This study explored the differences between the organisation of maternity care in Britain and the Netherlands. The debates within each national system between proponents of high-technology obstetric hospitals and those of low-technology maternity care were analysed. This specific comparison was approached through a qualitative analysis and a quantitative content analysis. In the Netherlands I analysed the debate between home and hospital-birth supporters in a medical journal in 1986-1987 and in Scotland I analysed the replies to Grampian Health Board's proposals to close peripheral maternity units in 1987-1988. At a theoretical level the distinction is made between 'medical' and 'social' model of childbirth. Three levels of approaching the differences between these two models were unravelled in order to come to a better understanding of reality. One of the central points is question of risk in childbirth, which is the dividing factor between models of childbirth. The concepts of 'patriarchy' and 'medicalisation' are rejected as possible explanations for the differences between the Dutch and British organisation of maternity care. I explore the possibility of Jamous and Peloille's I/T ratio as an explanatory tool, and suggest a minor adaptation to this theory. Furthermore, in order to incorporate the state intervention in the interprofessional competition between midwives and doctors I suggest that Abbott's theory of 'systems of professions' could bring some light on the question. Finally, I suggest as a policy conclusion that a risk selection list similarly to the one in existence in the Netherlands should be drawn up in Britain. However, such a list should not be drawn up by obstetricans only or even a committee wherein obstetricians form a majority. I argue that a committee for the drawing up of national selection criteria should include representatives from midwives, health visitors and consumers.

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Introduction: Maternal and child care is one of the priority health issues that have been identified as requiring urgent attention in South Africa. Despite various efforts, South Africa has not seen improvements in maternal and perinatal outcomes. It is therefore essential that services and practices in hospitals rendering maternity care be reviewed and audited, so that current services can be improved and new services developed if necessary. In Schweizer-Reneke Hospital the clinical outcomes and clinical practices at the maternity unit have never been clearly described. The aim of the study was to describe the clinical outcomes and the associated clinical practices in the maternity unit of the hospital from 1 January 2009 to 31 December 2009. Methodology: The study setting was the maternity unit of Schweizer-Reneke District Hospital, a level 1 district hospital in a rural district of the North West Province. It comprised of a retrospective review of data from the District Health Information System and of the delivery records, specifically the partogram from 1 January 2009 to 31 December 2009. The study also examined records of Perinatal Problem Identification Programme and Mortality and Morbidity Review meetings. The study population included all the patients who delivered at the maternity unit during the study period. The measurement tools for data collection were data capture sheets on excel spreadsheets. The source of the data was the maternity register, maternity case records, Perinatal Problem Identification Programme records, District Health Information System and Unit Administration files (for records of meetings). The researcher personally captured the data. Results: Out of 699 deliveries conducted at the hospital 80.1% were normal deliveries, 16.3% caesarean sections and 3.6% vacuum-assisted deliveries. The record review revealed errors in the number of caesarean sections and vacuum-assisted deliveries on the DHIS. The perinatal mortality rate was calculated to be 56 per 1000 live births during the study period. Again the record review identified more perinatal deaths (41) than what was reported on the DHIS. No maternal deaths were recorded during the study period. A total of 295 records were analysed for completeness of the partogram. Out of the 295 partograms analysed none of them had data completed according to standard. The analysis of the completion of the partogram show that there is a significant association between recording of certain aspects of the partogram (risk factors, parity, age, fetal heart, contractions, cervical dilatation, problems and management plan) and mode of delivery whereas with other aspects there is no significant association. The aspects of the partogram that were completed according to standard by the perinatal outcome were poorly recorded, ranging from 0% to 54%. The association between mode of delivery and perinatal outcome was found to be statistically significant (p value 0.000). All of the fresh stillbirths and 90% of macerated stillbirths were born by normal vertex delivery. For the period under study one MMR meeting was conducted. Conclusion: The study found that there were poor clinical practices and outcomes in the maternity unit of Schweizer-Reneke Hospital. There are signs of poor information management as indicated by the discrepancies between data on hospital records and the DHIS. The reasons for this could not be established. Perinatal Problem Identification Problem and Mortality and Morbidity Review meetings were not conducted regularly and therefore could not be used to improve clinical practices and outcomes. Recommendations: Major steps need to be taken to improve clinical governance within the maternity unit of Schweizer-Reneke Hospital. Strategies to recruit and retain Professional Nurses need to be developed. The high percentage of macerated stillbirths needs to be investigated at district level and antenatal care needs to be improved. Studies focusing on the direct effect of inadequate recording on mortality and morbidity and the causes or reasons for inadequate completion of the partogram are necessary.

