Improving the quality and safety of maternity services is an international top agenda item. This thesis describes the progress towards the development of a multidimensional approach to measure the quality and safety of care in ten maternity units in Oman based on three of the five dimensional Patient Safety Measurement and Monitoring Framework (PSMMF) which include measuring "past harm" and "anticipation and preparedness”. The three monitoring approaches used in this research are: (1) measuring the patient safety culture (2) measuring patient satisfaction (3) and monitoring caesarean section rates. The specific objectives of the research are to (1) measure patient safety culture level, (2) examine the association between nurse’s nationality and patient safety culture, (3) validate an Arabic language survey to measure maternal satisfaction about the childbearing experience, (4) measure patient satisfaction about the childbearing experience, and (5) to examine caesarean section rates across maternity units using statistical process control charts. This thesis started with four systematic reviews that focused on (1) the use of patient safety culture for monitoring maternity units (2) the available interventions to improve patient safety culture (3) Arabic surveys available for measuring maternal satisfaction and (4) the use of statistical process control charts for monitoring performance indicators. The overall conclusion from these reviews that these approaches are being increasingly used in maternity, found feasible and useful, and there are areas that need attention for future work. Five field studies were conducted to address the research aim and objectives. Patient safety culture was measured by a cross-sectional survey of all staff in the ten maternity units. It was found that safety culture in Oman is below the target level and that there is wide variation in the safety scores across hospitals and across different categories of staff. Non-Omani nurses have a more positive perception of patient safety culture than Omani nurses in all domains except in respect of stress recognition and this difference need further investigation and needs to be considered by designers of interventions to enhance patient safety culture. Using two existing validated English surveys, an Arabic survey was developed, validated, and used to measure maternal satisfaction with childbirth services. It was found that the new survey has good psychometric properties and that in all the ten hospitals, mothers were satisfied with the care provided during child delivery but satisfaction score varied across hospitals and groups of participants. Caesarean section rate in the last 17 years was examined using statistical process control charts to understand the variation across the ten hospitals. It was found that caesarean section rate is above the rate recommended by the World Health Organisation. Special cause variations were detected that warrant further investigation. In conclusion, the field studies demonstrated that it is feasible to use the three approaches to monitor quality and safety in maternity units. However, further work is required to use these data to enhance the quality and safety of care. Additionally, future work is needed to cover the other three dimensions of the PSMMF. / Ministry of Health in Oman,

Thesis (MSc)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: Background Caesarean section deliveries are the most common procedures performed by obstetricians in Zimbabwe. Surgical site infections (SSI) following caesarean section delivery result in increased hospital stay, treatment, cost, hospital readmission rates and related maternal morbidity and mortality. There is no national surveillance system for SSIs in Zimbabwe, however, information is available on number of cases of post-operative wound infection after caesarean section, but the denominator and definition used is not consistent. The objective of this study were develop and strengthen the surveillance system in Zimbabwe, to establish a clinical-based system in a setting with limited microbiological access, to measure post-operative SSI after caesarean section and to describe the associated risk factors and to determine whether feedback of SSI data has any effect on the surgical site infection incidence rate. Methodology This was a before and after study with two rolling cohort periods conducted at two Central hospitals in Harare, Zimbabwe. An Infection Prevention and Control (IPC) intervention was conducted in-between. During the pre-intervention period, baseline demographic and clinical data were collected using a structured questionnaire, and during the post-intervention period the