Human milk immune factors, maternal nutritional status, and infant sex: The INSPIRE study

OBJECTIVES

Breastfeeding is an energetically costly and intense form of human parental investment, providing sole-source nutrition in early infancy and bioactive components, including immune factors. Given the energetic cost of lactation, milk factors may be subject to tradeoffs, and variation in concentrations have been explored utilizing the Trivers-Willard hypothesis. As human milk immune factors are critical to developing immune system and protect infants against pathogens, we tested whether concentrations of milk immune factors (IgA, IgM, IgG, EGF, TGFβ2, and IL-10) vary in response to infant sex and maternal condition (proxied by maternal diet diversity [DD] and body mass index [BMI]) as posited in the Trivers-Willard hypothesis and consider the application of the hypothesis to milk composition.

METHODS

We analyzed concentrations of immune factors in 358 milk samples collected from women residing in 10 international sites using linear mixed-effects models to test for an interaction between maternal condition, including population as a random effect and infant age and maternal age as fixed effects.

RESULTS

IgG concentrations were significantly lower in milk produced by women consuming diets with low diversity with male infants than those with female infants. No other significant associations were identified.

CONCLUSIONS

IgG concentrations were related to infant sex and maternal diet diversity, providing minimal support for the hypothesis. Given the lack of associations across other select immune factors, results suggest that the Trivers-Willard hypothesis may not be broadly applied to human milk immune factors as a measure of maternal investment, which are likely buffered against perturbations in maternal condition.

Variation in Human Milk Composition Is Related to Differences in Milk and Infant Fecal Microbial Communities

Previously published data from our group and others demonstrate that human milk oligosaccharide (HMOs), as well as milk and infant fecal microbial profiles, vary by geography. However, little is known about the geographical variation of other milk-borne factors, such as lactose and protein, as well as the associations among these factors and microbial community structures in milk and infant feces. Here, we characterized and contrasted concentrations of milk-borne lactose, protein, and HMOs, and examined their associations with milk and infant fecal microbiomes in samples collected in 11 geographically diverse sites. Although geographical site was strongly associated with milk and infant fecal microbiomes, both sample types assorted into a smaller number of community state types based on shared microbial profiles. Similar to HMOs, concentrations of lactose and protein also varied by geography. Concentrations of HMOs, lactose, and protein were associated with differences in the microbial community structures of milk and infant feces and in the abundance of specific taxa. Taken together, these data suggest that the composition of human milk, even when produced by relatively healthy women, differs based on geographical boundaries and that concentrations of HMOs, lactose, and protein in milk are related to variation in milk and infant fecal microbial communities.

Household composition and the infant fecal microbiome: The INSPIRE study

OBJECTIVES

Establishment and development of the infant gastrointestinal microbiome (GIM) varies cross-culturally and is thought to be influenced by factors such as gestational age, birth mode, diet, and antibiotic exposure. However, there is little data as to how the composition of infants' households may play a role, particularly from a cross-cultural perspective. Here, we examined relationships between infant fecal microbiome (IFM) diversity/composition and infants' household size, number of siblings, and number of other household members.

MATERIALS AND METHODS

We analyzed 377 fecal samples from healthy, breastfeeding infants across 11 sites in eight different countries (Ethiopia, The Gambia, Ghana, Kenya, Peru, Spain, Sweden, and the United States). Fecal microbial community structure was determined by amplifying, sequencing, and classifying (to the genus level) the V1-V3 region of the bacterial 16S rRNA gene. Surveys administered to infants' mothers identified household members and composition.

RESULTS

Our results indicated that household composition (represented by the number of cohabitating siblings and other household members) did not have a measurable impact on the bacterial diversity, evenness, or richness of the IFM. However, we observed that variation in household composition categories did correspond to differential relative abundances of specific taxa, namely: Lactobacillus, Clostridium, Enterobacter, and Klebsiella.

DISCUSSION

This study, to our knowledge, is the largest cross-cultural study to date examining the association between household composition and the IFM. Our results indicate that the social environment of infants (represented here by the proxy of household composition) may influence the bacterial composition of the infant GIM, although the mechanism is unknown. A higher number and diversity of cohabitants and potential caregivers may facilitate social transmission of beneficial bacteria to the infant gastrointestinal tract, by way of shared environment or through direct physical and social contact between the maternal-infant dyad and other household members. These findings contribute to the discussion concerning ways by which infants are influenced by their social environments and add further dimensionality to the ongoing exploration of social transmission of gut microbiota and the "old friends" hypothesis.

What's Normal? Microbiomes in Human Milk and Infant Feces Are Related to Each Other but Vary Geographically: The INSPIRE Study

Background: Microbial communities in human milk and those in feces from breastfed infants vary within and across populations. However, few researchers have conducted cross-cultural comparisons between populations, and little is known about whether certain “core” taxa occur normally within or between populations and whether variation in milk microbiome is related to variation in infant fecal microbiome. The purpose of this study was to describe microbiomes of milk produced by relatively healthy women living at diverse international sites and compare these to the fecal microbiomes of their relatively healthy infants.

Methods: We analyzed milk (n = 394) and infant feces (n = 377) collected from mother/infant dyads living in 11 international sites (2 each in Ethiopia, The Gambia, and the US; 1 each in Ghana, Kenya, Peru, Spain, and Sweden). The V1-V3 region of the bacterial 16S rRNA gene was sequenced to characterize and compare microbial communities within and among cohorts.

