Highly improved perinatal states in Japan

Moral Distress in the Neonatal Intensive Care Unit Experienced by Nurses Caring for Critically Ill Neonates: A Phenomenological Study

AIMS

To elucidate the meaning of moral distress in nurses caring for critically ill neonates.

DESIGN

Qualitative study using Husserl's descriptive phenomenology.

METHODS

Between April and December 2022, unstructured interviews were conducted with 11 nurses with at least 3 years of neonatal intensive care unit experience in Japan. They were asked to recall experiences of moral distress and to speak freely about their thoughts and feelings at the time. The analysis followed Colaizzi's seven-step method.

RESULTS

Three themes ('organisational constraints', 'regret' and 'unshared experiences') and seven subtheme clusters were extracted from the nurses' narratives of moral distress, which was the basis of trauma. Subtheme clusters included 'wavering beliefs', 'guilt associated with the death of a child', 'powerlessness at being unable to help one's family' and 'mismatch with the perceptions and feelings of the family'.

CONCLUSION

Nurses experience various morally distressing events, but these are processed only as personal problems and give rise to feelings of self-negation. Therefore, trauma can develop as a result of experiences related to decision-making and the child's best interests. There is a need to improve nurses' moral resilience and ensure their psychological safety to alleviate moral distress.

IMPLICATIONS FOR THE PROFESSION

This study clarifies nurses' roles within the neonatal intensive care unit, potentially helping them to handle life-and-death issues and cope with feelings of moral distress.

IMPACT

This study elucidated the meanings of powerlessness underlying the moral distress experienced by neonatal intensive care unit nurses. These results will contribute to releasing suppressed feelings and thoughts and alleviating unavoidable moral distress in this setting.

REPORTING METHOD

This study was performed in accordance with the COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

Nurses with experience in neonatal intensive care unit nursing participated as interviewees. They also verified the credibility of survey results and ensured analytical rigour.

Obesity as a potential risk factor for stillbirth: The Japan Environment and Children's Study

The relationship between high body mass index (BMI) >25 kg/m2 and risk for stillbirth in the Japanese population remains unclear. This study aimed to estimate the impact of maternal obesity on the risk of stillbirth in a Japanese population. This prospective cohort study used data from the Japan Environment and Children's Study, which recruited pregnant individuals between 2011 and 2014. A total of 93,772 fetuses were considered eligible for inclusion in this study. Stillbirth (fetal death before or during labor at ≥22 completed weeks of gestation) rates were compared among four pre-pregnancy BMI groups: underweight (<18.5 kg/m2), reference (18.5 to <25.0 kg/m2), overweight (25.0 to <30.0 kg/m2), and obese (≥30.0 kg/m2). The association between pre-pregnancy BMI and the risk of stillbirth was estimated using multiple logistic regression analyses. The overall stillbirth incidence was 0.33% (305/93,722). Compared with the reference group, the risk of stillbirth was significantly higher in the overweight group (adjusted odds ratio [aOR]: 1.55; 95% confidence interval [CI]: 1.08-2.23) and the obese group (aOR: 2.60; 95% CI: 1.59-4.24). The overall incidence of early stillbirth (i.e., <28 weeks) was 0.17% (155/93,722). Similarly, after adjusting for potential confounding factors, the risk of early stillbirth was significantly higher in the obese group (aOR: 4.33; 95% CI: 2.44-7.70). Increased maternal BMI was associated with an increased risk of stillbirth in the Japanese population. Therefore, counselling women planning for pregnancy on the importance of an appropriate pre-pregnancy BMI to minimize the risk of stillbirth is important.

A Japanese survey of malignant disease in pregnancy

BACKGROUND

In recent years, the incidence of malignant disease in pregnancy has been increasing, but there are few large-scale surveys of malignant disease in pregnancy in Japan. The aim of this study was to survey malignant disease occurring during pregnancy in Japan.

