‘Make the Connection’ parenting skills programme: a controlled trial of associated improvement in maternal attitudes

ABSTRACT

Objective: Assess the effectiveness of Make the Connection (MTC), an attachment-focused parenting programme, in fostering maternal attitudes thought to underlie sensitive responding.

Background: Effective parenting programmes are likely to mitigate negative outcomes associated with insecure attachment in infancy. Negative maternal attitudes and cognitions are thought to underlie insensitive parenting behaviour, and thus constitute a promising target for intervention.

Methods: 180 mothers of young infants were assigned to experimental or waitlist control groups based on programme availability. Mothers completed questionnaires assessing parental attitudes at baseline, and again either after participating in MTC or after a 9-week waitlist period.

Results: Participants who completed MTC showed significant improvement in overall attitude with a medium effect size relative to the waitlist control group, which showed no change. A small but significant interaction with infant age was noted, such that mothers of younger infants showed slightly more attitude improvement. Relative to the control group, participation in Make the Connection was associated with significant improvement in all attitudes except for self-efficacy as a parent, which improved with time regardless of programme participation.

Conclusion: Make the Connection is effective in promoting positive parent-to-infant attachment and is a strong candidate for public health initiatives targeting parenting skills.     

Histological analysis of the ‘critical point’ in follicular development in mice

Aim:  To histologically examine ovarian follicular development in cycling mice.
Methods:   Mice were observed at 13:00 h at each stage of the estrous cycle. The ovaries were cut into complete serial sections. All sections were observed, and the size of each follicle was measured by using a micrometer. Follicles with advanced atresia were excluded and non-atretic healthy follicles were differentiated from atretic follicles.
Results:  The measurement of the number of follicles in each stage of the estrous cycle, with reference to their size, showed that in each mouse, the number of small healthy follicles (100–249 µm in average diameter) was approximately 100 for all stages and the number of medium-sized healthy follicles (250–349 µm) was close to 20 in only the metestrus and diestrus stages. In contrast, large healthy follicles (≥350 µm) showed marked changes throughout the estrous stage. Many healthy large follicles were observed in the proestrus stage, but they disappeared in the estrus stage, which suggests that they have ovulated. This was supported by observations of oocytes resuming meiosis in large healthy follicles.
Conclusion:  As follicular atresia was frequently observed in follicles of 250–399 µm diameter, this size range may be a 'critical point' for atresia. The results suggest that there is a 'critical point' in follicular development, and that only follicles that pass this point will ovulate, while those that do not will become atretic follicles. (Reprod Medical Biol 2004; 3 : 141–145)     

Tensions and conflicts in ‘choice’: Womens’ experiences of freebirthing in the UK

Backgroundthe concept of choice is a central tenet of modern maternity care. However, in reality women’s choice of birth is constrained by a paucity of resources and dominant medical and risk adverse discourses. In this paper we add to this debate through highlighting the tensions and conflicts that women faced when enacting a freebirthing choice.Methodssecondary analysis of data collected to explore why women choose to freebirth in the UK was undertaken. Ten women were recruited from diverse areas of the UK via invitations on freebirthing websites. Women provided a narrative and/or participated in an in-depth interview. A thematic analysis approach was used.Findingswe present three key themes. First ‘violation of rights’ highlights the conflicts women faced from maternity care systems who were unaware of women’s legal rights to freebirth, conflating this choice with issues of child protection. ‘Tactical planning’ describes some of the strategies women used in their attempts to achieve the birth they desired and to circumnavigate any interference or reprisals. The third theme, ‘unfit to be a mother’ describes distressing accounts of women who were reported to social services.Conclusion and implications for practicewomen who choose to freebirth face opposition and conflict from maternity providers, and often negative and distressing repercussions through statutory referrals. These insights raise important implications for raising awareness among health professionals about women’s legal rights. They also emphasise a need to develop guidelines and care pathways that accurately and sensitively support the midwives professional scope of practice and women’s choices for birth.     

Perceptions of nearly graduated fourth year midwifery students regarding a ‘good midwife’ in the Netherlands

ObjectiveMidwifery students have the challenge to learn to be autonomous and capable midwives to ensure a safe and emotionally satisfying experience for mothers (to be) and their babies. They have to develop and acquire knowledge and skills for practice, and they have to adopt and internalize the values and norms of the midwifery profession in order to socialize as a midwife.In this study we explored conceptualisations of ‘good midwives’ among nearly graduated final year midwifery students as a result of their professional socialization process.DesignA cross-sectional study consisting of an one open-ended question was undertaken. Data was analyzed qualitatively, inductively and deductively by using Halldorsdottir’s theory of the primacy of a good midwife.SettingOne of three midwifery academies in the Netherlands in July 2016 were included.ParticipantsAll midwifery students (N=67) in their final year were included.FindingsStudent midwives gave broad interpretations of the features of a good midwife. Three themes - next to the themes already conceptualised by Halldorsdottir - were revealed and mentioned by nearly graduated Dutch midwifery students. They added that a good midwife has to have specific personal characteristics, organizational competences, and has to promote physiological reproductive processes in midwifery care.Key ConclusionsStudents’ views are broad and deep, reflecting the values they take with them to real midwifery practice. The results of this study can serve as an indicator of the level of professional socialization into the midwifery profession and highlight areas in which changes and improvements to the educational program can be made.     

