Midwifery: A name to conjure with?

This article is a reflection on the question of what meaning is attached to the professional terms we use to describe ‘a midwife’ internationally and whether this matters. During the 33rd International Confederation of Midwives Triennial Congress in Bali last summer a wide range of midwives were asked what name is given to midwives in their country and this is an account of the conversations that followed

Exploration of Perceptions and Attitudes of Couples in the Preconception Period in Relation to Healthy Eating and Healthy Body Weight: A Qualitative Study.

Evidence suggests that parental overweight/obesity during the preconception period, which can be a year before conception [1], may adversely affect offsprings’ metabolic health in later life [2]. This study aimed to explore couples’ perceptions toward healthy eating and lifestyles in the preconception period, which can help inform the development of targeted interventions. Eight pregnancy-planning couples were recruited using purposive–snowballing sampling and participated in a semi-structured online interview. Recordings were anonymised, transcribed verbatim, and analysed using phenomenological thematic analysis [3]. Couples’ mean overall age was 34.3 years, and BMI was 26.8 kg/m2, while the majority held a postgraduate degree (n = 9). Data analysis revealed seven themes: mental health matters; lifestyle behaviours that could change; physical health matters; establishing healthier habits; all things diet; preconception knowledge; and need for guidance. Data indicated limited preconception knowledge, particularly evident in men. During our interview, most men realised that men’s preconception period can be important, indicating a lack of knowledge, and expressed interest in learning more: “…I would be happy also to ask for a professional advice, I’m just not sure if I would before this interview-if I would consider it necessary, now I do to be honest…”. The main motivators for making any dietary or lifestyle changes were to support maternal health, offer the “best start” to their child, and ensure they did the best they could to support a pregnancy. Most participants looked for information online when unsure and would welcome an online educational tool with opportunities to ask questions. Many explained that it is important to avoid information overload, while a few explained they did not look for information at all. Stress was a significant factor affecting efforts to implement changes (diet, smoking, body weight, sleep, exercise) and was one of the main behaviours that participants wanted to manage. Based on the results of this study, there is a paucity of knowledge around men’s preconception health. An online interactive education tool could support couples in the preconception period to achieve healthier habits

Adaptation to experimental jet-lag in R6/2 mice despite circadian dysrhythmia.

The R6/2 transgenic mouse model of Huntington's disease (HD) shows a disintegration of circadian rhythms that can be delayed by pharmacological and non-pharmacological means. Since the molecular machinery underlying the circadian clocks is intact, albeit progressively dysfunctional, we wondered if light phase shifts could modulate the deterioration in daily rhythms in R6/2 mice. Mice were subjected to four x 4 hour advances in light onset. R6/2 mice adapted to phase advances, although angles of entrainment increased with age. A second cohort was subjected to a jet-lag paradigm (6 hour delay or advance in light onset, then reversal after 2 weeks). R6/2 mice adapted to the original shift, but could not adjust accurately to the reversal. Interestingly, phase shifts ameliorated the circadian rhythm breakdown seen in R6/2 mice under normal LD conditions. Our previous finding that the circadian period (tau) of 16 week old R6/2 mice shortens to approximately 23 hours may explain how they adapt to phase advances and maintain regular circadian rhythms. We tested this using a 23 hour period light/dark cycle. R6/2 mice entrained to this cycle, but onsets of activity continued to advance, and circadian rhythms still disintegrated. Therefore, the beneficial effects of phase-shifting are not due solely to the light cycle being closer to the tau of the mice. Our data show that R6/2 mice can adapt to changes in the LD schedule, even beyond the age when their circadian rhythms would normally disintegrate. Nevertheless, they show abnormal responses to changes in light cycles. These might be caused by a shortened tau, impaired photic re-synchronization, impaired light detection and/or reduced masking by evening light. If similar abnormalities are present in HD patients, they may suffer exaggerated jet-lag. Since the underlying molecular clock mechanism remains intact, light may be a useful treatment for circadian dysfunction in HD

The effectiveness of couples’ lifestyle interventions (Randomised Controlled Trials) on weight change: A systematic review and meta-analysis

Background: Obesity is still a major public health concern and a plethora of lifestyle-interventions targeting weight-loss at individual level have shown poor success. Health related behaviours including eating, tend to be concordant in couples which means they might share an obesity risk or support each other’s effort to change these behaviours i.e. weight loss. The aim of this systematic review (SR) and meta-analysis (MA) of randomised controlled trials (RCTs) was to assess the weight change effects of lifestyle interventions targeting couples compared to individuals or no-intervention

Caesarean Section rates in South Asian cities: Can midwifery help stem the rise?

