Background: Medical tourism is arising in Asian countries and in Hong Kong, the maternal tourism is evolving due to the influx of non-entitled pregnant women from mainland China for deliveries. The visitors were attracted not only by the technical advancement of Hong Kong healthcare system, but its special administrative background which grants the babies with a permanent resident identity as well as the citizenship benefits regardless to their parental status. Besides, the parents could avoid penalties from the "One Child Policy" in China. With the limited healthcare resources, non-local mothers started to compete with the local mothers for obstetric services. The community raised their concerns in developing of maternity tourism and verbalised their demands in protecting local rights and equity to resources. Aims and Objectives: There are limited published researches available on maternal tourism or the specific situation faced by Hong Kong. By analysing grey literature, this paper would like to suggest the impact exerted on the healthcare system by the influx of non-eligible mothers with a medical tourism framework. Results: The impact of non-local-mother deliveries on healthcare system were discussed in the areas of governance, delivery, financing, human resources and regulation. Future research could be done on assessing the priorities in the framework components and the direction, effectiveness of the management strategies for non-entitled deliveries. / published_or_final_version / Public Health / Master / Master of Public Health

Haiti's political and economy history has led to a maternity care system that lies out of reach, geographically and financially, of most Haitians, resulting in excessively high maternal and infant mortality. The most common birth practitioners are homebirth midwives (matwòns), who attend roughly three-fourths of all births in Haiti (UNICEF), often without the benefit of emergency obstetric services. In this ethnographic study, I examine how matwòns experience caring for mothers and babies in extraordinarily low-resource and high-risk settings. This qualitative research employed a critical approach and feminist research methodologies. In in-depth interviews I asked participants to describe the challenges they find in their work. Then, in an innovative style of group meeting called Open Space, matwòns reflected on those challenges collectively, with an aim to ameliorate their current situations. Data analysis utilized a modified grounded theory approach, which allowed the matwòns' own narratives to determine the categories of analysis. Emergent themes resulting from this analysis revealed four main challenges in the work of matwòns, as well as matwòns' own strategies to mitigate those challenges. The four broad challenges, which include physical risks, social/spiritual threats, a lack of livelihood, and an obligation to practice, are experienced either as episodic hazards or chronic stressors. Matwòns' personal mitigation strategies centered on two broad approaches, providing protection, and offering service. However, the Open Space meeting created an opportunity for matwòns to strategize collective mitigation efforts through professional organization. Based on these findings, I argue that a more nuanced understanding of matwòns' experiences reveals their adaptive skills, which, in part, resemble Davis Floyd's (2007) notion of a postmodern midwife, and offers opportunities for mutual accommodation (Jordan 1997[1978]). Recommendations include support and advocacy for the self-organization of Haitian matwòns, as well as their greater inclusion in efforts to improve maternal and infant health outcomes in post-earthquake Haiti. / Graduation date: 2013

