Dissertationen zum Thema „Childbirth“

Epidural analgesia has increased in usage dramatically in the United States as a means of comfort for labor pain. Prior studies have connected epidural analgesia to an increase in cesarean birth rate, an increase in use of instrumentation, an increase in length of labor, episiotomy rate, and maternal fever. Epidural analgesia has produced additional costs to the patient and society. The purpose of this study is to examine the relationship between epidural analgesia during childbirth and childbirth outcomes. The data for this study were obtained from a retrospective patient record review of 200 systematically selected labor patients who delivered in 2002 at a midwestern hospital. The epidural analgesia rate was 72% at this facility in 2002, a signi?cant increase from the previous 5 years. Using the Chi-square test of independence, 3 relationship was established between epidural analgesia and four of the variables examined. A statistically signi?cant relationship was found to exist between epidural analgesia and cesarean birth rate, pitocin augmentation, and the ?rst and second stages of labor with the total sample. The results of the study are important for healthcare providers who are relaying in?uential wellness information to childbearing women and their partners. The results indicate a need for further education for healthcare providers on alternative methods of pain relief for their patients during childbirth.

A review ofthe literature revealed that norsearch to date has focused on women's recovery from post-natal trauma. The aim ofthe current study was to explore the 'lived experience ofrecovery' (Deegan, 1988) using a qualitative approach. A purposive sample ofeleven participants who felt that they had made a partial or fuII recovery after being traumatised by childbirth completed written accounts oftheir recovery. Retrospective assessment ofwomen's PTSD symptoms when they were at their worst indicated that fIve women had met fuII criteria for PTSD according to a checklist based on the Post-traumatic Distress Scale (Foa, 1995), and all nine participants who returned the checklist could be considered as 'partial PTSD'. Analysis ofrecovery stories produced four main themes. Women's recovery was aided by the provision ofvalidation and support and a healing birth experience. Recovery was hindered by items that kept them living the trauma and feelings ofloss. Despite making a partial recovery, some women could not progress further as they continued to feel an intense sense ofloss at not having had their desired 'good' birth experience. This had implications for their mood, behaviour and perception ofthemselves as mothers.

Research on knowing in childbirth has largely been a quantitative process. The purpose of this study was to better understand the ways nine, first-time mothers learn about birth. A phenomenological approach using a feminist view was used to analyze two in-depth interviews and journals to understand first time expectant mothers' experiences of knowing in childbirth. The findings demonstrated a range of knowledge that contributed to issues of control, confidence, hope, and conflict. The participants also described an increased dependency on their mothers and a lack of intuition contiguous to the birth process. These findings contribute understanding as to how expectant mothers know birth, suggesting that their knowing does not diminish conflict surrounding and may even exacerbate it. Childbirth educators may want to include instruction on negotiating power differential in relationships encountered during childbirth, and to assess the expectant mother's view of birth and her expectations for birth. Schools of nursing should consider the inclusion of women-centered care curricula in schools of nursing at both the undergraduate and graduate levels. Clearly, the politics surrounding birthing remain in place and must be removed to provide a supportive environment for normal birth.

The aim of this study was to assess risk factors to PTSD following childbirth incorporating a longitudinal design. Since the introduction of DSM-IV (APA, 1994) there has been an awareness in the literature that women can develop PTSD following childbirth. The first study in this thesis provides a comprehensive review of the literature in this area and the clinical implications of the disorder. The aim of the second study was to investigate the factor structure of a questionnaire measure (PLDQ) that has been used in past studies to assess women's perceptions of labour and delivery. The findings from this study indicate that the PLDQ consists of three internally reliable factors that can assess a woman's perception of pain, staff support/care and fear during labour and delivery. The scale can differentiate among women on these factors according to type of delivery. The aim of the third paper was to assess risk. factors to PTSD across time in the antenatal period, appraisal factors during delivery with the PLDQ, and maintenance factors in the postnatal period. There is an absence of studies in the literature that assess risk factors to PTSD over time. The results of this study indicate that postnatal depression (PND) and a negative appraisal of staff support and care during labour and delivery can predispose women to PTSD at 5-8 weeks following delivery. At 10 -14 weeks the relationship between PTSD and PND was still consistent. The clinical implications of the research are discussed for screening women at risk of PTSD following childbirth, assessment of a woman's appraisal of a difficult labour and delivery and the provision of support in the postnatal period.

Introduction: In Western countries, about one pregnant woman in five experiences a considerable fear of childbirth (FOC). Consequently FOC is an important topic for midwives, being pregnant women’s main care givers. Also, although many aspects of FOC have been studied, almost no studies have into detail applied a theoretical frame of reference for studying pregnant women’s expectations for their upcoming labour and delivery. Therefore, the theory of self-efficacy, here regarding pregnant women’s belief in own capability to cope with labour and delivery, has been applied with the aim to better understand the phenomenon of FOC. Aim: The overall aims of the thesis were to describe midwives´ perceptions and views on FOC and to expand the current knowledge about expectations for the forthcoming birth in nulliparous women in the context of FOC. Method: Study I had a descriptive design. In total 21 midwives, distributed over four focus-groups, participated. Data were analysed by the phenomenographic approach. Studies II and III had cross sectional designs. Study II comprised 726 midwives, randomly selected from a national sample that completed a questionnaire that addressed the findings from Study I. Study III included 423 pregnant nulliparous women. FOC was measured using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), self-efficacy by the Childbirth Self-Efficacy Inventory (CBSEI). Study IV had a descriptive interpretative design. Seventeen women with severe FOC were conveniently selected from the sample of Study III and individually interviewed. Content analyses, both deductive and inductive, were performed. Method: Study I had a descriptive design. In total 21 midwives, distributed over four focus-groups, participated. Data were analysed by the phenomenographic approach. Studies II and III had cross sectional designs. Study II comprised 726 midwives, randomly selected from a national sample that completed a questionnaire that addressed the findings from Study I. Study III included 423 pregnant nulliparous women. FOC was measured using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), self-efficacy by the Childbirth Self-Efficacy Inventory (CBSEI). Study IV had a descriptive interpretative design. Seventeen women with severe FOC were conveniently selected from the sample of Study III and individually interviewed. Content analyses, both deductive and inductive, were performed. Conclusions: Swedish midwives regard severe FOC as a serious problem that influences pregnant women’s view on the forthcoming labour and delivery. Midwives at antenatal care clinics, compared to colleagues working at labour wards, experience a greater need for training in care of pregnant women with severe FOC. Self-efficacy is a useful construct and the self-efficacy theory an applicable way of thinking in analysing fear of childbirth. The self-efficacy concept might be appropriate in midwives’ care for women with severe FOC.