The occurrence of ‘maternity blues’ in Scottish and Japanese women: A meta-analysis

Abstract

Second level of analysis of the data provided by Morsbach & Ors (1983) suggests that their findings are more significant than they claimed.     

A survey of scientists’ awareness of and attitudes to the use of human blood products and alternatives in human assisted reproductive technology

Scientists working in assisted reproduction [members of Scientists in Reproductive Technology (SIRT) Australia, and subscribers of the online forums EmbryoMail and Quartec] were invited to complete an online questionnaire on the use of human blood products in assisted reproductive technologies (ART). A total of 260 started the questionnaire, with 208 (80%) completing it. A total of 62% of respondents had worked in human ART ≥8 years and 68% had post-graduate qualifications. The majority (82%) reported using products of animal or human origin, with 75% knowing why protein was added to culture media and 41% not worried by this. Almost half (49%) of respondents were unaware of regulations surrounding the use of human blood products in health care and 70% were unaware of adverse events involving human blood products in human ART. Most respondents (70%) indicated that they were not concerned about infections such as hepatitis, but agents such as prions were a cause for concern (57%). A total of 57% of respondents were unaware of alternatives, but 77% would use a suitable alternative. Using blood products in human ART is surrounded by a lack of awareness, often independent of respondents’ qualifications or experience. A better understanding of these products and possible alternatives is required if informed decisions about their suitability are to be made.     

Decision-making in operative vaginal delivery: when to intervene,where to deliver and which instrument to use? Qualitative analysis of expert clinical practice

Objective

To identify the decision-making process involved in determining when to intervene, where to deliver and the optimal choice of instrument for operative vaginal deliveries in the second stage of labour.

Study design

A qualitative study using interviews and video recordings took place at two university teaching hospitals (St. Michael's Hospital Bristol and Ninewells Hospital, Dundee). Ten obstetricians and eight midwives were identified as experts in conducting or supporting operative vaginal deliveries. Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low cavity vacuum and mid-cavity rotational forceps deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and then compared for consistency of interpretation. The experts reviewed the coded interview and video data for respondent validation and clarification. The themes that emerged following the final coding were used to identify the decision-making process when planning and conducting an operative vaginal delivery. Key decision points were reported in selecting when and where to conduct an operative vaginal delivery and which instrument to use.

Results

The final decision-making list highlights the various decision points to consider when performing an operative vaginal delivery. We identified clinical factors that experts take into consideration when selecting where the delivery should take place and the preferred choice of instrument.

Conclusion

This detailed illustration of the decision-making process could aid trainees’ understanding of the approach to safe operative vaginal delivery, aiming to minimise morbidity.     

Evidence-based medicine and the role of the private sector in assisted reproduction: a response to Dr Fishel’s commentary ‘Evidenced-based medicine and the role of the National Health Service in assisted reproduction’

We respond to Dr Fishel’s commentary on evidenced-based medicine in assisted reproduction and the role of the UK’s National Health Service. We agree that proper randomised clinical trials are not easy to set up or execute. Recruitment is also challenging but requires that all personnel involved in the study, clinicians, embryologists and nurses, agree with its aims and buy in to the need for an answer. Those who believe fervently in the method under scrutiny prior to the availability of robust evidence are likely to undermine the success of any trial. New technologies are not necessarily better technologies. Neither is the supposed ‘logic’ of a treatment nor anecdotal clinical experience a substitute for evidence properly gained and fairly demonstrated. Dr Fishel would agree that the first obligation of healthcare professionals, whether they are in the public or private sector, is not to do harm to their patients. Adopting new interventions without rigorous assessment of the potential for harm flies in the face of this basic principle.     

The Labour Progression Study (LaPS): Duration of labour following Zhang's guideline and the WHO partograph – A cluster randomised trial

ObjectiveTo investigate labour duration in different phases of labour when adhering to Zhang's guideline for labour progression compared with the WHO partograph.DesignA secondary analysis of a cluster randomised controlled trial.SettingFourteen Norwegian birth care units, each with more than 500 deliveries per year constituted the clusters.ParticipantsA total of 7277 nulliparous women with singleton foetus in a cephalic presentation and spontaneous onset of labour at term were included.InterventionSeven clusters were randomised to the intervention group that adhered to Zhang's guideline (n = 3972) and seven to the control group that adhered to the WHO partograph (n = 3305) for labour progression.MeasurementsThe duration of labour from the first registration of cervical dilatation (≥ 4 cm) to the delivery of the baby and the duration of the first and second stages of labour; the time-to-event analysis was used to compare the duration of labour between the two groups after adjusting for baseline covariates.FindingsThe adjusted median duration of labour was 7.0 h in the Zhang group, compared with 6.2 h in the WHO group; the median difference was 0.84 h with 95% confidence interval [CI] (0.2–1.5). The adjusted median duration of the first stage was 5.6 h in the Zhang group compared with 4.9 h in the WHO group; the median difference was 0.66 h with 95% CI (0.1–1.2). The corresponding adjusted median duration of the second stage was 88 and 77 min; the median difference was 0.18 h with 95% CI (0.1–0.3).Key Conclusions: The women who adhered to Zhang's guideline had longer overall duration and duration of the first and second stages of labour than women who adhered to the WHO partograph.Implications for practice: Understanding the variations in the duration of labour is of great importance, and the results offer useful insights into the different labour progression guidelines, which can inform clinical practice.     