impact of the interventions was measured. Convenience sampling was employed. Results A total of 290 women consented to participate in the study in the pre intervention period, 86.9% (n= 252) completed the 30-days post-operative follow-up and the incidence rate of SSI was 29.0% (n=73, 95% CI:23.4-35.0) Interventions developed included: training in Infection Prevention and Control for health workers; implementation of a protocol for cleaning surgical instruments; dissemination of information on post-operative wound management for the women. After implementation of the intervention, 314 women were recruited for the post-intervention, 92.3%(n= 290) completed the 30-day follow-up and there was a significant (p<0.001) reduction in the incidence rate of SSIs to 12.1 % (n=35, 95% CI: 8.3 -15.8) during this period. Development of SSI after caesarean section was found to be significantly associated with emergency surgery (p<0.001), surgical wound class IV (p=0.001) and shaving at home (p<0.001) at both pre- intervention and post-intervention periods. Stellenbosch University https://scholar.sun.ac.za iii Conclusion This study shows that caesarean section can be performed with low incidence of SSI if appropriate interventions such as training in IPC, adequate cleaning of equipment and education in wound-care for the mother are adhered to. It also demonstrated a simple surveillance data collection tool can be used on a wide scale in resource limited countries to assist policy makers with monitoring and evaluation of SSI rates as well as assessment of risk factors. / AFRIKAANSE OPSOMMING: Agtergrond Keisersnitte is die mees algemene prosedure wat uitgevoer word deur obstetriese dokters in Zimbabwe. Chirurgiese wond infeksies wat op keisersnitte volg lei tot verlengde hospitaal verblyf, behandeling, koste, heropname koerse en verwante moederlike morbiditeit en mortaliteit. Alhoewel daar geen nasionale waaktoesig sisteem vir chirurgiese wondinfeksies is nie, is informasie beskikbaar vir ‘n aantal gevalle wat post-operatiewe wondinfeksie na ‘n keisersnit onwikkel het, maar die noemer en definisie word inkonsekwent gebruik. Die doel van hierdie studie was om die waaktoesig sisteem in Zimbabwe te ontwikkel en te versterk, om ‘n klinies-gebasseerde sisteem te vestig in ‘n opset met beprekte mikrobiologiese toegang, om postoperatiewe chirurgiese wond infeksies na keisersnitte te meet en om die geassosieerde risikofaktore te beskryf en om vas te stel of terugvoering van chirurgiese wondinfeksie data enige effek op die infeksiekoerse na keisersnitverlossings gehad het. Metodologie Hierdie was ‘n voor-en-na studie met twee kohort periodes uitgevoer by twee sentrale hospitale in Harare, Zimbabwe. ‘n Infeksievoorkoming en –beheer intervensie was tussenin uitgevoer. Tydens die pre-intervensie periode was basislyn demografiese en kliniese data ingesamel deur middel van ‘n gestruktureerde vraeboog, en gedurende die post-intervensie fase was die impak van die intervensies gemeet. Gerieflikheidsteekproefneming was geimplementeer. Resultate ‘n Totaal van 290 vroue het toestemming verleen om aan die studie deel te neem in die pre-intervensie periode, waarvan 86.9% (n=252) die 30 day post-operatiewe opvolg voltooi het en die insidensiekoers van chirurgiese wondinfeksies was 29.0% (n=73, 95% CI:23.4-35.0) Intervensies wat onwikkel was het ingesluit: opleiding in Infeksie Voorkoming en -Beheer vir gesondheidswerkers; die implementering van ‘n protokol om chirurgiese instrumente skoon te maak; disseminering van informasie oor post-operatiewe wondhantering vir vroue. Na die implimentering van die intervensie was 314 vroue gewerf in die post-intervensie fase, waarvan 92.3% (n=290) die 30 dae opvolg voltooi het. Daar was ‘n beduidende (p<0.001) verlaging in die insidensiekoers van chirurgiese wondinfeksies na 12.1% (n=35, 95% CI: 8.3-15.8) gedurende hierdie periode. Stellenbosch University https://scholar.sun.ac.za v Daar was bevind dat chirurgiese wondinfeksies beduidend geassosieer was met noodchirurgie (p<0.001), chirurgiese wondklassifikasie IV (p=0.001) en skeer van hare by die huis (p<0.001) by beide die pre-intervensie en post-intervensie periodes. Gevolgtrekking Hierdie studie wys dat keisersnitte uitgevoer kan word met ‘n lae insidensie van chirurgiese wondinfeksies indien toepaslike intervensies, soos opleiding in infeksievoorkoming en beheer, voldoende skoonmaak van toerusting en opvoeding in wondsorg vir die moeders. Dit het ook aangedui dat ‘n eenvoudige data-insameling instrument op ‘n wye basis gebruik kan word in beperkte-hulpbron lande om beleidmakers te help met monitering en evaluering van chirurgiese wondinfeksie koerse, asook die assessering van risikofaktore.

