Perinatal mental disorders in Switzerland : prevalence estimates and use of mental-health services

Background: Perinatal mental disorders (PMDs) are the most common complication of pregnancy and the first postpartum year. Since PMD prevalence and use of mental-health services by perinatal women in Switzerland are unknown, we analysed existing health statistics. Methods: We used statistics from a large health insurance company, hospitals and freelance midwives. We assessed the annual rates of mental healthcare use in perinatal women (n = 13 969). We ascertained the annual rates of PMD treatment in obstetric inpatients (n = 89 699), and annual rates of PMD records by freelance midwives (n = 57 951). In 15 104 women who gave birth in 2012 or 2013, we assessed use of mental-healthcare before and during pregnancy, and in the postpartum year. For the same sample, we determined proportions of medication and consultation treatments. We used multiple regression analysis to estimate the influence of PMD on overall healthcare costs of mandatory health insurance. Results: The annual rate of mental-healthcare use by perinatal women was 16.7%. The annual rate of PMD treatment in obstetric inpatients was 1.1%. The annual rate of PMD records in the midwifery care setting was 2.9%. Women with PMD use mental health services mainly in non-obstetric outpatient settings. Medication was the most frequent treatment. Primary care providers and mental health specialists contributed almost equally to consultation treatments. PMD during pregnancy raised overall costs of healthcare in the postpartum year by 1214 Swiss francs. Conclusions: Health-system research and perinatal healthcare should take into consideration the high prevalence of PMD. Real PMD prevalence may be even higher than our data suggest and could be assessed with a survey using our model of PMD prevalence

Differing needs of mothers and fathers during their child’s end-of-life care: secondary analysis of the “Paediatric end- of-life care needs” (PELICAN) study

Background: Mothers and fathers are severely challenged when providing care for their terminally ill child at end of life. Caregiving needs have been studied predominantly in mothers. Differences in caregiving needs between mothers and fathers during their child’s end of life have not, however, been explored so far. This knowledge is of importance to best meet individual parental needs in paediatric end-of-life care. Methods: Secondary analysis of a quantitative survey on parental needs during their child’s last 4 weeks of life, collected in the Swiss multicentre “Paediatric End-of-Life Care Needs” (PELICAN) study. Caregiving needs of mothers and fathers (parental dyad) who had lost a child due to a cardiological, neurological or oncological disease or during the neonatal period in the years 2011–2012 were retrospectively assessed using a questionnaire representing six evidence-based quality domains of paediatric palliative and end-of-life care. Results: Seventy-eight parental dyads were included in this analysis. Differences between mothers and fathers were mostly found around needs to be supported as a family. In all, 28 out of 34 needs-related questionnaire items were scored higher by mothers than by fathers, indicating higher importance for that need to be met. The results indicate that these differences might relate to different caregiving roles and gender-specific coping strategies. Conclusions: To best meet parental needs in paediatric end-of-life care, particular attention should be paid to both mothers and fathers and their specific caregiving roles, as differences in these roles might influence their needs in this exceptional situation. Therefore, healthcare professionals should identify how parental dyads mutually navigate care for their sick child to best meet their needs in support. Additionally, mothers and fathers should be supported in their individual coping strategies

Barriers and facilitators of maternal healthcare utilisation in the perinatal period among women with social disadvantage: A theory-guided systematic review

Background: Women with social disadvantage have poorer perinatal outcomes compared to women in advantaged social positions, which may be linked to poorer healthcare utilisation. Disadvantaged groups may experience a greater diversity of barriers (e.g., feeling embarrassed about pregnancy, lack of transportation) or barriers judged to be particularly difficult (e.g., embarrassment about pregnancy). They may also experience barriers more frequently (e.g., depression). Using Levesque et al.’s (2013) framework of healthcare access, our review identifies the barriers and facilitators that affect maternal healthcare utilisation in the perinatal period among women with social disadvantage in high-income nations. Objectives: Our review searches for the barriers and facilitators affecting maternal healthcare utilisation in the perinatal period, from pregnancy to the first year postpartum, among women with social disadvantage (Prospero registration CRD42020151506). Design: We conducted a theory-guided systematic review. PubMed, Embase, MEDLINE, PsycINFO, and Social Science Citation Index databases were searched for publications between 1999 and 2018. Findings: 37 articles out of 12’972 were included in the qualitative synthesis. 19 domains of barriers and facilitators were extracted. Domains on the provider side includes ‘information regarding available treatments’ and ‘trustful relationships.’ On the user-side, domains include ‘awareness of pregnancy’ and ‘unplanned/unwanted pregnancy’ Key conclusions: Provider- and user-side characteristics interact to affect access. User-side characteristics that pose a barrier can be offset by provider-side characteristics that lower barriers to access. Implications for practice: User-side characteristics (e.g., lack of awareness of pregnancy) play an important role in the initial steps toward access. Among women with social disadvantage, reducing barriers may require active outreach on the part of providers

Mediating processes underlying the associations between maternal obesity and the likelihood of cesarean birth.

