A concept analysis of women's vulnerability during pregnancy, birth and the postnatal period

The effect of cortisol in early pregnancy on postpartum depressive symptoms

The first months after childbirth are a tremendous challenge for women and, consequently, a time when women's mental health problems often arise. Knowledge of the prenatal predictors of these problems is of fundamental importance in preventing them. This study aimed to test whether first trimester hair cortisol influenced maternal postpartum depressive symptoms. The women (N = 75) were tested twice: in the first trimester of pregnancy and within three months after giving birth. In the first trimester, they had hair samples taken and were examined using a sociodemographic survey and questionnaires: the Edinburgh Postnatal Depression Scale (EPDS), the Perceived Stress Scale (PSS-10), and the Zimbardo Time Perspective Inventory. After delivery, women completed a survey about the course of delivery and their child's health, EPDS, and PSS-10. Low hair cortisol concentration in the first trimester was a predictor of a high level of postpartum depressive symptoms. This relationship was mediated by fatalistic time perspective. The results suggest that low hair cortisol concentration in the first trimester of pregnancy indicates a high probability of postpartum depression, and that low levels of cortisol may be associated with passivity, a sense of lack of control, and helplessness.

Resilience in maternal, newborn, and child health in low- and middle-income countries: findings from a scoping review

OBJECTIVES

The research objectives were to identify and synthesise prevailing definitions and indices of resilience in maternal, newborn, and child health (MNCH) and propose a harmonised definition of resilience in MNCH research and health programmes in low- and middle-income countries (LMICs).

DESIGN

Scoping review using Arksey and O'Malley's framework and a Delphi survey for consensus building.

PARTICIPANTS

Mothers, new-borns, and children living in low- and middle-income countries were selected as participants.

OUTCOMES

Resilience as defined by the authors was deduced from the studies.

RESULTS

Twenty-two out of 76,566 cited studies published between 2006 and 2010 were included in the review. Thirteen (59.1%) examined maternal resilience, and nine (40.9%) examined newborn and child health resilience; most of the included studies were quantitative (n = 17; 81%). Seven studies defined 'resilience' in the context of maternal health, most of which described the term at the individual level. 'Maternal resilience' was measured using validated scales in five studies; another five defined newborn and child resilience. Only one reviewed study used maternal characteristics to identify newborn and child resilience. The synthesised consensus definition of 'maternal, newborn, and child resilience' is 'A woman's ability to prevent or adapt to significant and challenging circumstances including threats, tragedy, and trauma to herself during pregnancy, childbirth, and puerperium and to her neonates or children five years or younger'.

CONCLUSION

The information identified was limited but included a few definitions of resilience in MNCH and an index of child resilience in LMICs. The proposed definition is useful for MNCH programme implementation and interventions in LMICs. Scoping review registration: The protocol for this review was registered in the open science framework at the registered address ( https://osf.io/jt6nr ).

Adaptability as a Journey: A Constructivist Grounded Theory Study Exploring the Transition to Motherhood in the Context of Bipolar Disorder

Despite growing evidence that women with bipolar disorder (BD) diagnoses are at a particularly increased risk for perinatal mental and physical health complications, our understanding of their experiences and support needs from pre-conception to early postnatal years is still in its early stages. To address this gap, a qualitative study was carried out employing a constructivist grounded theory approach to identify the underlying processes shaping women's journeys to motherhood in the context of BD. In-depth, semi-structured online interviews were conducted with 10 mothers worldwide with a pre-existing diagnosis of BD and a first child under 5 years of age. Mothers' experiences revolved around a constant interplay between vulnerability and adaptability, leading to the development of the substantive theory of adaptability as a journey. This study proposes that becoming adaptable constitutes a process, with the concept of "projecting adaptability" being influential in this journey. Characterized by the interconnected elements of self-awareness of vulnerability, perceived support from external sources, and ownership of experiences, the ability to envision an adaptable version of oneself along with understanding the path to achieving it played a significant role in women's experiences. Overall, there is a need for a more dynamic understanding of these experiences, providing appropriate support rather than viewing women as simply vulnerable or adaptable. Further research is necessary to explore the transferability of this theoretical framework, especially among mothers from diverse socio-economic backgrounds.

Exploring psychosocial vulnerability among Dutch pregnant women: a register study

In the Netherlands adverse perinatal outcomes are also associated with non-medical factors which vary across geographical locations. This study analyses the presence of non-medical vulnerabilities in pregnant women in two regions with high numbers of psychosocial adversity using the same definition for vulnerability in both regions. A register study was performed in 2 regions. Files from women in midwife-led care were analyzed using a standardized case report form addressing non-medical vulnerability based on the Rotterdam definition for vulnerability: measurement A in Groningen (n = 500), measurement B in South-Limburg (n = 538). Only in South-Limburg a second measurement was done after implementing an identification tool for vulnerability (C (n = 375)). In both regions about 10% of pregnant women had one or more urgent vulnerabilities and almost all of these women had an accumulation of several urgent and non-urgent vulnerabilities. Another 10% of women had an accumulation of three or more non-urgent vulnerabilities. This study showed that by using the Rotterdam definition of vulnerability in both regions about 20% of pregnant women seem to live in such a vulnerable situation that they may need psychosocial support. The definition seems a good tool to determine vulnerability. However, without considering protective factors it is difficult to establish precisely women's vulnerability. Research should reveal whether relevant women receive support and whether this approach contributes to better perinatal and child outcomes.

Improving integrated care for (future) parents facing vulnerable circumstances in the early life course of their (future) child: An action research protocol

INTRODUCTION

Suboptimal circumstances during the early life course, ranging from 100 days before conception to 1000 days following birth, significantly impact a child's future health and well-being. To optimize these circumstances, collaboration is needed which includes professionals working in medical, social and public domains, as well as parents. This action research protocol aims to improve care for (future) parents facing suboptimal circumstances during the early life course by enhancing inter-professional, cross-domain collaboration and (future) parents-professional collaboration. By employing iterative action research cycles, we seek to foster integrated care pathways and improve continuity of care across the medical, social and public domains. The research will be conducted in Rotterdam, the Netherlands.

METHODS AND ANALYSIS

Four action research cycles incorporating descriptive qualitative and quantitative studies, including focus groups, questionnaires and observations with (future) parents facing suboptimal circumstances, professionals and policymakers. This intervention study will not only foster improved, integrated care around identification of the need of additional support, referral and care, but also foster the necessary conditions for a self-supporting neighbourhood care learning network of (future) parents, professionals and policymakers to encourage bidirectional feedback and enable reflection beyond a single organisation. These interventions will also be evaluated.

DISSEMINATION

The results will be disseminated through peer-reviewed publications, layman summaries, regional and national knowledge platforms and presentations and factsheets relevant to all involved actors.

Associations of couples' balanced time perspective with maternal prenatal hair cortisol concentration and perceived stress

OBJECTIVE

The stress experienced by a woman during pregnancy not only has a negative impact on her well-being and physical health but also adversely affects the fetus. Stress is strongly linked with time perspective, defined as the tendency to focus on the past, present, or future. The study aimed to investigate how couples' balanced time perspective was related to maternal prenatal hair cortisol concentration and perceived stress in the first and third trimesters of pregnancy.

METHOD

The participants were pregnant women and their male partners (84 couples). Women completed online questionnaires: the Zimbardo Time Perspective Inventory (ZTPI), the Dark Future Scale (DFS), and the Perceived Stress Scale, while men completed online versions of the ZTPI and the DFS. These questionnaire measurements were conducted in the first and third trimesters. Maternal cortisol levels were measured in hair samples taken during gynecological visits, in the first and third trimesters.

RESULTS

The study revealed that the more unbalanced the partner's time perspective, the more unbalanced the pregnant woman's time perspective and, consequently, the higher the stress perceived by the pregnant woman. This effect was present in both the first (B = 1.06, SE =.36, p <.001, 95 % CI [.398, 1.826]) and the third trimesters (B =.98, SE =.36, p <.001, 95 % CI [.327, 1.774]). Moreover, the more unbalanced the partner's time perspective, the more unbalanced the woman's time perspective and, consequently, the lower the hair cortisol concentration in the first trimester (B = -.08, SE =.04, p <.05, 95 % CI [-.171, -.010]). Partner's unbalanced time perspective in the first trimester was also a predictor of stress perceived by the woman in the third trimester (t = 2.38, p <.05).

CONCLUSIONS

The results suggest the significance of the partner's time perspective for the pregnant woman's mental health. The partner's unbalanced, negative time perspective in the first trimester may increase the pregnant woman's stress in the third trimester. This effect can be even stronger than that of the woman's time perspective.

Exploring perceptions of vulnerability among women facing psychosocial adversity before, during and after pregnancy: A qualitative interview-study using thematic analysis

OBJECTIVE

The term 'vulnerable' is often used to describe women facing psychosocial adversity during pregnancy, implying a heightened risk of experiencing suboptimal pregnancy outcomes. While this label might facilitate the pathway to appropriate care, it can be perceived as stigmatizing by the women it intends to help, which could deter their interaction with healthcare services. This study explores how women facing psychosocial adversity before, during and after pregnancy perceive the concept of vulnerability and experience being labeled as such.