A sharp increase in caesarean section (CS) rates at the Muhimbili National Referral Hospital (MNH) – a tertiary referral hospital in Tanzania – by 50% in 2000–2011, was associated with concomitant increase in maternal complications and deaths and inconsistent improvement in newborn outcomes. The aims of this thesis were to explore care providers’ in-depth perspective of the reasons for these high rates of CS, and to evaluate and improve standards of care for the most common indica-tions of CS, obstructed labour and fetal distress, which are also major causes of adverse maternal and neonatal outcomes. This thesis reports an investigation performed at MNH, Tanzania. For Paper I, qualitative methods were employed and demonstrated how care providers dismissed their responsibility for the rising CS rate; and, instead, projected the causes onto factors beyond their control. Additionally, dysfunctinal teamwork, transparency, and previous poorly conducted clinical audits led to fear of blame among care providers in cases of poor outcome that subsequently encougared defensive practise by assigning unnecessary CS. Papers II and III evaluated stand-ards of care using a criteria-based audit (CBA) of obstructed labour and fetal dis-tress. After implementing audit-feedback recommendations, the standards of diag-nosis of fetal distress improved by 16% and obstructed labour by 7%. Similarly, the standards of management preceding CS improved tenfold for fetal distress and doubled for obstructed labour. The impact of the CBA process was evaluated by comparing the maternal and perinatal outcomes categorized into Robson groups (Paper IV) of all deliveries occurring before and after the audit process (n=27,960). After the CBA process, there was a 50% risk reduction of severe perinatal morbidi-ty/mortality for patients with obstructed labour. The overall CS rates increased by 10%, and this was attributed to an increase in the CS rate among breech, term preg-nancies (Robson group 6), and preterm pregnancies (Robson group 10) that specifi-cally had reduced risk of poor perinatal outcome. The overall neonatal distress rates were also reduced by 20%, and this was attributed to a decrease in the neonatal distress rate among low-risk, term pregnancies (Robson group 3). Importantly, the increased rates of poor perinatal outcomes were associated with referred patients that had higher risk of neonatal distress and PMR than non–referred patients, after CBA process.  In conclusion, the studies managed to educate the care providers to take on their roles as decision-makers and medical experts to minimize unnecessary CS, using the available resources. Care providers’ commitment to achieve the best practice should be sustained and effort for stepwise upgrading quality of obstetric care should be supported by the hospital management from the primary to tertiary referral level.

Sammanfattning I Sverige är förekomsten av förlossningsrädsla sedan tidigare uppskattad till 20 % (Eriksson &amp; Nilsson, 2009). Denna relativt höga andel förlossningsrädda kvinnor gör det angeläget att som barnmorska kunna identifiera de riskfaktorer som gör att kvinnor som löper risk att utveckla eller redan lider av förlossningsrädsla. Syfte: Det övergripande syftet var att undersöka prevalens av förlossningsrädsla i sen graviditet och under förlossningen, mätt ett år efter förlossning. Syftet var också att undersöka om det finns skillnader gällande graden av förlossningsrädsla före och efter förlossning mellan olika grupper av kvinnor. Metod: En longitudinell kohortstudie utförd i form av en enkätstudie, uppdelad i tre enkäter. Det var 153 mödravårdsmottagningar i Sverige som inkluderades i studien. Antalet studiedeltagare vid första enkäten var 3284 och i den tredje 1360 studiedeltagare. Resultat: I sen graviditet var prevalensen förlossningsrädsla 26,4 %. Ett år efter förlossningen var det en snarlik prevalens, 28,4%, det vill säga ingen skillnad. De kvinnor som genomgått akut kejsarsnitt eller en instrumentell förlossning hade en ökad förlossningsrädsla uppmätt ett år efter förlossningen (M=7,35) jämfört med innan förlossningen (M=5,53). Slutsats: Då resultatet visar att kvinnor som genomgått ett akut kejsarsnitt eller en instrumentell förlossning har en signifikant ökad grad av oro och rädsla uppmätt ett år efter förlossningen, är det av stort värde att följa upp dessa kvinnor, att erbjuda dem stöd i tid inför nästkommande graviditet och förlossning. Det kan vara för sent att sätta in insatser när kvinnan redan är gravid. Det är också av värde att i största möjliga mån sträva efter en vaginal förlossning med bra stöd, information, smärtlindring