METHODS

Malignant disease in pregnancy was defined as diagnosis or treatment for malignant disease, except in situ carcinoma during pregnancy, or within 1-year postpartum. First, a primary survey questionnaire of the incidence of malignant disease in pregnancy and the number of deliveries over the course of 2014 was sent to 510 medical centers in Japan. Second, the survey questionnaires on the incidence of malignant diseases in pregnancy were collected and analyzed in detail.

RESULTS

Of the 510 medical centers, 411 (81%) responded to the survey. There were 215,372 deliveries and 189 incidents (0.09%) of malignant disease in pregnancy. Of the 189 patients with malignancy, 157 detailed responses about the patients were received. The most frequently encountered cancer types were cervical cancer (36%), breast cancer (24%), and ovarian cancer (15%). During the 2 years after delivery, 15 patients (1 with breast cancer, 2 with ovarian cancer, 3 with hematologic malignancy, 4 with intestinal cancer, and 5 with others) died of the disease; most of them had advanced disease. In particular, 88% of the patients with intestinal cancers at diagnosis had advanced disease, and half of them died of disease.

CONCLUSIONS

In Japan, the most common malignancies in pregnancy in order of frequency are cervical cancer, breast cancer, and ovarian cancer. Early diagnosis and appropriate management of cancer during pregnancy are important for improving maternal and neonatal outcomes, because advanced diseases have a poor prognosis.

Causes and risk factors for singleton stillbirth in Japan: Analysis of a nationwide perinatal database, 2013-2014

Over 80% of perinatal mortality in Japan is due to stillbirths after 22 weeks of gestation, with one in 300 families experiencing fetal loss every year. This study aimed to assess causes and risk factors for singleton stillbirth in Japan. A retrospective cross-sectional study was conducted using the Japan Society of Obstetrics and Gynecology Perinatal Database from January 2013 to December 2014. A total of 379,211 births including 2,133 stillbirths were analyzed. Causes of death were classified into eight categories. A multi-level Poisson regression model was used to assess the relationship between stillbirth and key covariates. Causes of death were unknown in 25–40% of stillbirths across gestational age. Placental abnormality accounted for the largest proportion of known causes, followed by umbilical cord abnormality. Stillbirth risk was increased among small-for-gestational-age infants (adjusted relative risk [ARR]: 3.78, 95% confidence interval [CI]: 3.31–4.32) and nulliparous women (ARR: 1.19, 95% CI: 1.05–1.35). Maternal underweight, pregnancy-induced hypertension and oligohydramnios showed a protective effect. Our finding suggests that stillbirths occurring among women with known complications are likely already being prevented. Further reduction in stillbirths must target small-sized fetuses and nulliparous women. Improved recording of the causal pathways of stillbirths is also needed.

Absence of neonatal intensive care units in secondary medical care zones is an independent risk factor of high perinatal mortality in Japan

AIM

National medical projects are carried out according to medical care plans directed by the Medical Care Act of Japan. In order to improve Japanese perinatal medical care, it is necessary to determine the factors that might influence perinatal outcome.

METHODS

Statistical data of births and perinatal deaths were obtained for all municipalities in Japan from 2008 to 2012 from the Portal Site of Official Statistics of Japan (e-Stat). The perinatal mortality of all 349 Japanese secondary medical care zones was calculated. The number of neonatal intensive care units (NICUs), maternal-fetal intensive care units (MFICUs), pediatricians and obstetricians in 2011 were also obtained from e-Stat. Nine secondary medical care zones in two prefectures, Fukushima (7) and Miyagi (2) were excluded to eliminate the influence of the 2011 Great East Japan Earthquake.

RESULTS

The 340 secondary medical care zones were divided into three groups according to population size and density: metropolis, provincial city, and depopulation. The number of secondary medical care zones in each group were 52, 168, and 120, respectively. The secondary medical care zones in the depopulation group had fewer pediatricians and significantly fewer NICUs and MFICUs than the metropolis group, but there was no significant difference in perinatal mortality. The only independent risk factor for high perinatal mortality, determined by multivariable analysis, was the absence of an NICU (P = 0.011).

CONCLUSIONS

To consider directions in perinatal medical care, planned arrangement and appropriate access to NICUs is indispensable.