Childbirth is an emotional and physical experience, which may have permanent or longterm positive or negative consequences. Key predictive factors of traumatic and positive childbirth have been previously identified. Criticisms however have been levied towards the pre-dominantly quantitative-based, pathological focus of the literature. Few empirical studies have examined the positive nature of childbirth. Research has also focused on isolated aspects of the pre, intra and post-partum period, as opposed to women's global perceptions. The need to consult with women who have endured traumatic and non-traumatic childbirth and to identify the complex interplay of factors associated with these events has been highlighted in the literature. This research comprises an interpretive phenomenological study. By recruiting and interviewing women who had experienced a self-defined traumatic and positive birth, the research aimed to generate a deeper understanding of the meanings and lived experiences of diverse childbirth events. A further aim was to explore how women achieved a subsequent positive birth following a traumatic episode, as well as the impact of this experience on maternal wellbeing. Through purposive sampling methods, a total of fourteen women were engaged over two recruitment phases. In phase one an interview was held with ten women who had already experienced a self-defined traumatic and positive birth. In phase two, four vomen were recruited on a longitudinal basis; interviews were held after a traumatic (interview 1) and subsequent birth (interview 2). In addition, all women (across both phases) were also involved in a final interpretation meeting. Thirty-two interviews were held in total. Data were collected through in-depth interviews. Data analysis was undertaken through an interpretive framework based on Heideggerian and Gadamerian hermeneutics. The findings present the women's childbearing journey of tragedy and joy through seven interpretive themes. A theoretical framework has re-conceptualised the women's birth narratives as a hero's tale. This represents a heroic journey of adversity, trials, courage, determination and triumph. A unique psychosocial model has been synthesised by integrating aspects of the theories of Carl Jung (1968, 1989, 2006), Abraham Maslow (1962, 1970a&b) and Martin Heidegger (1962, 1976, 1977). This model has provided a holistic conceptual framework of women's childbirth experiences. The framework explores the psychosocial motivators and influences on women's childbirth experiences. It emphasises the importance of socio-contextual factors to determine a woman's growth potential during childbirth; as well as how growth-inhibiting (traumatic birth) and growth-enhancing (joyful birth) experiences are internalised by women. This model offers the basis through which a whole systems salutogenic orientation to maternity care can be achieved. Original insights into the transformative, cathartic and self-validating nature of a redemptive birth are also presented. The practical implications of these findings and suggestions for future research have been offered.

The aims of this study were to describe the childbirth preferences of nulliparous women in early pregnancy and to develop a model of the predictors of those preferences. Participants were recruited with Facebook advertisements and data were collected from 344 women via online survey. Predictors were measured using the Utah Test for the Childbearing Year. Predictors of childbirth preferences (type of birth care provider, birth setting, mode of delivery, and use/avoidance of pain medication) were tested using structural equation modeling. Conventional content analysis was employed to analyze women’s reasons for selecting the type of provider and setting they expected for their delivery. Although the majority of respondents preferred physicians and hospital birth, the proportions of women who preferred midwifery care and planned home birth were higher than currently access those types of care in the U.S. More respondents preferred to use pain medication than to avoid it. Over 95% of respondents preferred vaginal delivery. Women who had an internal locus of control and perceived their childbearing role to be one of active participation were more likely than women who saw their role as a passive one to prefer midwifery care, home birth, vaginal delivery, and to avoid pain medication. Women who saw the provider’s role as dominant to their own were more likely to prefer physicians and hospital birth than those who viewed the provider’s role as a collaborative one. The more fearful/painful women expected birth to be, the more likely they were to prefer cesarean delivery.

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Bachelors
Nursing
Nursing

Drawing on both qualitative and quantitative data, the thesis describes and explains both the current patterns of natural protection against pregnancy and the use of modern contraception in the period following childbirth in two populations, one rural and one urban, in Bangladesh. First, quantitative data gathered through demographic surveillance systems of the International Centre for Diarrhoeal Disease Research, Bangladesh are used to explore the patterns and differentials in breastfeeding, postpartum amenorrhoea and risk of pregnancy in the months following birth in the two study populations. Next, the surveillance data are used to describe the patterns of adoption of contraception in relation to time postpartum, breastfeeding and menstrual status for the two study populations. Extensive use is made of life table methods, hazard models and logistic regression techniques in these analyses. Qualitative data gathered through in-depth interviews with users of contraception are then used to identify key themes of understanding that influence women's behaviour, including contraceptive uptake, in the period following childbirth. The current knowledge, attitudes and practices of family planning providers in the two study populations are next described using qualitative data collected through a series of in-depth interviews and group discussions. Findings from the quantitative and qualitative analyses are then integrated in order firstly, to explain the current patterns and recent trends in contraceptive use and lactational protection against pregnancy following childbirth, and secondly to explore their potential implications for birth intervals and fertility. Finally, important issues are identified and recommendations made for improvements to postpartum family planning programme approaches in Bangladesh.

Between 4 and 40% of women will suffer permanent pelvic floor trauma in childbirth. Irreversible damage to the pelvic floor at the time of vaginal birth may take the form of trauma to the levator ani complex or obstetric anal sphincter injury (OASI). Long-term sequelae include pelvic organ prolapse, its recurrence after surgical repair, urinary and fecal incontinence, sexual dysfunction and chronic pelvic pain. Detection rates are poor, especially for levator ani trauma, which is often clinically undetectable at the time of vaginal birth. Translabial ultrasound is an objective method for the diagnosis of irreversible pelvic floor trauma and was used in observational studies for this thesis. Original studies undertaken for this thesis showed antenatal risk factors for levator avulsion include increasing maternal age (OR 1.05, p=0.019), lower body mass index (BMI; OR 0.94, p=0.018), and increasing bladder neck descent (BND; OR 0.97, p=0.026). Intrapartum risk factors identified include longer second stage (OR 1.02, p=0.01), OASI (OR 3.2, p= 0.002), and the use of forceps (OR 2.9, p=0.001). The latter is by far the strongest modifiable risk factor and should be avoided. Predictors of atraumatic normal vaginal delivery were younger maternal age (OR 0.93, p<0.001) and earlier gestation at delivery (OR 0.78, p=0.001), which is relevant to family planning. Overall, rates of atraumatic normal vaginal delivery in our population were much lower than generally assumed at 33-40%. An in vitro study showed that the predicted effect of forceps on avulsion risk is not explained by an increase in space requirement alone. It is likely that the main factor determining the traumatic potential of forceps is increased force over time, i.e., the characteristics of the pull exerted by the operator. Finally, it was found that conversion of a primary vacuum to a forceps delivery would result in an overall increase in major pelvic floor trauma from 31% to 39% of primiparas (p=0.018). Current trends towards the use of forceps to reduce Caesarean section rates are likely to result in an inadvertent increase in rates of levator avulsion and OASI. As current methods of anal sphincter repair and surgery for pelvic organ prolapse have high rates of failure, good obstetric care should emphasize the prevention of pelvic floor trauma at the time of a woman’s first birth.

