Women's views and experiences of breast feeding: positive,negative or just good for the baby?

Objective

to explore women's views and experiences of breast feeding, regardless of whether or not they breast fed, or length of breast feeding.

Design

data from a randomised controlled trial (where neither of two education interventions increased breast-feeding initiation or duration compared with standard care; ISRCTN21556494) were pooled and analysed as a cohort. This paper presents the analysis of two questions that women were asked in a telephone interview at 6 months post partum: ‘Overall, how do you feel about breast feeding?; and ‘Do you have any other comments on breast feeding (positive or negative)?’ The questions were asked of all women, regardless of breast feeding duration. Responses were coded using simple thematic analysis. Data were read through several times to gain an overall perspective then categorised into key themes. Individual women's comments often fitted into more than one category, and were coded accordingly.

Setting

a public, tertiary, women's hospital in Melbourne, Australia.

Participants

981 primiparous women, of whom 889 had 6-month data available.

Findings

three broad themes emerged that described women's views on breast feeding: positive views; negative views; and comments on the fact that breast feeding was good for the baby, and that was an important part of why they were breast feeding. Breast feeding in public was a predominant theme irrespective of whether women were continuing to breast feed, and of the 68 who commented on this topic, 58 (85%) made negative comments.

Key conclusions

factors which influence breast feeding are numerous and complex, and many women described both positive and negative feelings about breast feeding. These areas are important to explore and incorporate when designing interventions aimed at increasing the proportion of women who breast feed.

Implications for practice

it is important that care providers are aware of, and sensitive to, the complex personal and sociocultural factors that influence women's decisions about baby-feeding.     

Environmental contaminants, fertility, and multioocytic follicles: a lesson from wildlife?

The overall contribution of environmental exposures to infertility is unknown, but a growing scientific database suggests that exposure to various environmental factors, both in utero and neonatally, could dramatically affect adult fertility. Studies of various contaminant-exposed wildlife populations suggest that multiple mechanisms contribute to changes in gonadal development, maturation of germ cells, fertilization, and pregnancy; specifically, the endocrine processes supporting these events. Although great debate and extensive research has occurred during the last decade surrounding fertility, fecundity, and semen quality, much less work has focused on environmental alterations in oocyte development and maturation. Exposure of the developing ovary to estrogens, whether of pharmaceutical (e.g., diethylstilbesterol) or environmental (e.g., phytoestrogens, pesticides with estrogenic action) origin, can disrupt early oogenesis and folliculogenesis leading to a pathology termed the multioocytic follicle (polyovular follicle), which in rodents reduces fertilization and embryonic survival rates. The mechanism underlying this pathology is hypothesized to involve a disruption in the gonadotropin-estrogen-inhibin/activin signaling pathway. Given the conserved nature of vertebrate oogenesis and folliculogenesis, we suggest that perturbations of these phenomena in humans, caused by environmental contaminant exposure, could lead to altered fertility, as has been reported in wildlife and laboratory rodent models.     

Adam Nash: legally speaking,a happy ending or slippery slope?

The birth of Adam Nash, following IVF and then preimplantation genetic diagnosis (PGD) on the resulting 15 embryos to find which would be a potential bone marrow match for his older sibling, suffering from Fanconi's anaemia, is the first reported case of genetic selection of an embryo to save the life of an existing person. The case has stirred debates worldwide over the appropriateness and implications of using the technique for this and related purposes. Legally, it is suggested that embryos are indeed entitled to special respect because of their potential for life, but certain principles must not be overlooked, and the Nash case was wholly within acceptable legal principles. The legal perspective offered here concludes: (i) while embryos are entitled to certain protections, the mere fact that they are extracorporeal raises the danger that the rights and protections assigned to them will be wrongly elevated over the legally protected procreation rights of the adults who create them; (ii) divorce litigation involving "custody" of embryos is not a direct parallel and legal analogies must be distinguished; (iii) the status of embryos must be carefully defined; and (iv) a national or international, multi-disciplinary body should be created to grapple with the developing issues and uses that are sure to follow.     

Perinatal mortality: a sporadic event or a recurrent catastrophe?