och förebyggande av komplikationer. / Abstract The prevalence of fear of birth in Sweden has been estimated at 20 % (Eriksson &amp; Nilsson, 2009). Because of this relatively high number of women with fear of birth it is crucial that midwives are able to identify the risk factors associated with developing fear of birth and identify women who experience fear of birth. Aim of study: The overall aim was to examine the prevalence of women experiencing fear of birth during late pregnancy and during birth, examined one year after giving birth. Moreover, the aim of the study was to investigate if there were differences in the level of fear of birth before and after giving birth between different groups of women. Method: A longitudinal cohort study was conducted by means of three self-report questionnaires. There were 153 Swedish prenatal clinics included in the study. The number of participants in the first questionnaire were 3284 and the in the third 1360 participants. Results: During late pregnancy the prevalence of fear of birth was 26.4%. One year after the delivery there was similar prevalence, 28.4%, namely no difference. The women whom have had an emergency caesarean section or an assisted delivery had higher degree of fear of birth one year after delivery (M=7,35) compared to before giving birth (M=5,53). Conclusion: The result of the study shows that women that had an emergency caesarian section or an assisted delivery experienced a significantly higher level of fear and concern measured one year after delivery, therefore it would be of great importance to conduct a follow-up with these women. It is also important to offer them early support before their next pregnancy and delivery. It could be too late to do this when the woman is already pregnant. It is also important, to the greatest extent possible, to aim for a vaginal delivery with the help of good support, information, pain management and prevention of complications.

Bakgrund: Antalet kejsarsnitt ökar såväl globalt som i Sverige. Kejsarsnitt är ett kirurgiskt ingrepp som innebär risker för såväl kvinna som barn. Trots risker önskar förstföderskor att genomgå ingreppet istället för en vaginal förlossning. Barnmorskors professionella stöd är av stor vikt för förstföderskors upplevelse inför, under samt efter sin förlossning. Studien utfördes för att förstå orsakerna till att förstföderskor önskar elektivt kejsarsnitt. Syfte: Var att fördjupa förståelsen kring förstföderskors önskan om elektivt kejsarsnitt. Metod: Kvalitativ innehållsanalys med en induktiv ansats. Datainsamlingen resulterade i 14 bloggar från sökmotorn Google.se som analyserades. Resultat: Analysen resulterade i tre teman: Sökandet efter trygghet inför sin förlossning, Tankar på en vaginal förlossning väcker varierande känslor och Val av förlossningsmetod - en rättighet samt sju subteman. Mest framträdande var känsla av brist på kontroll och otrygghet inför en vaginal förlossning. Möjligheten att få välja förlossningsmetod ansågs vara en mänsklig rättighet. Konklusion: Förstföderskor som önskar elektivt kejsarsnitt sökte trygghet inför sin förlossning. Elektivt kejsarsnitt ingav trygghet då det uppfattades som en mer kontrollerad och säker förlossningsmetod både för kvinnan och barnet. Föreställningen av att genomgå en vaginal förlossning skapade rädsla och obehag. / Background: The number of caesarean sections increases both globally and in Sweden. Although caesarean section is a surgical procedure that involves risks for both women and child, first-time mothers wish to undergo the procedure instead of a vaginal delivery. The midwife's professional support is important for first-time mothers before, during and after childbirth. This study was conducted to understand the reasons why first-time mothers want elective caesarean section. Aim: To deepen the understanding of first-time mothers wish for elective caesarean section. Method: A qualitative content analysis with an inductive approach was used. Google.se was used for data collection, the collection resulted in 14 blogs. Result: The analysis resulted in three themes: The wish for security during childbirth, Thoughts on a vaginal delivery raises a variety of emotions and Choice of birthing method - a right and seven sub-themes. Most prominent was the feeling of lack of control and insecurity for a vaginal delivery. Choice of birthing method was considered a human right. Conclusion: First-time mothers strive for security during childbirth. Elective caesarean section was described as a safe and controlled birthing method. Thoughts on a vaginal delivery raises fear and discomfort for first-time mothers.