The recent discovery of Chinese medical manuscripts in a tomb dated to the second century BC in Ma-wang-tui, Ch'ang-sha, has revealed extremely interesting new information on the subject of ancient Chinese childbirth practices. The scrolls contain detailed advice concerning a proper and auspicious treatment of the placenta, an astronomical chart for choosing the perfect location for the burial of the placenta, and a description of the custom of exposing the newborn infant on the earth directly after birth. This paper offers a translation of these paragraphs and an interpretation based on a Japanese medical text that reflects Chinese medieval practices, basic knowledge of Chinese cosmology, society and religion and also general cross-cultural patterns for the treatment of the placenta that have been established through an anthropological research into placenta-related practices, beliefs and mythology from many different traditional cultures.

Purpose. Explore the organizational barriers and examine determinants of nurses' intentions to practice continuous labour support (CLS). Design. Exploratory two-phase study using qualitative and quantitative methods. Participants. Childbirth nurses, educators and managers from two birthing units on two campuses of one hospital, in an urban city in Ontario, Canada. Phase I, N=10/10; Phase II, N = 97/129. Methods. Semi-structured interviews with content analysis followed by a survey using the Theory of Planned Behavior with descriptive, univariate and multiple regression analyses. Results. Unit acuity, method of patient assignment, need to cover other nurses for break and nurse-patient ratio, were the most frequently reported barriers. Nurses' attitude scores, subjective norm scores and intention scores toward providing CLS to women with epidural analgesia were lower than those for a non-epidural case study. Conclusions. Organizational barriers impact nurses' ability to provide CLS. Nurses have lower intentions to provide CLS to women with epidural analgesia.

No childbirth education (CE) programs are available in the public sectors in Jordan. Many studies from Jordan recommended that pregnant women be educated about their health needs during pregnancy and childbirth. From the literature, CE programs were found to have positive effects on pregnancy and childbirth outcomes. Four focus groups with pregnant women, midwives and physicians were conducted to examine the perceptions of pregnant women, midwives and physicians regarding the content, feasibility, and challenges of implementing a CE program in Jordan. The 4 focus groups, two with pregnant women (one group with 8 primiparous women and one group with 6 multiparous women), one with 8 midwives, and one with 6 physicians were presented with the content, timing, and a description of three existing CE programs. Findings indicated that pregnant women’s sources of knowledge about pregnancy and childbirth were mainly from other females and doctors but not from midwives. Younger pregnant women reported the Internet as an important source of pregnancy and childbirth knowledge. Findings showed that women were not sure of what they wanted to learn. Midwives and physicians wanted to include warning signs, physical exercises, psychological changes, vii nutrition, breast feeding, newborn heath, sexually transmitted diseases, pain management, postpartum physiology and care, family planning, and planning of pregnancy as content in a new CE program. All participants reported the need to include husbands in CE. However, husbands were considered a potential challenge to implementing a CE program. Other challenges were cost, staff, clients’ responses, and governmental policies. Midwives and physicians thought that CE should be included in free antenatal care. All participants reported support for a new CE program. Midwives and physicians suggested implementing the new program within the facilities of the Ministry of Health (MOH). This would decrease cost and the need for staffing for the new program. They suggested that the CE program could benefit from potential support from international sponsors that affiliate with the MOH. Potential benefits of CE could potentially help gain support from the MOH decision makers and the community in Jordan.

In my secondary analysis of a large online survey data set (n = 3,680 university students), I used both quantitative and qualitative data analysis techniques to better understand factors contributing to students’ fear of childbirth. Albert Bandura’s social learning theory served as my conceptual framework to guide the development of a 6-item fear of birth scale and my selection of covariates that may be associated with fear of birth among Canadian students. I triangulated themes inductively derived from comments about labour and birth (n=1337) written by female respondents who scored in the high and low range on the fear of birth scale with the quantitative results to improve understanding of the phenomenon. Fear of childbirth affected approximately 1 in 7 female students; very few male students exhibited fear of birth (< 4%). Concerns over physical changes during pregnancy and birth were strongly associated with Cesarean section (CS) preference among male and female students. Having learned about pregnancy and birth through the media was associated with higher fear scores, compared to other sources of information. When examining predictors of childbirth fear in a logistic regression model, I found two factors decreased fear of birth: increased confidence in students’ knowledge of pregnancy and birth and having witnessed a birth first hand. Qualitative themes extended my understanding of the fear of birth scores, by indicating that fear of pain is a dominant dimension of childbirth fear among female students. Obstetric interventions, such as elective CS, are favoured by students with high fear of birth, and seen as a way to circumvent the pain of childbirth. Women with high and low fear of birth supported the theme that mode of delivery is a woman’s choice; however, students with low fear of birth were more likely to view birth as a natural and normal process and express concerns that obstetric interventions may carry unacceptable risks. Comments from students with high fear of birth supported the themes that pain of childbirth is unmanageable and birth is a painful and frightening ordeal. Findings from my study have important implications for education, practice and research.

Background: The birth experience has long-term implications on women’s health. Previous research mainly focuses on risk factors and traumatic birth. The lack of a salutogenic perspective on the birth experience is troublesome since childbirth generally is a healthy life event with the capability of empowering women and their families.  Objectives: The aim of this study was to describe what contributes to women’s sense of security during childbirth and what the meaning of a sense of security during childbirth is. Method: The study had a qualitative design. Semi-structured interviews were conducted with 13 informants who had given birth at home or in hospital, the last 3-20 months. Both vaginal and cesarean births among primiparous and multiparous women were represented in the material. Data was analyzed with qualitative content analysis. Results: Aspects that contributed to a sense of security were presented in the two themes “Support and assistance from a respecting team” and “The strengthening of women’s own ability in childbirth”. The third theme, “Sense of security enables emotional growth”, described the informants’ view of the meaning of a sense of security.  Conclusion:The results contribute to the knowledge of how midwives can model their support to women in order to empower them and increase their sense of security during childbirth. It provides a deepened understanding for the concept of sense of security, seen as a continuum, and as an inseparable part of women’s birth experiences.  Keywords: birth experience, control, sense of security, support, qualitative content analysis
Bakgrund:Förlossningsupplevelsen påverkar hälsa och välbefinnande hos kvinnor och deras familjer. Tidigare forskning har främst fokuserat på riskfaktorer och följderna av en traumatisk förlossningsupplevelse. Avsaknaden av ett salutogent perspektiv på förlossningsupplevelsen inom barnmorskans forskningsfält är problematiskt eftersom de flesta förlossningar är friska, normal livshändelse som kan stärka kvinnor och deras familjer.  Syfte:Studiens syfte var att beskriva vilken betydelse som känslan av trygghet har under en förlossning och hur en känsla av trygghet kan uppnås och stärkas. Metod:Studien hade en kvalitativ design. Semistrukturerade intervjuer genomfördes med 13 informanter som fött barn de senaste 3 - 20 månaderna, hemma eller på förlossningsavdelning. Bland informanterna fanns både förstföderskor och omföderskor som fött barn vaginalt eller med kejsarsnitt. Data analyserades med kvalitativ innehållsanalys.  Resultat:Självtillit, valmöjlighet gällande förlossningsplats, fokus och kontroll bidrar till kvinnors känsla av trygghet under förlossningen. Stöd från en känd barnmorska ökade kvinnors känsla av trygghet och bidrog till en positiv förlossningsupplevelse. Aspekter som förstärkte känslan av trygghet presenterade i två teman, “Stöd och bistående” och “Egen förmåga och inre styrka”. Det tredje temat, “Känslan av trygghet möjliggör emotionell utveckling”, beskrev betydelsen av en känsla av trygghet. Slutsats:Studiens resultat bidrar med kunskap om hur barnmorskor kan anpassa sitt stöd under förlossning så att det stärker kvinnors egenförmåga och känsla av trygghet. Studien bidrar till att förbjuda förståelsen för känslan av trygghet, sedd som ett kontinuum och en oskiljaktig del av kvinnors förlossningsupplevelser.  Nyckelord:förlossningsupplevelse, kontroll, kvalitativ innehållsanalys, stöd, trygghet

