 2014, using Florida’s linked birth certificate and hospital discharge data. We initially conducted a Kitagawa analysis to evaluate the components of the increased rate of severe maternal morbidity between 2005 and 2014. Additionally, we performed a multivariable regression analysis to estimate the contribution of the multiple factors to differences in the rate of severe maternal morbidity in 2005 and 2014. The rate of severe maternal morbidity in 2014 was 19.3 per 1,000 live births, which was 1.65 times higher than the rate in 2005. Nearly all of the excess severe maternal morbidity and blood transfusions in 2014 can be explained by differences in the rate of severe maternal morbidity and blood transfusion between the two time periods. In total, sociodemographic factors, medical factors, and individual and hospital health service factors explained 9.1% of the overall severe maternal morbidity increase in 2014 compared with 2005, and only explained 2.5% of the increase in blood transfusions during this time period. Our study findings indicate that the increase in the rate of severe maternal morbidity is comprised almost entirely by an increase in the rate of blood transfusions. Further research will need to be conducted to explain the increase in the rate of severe maternal morbidity and blood transfusions. Consistent with national trends, the rates of severe maternal morbidity have been increasing in Florida. This increase is driven almost entirely by blood transfusions and cannot be explained by traditional factors that are readily available in current datasets. In addition to the differences between the trends of blood transfusions and the 20 severe maternal morbidity conditions, there are also differences in risk factors associated with these different conditions. Prepregnancy overweight and obesity is associated with a protective effect with blood transfusions and disseminated intravascular coagulation that is not seen in the other conditions. Therefore, initiatives to decrease the rates of severe maternal morbidity will need to take these differences into account.

This study examines the psychological issues of personal responsibility and control in the childbirth process. It examines the implications of the woman's preparation process and the choices she makes during pregnancy and childbirth. It also explores the way in which the birthing environment and the woman's interpersonal relationships affect her experience of personal control within the context of the childbirth period. Use was made of the case study research design. This qualitative design involved indepth exploration, of cases in which the women had recently given birth to their first child in the local hospital of a small town. The data analysis involved the use of a "reading guide", established by the researcher to allow for the examination of the data specifically in terms of the themes in question. Within the study the importance and value of the woman's accurate and sufficient preparation for the birth was seen to facilitate a realistic sense of predictability, which led to an increased awareness and ability of the woman to remain in control. This, along with the active participation of the husband and supportive network in the hospital, allowed for a sharing of the responsibility within the labour situation. This taking and appropriately yielding of control and responsibility had positive effects on the woman's experience of the event and for initial mother-infant bonding

During pregnancy, increased uterine blood-flow and efficient placental perfusion is essential for a successful outcome. Despite the essential role of these vascular beds, data on the physiological mechanisms involved in the maintenance of a high-flow/low resistance circulation within the uterus and placenta are limited. The need to fully understand the regulation of blood-flow within the uterine and feto-placental circulations is further highlighted by pathological pregnancies which are characterised by vascular dysfunction within these circulations. Oestrogen and insulin-like growth factor-I (IGF-I) levels increase during pregnancy and correlate with increased uterine blood flow. In vivo and in vitro studies of other vascular beds show that both 17-β oestradiol and IGF-I act as vasodilators. However, surprisingly little is known of their vaso-active effects on human uterine and placental arteries. The aims of the studies described within this thesis, were to investigate, ex vivo, the possible roles of oestrogen and IGF-I in regulating human placental and uterine vascular beds in vivo. Placental chorionic plate arteries and myometrial demonstrated acute vasodilation in response to oestrogen. Vascular bed differences in ER-responsiveness were observed; vasodilation within myometrial arteries was elicited by both oestrogen receptors, ERα and ERβ, although activation of the latter receptor generated a greater response. In contrast, oestrogen-dependent acute vasodilation of placental arteries was via ERβ alone. Furthermore, species differences, between human and rat arteries, were demonstrated in terms of ER-responsiveness. The predominant ER receptor within human arteries studied was ERβ, whilst rat arteries demonstrated a predominantly ERα-mediated mechanism of oestrogen-induced vasodilation. The data presented suggests that within the uterine vascular bed, oestrogen-induced vasodilation involves both an endothelium-dependent and –independent mechanism of action, whilst within the placenta, oestrogen-mediated vasodilation is endothelial-independent. Indeed, data suggests that oestrogen influences the level of intracellular calcium of vascular smooth cells to induce vasodilation of placental arteries.IGF-I did not have a vaso-active effect on chorionic plate arteries isolated from the placenta. However, uterine myometrial arteries exhibited reduced vaso-reactivity in the presence of IGF-I, demonstrated by a depressed response to the vasoconstrictor, U46619. Collectively, these data contribute towards a further understanding of the regulatory mechanisms of the uterine circulation, by identifying oestrogen and IGF-I as possible regulators of the uterine vasculature during pregnancy. Additionally, oestrogen may also have a role in controlling the feto-placental circulation. In the future, targeting ERb may offer a therapeutic strategy for increasing uterine/placental perfusion in pregnancies complicated by vascular dysfunction.