Results: Core genera in feces were Streptococcus, Escherichia/Shigella, and Veillonella, and in milk were Streptococcus and Staphylococcus, although substantial variability existed within and across cohorts. For instance, relative abundance of Lactobacillus was highest in feces from rural Ethiopia and The Gambia, and lowest in feces from Peru, Spain, Sweden, and the US; Rhizobium was relatively more abundant in milk produced by women in rural Ethiopia than all other cohorts. Bacterial diversity also varied among cohorts. For example, Shannon diversity was higher in feces from Kenya than Ghana and US-California, and higher in rural Ethiopian than Ghana, Peru, Spain, Sweden, and US-California. There were limited associations between individual genera in milk and feces, but community-level analyses suggest strong, positive associations between the complex communities in these sample types.

Conclusions: Our data provide additional evidence of within- and among-population differences in milk and infant fecal bacterial community membership and diversity and support for a relationship between the bacterial communities in milk and those of the recipient infant's feces. Additional research is needed to understand environmental, behavioral, and genetic factors driving this variation and association, as well as its significance for acute and chronic maternal and infant health.

Deep breast pain during lactation: a case-control study in Sweden investigating the role of Candida albicans

Background

Deep breast pain during lactation, with or without accompanying nipple pain and soreness continues to be anecdotally linked to infection by Candia albicans despite lack of robust evidence in the literature that Candida albicans is the cause of women’s breast symptoms.

Methods

A case-control study of breastfeeding women in Sweden with (n 35) and without (n 35) symptoms that may be attributable to Candida albicans was carried out. The symptoms were radiating, burning and penetrating or non-penetrating breast pain with or without associated nipple pain during or after breastfeeding. The primary aim of the study was to test the hypothesis that breastfeeding women with symptoms commonly associated with Candida albicans infection will have a growth of Candida albicans in their breast milk significantly more often than women without these symptoms. A secondary aim was comparison of breastfeeding self-efficacy, measured by the BSES-SF (Breastfeeding Self Efficacy Scale –Short Form), between cases and controls.

Results

None of the women in the control group and eight of the women in the case group showed a growth of Candida albicans in their breast milk (p <  0.01), which confirms the hypothesis. There were no statistically significant differences in severity or type of symptoms between those in the case group with and without growth of Candida albicans in their breast milk. Results of the BSES-SF measurement showed no statistically significant differences between cases and controls. However, when analyses were stratified for parity, multiparous controls showed statistically significant higher scores for breastfeeding self-efficacy than multiparous cases.

Conclusions

Neither clinical symptoms nor microbial cultivation appear to be reliable means for making a diagnosis of Candida albicans infection of the breast. Skilled breastfeeding consultants should offer support and help with positioning, attachment and identification of physical impediments to successful breastfeeding. Professionals should be aware that it is possible that uncertainty in the breastfeeding situation may to some extent account for mothers’ breast symptoms. The ISRCTN (International Standard Randomised Controlled Trial Number) identity for this case-control study is ISRCTN88839993. The study was retrospectively registered on 30 November 2016.

"I Didn't Know What to Ask About": First-Time Mothers' Conceptions of Prenatal Preparation for the Early Parenthood Period

The aim of this phenomenographic study was to describe first-time mothers' conceptions of prenatal preparation for the early parenthood period in relation to their experiences of early parenthood. Eighteen first-time mothers were interviewed approximately 1 month after giving birth. The categories identified in the analysis were: accessing appropriate sources of support, gaining knowledge to form realistic expectations, and mobilizing and strengthening personal resources. First-time mothers want health professionals to actively address postnatal issues as they have difficulties in knowing prenatally what knowledge will prepare them for early parenthood. Both professional and peer support during pregnancy were conceived as important for gaining knowledge. Professionals can support by guidance to reliable sources of information and encouraging personal reflections and partner communication.

Midwifery students' experiences of learning through the use of written reflections - An interview study

In an effort to strengthen midwifery students' learning process, written reflections during the students' clinical practice at birth units have been applied. The aim of this study was to examine how students of midwifery experienced the writing of daily reflections on their practice at birthing units. An interview study was carried out using an inductive method with descriptive design. During 2013 (n = 12) and 2014 (n = 7), respondents were recruited from two cohorts of midwifery students (n = 19) at a university in southern Sweden. Narrative interviews were carried out. The interviews were analysed with thematic content analysis. One theme including four categories emerged from the analysis. The theme was "An educational strategy for the present and the future". The four categories were "Towards personal and professional development", "Reflection requires effort", "Supervisors' commitment" and "Clarification of the rationale". Daily written reflections are useful for students' personal and professional development during clinical practice/placement. In order for the reflections to be used optimally, students must be given clear instructions on the purpose of their use and be given enough time to write them. Furthermore, supervisors must provide constructive feedback on the students' written reflections.

What's Normal? Immune Profiling of Human Milk from Healthy Women Living in Different Geographical and Socioeconomic Settings

Human milk provides a very wide range of nutrients and bioactive components, including immune factors, human milk oligosaccharides, and a commensal microbiota. These factors are essential for interconnected processes including immunity programming and the development of a normal infant gastrointestinal microbiome. Newborn immune protection mostly relies on maternal immune factors provided through milk. However, studies dealing with an in-depth profiling of the different immune compounds present in human milk and with the assessment of their natural variation in healthy women from different populations are scarce. In this context, the objective of this work was the detection and quantification of a wide array of immune compounds, including innate immunity factors (IL1β, IL6, IL12, INFγ, TNFα), acquired immunity factors (IL2, IL4, IL10, IL13, IL17), chemokines (IL8, Groα, MCP1, MIP1β), growth factors [IL5, IL7, epidermal growth factor (EGF), granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, TGFβ2], and immunoglobulins (IgA, IgG, IgM), in milk produced by healthy women of different ethnicities living in different geographic, dietary, socioeconomic, and environmental settings. Among the analyzed factors, IgA, IgG, IgM, EGF, TGFβ2, IL7, IL8, Groα, and MIP1β were detected in all or most of the samples collected in each population and, therefore, this specific set of compounds might be considered as the "core" soluble immune factors in milk produced by healthy women worldwide. This approach may help define which immune factors are (or are not) common in milk produced by women living in various conditions, and to identify host, lifestyle, and environmental factors that affect the immunological composition of this complex biological fluid. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02670278.