Background: Although giving birth is a positive experience for many, some 10% of pregnant Swedish women suffer from severe fear of childbirth (FOC), which impairs their daily functioning and poses a risk for a negative delivery experience. This thesis focuses on the mental and health-economic effects of severe FOC, and explores new treatment options for childbirth-related anxiety. Aims: (i) to investigate the prevalence of and variables associated with severe FOC, (ii) to estimate the cost of illness of severe FOC and (iii) to explore whether Internetbased cognitive behaviour therapy (ICBT) is feasible for treating pregnant women with severe FOC and those with childbirth-related symptoms of posttraumatic stress disorder (PTSD). Design and Results: Study 1: In a cross-sectional study 1635 pregnant women were asked about their FOC via the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), and provided socio-demographic data and information of their preferred mode of delivery. It was found that 15.6% of the participants had a severe FOC, which also strongly correlated with the preference of a caesarean section. Study 2: In a prospective case-control cohort study we mapped all visits, in-patient care, sick leave and delivery variables from medical records and estimated the societal costs in two groups of women; one group with severe FOC and one with low FOC. The costs for the group with severe FOC were 38% higher than for the low FOC group. Study 3: Twenty-eight nulliparous women with severe FOC were self-recruited to an eight weeks ICBT program for severe FOC. Fifteen women followed the entire program. Their FOC decreased significantly after treatment (Cohen’s d=0.95, p<0.0001), which means that ICBT is feasible and an option for treating women with severe FOC. Study 4: Fifteen participants in Study 3 wrote narratives of the imminent delivery before as well as after therapy. After treatment, the women had a more realistic attitude towards childbirth, more self-confidence and more active coping strategies. Partners and staff were perceived as more helpful, and the women were more aware of the child they were bearing. Study 5: Fifty-six women with a traumatic delivery experience were included in a randomized wait-list controlled study (RCT) of the effects of an eight week long ICBT program for childbirth-related PTSD symptoms. These symptoms decreased in both groups during active therapy, while the between-group effect size varied depending on measurements. Psychiatric comorbidity decreased in both groups after active treatment. Conclusion: Severe FOC is prevalent among Swedish pregnant women, and the cost of illness of this marker of peripartum psychological vulnerability is considerable when treated using standard care. A new treatment option for this group with ICBT seems feasible and is associated with more realistic attitudes towards the imminent delivery. An RCT with eight weeks of ICBT for parous women with PTSD symptoms also had promising results. As severe FOC is prevalent and associated with mental and economic burdens for the individual and the society, there is an urgent need to expand the research field. It is important to find feasible and effective treatments that can be applied on a large scale.
Denna avhandling undersöker (i) hur vanligt det är att svenska gravida kvinnor lider av rädsla för förlossningen, och (ii) hur detta påverkar kvinnornas sjukvårdskonsumtion under denna period samt vilka kostnader detta innebär för samhället; testar och utvärderar (iii) nya behandlingsmetoder för rädsla för förlossningen och för posttraumatiska stressymptom efter en traumatisk förlossning. Avhandlingen består av fem delstudier: Studie 1 var en studie bland 1635 gravida kvinnor och visade att mer än var tionde gravid kvinna har svår förlossningsrädsla. Denna hade samband med kvinnornas önskemål om planerat snitt som förlossningssätt, och hos omföderskor, med tidigare negativa upplevelser av förlossningen. Studie 2 jämförde sjukvårdskonsumtion och sjukskrivning under graviditet och den första tiden efter förlossningen hos förstföderskor med svår respektive lindrig förlossningsrädsla, vilka omhändertagits i den ordinarie förlossningsvården. Gruppen med svår förlossningsrädsla visade sig ha avsevärt högre kostnader orsakade av att de i genomsnitt hade högre sjukskrivningstal under graviditet och fler besök på grund av psykiska besvär, samt oftare förlöstes med kejsarsnitt och hade komplicerade förlossningar. I Studie 3 testade 28 förstföderskor med svår förlossningsrädsla en ny behandlingsmetod med kognitiv beteendeterapi (KBT) via internet. Behandlingen medförde att kvinnornas rädsla kraftigt minskade från företill efter behandling. I Studie 4 skickade 15 av kvinnorna i Studie 3 in berättelser via nätet om hur de föreställde sig att deras förlossning skulle bli, såväl innan terapin startade som när den var avslutad. Efter genomförd terapi hade kvinnorna en mer realistisk attityd till förlossningen än före terapin och visade tecken på att ha ett bättre självförtroende och mer aktiva strategier att hantera den kommande förlossningen. Studie 5 utforskade om kvinnor, som upplevt en traumatisk förlossning, kan bli hjälpta av behandling med KBT via internet. Traumatiserade kvinnor slumpades till att antingen få behandling direkt eller få behandlingen efter en väntetid (kontrollgruppen). I båda grupperna minskade kvinnornas posttraumatiska stressymtom, liksom förekomsten av depression och andra ångestproblem. Sammanfattning: Avhandlingen visar att svår förlossningsrädsla är vanligt förekommande och medför lidande för kvinnor och ökade kostnader för samhället i samband med graviditet och förlossning, när detta problem hanteras i den vanliga vården. Två internetbaserade studier testar kognitiv beteendeterapi som behandling för svår förlossningsrädsla och för problem efter en traumatisk förlossning och visar att dessa behandlingsformer tycks fungera väl och i framtiden skulle kunna utgöra ett alternativ som medför att vård görs tillgänglig också för kvinnor som inte har tillgång till kvalificerade hjälpinsatser på andra sätt. Svår förlossningsrädsla och ångestproblem efter en traumatisk förlossning föreligger ofta tillsammans med annan psykisk sjuklighet varför diagnostik och behandling behöver utföras av personer med tillräcklig kompetens för dessa uppgifter. Otillräckligt behandlad/icke behandlad svår förlossningsrädsla ökar riskerna för att kvinnan upplever en kommande förlossning som traumatisk. Avhandlingens slutsatser behöver undersökas i fler och större studier, och, avseende behandlingsstudierna, i undersökningar som har tillräckligt stora kontrollgrupper. Om sådana studier bekräftar dessa preliminära fynd, blir frågan om screening för svår förlossningsrädsla aktuell eftersom det då finns såväl bra screeninginstrument som behandling som skulle kunna göras tillgänglig för stora grupper. Kommer samhället i denna situation att ha råd att inte försöka förebygga individuellt lidande och stora merkostnader för kvinnor med svår förlossningsrädsla?
Tämän tutkimuksen tavoitteena on tutkia (i) kuinka yleinen synnytyspelko on ruotsalaisten raskaana olevien naisten keskuudessa ja (ii) kuinka se vaikuttaa heidän terveyden‐ ja sairaanhoitopalveluiden kulutukseen raskauden aikana ja sen jälkeen, sekä selvittää miten synnytyspelko vaikuttaa yhteiskunnan kustannuksiin; kehittää, testata ja arvioida (iii) uusia hoitomuotoja synnytyspelon sekä synnytyksestä johtuvien psykologisen trau man (posttraumaattinen stressi, PTSD) hoitoon.' Tämä väitöskirja koostuu viidestä osatyöstä: 1. Ensimmäinen osatyö tutki synnystyspelon yleisyyttä 1635 raskaana olevan naisen keskuudessa. Tutkimus osoitti että joka seitsemäs raskaana oleva nainen Ruotsissa kärsii vakavasta synnytyspelosta. Keisarinleikkaus toiveen takana on usein vakava synnystyspelko. Uudelleen synnyttäjillä synnytyspelkoon vaikuttaa myös aiempi traumaattinen synnytyskokemus. 2. Toisessa osatyössa verrattiin ensisynnyttäjien terveyden- ja sairaanhoitokustannuksia sekä sairaslomapäiviä raskauden aikana, synnyksen yhteydessä sekä sitä seuraavan kolmen ensimmäisen kuukauden aikana. Vertailuryhmät seurasivat tavallista äitiysneuvolaohjelmaa, ryhmistä toisella oli vakava ja toisella lievä synnytyspelko. Vakavasta synnytyspelosta kärsivien naisten terveyden ja sairaanhoitopalvelujen käyttö osoittautui huomattavasti korkeammaksi kuin vertailuryhmässä. 3. Kolmannessa osatyössa 28 vakavasta synnytyspelosta kärsivää ensisynnyttäjää, testasi uutta ratkaisukeskeiseen terapiaan (KBT) pohjautuvaa Internetin kautta ohjattua psykologista hoito-ohjelmaa. Hoito lievensi huomattavasti osallistujien synnytyspelkoa. 4. Neljännessä osatyössä 15 naista (edellisestä osatyöstä 3) kirjoittivat osana terapiaansa kertomuksen tulevan synnytyksensä odotuksista. Sama tehtävä kertautui ennen terapian alkua sekä sen jälkeen. Kertomusten yhtäläiset teemat tunnistettiin minkä jälkeen ennen ja jälkeen hoitoohjelmaa kirjoitettujen kertomusten teemoja vertailtiin. Hoidon jälkeen naisten odotukset pohjautuivat suuremmassa määrin tietoon, he kuvailivat itsensä varmemmiksi sekä paremmin  valmistautuneiksi tulevaa synnytystä ajatellen. 5. Viides osatyö tutki Internetin kautta ohjatun ratkaisukeskeisen terapian (KBT) vaikutusta naisiin jotka kärsivät synnytyksen jälkeisestä henkisestä traumasta. Naiset satunnaistettiin tutkimuksessa joko välittömän hoidon ryhmään tai odotuslista ryhmään, joka sai saman hoidon myöhemmin. Hoidon jälkeen PTSD oireet vähenivät sekä hoitoettä kontrolliryhmässä. Myös masentuneisuus ja ahdistusoireet väheniväthoidon myötä. Yhteenvetona voidaan oheisista tutkimuksista todeta että synnytyspelko on yleinen ruotsalaisten raskaana olevien naisten keskuudessa. Synnytyspelko aiheuttaa kärsimystä sekä raskaana olevalle naiselle mutta myös lisäkustannuksia yhteiskunnalle. Kahdessa Internetin kautta ohjatussa ratkaisukeskeisessä hoito-ohjelmassa testattiin uusia hoitomuotoja raskaana oleville ensisynnyttäjille sekä synnytyksen jälkeisistä traumaoireista kärsiville naisille. Tulokset osoittavat, että Internetin kautta ohjattu hoito toimii näissä ryhmissä hyvin ja saattaisi tulevaisuudessa olla vaihtoehto kohderyhmille, joille sopivaa terapeuttista hoitoa nykytilanteessa ei voida tarjota. Koska vaikea synnytyspelko ja synnytystä seuraavat PTSD oireet esiintyvät usein muiden mielialahäiriöiden rinnalla, on tärkeää, että näitä naisia hoitavalla henkilökunnalla on tarpeellinen pätevyys hoitaa myös mielenterveysongelmia. Hoitamatta jätetty tai puutteelisesti hoidettu synnytyspelko lisää raskaana olevan naisen riskiä kokea synnytyksensä traumaattisena. Tulevissa tutkimuksissa tämän tutkimusprojektin tulokset ja johtopäätökset on syytä toistaa useammissa ja ennen kaikkea suuremmissa ryhmissä. Jos tutkimustemme alustaville tuloksille löytyy tukea, nousee kysymys synnystyspelon seulonnasta äitiysneuvoloissa ajankohtaiseksi; sekä seulontamenetelmä että tehokas hoitotapa ovat olemassa ja voitaisiin tarjota suuremmille kohderyhmille. Onko yhteiskunnalla sellaisessa tilanteessa varaa olla ennaltaehkäisemättä synnystyspelkoisten naisten kärsimystä?