It has been reported world wide that over the past fifty years production has dramatically increased in dairy cattle but at the same time fertility rates have steadily declined, particularly in mature cows. Fertility of heifers that were bred for the first time has not been affected. One of the major reasons for such fertility decline in mature cows could be impaired progesterone production. Therefore relationships of parity with reproductive performance, its effect on progesterone concentrations and genes associated with progesterone synthesis were examined in this thesis. In the first experiment, breeding records of 163 Holstein heifers and cows in 1st, 2nd, and 3rd/4th parities were used to compare pregnancy rates among heifers and parity cows and between parity cows. Progesterone levels of heifers, 1st, 2nd, and 3rd/4th parity (10 animals each group) were measured from milk and blood samples. First and second inseminations pregnancy rates were higher in heifers compared to other parity cows. Furthermore 1st parity cows showed higher pregnancy rates than 2nd and 3rd/4th parity cows. However, P₄ levels were not significantly different among animals of different parity. In the second experiment, expression levels of steroidogenic genes – StAR, P450scc, 3-β HSD; apoptotic genes Bax and Bcl-2; and HSP70 in corpus luteum obtained from six heifers and three 2nd/3rd parity lactating cows were compared using RT-PCR. Relative optical density with house keeping gene was obtained for each gene. Analysis of variance revealed that expression levels of steroidogenic and Bax genes are higher (p<0.05) in cows than heifers. HSP70 gene and Bcl-2 gene expressions were not different (P>0.05) between the two groups. This study confirmed a clear relationship between parity and reproductive performance. There was no significance relationship between parity and circulating progesterone levels. Steroidogenic genes expression was higher in lactating cows than heifers and no differences were seen in mRNA levels of Bcl2, and HSP70 genes between heifers and mature cows. Bax mRNA expression was higher in mature cows suggesting that the lifespan of corpus luteum may be compromised in 2nd and 3rd parity cows, resulting in early embryonic mortality and reduced pregnancy rates. / Land and Food Systems, Faculty of / Graduate

No description available.

