Sofia Quintero Romero: Protection and Support of Breastfeeding With a Feminist and Social Justice Lens

Sofia Quintero Romero graduated as a medical doctor at Universidad del Rosario, Bogotà, Colombia, in 1977. She spent a compulsory rural year working in a remote indigenous community in the Sierra Nevada de Santa Marta in Columbia. In 1979 she worked in Bolivia for Terre des Hommes and Oxfam, evaluating their health projects with the Aymara Indians and in the tin mines. She had to leave Colombia for political reasons and went to England, where she obtained, in 1981, an MSc in Community Health at the London School of Hygiene & Tropical Medicine (LSHTM). That's where she met her husband, Adriano Cattaneo. She then worked in Mozambique and Nicaragua where she was in charge of maternal and child health services at the regional level. Since 1990, she devoted her time to the protection, promotion, and support of breastfeeding. Sofia obtained a PhD in Maternal and Child Health at the University of Bologna, Italy, and a Diploma in Breastfeeding Theory and Practice at the Child Health Institute in London UK. She taught hundreds of breastfeeding courses for health professionals and peer counsellors in Italy and in dozens of countries abroad, using the World Health Organization/United Nations Children's Fund (WHO/UNICEF) manuals. In the past 15 years, she changed her approach for breastfeeding education to biological nurturing. Sofia has been a member of the International Baby Food Action Network (IBFAN) since 1992 and coordinated the Nestlé Boycott in Italy. She retired in 2018.

Building an Evidence Base for the Protection and Support of Breastfeeding: An Interview With Adriano Cattaneo

Adriano Cattaneo holds an MD degree from the University of Padua, Italy, and an MSc from the London School of Hygiene and Tropical Medicine. He spent most of his professional career in low-income countries, including 4 years as medical officer with the World Health Organization (WHO) in Geneva. After returning to Italy, he worked for 20 years as an epidemiologist at the Unit for Health Services Research and International Health, the Institute for Maternal and Child Health (IRCCS Burlo Garofolo) in Trieste, a WHO Collaborating Centre for Maternal and Child Health. He is the author of more than 220 publications in scientific journals and books, more than 100 of which are in peer reviewed journals. He has been affiliated with International Baby Food Action Network (IBFAN) in Italy since it was created in 2001. As project coordinator of two European Union funded projects, he played an important role in the development of the document Protection, Promotion and Support of Breastfeeding in Europe: A Blueprint for Action, a tool tested and used for the development of national breastfeeding policies and programs. He retired in 2014.

Lactation Newsmakers: Documenting our History-The Current State of Breastfeeding in Ukraine: An Interview With Lidiia Romanenko and Olha Shlemkevych

In this issue, we are featuring an interview with two medical doctors from Ukraine, who are specialists in breastfeeding, and work with the implementation of the Baby-Friendly Hospital Initiative (BFHI) in Ukraine. The authors met during the Eleventh BFHI Network Meeting of Country Coordinators from Industrialized Countries, Eastern Europe, and the Commonwealth of Independent States, in Brussels in June 2022 (Hernández-Aguilar, M. T., 2022). Ukrainian citizens have lived in a war situation since February 24, 2022, when Russia first attacked; this has had a huge impact on infant feeding issues.

Factors associated with exclusive breastfeeding at discharge during the COVID-19 pandemic in 17 WHO European Region countries

BACKGROUND

Exclusive breastfeeding is the optimal infant nutrition, providing infants immunoprotection against many diseases including SARS-CoV-2 infection. Restrictions during the COVID-19 pandemic may have negatively affected breastfeeding practices in maternity care facilities. The aims of the study were to examine exclusive breastfeeding rates at discharge over time and to identify factors associated with exclusive breastfeeding during the pandemic.

METHODS

A cross-sectional survey was conducted among mothers who gave birth in a maternity care facility in the World Health Organization (WHO) European Region countries during the COVID-19 pandemic. The socio-ecological model was employed to examine intrapersonal, interpersonal, organizational, and community/society factors associated with maternal report of exclusive breastfeeding at the time of discharge.

RESULTS

There were 26,709 participating mothers from 17 European Region countries who were included in the analysis. Among the mothers, 72.4% (n = 19,350) exclusively breastfed and 27.6% (n = 7,359) did not exclusively breastfeed at discharge. There was an overall decline in exclusive breastfeeding rates over time (p = 0.015) with a significantly lower rate following the publication of the WHO breastfeeding guidelines on 23 June 2020 (AOR 0.88; 95% CI 0.82, 0.94). Factors significantly associated with exclusive breastfeeding outcomes in the logistic regression analysis included maternal age, parity, education, health insurance, mode of birth, inadequate breastfeeding support, lack of early breastfeeding initiation, lack of full rooming-in, birth attendant, perceived healthcare professionalism and attention, facility room cleanliness, timing of birth, and location of birth.

CONCLUSIONS

Results from the study indicate the decline in exclusive breastfeeding rates in the WHO European Region during the COVID-19 pandemic. Using the socio-ecological model to identify factors associated with breastfeeding outcomes facilitates an integrated and holistic approach to address breastfeeding needs among women across the region. These findings demonstrate the need to augment breastfeeding support and to protect exclusive breastfeeding among mother-infant dyads, in an effort to reverse the declining exclusive breastfeeding rates. The study highlights the need to educate mothers and their families about the importance of exclusive breastfeeding, reduce maternal-infant separation, increase professional breastfeeding support, and follow evidence-based practice guidelines to promote breastfeeding in a comprehensive and multi-level manner.

TRIAL REGISTRATION NUMBER

Clinical Trials NCT04847336.

Quality of health care around the time of childbirth during the COVID-19 pandemic: Results from the IMAgiNE EURO study in Norway and trends over time

OBJECTIVE

To describe maternal perception of the quality of maternal and newborn care (QMNC) in facilities in Norway during the first year of COVID-19 pandemic.

METHODS

Women who gave birth in a Norwegian facility from March 1, 2020, to October 28, 2021, filled out a structured online questionnaire based on 40 WHO standards-based quality measures. Quantile regression analysis was performed to assess changes in QMNC index over time.

RESULTS

Among 3326 women included, 3085 experienced labor. Of those, 1799 (58.3%) reported that their partner could not be present as much as needed, 918 (29.8%) noted inadequate staff numbers, 183 (43.6%) lacked a consent request for instrumental vaginal birth (IVB), 1067 (34.6%) reported inadequate communication from staff, 78 (18.6%) reported fundal pressure during IVB, 670 (21.7%) reported that they were not treated with dignity, and 249 (8.1%) reported experiencing abuse. The QMNC index increased gradually over time (3.68 points per month, 95% CI, 2.83-4.53 for the median), with the domains of COVID-19 reorganizational changes and experience of care displaying the greatest increases, while provision of care was stable over time.