Maternal birth trauma in particular pelvic floor trauma (PFT) is of increasing concern in recent years, mainly due to its association with long term morbidities affecting women’s quality of life. Prediction is difficult and likely to raise ethical, moral and health economic questions, and attempts at primary and interval reconstruction have had only limited success. This work was designed to explore multiple aspects of PFT with a particular focus on prevention and its effect on pelvic organ support through one prospective multicentre randomised controlled trial, two cross-sectional and four retrospective studies, involving 3D/4D Translabial Ultrasound as the principal study tool. The incidence and prevalence of levator ani muscle (LAM) avulsion, microtrauma and sonographic external anal sphincter defects was found to be 13.1%-24%, 13.8%-62% and 12.4% respectively, showing that somatic maternal birth trauma is very common. In a randomised controlled trial, antepartum use of Epi-No® birth trainer was found to be unlikely of clinical benefit in the prevention of pelvic floor trauma. Two observational studies showed that there was no difference in the prevalence of levator avulsion and sonographic EAS defects between women who were vaginally primiparous or multiparous, and that the effect of vaginal birth on hiatal dimensions was largely limited to the first birth. These two observational studies suggest that it is the first vaginal birth that is by far the most traumatic. Another observational study showed that LAM avulsion can be diagnosed clinically by digital palpation, but may require a longer learning curve than imaging. Confirmation by imaging is necessary in high risk cases as part of surgical planning. LAM avulsion was also shown to be associated with increased levator urethra gap (LUG) on ultrasound. LUG and LAM avulsion are associated with signs and symptoms of female pelvic organ prolapse. Variations in obstetric practice such as tolerance of longer second stages and increased Forceps rates are likely to lead to higher rates of pelvic floor trauma. In conclusion, prevention of PFT should focus on the first vaginal birth. Antepartum use of the Epi-No® device is unlikely to be beneficial. LAM avulsion can be diagnosed clinically but involves a longer learning curve, making confirmation by imaging essential. LAM trauma is associated with POP in both symptomatic and asymptomatic cohorts.

