Over the past decade there has been a substantial increase in evidence suggesting an increased risk of adverse pregnancy outcomes from ambient air pollution exposure. However, there is yet to be enough convincing evidence to confirm a causal link between specific air pollutants and adverse pregnancy outcomes. The objective of this project was to address the paucity of evidence from the UK on the risk from air pollution in pregnancy. The research aim was to investigate the effects of ambient air pollution on adverse pregnancy outcomes using retrospective birth outcome data from the ‘North West Perinatal Survey Unit’ (NWPSU) during the period 2004 to 2008.In addition, primarily to determine the most appropriate exposure estimation method, a prospective comparison study (n=85) was performed to compare personal measurements of nitrogen oxides (NOx) and specifically nitrogen dioxide (NO₂) with commonly used exposure estimation techniques. This study informed two further studies which quantified the effects from air pollution in pregnancy using a large retrospective cohort from the NWPSU. The first, investigated the effects of maternal residential proximity to major roads on low birthweight (LBW), small for gestational age (SGA) and preterm birth (PTB). The second, investigated the effects of NOx, NO₂, carbon monoxide (CO) and particulate matter (PM₂.₅ and PM₁₀) based on estimates from a novel spatio-temporal air pollution model and stationary monitor sites on SGA, PTB and mean birth weight change. Linear and logistic regression models were used to quantify the risk of adverse pregnancy outcomes from living in close proximity to a major road and to specific ambient pollutants. Odds ratio (OR) associations and mean birth weight change were calculated for each of the pollutants with exposure averaged over the entire pregnancy and for specific pregnancy periods to establish critical windows of exposure. Models were adjusted for maternal age, ethnicity, parity, socio-economic status, birth season, body mass index and smoking. No statistically significant associations were found between living <200m from a major road and adverse pregnancy outcomes. Based on the spatio-temporal modelled air pollution estimates, an increased risk of SGA was found in later pregnancy with NO₂ (OR=1.14, 95%CI= 1.00-1.30), CO (OR=1.21, 1.02-1.42), PM₂.₅ (OR=1.10, 1.00-1.21) and PM₁₀ (OR=1.12, 1.00-1.25). This study provides additional evidence that women exposed to high air pollution concentrations in pregnancy are at an increased risk of an SGA birth, but not for PTB. However, there was no evidence of an effect on SGA for exposures below the current legal air quality limits.

Since the introduction of coffee to Europe in the early 17th century its popularity has steadily increased and, water apart, is the most widely consumed beverage globally. Being derived from a plant, a cup of coffee represents a complex mixture of naturally occurring chemicals such as caffeine, coffee oils and chlorogenic acid. As the popularity for coffee has grown so too has the interest surrounding its possible biological and pharmacological effects. A small number of studies suggest potential risks and benefits associated with coffee consumption in pregnancy; however these have yet to provide definitive conclusions. Furthermore government advice does not directly address coffee intake during pregnancy and there is no information regarding womens’ and midwives’ views and opinions on this increasingly important issue. This was a mixed-method research study, with both a qualitative and quantitative components. Firstly, I aimed to gain insight into womens’ and midwives’ views and opinions on coffee consumption during pregnancy. Informed written consent was obtained from women attending the hospital for their antenatal care. These women were of varying gestational age, ethnic background, socioeconomic status and age. Informed written consent was also obtained from midwives from varying disciplines and experience levels; those from academia, research and practicing midwives included. I recruited twenty participants in each group. Information and perspectives were gathered through semi-structured face-to-face or telephone interviews. Interviews were analysed with the Framework method of analysis. The second quantitative arm of my study investigated the effect of specific coffee chemicals on placental and myometrial vascular function. Human chorionic plate arteries, isolated from placental biopsies, and maternal myometrial arteries isolated from myometrial biopsies, were assessed by wire myography. Contraction and relaxation were determined to incremental doses of caffeic acid, chlorogenic acid and caffeine. The antioxidative properties of these chemicals were also assessed in response to application of reactive oxygen species. My findings indicated that women and midwives’ were unsure of the information surrounding coffee consumption. Pregnant women and midwives’ discussed the provision of information, sources of information and supplementing information. Findings also indicated that the relationship between health care professional and pregnant women can influence willingness to accept information and womens’ level of pregnancy stress. My laboratory studies indicated that the active coffee chemicals did not significantly impact on placental or myometrial arterial function. The chemicals investigated did not elicit any significant protective antioxidative effects. Combining methods allowed for a more comprehensive primary study to be completed. My literature search indicated that there was a clear gap in the knowledge surrounding coffee and its consumption during pregnancy. There is a clear lack of evidence-based information accessible to women regarding consumption. Midwives feel ill-equipped to provide women with information on coffee but err on the side of caution with their advice. Laboratory studies indicate that the coffee chemicals investigated did not induce an effect and cast doubts on the potential antioxidative effects that have been previously quoted in the literature.

