Who benefits from hospital birth? Perceptions of medicalised pregnancy and childbirth among Andean migrants in Santa Cruz de la Sierra, Bolivia

This paper uses ethnographic data on reproductive experiences of indigenous Andean migrant women in the lowland eastern Bolivian city of Santa Cruz de la Sierra as a starting point for discussion of different perspectives on the efforts of the Bolivian state to biomedicalise the processes of pregnancy and childbirth. Pregnant women and babies up to six months of age are covered by the state-funded Universal Mother-Infant Insurance (SUMI) that favours the use of biomedical facilities over the services of traditional midwives that are not covered by the insurance. Unlike in the western Andean highlands of Bolivia, most women in Santa Cruz give birth in hospitals while actively negotiating their options. They are not motivated by strictly medical factors as social or economic circumstances also come into play. Simultaneously, the increased levels of hospital deliveries in Bolivia translate into decreased levels of maternal and perinatal mortality, which in turn help Bolivian statistics to fare better from the point of view of the government and international bodies, such as the WHO. However, the restrictions on qualifying for SUMI are such that women in Santa Cruz are often forced to meet the costs of medical services themselves. I argue that the initial socio-biomedical intention of SUMI has become obscured by its political impact

Who benefits from hospital birth? Perceptions of medicalised pregnancy and childbirth among Andean migrants in Santa Cruz de la Sierra, Bolivia

This paper uses ethnographic data on reproductive experiences of indigenous Andean migrant women in the lowland eastern Bolivian city of Santa Cruz de la Sierra as a starting point for discussion of different perspectives on the efforts of the Bolivian state to biomedicalise the processes of pregnancy and childbirth. Pregnant women and babies up to six months of age are covered by the state-funded Universal Mother-Infant Insurance (SUMI) that favours the use of biomedical facilities over the services of traditional midwives that are not covered by the insurance. Unlike in the western Andean highlands of Bolivia, most women in Santa Cruz give birth in hospitals while actively negotiating their options. They are not motivated by strictly medical factors as social or economic circumstances also come into play. Simultaneously, the increased levels of hospital deliveries in Bolivia translate into decreased levels of maternal and perinatal mortality, which in turn help Bolivian statistics to fare better from the point of view of the government and international bodies, such as the WHO. However, the restrictions on qualifying for SUMI are such that women in Santa Cruz are often forced to meet the costs of medical services themselves. I argue that the initial socio-biomedical intention of SUMI has become obscured by its political impact. Keywords: biomedicalization; traditional medicine; migration; childbirth; Santa Cruz de la Sierra; indigenous peoples

The meanings of sobreparto : postpartum illness and embodiment of emotions among Andean migrants in Santa Cruz de la Sierra, Bolivia

This thesis concerns a postpartum condition known as sobreparto among female Andean migrants in the lowland city of Santa Cruz de la Sierra, Bolivia. While sobreparto is a traditionally Andean illness, its occurrence in the lowland city of Santa Cruz opens up new dimensions of analysis. In addition to exposing transformations of the traditional understandings of health, illness, and the body, the study of this phenomenon in an atypical setting sheds new light on issues such as migration, social networks, biomedicalisation, or gender patterns. By means of narratives of lives interrupted by sobreparto, it is possible to locate this condition within a wider frame of life trajectories, exposing motifs beyond the temporarily dysfunctional body. I argue that the narratives of sobreparto can be used as a springboard for a study of transformations in the understandings of motherhood and womanhood, migration and social networks, as well as emotions. Looking at these processes through the lens of a postpartum illness also reveals the connections between the ill body, the troubled mind, and imperfect social relationships. On the one hand, sobreparto can be analysed at the micro-level – in terms of an understanding of the body, individual reproductive histories, or the availability of other people’s support. On the other hand, sobreparto constitutes a commentary on phenomena occurring at the macro-level, such as large-scale internal migration in Bolivia or the increasing domination of biomedicine as a model of health and illness. The city of Santa Cruz offers a unique setting for scrutinising these changes using a traditionally Andean postpartum illness as a point of departure. Being much more than a postpartum bodily dysfunction, sobreparto, therefore, can be used as a lens through which it is possible to see the interplay of social and political macro- and micro-processes in people’s lives at the time of reproduction

Modeling of mechanical phenomena in the platinum-chromium coronary stents

This study discusses the geometrical model of a coronary stent with known design and strength analysis using the finite element method. The coronary stent model was made of platinum and chromium alloy. Static analysis based on compression of the coronary stent was also performed. The aim of the analysis was to examine the strength of the stent structure. The study analyzed stresses, plastic strains and displacements after applying a constant load to the stent walls. The mechanical phenomena such as percentage degree of shortening (foreshortening), relative narrowing and area of stent covering were also determined