METHODS

We conducted a thematic analysis of semi-structured, in-depth interviews. Through purposive sampling targeting maximum variation, ten women of diverse backgrounds were included.

RESULTS

Three central themes emerged: defining vulnerability, embracing vulnerability and the feeling of being stigmatized. Women perceived vulnerability as an inability to adequately care for themselves or their children, necessitating additional support alongside routine antenatal care. Acceptance of the 'vulnerable' label came when it also acknowledged their proactive efforts and strengths to improve their situation. Conversely, if discussions surrounding vulnerability failed to recognize women's agency - specifically, their personal journeys and the courage needed to seek support - the label was perceived as stigmatizing.

CONCLUSIONS

Addressing vulnerability effectively in maternity care requires a nuanced, patient-centered approach, acknowledging both the challenges and strengths of women facing psychosocial adversities. Emphasizing personal narratives and their courage in seeking support can mitigate the stigmatizing effects of the 'vulnerable' label. Integrating these narratives into maternal healthcare practices can foster deeper connections with the women involved, enhancing the overall quality of care.

The extent of implementation and perceptions of maternity and social care professionals about two interprofessional programs for care for pregnant women: a mixed methods study

BACKGROUND

In 2018, the Dutch government initiated the Solid Start program to provide each child with the best start in life. Key program elements are a biopsychosocial perspective on pregnancy and children's development and stimulating local collaborations between social and health domains, with a specific focus on (future) families in vulnerable situations. Two programs for interprofessional collaboration between maternity and social care professionals to optimize care for pregnant women in vulnerable situations were developed and implemented, in Groningen in 2017 and in South Limburg in 2021. This paper describes the extent of implementation of these programs and the perceptions of involved professionals about determinants that influence program implementation.

METHODS

We conducted a mixed-methods study in 2021 and 2022 in two Dutch regions, Groningen and South Limburg. Questionnaires were sent to primary care midwives, hospital-based midwives, obstetricians (i.e. maternity care professionals), (coordinating) youth health care nurses and social workers (i.e. social care professionals), involved in the execution of the programs. Semi-structured interviews were held with involved professionals to enrich the quantitative data. Quantitative and qualitative data were collected and analyzed using Fleuren's implementation model.

RESULTS

The findings of the questionnaire (n = 60) and interviews (n = 28) indicate that professionals in both regions are generally positive about the implemented programs. However, there was limited knowledge and use of the program in Groningen. Promoting factors for implementation were mentioned on the determinants for the innovation and the user. Maternity care professionals prefer a general, conversational way to identify vulnerabilities that connects to midwives' daily practice. Low-threshold, personal contact with clear agreements for referral and consultation between professionals contributes to implementation. Professionals agree that properly identifying vulnerabilities and referring women to appropriate care is an important task and contributes to better care. On the determinants of the organization, professionals indicate some preconditions for successful implementation, such as clearly described roles and responsibilities, interprofessional training, time and financial resources.

CONCLUSIONS

Areas for improvement for the implementation of interprofessional collaboration between maternity care and social care focus mainly on determinants of the organization, which should be addressed both regionally and nationally. In addition, sustainable implementation requires continuous awareness of influencing factors and a process of evaluation, adaptation and support of the target group.

Meeting the needs of pregnant women in socially vulnerable situations: A phenomenological qualitative study

Objective

Vulnerability relates to fragile physical, psychological, and socio-environmental circumstances. Pregnant women's social vulnerability can lead to disruptions in their medical follow-ups, prematurity, and increased infant mortality rates, such that their special needs must be considered. Yet, despite different governments' 'perinatality' plans, international literature suggests their care can be improved. Although quantitative studies regularly evaluate these plans, few studies have assessed vulnerable pregnant women's views. This study explores the needs and expectations of vulnerable women regarding their follow-ups during pregnancy and identified strategies to improve their circumstances.

Methods

The study was a phenomenological qualitative study involving semi-structured interviews with women who gave birth in the past six months (December 2017 to June 2018) and who fulfilled at least one vulnerability criterion. The women were recruited by French midwives and general practitioners (GPs).

Findings

Concerning these vulnerable pregnant women, three phenomenological categories emerged: 1) they need to be monitored by a single trusted contact; 2) they seek medical and social support adapted to their situations that addresses their needs; and 3) they expect kind and person-centred communication skills from professionals who provide them appropriate information.

Conclusion

We identified various international recommendations to screen and care for vulnerable pregnant women, but still these women often experience numerous challenges. Finally, the implementation of recommendations for healthcare professionals based on women's real-life experiences could help optimise the identification of vulnerable pregnant women as well as their follow-up care.

Views and preferences of food-insecure pregnant women regarding food insecurity screening and support within routine antenatal care

BACKGROUND

Food insecurity is a public health concern that has profound impact on physical and mental health, and on social well-being. Pregnancy is a period in which food insecurity is likely to be particularly deleterious, due to the serious impact on both mother and child. Food insecurity is not routinely screened in antenatal healthcare settings, and the preferences of pregnant women regarding food insecurity screening and support are poorly understood. This study aimed to determine the views and preferences of food-insecure pregnant women regarding food insecurity screening and support within antenatal healthcare.

METHODS

This qualitative descriptive study used face-to-face semi-structured interviews, conducted in February and March 2023, to gain the views of purposively sampled food-insecure, pregnant women in Melbourne, Australia. Food insecurity was evidenced by an affirmative response to at least one of three assessment items in a screening questionnaire. Qualitative content analysis was conducted to summarise the views and preferences of women.

RESULTS

Nineteen food-insecure pregnant women were interviewed. Three themes were identified: (1) acceptability of being screened for food insecurity, (2) concerns about the consequences of disclosure and (3) preferences regarding food insecurity screening and supportive strategies that could be offered within an antenatal healthcare setting.

CONCLUSION

Women were accepting of food insecurity screening being conducted within routine healthcare. Women identified potential benefits of routine screening, such as feeling supported by their clinician to have a healthy pregnancy and less pressure to voluntarily ask for food assistance. Women gave suggestions for the implementation of food insecurity screening to optimise their healthcare experience, maintain their dignity and feel able to disclose within a safe and caring environment. These results indicate that food insecurity screening in the antenatal setting is likely to have support from pregnant women and is urgently needed in the interest of promoting optimal nutrition for women and children.

PATIENT CONTRIBUTION

Pregnant women with lived experience of food insecurity were purposively sampled to obtain their insights regarding screening and support within a pregnancy healthcare setting. Member-checking occurred following data collection, whereby all participants were offered the opportunity to review their interview transcript to ensure trustworthiness of the data.

Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action

Maternal outcomes throughout pregnancy, childbirth, and the postnatal period are influenced by interlinked and interdependent vulnerabilities. A comprehensive understanding of how various threats and barriers affect maternal and perinatal health is critical to plan, evaluate and improve maternal health programmes. This paper builds on the introductory paper of the Series on the determinants of maternal health by assessing vulnerabilities during pregnancy, childbirth, and the postnatal period. We synthesise and present the concept of vulnerability in pregnancy and childbirth, and map vulnerability attributes and their dynamic influence on maternal outcomes in early and late pregnancy and during childbirth and the postnatal period, with a particular focus on low-income and middle-income countries (LMICs). We summarise existing literature and present the evidence on the effects of various reparative strategies to improve pregnancy and childbirth outcomes. Lastly, we discuss the implications of the identified vulnerability attributes and reparative strategies for the efforts of policymakers, healthcare professionals, and researchers working towards improving outcomes for women and birthing people in LMICs.

Cultural brokering in pregnancy care: A critical review

People who speak languages other than English face structural barriers in accessing the US healthcare system. With a growing number of people living in countries other than their countries of birth, the impact of language and cultural differences between patients and care teams on quality care is global. Cultural brokering presents a unique opportunity to enhance communication and trust between patients and clinicians from different cultural backgrounds during pregnancy care-a critical window for engaging families in the healthcare system. This critical review aims to synthesize literature describing cultural brokering in pregnancy care. We searched keywords relating to cultural brokering, pregnancy, and language in PubMed, Embase, and CINAHL and traced references of screened articles. Our search identified 33 articles. We found that cultural brokering is not clearly defined in the current literature. Few of the articles provided information about language concordance between cultural brokers and patients or clinicians. No article described the impact of cultural brokering on health outcomes. Facilitators of cultural brokering included: interprofessional collaboration within the care team, feeling a family connection between the cultural broker and patients, and cultivating trust between the cultural broker and clinicians. Barriers to cultural brokering included: misunderstanding the responsibilities, difficulty maintaining personal boundaries, and limited availability and accessibility of cultural brokers. We propose cultural brokering as interactions that cover four key aims: (1) language support; (2) bridging cultural differences; (3) social support and advocacy; and (4) navigation of the healthcare system. Clinicians, researchers, and policymakers should develop consistent language around cultural brokering in pregnancy care and examine the impact of cultural brokers on health outcomes.

Strengths, weaknesses, opportunities and threats of peer support among disadvantaged groups: A rapid scoping review

Objective

To explore the current state of knowledge and evidence about peer support for various disadvantaged groups; to identify the strengths, weaknesses, opportunities, and threats of peer support to critically reflect on peer support within health and social services.