What's normal? Oligosaccharide concentrations and profiles in milk produced by healthy women vary geographically

Background: Human milk is a complex fluid comprised of myriad substances, with one of the most abundant substances being a group of complex carbohydrates referred to as human milk oligosaccharides (HMOs). There has been some evidence that HMO profiles differ in populations, but few studies have rigorously explored this variability.Objectives: We tested the hypothesis that HMO profiles differ in diverse populations of healthy women. Next, we examined relations between HMO and maternal anthropometric and reproductive indexes and indirectly examined whether differences were likely related to genetic or environmental variations.Design: In this cross-sectional, observational study, milk was collected from a total of 410 healthy, breastfeeding women in 11 international cohorts and analyzed for HMOs by using high-performance liquid chromatography.Results: There was an effect of the cohort (P < 0.05) on concentrations of almost all HMOs. For instance, the mean 3-fucosyllactose concentration was >4 times higher in milk collected in Sweden than in milk collected in rural Gambia (mean ± SEM: 473 ± 55 compared with 103 ± 16 nmol/mL, respectively; P < 0.05), and disialyllacto-N-tetraose (DSLNT) concentrations ranged from 216 ± 14 nmol/mL (in Sweden) to 870 ± 68 nmol/mL (in rural Gambia) (P < 0.05). Maternal age, time postpartum, weight, and body mass index were all correlated with several HMOs, and multiple differences in HMOs [e.g., lacto-N-neotetrose and DSLNT] were shown between ethnically similar (and likely genetically similar) populations who were living in different locations, which suggests that the environment may play a role in regulating the synthesis of HMOs.Conclusions: The results of this study support our hypothesis that normal HMO concentrations and profiles vary geographically, even in healthy women. Targeted genomic analyses are required to determine whether these differences are due at least in part to genetic variation. A careful examination of sociocultural, behavioral, and environmental factors is needed to determine their roles in this regard. This study was registered at clinicaltrials.gov as NCT02670278.

Diagnostic methods for mastitis in cows are not appropriate for use in humans: commentary

Healthcare workers are now being targeted for marketing of diagnostic tools for mastitis that were developed for the dairy industry and which aim to provide information regarding choice of antibiotic treatment. Meanwhile, scientists are striving to understand how the human microbiome affects health and wellbeing and the importance of maintenance of bacterial balance in the human body. Breast milk supplies a multitude of bacteria to populate the baby's intestinal tract and kick-start the immune system. Researchers propose a paradigm shift in the understanding of bacterial content in breast milk and an alternative paradigm for the understanding of lactational mastitis: there is the beginning of evidence that many cases of lactational mastitis will resolve spontaneously. An international group of researchers is attempting to answer how dietary habits, birth mode, genetics and environmental factors may impact the bacterial content of breast milk. Until we have more comprehensive knowledge about the human milk microbiome, diagnostic aids for identification of women in need of antibiotic therapy for mastitis remain unreliable. Diagnostic aids could lead to the injudicious use of antibiotic therapy, which in turn may rob the infant of bacteria valuable for development of its immune system. The marketing of diagnostic aids for use in human medicine, that were originally developed for use in cows, is neither evidence-based nor good ethical practice.

Treatment of Provoked Vulvodynia in a Swedish cohort using desensitization exercises and cognitive behavioral therapy

BACKGROUND

Problems related to pain during vaginal penetration are complex and the etiology is multi-factorial. It was the aim of the present study to measure whether treatment using desensitization exercises and cognitive behavioral therapy (CBT) for women with provoked vulvodynia (PVD) could increase sexual interest, sexual satisfaction and response whilst decreasing experiences of sexual pain.

METHODS AND OUTCOME MEASURES

Sixty women suffering from PVD were treated during a 10-week period with a combination of mucosal desensitization and pelvic floor exercises and CBT. The McCoy Female Sexuality Questionnaire (MFSQ) was used to measure efficacy of the treatment. The Hospital Anxiety and Depression Scale (HADS) was used to measure psychological distress. The primary outcome measurements were changes in scores for the MFSQ and changes in individual items on the MFSQ directly after treatment completion. Secondary outcome measurements were changes in the MFSQ items 6 months after treatment and changes in HADS sub-scales 6 months after treatment. Statistical comparisons of answers to the MFSQ were carried out using the Wilcoxon signed rank test (paired). Validity of the MFSQ in this study was measured by testing one global question about sexuality and total scores on MFSQ using Spearman's correlation test.

RESULTS

Study participants reported a statistically significant increase in sexual fantasies, increased sexual pleasure, excitement and vaginal lubrication after treatment was completed. PVD occurred less often which resulted in significantly less avoidance of sexual intercourse, increased frequency of masturbation and intercourse. All improvements were sustained at 6 months after treatment ended. Two questions showed no significant changes, these pertained to the individual's contentment with her partner as a lover and a friend. The anxiety sub-scale of the HADS showed a significantly decreased level of anxiety at 6 months follow-up but no change in the scores on the depression sub-scale.