CONCLUSION

Although several measures showed high QMNC in Norway during the first year of the COVID-19 pandemic, and a gradual improvement over time, several findings suggest that gaps in QMNC exist. These gaps should be addressed and monitored.

Quality of maternal and newborn care around the time of childbirth for migrant versus nonmigrant women during the COVID-19 pandemic: Results of the IMAgiNE EURO study in 11 countries of the WHO European region

OBJECTIVE

To describe the perception of quality of maternal and newborn care (QMNC) around the time of childbirth among migrant and nonmigrant women in Europe.

METHODS

Women who gave birth at a health facility in 11 countries of the WHO European Region from March 2020 to July 2021 were invited to answer an online questionnaire including demographics and childbirth experience. Data were analyzed and compared for 1781 migrant and 20 653 nonmigrant women.

RESULTS

Migrant women who experienced labor perceived slightly more difficulties in attending routine antenatal visits (41.2% vs 39.4%; P = 0.001), more barriers in accessing facilities (32.9% vs 29.9%; P = 0.001), lack of timely care (14.7% vs 13.0%; P = 0.025), inadequate room comfort and equipment (9.2% vs 8.5%; P = 0.004), inadequate number of women per room (9.4% vs 8.6%; P = 0.039), being prevented from staying with their baby as they wished (7.8% vs 6.9%; P = 0.011), or suffering abuse (14.5% vs 12.7%; P = 0.022) compared with nonmigrant women. For women who had a prelabor cesarean, migrant women were more likely not to receive pain relief after birth (16.8% vs.13.5%; P = 0.039) and less likely to provide informal payment (1.8% vs 4.4%; P = 0.005) compared with nonmigrant women. Overall, the QMNC index was not significantly different for migrant compared with nonmigrant women.

CONCLUSION

Gaps in overall QMNC were reported by both migrant and nonmigrant women, with improvements to healthcare necessary for all.

Women's perspectives on the quality of hospital maternal and newborn care around the time of childbirth during the COVID-19 pandemic: Results from the IMAgiNE EURO study in Slovenia, Croatia, Serbia, and Bosnia-Herzegovina

OBJECTIVE

To assess the quality of maternal and newborn care (QMNC) in countries of the former Yugoslavia.

METHOD

Women giving birth in a facility in Slovenia, Croatia, Serbia, and Bosnia-Herzegovina between March 1, 2020 and July 1, 2021 answered an online questionnaire including 40 WHO standards-based quality measures.

RESULTS

A total of 4817 women were included in the analysis. Significant differences were observed across countries. Among those experiencing labor, 47.4%-62.3% of women perceived a reduction in QMNC due to the COVID-19 pandemic, 40.1%-69.7% experienced difficulties in accessing routine antenatal care, 60.3%-98.1% were not allowed a companion of choice, 17.4%-39.2% reported that health workers were not always using personal protective equipment, and 21.2%-53.8% rated the number of health workers as insufficient. Episiotomy was performed in 30.9%-62.8% of spontaneous vaginal births. Additionally, 22.6%-55.9% of women received inadequate breastfeeding support, 21.5%-62.8% reported not being treated with dignity, 11.0%-30.5% suffered abuse, and 0.7%-26.5% made informal payments. Multivariate analyses confirmed significant differences among countries, with Slovenia showing the highest QMNC index, followed by Croatia, Bosnia-Herzegovina, and Serbia.

CONCLUSION

Differences in QMNC among the countries of the former Yugoslavia during the COVID-19 pandemic were significant. Activities to promote high-quality, evidence-based, respectful care for all mothers and newborns are urgently needed.

CLINICALTRIALS

gov Identifier: NCT04847336.

Rates of instrumental vaginal birth and cesarean and quality of maternal and newborn health care in private versus public facilities: Results of the IMAgiNE EURO study in 16 countries

OBJECTIVE

To explore the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic by facility type among 16 European countries, comparing rates of instrumental vaginal birth and cesarean.

METHODS

Women who gave birth in the WHO European Region from March 1, 2020, to February 7, 2022, answered a validated online questionnaire. Rates of instrumental birth, instrumental vaginal birth, and cesarean, and a QMNC index were calculated for births in public versus private facilities.

RESULTS

Responses from 25 206 participants were analyzed. Women giving birth in private compared with public facilities reported significantly more frequent total cesarean (32.5% vs 19.0%; aOR 1.70; 95% CI 1.52-1.90), elective cesarean (17.3% vs 7.8%; aOR 1.90; 95% CI 1.65-2.19), and emergency cesarean before labor (7.4% vs 3.9%; aOR 1.39; 95% CI 1.14-1.70) (P < 0.001 for all comparisons), with analyses by country confirming these results. QMNC index results were heterogeneous across countries and regions in the same country and were largely affected by geographical distribution of regions rather than by type of facility alone.

CONCLUSION

The study confirms that births in private facilities have higher odds of cesarean. It also suggests that QMNC should be closely monitored in all facilities to achieve high-quality care, independent of facility type or geographical distribution.

CLINICALTRIALS

GOV IDENTIFIER

NCT04847336.

Women's perspectives on the quality of maternal and newborn care in childbirth during the COVID-19 pandemic in Latvia: Results from the IMAgiNE EURO study on 40 WHO standards-based quality measures

OBJECTIVE

To investigate women's perspectives on the quality of maternal and newborn care (QMNC) around the time of childbirth during the COVID-19 pandemic in Latvia, comparing the years 2020 and 2021, among women who went into labor or had a prelabor cesarean.

METHODS

Women giving birth in healthcare facilities in Latvia from March 1, 2020, to October 28, 2021, answered an online questionnaire including 40 WHO standards-based quality measures. Descriptive and multivariate quantile regression analyses were performed to compare QMNC in 2020 and 2021.

RESULTS

2079 women were included in the analysis: 1860 women who went into labor (group 1) and 219 with prelabor cesarean (group 2). Among group 1, 66.4% (n = 99/149) of women received fundal pressure in an instrumental vaginal birth, 43.5% (n = 810) lacked involvement in choices, 17.4% (n = 317) reported suffering abuse, 32.7% (n = 609) reported inadequate breastfeeding support while 5.2% (n = 96) lack of early breastfeeding. A significant reduction in QMNC due to the COVID-19 pandemic was reported by 29.5% (n = 219) and 25.0% (n = 270) of respondents in 2020 and 2021, respectively (P = 0.045). Multivariate analyses highlighted a significantly lower QMNC index for 2020 compared with 2021 (P < 0.001).

CONCLUSION

This first study investigating QMNC in Latvia showed significant gaps in QMNC perceived by respondents, with slightly better results in 2021. Appropriate healthcare strategies to improve health care for women and newborns in Latvia are required.

CLINICALTRIALS

gov Identifier:NCT04847336.

Quality of maternal and newborn care in Switzerland during the COVID-19 pandemic: A cross-sectional study based on WHO quality standards

OBJECTIVE

To explore quality of maternal and newborn care (QMNC) in healthcare facilities during the COVID-19 pandemic in Switzerland.