Mistreatment experienced by women delivering in healthcare institutions is a concerning pattern reproduced and normalized in health systems globally, causing widespread harm. Women’s reports and observations of childbirth practices in institutions have revealed that disturbing proportions of deliveries are characterized by indignity, humiliation, and neglect. The enormity of the problem constitutes a social catastrophe, as potentially hundreds of thousands are affected daily at a profoundly important moment of personal, family, and social life. Growing global concern has elicited research on mistreatment’s prevalence and characteristics, with limited attention to developing explanatory theory. The observed patterns indicate that mistreatment is systemic; therefore, social theory is required to understand why mistreatment persists, despite official norms that prohibit mistreatment and promulgate respectful care. Diane Vaughan’s normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. The theory posits that organizational structures and processes are distorted due to resource scarcity combined with production pressures resulting in normalized organizational deviance in daily micro-level transactions. Furthermore, regulatory systems are unable to capture and mitigate the problem. Vaughan’s multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance.To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case because it was the site of a seminal study to measure the prevalence of mistreatment, explore its causes, and develop and test interventions to reduce its occurrence. My participation in designing and conducting this study provided understanding of the phenomenon which formed the foundation of this dissertation. Novel theory was first elaborated through a systematic review of literature on maternal health care and the government health system in Tanzania. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan’s theory and additional organizational theories, resulting in a nascent theory. A qualitative theory-driven approach was then applied to verify and expand the nascent theory using qualitative exploratory data from the study in Tanzania described above. The data included eight focus group discussions and 37 in-depth interviews involving 91 individuals representing community and health system stakeholders. Data were analyzed deductively and inductively using the theory’s framework while allowing for emergent constructs. Analysis based on the literature review revealed that normalized scarcity at the macro-level combined with production pressures that emphasized biomedical care and imbalanced power-dependence on limited financial sources altered values, structures, and processes in the health system. Meso-level actors strove to achieve production goals with limited autonomy and insufficient resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. The nascent theory developed through literature review was largely supported by the qualitative data, while providing further nuance and elucidating new components. Moral distress, which occurs when one knows the right thing to do but is prevented from taking the right action due to institutional constraints, emerged as an important systems effect of organizational dysfunction. In addition, the qualitative data revealed that managers coped with dual roles as both managers and providers and that the service interaction includes families, not solely providers, women, and newborns. The challenges in the regulatory environment also were clarified, highlighting that monitoring and observing mistreatment was hindered due to structural secrecy and the nature of mistreatment. The nascent theory revealed the importance of emotional labor and emotion work in understanding mistreatment. Emotional labor has been widely acknowledged as an important aspect of healthcare provision, especially for a positive patient experience; yet there has been limited attention to emotion work as the underlying effort required to provide respectful maternity care and prevent mistreatment. Qualitative data from the exploratory formative research were further analyzed to explore the characteristics of emotion work. 22 interviews and 3 focus groups with 44 maternity providers from different levels of care provision in two districts were analyzed using thematic analysis combined with affinity diagramming. Six key themes were identified that provide a deeper understanding of the emotion work required of maternity providers, including 1) expected to love and care for patients; 2) controlling emotions; 3) managing patient expectations in the face of system shortages; 4) providers are human beings too; 5) nurses are perceived as harsh; and 6) limited system support for emotion work. The themes and corresponding sub-themes highlight that the nature of childbirth care, the context, and gender norms influence the ability to exert emotion work and thus provide respectful care. Emotion work was expected but good performance was unacknowledged by the system. Additional resources are required, not only to ensure the most basic of resources to provide quality of care, but to ensure sufficient organizational support to address the emotional demands of providers. Systems need to acknowledge the extra effort required for emotion work and support and train providers to provide this care, as well as help them to manage difficult emotions that they experience due to the nature of their work. Analogical comparison with another case of organizational deviance enabled a novel approach to elaborate theory. Normalization of organizational deviance proved useful for understanding mistreatment. This theory and others from organizational sociology that explore why things go wrong in organizations may be relevant for other areas of persistent systems failure and underperformance. Further theory testing in different contexts and types of health systems is needed to understand the generalizability of the nascent theory and advance its development. In addition, many of the constructs, such as emotional labor and moral distress, have not been widely applied in low- and middle-income settings and require deeper study. This theory reveals the systemic factors driving mistreatment and can guide the identification of system leverage points to transform health systems towards ensuring a respectful experience during childbirth for women and their newborns. Ensuring that adequate resources are provided to achieve targets is essential, but organizational support to address the emotional demands of providers must also be provided. These changes will ease the burden among providers and managers struggling to provide care in under-resourced health systems. The extra effort required for emotion work should be acknowledged and appropriate training provided, as well as support for providers to manage the difficult emotions that they experience due to the nature of their work. The findings may also have implications beyond childbirth, as the theory highlights the conditions that may lead to burnout and poor mental health among providers, an ongoing problem worldwide that was exacerbated by the COVID-19 pandemic.