Methods

A rapid scoping review was conducted according to Arksey and O'Malley's framework, aiming to identify eligible studies in PubMed, APA PsychInfo, Education Resources Information Center, Cochrane Library, Academic Search Premier, ScienceDirect, Directory of Open Access Journals, ResearchGate, WorldCat, and Google Scholar. According to Rodgers' concept analysis steps and the SWOT model, data was reported using thematic synthesis.

Results

Forty-five studies were included, describing a variety of peer support initiatives among groups of young migrants and unsupervised minors, young adults with autism, people with (mental) health problems, foster/shelter families, vulnerable pregnant women, people outside the labour force, older adults, and homeless people. The strength of peer support is its positive effect on the quality of life among vulnerable people. The weakness is represented by peers both being too involved and focused on personal interest or by peers lacking expertise and knowledge. Opportunities for peer support are mutual learning, the anticipated long-term effects, and the potential to facilitate social inclusion. Culture, language barriers, drop-out rates, securing sustainability, and peers' lack of time and commitment are regarded as threats to peer support.

Conclusion

Although peer support offers good outcomes for various groups of vulnerable people, the weaknesses and threats need to be considered to provide and proliferate peer support.

Pregorexia: a systematic review and meta-analysis on the constructs of body image dissatisfaction and eating disturbances by gestational age in the peripartum

PURPOSE

Pregorexia is a phenomenon posited to occur in the peripartum, characterized by an attempt to counter pregnancy's physiological changes in body shape through reduced calorie intake or increased physical activity.

METHODS

In this pre-registered systematic review and meta-analysis, body image dissatisfaction and eating psychopathology in the peripartum according to gestational age were formally assessed. PubMed was searched up to May 2023. Selection criteria were represented by studies on body image concerns or eating psychopathology in the peripartum (up to 1 year after delivery). The population needed to include women from the general population or among patients with a history of (or current) eating disorder. For the meta-analysis, 17 studies were included: 10 for body image dissatisfaction (2625 individuals overall), 7 for eating behaviors (2551 individuals overall). The interplay between body image and the following themes was examined in depth: the adoption of breastfeeding, peripartum depression, sociocultural influences on body image, sexual disturbances, experiencing or reporting an altered food intake.

RESULTS

Progressive dissatisfaction with body image during pregnancy by gestational age was observed, stably elevated for at least 12 months postpartum. Eating psychopathology was observed as elevated only at 12 months in the postpartum, but not during pregnancy.

DISCUSSION

The current work offers normative values of body image satisfaction and eating psychopathology in the peripartum by gestational age. The relevance of current results was discussed, in order to inform both current clinical practice and future public policies.

LEVEL OF EVIDENCE

Level I-Evidence obtained from: systematic reviews and meta-analyses.

The experience of pregnant women in contexts of vulnerability of prenatal primary nursing care: a descriptive interpretative qualitative study

BACKGROUND

Prenatal primary nursing care contributes to improving the health outcomes of mothers and unborn babies. Some pregnant women in contexts of vulnerability experience prenatal nursing care in a positive way, while some do not. A better understanding of factors influencing this experience could help improve prenatal nursing care. The aim of this study was to describe factors influencing the prenatal primary nursing care experience of pregnant women in contexts of vulnerability.

METHODS

Thorne's qualitative interpretative descriptive approach was used. Twenty-four pregnant women in contexts of vulnerability were recruited in local community service centers in Quebec, Canada, using purposive and snowball samplings, to carry out a semi-structured interview. Participants were 16 years old and over, in their second or third trimester, or had given birth in the previous year, and received prenatal nursing care through community health services. Data collection methods included a logbook, sociodemographic questionnaire and semi-structured interview on vulnerable pregnant women's experience with prenatal primary nursing care. The Qualitative Analysis Guide of Leuven guided the inductive thematic analysis, following a constant comparative iterative process.

RESULTS

The women's experience was initially influenced by the fulfillment of their needs and expectations. These stem from their previous or current pregnancy experiences, their motivation to receive prenatal care, their family concerns as well as their contexts of vulnerability. From the pregnant women's perspective, the main factors that influenced their experience were the nurse's approach, characteristics and interventions that all impact on their relationship with nurses, as well as the prenatal primary care organization, including the modalities of prenatal care (i.e. schedule, setting, duration, number and frequency of meetings), the continuity and the program's prenatal care services, such as referral to a nutritionist, social worker or other services.

CONCLUSIONS

A conceptual framework is proposed to describe relationships among the factors distributed in three dimensions that influence the experience of pregnant women in contexts of vulnerability and to guide nurses in the improvement of prenatal primary care. Considering the complexity of this experience, a person-centered approach is mandatory to promote a positive experience, equity and a better use of services.

The prevalence of respectful maternity care during childbirth and its determinants in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Respectful maternity care is the provision of woman-centered health care during childbirth that is friendly, abuse-free, timely, and discrimination-free. Although several epidemiological studies on the magnitude and determinants of Respectful maternity care in Ethiopia have been conducted, the results have been inconsistent and varied. This makes drawing equivocal conclusions and evidence at the national level harder. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of respectful maternity care and its determinants in Ethiopia.

METHODS

Studies conducted from 2013 to June 30, 2022, were searched by using PubMed, Google Scholar, Science Direct, Scopus, ProQuest, Web of Science, Cochrane Library, and Direct of Open Access Journals. Searching was carried out from May 15- June 30, 2022. In total, sixteen studies were considered in the final analysis. The data were extracted using Microsoft Excel and analyzed using STATA 16 software. The methodological quality of included studies was assessed by using Joanna Briggs Institute's critical appraisal checklist for prevalence studies. To estimate the pooled national prevalence of respectful maternity care, a random effect model with a DerSimonian Laird method was used. To assess the heterogeneity of the included studies, the Cochrane Q test statistics and I2 tests were used. To detect the presence of publication bias, a funnel plot and Begg's and Egger's tests were used.

RESULTS

Sixteen studies were eligible for this systematic review and meta-analysis with a total of 6354 study participants. The overall pooled prevalence of respectful maternity care in Ethiopia was 48.44% (95% CI: 39.02-57.87). Receiving service by CRC-trained health care providers [AOR: 4.09, 95% CI: 1.73, 6.44], having ANC visits [AOR: 2.34, 95% CI: 1.62, 3.06], planning status of the pregnancy [AOR = 4.43, 95% CI: 2.74, 6.12], giving birth during the daytime [AOR: 2.61, 95% CI: 1.92, 3.31], and experiencing an obstetric complication[AOR: 0.46, 95% CI: 0.30, 0.61] were identified as determinants of RMC.

CONCLUSION

As per this meta-analysis, the prevalence of respectful maternity care in Ethiopia was low. Managers in the health sector should give due emphasis to the provision of Compassionate, Respectful, and Care(CRC) training for healthcare providers, who work at maternity service delivery points. Stakeholders need to work to increase the uptake of prenatal care to improve client-provider relationships across a continuum of care. Human resource managers should assign an adequate number of health care providers to the night-shift duties to reduce the workload on obstetric providers.

Vulnerability in maternal, new-born, and child health in low- and middle-income countries: Findings from a scoping review

OBJECTIVES

To identify and synthesise prevailing definitions and indices of vulnerability in maternal, new-born and child health (MNCH) research and health programs in low- and middle-income countries.

DESIGN AND SETTING

Scoping review using Arksey and O'Malley's framework and a Delphi survey for consensus building.

PARTICIPANTS

Mothers, new-borns, and children living in low- and middle-income countries were selected as participants.

OUTCOMES

Vulnerability as defined by the authors was deduced from the studies.

RESULTS

A total of 61 studies were included in this scoping review. Of this, 22 were publications on vulnerability in the context of maternal health and 40 were on new-born and child health. Definitions used in included studies can be broadly categorised into three domains: biological, socioeconomic, and environmental. Eleven studies defined vulnerability in the context of maternal health, five reported on the scales used to measure vulnerability in maternal health and only one study used a validated scale. Of the 40 included studies on vulnerability in child health, 19 defined vulnerability in the context of new-born and/or child health, 15 reported on the scales used to measure vulnerability in child health and nine reported on childhood vulnerability indices. As it was difficult to synthesise the definitions, their keywords were extracted to generate new candidate definitions for vulnerability in MNCH.

CONCLUSION

Included studies paid greater attention to new-born/ child vulnerability than maternal vulnerability, with authors defining the terms differently. A definition which helps in improving the description of vulnerability in MNCH across various programs and researchers was arrived at. This will further help in streamlining research and interventions which can influence the design of high impact MNCH programs.

SCOPING REVIEW REGISTRATION

The protocol for this review was registered in the open science framework at the registered address (https://osf.io/jt6nr).