The aim of the thesis is to analyze the economic profitability of current obstetric facilities in the Czech Republic. The theoretical part deals with economic aspects of health such as health determinants and their effect on human health, the specific of health care and role of the state in health care. Further work is focused on exploring different types of health systems, the principles of financing Czech healthcare system and its development in recent years. Despite the increasing role of direct financing of health care and higher patient participation, the public sector still plays the most important role, which follows from the Charter of Fundamental Rights and Freedoms. Based on available data on infant mortality the efficiency of functioning of the Czech and American health care system will be compared. Infant mortality in the Czech Republic is very low and our country in this regard is placed on the top places in the world. The practical part deals with analysis of the costs of planned caesarean section, including the total time a mother spends in hospital. Furthermore, the practical part deals with the future of obstetrics in the Czech Republic in terms of plans for the closing of small hospitals with low numbers of births and infant homes replacing foster care. The final part deals with births at home as a substitute for births in hospitals. This topic is now getting into media interest when it is discussed to ensure adequate care in childbirth and health risks for mother and newborn.

Pregnancy and childbirth are important life experiences in a woman’s psychosocial and psychological development. For many women, vaginal birth is still considered an integral part of being a woman and becoming a mother. Furthermore, it is thought to promote maternal well-being through helping women to match their expectations to experiences. For these women, a failed natural birth can be a psychological, psychosocial, and existential challenge that can result in significant and far-reaching consequences for their psychological wellbeing. Research, especially recent research, on the experiences of women who most wanted to, but were unable to deliver their babies naturally is relatively rare. This is surprising given the potential implications of these experiences on a mother’s emotional well-being, as well as for her feelings towards her new baby. Nevertheless, literature on the topic presents a coherent perspective on the problem and indicates that these women experience difficulties in adapting to not being able to fulfill their dream of delivering their baby naturally. There is no existing research on the subjective experiences of South African women who delivered their babies by unplanned Caesarean section. This study therefore aimed to contribute to knowledge that may fill this gap to some extent. Through purposeful sampling, ten mothers who had wanted to deliver their babies naturally, but had not been able to for whatever reason, were selected as the study sample. Various aspects of their birth experiences were explored in indepth phenomenological interviews. This allowed the researcher to probe certain aspects offered by participants in order to understand and explore their contributions in as much depth as possible. A semi-structured, open-ended approach allowed for the exploration of relevant opinions, perceptions, feelings, and comments in relation to the women’s unplanned Caesarean experiences. The transcribed data was synthesized within a framework of phenomenological theory, where women’s experiences were analyzed and explored in an attempt to understand how participants made sense of their experiences. The different aspects of women’s experiences were explored in three substudies. The results are reported in three manuscripts/articles. Research suggests that post-partum adjustment difficulties are influenced by the potentially virulent stress reactions generated in response to a perceived birth trauma. The objective of the first article was to explore women’s labour and birthing accounts with specific regard to the subsequent stress responses experienced. The stress responses experienced by the women in this study both prior to, and during the Caesarean section were predominantly anxiety-based. This was distinguished from the post-partum period, where women described having experienced more depressive symptoms. Post-traumatic stress responses are associated with negative perceptions of the birth, self and infant. The experience of adverse emotional consequences during the post-partum period can undermine a woman’s ability to successfully adapt to her role as a mother, meet the needs of her infant, and cope with post-partum challenges. The second article highlighted the possible impact of women’s unexpected and potentially traumatic childbirth experiences on initial mother-infant bonding. The unplanned Caesarean sections left mothers feeling detached from the birthing process and disconnected from their infants. Passivity, initial separation, and delayed physical contact further compromised mother-infant interaction. Postpartum physical complications and emotional disturbances