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Background: Gestational diabetes mellitus (GDM) affects between 2-40% of pregnancies worldwide, depending on diagnostic and screening methods. Changes in screening practices are not well understood because administrative sources lack data on whether or how individuals were screened. The objectives of this thesis were to: 1) validate a method to identify prenatal screening for GDM and other conditions in administrative health data; 2) describe changes in GDM screening; 3) evaluate the relative contributions of screening and population characteristics to changes in GDM risk; 4) characterize the impact of the COVID-19 pandemic on pregnancy weight gain and infant birthweight. Methods: Laboratory billing records from BC’s universal health insurance system for prenatal screening tests were compared with medical records by calculating validation properties. All pregnancies (birth >20wks or >500g) in British Columbia, Canada, 2005-2019, with linked perinatal health and administrative data, were used to examine time trends in GDM screening methods, trends within subgroups, and the effect of screening changes on prevalence. A second cohort from Washington State, 2016-2020, was analyzed using an interrupted time series design, to assess COVID-19 impacts on pregnancy weight gain and infant birthweight using z-scores. Results: GDM screening in laboratory billing records had a high sensitivity (97% [95% CI: 90, 99]) and specificity (>99% [95% CI: 86,

Background:Quality improvement initiatives require collective and coordinated actions from multiple members of a health care organization. Preparing health workers prior to implementation by assessing their organizational readiness for change (ORC) may be effective for ensuring greater implementation success. Although common in other fields, measuring readiness in health organizations is less common, especially in lower- and middle-income countries (LMIC). This study aims to assess ORC in multiple Indonesian hospitals prior to implementation of a maternal and newborn quality improvement program.Methods:The Organizational Readiness for Change Assessment (ORCA) measurement tool based on the Promoting Action on Research in Health Services (PARIHS) was adapted to the Indonesian context, then internal reliability and factor structure of the primary scales was examined: evidence, context, and facilitation. The Indonesian version of the instrument was administered to respondents in hospitals prior to engagement in program implementation (n=36). Then linear regression analyses were conducted to examine associations between hospital level ORC scores and multiple outcomes of program implementation success, including performance of maternal and newborn clinical standards and provision of related services while adjusting for education level, clinical experience, and leadership experience.Results:Cronbach alpha for the three scales was 0.72, 0.94, 0.97, respectively; confirmatory factor analysis showed good fit for models including items on each of the three scales. The ORCA context scale was positively associated with performance of two maternal clinical standards. A higher ORCA context score was associated with greater implementation of active management of the third stage of labor after one and two implementation quarters (beta = 27.35, 95%CI 1.27, 53.44; beta = 27.71, 95%CI 3.29, 41.59). A higher ORCA context score was also associated with greater implementation of management of severe pre-eclampsia/eclampsia after two and three implementation quarters (beta = 37.46, 95%CI 13.52, 61.41; beta =33.31, 95%CI 8.68, 57.94).Conclusion:This study confirmed the reliability and validity of the ORCA instrument in a middle-income country and added evidence for the utility of assessing ORC prior to quality improvement initiatives in healthcare environments. Health care organizations in LMICs may improve the likelihood of success by addressing ORC prior to program implementation.

Background: Clinical practice guidelines indicate that over 80% of women with a previous caesarean should be offered a planned vaginal birth after caesarean (VBAC), however only one third of eligible women choose to plan a VBAC. Shared decision-making (SDM) interventions support women to make choices based on their informed preferences. To facilitate implementation of SDM it is necessary to understand the patient (micro), health services (meso), and policy (macro) factors that influence decision-making. Objectives: My objective is to explore attitudes toward and experiences with decision-making for mode of birth after caesarean section in British Columbia (BC) to identify factors that influence implementation of SDM. Methods: In-depth, semi-structured interviews were conducted with women eligible for VBAC, care providers, and health service decision makers recruited from three rural and two urban BC communities. Integrated knowledge translation (iKT) principles guided study design, while constructivist grounded theory informed iterative data collection and analysis. Findings were interpreted using complex adaptive systems theory (CAS). Results: Analysis of interviews (n=57) and CAS interpretation revealed that the factors influencing decisions resulted from interactions between the micro, meso, and macro levels of the health care system. Women formed early preferences for mode of delivery (after the primary caesarean) through careful deliberation of the social risks and benefits of mode of delivery. Physicians acted as information providers of clinical risks and benefits, with limited discussion of patient preferences. Decision makers serving large hospitals revealed concerns related to liability and patient safety. These stemmed from limited access to surgical resources, which had resulted from budget constraints. To facilitate mutual understanding among stakeholder groups, iKT activities included policy dialogues and the creation of a policy brief. Conclusion: To facilitate the effective implementation of SDM in clinical practice for mode of delivery after a previous caesarean section, it is necessary to address the needs of women, care providers, and decision makers. These include initiating decision support immediately after the primary caesarean, assisting women to address the social risks that influence their preferences, managing perceptions of risk related to patient safety and litigation among physicians, and access to surgical resources.

Background: Given a paucity of information regarding the impact of expanding access to highly active antiretroviral therapy (HAART) on sexual and reproductive decision-making and behaviours of women in high HIV prevalence settings in sub-Saharan Africa, the objectives of thesis were: To assess whether use and duration of HAART was associated with (1) recent sexual activity among HIV-positive women across three high HIV prevalence settings; (2) fertility intentions and (3) contraceptive use and method mix patterns among women in Soweto, South Africa. And, (4) to develop a reliable HAART optimism scale for use among HIV-positive women and to test the scale’s validity against measures of sexual and reproductive decision-making and behaviours among women in Mbarara, Uganda.Methods: Quantitative data were drawn from surveys and medical record reviews conducted among 751 women attending the Perinatal HIV Research Unit in Soweto, South Africa (253 HAART-experienced, 249 HAART-naïve, and 249 HIV-negative) and 540 HIV-positive women (half of whom were receiving HAART) attending Mbarara University’s HIV clinic in Uganda. Surveys assessed socio-demographics, HIV status and HAART history, sexual and reproductive health decision-making and behaviours, HIV-related clinical assessments, and HAART optimism.Results: The analyses revealed that HIV-positive women receiving HAART are more likely to use contraception overall and dual protection in particular, with minimal differences in fertility intentions or sexual activity relative to their HAART-naïve counterparts. Moreover, optimism about the effects of HAART, rather than actual use or non-use, may be a more important predictor of fertility intentions and sexual activity of HIV-positive women. Overall, HIV-positive women are less likely to report fertility intentions and more likely to use contraception (and condoms in particular) relative to HIV-negative women from the same community.Conclusions: The findings highlight the potential great value and urgent need for improved integration between HIV prevention, testing, and HAART services and sexual and reproductive health (SRH) programming to address the diverse SRH needs of HIV-infected and –affected women in HIV endemic settings. Such integration is essential to better support the rights of all women to be sexually active and safely achieve their reproductive goals, while minimizing HIV transmission risks.