BACKGROUND Pregnant women with obesity are more likely to experience cesarean birth compared to women without obesity. Yet, little is known about the underlying mechanisms. The objective of this study was therefore to evaluate how mediators contribute to the association between obesity and prelabor/intrapartum cesarean birth. METHODS We retrospectively analyzed Swiss cohort data from 394,812 singleton, cephalic deliveries between 2005 and 2020. Obesity (BMI ≥ 30 kg/m2 ) was defined as the exposure and prelabor or intrapartum cesarean birth as the outcomes. Hypothesized mediators included gestational comorbidities, large-for-gestational-age infant, pregnancy duration >410/7 weeks, slower labor progress, labor induction, and history of cesarean birth. We performed path analyses using generalized structural equation modeling and assessed mediation by a counterfactual approach. RESULTS Women with obesity had a cesarean birth rate of 39.36% vs. 24.12% in women without obesity. The path models mainly showed positive direct and indirect associations between obesity and cesarean birth. In the total sample, the mediation models explained up to 39.47% (95% CI 36.92-42.02) of the association between obesity and cesarean birth, and up to 57.13% (95% CI 54.10-60.16) when including history of cesarean birth as mediator in multiparous women. Slower labor progress and history of cesarean birth were found to be the most clinically significant mediators. CONCLUSIONS This study provides empirical insights into how obesity may increase cesarean birth rates through mediating processes. Particularly allowing for a slower labor progress in women with obesity might reduce cesarean birth rates and prevent subsequent repeat cesarean births in multiparous women

Adverse perinatal outcomes for obese women are influenced by the presence of comorbid diabetes and hypertensive disorders

Maternal obesity often occurs together with comorbid diabetes and hypertensive disorders. All three conditions are independently associated with negative perinatal outcomes. Our objective was to determine the risk and burden of adverse perinatal outcome that could be attributed to maternal obesity in combination with a comorbid status. We analyzed data from 324'664 singleton deliveries in Switzerland between 2005 and 2016. For the association of maternal obesity in the presence or absence of comorbidities with various perinatal outcomes, we estimated adjusted relative risk (RR) using multivariable regression modeling and determined the multivariable-adjusted attributable fraction of the population (AFp). Obesity was a main predictor for macrosomia, fracture of the clavicle, failure to progress in labor and prolonged labor. By stratifying women based on comorbidities, we identified significantly increased risk for preterm birth and early neonatal death only for women diagnosed with a comorbidity. However, various other outcomes were independently associated with either obesity or comorbidities. The AFp showed greatest reduction in comorbidities (15.4/15.0/13.2%), in macrosomia (6.3%) and in shoulder dystocia (4.8%) if all women were to become non-obese. We suggest that comorbidities such as diabetes and hypertensive disorders should be considered when relating maternal obesity to adverse perinatal outcomes

Perinatal mental health care from the user and provider perspective: protocol for a qualitative study in Switzerland

Background: Mental disorders in the perinatal period (PMD) can severely harm women and their children if not detected early and treated appropriately. Even though mental health care is covered by health insurance and is used widely by women in the perinatal period in Switzerland, it is not known if the care provided is meeting the needs of the patients and is efficient in the view of health care professionals. The aim of this study is to identify strengths, gaps and requirements for adequate mental health care in the perinatal period from the perspectives of patients and care providers for a wide range of relevant mental disorders. Methods: In the qualitative study we conduct (1) semi-structured single interviews with former PMD patients to obtain narratives about their experiences and needs for health care for their condition. Women are included who have been treated for PMD but are mentally stable at the time of the interview (n = 24). We will stratify the sample by 4 clusters of relevant ICD-10 F-diagnoses, covering the most frequent and the most severe mental disorders. We will further stratify the sample based on whether the women already had experience with psychiatric or psychological health care or not before their last episode of PMD. We will also conduct (2) three interprofessional focus groups with health and social care professionals involved in perinatal care, and a health insurance representative. The focus groups will consist of 5–8 professionals. Data collection and thematic analysis will consider Levesque’s et al. (2013) conceptual model on access to health care. Discussion: The study will provide fundamental data on the experiences and perspectives about perinatal mental health care from user and provider perspectives. The study will generate the evidence base needed to develop models of integrated, coordinated, patient- and family-centred care that is accessed by women with various types of PMD. Trial registration: The study was registered on ClinicalTrials.gov in November 2019 under the identifier NCT04185896

Informal coercion during childbirth: risk factors and prevalence estimates from a nationwide survey of women in Switzerland