A mixed method study to explore the maternal impact and outcomes of a specialist Building Attachment and Bonds Service (The BABS Study)

Our intent was to explore if maternal anxiety, depression, reflective functioning and level of attachment significantly changed after the Building Bonds and Attachment Service (BABS) Intervention. We measured outcomes for 46 at risk mothers via HADS; MAAS; MPAS and P-PRFQ. Our findings, triangulated with 32 semi structured interviews identified that BABS intervention made a significant difference to participants who were admitted during the antenatal period (Pregnant group: depression 9.63[CI:7.63-11.63; p < 0.001]; anxiety 9.40[CI: 7.56-11.24]; p < 0.001]; reflective functioning 30.78[CI:24.84-36.72; p < 0.001] and maternal attachment 8.78[CI:4.08-13.48]; p 0.001). Suicidal contemplation was prevented for two women. Our conclusions explained the service made a significant difference to the lives of mothers between baseline and post intervention for pregnant mothers with anxiety and depression who struggled to bond with their baby. Appropriate referral may help to increase accessibility to those who may benefit most. Further research needs to test if this care model would be acceptable to culturally diverse populations.

Interventions for vulnerable pregnant women: Factors influencing culturally appropriate implementation according to health professionals: A qualitative study

Background

Proper implementation of interventions by health professionals has a critical effect on their effectiveness and the quality of care provided, especially in the case of vulnerable pregnant women. It is important, therefore, to assess the implementation of interventions in care settings to serve as input to improve implementation.

Objective

The aim of this study is to identify factors that influence the implementation of interventions for vulnerable pregnant women in the North of the Netherlands from the perspective of health professionals. In this region, an intergenerational transfer of poverty is apparent, leading to many health problems and the transfer of unhealthy lifestyles and the associated diseases to subsequent generations.

Methods

We used a qualitative research design. Semi-structured interviews with 39 health professionals were conducted between February 2019 and April 2020. To analyse the findings, the MIDI (Measurement Instrument for Determinants of Innovations) was used, an instrument designed to identify what determinants influence the actual use of a new or existing innovation.

Results

We found two themes that influence the implementation of interventions: 1. The attitude of health professionals towards vulnerable pregnant women: stereotyped remarks and words expressing the homogenization of vulnerable pregnant women. 2. A theme related to the MIDI determinants, under which we added six determinants.

Conclusion

Our research showed that many factors influence the implementation of interventions for vulnerable pregnant women, making the optimal implementation of interventions very complex. We highlight the need to challenge stereotypical views and attitudes towards specific groups in order to provide relation-centred care, which is extremely important to provide culturally appropriate care. Health professionals need to reflect on their own significant influence on access to and the use of care by vulnerable groups. They hold the key to creating partnerships with women to obtain the best health for mothers and their babies.

Experiences and needs of women in vulnerable situations receiving additional interventions in maternity care: a qualitative study

BACKGROUND

Tailoring an intervention to the needs and wishes of pregnant women in vulnerable situations (e.g., socioeconomic disadvantages) can reduce the risk of adverse outcomes and empower these women. A relatively high percentage of pregnant women in the North of the Netherlands are considered vulnerable to adverse pregnancy outcomes because of their low socioeconomic status and the intergenerational transmission of poverty. In order to improve perinatal and maternal health, next to standard prenatal care, various interventions for pregnant women in vulnerable situations have been developed. We do not know to what extent these additional interventions suit the needs of (pregnant) women. Therefore, the aim of this study is to gain insight into the experiences and needs of women in vulnerable situations who receive additional maternity care interventions in the Northern Netherlands.

METHODS

Qualitative research was performed. We used a phenomenological framework, which is geared towards understanding people's experiences in the context of their everyday lives. In-depth semi-structured interviews were conducted with 17 pregnant women in vulnerable situations living in the Northern Netherlands. A thematic analysis was carried out.

RESULTS

We found three themes that reflect the experiences and needs of pregnant women in vulnerable situations in relation to the intervention they receive. These themes relate to the care provided by health professionals, to the impact of being offered an intervention, and to practical issues related to receiving an additional intervention. We found that the needs of pregnant women in vulnerable situations who received an additional maternity care intervention varied. This variation in needs was mainly related to practical issues. Women also expressed common needs, namely the desire to have control over their situation, the wish to receive tailor-made information about the intervention, and the wish for the intervention to be specifically tailored to their circumstances.

CONCLUSIONS

Living in vulnerable situations and being offered additional care evoked diverse reactions and emotions from pregnant women. We recommend that health professionals ensure open and clear communication with women, that they ensure continuity of care and relationship-centered care, and that they become aware of the process of stigmatization of women in vulnerable situations.

The Prenatal Primary Nursing Care Experience of Pregnant Women in Contexts of Vulnerability: A Systematic Review With Thematic Synthesis

The contexts of vulnerability are diversified and cover a wide range of situations where pregnant women are likely to experience threats or disparities. Nurses should consider the particular circumstances of women in contexts of vulnerability. We used a qualitative thematic synthesis to describe the experience of these women regarding their prenatal primary nursing care. We identified that the women's experience is shaped by the prenatal care. The fulfillment of their needs and expectations will guide their decision regarding the utilization of their prenatal care. We propose a theoretical model to guide nurses, promoting person-centered delivery of prenatal care.

Social determinants of vulnerability in the population of reproductive age: a systematic review

Background

The health of an (unborn) child is largely determined by the health and social determinants of its parents. The extent to which social determinants of parents or prospective parents affect their own health depends partly on their coping or resilience abilities. Inadequate abilities allow negative effects of unfavourable social determinants to prevail, rendering them vulnerable to adverse health outcomes. Addressing these determinants in the reproductive-aged population is therefore a key approach in improving the health of the future generation. This systematic review aims to synthesise evidence on social determinants of vulnerability, i.e., inadequate coping or low resilience, in the general population of reproductive age.

Methods

The databases EMBASE, Medline, PsycINFO, CINAHL, Google Scholar, Web of Science, and Cochrane Library, were systematically searched from database inception to December 2th 2021.

Observational studies examining social determinants and demographics in relation to vulnerability among the general population of reproductive age (men and women aged 18-40 years), conducted in a high-income country in Europe or North America, Australia or New Zealand were eligible for inclusion. Relevant data was extracted from each included article and findings were presented in a narrative and tabulated manner.

Results

We identified 40,028 unique articles, of which 78 were full text reviewed. Twenty-five studies were included, of which 21 had a cross-sectional study design (84%). Coping was the most frequently assessed outcome measure (n = 17, 68%). Thirty social determinants were identified. Overall, a younger age, lower socioeconomic attainment, lack of connection with the social environment, and adverse life events were associated with inadequate coping or low resilience.

Conclusions

This review shows that certain social determinants are associated with vulnerability in reproductive-aged individuals. Knowing which factors make people more or less vulnerable carries health-related implications. More high-quality research is needed to obtain substantial evidence on the strength of the effect of these social conditions in this stage of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13651-6.

The Level of Fear Experienced by the Individuals and their Applications to Health Institutions during the Covid-19 Pandemic

AIM

The study aims to investigate the effect of the level of fear experienced by individuals during the COVID-19 pandemic on their application to health institutions.

METHOD

This descriptive study was conducted between July and September 2020 with the participants who met the inclusion criteria in Turkey. When the mean COVID-19 Fear Scale score was considered and the standard deviation values ​​were taken as 18.83 ± 6.01, the sample size was determined as 98 individuals, with 95% confidence level, 90% test power, and 0.331 effect size. With the snowball sampling method, the study was carried out with 577 people who filled out the Google form. The Personal Information Form and the COVID-19 Fear Scale were used as data collection tools. The data were analyzed with SPSS 20.0. Descriptive statistics, correlation, Mann-Whitney U (U), and Kruskal-Wallis tests were performed to analyze the data. Ethics committee approval was obtained prior to the study.

RESULTS

The mean age of the participants was 32.06 ± 11.25 (min 18-max 71); 77.8% were female; 66% were university graduates, and 54.9% were single. The total mean score of the participants from the COVID-19 Fear Scale was determined as 16.84 ± 5.68 (min 7-max 34), which points to moderate level of fear. The COVID-19 Fear Scale scores of the female participants, the participants with high income, and those living with their families were found to be higher (p < 0.05). The COVID-19 Fear Scale scores were found to be higher in those who sleep less than 7 hours a day, who have a psychological disorder, who applied to health institutions during the coronavirus process, and who postponed their application to health institutions in an emergency due to the fear of infection (p < 0.05).

CONCLUSION

It has been determined that during the coronavirus process, 21.5% of individuals attend in person to health institutions and 40.7% of individuals attend in person to health institutions in emergencies. It was found that the level of fear was higher in the participants who applied to health institutions during the pandemic. The participants who postponed their application to health institutions in emergencies due to the fear of infection were found to have higher levels of fear.

Designing a respectful maternity care guideline: a multiphase study

Background

There is no comprehensive guideline for respectful maternity care (RMC) promotion in Iran. This study aimed to design a RMC guideline based on a multiphase study.

Methods

In this multiphase mixed-methods study, recommendations were made for RMC promotion through the data obtained from Phase I (i.e., the quantitative section with a cross-sectional design), Phase II (i.e., the qualitative section with a content analysis method), and Phase III (i.e., focus group discussions with birth attendants as well as opinions of the specialized panel through the Delphi technique). The composed recommendations were then analyzed and finalized by relevant specialists in terms of execution capacity, approvability, and cost-effectiveness within the current context of Iran. Eventually, the resultant guideline were evaluated and approved by two members of the research team specializing in the research area in accordance with the Appraisal of Guideline for Research and Evaluation (AGREE).