Developing a safety culture: The unintended consequence of a ‘one size fits all’ policy. Background Adverse events in maternity care are relatively common but often avoidable. Evidence suggests it is necessary to understand the safety culture of an organisation to make improvements to patient safety. The safety domains that are thought to influence safety culture in health care include: Safety Climate; Teamwork; Working Conditions; Perceptions of Management; Job Satisfaction; and Stress Recognition. Little is known about the safety culture in the Australian maternity setting, which was the impetus for this Study. This thesis reports an examination of the safety culture in a maternity service in New South Wales (NSW). Setting The Study took place in one maternity service located in two public hospitals in NSW, Australia. Concurrently, both hospitals were undergoing an organisational restructure. Design This mixed method research study used a concurrent triangulation design and included two Studies. The Policy Study explored the policy context in which the maternity service was situated; and, the Service Study examined the safety culture within the maternity service. Data collection included: • A policy audit and chronological mapping of the key policies influencing safety culture within the maternity service. • Safety culture surveys, the Safety Attitudes Questionnaire and Safety Climate Scale (59/210, 28% response rate) that measured the following six safety culture domains; Safety climate; Teamwork climate; Job Satisfaction; Perceptions of management; Stress recognition and Working conditions (Sexton et al., 2004). • Semi-structured interviews (15) with key maternity, clinical governance and policy stakeholders. Results The safety culture was found to be lacking across all six safety domains. The key finding was that the overarching policy context created unintended consequences for the maternity service and adversely influenced their capacity to have a positive safety culture. These unintended consequences reduced their available infrastructure and capacity to respond to adverse events; and created a lack of leadership at all levels to drive the safety and quality agenda. The safety culture was also influenced by inadequate communication during the escalation of care; inadequate supervision of junior medical staff; difficulty ensuring the right staffing and skill mix, and low staff morale. Conclusion The safety culture in this maternity setting was complex, context-specific but importantly, influenced by the broader policy context in which it was situated. This Study provides evidence that the policy context needs to be included as a seventh safety culture domain in health care. This Study has demonstrated the importance of policy on the capacity to ensure patient safety. Implications The policy context has not been previously identified as being important when addressing the safety culture in health care. Considering the influence of the policy context in relation to safety culture is an important step to develop strategies to improve patient safety in other settings. This is an area for future research.

Coyote Midwives is a documentary film about the birth workers who are leading alternative maternity care and reproductive justice in the state of Illinois. This film examines the medicalization of labor and delivery, the patriarchal norms that constitute a threat to a birthing parent’s health, and the structure in place to ensure that birth remains exclusively physician-controlled. Coyote Midwives captures the energy, spirit, and empowering potential of birth, the negotiation and compromise of “professionalizing” midwives, and the networks of criminalized, black market, safe maternity care that persevere despite the illegalities.

Thesis advisor: Brian Gareau / Thesis advisor: Stephen Pfohl / This ethnographic study follows Greater Boston birth workers to understand the following questions: 1) What do area birth workers see as the problems within the maternity care system? 2) What role does knowledge, i.e. medical vs. alternative knowledge, play in their work? 3) What is their reason for doing this work? 4) How do they go about their work? In analyzing my ethnographic data, I used theory on discourse, power and knowledge (Foucault 1973; 1971; 1978; 1980), childbirth and authoritative knowledge (Davis-Floyd & Sargent 1997), the commodification of healthcare (Rylko-Bauer & Farmer 2002), and social movement theory, including work on communities of practice (Wenger 1998), reflexive consumption and citizen publicizers (DuPuis 2000) and consciousness-raising (Hooks 2000). Through this I find that Greater Boston birth workers find fault with the singularity of medical discourse surrounding birth and with the fact that the commodification of healthcare has resulted in lower quality care for marginalized populations, primarily people of color and low socioeconomic status (SES) individuals. Furthermore, Greater Boston birth workers aim to advocate for their clients through the unique discourse about birth which their community has formed. By employing narratives counter to medicalized birth and sharing alternative, experiential knowledge, birth workers allow women to be conscious of the ways the medical maternity system does them a disservice. / Thesis (BA) — Boston College, 2019. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: Scholar of the College. / Discipline: Sociology.