Maternal tolerance during pregnancy increases the risk of infection with certain intracellular pathogens such as Salmonella enterica serovar Typhimurium (S.Tm). Systemic S.Tm infection during pregnancy in normally resistant 129X1/SvJ mice, with a functional natural resistance-associated macrophage protein-1 (Nramp1), leads to severe placental infection followed by fetal and maternal death. We hypothesized infection-induced inflammatory trophoblast cell death contributes to adverse pregnancy outcomes. We therefore investigated the kinetics of systemic and oral S.Tm infection in wild-type and gene deficient mice with defects in specific inflammatory pathways. Systemic infection with S.Tm resulted in preferential placental replication compared to other tissues in Nramp1+/+ mice. At 24 hours, <25% of individual placentas per mouse were infected, progressively increasing to >75% by 72 hours which correlated with a steady increase in resorption rates. Moreover, placental infection was associated with increased neutrophils, macrophages and natural killer cells whereas neutrophil numbers in the spleen remained unchanged, suggesting dichotomous modulation of inflammation in the systemic compartment compared to the feto-maternal interface. Oral infection resulted in systemic dissemination of the bacteria, substantial placental colonization and fetal loss five days post-infection in C57BL/6J mice. Systemic infection in pregnant cell death deficient Rip3-/-Nramp1+/+ mice (with defective necroptosis) resulted in decreased fetal demise relative to Nramp1+/+ and Caspase-1,11-/-Nramp1+/+ mice (with defective pyroptosis) suggesting a role for necroptotic inflammation. This study provides insight into the kinetics and mechanism of inflammation and cell death during placental S.Tm infection. Such studies may assist in the rational management of foodborne pathogens contracted during pregnancy.

Introduction: Medication use by women of childbearing age is common. During pregnancy, medications should be used cautiously because some are teratogenic and/or feto-toxic, especially during the first trimester. Few studies have assessed exposure to contraindicated medications in developing countries. Aims and objectives: The overall aim was to assess the risk of exposure to contra-indicated medicines in early pregnancy (less than 13 weeks gestation) in Malawi. Specific objectives were to (i) determine the proportion of women inadvertently prescribed contraindicated medicines in the first trimester of pregnancy in a general outpatient clinic; (ii) explore women's beliefs, views and practices concerning medication use during pregnancy; (iii) determine the prevalence of congenital abnormalities by review of records at community and central hospital sites; (iv) to make appropriate recommendations for policy and practice in Malawi relating to medication use in pregnancy. Methods: A mixed methods approach was used. Survey data were collected at an outpatient clinic at Mitundu Community Hospital (MCH) between 1st February 2010 and 30th July 2010 to determine the range of medicines taken by potentially pregnant women. A pregnancy test established the pregnancy rate in this group. These data were summarised using descriptive and inferential statistics, and the proportions of exposed women who were pregnant were estimated. To understand women's beliefs, views and practices, semi-structured interviews were held with 21 pregnant women at their first visit to an antenatal clinic at MCH. The main themes were identified by Framework analysis. Retrospective data were abstracted from birth registers at MCH and Kamuzu Central Hospital (KCH) to estimate the prevalence of congenital abnormalities. Results: Of 1103 women prescribed contraindicated medicines in the outpatient clinic, 272 were potentially pregnant. Of the 63 (23.2%) confirmed pregnant (95% CI 18.3%-28.6%), 20 knew or thought they were pregnant, 22 were not sure and 21 did not think they were pregnant. Only 153 (55.9%) were asked about pregnancy by a medical officer before prescription. 3.2% of all pregnant women (95% CI 2.5%-4.1%) attending the clinic were estimated to have been prescribed contraindicated medicines. Eight pregnant women also self-prescribed unsuitable modern medications. Women accepted as safe any medications prescribed in the clinic. They also accepted potions given by traditional birth attendants to counter witchcraft, which they believed caused pregnancy loss. They did not associate use of these medicines with congenital abnormalities, the prevalence of which (6.58/1000 births at MCH, 14.55/1000 births at KCH) was similar to international figures. Conclusion: The study highlights areas of concern for practice, policy and research relevant to maternal health care in Malawi. Clinicians need to reduce the rate of exposure to potentially harmful medicines by paying attention to the possibility of pregnancy in women of childbearing age. There is also a need to facilitate public awareness especially among women about dangers of taking medicines.