Background: Maternal anxiety in pregnancy has been associated with an increased risk of poor obstetric outcome, including preterm delivery, low birth weight and emergency caesarean delivery. Furthermore, mothers suffering from antenatal anxiety are more likely to experience delivery complications and develop postnatal depression. Consequently, the National Institute of Clinical and Health Excellence (NICE) in the UK have emphasised the need for non-pharmacological interventions to help reduce antenatal anxiety. Yoga may be a suitable intervention as it incorporates relaxation techniques with physical exercise that can be customised for pregnant women. Furthermore, it has been shown to be as effective as cognitive behavioural therapy in reducing anxiety in non-pregnant women. Aim: To develop and pilot a randomised controlled trial that tests a yoga-based relaxation therapy designed to help reduce maternal anxiety in pregnancy. Method: This thesis is divided into two sections. The first details the methodology, results and implications of pilot work conducted to develop the design for the larger RCT. This pilot work entailed (1) a survey of yoga instructors to examine the usual structure of yoga classes and the features of a class that make it beneficial, (2) a pilot study with the preliminary design for the larger RCT applied to women already attending antenatal yoga sessions, (3) a discussion group with yoga instructors who took part in the pilot study and (4) service user feedback on study design. The second section focuses on the implementation and findings of the RCT where pregnant women were recruited through an ultrasound department and community midwives. Pregnant women were subsequently randomised to either treatment-as-usual (TAU) or an 8-week programme of antenatal yoga to test whether a single session of yoga significantly lowered maternal anxiety and levels of the stress hormone cortisol, and whether multiple sessions help to reduce maternal anxiety, specifically fear of childbirth. Results Participants who attended antenatal yoga showed a significant decrease in fear of childbirth compared to at baseline. Furthermore, the decrease in scores was significantly greater than that observed for the control group. In contrast the control group showed significantly elevated depression scores post-intervention when compared to those that received yoga. A single session of yoga was shown to reduce both subjective ratings of anxiety and stress hormone levels. This effect remained at the final session of the intervention. Conclusion: These preliminary data suggest yoga to be a potentially useful intervention, both in the short and long term, in helping to reduce women’s anxieties towards labour and delivery. However further research is required to identify ways to research complementary therapies, which are readily available within the community, to help maintain the fidelity of comparison groups in scientific research.

Context: The Olo (egg-milk-orange) intervention offers vulnerable pregnant women food vouchers and supplements, tools, and nutritional counselling to support healthy pregnancy outcomes. Goal: To evaluate Olo’s contribution to the nutritional intakes and eating practices, as well as participants’ appreciation of the intervention. Methods: Participants (n=30) responded to questionnaires, dietary recalls and participated in a semi-structured interview (n=10). Results: Olo reduced the proportion of participants at risk of inadequate intakes for many micronutrients, mainly due to the prenatal multivitamins rather than the food offered. Most participants (96.7%) did not follow Olo’s typical recommendations but if so, they would have hypothetically consumed an average of 746 additional calories and be at risk of excessive intakes for folic acid (80.0%) and iron (33.3%). Olo also contributed to reduce the impact of isolation and solitude. Conclusion: The Olo intervention may need to be adapted to better respond to the participants’ social and dietary needs.