Results

The results of this multiphase study led to 80 recommendations for RMC promotion. The recommendations were classified as eight areas called recommendations for the pregnancy period, recommendations for the labor period and delivery, recommendations for the neonatal period, occupational recommendations, supervision recommendations, national policy recommendations, recommendations for training students and staff, and general public recommendations.

Discussion

Based on the outcomes of disrespect and abuse, it is recommended to provide comprehensive guideline for policymakers and planners to formulate plans through the RMC promotion approach. Healthcare service policymakers can use this guideline to design some interventions to meet women’s financial, psychological, and legal needs.

Disrespect and abuse in the delivery room is associated with negative experience of delivery and poor maternal care quality index. Also, disrespect and abuse is the main barrier to achieving maternal health outcomes. In spite of the considerable achievements in maternal and child health, there is still a large number of maternal and neonatal mortality worldwide. It seems that disrespect and abuse is a key potential obstacle hindering access to delivery facilities and skilled care providers. To achieve the sustainable development 2030 goals developed by the World Health Organization (WHO) (Goal 3.1: Ensure health lives and promote well-being for all at all ages: reduce the global maternal mortality ratio to less than 70 per 100,1000 live birth), stakeholders and relevant institutions should consider respectful pregnancy and delivery care services as a key solution to reducing maternal mortality. Nevertheless, there is no comprehensive guideline with regards to respectful maternity care in the WHO or provided by other countries. In this multiphase mixed-methods study, recommendations were made for respectful maternity care promotion through the data obtained from Phase I (i.e., the quantitative section with a cross-sectional design), Phase II (i.e., the qualitative section with a content analysis method), and Phase III (i.e., focus group discussions with birth attendants as well as opinions of the specialized panel through the Delphi technique). The composed recommendations were then analyzed and finalized by relevant specialists in terms of execution capacity, approvability, and cost-effectiveness within the current context of Iran. The results of this multiphase study led to 80 recommendations for RMC promotion. The recommendations were classified as eight areas called recommendations for the pregnancy period, recommendations for the labor period and delivery, recommendations for the neonatal period, occupational recommendations, supervision recommendations, national policy recommendations, recommendations for training students and staff, and general public recommendations.

Ethical considerations of preconception and prenatal gene modification in the embryo and fetus

The National Academies of Sciences and Medicine 2020 consensus statement advocates the reinstatement of research in preconception heritable human genome editing (HHGE), despite the ethical concerns that have been voiced about interventions in the germline, and outlines criteria for its eventual clinical application to address monogenic disorders. However, the statement does not give adequate consideration to alternative technologies. Importantly, it omits comparison to fetal gene therapy (FGT), which involves gene modification applied prenatally to the developing fetus and which is better researched and less ethically contentious. While both technologies are applicable to the same monogenic diseases causing significant prenatal or early childhood morbidity, the benefits and risks of HHGE are distinct from FGT though there are important overlaps. FGT has the current advantage of a wealth of robust preclinical data, while HHGE is nascent technology and its feasibility for specific diseases still requires scientific proof. The ethical concerns surrounding each are unique and deserving of further discussion, as there are compelling arguments supporting research and eventual clinical translation of both technologies. In this Opinion, we consider HHGE and FGT through technical and ethical lenses, applying common ethical principles to provide a sense of their feasibility and acceptability. Currently, FGT is in a more advanced position for clinical translation and may be less ethically contentious than HHGE, so it deserves to be considered as an alternative therapy in further discussions on HHGE implementation.

Insight into the process of postpartum care utilisation and in-home support among vulnerable women in the Netherlands: an in-depth qualitative exploration

OBJECTIVE

To gain insight into the process of postpartum care utilisation and in-home support among vulnerable women.

DESIGN, METHOD, PARTICIPANTS AND SETTING

A qualitative interview study was conducted among 23 pregnant and postpartum vulnerable women in the Netherlands, following a grounded theory approach. Women were determined as vulnerable by their healthcare providers. Theoretical sampling of participants was applied and was alternated by data analysis to include information-rich cases until saturation was achieved.

RESULTS

A conceptual framework of postpartum care utilisation was generated consisting of three phases: pregnancy, early postpartum period and late postpartum period. Within these phases, information provision, parenting self-efficacy and social network were identified as overarching themes. Perceived inadequate information on content of postpartum care posed a major barrier to forming realistic expectations during pregnancy and hindered its utilisation. Low self-efficacy facilitated postpartum care utilisation. All women experienced increased self-efficacy during and after postpartum care. Support from a social network influenced expectations regarding the added value of postpartum care during pregnancy, and lowered actual utilisation during the postpartum period. The costs of postpartum care and the role of the maternity care assistant acted as general barriers or facilitators influencing the three overarching themes and therefore postpartum care utilisation indirectly.

CONCLUSIONS

Our findings suggest that postpartum care utilisation among vulnerable women may be improved by considering the particular phase and relevant themes applying to individual women, and adapt care accordingly. We recommend to provide comprehensive, understandable information and to emphasise the gains of postpartum care in improving self-efficacy for vulnerable women. Moreover, involving a woman's social network in postpartum care may add value to this care for this population.

Resilience and Stress during Pregnancy: A Comprehensive Multidimensional Approach in Maternal and Perinatal Health

This narrative review addresses resilience and stress during pregnancy, which is part of a broader concept of maternal health. Pregnancy and postpartum are opportune periods for health promotion interventions, especially because the close contact of the women with health professionals. In this way, it can be considered a useful window of opportunity to identify women at higher risk for adverse outcomes. Integrated health is a concept that aims at providing comprehensive care related to the promotion of individuals' physical, mental, and social well-being. In this context, stress during pregnancy has been targeted as a remarkable condition to be addressed whether due to individual issues, social issues, or specific pregnancy issues, since it is directly and indirectly associated with pregnancy complications. Stress is associated with preterm birth, postpartum depression, anxiety, child neurodevelopment, and fetal distress. The way that an individual faces a stressful and adverse situation is called resilience; this reaction is individual, dynamic, and contextual, and it can affect maternal and fetal outcomes. Low resilience has been associated with poorer pregnancy outcomes. The social context of pregnancy can act as a protective or contributory (risk) factor, indicating that environments of high social vulnerability play a negative role in resilience and, consequently, in perceived stress. A given stressor can be enhanced or mitigated depending on the social context that was imposed, as well as it can be interpreted as different degrees of perceived stress and faced with a higher or lower degree of resilience. Understanding these complex mechanisms may be valuable for tackling this matter. Therefore, in the pregnancy-puerperal period, the analysis of the stress-resilience relationship is essential, especially in contexts of greater social vulnerability, and is a health-promoting factor for both the mother and baby.

Health literacy among pregnant women in a lifestyle intervention trial: protocol for an explorative study on the role of health literacy in the perinatal health service setting

INTRODUCTION

Pregnancy is a vulnerable period that affects long-term health of pregnant women and their unborn infants. Health literacy plays a crucial role in promoting healthy behaviour and thereby maintaining good health. This study explores the role of health literacy in the GeMuKi (acronym for 'Gemeinsam Gesund: Vorsorge plus für Mutter und Kind'-Strengthening health promotion: enhanced check-up visits for mother and child) Project. It will assess the ability of the GeMuKi lifestyle intervention to positively affect health literacy levels through active participation in preventive counselling. The study also explores associations between health literacy, health outcomes, health service use and effectiveness of the intervention.

METHODS AND ANALYSIS

The GeMuKi trial has a hybrid effectiveness-implementation design and is carried out in routine prenatal health service settings in Germany. Women (n=1860) are recruited by their gynaecologist during routine check-up visits before 12 weeks of gestation. Trained healthcare providers carry out counselling using motivational interviewing techniques to positively affect health literacy and lifestyle-related risk factors. Healthcare providers (gynaecologists and midwives) and women jointly agree on Specific, Measurable, Achievable Reasonable, Time-Bound goals. Women will be invited to fill in questionnaires at two time points (at recruitment and 37th-40th week of gestation) using an app. Health literacy is measured using the German version of the Health Literacy Survey-16 and the Brief Health Literacy Screener. Lifestyle is measured with questions on physical activity, nutrition, alcohol and drug use. Health outcomes of both mother and child, including gestational weight gain (GWG) will be documented at each routine visit. Health service use will be assessed using social health insurance claims data. Data analyses will be conducted using IBM SPSS Statistics, version 26.0. These include descriptive statistics, tests and regression models. A mediation model will be conducted to answer the question whether health behaviour mediates the association between health literacy and GWG.

ETHICS AND DISSEMINATION

The study was approved by the University Hospital of Cologne Research Ethics Committee (ID: 18-163) and the State Chamber of Physicians in Baden-Wuerttemberg (ID: B-F-2018-100). Study results will be disseminated through (poster) presentations at conferences, publications in peer-reviewed journals and press releases.

TRAIL REGISTRATION

German Clinical Trials Register (DRKS00013173). Registered pre-results, 3rd of January 2019, https://www.drks.de.