The purpose of this study was to analyse and describe the factors that influence the choice of site of delivery by pregnant women in Mukono district. By employing quantitative, non experimental research methods, 431 women were interviewed by using structured questionnaires. These women had either delivered at; home, TBA, private or public clinic and 72% had been delivered by skilled attendants. Choice of delivery site was influenced by the attitudes of health workers which were rather poor in public sites, proximity of site, attendance of antenatal clinic at a site, availability of supplies and drugs, plus level of care including emergency obstetric care. / Health Studies / M. A. (Public Health)

Introduction: Evidences indicate that human immuno-deficiency virus (HIV) and diabetes (DM) impact pregnancy outcomes but no experience on the integrated service delivery of HIV, DM and pregnancy care. This study explored the domains and levels of integration among DM, HIV and pregnancy care to prepare a service delivery model in Ethiopia. Methods: A sequential exploratory mixed method and the integration theoretical framework guided the study. An exploratory qualitative phase used focused group discussion, in-depth interview and observation to explore the level of integration and to refine a questionnaire for the quantitative phase. The data were transcribed and coded for theme-based analysis. The descriptive quantitative phase described HIV, DM and pregnancy care services, and determined the burden of DM among HIV patients and the prevalence of pregnancy and pregnancy outcomes. Data was analysed using Epi-info. The findings were triangulated, discussed and interpreted. Results: Seven themes were generated: joint plan, shared budget, monitoring system, structural location, the need of policy guide, the practice of integrated service delivery and suggested integration approaches. A coordinated HIV and pregnancy care services were noted. There was a linkage between diabetes and HIV, and diabetes and pregnancy care. The 1.5% of diabetes among HIV, the low number of pregnancies per a mother in diabetes (1.8) and HIV (1.3); the high adverse pregnancy outcomes among HIV (13.4% abortion, 12.4% low birth weight (LBW), 3.5% pre-term birth, 2.1% congenital malformation) and diabetes (3.2% big baby, 3.2% LBW, 3.1% Cesarean-section); the respective absent and low (16.2%) diabetes screening service at anti-natal and HIV clinics, the absent pregnancy care service for diabetic females justified the development of the tripartite integrated service delivery model of diabetes, HIV and pregnancy care. Conclusions: The model suggests active diabetes screening, evaluation and treatment at HIV and antenatal clinics. It considers the coordination between non-communicable diseases (NCD), HIV and maternal health units. Pregnancy care could be coordinated at HIV and NCD units. Full integration can be practiced between HIV and pregnancy care units. Preparing policy guide, building the capacity of health providers, advocating and piloting the model may be prioritized before the implementation of the model. / Health Studies / D. Litt. et Phil. (Health Studies)

In Uganda, there are an estimated 200,000 women suffering from obstetric fistula, with 1,900 new cases expected annually. These figures, combined with a persistently high maternal mortality rate, have led to an international discourse that claims the solution to improving maternal health outcomes is facility-based delivery with a skilled birth attendant. In accord with this discourse, the Ugandan government criminalized traditional birth attendants in 2010. In this study, I examine the lived experience of traditional birth attendants and women who have suffered from an obstetric fistula in eastern Uganda. Using data collected from open-ended, semi-structured interviews, focus groups, and participant-observation, I describe the biocultural determinants of obstetric fistula. Based on findings, I argue that although emergency obstetric care is critical to prevent obstetric fistula in cases of obstructed labor, the criminalization of the locally constructed system of care, TBAs, serves as yet another layer of structural violence in the lives of rural, poor women. Results demonstrate how political-economic and cultural determinants of obstetric fistula are minimized in favor of a Western prescribed, bio-medical solution, which is heavily resource dependent. This solution is promoted through a political economy of hope fueled by the obstetric imaginary, or the enthusiastic belief in Western-style biomedical obstetric care’s ability to deliver positive health outcomes for women and infants regardless of local context and constraints. Recommendations include increased obstetric fistula treatment facilities with improved communication from medical staff, decriminalization of traditional birth attendants and renewed training programs, and engaging local populations in maternal health discourse to ensure culturally competent programs. / Graduation date: 2013

The purpose of this study was to analyse and describe the factors that influence the choice of site of delivery by pregnant women in Mukono district. By employing quantitative, non experimental research methods, 431 women were interviewed by using structured questionnaires. These women had either delivered at; home, TBA, private or public clinic and 72% had been delivered by skilled attendants. Choice of delivery site was influenced by the attitudes of health workers which were rather poor in public sites, proximity of site, attendance of antenatal clinic at a site, availability of supplies and drugs, plus level of care including emergency obstetric care. / Health Studies / M. A. (Public Health)