Abstract This thesis presents the analysis and interpretation of a complex midwifery, obstetric and psychology related concern, commonly experienced by women to some degree as they enter/move through their perinatal journey. Fear of Childbirth is considered a naturally occurring phenomenon related to pregnancy and birth preparedness, but when severe it can also operate as an anxiety syndrome leading to phobic avoidance or severe distress and therefore contribute to the manifestation of poor perinatal outcomes. Mental health deterioration and negative birth outcomes can impact and impair the development of babies including their mother-baby bonding opportunities. Furthermore, a woman’s transition to motherhood may be threatened. This is the first study to examine Fear of Childbirth and related concerns at Westmead Hospital, a public hospital within the Western Sydney Local Health District providing care to a population with diverse cultural backgrounds. This planned prospective cohort study aimed to examine the prevalence of Fear of Childbirth in low-risk, primigravid women and account for associations between Fear of Childbirth and other factors such as mental health concerns, intimacy, and partnerships. The instruments used were the Wijma Delivery and Expectancy/Experience Questionnaire, Version A (W-DEQ A); Fear of Birth Scale (FOBS 1 (Calm/Worried) and FOBS 2 (No fear/Strong fear)); Depression, Anxiety and Stress Scale (DASS-21); Relationship Assessment Scale (RAS); and Female Sexual Function Index (FSFI). Maternal and neonatal birth outcomes were also examined as important secondary aims. First-time mothers (n=137) completed baseline questionnaires and were recruited in the gestation range of 13 weeks to 41 weeks. Of this sample, 35% completed a follow-up questionnaire which was offered at approximately 6-8 weeks post birth; baseline data were analysed only as the follow-up response rate was considered too low to provide valid findings. Firstly, 31.4% of primigravid women experienced ‘high’ Fear of Childbirth when a >66 cut-point on the W-DEQ A was applied, consistent with recent categorisations. The use of this cut-point was confirmed following the finding of a significant association between DASS-21 anxiety subscale and W-DEQ A using the >66 cut-point; and a significant association between the DASS-21 anxiety subscale was found using W-DEQ A cut-point of >85 but not >100. Chi-square tests were used to compare the three W-DEQ A cut-points against the two FOB variables and Self-Reported Anxiety. Using the >66 cut-point, there were significant associations between the W-DEQ A and FOBS 1 and FOBS 2; but no significant association with Self-Reported Anxiety. There were no substantial significant associations between the Fear of Childbirth variable and the variables assessing relationships and intimacy. The lack of finding may have been because a high proportion (78.8%) of the sample were married and partnered (97.1%). Subscale analyses within the W-DEQ A was conducted in line with recent recommendations. Investigating broader variables demonstrated a significant association between the DASS-21 Depression subscale and RAS. The two subscales most relevant to Fear of Childbirth and the current sample (Negative Emotions and Lack of Positive Emotions) were significantly associated with DASS-21 Anxiety and Self-Reported Anxiety. Regarding birth outcomes, W-DEQ A and FOBS 1 were significantly associated with induction of labour. Negative Emotions and Lack of Positive Emotions were also significantly associated with induction of labour (as opposed to augmentation or neither procedure) representing a higher Fear of Childbirth. Infant formula use was significantly associated with the W-DEQ A (>66 cut-point), DASS-21 subscales of Depression, Anxiety and Stress but not with FOB 1 and 2. Infant Formula was also associated with Fear of Childbirth, Negative Emotions subscale, but with borderline significance. In all cases, women who used formula supplements reported higher anxiety. Additional findings included low pregnancy class attendance with only 35% of the sample completing this form of preparedness. Further analysis found no fear or mental health associations related to attendance at classes. Emergency birth complications were not significantly associated with Fear of Childbirth or the other mental health variables. When excluding the data missing from the sample, the normal vaginal birth rate was 42.4% and instrumental birth rate was 15.9%. The emergency caesarean section rate was 34.9 %, and overall caesarean section rate was 40.2%. Maternal request for caesarean section was very low (0.8%) and perineal trauma most commonly resulted from staff intervention in the form of episiotomy (29.8%). The second highest perineal trauma finding was second-degree tears (19.8%). In conclusion, Fear of Childbirth and the mental health of women around the time of birth needs attention. The current sample of low-risk women reported an undesirable level of worry, with one third experiencing significant levels of Fear of Childbirth. When birthing for the first time, women who are more fearful of childbirth are possibly gravitating towards medicalised labour processes. They also tend to seek to use infant formula perhaps in part to cope in the first week of the neonate’s life which may perpetuate a reduction in breastfeeding or expressed breastmilk use. The caesarean section rate has demonstrated a unique contribution to the ongoing upward trend for Australian settings and in terms of a low-risk primigravid sample this warrants attention. Local data on prevalence, association, outcomes, and additionally important findings, once magnified, can signify areas of improvement for policy makers, stakeholders, psychosocial professionals, midwives, obstetricians and researchers to better assist childbearing women.

This thesis presents the findings of a doctoral study which analysed video tapes of labouring Australian women at the end of the 20th century, historical data from midwifery and medical textbooks, consumer material, and personal experience as a midwifery student in 1970- 1971. The data analysis was achieved using discourse analysis, but was influenced by Michel Foucault together with anthropological and sociological approaches, particularly as these can be applied to visual material. ‘Dirt’ is a commonly accepted term, but it becomes difficult to define as it is so dependant on the context. Since the discovery of the germ theory in the 19th century, however, it is difficult for western health professionals to conceive of dirt as being anything but unaesthetic, unhygienic and pathogenic. When analysing the data from this study, it became evident that birth and dirt have a close association. The changes that have occurred in childbirth have revolved around who and what is perceived as clean, and who and what is perceived as dirty. This thesis argues that ‘birth dirt’ exists, but, its form will vary depending on the time, the place, and the culture, although it is always centred around the physical reality of birth. Video tapes of the birthing process indicate that midwives, in their ritualised behaviours of containing, controlling and cleaning up the ‘dirt’ associated with birth, create a barrier between themselves and the women. ‘Dirt’ in this instance is the ‘contaminating’ body fluids and substances derived from the woman and her baby. The dirt relationship is a power relationship and the midwife is an essential part of its structure. The midwife is the dirty worker who maintains the cleanliness of the environment and controls the ‘dirt’ during birth. There is considerable rhetoric about midwives as being ‘with woman’, but the reality is that the midwives are more often ‘with dirt’.