Objective  The purpose of this study was to determine whether women who experienced perinatal mortality in their first delivery had, in their subsequent birth, a higher risk for adverse perinatal outcome. Methods  A population-based study was undertaken to compare all second deliveries of women with previous perinatal mortality in their first delivery to those with no such history. Deliveries occurred from 1988 to 2004 in a tertiary medical center. Patients lacking prenatal care, multiple gestations, and congenital malformations were excluded from the analysis. A multivariable logistic regression model and the Mantel–Haenszel procedure were carried out to control for confounders. Results  During the study period, out of 25,876 singleton second deliveries, 230 (0.9%) cases were of patients with previous perinatal mortality. Multivariable analysis with backward elimination showed a significant association between previous perinatal mortality and the following conditions: hypertensive disorders (OR = 2.6, 95% CI 1.7–3.9, P < 0.001), diabetes mellitus (OR = 2.4, 95% CI 1.5–3.7, P < 0.001), fertility treatment (OR = 2.7, 95% CI 1.6–4.7, P = 0.001), and younger maternal age (OR = 0.9, 95% CI 0.92–0.98, P < 0.001). Controlling for preterm delivery, using the Mantel–Haenszel procedure, the association between previous and subsequent perinatal mortality remained significant (weighted OR = 2.2, 95% CI 1.2–3.9, P = 0.010). Conclusion  Previous perinatal loss poses an independent risk for subsequent perinatal mortality. Prospective studies are warranted in order to establish the appropriate means of surveillance and/or interventions needed to decrease future adverse perinatal outcomes. Presented in part in the 27th annual meeting of the Society for Maternal-Fetal Medicine in San Francisco, CA. Dedicated with love to our dear friend and colleague Amit Rozen M.D. who tragically passed away prematurely on his 34th birthday.     

Preeclampsia, insulin signalling and immunological dysfunction: a fetal, maternal or placental disorder?

An inappropriate glycogen accumulation in preeclamptic placentas was described as secondary to biochemical alterations. Insulin resistance is widely accepted to be associated with preeclampsia, although its basis remain unclear. A family of putative insulin mediators, namely inositol phosphoglycans, were described to exert many insulin-like effects on lipid and glucose metabolism. A definite association between the P-type mediator (P-IPG) and preeclampsia was reported, being increased in placenta, urine, amniotic fluid and cord blood from human preeclamptic pregnancies. A strong link exists between insulin resistance and inflammation. Clear features of insulin resistance and systemic inflammatory activation were described in preeclampsia. It may be a consequence of the immunological dysfunction that occurs in preeclampsia that is temporized during sperm exposure and co-habitation which confuses the maternal immune network to perceive 'danger'. The over-expression of P-IPG during preeclampsia may be a counter-regulatory mechanism to insulin resistance since these molecules mimic insulin action. Besides, the lipidic form of P-IPG was reported to be similar to endotoxins, and may represent the 'danger signa'. We propose here a novel working theory on insulin resistance and preeclampsia.     

Preeclampsia,insulin signalling and immunological dysfunction: a fetal,maternal or placental disorder?

An inappropriate glycogen accumulation in preeclamptic placentas was described as secondary to biochemical alterations. Insulin resistance is widely accepted to be associated with preeclampsia, although its basis remain unclear. A family of putative insulin mediators, namely inositol phosphoglycans, were described to exert many insulin-like effects on lipid and glucose metabolism. A definite association between the P-type mediator (P-IPG) and preeclampsia was reported, being increased in placenta, urine, amniotic fluid and cord blood from human preeclamptic pregnancies. A strong link exists between insulin resistance and inflammation. Clear features of insulin resistance and systemic inflammatory activation were described in preeclampsia. It may be a consequence of the immunological dysfunction that occurs in preeclampsia that is temporized during sperm exposure and co-habitation which confuses the maternal immune network to perceive ‘danger’. The over-expression of P-IPG during preeclampsia may be a counter-regulatory mechanism to insulin resistance since these molecules mimic insulin action. Besides, the lipidic form of P-IPG was reported to be similar to endotoxins, and may represent the ‘danger signa’. We propose here a novel working theory on insulin resistance and preeclampsia.     

Three-dimensional sonography in prenatal diagnosis: a luxury or a necessity?