CONCLUSION

Treatment for PVD using desensitization exercises and cognitive behavioral therapy significantly improved sexual interest, response and activity and decreased the experience of pain. Larger studies and RCTs are required in order to draw conclusions about treatment and long term effects should be studied. Partners should be encouraged to participate in treatment regimes.

TRIAL REGISTRATION

The study is registered with ISRCTN registry, ID ISRCTN40416405.

Re-examination of old truths: replication of a study to measure the incidence of lactational mastitis in breastfeeding women

Background

The reported incidence of lactational mastitis varies greatly; the single highest reported incidence in the scientific literature is 33%. The purpose of this study was to collect data regarding incidence and experiences of lactational mastitis from women attending a meeting of lactation specialists and to compare findings in a similar population reported in 1990 by Riordan and Nichols.

Methods

A retrospective questionnaire study was carried out with a group of Danish lactation specialists in 2011. The questionnaire was constructed to replicate that used in 1990 and included questions about occurrence of mastitis, the infant’s age, breast segments afflicted, examination by a physician, use of antibiotics and possible causes of the illness.

Results

As in the earlier research, respondents in this study reported a 33% occurrence of lactational mastitis. This cannot however, be considered as the incidence of mastitis. In order to state the incidence it is necessary to impose a time limit for the collection of data and to know the size of the population at risk. Incomplete emptying of the breast was the factor most frequently cited as the cause of mastitis.

Conclusions

Researchers must strive to be as exact as possible when reporting definitions and incidences of mastitis and should attempt to identify the true population at risk – in this case, all women who were breastfeeding in the uptake area under study, during a specified time limit. Well-designed studies in different global locations are needed before any conclusions can been drawn about the range of incidences of mastitis.

Striving for scientific stringency: a re-analysis of a randomised controlled trial considering first-time mothers' obstetric outcomes in relation to birth position

Background

The aim of this study was to compare maternal labour and birth outcomes between women who gave birth on a birth seat or in any other position for vaginal birth and further, to study the relationship between synthetic oxytocin augmentation and maternal blood loss, in a stratified sample.

Methods

A re-analysis of a randomized controlled trial in Sweden. An on-treatment analysis was used to study obstetrical outcomes for nulliparous women who gave birth on a birth seat (birth seat group) compared to birth in any other position for vaginal birth (control group). Data were collected between November 2006 and July 2009. The outcome measurements included perineal outcome, post partum blood loss, epidural analgesia, synthetic oxytocin augmentation and duration of labour.

Results

The major findings of this paper were that women giving birth on the birth seat had shorter duration of labour and were significantly less likely to receive synthetic oxytocin for augmentation in the second stage of labour. Significantly more women had an increased blood loss when giving birth on the birth seat, but had no difference in perineal outcomes. Blood loss was increased regardless of birth position if women had been exposed to synthetic oxytocin augmentation during the first stage of labour.

Conclusions

The results of this analysis imply that women with a straightforward birth process may well benefit from giving birth on a birth seat without risk for any adverse obstetrical outcomes. However it is important to bear in mind that, women who received synthetic oxytocin during the first stage of labour may have an increased risk for greater blood loss when giving birth on a birth seat. Finally it is of vital importance to scrutinize the influence of synthetic oxytocin administered during the first stage of labour on blood loss postpartum, since excessive blood loss is a well-documented cause of maternal mortality worldwide and may cause severe maternal morbidity in high-income countries.

Trial registration

Unique Protocol ID: NCT01182038 ( http://register.clinicaltrials.gov)

Labour augmentation and fetal outcomes in relation to birth positions: a secondary analysis of an RCT evaluating birth seat births

OBJECTIVE

the aim of this study was to compare the use of synthetic oxytocin for augmentation, duration of labour and birth and infant outcomes in nulliparous women randomised to birth on a birth seat or any other position.

STUDY DESIGN

a randomised controlled trial in Sweden where 1002 women were randomised to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The outcome measurements included synthetic oxytocin augmentation, duration of the second stage of labour and fetal outcome. Analysis was by intention to treat.

SETTING

southern Sweden.

FINDINGS

the main findings of this study were that women randomised to the experimental group had a statistically significant shorter second stage of labour than women randomised to the control group. There were no differences between the groups for use of synthetic oxytocin augmentation or for neonatal outcomes.

CONCLUSIONS

women allocated to the birth seat had a significantly shorter second stage of labour despite similar numbers of women subjected to synthetic oxytocin augmentation in the study groups. The adverse neonatal outcomes did not differ between groups. The birth seat can be suggested as non-medical intervention used to reduce duration of second stage labour and birth. The birth seat can be suggested as a non-medical intervention that may facilitate reduced duration of the second stage of labour. Furthermore it is recommended that caregivers, both midwives and midwifery students, should learn skills to assist women in using a variety of birth positions.

TRIAL REGISTRATION

unique Protocol ID: Dnr 2009/739 (register.clinicaltrials.gov).

Swedish high school students' knowledge and attitudes regarding fertility and family building

BACKGROUND

Infertility is a serious problem for those who suffer. Some of the risks for infertility are preventable and the individual should therefore have knowledge of them. The purposes of this study were to investigate high-school students' knowledge about fertility, plans for family building and to compare views and knowledge between female and male students.

METHODS

A questionnaire containing 34 items was answered by 274 students. Answers from male and female students were compared using student's t-test for normally distributed variables and Mann-Whitney U-test for non-normal distributions. The chi-square test was used to compare proportions of male and female students who answered questions on nominal and ordinal scales. Differences were considered as statistically significant at a p-value of 0.05.