Thesis advisor: Sharlene N. Hesse-Biber
Birth Visionaries: An Examination of Unassisted Childbirth By Lauren Ashley Brown Sharlene Nagy Hesse-Biber, Thesis Chair This exploratory study inquires into unassisted childbirth, the act of giving birth without the presence of any birth professional (doctor, midwife or doula). Unassisted birth is on the radical fringe of alternatives to the dominant techno-medical birth common in American hospitals today. My research questions are what are women's motivations for choosing unassisted childbirth and what is the lived experience of unassisted childbirth? I will answer these questions through nine in-depth interviews and a grounded theory data analysis. My approach comes from a focus on the everyday lived experience of women as problematic as well as insights from anthropology of birth and feminist postmodern sociology of knowledge. This study is relevant to public health policy on pregnancy and birth, to those working on questions of technology and culture, and to those concerned with how biosocial rituals shape embodied experience. My findings also contribute to research about power in contemporary society, specifically how the body can be a cite for social control and resistance
Thesis (MA) — Boston College, 2009
Submitted to: Boston College. Graduate School of Arts and Sciences
Discipline: Sociology

Female genital mutilation (FGM) is defined by the World Health Organisation as the deliberate total or partial removal of the external female genitalia, or other deliberate injury to the female genitalia, which is carried out for non-therapeutic purposes. The practice is widely condemned. Even though the adverse effects of the practice have been well documented in many small studies and case reports, FGM is still common in many countries. The effects of this practice are also being felt in many developed countries due to substantial migration in recent years. One of the limiting factors in encouraging eradication is the availability of high quality evidence of the effects of the practice on the process of childbirth. By highlighting the effects of FGM on the process of childbirth, the objective was to encourage policy makers, in co-operation with many relevant organisations, to work together to eradicate the procedure. This original study investigates the effects of FGM on the process of childbirth using a large international epidemiological case control study involving three centres in three different countries. The inclusion criteria were strict and comprised of agreement by the woman and or her husband to participate in the study, for a normal singleton pregnancy at term with a cephalic presentation which resulted in a normal baby, for the women with and without FGM during the period of study. Women who did not fulfil these criteria were excluded. Maternal outcome measures included length of labour, obstruction to the progress of labour, operative delivery, urine retention, perineal complications, intrapartum and postpartum haemorrhage and blood loss during the process of labour. Newborn outcome measures included birth status at delivery, Apgar scores at 5 and 10 minutes, requirement for resuscitation, admission to special care unit and time taken from delivery to the first breast feed. Psychological sequelae were not assessed. The total number of participants in these three centres was 1,970 women; 526 with no FGM (control) and 1444 with different types of FGM. Every effort was taken to keep confidentiality and not to interfere with management of labour during data collection. The results indicate a highly significant difference between the two groups when comparing length of the process of labour, mode of delivery and the need for instrumental deliveries, episiotomies and tears, blood loss during and after delivery, the need for catheterisation following deliveries and duration of hospital stay following birth. Adverse effects were not confined to women and were found to have extended to the new-borns in the two groups again with highly significant difference with regard to birth trauma, requirement for resuscitation and medical attention. The time taken for the first breast contact was different in the two groups with possible effects which may be difficult to establish and require further research. The data provide clear evidence that the practice of FGM is associated with clinical adverse effects, which are not only confined to women but involve the newborn as well. It is hoped that this systematic and comprehensive collection of evidence will make a substantial contribution to the world wide effort to eradicate this harmful practice.

As the first analytic history of Ethiopian medicine, this thesis explores the interchange between the institutional development of a national medical network and the lived experiences of women as patients and practitioners of medicine from the years 1940-1975. Using birth and gender as mechanisms to explore the nation's public health history allows me to pursue alternative threads of enquiry: I ask questions not only about state activities and policy pursuits, but also about the relevance and acceptance of those actions in the lives of the citizenry. This thesis is also the first medical history of a non-colonial African country, opening up new questions about the role of non-Western actors in the expansion of Western medicine in the twentieth century. I explore the ways in which the exceptional history of Ethiopia can be couched in existing narratives of African modernity, medicine, and birth history. Issues of local agency and the creation of new social elites in the pursuit of modernity are all pertinent to the case of Ethiopia. Through both extensive archival research and oral interviews of nearly 200 participants in Haile Selassie's medical campaigns, I argue that the extent to which the imperial medical project in Ethiopia 'succeeded' was highly predicated on pre-existing conditions of gender, class, and geography.

Current policy (DoH 2004a), in response to critiques of the biomedical model of pregnancy, advocates choice and control for women within maternity care and promotes women as active childbirth consumers and decision-makers. This model equates choice to increased quality of experience, in the recognition that pregnancy and childbirth are both a physical and psychological experience. However to date the assumed psychological benefit of offering women choice remains unproven. The aim of this thesis is to explore women's psychology and experiences of pregnancy, and early motherhood, within the context of choice in contemporary maternity care. This will be achieved by assessing the impact of women's pregnancy and childbirth management choices on psychological well-being in the antenatal and postnatal periods and examining the ways in which women perceive and relate their experiences of pregnancy and childbirth and early motherhood in the context of their choice. This thesis argues that understanding of women's maternity experiences necessitates a need to go beyond traditional accounts. Whilst it is important to assess how women respond emotionally to pregnancy, childbirth and new motherhood, there is further a need to comprehend the meanings and understandings that women attach to their maternity experience. Hence, in an attempt to address its own critique, this study adopts a mixed methodology design and uses both a prospective cohort research design and a narrative approach within a single study. In doing so, it addresses the conflict inherent in the use of traditionally opposing methodological stances and argues for a pragmatic approach which aims to understand women's psychology and experiences through a multi-dimensional and integrated frame. Results revealed that no one care option revealed psychological benefit. The statistically significant differences observed occurred over time and exposed largely corresponding profiles across the groups. The mixed method approach promoted a powerful and illuminating interpretation of the concept of choice in maternity care. Women's narratives revealed the strong and powerful role that maternity influences and discourses play in constructing idealised identities, for women, across their maternity experience. These influences underpin and inform how women represent their psychological status and both facilitate and/or constrain maternity choices.

Unassisted childbirth--giving birth at home without a midwife or physician present--emerged as a movement in mid-20th century North America. While only a small number of women choose to give birth unassisted, its significance extends far beyond its numbers. Unassisted birth illuminates trends in maternity care practices that drive, and sometimes force, women to choose unassisted birth. It also is part of a larger set of connected values and lifestyle choices, including home schooling, breastfeeding, co-sleeping, ecological awareness, cloth diapering, sustainable living, and alternative medicine. Finally, the emergence of UC as a conscious birth choice requires a re-examination of how we understand, frame, and interpret childbirth paradigms. There is very little written about unassisted birth in the academic world, although media reports on the practice have become increasingly prevalent since 2007. This dissertation begins the conversation for a scholarly inquiry into unassisted birth. My research is based primarily on interviews, essay-response surveys, and archives of internet discussion groups. After setting unassisted birth in historical context, I explain why women make this choice; the knowledge sources they privilege; how they understand the concepts of safety, risk, and responsibility, and their complex and sometimes contradictory relationship with midwifery. I also examine midwifery, and to a smaller degree, obstetrical, perspectives on unassisted birth, focusing on how birth attendants who are sympathetic to UC reconcile that with their training and experience attending births. Unassisted birth has changed the core questions we need to ask about birth. Instead of home or hospital?, natural or epidural?, or midwife or obstetrician?, questions asked by existing models of childbirth, unassisted birth poses a different set of core questions: Is birth disturbed or undisturbed? Is it social or intimate? managed or intuitive? attended or unattended?