The use of assisted reproductive technologies (ART) in Canada has increased rapidly over the past decade, with a 235% increase in reported ART cycle starts and a 190% increase in resultant clinical pregnancies from 2008-2018, outpacing our understanding of potential adverse perinatal outcomes. This dissertation project recognizes that the use of ART will continue to increase in both scale and scope, and that it will continue to be a valued means of overcoming infertility and involuntary childlessness. The balance of risks and benefits of these rapid technological innovations for human health is uncertain. Therefore, this project seeks to produce evidence about both the risks associated with ART as well as component treatment factors amenable to modification to make its use safer. While available evidence indicates that medically assisted pregnancies are at greater risk of placental complications, data are scarce, and estimates of specific effects are varied and not reported in the context of service provision for Canada. Linking data from the Canadian Assisted Reproductive Technologies Register to the Better Outcomes Registry & Network Ontario data, this project commenced with a foundational retrospective cohort study to assess the relationship between ART (in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI)) and placental and placentally-mediated complications by comparing assisted conceptions from four years of ART cycle starts to non-assisted conceptions. Building on the findings from the foundational study, two additional studies were performed to investigate the contributions of two treatment factors, day or stage of embryo at transfer and cryopreservation, to the observed patterns of risk. Compared to non-assisted pregnancies, we find that assisted pregnancies are associated with an increased risk of placental and placentally-mediated complications. Within assisted pregnancies, risk profiles are best achieved by stratifying the analysis by both treatment type (IVF or ICSI) and embryo transfer type (fresh or frozen), in keeping with clinical practice. Although we did not find the day or stage of embryo at transfer to be a primary independent contributor to the observed increase in risk of these complication, patterns observed in the relationship between method of cryopreservation and these outcomes warrant further investigation. This thesis concludes by arguing for the pursuit of a hierarchy of risk approach to the use of ART, which is supported by the findings of this project, as it may be the most effective method to guide technological innovation and policy implementation to mitigate the risks associated with ART while not being overly restrictive of the options available to those seeking to build a family.

Reproductive physiology in production animals is a key economic component of longevity and profitability of animal farming. There are several components that can benefit or compromise adequate pregnancy periods. Sheep production is not only a very important economic activity for farmers around the United States, but sheep are also an important medical and surgical model to study human diseases. Our findings suggest that estradiol-17 beta could be involved in acute increased plasma volume early in gestation which can benefit overall gestation. We report that umbilical blood flow decreases upon nutrient restriction in adolescent ewes and does not recover upon realimentation. Finally, we suggest that a similar umbilical blood flow, placental development and plasma volume expansion in twins and singleton pregnancies could be enough to obtain similar birthweights in singletons and twins.

The following study explores the conditions under which former adolescent mothers were successfully or unsuccessfully reintegrated back into high school before and after giving birth. 12 semi-structured, in-depth, interviews were conducted with former adolescent mothers aged 22-23. An exploratory qualitative research approach was adopted as the study sought to acquire information that was specific to the social context and opinions of the former adolescent mothers. In addition, the study sought to explore the factors that contributed to the successful or unsuccessful reintegration of former adolescent mothers back into schools making sense of their recollections of their experiences before and after giving birth. The findings show that despite the interlinked causal factors that may have led to the unplanned pregnancies of adolescent mothers, the journey of adolescent pregnancy and motherhood worked to reinforce their motivation to complete school. Furthermore, the findings indicate that successful reintegration into high school and dealing with adolescent pregnancy and motherhood required various interventions that involved schools, families and the community to ensure the best possible chances for successful reintegration into high school. Recommendations were suggested in the study to enhance the provision of support interventions in managing adolescent pregnancy and parenthood, including, revised curriculum of sexual education, educator training and development, as well as provision of support by families and communities. / Mini Dissertation (MSoSci)--University of Pretoria, 2020. / Sociology / MSoSci / Unrestricted