RESULTS

Analyses showed that 234 (85%) intended to have children. Female students felt parenthood to be significantly more important than male students: p = <0.01. The mean age at which the respondents thought they would like to start to build their family was 26 (± 2.9) years. Men believed that women's fertility declined significantly later than women did: p = <0.01. Women answered that 30.7% couples were involuntarily infertile and men answered 22.5%: p = <0.01. Females thought it significantly more likely that they would consider IVF or adoption than men, p = 0.01. Men felt they were more likely to abstain from having children than women: p = <0.01. Women believed that body weight influenced fertility significantly more often than men: p = <0.01 and men believed significantly more often that smoking influenced fertility: p = 0.03. Both female and male students answered that they would like to have more knowledge about the area of fertility.

CONCLUSIONS

Young people plan to start their families when the woman's fertility is already in decline. Improving young people's knowledge about these issues would give them more opportunity to take responsibility for their sexual health and to take an active role in shaping political change to improve conditions for earlier parenthood.

No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial

BACKGROUND

The WHO advises against recumbent or supine position for longer periods during labour and birth and states that caregivers should encourage and support the woman to take the position in which she feels most comfortable. It has been suggested that upright positions may improve childbirth outcomes and reduce the risk for instrumental delivery; however RCTs of interventions to encourage upright positions are scarce. The aim of this study was to test, by means of a randomized controlled trial, the hypothesis that the use of a birthing seat during the second stage of labor, for healthy nulliparous women, decreases the number of instrumentally assisted births and may thus counterbalance any increase in perineal trauma and blood loss.

METHODS

A randomized controlled trial in Sweden where 1002 women were randomized to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The primary outcome measurement was the number of instrumental deliveries. Secondary outcome measurements included perineal lacerations, perineal edema, maternal blood loss and hemoglobin. Analysis was by intention to treat.

RESULTS

The main findings of this study were that birth on the birth seat did not reduce the number of instrumental vaginal births, there was an increase in blood loss between 500 ml and 1000 ml in women who gave birth on the seat but no increase in bleeding over 1000 ml and no increase in perineal lacerations or perineal edema.

CONCLUSIONS

The birth seat did not reduce the number of instrumental vaginal births. The study confirmed an increased blood loss 500 ml - 1000 ml but not over 1000 ml for women giving birth on the seat. Giving birth on a birth seat caused no adverse consequences for perineal outcomes and may even be protective against episiotomies.

National survey of how acupuncture education is organised for Swedish midwives

OBJECTIVE

in Sweden, acupuncture education is required before midwives can use the method in clinical practice. Courses in acupuncture are usually organised by private individuals or companies, and each health facility decides on the adequacy of the educational package. Therefore, there is no overall standard or quality control for free-standing courses of acupuncture education for midwives. The aim of this study was to survey the education given to Swedish midwives in the use of acupuncture treatment in the obstetric area.

DESIGN

a postal survey using a structured questionnaire.

SETTING

organisers of acupuncture education.

PARTICIPANTS

18 acupuncture instructors.

MEASUREMENTS AND FINDINGS

acupuncture courses were usually organised outside universities and colleges. The courses were similar in terms of extent and content, and were mainly based on a Western medical approach. The recommended indications were extensive despite a lack of scientific evidence. The most common instructor profile was a midwife without any academic degree.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

courses differed considerably in the extent to which they were research based. Continuing professional education for midwives should be given at the same academic level, at least, as basic midwifery education.

Womens' opinions on intrapartal care: development of a theory-based questionnaire

AIM

To develop a patient questionnaire specific to intrapartal care, based on the theoretical foundation of the general instrument Quality from the Patient's Perspective (QPP).

BACKGROUND

Existing general patient questionnaires do not take intrapartal care aspects fully into account, and available intrapartal-specific patient questionnaires tend to have a weak theoretical foundation.

DESIGN

A cross-sectional, nationwide study carried out during a two-week period in 2007 at Swedish maternity units.

METHOD

An intrapartal-specific QPP-questionnaire (QPP-I) was developed by combining a selection of 22 items from the short and long versions of the QPP with 10 newly constructed items. Responses were obtained from 739 women (63% response rate). The dimensionality of the QPP-I was assessed using structural equation modelling (a nested factor model). Non-parametric statistics were used for subgroup comparisons.

RESULTS

A nested model with a general factor including all 32 items and 10 subordinate factors was developed. Most scales had acceptable reliability coefficients (0.73-0.93), and a meaningful pattern of subgroup differences was obtained.

CONCLUSIONS

The QPP-I is theory based and has its roots in a patient perspective. It was developed using a nationwide sample of Swedish women receiving intrapartal care, and an advanced statistical method was used. The outcome of this initial empirical trial was promising but needs to be tested in different countries and cultures.

RELEVANCE TO CLINICAL PRACTICE

By combining womens' responses on perceived reality and subjective importance ascribed to the various aspects of care measured, the QPP-I offers the care provider better guidelines on which elements to focus quality improvement work on, than would be the case if only a rank order of perceived reality ratings was available.

Toward a clarification of the concept of mastitis as used in empirical studies of breast inflammation during lactation

The objective of this study is to clarify use of the term mastitis in empirical studies of lactational mastitis. Eighteen articles published between 1998 and 2008 were critically analyzed, and a concept clarification of the term mastitis was carried out. Four articles suggested that mastitis was an infection, 4 made no mention of the etiology of symptoms, and 10 articles described mastitis as an inflammation or an infection. Eight studies made no use of distinctions between milk stasis, noninfectious mastitis, and infectious mastitis. Bacterial cultivation was used in 5 articles, and 1 article measured leukocytes and C-reactive protein. Several different causes were cited. Antibiotics were suggested as appropriate treatment in 4 articles. Use of the concept of mastitis in empirical studies remains inconsistent and may do so until the etiology of symptoms is understood. Understanding is also needed as to why some women who present with symptoms suggesting septic reaction recover without antibiotic therapy.

