Women, Midwives, and a Medical Model of Maternity Care in Switzerland

This paper presents a case study on the organisation of maternity healthcare in Switzerland, which has a costly healthcare system with high intervention rates within an obstetric-led maternity care model. Evidence has shown that midwifery care is associated with lower cost, higher satisfaction rates amongst women and less intervention. However, in the current model, midwives are both marginalised and underutilised. The paper focusses on the distribution of power and knowledge between midwives, women and the medical model. The varying power structures that shape the maternity care system in Switzerland are examined, using a case study approach that draws on Foucault’s concepts of the gaze, surveillance, disciplinary power, and the docile body. This paper will critically analyses the model of maternity care received by women in Switzerland and how it negatively impacts on both women’s personal and midwives’ professional autonomy whilst simultaneously driving up costs. A better understanding of the underlying power structures operating within the maternity care system may facilitate the implementation of more midwifery led care currently being endorsed by the Swiss Midwifery Association and some government agencies. This could result in reduced cost and lower intervention rates

Midwifery continuity of care versus standard maternity care for women at increased risk of preterm birth : a hybrid implementation–effectiveness, randomised controlled pilot trial in the UK

Background Midwifery continuity of care is the only health system intervention shown to reduce preterm birth (PTB) and improve perinatal survival, but no trial evidence exists for women with identified risk factors for PTB. We aimed to assess feasibility, fidelity, and clinical outcomes of a model of midwifery continuity of care linked with a specialist obstetric clinic for women considered at increased risk for PTB. Methods and findings We conducted a hybrid implementation–effectiveness, randomised, controlled, unblinded, parallel-group pilot trial at an inner-city maternity service in London (UK), in which pregnant women identified at increased risk of PTB were randomly assigned (1:1) to either midwifery continuity of antenatal, intrapartum, and postnatal care (Pilot study Of midwifery Practice in Preterm birth Including women’s Experiences [POPPIE] group) or standard care group (maternity care by different midwives working in designated clinical areas). Pregnant women attending for antenatal care at less than 24 weeks’ gestation were eligible if they fulfilled one or more of the following criteria: previous cervical surgery, cerclage, premature rupture of membranes, PTB, or late miscarriage; previous short cervix or short cervix this pregnancy; or uterine abnormality and/or current smoker of tobacco. Feasibility outcomes included eligibility, recruitment and attrition rates, and fidelity of the model. The primary outcome was a composite of appropriate and timely interventions for the prevention and/or management of preterm labour and birth. We analysed by intention to treat. Between 9 May 2017 and 30 September 2018, 334 women were recruited; 169 women were allocated to the POPPIE group and 165 to the standard group. Mean maternal age was 31 years; 32% of the women were from Black, Asian, and ethnic minority groups; 70% were in employment; and 46% had a university degree. Nearly 70% of women lived in areas of social deprivation. More than a quarter of women had at least one pre-existing medical condition and multiple risk factors for PTB. More than 75% of antenatal and postnatal visits were provided by a named/partner midwife, and a midwife from the POPPIE team was present at 80% of births. The incidence of the primary composite outcome showed no statistically significant difference between groups (POPPIE group 83.3% versus standard group 84.7%; risk ratio 0.98 [95% confidence interval (CI) 0.90 to 1.08]; p = 0.742). Infants in the POPPIE group were significantly more likely to have skin-to-skin contact after birth, to have it for a longer time, and to breastfeed immediately after birth and at hospital discharge. There were no differences in other secondary outcomes. The number of serious adverse events was similar in both groups and unrelated to the intervention (POPPIE group 6 versus standard group 5). Limitations of this study included the limited power and the nonmasking of group allocation; however, study assignment was masked to the statistician and researchers who analysed the data. Conclusions In this study, we found that it is feasible to set up and achieve fidelity of a model of midwifery continuity of care linked with specialist obstetric care for women at increased risk of PTB in an inner-city maternity service in London (UK), but there is no impact on most outcomes for this population group. Larger appropriately powered trials are needed, including in other settings, to evaluate the impact of relational continuity and hypothesised mechanisms of effect based on increased trust and engagement, improved care coordination, and earlier referral on disadvantaged communities, including women with complex social factors and social vulnerability. Trial registration We prospectively registered the pilot trial on the UK Clinical Research Network Portfolio Database (ID number: 31951, 24 April 2017). We registered the trial on the International Standard Randomised Controlled Trial Number (ISRCTN) (Number: 37733900, 21 August 2017) and before trial recruitment was completed (30 September 2018) when informed that prospective registration for a pilot trial was also required in a primary clinical trial registry recognised by WHO and the International Committee of Medical Journal Editors (ICMJE). The protocol as registered and published has remained unchanged, and the analysis conforms to the original plan

Vielfalt erweiterter Hebammenrollen in Grossbritannien

Erfahrene Fachpersonen zu begleiten, um zu lernen, das haben alle schon mal getan. Um Impulse zur Gestaltung von «Advanced Practice Midwife»-Rollen in der Schweiz zu erhalten, ist auch der Blick über die Grenze wertvoll. Diese Möglichkeit haben Masterstudierende an der Berner Fachhochschule im Rahmen von «Transfer-Auslandpraktika». Eine Absolventin schaute in Grossbritannien Hebammen mit erweiterten Berufsrollen über die Schulter: einer «Specialist Female Genital Mutilation Midwife» und einer «Consultant Midwife»

Allostery in Recombinant Soluble Guanylyl Cyclase from Manduca sexta*

Soluble guanylyl/guanylate cyclase (sGC), the primary biological receptor for nitric oxide, is required for proper development and health in all animals. We have expressed heterodimeric full-length and N-terminal fragments of Manduca sexta sGC in Escherichia coli, the first time this has been accomplished for any sGC, and have performed the first functional analyses of an insect sGC. Manduca sGC behaves much like its mammalian counterparts, displaying a 170-fold stimulation by NO and sensitivity to compound YC-1. YC-1 reduces the NO and CO off-rates for the ∼100-kDa N-terminal heterodimeric fragment and increases the CO affinity by ∼50-fold to 1.7 μm. Binding of NO leads to a transient six-coordinate intermediate, followed by release of the proximal histidine to yield a five-coordinate nitrosyl complex (k6-5 = 12.8 s-1). The conversion rate is insensitive to nucleotides, YC-1, and changes in NO concentration up to ∼30 μm. NO release is biphasic in the absence of YC-1 (koff1 = 0.10 s-1 and koff2 = 0.0015 s-1); binding of YC-1 eliminates the fast phase but has little effect on the slower phase. Our data are consistent with a model for allosteric activation in which sGC undergoes a simple switch between two conformations, with an open or a closed heme pocket, integrating the influence of numerous effectors to give the final catalytic rate. Importantly, YC-1 binding occurs in the N-terminal two-thirds of the protein. Homology modeling and mutagenesis experiments suggest the presence of an H-NOX domain in the α subunit with importance for heme binding