Midwives recommend antenatal HIV testing in pregnancy for all women. However,limited information is available on the experience of testing HIV positive in pregnancy.This thesis explored women’s experiences of receiving a positive HIV test resultfollowing antenatal screening in United Kingdom (UK). Black Africa women have highlevels of HIV infection in the UK and notably all participants were African in origin.The theoretical basis for the study was hermeneutic phenomenology, proposed byHeidegger (1962) and further guided by van Manen (1990), exploring essence andmeaning of this lived experience. Thirteen women were recruited and participated in asemi-structured interview. Participants were recruited from two NHS sites, several HIVsupport organisations and a national advert, in order to obtain diversity of this livedexperience.The emergent phenomenon is transition and transformation of “being,” as womenintegrated HIV into their lives. As women transformed with the HIV diagnosis theybalanced major themes. The major themes consisted of shock and disbelief; anger andturmoil; loss of old self; stigma and confidentiality issues and acceptance and resilience.Primary and secondary themes included: extreme reaction on being given a diagnosiswith a cultural belief that they would die; disbelief as the result was unexpected;sadness and loss of their old self; turmoil wanting to terminate the pregnancy; isolationfrom significant others; breakdown of their relationship and considering suicide and selfharm. Most reported the pervasiveness of stigma, and how they managed both thisstigma and HIV in their lives; growing resilience was apparent with time. Copingstrategies included keeping HIV “secret” and their child or children becoming the primefocus of life, with less importance on self.This study gives midwives a unique understanding of the complexities for womentesting HIV positive and supports Bonanno (2009) and Kübler Ross’ (1969 & 2005)findings on personal loss. Additionally this study provides a unique insight into thephenomenon of transition and transformation for women who tested positive inpregnancy and explores the factors and impact of testing HIV positive. The impact of anHIV diagnosis is culturally difficult for African women and had major implications andchallenges for their future life. Midwives are crucial in supporting and improving theexperience of women when they test HIV positive.

This thesis examines the post childbirth employment behaviour of women in England and Wales who are self-employed during pregnancy. It presents a secondary analysis of nationally representative data for England and Wales via the 2001 Individual Sample of Anonymised Records and the Millennium Cohort Study (2001-2005).A multinomial regression analysis of Census data is used to assess self-employed labour supply for women of childbearing age. In addition to this a combination of descriptive statistics and logistic regressions are used to examine the post-childbirth employment trajectories and outcomes of women who worked as self-employed during pregnancy.The majority (eighty percent) of women who are self-employed during pregnancy go on leave from their job rather than finish work, and only seventeen percent of these women are absent from self-employment at nine months postpartum. A comparable percentage of employees make the same transitions back to work but the self-employed women return quicker, with twenty-five percent returning in less than one month. The factors associated with a continuation in employment can vary between the two types of work. Whilst educational qualifications are positively associated with continuing to work as an employee, this does not apply to those who are self-employed. Evidence suggests that maternity pay influences whether women continue in self-employment and the number of women who do not receive Statutory Maternity Pay or Maternity Allowance is a cause for concern. The thesis also considers such women’s preferred working hours, time with children, working schedules and autonomy as indicators of the mothers’ work-family balance. The data suggests that in England and Wales (2001-02) the women who returned to self-employment within nine months of birth did not have an increased work-family balance when compared to their employee counterparts. On the basis of the findings, I discuss the possibility that self-employed women may benefit from financial assistance beyond what is currently offered.

The purpose of this study was to examine the effect of a breastfeeding education program on breastfeeding initiation rates, breastfeeding knowledge, and attitude towards breastfeeding among teenage mothers at an urban school for pregnant and parenting teens. Breastfeeding initiation rose from 35.7% in the control group to 85.2% in the treatment group. The mean score on the Breastfeeding Knowledge Subscale was significantly higher for the treatment group but not the control group. There was not a significant increase in mean scores on the Breastfeeding Attitude Subscale. Participants who initiated breastfeeding scored also had a significant increase in scores from pretest to posttest on the Breastfeeding Knowledge Subscale, while participants who did not initiate breastfeeding did not.