A national survey of how acupuncture is currently used in midwifery care at Swedish maternity units

OBJECTIVE

it is not known how acupuncture is used in midwifery care in Sweden and what kind of requirements health-care providers have for midwives and acupuncture training programmes. The aims of this study were to survey indications for the use of acupuncture in midwifery care in Sweden, and to examine the criteria and requirements used for purchase of acupuncture education programmes.

DESIGN

a postal survey using a structured questionnaire.

SETTING

45 maternity units in Sweden.

PARTICIPANTS

the midwife-in-charge of the units.

MEASUREMENTS AND FINDINGS

the most common indications for the use of acupuncture were relaxation, pain relief, retained placenta, after pains, milk stasis during lactation, hyperemesis and pelvic instability. Specific requirement for acupuncture education were provision of a short course during weekdays including a follow-up course.

KEY CONCLUSION

acupuncture is widely used for many indications in Swedish maternity units despite weak or no evidence to support effectiveness in midwifery care. Requirements for acupuncture education did not seem to be in accordance with what might be expected for this type of qualified intervention.

IMPLICATIONS FOR PRACTICE

the use of acupuncture in midwifery care should not persist until systematic evaluation of the effect of this method is carried through.

Evaluation of changes in postnatal care using the "Parents' Postnatal Sense of Security" instrument and an assessment of the instrument's reliability and validity

BACKGROUND

A sense of security is important for experiences of parenthood in the early postpartum period. The objectives of this study were to evaluate two models of postnatal care using a questionnaire incorporating the Parents' Postpartum Sense of Security (PPSS) instrument and to test the validity of the PPSS instrument.

METHODS

Postal surveys were sent to 234 mothers who had experienced two different forms of postnatal care (study group and control group) and returned by 86.8%. These two groups of mothers were compared for total scores on the PPSS instrument. Demographic variables and mothers' opinions about care interventions were also compared and these variables were tested for correlations with the total PPSS score. A regression analysis was carried out to assess areas of midwifery care which might affect a sense of security. The internal consistency and concurrent validity of the instrument were tested for the total population.

RESULTS

there were no significant differences between the groups for scores on the PPSS instrument. A total of three variables predicted 26% of the variability on the PPSS scores for the study group and five variables predicted 37% of the variability in the control group. One variable was common to both: "The midwives on the postnatal ward paid attention to the mother as an individual". There were significant correlations between the total PPSS scores and scores for postpartum talks and visits to the breastfeeding clinic. There was also a significant correlation between the single question: "I felt secure during the first postpartum week" and the total PPSS score. Tests for internal consistency and concurrent validity were satisfactory.

CONCLUSION

The proposed new model of care neither improved nor impaired mothers' feelings of security the week following birth. Being seen as an individual by the midwife who provides postnatal care may be an important variable for mothers' sense of postnatal security. It is possible that postpartum talks may encourage the processing of childbirth experiences in a positive direction. Availability of breastfeeding support may also add to a sense of security postpartum. The PPSS instrument has shown acceptable reliability and validity.

Care in labor: a Swedish survey using the Bologna Score

BACKGROUND

An important part of midwives' area of responsibility is to strive to keep birth normal. Interventions during childbirth are costly and may disrupt the course of normal labor. The aim of this study was to describe, by use of the Bologna Score, how birth is managed in Sweden.

METHODS

A prospective cross-sectional study in a national sample was performed. All (n = 51) Swedish maternity units were invited to participate and 36 (70.6%) agreed. Midwives collected data, in accordance with the Bologna Score, for all deliveries occurring during a 2-week period in 2007.

RESULTS

Qualified health personnel assisted at almost all deliveries (99.9%), and a vaginal birth was planned for 84 percent of the women. A Bologna Score of 5 signifies that birth has been managed using recommended evidence-based practice, which was achieved for 22.7 percent of the planned vaginal births. Use of the supine position and some interventions were responsible for loss of points. The percentage of 5-point scores varied greatly among units (0-53.1%).

CONCLUSIONS

The findings suggest that in Sweden, birth is managed according to scientific evidence to a limited degree. Large differences among units also suggest that care in childbirth is based on attitudes rather than on scientific evidence. The Bologna Score was easy to use and gave a good picture of how care was given at the participating maternity units. We suggest that the instrument is useful as a quality indicator for intrapartum care.

The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment

Background

The role of bacterial pathogens in lactational mastitis remains unclear. The objective of this study was to compare bacterial species in breast milk of women with mastitis and of healthy breast milk donors and to evaluate the use of antibiotic therapy, the symptoms of mastitis, number of health care contacts, occurrence of breast abscess, damaged nipples and recurrent symptoms in relation to bacterial counts.

Methods

In this descriptive study, breast milk from 192 women with mastitis (referred to as cases) and 466 breast milk donors (referred to as controls) was examined bacteriologically and compared using analytical statistics. Statistical analyses were also carried out to test for relationships between bacteriological content and clinical symptoms as measured on scales, prescription of antibiotics, the number of care contacts, occurrence of breast abscess and recurring symptoms.

