From home to hospital : 'safe motherhood', hospitalisation and the birthing transition in Thailand (1945-2006)

This research explores Thailand's birthing transition (1945-2006), analysing socio-political contexts, identifying key determinants, describing change processes, outcomes and impact, including women's experiences. Maternal mortality decreased substantially from the mid-1900s, when lay-midwife-attended homebirth was usual. Nevertheless, following widespread hospitalisation, a caesarean "epidemic" transpired and birthing became dehumanised. What influenced this transition? Is birth 'safer'? To what extent does the contemporary maternity system support woman-centred, evidence-based, equitable, quality care? Using a multidisciplinary, mixed-methods approach, this study analysed qualitative and quantitative data from national datasets and in-depth interviews with diverse women and informants. Findings detail major changes in birthing ecologies, cultures, outcomes, and women's experiences. Historically, birthing incorporated holistic support from trusted caregivers, utilising rituals, empowering most women to birth successfully. Complications and deaths did occur, where cosmological influences were implicated. Maternal mortality was already 'low' before widespread hospitalisation. According to internationally-advocated 'safe motherhood' strategies; reduced fertility, and potentially 'skilled attendants', had the greatest impact, along with improvements in women's wellbeing. These assertions are supported by evidence of poorer health and outcomes among marginalised populations where health improvements have lagged, and access to reproductive services is problematic. The importance of pro-equity strategies addressing the social determinants of maternal health, are highlighted. Birthing has been redefined, now largely technocratic. The biomedical, obstetric care model predominates, influenced by perceptions of safety and comfort, while midwifery-led care is unavailable. Institutionalised birthing has accompanied the proliferation of policies and practices that are not evidence-based, have resulted in increased iatrogenic risks through overmedicalisation, produced minimal widespread outcomes improvements, and is rarely woman-centred, as women's rights are not often actualised. System-wide inequities were observed, where obstetric services are high-cost, privilege doctors and private providers, while poor, rural, and ethnic-minority women remain disadvantaged with limited access to resources for health. Significant parallels were found between industrialised-country transitions and that occurring in industrialising settings. Increased demand for biomedicalised birth occurred through a transference process. Despite a largely 'successful' care model, according to women's desires for safety and comfort, biomedical knowledge acquired authoritative status, while lay-midwifery care was subjugated. Biomedicine became culturally acceptable, as women believed their experiences could be improved, transferring trust from traditional care. Conversely, much about 'traditional' care is supported by current evidence, and modern-day childbirth does not always promote healthy outcomes. 'Traditional' knowledge could enhance contemporary care. Findings support a reorientation of maternity services, to offer quality midwifery-led care, thereby protecting and promoting humanised, normal and healthy birth, achieving broad health improvements. Findings are relevant to policy-makers internationally, seeking to improve maternal health, prevent deaths, and promote healthy experiences and outcomes. Following international health and rights definitions, I assert evidence supports the widespread acceptance of 'social' care models including midwifery-led care as a primary strategy, and these should be supported through international initiatives. I argue a reorienting of 'safe motherhood' is needed to put women first, since 'safety' is more than survival, that risk discourses be balanced with normalcy, that women's experiences be optimised through respecting their rights; to ensure care is woman-centred, evidence-based, quality, equitable and sustainable

Better together: a qualitative exploration of women’s perceptions and experiences of group antenatal care using focus groups and interviews

Problem. Childbearing women from socio-economically disadvantaged communities and minority ethnic groups are less likely to access antenatal care and experience more adverse pregnancy outcomes. Background. Group antenatal care aims to facilitate information sharing and social support. It is associated with higher rates of attendance and improved health outcomes. Aims. To assess the acceptability of a bespoke model of group antenatal care (Pregnancy Circles) in an inner city community in England, understand how the model affects women’s experiences of pregnancy and antenatal care, and inform further development and testing of the model. Methods. A two-stage qualitative study comprising focus groups with twenty six local women, followed by the implementation of four Pregnancy Circles attended by twenty four women, which were evaluated using observations, focus groups and semi-structured interviews with participants. Data were analysed thematically. Findings. Pregnancy Circles offered an appealing alternative to standard antenatal care and functioned as an instrument of empowerment, mediated through increased learning and knowledge sharing, active participation in care and peer and professional relationship building. Multiparous women and women from diverse cultures sharing their experiences during Circle sessions was particularly valued. Participants had mixed views about including partners in the sessions. Conclusions. Group antenatal care, in the form of Pregnancy Circles, is acceptable to women and appears to enhance their experiences of pregnancy. Further work needs to be done both to test the findings in larger, quantitative studies and to find a model of care that is acceptable to women and their partners

With good intentions: complexity in unsolicited informal support for Aboriginal and Torres Strait Islander peoples. A qualitative study

<p>Abstract</p> <p>Background</p> <p>Understanding people's social lived experiences of chronic illness is fundamental to improving health service delivery and health outcomes, particularly in relation to self-management activity. In explorations of social lived experiences this paper uncovers the ways in which Aboriginal and Torres Strait Islander people with chronic illness experience informal unsolicited support from peers and family members.</p> <p>Methods</p> <p>Nineteen Aboriginal and Torres Islander participants were interviewed in the Serious and Continuing Illness Policy and Practice Study (SCIPPS). Participants were people with Type 2 diabetes (N = 17), chronic obstructive pulmonary disease (N = 3) and/or chronic heart failure (N = 11) and family carers (N = 3). Participants were asked to describe their experience of having or caring for someone with chronic illness. Content and thematic analysis of in-depth semi-structured interviews was undertaken, assisted by QSR Nvivo8 software.</p> <p>Results</p> <p>Participants reported receiving several forms of unsolicited support, including encouragement, practical suggestions for managing, nagging, growling, and surveillance. Additionally, participants had engaged in 'yarning', creating a 'yarn' space, the function of which was distinguished as another important form of unsolicited support. The implications of recognising these various support forms are discussed in relation to responses to unsolicited support as well as the needs of family carers in providing effective informal support.</p> <p>Conclusions</p> <p>Certain locations of responsibility are anxiety producing. Family carers must be supported in appropriate education so that they can provide both solicited and unsolicited support in effective ways. Such educational support would have the added benefit of helping to reduce carer anxieties about caring roles and responsibilities. Mainstream health services would benefit from fostering environments that encourage informal interactions that facilitate learning and support in a relaxed atmosphere.</p