Introduction: Caesarean section (CS) is a life-saving surgical intervention for delivering a baby when complications arisein childbirth. World Health Organization recommends a rate of CS from 10% to 15%. However, CS rates increased steadily in recent decades and have almost doubled from 12.1% in 2000 to 21.1% in 2015. Therefore, this has become a global public health problem. The main purpose of the scoping review article is to give an overview and analysis of the rising CS use in four South Asian countries: Bangladesh, India, Nepal and Pakistan. Methods: A scoping review was carried-out using several bibliographic electronic databases (MEDLINE, EMBASE, SCOPUS, CINAHL and Web of Science), organizational websites and open access journal databases. Literature was searched from December 2011 to December 2018 for articles reporting hospital-based CS rates.Inclusion criteria were primary studies conducted ininstitutional setting in Bangladesh, India, Nepal and Pakistan and published in the English language. Results: We have included 43 studies. Together these studies show that the rate of CS is increasing in all four countries: Nepal, Bangladesh, Pakistan and India. However, this isuneven with very low rates in rural and very high rates in urban settings, theco-existence of ‘Too Little Too Late & Too Much Too Soon’. Hospital based studies have shown that the CS rate is higher in urban and private hospitals. Age, education andsocio-economic status of women, urban residence and distance from health facility are associated with CSs. CS is higher among highlyeducated affluent urban women in private hospitals in South Asian Countries. Conclusion: Rising CS rates in South Asian cities, particularly in specific groups of women, present a challenge to hospital staff and managers and policy-makers. The challenge is to avoid ‘Too Much Too Soon’ in otherwise healthy urban women and avoid ‘Too Little Too Late’ in women living in remote and rural area and in poor urban women

Factors contributing to rising cesarean section rates in South Asian countries: A systematic review

Rising cesarean section (CS) rates are a global public health problem. The systematic review investigates key indications for performing CS and factors significantly associated with the rising rate of CS in South Asia. Primary studies in South Asia published between January 2010 and December 2018 were searched using relevant electronic databases: MEDLINE, Scopus, PubMed, Web of Science, CINAHL, NepJOL, and BanglaJOL. A narrative synthesis of the indications for performing CS and factors significantly associated with the rising CS rates was performed using content analysis. A total of 68 studies were included in this review. The most common medical indication for CS was fetal distress, followed by previous CS, antepartum hemorrhage (including placenta previa/abruption), cephalopelvic disproportion, failed induction, hypertensive disorders in pregnancy, oligohydramnios, and non-progress of labor. Maternal request was the most common non-medical indication for conducting CS. Higher maternal age was the most common significant factor associated with the rising CS rate followed by higher maternal education, urban residency, higher economic status, previous CS, pregnancy/childbirth complications, and lower parity/nulliparity. Preference for CS and increasing private number hospital were also factors contributing to the rising rate. Several key indicators and factors significantly associated with rising CS rate are revealed. These key indicators and significant factors reflect the global trend. Reduction in the use of primary CS, unless medically warranted, would help stem rates of CS. Realistic and candid explanation to pregnant women and their families regarding the benefits of vaginal birth for women and babies should form an integral part of maternity care as these are issues of public health

A brief history and indications for cesarean section

Cesarean section (CS) is one of the oldest surgical operations. Originally,this surgery was performed post-mortem by cutting open the woman’s abdomen to remove a dead or alive fetus. It was therefore not intended for saving the mother in ancient times. Roman law and religious rituals shaped the procedure until the Middle Ages. At that time, the indication of CS was only post-mortem. Although CS became a medical procedure in the Renaissance, maternal mortality was extremely high, mainly due to hemorrhage and puerperal infection. The reason for performing CS was to rescue the mother and fetus from protracted labor as a last resort. Since the late 19th century, with the introduction of chloroform and the developments of surgical techniques, and the availability of blood transfusion in the early twentieth century, CS became a relatively safe procedure, further helped by the introduction of antibiotics after World War II. Then, CS was increasingly an intervention to preserve the health and safety of both mother and fetus. During the 21st century, CS has been performed even without medical indication, such as maternal choice. Advancement of obstetric practice technologically and professionally during the period as well as changing attitudes of both obstetricians and childbearing women meant indications for CS are no longer limited to medical/obstetric indications. CS is perceived as a safer mode of childbirth. Therefore, the indications of CS have been changed drastically from ancient times (rescuing a baby from dying or dead mother) to the 21st century (maternal choice/reproductive rights)