Results

Five main bacterial species were found in both cases and controls: coagulase negative staphylococci (CNS), viridans streptococci, Staphylococcus aureus (S. aureus), Group B streptococci (GBS) and Enterococcus faecalis. More women with mastitis had S. aureus and GBS in their breast milk than those without symptoms, although 31% of healthy women harboured S. aureus and 10% had GBS. There were no significant correlations between bacterial counts and the symptoms of mastitis as measured on scales. There were no differences in bacterial counts between those prescribed and not prescribed antibiotics or those with and without breast abscess. GBS in breast milk was associated with increased health care contacts (p = 0.02). Women with ≥ 10⁷ cfu/L CNS or viridans streptococci in their breast milk had increased odds for damaged nipples (p = 0.003).

Conclusion

Many healthy breastfeeding women have potentially pathogenic bacteria in their breast milk. Increasing bacterial counts did not affect the clinical manifestation of mastitis; thus bacterial counts in breast milk may be of limited value in the decision to treat with antibiotics as results from bacterial culture of breast milk may be difficult to interpret. These results suggest that the division of mastitis into infective or non-infective forms may not be practically feasible. Daily follow-up to measure the subsidence of symptoms can help detect those in need of antibiotics.

A descriptive study of Swedish women with symptoms of breast inflammation during lactation and their perceptions of the quality of care given at a breastfeeding clinic

BACKGROUND

Women's perceptions of quality of care during episodes of breast inflammation have been scantily explored. It was the objective of the present study to describe a cohort of breastfeeding women with inflammatory symptoms of the breast during lactation regarding demographical variables, illness history and symptoms at first contact with a breastfeeding clinic and to explore their physical health status, psychological well-being and perceptions of quality of care received, at a six-week postal follow-up.

METHODS

This is a descriptive study set at a midwife-led breastfeeding clinic in Sweden, which included a cohort of women with 210 episodes of breast inflammation. The women had taken part in a RCT of acupuncture and care interventions and were recruited between 2002 and 2004. Of the total cohort, 176 (84 %) responded to a postal questionnaire, six weeks after recovery.

RESULTS

Of the 154 women for whom body temperature was recorded at the first visit, 80 (52%) had fever ranging from 38.1 degrees C to 40.7 degrees C. There was no significant difference between those with favourable outcomes (5 or less contact days) and those with less favourable outcomes (6 or more contact days) for having fever or no fever at first contact. Thirty-six percent of women had damaged nipples. Significantly more women with a less favourable outcome (6 or more contact days) had damaged nipples. Most women recovered well from the episode of breast inflammation and 96% considered their physical health and 97% their psychological well-being, to be good, six weeks after the episode. Those whose illness lasted 6 days or more showed less confidence in the midwives and in the care given to them. Twenty-one (12%) women contacted health care services because of recurring symptoms and eight of the 176 responders (4.5%) were prescribed antibiotics for these recurring symptoms. A further 46 women (26% of the responders) reported recurring symptoms that they managed without recourse to health care services.

CONCLUSION

Initial fever may not be indicative of outcomes for women with inflammatory breast symptoms and treatment by antibiotic therapy may be necessary less often than has been supposed. Women who are also suffering from damaged nipples may need special attention. Those with protracted symptoms were less satisfied with care and showed less confidence in caregivers. International research collaboration might help us find the optimal level of antibiotic therapy for this group of women. This is an important consideration for the global community.

A randomised-controlled trial in Sweden of acupuncture and care interventions for the relief of inflammatory symptoms of the breast during lactation

OBJECTIVES

to further compare acupuncture treatment and care interventions for the relief of inflammatory symptoms of the breast during lactation and to investigate the relationship between bacteria in the breast milk and clinical signs and symptoms.

DESIGN

randomised, non-blinded, controlled trial of acupuncture and care interventions.

SETTING

a midwife-led breast feeding clinic in Sweden.

PARTICIPANTS

205 mothers with 210 cases of inflammatory symptoms of the breast during lactation agreed to participate. The mothers were randomly assigned to one of three treatment groups, two of which included acupuncture among the care interventions and one without acupuncture. All groups were given essential care. Protocols, which included scales for erythema, breast tension and pain, were maintained for each day of contact with the breast feeding clinic. A Severity Index (SI) for each mother and each day was created by adding together the scores on the erythema, breast tension and pain scales. The range of the SI was 0 (least severe) to 19 (most severe).

FINDINGS

no significant difference was found in numbers of mothers in the treatment groups, with the lowest possible score for severity of symptoms on contact days 3, 4 or 5. No statistically significant differences were found between the treatment groups for number of contact days needed until the mother felt well enough to discontinue contact with the breast feeding clinic or for number of mothers prescribed antibiotics. Significant differences were found in the mean SI scores on contact days 3 and 4 between the non-acupuncture group and the two acupuncture groups. Mothers with less favourable outcomes (6 contact days, n=61) were, at first contact with the midwife, more often given advice on correction of the baby's attachment to the breast. An obstetrician was called to examine 20% of the mothers, and antibiotic treatment was prescribed for 15% of the study population. The presence of Group B streptococci in the breast milk was related to less favourable outcomes.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

if acupuncture treatment is acceptable to the mother, this, together with care interventions such as correction of breast feeding position and babies' attachment to the breast, might be a more expedient and less invasive choice of treatment than the use of oxytocin nasal spray. Midwives, nurses or medical practitioners with specialist competence in breast feeding should be the primary care providers for mothers with inflammatory symptoms of the breast during lactation. The use of antibiotics for inflammatory symptoms of the breast should be closely monitored in order to help the global community reduce resistance development among bacterial pathogens.