METHODS

Women giving birth in Switzerland answered a validated online questionnaire including 40 WHO standards-based quality measures. QMNC score was calculated according to linguistic region and mode of birth. Differences were assessed using logistic regression analysis adjusting for relevant variables.

RESULTS

A total of 1175 women were included in the analysis. Limitations in QMNC during the pandemic were reported by 328 (27.9%) women. Several quality measures, such as deficient communication (18.0%, n = 212), insufficient number of healthcare professionals (19.7%, n = 231), no information on the newborn after cesarean (26.5%, n = 91) or maternal and newborn danger signs (34.1%, n = 401 and 41.4% n = 487, respectively) suggested preventable gaps in QMNC. Quality measures significantly differed by linguistic region and mode of birth. Multivariate analysis established a significantly lower QMNC for women in French- and Italian-speaking regions compared with the German-speaking region. Moreover, in several quality indicators reflecting communication with healthcare providers, women who did not answer the questionnaire in one of the Swiss national languages had significantly worse scores than others. A significant lower QMNC was also found for young and primiparous women and for those who experienced cesarean or instrumental vaginal birth.

CONCLUSION

Women giving birth in Switzerland during the pandemic reported notable gaps in QMNC. Providers should be attuned to women who are younger, primiparous, and those who had an emergency cesarean or instrumental vaginal birth given the lower QMNC reported by these groups. Women who did not respond in a Swiss national language may need improved communication strategies.

Women's assessment of the quality of hospital-based perinatal care by mode of birth in Romania during the COVID-19 pandemic: Results from the IMAgiNE EURO study

OBJECTIVE

To assess women's perceptions of the quality of maternal and newborn care (QMNC) received in hospitals in Romania during the COVID-19 pandemic by mode of birth.

METHODS

A validated anonymous online questionnaire based on WHO quality measures. Subgroup analysis of spontaneous vaginal birth (SVB), emergency cesarean, and elective cesarean and multivariate analyses were performed, and QMNC indexes were calculated. Maternal age, educational level, year of birth, mother born in Romania, parity, type of hospital, and type of professionals assisting the birth were used for multivariate analysis.

RESULTS

A total of 620 women completed the survey. Overall, several quality measures suggested gaps in QMNC in Romania, with the lowest QMNC indexes reported for provision of care and availability of resources. Women who had either elective or emergency cesarean compared with those who had SVB more frequently lacked early breastfeeding (OR 2.04 and 2.13, respectively), skin-to-skin contact (OR 1.73 and 1.75, respectively), rooming-in (OR 2.07 and 1.96, respectively), and exclusive breastfeeding at discharge (OR 2.27 and 1.64, respectively). Compared with elective cesarean, emergency cesarean had higher odds of ineffective communication by healthcare providers (OR 1.65), lack of involvement in choices (OR 1.58), insufficient emotional support (OR 2.07), and no privacy (OR 2.06). Compared with other modes of birth, a trend for lower QMNC indexes for emergency cesarean was observed for all domains, while for elective cesarean the QMNC index for provision of care was significantly lower.

CONCLUSION

Quality indicators of perinatal care remain behind targets in Romania, with births by cesarean the most affected.

CLINICALTRIALS

GOV IDENTIFIER

NCT04847336.

Regional differences in the quality of maternal and neonatal care during the COVID-19 pandemic in Portugal: Results from the IMAgiNE EURO study

OBJECTIVE

To compare women's perspectives on the quality of maternal and newborn care (QMNC) around the time of childbirth across Nomenclature of Territorial Units for Statistics 2 (NUTS-II) regions in Portugal during the COVID-19 pandemic.

METHODS

Women participating in the cross-sectional IMAgiNE EURO study who gave birth in Portugal from March 1, 2020, to October 28, 2021, completed a structured questionnaire with 40 key WHO standards-based quality measures. Four domains of QMNC were assessed: (1) provision of care; (2) experience of care; (3) availability of human and physical resources; and (4) reorganizational changes due to the COVID-19 pandemic. Frequencies for each quality measure within each QMNC domain were computed overall and by region.

RESULTS

Out of 1845 participants, one-third (33.7%) had a cesarean. Examples of high-quality care included: low frequencies of lack of early breastfeeding and rooming-in (8.0% and 7.7%, respectively) and informal payment (0.7%); adequate staff professionalism (94.6%); adequate room comfort and equipment (95.2%). However, substandard practices with large heterogeneity across regions were also reported. Among women who experienced labor, the percentage of instrumental vaginal births ranged from 22.3% in the Algarve to 33.5% in Center; among these, fundal pressure ranged from 34.8% in Lisbon to 66.7% in Center. Episiotomy was performed in 39.3% of noninstrumental vaginal births with variations between 31.8% in the North to 59.8% in Center. One in four women reported inadequate breastfeeding support (26.1%, ranging from 19.4% in Algarve to 31.5% in Lisbon). One in five reported no exclusive breastfeeding at discharge (22.1%; 19.5% in Lisbon to 28.2% in Algarve).

CONCLUSION

Urgent actions are needed to harmonize QMNC and reduce inequities across regions in Portugal.

Individual and country-level variables associated with the medicalization of birth: Multilevel analyses of IMAgiNE EURO data from 15 countries in the WHO European region

OBJECTIVE

To investigate potential associations between individual and country-level factors and medicalization of birth in 15 European countries during the COVID-19 pandemic.

METHODS

Online anonymous survey of women who gave birth in 2020-2021. Multivariable multilevel logistic regression models estimating associations between indicators of medicalization (cesarean, instrumental vaginal birth [IVB], episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country level.

RESULTS

Among 27 173 women, 24.4% (n = 6650) had a cesarean and 8.8% (n = 2380) an IVB. Among women with IVB, 41.9% (n = 998) reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% (n = 4048) had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalization. For example, women who reported having a cesarean, IVB, or episiotomy reported not feeling treated with dignity more frequently than women who did not have those interventions (odds ratio [OR] 1.37; OR 1.61; OR 1.51, respectively; all: P < 0.001). Country-level variables contributed to explaining some of the variance between countries.

CONCLUSION

We recommend a greater emphasis in health policies on promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor medicalization of reproductive care.

Quality of maternal and newborn care around the time of childbirth in Luxembourg during the COVID-19 pandemic: Results of the IMAgiNE EURO study

OBJECTIVE

To investigate the quality of maternal and newborn care (QMNC) during childbirth in Luxembourg from women's perspectives.

METHODS

Women giving birth in facilities in Luxembourg between March 1, 2020, and July 1, 2021, answered a validated online WHO standards-based questionnaire as part of the multicountry IMAgINE EURO study. Descriptive and multivariate quantile regression analyses were performed.