Classification of Caesarean Section: A Scoping Review of the Robson classification

Caesarean section (CS) rate is rising dramatically worldwide. WHO recommended CS rate of 10-15% at population level would not be the ideal rate at the hospitals level due to the differences on population they have been serving. At the hospital level, a perfectly effective system is necessary to understand the trends and causes of rising trends of CS as well as to implement effective measures where necessary to control the same. Hence, WHO recommended the Robson classification, which is also called the 10-group classification of CS (TGCS) as a global standard tool to assess, monitor and compare CS rates within healthcare facilities over time, and between health facilities. The Robson classification, proposed by Dr Michael Robson in 2001, is a system that classifies all women at admission at a specific health facility for childbirth into 10 groups based on five basic obstetric characteristics (parity, gestational age, onset of labour, foetal presentation and number of foetuses). This classification is easy and simple and mutually exclusive, highly reproducible, easily applicable, and useful to change clinical practice. It has many strengths such as simplicity, flexibility (further subdivisions can be made to increase homogeneity within groups). This classification helps to identify and analyse the contribution of each group to overall CS rates. It also allows distinguishing the main group of women who contributes most and least to the overall CS rates; so that the CS rates can be monitored in a meaningful, reliable, and action-oriented manner in each health facility for optimal use of C

Caesarean section for non-medical reasons: A rising public health issue

Background: Caesarean section (CS) is a life-saving surgical intervention for childbirth. Emphasis is given to perform CS only for valid medical reasons. However, performing CS on non-medical indications is increasing worldwide. The scoping review aims to explore the non-medical reasons for performing CS. Methods: Articles on CS for non-medical reasons were searched using several electronic databases: PubMed, MEDLINE, CINAHL and open access journal databases such as Nepal journals on-line (NepJOL) and Bangladesh journals on-line (BanglaJOL). Additional articles were searched from the reference list of the selected articles and organizational websites. Eligible full-text articles were appraised, and relevant data were extracted. Narrative synthesis of extracted data was performed using a content analysis. Results: Maternal request is the most common non-medical indication of performing CS. The main reason of women’s preference for a CS is to avoid labour pain followed by certainty/convenience, avoid damage pelvic floor and vaginal trauma, and safer for baby. Similarly, the main reason for requesting a CS is fear of labour pain followed by fear of childbirth, safer mode of birth for both mother and baby and maintaining pelvic floor integrity. The main reasons of willingness to perform CS by obstetrician were fear of litigation, financial incentives and convenience. The ethical aspect of non-medically indicated CS remains complex. Conclusions: Performing CS without medical indications is a rising public health issue which has created medical, financial and ethical dilemmas in obstetrics care. The reasons for maternal request for a CS should be explored well. Obstetric care must include education of pregnant women on mode of childbirth including indications, risks and benefits of CS during antenatal visits

Caesarean Section for Non-medical Reasons: A Rising Public Health Issue

Background: Caesarean section (CS) is a life-saving surgical intervention for childbirth. Emphasis is given to perform CS only for valid medical reasons. However, performing CS on non-medical indications is increasing worldwide. The scoping review aims to explore the non-medical reasons for performing CS. Methods: Articles on CS for non-medical reasons were searched using several electronic databases: PubMed, MEDLINE, CINAHL and open access journal databases such as Nepal journals on-line (NepJOL) and Bangladesh journals on-line (BanglaJOL). Additional articles were searched from the reference list of the selected articles and organizational websites. Eligible full-text articles were appraised, and relevant data extracted. Narrative synthesis of extracted data was performed using a content analysis. Results: Maternal request is the most common non-medical indication of performing CS. The main reason of women’s preference for a CS is to avoid labour pain followed by certainty/convenience, avoid damage pelvic floor and vaginal trauma, and safer for baby. Similarly, the main reason for requesting a CS is fear of labour pain followed by fear of childbirth, safer mode of birth for both mother and baby and maintaining pelvic floor integrity. The main reasons of willingness to perform CS by obstetrician were fear of litigation, financial incentives and convenience. The ethical aspect of non-medically indicated CS remains complex. Conclusions: Performing CS without medical indications is a rising public health issue which has created medical, financial and ethical dilemmas in obstetrics care. The reasons for maternal request for a CS should be explored well. Obstetric care must include education of pregnant women on mode of childbirth including indications, risks and benefits of CS during antenatal visits