A grounded theory study of Swedish women's experiences of inflammatory symptoms of the breast during breast feeding

OBJECTIVE

to gain an understanding of the experiences of women who have had an episode of inflammatory symptoms of the breast during lactation.

DESIGN

a grounded theory approach, inspired by Glaser and Strauss, was used in an interview study.

SETTING

the study was carried out at a midwife-led breast-feeding clinic in Sweden.

PARTICIPANTS

the strategic sample consisted of 14 mothers, all of whom had had an episode of breast inflammation between 10 and 22 weeks before the interview. Nine were primiparous. Ages ranged between 24 and 38 years.

FINDINGS

the analysis resulted in the emergence of one core category and five conceptual categories. The core category was 'the will to breast feed', and the five conceptual categories were 'perspectives on breast feeding', 'personal strategies', 'enduring and adjustment', 'support' and 'causal frameworks'. The core category was reflected in all the other categories and was dependent on them.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

an episode of breast inflammation is a possible threat to the maintenance of breast feeding, but the will to breast feed may make it possible for mothers to withstand physical and emotional difficulties caused by the illness. Breast-feeding mothers may have chosen a goal for the length of time they wish to breast feed, and the attainment of this goal is prestige-filled. Midwives, throughout the chain of care, could improve the amount and type of information given about the demands and possible complications of breast feeding. The availability of immediate clinical expertise for these mothers is an important factor, and health-care planners should be aware of this.

Factors related to breast abscess after delivery: a population-based study

OBJECTIVE

To investigate whether there are underlying factors, other than breastfeeding behaviours, which may contribute to the development of breast abscess during the year following delivery.

DESIGN

A population-based study.

SETTING

In Sweden.

POPULATION

The 1,454,068 singleton deliveries during 1987-2000. Methods Data retrieval from two national patient registers: the Medical Birth Registry and the National Discharge Register. Stratified Mantel-Haenszel analysis.

MAIN OUTCOME MEASURES

Odds ratios with 95% confidence intervals for possible risk factors for breast abscess in the year following delivery.

RESULTS

During the year following delivery 1401 women had surgery because of a breast abscess. This gives a rate of 0.1%. Sixty-five percent of cases occurred between three and eight weeks postpartum. An annual increase in the odds ratio (OR) was found between 1993 and 1999. Lowest risk was found among mothers who were < or =24 years and a significantly increased risk among mothers > or =30 years. There was a 3.6-fold increased risk for breast abscess associated with primiparity and OR for post-maturity (>41 weeks) was 5.

CONCLUSION

Primiparous women appear to be at a greater risk for the development of breast abscess during lactation than multiparous women. Mothers over the age of 30 years and those who give birth post-maturely are also at a significantly increased risk. Primiparous women and women over 30 years could be targeted for extra information in preparation for parenthood classes about how to avoid over distension of the breasts during breastfeeding. Further research is needed to understand the role of post-maturity and to investigate why some women recover spontaneously from inflammatory processes of the breast.

Effects of acupuncture and care interventions on the outcome of inflammatory symptoms of the breast in lactating women

OBJECTIVES

To compare modes of care and treatment for lactating women with inflammatory symptoms of the breast, with special focus on the use of acupuncture.

METHOD

Eighty-eight mothers were randomized into three treatment groups. All three groups were given advice regarding emptying of the breasts and care in the form of comfort interventions. Acupuncture was included in the treatment regime for two of the groups. A severity index was created by adding together scores for signs and symptoms: breast tension, erythema and pain.

FINDINGS

Mothers in all groups expressed relative satisfaction with the breastfeeding situation despite considerable discomfort. There was no significant difference between the groups for the number of mothers requiring more than three contact days for recovery nor for their severity index scores on day 3. These findings must be interpreted with care but may suggest that care interventions play as great a part in the recovery of these women as acupuncture treatment or the use of oxytocin spray. Antibiotic therapy was used in 9% of the study population, which is in contrast to other studies. PROPOSED FUTURE ACTION: Based on these results, a new study has been designed to test the hypothesis that acupuncture hastens recovery from inflammatory processes in the lactating breast and approximately 200 mothers will be randomized in a new expanded study.

A comparative study of breast feeding after traditional postnatal hospital care and early discharge

OBJECTIVE

To provide quality assurance for the care plan and working structure within the early discharge unit at the Women's Clinic, Central Hospital, Helsingborg, Sweden.

DESIGN

Survey, using postal questionnaire.

SETTING

The Women's Clinic, Central Hospital, Helsingborg, Sweden.

PARTICIPANTS

304 women with babies of six months of age, delivered at the Central Hospital, Helsingborg, between September and December 1993 and who, together with their baby, met the criteria for early discharge. Early discharge is generally defined in Sweden as discharge before 72 hours postpartum.

MEASUREMENTS AND FINDINGS

Of the participants 41% chose early discharge (ED) and 59% chose traditional hospital care (THC). Four groups were studied for breast feeding frequency - THC primiparae, ED primiparae, THC multiparae and ED multiparae. Further division was made for breast feeding at 2, 4 and 6 months of age. The four main groups were examined for demographic differences. A difference was found in education level; early discharge mothers had a lower level of education than THC mothers. No significant difference was found for the frequency or duration of breast feeding between the early discharge and the traditional hospital care groups, despite the higher education level in the traditional hospital care group.

IMPLICATIONS FOR PRACTICE

A possible explanation for this finding is that a care plan aimed at supporting the individual's responsibility and participation, providing relevant knowledge and a subliminal communication of trust in the competence of parent and child, is of particular significance for women with less education. The presence and participation of the baby's father at an early stage may also be a factor.