have important implications for a woman’s perceptions of herself as a mother and her ability to provide for her infant, her self-esteem, and feelings of relatedness with her baby. Adverse responses to a traumatic birth experience could therefore influence the establishment of a maternal role identity, the formation of balanced maternal attachment representations, the caregiving system, and ultimately initial motherinfant bonding. In the third article, women’s experiences were contextualized in relevant coping resources and strategies. The processes occurring during a traumatic birth experience, such as during an unplanned Caesarean section, could be influenced by perceived strengths when coping with the stress related to the incident. The mothers in this study described several factors and coping strategies that they perceived to have been effective in reducing the impact of their traumatic birth experiences. These included active coping strategies, problem-focused coping strategies, and emotion-focused coping strategies. Coping strategies could result in reassessment of the birth process, and be associated with a more positive, acceptable and memorable experience. This study contributes to nursing, midwifery and psychological literature, by adding to the professional understanding of the emotional consequences of surgical delivery on South African childbearing women. This exploration therefore has important implications for preventative measures, therapeutic intervention, and professional guidance. However, the restricted sample may limit the generalizability of results. Further investigation of the experiences of a larger, more biographically and culturally diverse population could be instrumental in the development of knowledge and understanding in this field of study. / Thesis (PhD (Psychology))--North-West University, Potchefstroom Campus, 2013

Pregnancy and childbirth are important life experiences in a woman’s psychosocial and psychological development. For many women, vaginal birth is still considered an integral part of being a woman and becoming a mother. Furthermore, it is thought to promote maternal well-being through helping women to match their expectations to experiences. For these women, a failed natural birth can be a psychological, psychosocial, and existential challenge that can result in significant and far-reaching consequences for their psychological wellbeing. Research, especially recent research, on the experiences of women who most wanted to, but were unable to deliver their babies naturally is relatively rare. This is surprising given the potential implications of these experiences on a mother’s emotional well-being, as well as for her feelings towards her new baby. Nevertheless, literature on the topic presents a coherent perspective on the problem and indicates that these women experience difficulties in adapting to not being able to fulfill their dream of delivering their baby naturally. There is no existing research on the subjective experiences of South African women who delivered their babies by unplanned Caesarean section. This study therefore aimed to contribute to knowledge that may fill this gap to some extent. Through purposeful sampling, ten mothers who had wanted to deliver their babies naturally, but had not been able to for whatever reason, were selected as the study sample. Various aspects of their birth experiences were explored in indepth phenomenological interviews. This allowed the researcher to probe certain aspects offered by participants in order to understand and explore their contributions in as much depth as possible. A semi-structured, open-ended approach allowed for the exploration of relevant opinions, perceptions, feelings, and comments in relation to the women’s unplanned Caesarean experiences. The transcribed data was synthesized within a framework of phenomenological theory, where women’s experiences were analyzed and explored in an attempt to understand how participants made sense of their experiences. The different aspects of women’s experiences were explored in three substudies. The results are reported in three manuscripts/articles. Research suggests that post-partum adjustment difficulties are influenced by the potentially virulent stress reactions generated in response to a perceived birth trauma. The objective of the first article was to explore women’s labour and birthing accounts with specific regard to the subsequent stress responses experienced. The stress responses experienced by the women in this study both prior to, and during the Caesarean section were predominantly anxiety-based. This was distinguished from the post-partum period, where women described having experienced more depressive symptoms. Post-traumatic stress responses are associated with negative perceptions of the birth, self and infant. The experience of adverse emotional consequences during the post-partum period can undermine a woman’s ability to successfully adapt to her role as a mother, meet the needs of her infant, and cope with post-partum challenges. The second article highlighted the possible impact of women’s unexpected and potentially