RESULTS

A total of 493 women were included, representing 5.2% of women giving birth in the four maternity hospitals in Luxembourg during the study period. Most quality measures suggested high QMNC, although specific gaps were observed: 13.4% (n = 66) of women reported not being treated with dignity, 9.1% (n = 45) experienced abuse, 42.9% (n = 30) were not asked for consent prior to instrumental vaginal birth, 39.3% (n = 118) could not choose their birth position, 27% (n = 133) did not exclusively breastfeed at discharge (without significant differences over time), 20.5% (n = 101) reported an insufficient number of healthcare professionals, 20% (n = 25) did not receive information on the newborn after cesarean, and 41.2% (n = 203) reported lack of information on newborn danger signs before discharge. Multivariate analyses highlighted higher reported QMNC indexes among women born outside Luxembourg and delivering with a gynecologist, and significantly lower QMNC indexes in women with the highest education levels and those delivering in the hospital offering some private services.

CONCLUSIONS

Despite maternal reports suggesting an overall high QMNC in Luxembourg, improvements are needed in specific aspects of care and communication, mostly related to maternal autonomy, respect, and support, but also number and competencies of the health workforce.

The Power of Consumer Activism From the Kennedy Hearings to the International Code: An Interview With Leah Margulies (Part II)

Leah Margulies was Director of the Infant Formula Program at the Interfaith Center on Corporate Responsibility in New York City (NYC) from 1975 to 1985. She is a founder of the International Nestle Boycott, Corporate Accountability (formerly INFACT), and one of the founders of the International Baby Food Action Network (IBFAN). She was hired at UNICEF in 1982 to set up the legal office for implementation of the International Code of Marketing Breastmilk Substitutes, as part of the Baby Friendly Hospital Initiative. Previously, she was legal advisor to the Environment Unit of the United Nations Centre on Transnational Corporations. From 2006 to 2016, she was Project Director of LawHelpNY at the NYC Bar Association. Currently, she works for a legal non-profit, representing low-income Brooklynites, defending them against eviction. She is a lawyer, a Second Wave Feminist, and a member of Veteran Feminists of America. She is also a musician and founding member of a pioneering women's rock band that played at the first national women's march for abortion rights in Washington, DC, 1972.

Exclusive breastfeeding during the COVID-19 pandemic in 17 WHO European Region countries

Background

Maternal experience of labour and delivery is multidimensional and is influenced by a variety of factors.

Aim

to report maternal childbirth experience as described by the women themselves during the COVID-19 pandemic in Sweden using a WHO Standards-based tool adapted for an online survey (Quality of maternal and newborn care-QMNC).

Methods

Women ≥ 18 years of age who gave birth from March 1, 2020 to June 30, 2021 were asked to give voluntary consent to participate in an online survey. The survey included 40 questions on four key domains: provision of care, experience of care, availability of human and physical resources and organisational changes due to COVID-19.

Results

5003 women were included in the analysis. Among those who underwent labour (n = 4528), 46.7% perceived a reduction in QMNC due to the COVID-19 pandemic, 50.7% were not allowed a companion of choice, 62.5% reported that health workers were not always using protective personal equipment and 36.5% rated the number of health workers as “insufficient”. Fundal pressure was applied in 22.2% of instrumental vaginal births and 36.8% received inadequate breastfeeding support. In addition, 18.4% of women did not feel treated with dignity and 6.9% reported some form of abuse. In general, findings were significantly worse among women who did not undergo labour (n = 475).

Conclusions

Swedish mothers’ satisfaction of care provided during childbirth was strongly influenced by many variables. Actions to promote high-quality, evidence-based, patient-centered respectful care for all mothers and newborns are urgently needed.

Quality of facility-based maternal and newborn care around the time of childbirth during the COVID-19 pandemic

Background

Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID19 pandemic, as defined by WHO Standards, are lacking.

Methods

Women who gave birth in 12 countries of the WHO European Region from March 1, 2020 - March 15, 2021 answered an online questionnaire, including 40 WHO Standard-based Quality Measures.

Results

21,027 mothers were included in the analysis. Among those who experienced labour (N = 18,063), 41.8% (26.1%- 63.5%) experienced difficulties in accessing antenatal care, 62% (12.6%-99.0%) were not allowed a companion of choice, 31.1% (16.5%-56.9%) received inadequate breastfeeding support, 34.4% (5.2%-64.8%) reported that health workers were not always using protective personal equipment, and 31.8% (17.8%-53.1%) rated the health workers’ number as “insufficient”. Episiotomy was performed in 20.1% (6.1%-66.0%) of spontaneous vaginal births and fundal pressure applied in 41.2% (11.5% -100%) of instrumental vaginal births. In addition, 23.9% women felt they were not treated with dignity (12.8%-59.8%), 12.5% (7.0%-23.4%) suffered abuse, and 2.4% (0.1%-26.2%) made informal payments. Most findings were significantly worse among women with prelabour caesarean birth (N = 2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significantly lower QMNC Indexes and Luxemburg showing a significantly higher QMNC Index than the total sample. Younger women and those with operative births also reported significantly lower QMNC Indexes.

Conclusions

Mothers reports revealed large inequities in QMNC across countries of the WHO European Region. Quality improvement initiatives to reduce these inequities and promote evidence-based, patient-centred respectful care for all mothers and newborns during the COVID-19 pandemic and beyond are urgently needed.

Funding: The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.

The Power of Consumer Activism: An Interview With Leah Margulies [Part 1]

Leah Margulies was Director of the Infant Formula Program at the Interfaith Center on Corporate Responsibility in NYC from 1975 to 1985. She is a founder of the International Nestlé Boycott, Corporate Accountability (formerly INFACT), and one of the founders of the International Baby Food Action Network (IBFAN). She was hired at UNICEF in 1982 to set up the legal office for implementation of the International Code of Marketing Breast-Milk Substitutes, as part of the Baby Friendly Hospital Initiative. Previously, she was legal advisor to the Environment Unit of the United Nations Centre on Transnational Corporations. From 2006 to 2016, she was Project Director of LawHelpNY at the NYC Bar Association. Currently, she works for a legal non-profit, representing low-income Brooklynites, defending them against eviction. She is a lawyer, a second Wave Feminist, and a member of Veteran Feminists of America. She is also a musician and founding member of a pioneering women's rock band that played at the first national women's march for abortion rights in Washington, DC, 1972.