Three-dimensional sonography revolutionized ultrasound imaging with its capacity to depict an unlimited number of planes in which the object of interest can be displayed. The addition of numerous modalities of image rendering promotes three-dimensional sonography to the top of the spectrum of diagnostic imaging in obstetrics and gynecology. The aim of this article is to present our experience in 3-D sonography during the second and third trimester of pregnancy and to give a comparative review of literature. 247 patients in gestational age ranging from 12 to 40 weeks of gestation were examined over a three year period. The majority of patients entered the study because fetal anomaly was suspected at two-dimensional sonography. Some patients were sent on to three-dimensional sonography because it was not possible to depict clearly normal fetal anatomy by two dimensional sonography. Out of 170 fetal anomalies three-dimensional sonographic analysis failed in only three cases. In all three anomaly was accompanied with severe oligohydramnios. Main advantages of three-dimensional ultrasound in perinatal medicine and antenatal diagnosis include scanning in the coronal plane, improved assessment of complex anatomic structures, surface analysis of minor defects, volumetric measuring of organs, "plastic" transparent imaging of fetal skeleton, spatial presentation of blood flow arborization and, finally, storage of scanned volumes and images. It is our decided opinion that three-dimensional sonography has gained a valuable place in prenatal diagnosis, becoming a necessity for every modern perinatal unit.     

Subtotal abdominal hysterectomy: a surgical advance or a backward step?

Objective To review the short and medium term outcomes of subtotal abdominal hysterectomy. We also describe the management of cervical stump complications by vaginal trachelectomy or large loop excision of the transformation zone.
Design Retrospective analysis.
Setting Warwick General Hospital, Warwickshire, UK.
Sample One hundred and fifty women underwent subtotal abdominal hysterectomy between 1993 and 1999. Five women had vaginal trachelectomy and another five had large loop excision of the transformation zone for complications relating to the cervical stump.
Results The prevalence of intra-operative and early post-operative complications was 4% and 7.3%, respectively. Twenty women (13.3%) had late complications, of whom 17 (11%) presented with symptoms directly related to the stump (two had also genuine stress incontinence). Three presented with genuine stress incontinence alone. The commonest problem was regular menstruation, which occurred in 12 women (8%). Ten of these women underwent vaginal trachelectomy or large loop excision of the transformation zone. None had intra-operative or post-operative complications.
Conclusions The high prevalences of cervical stump problems should be taken into account before a change in surgical procedure from total to subtotal hysterectomy is recommended. Further prospective studies with prolonged follow up are needed to evaluate the risks and benefits of retaining the cervix at hysterectomy. Total hysterectomy, preferably by the vaginal route, remains the procedure of choice for most women. Should a problem develop, vaginal trachelectomy or large loop excision of the transformation zone by an experienced surgeon are the best options for these women.     

Adolescent parenthood: a costly mistake or a search for love?

Family life is changing worldwide and an increasing number of women are choosing single parenthood. Adolescents who become pregnant and early childbearers do not always become pregnant unintentionally; some actively plan pregnancy while others are ambivalent mainly about the timing. This paper reports on a study using an ethnographic approach that explored the mothering experiences of five sole-supporting Australian teenage mothers who had a child over six months of age. It focuses on the story of one of them, a young woman who gave birth at 16 and set up home for herself and her son. Early childbearing is often a response to adverse social conditions such as poverty or homelessness and is not uncommonly chosen by teenage girls from socially deprived backgrounds. Educational and employment opportunities may be limited, whilst motherhood may provide a purpose in life when few other options are possible. Young women who make this choice need comprehensive services to support them in the parenting role, including appropriate health care, welfare and housing benefits, and support in dealing with parenting, a role which they may greatly desire but are not automatically well prepared for.     

Posterior Reversible Encephalopathy Syndrome: Nitroglycerine a Friend or a Foe?

Posterior reversible encephalopathy syndrome (PRES) refers to a clinico-radiological entity with characteristic features on neuroimaging and rapid onset of nonspecific symptoms including headache, seizure, altered consciousness and visual disturbance. It is a neurotoxic state in response to the acute changes in blood pressure leading to vasogenic oedema. It is often but not always associated with hypertension. However, control blood pressure is one of the mainstays of management in such cases. Nitroglycerine (NTG) is a potent vasodilator and is one of the drugs for treatment of hypertensive emergencies. It is found to worsen the cerebral oedema in PRES which is considered due to failure of cerebral blood pressure autoregulation. Here, we report two such cases where patients with PRES deteriorated with NTG infusion. However, the neurological condition of the patients improved drastically the next day. NTG could have further enhanced vasodilation, thus aggravating developing PRES, after autoregulation was lost because of high blood pressure.