The COVID-19 Pandemic in Spain: Experiences of Midwives on the Healthcare Frontline

Background: Midwives look after women during pregnancy, childbirth and puerperium. In Spain, the first wave of COVID was particularly virulent. There are few studies about the experiences of midwives providing care during the COVID pandemic and very few have been undertaken in the countries of southern Europe such as Spain. This article sets out to take a more in-depth look at the experiences of midwives who were on the frontline of care during the early months of the COVID-19 pandemic as well as to identify new needs and resilience strategies that can help midwives. Methods: A qualitative methodology of phenomenological tradition was used, interviewing 10 midwives from primary care, hospital and independent care. Results: After content analysis, three central categories emerged: (a) cascade of emotions; (b) professional occupation and concern for the women; (c) resisting the day-to-day; resilience and resistance strategies. Conclusions: Despite the difficulties, midwives are concerned about the loss of rights and autonomy and about the increased vulnerability of women. Midwives have become aware of the power they have in their actions both in health management and administration, as well as in the care of women, creating strategies to provide dignified care to their users.

The experiences and psychological outcomes for pregnant women who have had FGM: A systematic review

Female genital mutilation (FGM) is a global issue, with 200 million women and girls thought to be affected. FGM is defined as removal of female external genitalia, either partial or total, for non-medical purposes. FGM is embedded in tradition, including cultural beliefs about sexual behaviour. Associated risks include haemorrhage, infection, death, dyspareunia, childbirth complications and psychological issues. Although FGM negatively impacts on women's psychological wellbeing, little is known about the impact on pregnancy experiences. Psychological consequences of FGM are likely to be intensified during pregnancy when women have concerns about their own and their baby's wellbeing. This mixed-method systematic review aimed to provide insight into the psychological impact of FGM on women who subsequently become pregnant. Nine electronic databases were searched, using a search strategy to identify relevant studies. Studies were considered for inclusion if they were primary studies (qualitative, quantitative or mixed-method) involving pregnant women of any age who have previously undergone FGM. Relevant studies were evaluated using the MMAT appraisal tool. Analysis was guided by the review questions and the evidence identified. One quantitative and 9 qualitative papers were included. Qualitative data were analysed using meta-ethnography. Narrative analysis of the quantitative study was conducted. Findings relate to power of choice linked to reinfibulation, deinfibulation, birth procedures and pain management; importance of knowledgeable and sensitive health care professionals; and relived trauma experienced during childbirth. These findings could inform the development of supportive interventions for women with FGM within maternity services.

From Vulnerability to Disclosure: A Normative Approach to Understanding Trust in Obstetric and Intrapartum Nurse-Patient Communication

This study qualitatively examined how nurses, nurse practitioners, and nurse midwives construct the meaning of patient trust in their work caring for pregnant and laboring women. Twenty-two interviews were conducted with nurse participants employed at clinics, hospitals, and birth centers across Southeastern United States. Using a normative theoretical approach within the multiple goals framework, we identified five emergent themes that characterize trust as it shapes nurses' communicative goals: trust as the woman's acceptance of vulnerability and risk, the woman relinquishing control, the woman conceding to the nurse's expertise, the woman feeling heard, and the woman's disclosure of information. The results support previous studies, which conceptualized trust as vulnerability, risk, and disclosure whereas the remaining themes are original to this study. The results are interpreted both in light of existing links between trust and communication and the shifting and conflicting goals of nurses as they attempt to achieve their primary goal of optimal health outcomes. Passive constructions of trust that conflate it with women's acquiescent behaviors could have implications for the quality of communication between nurses and patients. In addition, trust, as understood by these participants, becomes situated as an instrumental means to achieving patient cooperation and desired health outcomes rather than a relational goal that supports women's agency throughout obstetric and intrapartum processes. This may be at odds with the modern movement toward patient-centered care and shared decision-making in U.S. maternity care.

Risk of Preterm Birth and Newborn Low Birthweight in Military Women with Increased Pregnancy-Specific Anxiety

INTRODUCTION

Prenatal maternal anxiety and depression have been implicated as possible risk factors for preterm birth (PTB) and other poor birth outcomes. Within the military, maternal conditions account for 15.3% of all hospital bed days, and it is the most common diagnostic code for active duty females after mental disorders. The majority of women (97.6%) serving on active duty are women of childbearing potential. Understanding the impact that prenatal maternal anxiety and depression can have on PTB and low birthweight (LBW) in a military population is critical to providing insight into biological pathways that alter fetal development and growth. The purpose of the study was to determine the impact of pregnancy-specific anxiety and depression on PTB and LBW within a military population.

MATERIAL AND METHODS

Pregnancy-specific anxiety and depression were measured for 246 pregnant women in each trimester. Individual slopes for seven different measures of pregnancy anxiety and one depression scale were calculated using linear mixed models. Logistic regression, adjusted and unadjusted models, were applied to determine the impact on PTB and LBW.

RESULTS

For each 1/10 unit increase in the anxiety slope as it related to well-being, the risk of LBW increased by 83% after controlling for parity, PTB, and active duty status. Similarly, a 1/10 unit rise in the anxiety slope related to accepting pregnancy, labor fears, and helplessness increased the risk of PTB by 37%, 60%, and 54%, respectively.

CONCLUSIONS

Pregnancy-specific anxiety was found to significantly increase the risk of PTB and LBW in a military population. Understanding this relationship is essential in developing effective assessments and interventions. Results emphasize the importance of prenatal maternal mental health to fetal health and birth outcomes. Further research is needed to determine the specific physiological pathways that link prenatal anxiety and depression with poor birth outcomes.

The experiential knowledge of migrant women about vulnerability during pregnancy: A woman-centred mixed-methods study

PROBLEM

Within maternity care policies and practice, pregnant migrant women are regarded as a vulnerable population.

BACKGROUND

Women's experiential knowledge is a key element of woman-centred care but is insufficiently addressed in midwifery practice and research that involves migrant women.

AIM

To examine if pregnant migrant women's experiential knowledge of vulnerability corresponds with sets of criteria of vulnerability, and to explore how migrant women make sense of vulnerability during pregnancy.

METHODS

A sequential two-phased mixed-methods study, conducted in the Netherlands, integrating survey data of 89 pregnant migrant women and focus group data obtained from 25 migrant mothers - living in deprived areas according to the Dutch socio-economic index.

RESULTS

Criteria associated with vulnerability were reported by 65.2% of the participants and 62.9% of the participants reported adverse childhood experiences. On a Visual Analogue Scale, ranging from 0 (not vulnerable) to 10 (very vulnerable), participants self-reported sense of vulnerability showed a mean score of 4.2 (±2.56). Women's experiential knowledge of vulnerability significantly correlated with the mean sum score of clinical criteria of vulnerability (r .46, p .002) and with the mean sum score of adverse childhood experiences (r .48, p<.001). Five themes emerged from the focus group discussions: "Look beyond who you think I am and see and treat me for who I really am", "Ownership of truth and knowledge", "Don't punish me for being honest", "Projection of fear" and "Coping with labelling".

CONCLUSION

Pregnant migrant women's experiential knowledge of vulnerability is congruent with the criteria. Calling upon experiential knowledge is an attribute of the humane woman-midwife relationship.

Prevalence and risk factors of perinatal depression among women in rural Bihar: A community-based cross-sectional study

BACKGROUND

Perinatal depression (PND) is one of the most common mental disorders occurring during the perinatal period among women. Few studies examined prevalence and risk factors of PND from rural settings in India. This study aimed to estimate the prevalence of perinatal depression and identify social risk factors for it among women from rural Bihar.

MATERIALS AND METHODS

A cross sectional study was conducted in a community setting in rural areas of Bihar. All perinatal women were screened through a door to door survey and recruited after obtaining informed consent. A semi-structured proforma was used to collect sociodemographic characteristics and family related variables. Edinburgh postnatal depression scale (EPDS) was used to screen for perinatal depression.

RESULTS

A total of 564 perinatal women were recruited into the study. The estimated prevalence of PND was 23.9 % (95 % CI: 20.6,27.6). Multivariate analysis showed perinatal depression was associated with physical illness in the mother, previous history of abortion, poor financial status and ill-treatment by in-laws.

CONCLUSION

Prevalence of perinatal depression among women is high in rural settings of North India. A multitude of factors ranging from physical, obstetric, economic and family related confer a high risk for PND. Comprehensive interventions are needed to address these risk factors of perinatal depression.

Factors Associated With a Trusting Relationship Between Pregnant and Postpartum Women With Substance Use Disorders and Maternity Nurses

Trusting relationships between pregnant and postpartum women with substance use disorders (SUDs) and maternity nurses can improve health outcomes for women and their infants. This study was conducted to identify factors associated with the formation of trust in these nurse–patient relationships. Using a qualitative description approach, semi-structured interviews were conducted with 10 women who used substances during pregnancy and 15 maternity nurses. The narratives were analyzed with standard content analytic techniques. Findings revealed that six characteristics of nurses and five characteristics of women fostered or hindered the formation of trusting relationships. The characteristics of the maternity nurses were (a) interpersonal connections, (b) demeanor toward women, (c) ways of providing care, (d) approaches to providing information, (e) attitudes toward substance use, and (f) addiction expertise. The characteristics of the women were (a) engagement with nurses, (b) demeanor toward nurses, (c) attitudes toward care, (d) investment in recovery, and (e) ways of interacting with infant. The characteristics provide a framework by which maternity nurses can examine their attitudes and behaviors toward women with SUDs and inform the development of strategies to enhance their practice with this population.