Travelling the World to Lecture and to Share Expertise About Breastfeeding: An Interview With Elizabeth Hormann, BA, EdM

In this issue's Lactation Newsmakers: Documenting our History, we are featuring Elizabeth Hormann, who has been a force in breastfeeding advocacy globally for over a half century of counselling, teaching, and writing to create a better experience for breastfeeding mothers. Elizabeth Hormann was born and raised in the United States. She has a bachelor's degree from Boston College (1967) and a master's degree from Harvard University's Graduate School of Education (1976). In 1972, she started training and lecturing at conferences, while raising her five breastfed children. Just after receiving her IBCLC in 1986, she changed continents moving to live and work in Germany. She was a role model, influencing the development of the IBCLC accreditation in Europe. Elizabeth Hormann was a pioneer in lecturing and sharing expertise during the 1980s, when there was a renewed interest in breastfeeding and a huge demand on breastfeeding education for health professionals. She helped to advance the Baby-Friendly Hospital Initiative (BFHI) in many countries, as a trainer and as an assessor. Over the years, she shared her expertise about relactation breastfeeding and infant feeding during emergencies. As the author and a translator of a number of breastfeeding books, her influence has been felt across Europe and Africa.

Quality of facility-based maternal and newborn care around the time of childbirth during the COVID-19 pandemic: online survey investigating maternal perspectives in 12 countries of the WHO European Region

BACKGROUND

Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic, as defined by WHO Standards, are lacking.

METHODS

Women who gave birth in 12 countries of the WHO European Region from March 1, 2020 - March 15, 2021 answered an online questionnaire, including 40 WHO Standard-based Quality Measures.

FINDINGS

21,027 mothers were included in the analysis. Among those who experienced labour (N=18,063), 41·8% (26·1%- 63·5%) experienced difficulties in accessing antenatal care, 62% (12·6%-99·0%) were not allowed a companion of choice, 31·1% (16·5%-56·9%) received inadequate breastfeeding support, 34·4% (5·2%-64·8%) reported that health workers were not always using protective personal equipment, and 31·8% (17·8%-53·1%) rated the health workers' number as "insufficient". Episiotomy was performed in 20·1% (6·1%-66·0%) of spontaneous vaginal births and fundal pressure applied in 41·2% (11·5% -100%) of instrumental vaginal births. In addition, 23·9% women felt they were not treated with dignity (12·8%-59·8%), 12·5% (7·0%-23·4%) suffered abuse, and 2·4% (0·1%-26·2%) made informal payments. Most findings were significantly worse among women with prelabour caesarean birth (N=2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significant lower QMNC Indexes and Luxemburg showing a significantly higher QMNC Index than the total sample. Younger women and those with operative births also reported significantly lower QMNC Indexes.

INTERPRETATION

Mothers reports revealed large inequities in QMNC across countries of the WHO European Region. Quality improvement initiatives to reduce these inequities and promote evidence-based, patient-centred respectful care for all mothers and newborns during the COVID-19 pandemic and beyond are urgently needed.

FUNDING

The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.

STUDY REGISTRATION

ClinicalTrials.gov Identifier: NCT04847336.

Interview Marina Rea: A Militant Doctor Active in the Endless Fight for Breastfeeding as a Human Right - A Luta Continua!

Marina Ferreira Rea is a Brazilian medical doctor. She has a masters and a doctorate degree in public health from the University of São Paulo (USP). She specialized in breastfeeding at Wellstart International, and completed post-doctoral research at Columbia University, New York, USA, focusing on working women and breastfeeding. She was a researcher at the Health Institute at Columbia University in New York, the Center for Population and Family Health, and at the postgraduate studies, Nutrition in Public Health, University of São Paulo, where she advised many students and published many articles and books (a few selected below). She was a Coordinator of International Breastfeeding Actions at the World Health Organization (Geneva), in the early 1990s, when actions like the Baby-Friendly Hospital Initiative, breastfeeding counseling, and other courses were started. During this same period, the World Alliance for Breastfeeding Action (WABA) and World Breastfeeding Week were initiated. In 1981 she participated in the launching of the International Code of Marketing of Breastmilk Substitutes. Marina Rea is a member of the International Baby Food Action Network and its Latin American policy committee, and is the founder of the International Baby Food Action Network (IBFAN) Brazil group. Since 2017, she has been a member of the IBFAN Global Council. She is now retired but continues to volunteer as an IBFAN member. She has two daughters and four grandchildren. A more detailed curriculum vitae in Portuguese can be found here: http://lattes.cnpq.br/8193850878281835 (MR = Marina Rea; MA = Maryse Arendt).

Quality of care at childbirth: findings of IMAgiNE EURO in Italy during the first year of the COVID‐19 pandemic

Objective

Investigate the quality of maternal and newborn care (QMNC) during childbirth in the first year of COVID‐19 pandemic in Italy, from the mothers' perspective, as key service users.

Methods

Women who gave birth in an Italian facility from March 1, 2020 to February 29, 2021 answered an online questionnaire including 40 WHO Standard‐based Quality Measures. Descriptive and multivariate quantile regression analyses were performed.

Results

In total, 4824 women were included, reporting heterogeneity of practices across regions: among 3981 women who underwent labour 78.4% (63.0%–92.0%) were not allowed a companion of choice, 44.6% (28.9%–53.3%) had difficulties in attending routine antenatal visits, 36.3% (24.9%–61.1%) reported inadequate breastfeeding support, 39.2% (23.3%–62.2%) felt not involved in medical choices, 33.0% (23.9%–49.3%) experienced unclear communication from staff, 24.8% (15.9%–39.4%) were not always treated with dignity and 12.7% (10.1%–29.3%) reported abuses. Findings in the group of women who did not experience labour were substantially similar. Multivariate analyses confirmed a significant lower QMNC index for regions in southern Italy compared to North and Central regions.

Conclusion

Mothers reported substantial inequities in the QMNC across Italian regions. Future studies should monitor QMNC over time. Meanwhile, actions to ensure high QMNC for all mothers and newborns across Italy are urgently required.

Mothers giving birth in the first year of the COVID‐19 pandemic reported substantial inequities across Italian regions in the QMNC around the time of childbirth.

An Interview With Gabrielle Palmer, Campaigner Author and Nutritionist, Who Learned From Women Around the World

Gabrielle Palmer has written, taught, and campaigned about infant nutrition issues, particularly the unethical marketing of baby foods, since the 1970s. Her seminal book, The Politics of Breastfeeding: When Breasts are Bad for Business, has guided many breastfeeding advocates for over 40 years through three editions and multiple printings. As a breastfeeding counsellor during the 1970s, she helped establish the United Kingdom's advocacy pressure group Baby Milk Action. She worked as a volunteer in Mozambique during the 1980s. During the 1990s she co-directed the International Breastfeeding Practice and Policy course at the Institute of Child Health, University College London, until she went to live for 2 years in China. Over the years, she has worked for various health and development agencies, including serving as HIV and Infant Feeding Officer for the United Nations Children's Fund, New York, and also taught at The London School of Hygiene and Tropical Medicine (LSHTM). She is a mother and a grandmother. (This is a verbatim interview that has been edited for readability: MA = Maryse Arendt; GP = Gabrielle Palmer).

An Interview With Patti Rundall: A Passionate Activist, Full of Energy!