Objective: To analyze factors that lead nurses and doulas to have positive views of each other. Design: A multivariate analysis of a cross-sectional survey, the Maternity Support Survey. Setting: Online survey with labor and delivery nurses, doulas, and childbirth educators in the United States and Canada. Participants: A convenience sample of 704 labor and delivery nurses and 1,470 doulas. Methods: Multiple regression analysis was used to examine five sets of hypotheses about nurses' and doulas' attitudes toward each other. Scales of nurses' attitudes toward doulas and doulas' attitudes toward nurses included beliefs that nurses/doulas enhance communication, are collaborative team members, enhance a woman's birth experience, interfere with the ability to provide care, or interfere with relationships with the women for whom they care. Results: For nurses, exposure to doulas in their primary hospitals was associated with more positive views, whereas working more hours, feeling overworked, and a preference for clinical tasks over labor support were associated with more negative views of doulas. For doulas, working primarily in one hospital and certification were associated with more positive views of nurses. Nurses with more positive attitudes toward common obstetric practices had more negative attitudes toward doulas, whereas doulas with more positive attitudes toward common obstetric practices had more positive attitudes toward nurses. Conclusion: Our findings show factors that influence mutual understanding and appreciation of nurses and doulas for each other. These factors can be influenced by educational efforts to improve interprofessional collaboration between these maternity care support roles.

Bakgrund: Antalet förstföderskor som använder sig av EDA har ökat och idag använder dryga hälften EDA under förlossning. Det är den mest effektiva smärtlindringsmetoden som förlossningsvården har att tillgå. EDA vid förlossning är dock förknippat med biverkningar och risker. Barnmorskor har en viktig roll att ge information och undervisning om smärtlindring till gravida kvinnor. Syfte: Syftet med studien var att undersöka förstföderskors kunskaper och behov av information om EDA inför förlossning. Metod: Studien genomfördes och analyserades med metoden kvalitativ innehållsanalys med induktiv ansats. Semistrukturerade intervjuer genomfördes med åtta förstföderskor. Resultat: De analyserade intervjuerna utmynnade i två huvudkategorier; EDA är en metod med fördelar och nackdelar och Förstföderskor har behov av olika information på olika sätt, med tre, respektive två, tillhörande underkategorier. Konklusion: Kvinnornas kunskaper varierade, och många var osäkra. De hade behov av olika information om EDA på flera olika sätt. De upplevde att det varken fanns tid eller möjlighet för diskussion om EDA med barnmorskor, vilket kunde bidra till en känsla av att inte ha fått tillräckligt med information. Barnmorskor behöver därför blir bättre på att erbjuda förstföderskor information om EDA, men även annan smärtlindring som används under förlossning, förslagsvis genom uttökad tid på MHV. / Background: The number of primparas who use EDA has increased, and today more than half of them use EDA during childbirth. It is the most effective method of pain relief that is available in maternity care. EDA during childbirth is, however, associated with side effects and risks. Midwives have an important role to provide information and education about pain relief to pregnant women. Purpose: The purpose of this study was to investigate primiparas knowledge and need of information about EDA during childbirth. Method: The study was conducted and analyzed by qualitative content analysis method with inductive approach. Semi-structured interviews were conducted with eight primiparas. Results: The analyzed interviews resulted in two main categories; EDA is a method with advantages and disadvantages and Primiparas need different information in different ways, with three and two associated subcategories. Conclusion: The women's knowledges varied, and many were unsure. They needed different information about EDA in several different ways. They felt that there was neither time nor opportunity for discussion about EDA with midwives, which could contribute to a feeling of not having received sufficient information. Midwives must therefore improve in offering primiparas information about EDA, but also other forms pain relief used during childbirth, suggested by extended time at maternal health care.

This thesis is a hermeneutic phenomenological study of the concept of disclosure in maternity care contexts using the example of sexual orientation. There is a significant body of literature within psychology and sociology relating to the health and social purposes and consequences of disclosure. There is a further body of outcomes-focused evidence relating to disclosure of sexual orientation in health care. There is, however, little research undertaken into the disclosure of sexual orientation in pregnancy as an action with motive and purpose. This study aimed to address this issue. The study employed unstructured interviews with eight lesbian mothers, seven of whom were birth mothers and one was a social mother. The hermeneutic method used an iterative process of analysis integrating researcher pre-understandings, thematic analysis of individual interview transcripts and broader analysis of the individual interview data within the total interview data, exploring the parts within the whole. The aim was to identify the shared meaning of disclosure for the participants Data analysis resulted in five main themes: being invisible/visible; being upfront; being me; being entitled; being safe. An additional finding was the process of managing negativity through strategies such as rationalisation. Three encompassing concepts were identified: protection; power; and identity. Two motivations for disclosure were also identified: pro-action and altruism The thesis concludes that disclosure is a motivated and purposeful act which has real meaning and consequences. It makes extensive recommendations for midwifery practice including acknowledging the disclosure, understanding the legal complexity, and recognising the lesbian family. Recommendations for policy suggest having explicit and detailed policies that include information about how to be inclusive rather than only abstract concepts of inclusion. Recommendations for research include qualitative and quantitative research with midwives about attitudes and knowledge as well as research exploring the role of the social mother in promoting family health outcomes.