Revisión por pares / El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / OBJECTIVE: To examine the construct validity of the 9 item Traumatic Events Questionnaire (TEQ) and to evaluate the extent to which experiences of trauma assessed using the TEQ are associated with symptoms of psychiatric disorders among 3342 pregnant women in Lima, Peru. METHODS: Symptoms of depression were assessed using the Patient Health Questionnaire-9 (PHQ-9) and Edinburgh Postnatal Depression Scale (EPDS) while the PTSD Checklist-civilian (PCL-C) and Generalized Anxiety Disorder-7 (GAD-7) were used to assess symptoms of PTSD and generalized anxiety. Hierarchical logistic regression procedures were used to evaluate relations between TEQ and symptoms of psychiatric disorders. RESULTS: The majority of participants (87.8%) experienced at least one traumatic event (mean = 2.5 events). The trauma occurrence score was moderately correlated with symptoms of PTSD (PCL-C: rho = 0.38, P-value < 0.0001), depression (EPDS: rho = 0.31, P-value < 0.0001; PHQ-9: rho = 0.20, P-value < 0.0001), and GAD (GAD-7: rho = 0.29, P-value < 0.0001). Stronger correlations were observed between the trauma intensity score with symptoms of psychiatric disorders (PCL-C: rho = 0.49, P-value < 0.0001; EPDS: rho = 0.36, P-value < 0.0001; PHQ-9: rho = 0.31, P-value < 0.0001; GAD-7: rho = 0.39, P-value < 0.0001). CONCLUSION: Given the high burden of trauma experiences and the enduring adverse consequences on maternal and child health, there is an urgent need for integrating evidence-based trauma informed care programs in obstetrical practices serving Peruvian patients. / Revisión por pares

MPH / Department of Public Health / Pregnancy can be a great experience. However, for some, it is not, especially when they are still students. Pregnant students experience many challenges, which include dropping out of school. Pregnant students thus need support from family members and friends to cope. The purpose of the study was to explore the lived experiences of pregnant students at the University of Venda, Limpopo Province. The study was conducted at the University of Venda (UNIVEN), situated in the scenic Vhembe District of the Limpopo Province. A qualitative approach, using a phenomenological design, was used for this study. A sample size of 20 pregnant students was selected from the target population through convenience sampling and data were collected through a semi-structured interview. An interpretative phenomenological approach was used to analyse the data. The study findings show that pregnant students encounter countless experiences, such as maternal stress and anxiety, inability to cope, poor concentration, low self-esteem, absenteeism and poor performance. In addition, pregnant students relied on the social support they received from friends, family and partner to cope. The study recommends that the institution should offer adequate services to pregnant students, such as attending Antenatal Care (ANC) at the University Clinic to reduce the likelihood of absenteeism and dropout rate amongst pregnant students

Evidence-based Canadian physical activity guidelines established specifically for pregnant women have shown to improve maternal and fetal outcomes, including prevention of adversities such as excess gestational weight gain, preeclampsia, and gestational diabetes. Unfortunately, most pregnant women fail to meet recommended guidelines for physical activity, and in many circumstances, the prevailing motive is due to a fear of overexertion and overheating harming the fetus. These concerns stem from reports of teratogenesis related to hyperthermia in several animal studies resulting in congenital fetal malformations. Although, due to disparities in thermoregulation between humans and animals, the findings are not entirely applicable to pregnant women. During exercise, the heat produced requires a given source of heat loss (i.e., skin blood flow/sweating) to maintain thermal homeostasis and a stable core temperature, preventing a continual rise in core temperature (i.e., teratogenesis). This thesis aims to separate the influence of pregnancy and body weight on oxygen consumption, heat production, heart rate, and rating of perceived exertion at rest (Study 1) and then during exercise (Study 2). On the other side of the heat balance equation is heat loss mechanisms; currently, the limited existing literature suggests that dry and evaporative heat loss increases as pregnancy progresses. Unfortunately, these findings are also based almost exclusively on animal studies. There has not been an established understanding of physiological, perceptual/behavioural responses in heat loss in pregnant women from early to late pregnancy, and the final study in this thesis sought to map the current literature in the format of a scoping review (Study 3). The findings of this thesis provide evidence that physiological measurements of oxygen consumption, heat production and heart rate are not influenced by stage of pregnancy, the responses increases/decrease according to total body mass. Additionally, both dry and evaporative heat loss responses appear to increase from early to late pregnancy.