Since 1980, alongside IBFAN partners, Patti Rundall has worked to build collaborative networks that help countries bring in legally binding controls based on the International Code of Marketing of Breastmilk Substitutes and the United Nations World Health Assembly (WHA) Resolutions. Conflicts of interest and their impact on policymaking, research, education, and health systems has been a cross-cutting theme of her work, which has focused on the adoption and strengthening of the European Union's baby food legislation and the improvement of Codex Global Trading Standards. With IBFAN, she helped countries adop many resolutions including WHA Resolution 49.15 https://www.who.int/nutrition/topics/WHA49.15_iycn_en.pdf?ua=1 (1996) about conflicts of interest; she helped found and launch the Conflicts of Interest Coalition at the UN General Assembly. Patti is a founder of Baby Feeding Law Group (the alliance of 23 United Kingdom health professional and mother-support organizations), a member of the Infant Feeding in Emergencies core group and a leader in company campaigns (e.g., the Nestlé Boycott). She represented IBFAN on the European Commission's Platform for Action on Diet and Physical Activity from 2007 until 2019. In the year 2000 she was awarded the title Officer of the British Empire (OBE) for her service to infant nutrition. (This is a verbatim interview: MA = Maryse Arendt; PR = Patti Rundall.).

Are our babies off to a healthy start? The state of implementation of the Global strategy for infant and young child feeding in Europe

Background

To protect children’s right to optimal nutrition, WHO/UNICEF developed a Global Strategy for Infant and Young Child Feeding, endorsed by all 53 WHO/EURO Member States. The World Breastfeeding Trends Initiative (WBTi) is a tool for monitoring implementation of the Global Strategy. It comprises 15 indicators, ten referring to policies and programmes, and five to feeding practices. Each is scored on a scale of 10, giving a total score of 150 for Global Strategy implementation. To date, 18 WHO/EURO Member States – Armenia, Austria, Belgium, Bosnia and Herzegovina, Croatia, France, Georgia, Germany, Italy, Lithuania, North Macedonia, Malta, Moldova, Portugal, Spain, Turkey, Ukraine and United Kingdom – have conducted a WBTi assessment and produced a report.

Methods

Between June 2018 and May 2019, all 18 WBTi European reports were carefully read and analysed by a group of national WBTi coordinators. Descriptive data analysis, including inter-country comparisons, was conducted using frequencies and percentages. This paper summarises the findings. The full 88-page report will be published on the WBTi website.

Results

Three-quarters of 18 European countries have adequate maternity protection, and two-thirds have breastfeeding initiation rates of 50% or higher. However, ‘Preparedness and planning for appropriate and safe Infant and Young Child Feeding (IYCF) in emergencies’ is seriously neglected. Breastfeeding duration is far below WHO recommendations, with an average of 8.7 months. Only three European countries have a budget allocated for implementing IYCF policies and plans, and a third currently have no Baby-friendly designated maternity facilities. Bottle feeding is prevalent, despite its inherent risks, monitoring of IYCF practices is inadequate, with most countries not routinely collecting data, and violations of the International Code of Marketing of Breast-milk Substitutes are commonplace.

Conclusions

European governments are not doing enough to protect, promote and support sound infant and young child feeding practices. Political commitment at the highest level and adequate funding are required to ensure optimal IYCF for Europe’s babies. This report highlights worrying gaps, thereby providing governments, international organisations and other concerned parties with an opportunity to invest in priority areas and, by doing so, hopefully create a better future for our babies.

Protecting Breastfeeding From Conflicts of Interest

In order to maximize profits from sales of breastmilk substitutes, manufacturers use a whole gamut of strategies to interfere with the effective implementation of policies that protect, promote, and support breastfeeding (e.g., the International Code of Marketing of Breastmilk Substitutes with its subsequent World Health Assembly resolutions and the Global Strategy on Infant and Young Child Feeding). Their strategies create, among other problems, personal and institutional conflicts of interest. Effective Conflict of Interest policies are therefore needed for ensuring that governments, international organizations, non-governmental organizations, and health professionals can protect their independence, integrity, and credibility in order to work in the best interests of children. Conflicts of interest are discussed by Dr Lida Lhotska and Dr Judith Richter, who have been actively involved in these issues internationally. Lida Lhotska holds a BSc in Biology and a PhD in Anthropology. Her international work spans over 25 years. She headed the Infant Feeding and Care team for UNICEF and subsequently joined the IBFAN-Geneva Infant Feeding Association team, always focusing on advancing the protection of breastfeeding through legal and other policy measures. Judith Richter has a multidisciplinary background combining knowledge in the humanities with health sciences (PhD Social Sciences; MA Development Studies; MSc Pharmaceutical Sciences). Her work as a freelance researcher for United Nations agencies, governments, and civil society organizations and networks has centered on safeguarding their capacity to hold transnational corporations accountable. In her interview, Judith Richter explains why conflict of interest regulation matters to health professionals working in the field of lactation. (MA = Maryse Arendt; LL = Lida Lhotska; JR = Judith Richter).

Annelies Allain: Pioneer of the International Code of Marketing of Breastmilk Substitutes

Annelies Allain has been at the forefront of global efforts to support and promote breastfeeding for more than 30 years. Her accomplishments continue to affect all of us who work with breastfeeding families. Born in the Netherlands in 1945, Annelies Allain-van Elk received a scholarship and completed a BA from the University of Minnesota, Duluth, USA. Back in Europe, she obtained a BA in French language and literature (University of Geneva, Switzerland) as well as a translator's diploma. After 4 years working in West Africa and visits to South America, she returned to Geneva to obtain an MA in development studies. She is fluent in English, French, and Dutch and has working knowledge of Spanish, Portuguese, Italian, and German. Ms. Allain was a co-founder of IBFAN (1979) and the coordinator of IBFAN Europe (1980-1984). In 1984, she moved to Penang, Malaysia, and IBFAN work soon took over as a full-time job. She was instrumental in developing the Code Documentation Centre (1985) and by 1991 it became a foundation (ICDC) registered in the Netherlands. Subsequently, the Centre has trained over 2,000 officials from 148 countries about the International Code, making it the world's top International Code implementation institution. Among her many other education and advocacy activities, Ms. Allain was a co-founder of WABA (1990) and for many years has been a consultant with UNICEF and WHO's Western Pacific Regional Office on International Code implementation and monitoring. In this interview she provides a firsthand account of how most of the major global breastfeeding protection efforts influencing our current situation came into being. (This is a verbatim interview: MA = Maryse Arendt; AA = Annelies Allain.).