Death and the artificial placenta

Artificial Amnion and Placenta Technology (AAPT)—sometimes referred to as ‘Artificial Womb Technology’—could provide an extracorporeal alternative to bodily gestations, allowing a fetus delivered prematurely from the human uterus to continue development while maintaining fetal physiology. As AAPT moves nearer to being used in humans, important ethical and legal questions remain unanswered. In this paper, we explore how the death of the entity sustained by AAPT would be characterized in law. This question matters, as legal ambiguity in this area has the potential to compound uncertainty and the suffering of newly bereaved parent(s). We first identify the existing criteria used to delineate the legal characterization of death, which occurs before birth or during the immediate neonatal period in England and Wales. We then demonstrate that attempting to apply these in the context of AAPT gives rise to a number of challenges, which make it impossible to reach a definitive conclusion as to the nature of death in AAPT using the current legal framework. In doing so, we demonstrate that the current legal framework in England and Wales may be unable to adequately capture the situation of an entity being sustained by AAPT

How to specify healthcare process improvements collaboratively using rapid, remote consensus-building: a framework and a case study of its application.

BackgroundPractical methods for facilitating process improvement are needed to support high quality, safe care. How best to specify (identify and define) process improvements - the changes that need to be made in a healthcare process - remains a key question. Methods for doing so collaboratively, rapidly and remotely offer much potential, but are under-developed. We propose an approach for engaging diverse stakeholders remotely in a consensus-building exercise to help specify improvements in a healthcare process, and we illustrate the approach in a case study.MethodsOrganised in a five-step framework, our proposed approach is informed by a participatory ethos, crowdsourcing and consensus-building methods: (1) define scope and objective of the process improvement; (2) produce a draft or prototype of the proposed process improvement specification; (3) identify participant recruitment strategy; (4) design and conduct a remote consensus-building exercise; (5) produce a final specification of the process improvement in light of learning from the exercise. We tested the approach in a case study that sought to specify process improvements for the management of obstetric emergencies during the COVID-19 pandemic. We used a brief video showing a process for managing a post-partum haemorrhage in women with COVID-19 to elicit recommendations on how the process could be improved. Two Delphi rounds were then conducted to reach consensus.ResultsWe gathered views from 105 participants, with a background in maternity care (n = 36), infection prevention and control (n = 17), or human factors (n = 52). The participants initially generated 818 recommendations for how to improve the process illustrated in the video, which we synthesised into a set of 22 recommendations. The consensus-building exercise yielded a final set of 16 recommendations. These were used to inform the specification of process improvements for managing the obstetric emergency and develop supporting resources, including an updated video.ConclusionsThe proposed methodological approach enabled the expertise and ingenuity of diverse stakeholders to be captured and mobilised to specify process improvements in an area of pressing service need. This approach has the potential to address current challenges in process improvement, but will require further evaluation

GPs’ mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

Background:  Optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines — tacit, internalised guidelines developed over time from multiple sources — may be of particular importance in such situations. Aim:  To explore GPs’ decision-making on deprescribing antihypertensives in patients with multimorbidity aged ≥80 years, drawing on the concept of mindlines. Design and setting: Qualitative interview study set in English general practice. Method Thematic analysis of face-to-face interviews with a sample of 15 GPs from seven practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older patients with multimorbidity with hypertension. Results:  GPs are typically confident making decisions to deprescribe antihypertensive medication in older patients with multimorbidity when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making. Conclusion:  In the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop ‘mindlines’ over time through practicebased experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing and may be strengthened through reflective practice

Correction to: How to specify healthcare process improvements collaboratively using rapid, remote consensus-building: a frame work and a case study of its application.

BackgroundPractical methods for facilitating process improvement are needed to support high quality, safe care. How best to specify (identify and define) process improvements - the changes that need to be made in a healthcare process - remains a key question. Methods for doing so collaboratively, rapidly and remotely offer much potential, but are under-developed. We propose an approach for engaging diverse stakeholders remotely in a consensus-building exercise to help specify improvements in a healthcare process, and we illustrate the approach in a case study.MethodsOrganised in a five-step framework, our proposed approach is informed by a participatory ethos, crowdsourcing and consensus-building methods: (1) define scope and objective of the process improvement; (2) produce a draft or prototype of the proposed process improvement specification; (3) identify participant recruitment strategy; (4) design and conduct a remote consensus-building exercise; (5) produce a final specification of the process improvement in light of learning from the exercise. We tested the approach in a case study that sought to specify process improvements for the management of obstetric emergencies during the COVID-19 pandemic. We used a brief video showing a process for managing a post-partum haemorrhage in women with COVID-19 to elicit recommendations on how the process could be improved. Two Delphi rounds were then conducted to reach consensus.ResultsWe gathered views from 105 participants, with a background in maternity care (n = 36), infection prevention and control (n = 17), or human factors (n = 52). The participants initially generated 818 recommendations for how to improve the process illustrated in the video, which we synthesised into a set of 22 recommendations. The consensus-building exercise yielded a final set of 16 recommendations. These were used to inform the specification of process improvements for managing the obstetric emergency and develop supporting resources, including an updated video.ConclusionsThe proposed methodological approach enabled the expertise and ingenuity of diverse stakeholders to be captured and mobilised to specify process improvements in an area of pressing service need. This approach has the potential to address current challenges in process improvement, but will require further evaluation