Postpartum mood among universally screened high and low socioeconomic status patients during COVID-19 social restrictions in New York City

The mental health effects of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the Coronavirus Disease 2019 (COVID-19) pandemic on postpartum women are of increasing concern among mental health practitioners. To date, only a handful of studies have explored the emotional impact of the pandemic surrounding pregnancy and none have investigated the consequence of pandemic-related social restrictions on the postpartum mood of those living among different socioeconomic status (SES). All postpartum patients appearing to the Mount Sinai Health System for their postpartum appointment between January 2, 2020 and June 30, 2020, corresponding to before and during pandemic imposed social restrictions, were screened for mood symptomatology using the Edinburgh Postnatal Depression Scale (EPDS). Each patient's socioeconomic status (high/low) was determined by their location of clinical service. A total of 516 postpartum patients were screened. While no differences in EPDS scores were observed by SES prior to social restrictions (U = 7956.0, z = - 1.05, p = .293), a significant change in mood symptomatology was observed following COVID-19 restrictions (U = 4895.0, z = - 3.48, p < .001), with patients living in lower SES reporting significantly less depression symptomatology (U = 9209.0, z = - 4.56, p < .001). There was no change in symptomatology among patients of higher SES (U = 4045.5, z = - 1.06, p = .288). Postpartum depression, the most common complication of childbearing, is a prevalent, cross-cultural disorder with significant morbidity. The observed differences in postpartum mood between patients of different SES in the context of temporarily imposed COVID-19-related social restrictions present a unique opportunity to better understand the specific health and social support needs of postpartum patients living in urban economic poverty. Given that maternal mental illness has negative long-term developmental implications for the offspring and that poor mental health reinforces the poverty cycle, future health policy specifically directed towards supporting postpartum women living in low SES by ameliorating some of the early maternal burdens associated with balancing employment-family-childcare demands may assist in interrupting this cycle while simultaneously improving the long-term outcomes of their offspring.

Prenatal Stress Impairs Spinal Cord Oligodendrocyte Maturation via BDNF Signaling in the Experimental Autoimmune Encephalomyelitis Model of Multiple Sclerosis

One of the most substantial and established environmental risk factors for neurological and psychiatric disorders is stress exposure, whose detrimental consequences hinge on several variables including time. In this regard the gestational period is known to present an intrinsic vulnerability to environmental insults and thus stressful events during pregnancy can lead to severe consequences on the offspring's brain development with long-term repercussions throughout adulthood. On this basis, we investigated the long-lasting impact of prenatal stress exposure on the susceptibility to the experimental autoimmune encephalomyelitis (EAE), a well-established murine model of multiple sclerosis. Although stress is considered a triggering factor for this chronic, progressive, autoimmune disease, little is known about the underlying mechanisms. To this end, EAE was induced by immunization with MOG35-55/CFA and pertussis toxin administration in adult female C57BL/6 mice born from control or stressed dams exposed to restraint stress during the last days of gestation. Our results demonstrate that gestational stress induces a marked increase in the severity of EAE symptoms in adulthood. Further, we highlight an altered maturation of oligodendrocytes in the spinal cord of prenatally stressed EAE mice, as indicated by the higher levels of GPR17, a marker of immature oligodendrocyte precursor cells. These behavioral and molecular alterations are paralleled by changes in the expression and signaling of the neurotrophin BDNF, an important mediator of neural plasticity that may contribute to stress-induced impaired remyelination. Since several already marketed drugs are able to modulate BDNF levels, these results pave the way to the possibility of repositioning these drugs in multiple sclerosis.

Vulnerability: A concept synthesis and its application to the Emergency Department

AIM

The aim of this concept synthesis was to add clarity to the concept of vulnerability with application to the Emergency Department (ED) by critiquing, analysing and amalgamating published concept analyses.

BACKGROUND

The concept of vulnerability has been used widely, however it has various meanings. A clearer understanding of vulnerability and application to the ED may help healthcare professionals provide high quality care responsive to the needs of vulnerable individuals.

METHOD

Nine concept analyses of vulnerability were retrieved using Medline, CINAHL, and PsycINFO databases. After extracting data on each analysis, Walker and Avant's concept synthesis method was used to structure this synthesis, with a thematic synthesis approach used in the analysis.

FINDINGS

Four themes associated with vulnerability emerged from the synthesis. The first theme, vulnerability as a journey, reflected elements within an individual's life that perpetuate and exacerbate vulnerability. The second theme, vulnerability as susceptibility and risk, highlighted intrinsic and extrinsic elements that contribute to a state of risk. The third theme, positive and negative repercussions, emphasised lessons that can be learned from experience, with the fourth theme of a shared understanding indicating the importance of understanding the concept of vulnerability for patient care.

CONCLUSION

Findings from this synthesis highlight the multiple elements associated with a vulnerable state, evident in the context of the ED. With multiple ED-specific elements contributing to vulnerability, clarity of the term is important to inform ED-specific interventions designed to meet the needs of vulnerable populations.

Towards an integrated perinatal care pathway for vulnerable women: The development and validation of quality indicators

OBJECTIVE

Development and validation of a set of quality indicators for vulnerable women during the perinatal period.

DESIGN

A three-phase method was used. Phase 1 consisted of a literature review to identify publications for the development of care domains and potential QIs, as well as a quality assessment by the research team. In phase 2 an expert panel assessed the set of concept QIs in a modified three-round Delphi survey. Finally, semi-structured interviews with vulnerable women were conducted as a final quality assessment of a set of indicators (phase 3). Ethical approval was obtained from the ethics committee of the University Hospital Brussels and from the Ethics Committees of all the participating hospitals.

SETTING

The Flemish Region and the Brussels Capital Region in Belgium.

PARTICIPANTS

Healthcare and social care professionals (n = 40) with expertise in the field of perinatal care provision for vulnerable families. Vulnerable women (n = 11) who gave birth in one of the participating hospitals.

FINDINGS

The literature review resulted in a set of 49 potential quality indicators in five care domains: access to healthcare, assessment and screening, informal support, formal support and continuity of care. After assessment by the expert panel and vulnerable women, a final set of 21 quality indicators in five care domains was identified. First of all, organisation of care must involve an integrated multidisciplinary approach taking account of financial, administrative and social barriers (care domain 1: access to healthcare). Second, qualitative care includes the timely initiation of care, a general screening of the various aspects of vulnerability (biological, psychological, social and cognitive) and a risk assessment for all women (care domain 2: assessment and screening). Vulnerable women benefit from intensive formal and informal support taking account of individual needs and strengths (care domain 3: formal support; care domain 4: informal support). Finally, continuity of care needs to be guaranteed in line with vulnerable woman's individual needs (care domain 5: continuity of care).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Implementing quality indicators in existing and new care pathways offers an evidence-based approach facilitating an integrated view promoting a healthy start for woman and child. These quality indicators can assist healthcare providers, organisations and governmental agencies to improve the quality of perinatal care for vulnerable women.

Defining vulnerability in European pregnant women, a Delphi study

OBJECTIVE

Vulnerability among pregnant women is an important and complex theme in the everyday practice of midwives. Exchanging knowledge and best practices about vulnerability between midwives in Europe can contribute to improving the knowledge and skills of midwives and as a result improve the care for vulnerable pregnant women. We therefore start a consortium with midwives, midwifery teachers, researchers and students from organizations of seven European cities with the aim to exchange knowledge and best practices concerning vulnerable pregnant women between midwives. To be able to effectively exchange knowledge and best practices, our consortium started with this study focuses on establishing a mutual definition of vulnerable pregnant women. Therefore, the aim of this study is to develop a mutual definition of vulnerable pregnant women and to identify aspects related to vulnerability.

DESIGN

Delphi study with four rounds: (1) gathering existing knowledge from literature and definitions used by partners of the consortium, (2) and (3) two survey rounds and (4) an in-person consensus meeting.

SETTING

Consortium of midwives, midwifery teachers, researchers and students from Antwerp (Belgium), Ghent (Belgium), Turku (Finland), Milan (Italy), Piła (Poland), Lisbon (Portugal) and Rotterdam (The Netherlands) PARTICIPANTS: We included all consortium members in the Delphi study.

FINDINGS

Various aspects related to vulnerability and appropriate definitions were identified during the Delphi rounds. Consensus about the aspects related to vulnerability and the definition of vulnerable pregnant women was reached during the final consensus meeting. A vulnerable pregnant woman was defined as a woman who is threatened by physical, psychological, cognitive and/or social risk factors in combination with lack of adequate support and/or adequate coping skills.

KEY CONCLUSION

We reached consensus about a mutual definition of vulnerable pregnant women and aspects related to vulnerability within this consortium. The Delphi approach led to interesting discussions and was a valuable method to define the concept of vulnerable pregnant women within our project .