Diet adaptation in dog reflects spread of prehistoric agriculture

Adaptations allowing dogs to thrive on a diet rich in starch, including a significant AMY2B copy number gain, constituted a crucial step in the evolution of the dog from the wolf. It is however not clear whether this change was associated with the initial domestication, or represents a secondary shift related to the subsequent development of agriculture. Previous efforts to study this process were based on geographically limited data sets and low-resolution methods, and it is therefore not known to what extent the diet adaptations are universal among dogs and whether there are regional differences associated with alternative human subsistence strategies. Here we use droplet PCR to investigate worldwide AMY2B copy number diversity among indigenous as well as breed dogs and wolves to elucidate how a change in dog diet was associated with the domestication process and subsequent shifts in human subsistence. We find that AMY2B copy numbers are bimodally distributed with high copy numbers (median 2n_AMY2B=11) in a majority of dogs but no, or few, duplications (median 2n_AMY2B=3) in a small group of dogs originating mostly in Australia and the Arctic. We show that this pattern correlates geographically to the spread of prehistoric agriculture and conclude that the diet change may not have been associated with initial domestication but rather the subsequent development and spread of agriculture to most, but not all regions of the globe.

Traumatic stress and risk of severe mental illness: A nationwide cohort study

Introduction

A history of traumatic events is prevalent in people with schizophrenia spectrum disorders and mood disorders. However, little is known about their etiological relationship.

Objectives

To explore whether patients with acute or posttraumatic stress disorder are at higher risk of developing a schizophrenia spectrum disorder or mood disorder.

Methods

In this prospective cohort study using registers covering the entire Danish population, we used the Danish Psychiatric Central Research Register to identify patients with ICD-10 diagnoses of acute traumatic stress disorder and/or posttraumatic stress disorder. From inpatient and outpatient mental hospitals, we identified 4371 diagnoses with more than 18 million years of follow-up. Main outcomes and measures were relative risks (RR) with 95% confidence intervals (95% CI) of schizophrenia, schizophrenia spectrum disorder, bipolar disorder and mood disorder.

Results

The incidence of traumatic stress disorder (TSD) has increased steadily from 0.6% in 1996 to 6% in 2012, showed a higher incidence in women and an age distribution with a peak-incidence in early adulthood. We found that diagnoses of TSD increase the risk of schizophrenia (RR 5.85, 95% CI 3.59–8.91), schizophrenia spectrum disorder (RR 3.82, 95% CI 2.38–5.75), bipolar disorder (RR 5.83, 95% CI 3.11–9.83) and mood disorder (RR 4.10, 95% CI 3.15–5.22). Risks were high in the first year after diagnosis of TSD and declined going forward in time.

Conclusions

Our findings indicate that acute and posttraumatic stress disorder are etiological risk factors for schizophrenia spectrum disorders and mood disorders. If replicated, this may underline treatment of traumatized patients in prevention of severe mental disorder.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Gender differences in cadmium and cotinine levels in prepubertal children

Susceptibility to environmental stressors has been described for fetal and early childhood development. However, the possible susceptibility of the prepubertal period, characterized by the orchestration of the organism towards sexual maturation and adulthood has been poorly investigated and exposure data are scarce. In the current study levels of cadmium (Cd), cotinine and creatinine in urine were analyzed in a subsample 216 children from 12 European countries within the DEMOCOPHES project. The children were divided into six age-sex groups: boys (6-8 years, 9-10 years and 11 years old), and girls (6-7 years, 8-9 years, 10-11 years). The number of subjects per group was between 23 and 53. The cut off values were set at 0.1 µg/L for Cd, and 0.8 µg/L for cotinine defined according to the highest limit of quantification. The levels of Cd and cotinine were adjusted for creatinine level. In the total subsample group, the median level of Cd was 0.180 µg/L (range 0.10-0.69 µg/L), and for cotinine the median wet weight value was 1.50 µg/L (range 0.80-39.91 µg/L). There was no significant difference in creatinine and cotinine levels between genders and age groups. There was a significant correlation between levels of cadmium and creatinine in all children of both genders. This shows that even at such low levels the possible effect of cadmium on kidney function was present and measurable. An increase in Cd levels was evident with age. Cadmium levels were significantly different between 6-7 year old girls, 11 year old boys and 10-11 year old girls. As there was a balanced distribution in the number of subjects from countries included in the study, bias due to data clustering was not probable. The impact of low Cd levels on kidney function and gender differences in Cd levels needs further investigation.

Harmonized European human biomonitoring in small countries: Challenges, opportunities and lessons learned in Cyprus and Luxembourg from the DEMOCOPHES study

Background: To advance human biomonitoring (HBM) for policy support in Europe, a harmonized approach was developed (COPHES project, FP7 2009- 2012) and evaluated in 17 countries (DEMOCOPHES project, Life+, 2010-2012). Cyprus (CY) and Luxembourg (LU) tested the hypothesis that the COPHES European Protocol is applicable to small countries.Materials and methods: In 2011-12, the European Protocol was adopted and tested by CY and LU for the harmonized biomonitoring of 60 children and their mothers for cadmium, phthalates and cotinine in urine and for mercury in scalp hair in two sampling areas (urban, rural). Results: Both small countries achieved the preset goals for recruitment, sample collection and analysis, which allowed for the first time the assessment of children’s and mothers’ exposures to the selected chemicals in comparison with other countries. Capacity building was accomplished and communication actions were particularly effective, with both countries taking advantage of their small size to access participants, policy makers, other stakeholders and the press. Time constrains and requirements for capacity building were limiting factors. Conclusion: The COPHES European Protocol for HBM surveys is attainable in small countries. The following elements are fundamental in the design of a harmonized European HBM program, from the perspective of small countries: (a) consultation with and active involvement of the implementing countries, (b) flexibility for national decisions, while not compromising harmonization, (c) elaboration of standardized methods, procedures and documents (d) quality assurance mechanisms, (e) means of training and support.

Specialized psychosocial treatment plus treatment as usual (TAU) versus TAU for patients with cannabis use disorder and psychosis: the CapOpus randomized trial

BACKGROUND

Cannabis abuse in psychotic patients is associated with rehospitalizations, reduced adherence and increased symptom severity. Previous psychosocial interventions have been ineffective in cannabis use, possibly because of low sample sizes and short interventions. We investigated whether adding CapOpus to treatment as usual (TAU) reduces cannabis use in patients with cannabis use disorder and psychosis. Method A total of 103 patients with psychosis and cannabis use disorder were centrally randomized to 6 months of CapOpus plus TAU (n = 52) or TAU (n = 51). CapOpus consisted mainly of motivational interviewing and cognitive behaviour therapy (CBT). TAU was targeted primarily at the psychotic disorder. The primary outcome was self-reported days with cannabis use in the preceding month.

RESULTS

Pre-randomization cannabis use frequency was 14.9 [95% confidence interval (CI) 12.7-17.1] days/month. Post-treatment, the ratio of days/month with cannabis use in CapOpus versus TAU was 0.76 (95% CI 0.38-1.50) (p = 0.42), and 0.80 (95% CI 0.21-3.10) (p = 0.75) at the 4-month follow-up. From 46.4 (95% CI 36.4-56.3) monthly joints pre-randomization, consumption fell to 27.3 (95% CI 12.6-41.9) joints in CapOpus and 48.2 (95% CI 31.8-64.6) in TAU (p = 0.06). Follow-up amounts were 28.4 (95% CI 13.5-43.2) and 41.6 (95% CI 25.2-58.0) joints (p = 0.23). Several subgroup analyses suggested benefits of CapOpus.