Background: In many countries, the increase in facility births is accompanied by a high rate of obstetric interventions. Lower birthrates or elevated risk factors such as women’s higher age at childbirth and an increased need for control and security cannot entirely explain this rise in obstetric interventions. Another possible factor is that women are coerced to agree to interventions, but the prevalence of coercive interventions in Switzerland is unknown. Methods: In a nationwide cross-sectional online survey, we assessed the prevalence of informal coercion during childbirth, women’s satisfaction with childbirth, and the prevalence of women at risk of postpartum depression. Women aged 18 years or older who had given birth in Switzerland within the previous 12 months were recruited online through Facebook ads or through various offline channels. We used multivariable logistic regression to estimate the risk ratios associated with multiple individual and contextual factors. Results: In total, 6054 women completed the questionnaire (a dropout rate of 16.2%). An estimated 26.7% of women experienced some form of informal coercion during childbirth. As compared to vaginal delivery, cesarean section (CS) and instrumental vaginal birth were associated with an increased risk of informal coercion (planned CS risk ratio [RR]: 1.52, 95% confidence interval [1.18,1.96]; unplanned CS RR: 1.92 [1.61,2.28]; emergency CS RR: 2.10 [1.71,2.58]; instrumental vaginal birth RR: 2.17 [1.85,2.55]). Additionally, migrant women (RR: 1.45 [1.26,1.66]) and women for whom a self-determined vaginal birth was more important (RR: 1.15 [1.06,1.24]) more often reported informal coercion. Emergency cesarean section (RR: 1.32 [1.08,1.62]), being transferred to hospital (RR: 1.33 [1.11, 1.60]), and experiencing informal coercion (RR: 1.35 [1.19,1.54]) were all associated with a higher risk of postpartum depression. Finally, women who had a non-instrumental vaginal birth reported higher satisfaction with childbirth while women who experienced informal coercion reported lower satisfaction. Conclusions: One in four women experience informal coercion during childbirth, and this experience is associated with a higher risk of postpartum depression and lower satisfaction with childbirth. To prevent traumatic after- effects, health care professionals should make every effort to prevent informal coercion and to ensure sensitive aftercare for all new mothers

El MERCOSUR frente al ALCA: Perspectivas de su implementación para nuestra región

Para iniciar el análisis del “MERCOSUR frente al ALCA” vamos a partir de la siguiente afirmación: El Sistema Internacional, al igual que el Sistema Social, presenta desigualdades muy marcadas entre sus componentes, desigualdades éstas que en vez de reducirse han tendido a incrementarse con el correr del tiempo. Ampliándose inclusive la brecha entre ricos y pobres en los últimos 30 años.Instituto de Integración Latinoamericana (IIL

El MERCOSUR frente al ALCA: Perspectivas de su implementación para nuestra región

Para iniciar el análisis del “MERCOSUR frente al ALCA” vamos a partir de la siguiente afirmación: El Sistema Internacional, al igual que el Sistema Social, presenta desigualdades muy marcadas entre sus componentes, desigualdades éstas que en vez de reducirse han tendido a incrementarse con el correr del tiempo. Ampliándose inclusive la brecha entre ricos y pobres en los últimos 30 años.Instituto de Integración Latinoamericana (IIL

‘We felt like part of a production system’: A qualitative study on women’s experiences of mistreatment during childbirth in Switzerland

Introduction Mistreatment during childbirth is an issue of global magnitude that not only violates fundamental human rights but also seriously impacts women’s well-being. The purpose of this study was to gain a better understanding of the phenomenon by exploring the individual experiences of women who reported mistreatment during childbirth in Switzerland. Materials and methods This project used a mixed methods approach to investigate women’s experiences of mistreatment during childbirth in general and informal coercion specifically: The present qualitative study expands on the findings from a nationwide online survey on childbirth experience. It combines inductive with theoretical thematic analysis to study the 7,753 comments women wrote in the survey and the subsequent interviews with 11 women who reported being mistreated during childbirth. Results The women described a wide range of experiences of mistreatment during childbirth in both the survey comments and the interviews. Out of all survey participants who wrote at least one comment (n = 3,547), 28% described one or more experiences of mistreatment. Six of the seven types of mistreatment listed in Bohren and colleagues’ typology of mistreatment during childbirth were found, the most frequent of which were ineffective communication and lack of informed consent. Five additional themes were identified in the interviews: Informal coercion, risk factors for mistreatment, consequences of mistreatment, examples of good care, and what’s needed to improve maternity care. Conclusion The findings from this study show that experiences of mistreatment are a reality in Swiss maternity care and give insight into women’s individual experiences as well as how these affect them during and after childbirth. This study emphasises the need to respect women’s autonomy in order to prevent mistreatment and empower women to actively participate in decisions. Both individual and systemic efforts are required to prevent mistreatment and guarantee respectful, dignified, and high-quality maternity care for all