traumatic childbirth experiences on initial mother-infant bonding. The unplanned Caesarean sections left mothers feeling detached from the birthing process and disconnected from their infants. Passivity, initial separation, and delayed physical contact further compromised mother-infant interaction. Postpartum physical complications and emotional disturbances have important implications for a woman’s perceptions of herself as a mother and her ability to provide for her infant, her self-esteem, and feelings of relatedness with her baby. Adverse responses to a traumatic birth experience could therefore influence the establishment of a maternal role identity, the formation of balanced maternal attachment representations, the caregiving system, and ultimately initial motherinfant bonding. In the third article, women’s experiences were contextualized in relevant coping resources and strategies. The processes occurring during a traumatic birth experience, such as during an unplanned Caesarean section, could be influenced by perceived strengths when coping with the stress related to the incident. The mothers in this study described several factors and coping strategies that they perceived to have been effective in reducing the impact of their traumatic birth experiences. These included active coping strategies, problem-focused coping strategies, and emotion-focused coping strategies. Coping strategies could result in reassessment of the birth process, and be associated with a more positive, acceptable and memorable experience. This study contributes to nursing, midwifery and psychological literature, by adding to the professional understanding of the emotional consequences of surgical delivery on South African childbearing women. This exploration therefore has important implications for preventative measures, therapeutic intervention, and professional guidance. However, the restricted sample may limit the generalizability of results. Further investigation of the experiences of a larger, more biographically and culturally diverse population could be instrumental in the development of knowledge and understanding in this field of study. / Thesis (PhD (Psychology))--North-West University, Potchefstroom Campus, 2013

Background. Pregnant women need adequate antenatal care (ANC) and delivery care fortheir own health and for healthy children. Availability of such care has increased in Vietnam but maternal mortality remains high and variable between population groups. Aims. The general aim of this thesis is to describe and discuss the use of antenatal and delivery care in relation to demographic and socio-economic status and other factors in two health and demographic surveillance sites (HDSS), one rural and one urban. One specificaim of the thesis is to present experiences of running the urban HDSS. Methods. Between April 2008 and December 2009, 2,757 pregnant women were identifiedin the sites. Basic information was obtained from 2,515 of these. The use of ANC was followed to delivery for 2,132. Three indicators were used. ANC was considered overall adequate if the women started ANC within the first trimester, used three or more visits and received all the six recommended core services at least once during pregnancy. Delivery care was studied for all the 2,515 women. Main Findings. Nearly all 2,132 participants used ANC. The mean numbers of visits were 4.4 and 7.7 in the rural and urban areas. Mainly due to less than recommended use of core ANC services, overall ANC adequacy was low in some groups, particularly in the rural area (15.2%). The main risk factors for not having adequate ANC were (i) living in a rural area,(ii) low level of education, (iii) low economic status and (iv) exclusive use of private ANC providers. Rural women accessed ANC mainly at commune health centers and private clinics. Urban women accessed ANC and gave birth at central hospitals and provincial hospitals. Caesarean section (CS) was common among urban women (38.5%). Good socioeconomic condition and male babies were associated with delivery in hospitals and CS births. Almost all women had one or more antenatal ultrasound examination, the mean was about 4.5. Rural women spent 3.0% and 19.0% of the reported annual household income percapita for ANC and delivery care, respectively, compared to 6.1% and 20.6% for urbanwomen. The relative economic burden was heaviest for poor rural women. Conclusion. The coverage of ANC was high in both contexts but with large variations between population subgroups. The major concerns are that poor women in the rural area received incomplete services according to recommendations and that many women, particularly the well-off, in the urban area appeared to overuse technology, ultrasound scanning, delivery in highlevel health care and CS delivery. National maternal healthcare programs should focus on improving ANC service content in rural areas and controlling technology preference in urban. The pregnant women with relatives and friends as well as ANC providers share the responsibility for a positive development. All parties involved must be targeted to improve knowledge, attitudes and practices.