IMPLICATIONS FOR PRACTICE

In order to accomplish a project that aimed to improve care for vulnerable pregnant women it was important to first identify the population of vulnerable pregnant women with a mutual definition.

Journey of vulnerability: a mixed-methods study to understand intrapartum transfers in Tanzania and Zambia

BACKGROUND

Timely intrapartum referral between facilities is pivotal in reducing maternal/neonatal mortality and morbidity but is distressing to women, resource-intensive and likely to cause delays in care provision. We explored the complexities around referrals to gain understanding of the characteristics, experiences and outcomes of those being transferred.

METHODS

We used a mixed-method parallel convergent design, in Tanzania and Zambia. Quantitative data were collected from a consecutive, retrospective case-note review (target, n = 2000); intrapartum transfers and stillbirths were the outcomes of interest. A grounded theory approach was adopted for the qualitative element; data were collected from semi-structured interviews (n = 85) with women, partners and health providers. Observations (n = 33) of transfer were also conducted. Quantitative data were analysed descriptively, followed by binary logistic regression models, with multiple imputation for missing data. Qualitative data were analysed using Strauss's constant comparative approach.

RESULTS

Intrapartum transfer rates were 11% (111/998; 2 unknown) in Tanzania and 37% (373/996; 1 unknown) in Zambia. Main reasons for transfer were prolonged/obstructed labour and pre-eclampsia/eclampsia. Women most likely to be transferred were from Zambia (as opposed to Tanzania), HIV positive, attended antenatal clinic < 4 times and living > 30 min away from the referral hospital. Differences were observed between countries. Of those transferred, delays in care were common and an increase in poor outcomes was observed. Qualitative findings identified three categories: social threats to successful transfer, barriers to timely intrapartum care and reparative interventions which were linked to a core category: journey of vulnerability.

CONCLUSION

Although intrapartum transfers are inevitable, modifiable factors exist with the potential to improve the experience and outcomes for women. Effective transfers rely on adequate resources, effective transport infrastructures, social support and appropriate decision-making. However, women's (and families) vulnerability can be reduced by empathic communication, timely assessment and a positive birth outcome; this can improve women's resilience and influence positive decision-making, for the index and future pregnancy.

Women's vulnerability within the childbearing continuum: A scoping review

INTRODUCTION

The aim of this scoping review is to explore the concept of 'vulnerability' affecting pregnant women and to identify an appropriate definition of this term.

METHODS

Five stages were adopted for conducting the scoping review. A literature search was undertaken between 1 October 2017 and 5 January 2018, using three databases. Relevant publications were appraised, and semantic content analysis was performed to identify emergent themes and four determinants of the vulnerability concept. This involved combining items that seem to address the same issue.

RESULTS

Eleven publications were considered, and eight definitions of vulnerability were identified, and from these four themes emerged: poor health outcome or status; exposure to risk; complex social needs; and lack of resources. Further analysis of evidence found examples of groups of people considered to be vulnerable; they were reported into six matrices, mainly with social and psychological difficulties. From these, eleven themes arose. Following a semantic and content analysis of all themes, thirteen final themes were identified. They represent the characteristics associated with women considered to be vulnerable and are called indices of vulnerability. Semantic and content analysis allowed addressing the thirteen indices of vulnerability into four categories called determinants of the vulnerability concept: deficiency, need, risk exposure, and barriers.

CONCLUSIONS

The vulnerability could be defined as a lack of health, related to the presence of at least one of the four determinants. Midwives are the key to identify vulnerable women, offering appropriate care.

Safety and Pregnancy Massage: a Qualitative Thematic Analysis

BACKGROUND

Traditionally, safety and improving safety in the treatment of pregnant women has involved identifying risks that lead to errors or adverse events, and implementing strategies to mitigate potential harm. There is research that suggests that other factors such as a lack of service, lack of care or a lack of quality also contribute to participants feeling unsafe. Currently there is no evidence-based research on the psychological aspects of the safety of massage during pregnancy.

PURPOSE

The present study aim was to investigate women's perceptions and experiences of the safety of massage during pregnancy. This included exploring what attributes of the clinician or practice and events that occur during the massage helped pregnant women feel safe.

SETTING

Phone interview with participants from Victoria, New South Wales and Queensland.

PARTICIPANTS

20 women who received massage whilst pregnant.

RESEARCH DESIGN

Qualitative design using thematic analysis.

RESULTS

There were five main themes related to safety and massage: 1) Autonomy- able to voice my needs and be heard; 2) Pregnancy massage is more than just a massage; 3) When my therapist is experienced and qualified, I feel safer; 4) The continuity of the massage industry's message about the safety of massage; and 5) Decision-making around massage safety.

CONCLUSIONS

Safety is made up of not only the treatment that massage therapists provide, but also the environment they provide it in and how they administer both the treatment and the consultation. The lack of cohesion in messaging about the safety of massage during pregnancy makes women doubt the safety of massage.

PTSD post-childbirth: a systematic review of women's and midwives' subjective experiences of care provider interaction

OBJECTIVE

Review primary research regarding PTSD Post-Childbirth (PTSD-PC) that focussed on Quality of Provider Interaction (QPI) from the perspective of women who developed PTSD-PC, or midwives.

BACKGROUND

Up to 45% of women find childbirth traumatic. PTSD-PC develops in 4% of women (18% in high-risk groups). Women's subjective experiences of childbirth are the most important risk factor in the development of PTSD-PC, with perceived QPI being key.

METHODS

A systematic search was performed for PTSD-PC literature. Reviewed papers focussed on either women's subjective childbirth experiences, particularly QPI, or midwives' perspectives on QPI. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) tools, and a narrative synthesis of findings produced.

RESULTS

Fourteen studies were included. Three features of QPI contribute towards developing PTSD-PC: interpersonal factors; midwifery care factors; and lack of support.

CONCLUSION

QPI is a significant factor in the development of PTSD-PC and the identified key features of QPI have potential to be modified by midwives. The development of guidelines for midwives should be grounded on evidence highlighted in this review, along with further high-quality qualitative research exploring QPI from the perspective of women with PTSD-PC, but also midwives' knowledge and needs regarding their role within QPI.

Maternity experiences of mothers with multiple disadvantages in England: A qualitative study

Background

Disadvantaged mothers and their babies are at increased risk of poor perinatal outcomes and have less positive experiences of maternity care.

Aim

To explore the maternity care experiences of mothers with multiple disadvantages.

Methods

A qualitative descriptive study based on semi-structured interviews with 40 mothers with multiple disadvantages, using thematic analysis.

Findings

Four themes emerged: ‘A confusing and frightening time’, ‘Longing to be respected as an individual’, ‘The importance of choice and control’, and ‘Needing trust to feel safe’. Mothers brought feelings of powerlessness and low self-esteem to their encounters with maternity professionals, which could be significantly worsened by disrespectful care. They needed support to navigate the complex maternity system. Positive experiences were much more likely where the mother had received continuity of care from a specialist midwife or small team.

Discussion and conclusion

Mothers with multiple disadvantages value being treated as an individual, making informed choices, and feeling safe, but they may lack the confidence to ask questions or challenge disrespectful treatment. Training and supervision should enable maternity professionals to understand how confusing maternity care can be to very disadvantaged mothers. It should emphasise the need to provide accessible and empowering information and guidance to enable all mothers to make choices and understand the system. Leaders of maternity services need to do more to challenge negative staff attitudes and ensure that that all mothers are treated at all times with kindness, respect and dignity. Specialist midwives can deliver a high quality service to mothers experiencing multiple disadvantages.

Seeking help for perinatal psychological distress: a meta-synthesis of women's experiences

BACKGROUND

Women may not seek help for perinatal psychological distress, despite regular contact with primary care services. Barriers include ignorance of symptoms, inability to disclose distress, others' attitudes, and cultural expectations. Much of the evidence has been obtained from North American populations and may not, therefore, extrapolate to the UK.

AIM

To understand the factors affecting women's decision to seek help for perinatal distress.

DESIGN AND SETTING

Meta-synthesis of the available published qualitative evidence on UK women's experiences of seeking help for perinatal distress.

METHOD

Systematic searches were conducted in accordance with PRISMA guidelines. Databases searched were PubMed, Scopus, PsycINFO, PsycARTICLES, CINAHL, and Academic Search Complete. Searches of grey literature and references were also conducted. Studies were eligible for inclusion if they reported qualitative data on UK women's experiences of perinatal distress and contact with healthcare professionals. The synthesis was conducted using meta-ethnography.

RESULTS

In all, 24 studies were eligible for inclusion. Metasynthesis identified three main themes: identifying a problem, the influence of healthcare professionals, and stigma. These themes build on current understanding of help seeking by identifying the need for women to be able to frame their experience, for healthcare professionals to educate women about their roles, the need for continuity of care, and the way that being seen as a 'bad mother' causes women to self-silence.

CONCLUSION

Perinatal care provision needs to allow for continuity of care and for staff training that facilitates awareness of factors that influence women's help seeking. Further research is required, particularly in relation to effective means of identifying perinatal psychological distress.