This research analyses the first paternal experience of childbirth and its affects on how men experience themselves as fathers. The study adopts a moral and philosophical standpoint, to ensure that the experiences of other key stakeholders in the childbirth realm are considered. This recognises that childbirth is women�s business, and how, as a male researcher, I have the potential to impose my views from a position of social dominance. Qualitative data were collected from twenty four participants who described their experiences of childbirth, in five focus groups. Participants were men whose first experience of childbirth occurred from as recently as one month to five years ago. Twelve participants were then involved in individual interviews to discuss, in depth, their experiences of fathering. An interview was also conducted with a midwife to illuminate her experiences of men and childbirth. Using interpretive interactionism as the chosen method for data analysis, I have identified the first paternal experience of childbirth as an epiphany in its major form. Epiphanies of which there are four types; the major, the cumulative, the minor illuminative and the relived, are those experiences that have the potential to transform and even radically alter peoples lives, and how they define themselves and their relations with others (Denzin,1989b:15). Data were phenomenologically analysed and six primary childbirth and fathering themes have been identified. Men�s first experience of childbirth entails emotions that range from fear and anger to awe and amazement. The reason that this life experience constitutes an epiphany for men, is that it affects how they experience themselves as fathers. The memory of their partner�s labour and birth pain is significant in how men construct their paternal identity. Important to men is the ability to biologically sire a child, and in particular a son, the need to create the child in men�s own likeness and responsibility for financial provision and discipline of the child.

This thesis is about the pregnancy and childbirth experiences of two different groups of Asian women in Britain. It sets out to address the issues surrounding pregnancy and childbirth from the women's point of view. This is an attempt to redress the balance in the previous research on Asian women which has often portrayed them as a homogeneous group with "problems`. An overview of the literature focuses on how Asian communities and, in particular, Asian women are portrayed. In order to provide a context for the issues which emerge in this research, attention is paid, first, to how Asian communities and, in particular Asian women, are viewed by mainstream society and, second, to cultural attitudes towards the sexual politics of reproduction. The main theme of the research is the degree of control the women were able to exercise given the constraints of western medicalised childbirth practices in Britain, traditional childbirth practices and the role played by the women`s relatives during pregnancy and childbirth. The study draws on in-depth interviews (during and after pregnancy) with two samples of Asian women- the first Gujarati, the second Bangladeshi. In addition, two Gujarati case studies and two Bangladeshi case studies provide further insights into the lives of these two groups of women. The women's perceptions of their experiences of pregnancy and childbirth are emphasised by the use of the actual quotes which give some indication of the way these women conceptualised the issues which confronted them. The final chapter of the thesis concludes with a discusses of the position of Asian women within the current childbirth debate and makes suggestions for improving the delivery of maternity services to the Gujarati and Bangladeshi women in particular and to Asian women in general.

Posttraumatic growth describes positive changes following challenging events. Although such changes are well documented there remain a number of important areas for further research, some of which are addressed in this thesis. In particular, this thesis aimed to clarify the relationship between growth and adjustment following health events, explore growth in different cultures (UK and Africa), and examine growth following childbirth using a prospective design. First, two systematic reviews were carried out to examine (i) growth following health events and (ii) maternal wellbeing in African women. The first meta-analytic review found that growth following cancer and HIV/AIDS was associated with higher levels of positive mental health, higher subjective physical health, and lower levels of negative mental health. Moderating variables were time since the event, age, ethnicity, and type of negative mental health outcome. The second review found that maternal psychological problems in African women have a similar or slightly higher prevalence than reported in developed countries. Risk factors were broadly comparable although some culture-specific factors were also found. Three research studies were conducted. The first study qualitatively explored 55 Gambian women's experiences of pregnancy, childbirth, and the postnatal period. Thematic analysis identified five themes: (1) transition to adulthood, (2) physical difficulties, (3) value of children in relation to others, (4) children as a strain, and (5) going through it alone. Prospective studies of growth following childbirth were then carried out in the UK (N=125) and The Gambia (N=101). Women completed questionnaires during their third trimester of pregnancy and up to 12 weeks after birth. A proportion of women in both countries reported growth following childbirth. In the UK, higher levels of growth were associated with caesarean sections and prenatal posttraumatic stress symptoms. In The Gambia, higher growth was associated with lower income, lower education, and higher postnatal social support.

A high proportion of women in sub-Saharan Africa survive severe negative childbirth experiences each year, yet little is known about the psychological impact of maternal experiences on the mother and her baby in those countries. There is evidence from high income countries that the effects of posttraumatic stress symptoms following childbirth on mothers and their families can be long lasting. The aim of this exploratory mixed methods study was to examine the possible association between childbirth experiences and mother-infant interactions in a purposive sample of high risk mothers who delivered at an urban tertiary hospital in Uganda. The sample comprised of 49 mothers aged between 18-38 years and their 4-5-monthold babies. Each mother-infant dyad was observed in a 10-minute video recorded social interaction at home. All mothers completed self-report questionnaires assessing demographic factors, childbirth experiences, posttraumatic stress symptoms arising from labour and delivery, postpartum depression and maternal attachment style. Individual narrative interviews with 41 mothers were conducted exploring their experiences of pregnancy, labour, delivery and time spent at the hospital post-delivery. Quantitative data was analysed using descriptive statistics, Pearson correlations, ANOVA, and hierarchical multiple regressions and the narratives using structural narrative analysis. The findings were integrated using the weave strategy. Quantitative findings showed that fear of death, emergency caesarean section and prolonged labour were the most common problems during labour and delivery. Childbirth experiences were negatively associated with mother-infant interactions. Posttraumatic stress symptoms and postnatal depression were not associated with mother-infant interactions. The women’s experiences at the hospital partially predicted mother-infant interactions. Women’s narratives showed that experiences of childbirth were influenced by the mothers’ level of planning for pregnancy, personal circumstances, and cultural and religious beliefs about childbirth. The mothers’ experiences of childbirth demonstrated elements of restitution, chaos and quest narratives, mirroring aspects of illness narratives seen in populations living with chronic health conditions. These findings show that negative childbirth experiences present risks to both women’s postnatal mental health and their interactions with their infants. Two urgently required interventions for this population of women and their babies should involve 1) hospital organisational changes and staff training on quality intrapartum care. 2) Development and provision of trauma and attachment-based interventions for mothers and their infants.