CONCLUSIONS

CapOpus did not reduce the frequency, but possibly the amount, of cannabis use. This is similar to the findings of previous trials in this population. Implementation of CapOpus-type interventions is thus not warranted at present but subgroup analyses call for further trials.

Mindfulness-based stress reduction and mindfulness-based cognitive therapy: a systematic review of randomized controlled trials

Fjorback LO, Arendt M, Ørnbøl E, Fink P, Walach H. Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy - a systematic review of randomized controlled trials.

OBJECTIVE

  To systematically review the evidence for MBSR and MBCT.

METHOD

  Systematic searches of Medline, PsycInfo and Embase were performed in October 2010. MBSR, MBCT and Mindfulness Meditation were key words. Only randomized controlled trials (RCT) using the standard MBSR/MBCT programme with a minimum of 33 participants were included.

RESULTS

  The search produced 72 articles, of which 21 were included. MBSR improved mental health in 11 studies compared to wait list control or treatment as usual (TAU) and was as efficacious as active control group in three studies. MBCT reduced the risk of depressive relapse in two studies compared to TAU and was equally efficacious to TAU or an active control group in two studies. Overall, studies showed medium effect sizes. Among other limitations are lack of active control group and long-term follow-up in several studies.

CONCLUSION

  Evidence supports that MBSR improves mental health and MBCT prevents depressive relapse. Future RCTs should apply optimal design including active treatment for comparison, properly trained instructors and at least one-year follow-up. Future research should primarily tackle the question of whether mindfulness itself is a decisive ingredient by controlling against other active control conditions or true treatments.

Mortality among individuals with cannabis, cocaine, amphetamine, MDMA, and opioid use disorders: a nationwide follow-up study of danish substance users in treatment

Introduction

Little is known about the excess mortality associated with use of some illicit substances. In particular, this concerns the risks associated with injection drug use and psychiatric disorders.

Aims

This study estimated mortality following substance abuse treatment among primary users of cannabis, cocaine, amphetamine, MDMA, and opioids. The risks associated with injection drug use and psychiatric comorbidity were assessed.

Methods

A register of individuals in treatment for illicit substance disorders was linked with registers on psychiatric treatment and mortality. The study population consisted of 20581 individuals who received treatment in Denmark between 1996 and 2006. There were 1441 deaths recorded over 111445 person-years of follow-up.

Results

Standardized Mortality Ratios (SMRs) for primary users of specific substances were: Cannabis: 4.9, cocaine: 6.4, amphetamine: 6.0, heroin: 9.1, and other opioids 7.7. For MDMA the crude mortality rate was 1.75/1000 person-years, and the SMR was not significantly elevated. Sharing of syringes was associated with increased mortality in both primary users of opioids (hazard ratio (HR): 1.58 [95% CI 1.22–1.99], p < .001) and cocaine/amphetamine (HR: 9.52 (95% CI 3.94–23.02, p < .001). Overall, psychiatric comorbidity was associated with modestly increased mortality (HR: 1.15 [95% CI 1.03–1.29], p = .012) and in particular for primary users of cocaine/amphetamine (HR: 2.74 [95% CI 1.56–4.80], p < .001).

Conclusions

High SMRs were found among individuals who had received treatment for cannabis, cocaine, amphetamine, and opioid use disorders. Injection drug use was clearly associated with excess mortality, while the impact of psychiatric comorbidity was generally modest.

Oncolytic gene therapy for canine cancers: teaching old dog viruses new tricks

The use of viruses to treat cancer has been studied for decades. With the advancement of molecular biology, viruses have been modified and genetically engineered to optimize their ability to target cancer cells. Canine viruses, such as distemper virus and adenovirus, are being exploited for the treatment of canine cancer as the dog has proven to be a good comparative model for human cancer research and proof of concept investigations. In this review, we introduce the concept of oncolytic viruses and describe some of the preliminary attempts to use oncolytic viruses for the treatment of canine cancer.

A randomized study of massed three-week cognitive behavioural therapy schedule for panic disorder

OBJECTIVE

To compare the efficacy of massed vs. spaced group cognitive behavioural therapy (CBT) for patients with panic disorder with or without agoraphobia (PD).

METHOD

Thirty-nine PD patients were randomly assigned to massed group CBT (daily 4-h sessions in week 1, two 2-h sessions in week 2 and one 2-h session in week 3) or traditional spaced weekly group CBT (13 consecutive, weekly 2-h sessions). The content and number of hours in the two treatment schedules were identical. Outcome was assessed after treatment, and at 3, 6 and 18 months of follow-up.

RESULTS

Both treatment groups achieved significant improvement on all measures with large pre- to post-treatment and pre-treatment to follow-up effect sizes. No between-group differences were registered. Adherence and patient satisfaction did not differ between groups.

CONCLUSION

The massed, 3-week group CBT schedule proved to be effective and feasible for PD patients with outcomes comparable with that of standard, spaced group CBT.

Controversy Over the Diagnosis of ‘Cannabis-Induced Psychosis’

Background:

Both the ICD-10 and the DSM-IV operate with a diagnosis of cannabis-induced psychotic disorder. Despite this, the diagnosis is controversial.

A number of studies have shown that cannabis can induce short-lived psychotic symptoms, and that this could depend on factors such as genetic predisposition. To qualify for a diagnosis of ‘cannabis-induced psychosis’, however, the symptoms must last for at least 48 hours according to the ICD-10. This diagnosis has traditionally been regarded as benign, but this is based on a very limited number of studies.

Methods:

We have conducted two studies based on Danish treatment registers. Firstly, all patients who had received psychiatric treatment for cannabis-induced psychosis were followed for at least 3 years to determine the rate of subsequent treatment for schizophrenia-spectrum disorders. Secondly, familial predisposition for psychiatric disorders among subjects treated for cannabis-induced psychosis and schizophrenia was compared using competing risk analyses.

Results:

Schizophrenia spectrum disorders were diagnosed in 44.5% of the 535 subjects included in the first study. New psychotic episodes of any type were diagnosed in 77.2% and 47.1% received a diagnosis of schizophrenia spectrum disorders more than a year after the cannabis-induced psychosis.

Those who develop cannabis-induced psychosis and schizophrenia spectrum disorders both show elevated levels of predisposition for schizophrenia, other psychotic conditions, and other psychiatric disorders in first-degree relatives. In general, the level of predisposition is of similar magnitude in individuals treated for cannabis-induced psychosis and schizophrenia.

Conclusion:

Cannabis-induced psychosis could be an early sign of schizophrenia rather than a distinct clinical entity.