Målsetning:De sentrale problemstillingene oppsummeres gjennom følgende spørsmål: hvor mange andregangsfødende med keisersnittønske endret seg til å ønske vaginal fødsel ved tilbud om aten jordmor de blir kjent meder med på fødselen?Hvordan gikk fødselen i kjent jordmorgruppen?Hvordan var forekomsten av fødselskomplikasjoner ved første fødsel i hele gruppen sammenlignet med normalbefolkningen?Var det forskjeller mellom kjent jordmorgruppen og gruppen som holdt fast ved keisersnittønsketm.h.t. komplikasjoner ved første fødsel, mors alder, diagnoser hos mor eller barn og antall ultralydundersøkelser? Metode:En kvantitativ studie som ved gjennomgang av pasientjournaler fra 2006-2010 på Rikshospitalet fantalle andregangsfødende med et barn i hodeleie som ønsket keisersnitt og fikk tilbud om kjent jordmor. Statistikk fra Medisinsk fødselsregister, fra fødeavdelingens databaserog data fra journaler ble benyttetfor å undersøke forekomsten av fødselskomplikasjoner. Hovedresultat: 129 andregangsfødende med keisersnittønske fikk tilbud om kjent jordmor, 48 ble med i kjent jordmor gruppen og planla vaginal fødsel. Av disse fødte 81,2% vaginalt. De 129 kvinnene hadde opplevd signifikant mer komplikasjonerenn landsgjennomsnittet ved sin første fødsel. Iinnleding og diskusjon ble det lagt vekt på de helsemessige konsekvenser av den økende forekomsten av keisernitt, både planlagte og akutte. Kvinnene i keisersnittgruppen hadde fire ganger så ofte et helseproblem oppstått før svangerskap nummer to og de hadde signifikant oftere opplevd fødselsangst allerede i første svangerskap. Konklusjon: Den sterke økningen i keisersnitt over store deler av verden fører til at det skapes flere helseproblemer enn det løses. Populasjoners og individers helse blir negativt påvirket både mentalt og fysisk, på kort og lang sikt.Helsekonsekvensene diskuteresbåde på individ og gruppeplan i lys av begrepene health locus of control, sense of coherence, mestring, empowerment og folkehelse.Det er av avgjørende betydning å perfeksjonere fødselshjelpen ved vaginale fødsler og å forebygge negative fødselsopplevelser. Tiltak som ”kjent jordmor” hjelper kvinner medkeisersnittønsketil å ville føde vaginalt er viktige bidrag i denne sammenhengen / Aim: This study primarily aimed to determine how many second-time mothers hoping for a caesarean section changed their mind and requested a vaginal delivery when they had the opportunity to know their midwife in advance. Second it wasdetermined which delivery method was experienced by mothers in the known midwife group. The study also compares the rate of delivery complications experienced during first-time delivery for the whole study population compared to the mean population of Norwegian first time mothers. Finally the differences between the women choosing “known midwife” and those who choose caesarean section are explored regarding delivery complications and experience during first pregnancy Method:This quantitative study was conducted at Rikshospitalet in Oslo. All second-time mothers wanting a cesarean delivery without medical indication in 2006 to 2010 and having been offered to participate in the in “the known midwife project” were identified. The study used data from the Norwegian medical birth registry, delivery ward databases, and the patients’ personal journals. Among129 second time mothers desiring a caesarean delivery, 48 joined the “known midwife team” and planned a vaginal birth;the remaining 81 women choseto have a planned caesarean section and were called the “caesarean section group”. In the “known midwife group” 81.2% had a vaginal delivery. The 129 women had experienced significantly more complications than the mean population of Norwegian first time mothers during their first delivery. The women in the “caesarean section group” were four times more likely to have a health problem compared to women in the “known midwife group”. They were also more likely to have experienced birth anxiety during their first pregnancy. Conclusion: The consequences of caesarean section were discussed using terms such as health locus of control, sense of coherence, coping, empowerment, and public health.The major increase in caesarean sections worldwide has resulted in more health problems than they solve. Caesarian section has a negative short-and long-term impact on both mental and physical health. Therefore, it is vitally important to optimize vaginal delivery and prevent bad delivery experiences. Projects such as “the known midwife” help women who are afraid of having a vaginal delivery. Such projects should be encouraged / <p>ISBN 978-91-86739-36-2</p>