"The cut above" and "the cut below": the abuse of caesareans and episiotomy in São Paulo, Brazil

In the last 50 years, a rapid increase in the use of technology to start, augment, accelerate, regulate and monitor the process of birth has frequently led to the adoption of inadequate, unnecessary and sometimes dangerous interventions. Although research has shown that the least amount of interference compatible with safety is the paradigm to follow, vaginal birth is still being treated as if it carries a high risk to women's health and sexual life in Brazil. This paper describes the impact of the intervention model on women's birth experience, and discusses how the organisation of public and private maternity services in Brazil influences the quality of obstetric care. Brazil is known for high rates of unnecessary caesarean section ("the cut above"), performed in over two-thirds of births in the private sector, where 30% of women give birth. The 94.2% rate of episiotomy ("the cut below") in women who give birth vaginally, affecting the 70% of poor women using the public sector most, receives less attention. A change in the understanding of women's bodies is required before a change in the procedures themselves can be expected. Since 1993, inspired by campaigns against female genital mutilation, a national movement of providers, feminists and consumer groups has been promoting evidence-based care and humanisation of childbirth in Brazil, to reduce unnecessary surgical procedures.     

Barriers and Facilitators to the Implementation of First Trimester Medical Abortion With Mifepristone in the Province of Québec: A Qualitative Investigation

ObjectiveMifepristone became available in Canada in January 2017, but provincial medical policy delayed its use for medical abortion (MA) in Québec for 1 year. The objective of this study was to identify barriers and facilitators experienced by physicians who could potentially provide this newer abortion practice in Québec.MethodsThis study was part of the Canadian Contraception and Abortion Research Team-Mifepristone Implementation Study, an observational, prospective, mixed-methods study. Interviews were conducted with physicians representing all health regions of Québec. Using thematic analysis guided by diffusion of innovation theory, the study identified key barriers and facilitators to implementation.ResultsFrom January 2017 to March 2018, study investigators interviewed 25 family physicians and 12 obstetrician-gynaecologists. Most were women (81%), over 40 years old (65%), with >20 years in practice since residency (49%). Less than half of the sample provided abortion services (41%), and only 8% provided MA with mifepristone. Key barriers to implementation were: (1) uncertainty or confusion about policies regarding MA, (2) lack of human resources or support from colleagues, (3) uncertainty about product distribution, (4) confusion about professional collaboration, and (5) lack of local infrastructure. Key facilitators were: (1) perception of support and influence from colleagues, (2) previous experience with provision of first trimester MA, (3) requests for first trimester MA by patients or other physicians, and (4) knowledge of research on mifepristone MA.ConclusionDespite Health Canada's approval of mifepristone in Canada and supportive federal policies for provision of MA in primary care, physicians in the province of Québec face onerous barriers to the practice of mifepristone MA.     

‘I’m committed to her and the family’: positive accounts of vasectomy among New Zealand men

Background: More than 15 years ago, the International Conference on Population and Development (ICPD) identified men’s involvement with reproductive and contraceptive tasks as vital for improving women’s reproductive health worldwide. The uptake of vasectomy provides one measure of men’s involvement in reproductive and contraceptive actions, but uptake requires the negotiation of a complex set of social and psychological meanings related to masculinity, sexuality and contraceptive involvement. The limited research in this area paints a largely negative picture around vasectomy, emphasising fears, side effects, and men being pressured into having the operation, but it is not the only account of vasectomy. Objectives: The aim of this research was to examine the accounts of New Zealand men who had undergone vasectomy. Method: Interviews with 28 men who had opted to have a vasectomy (16 had children; 12 did not) based in New Zealand, a country with a high rate of vasectomy, offer a more positive portrayal of the meanings and experiences of vasectomy. Results: Men referred to vasectomy as a positive reflection of their identities, and their choice to have it as exemplifying personal characteristics they valued. Such accounts disrupt the common-sense story of vasectomy as negative or difficult for men, and allow it to be positioned as a positive choice for heterosexual male reproductive involvement and responsibility     

The role of lymphadenectomy in endometrial cancer: was the ASTEC trial doomed by design and are we destined to repeat that mistake?

Objective

This study examines the design of previous and future trials of lymph node dissection in endometrial cancer.

Methods

Data from previous trials were used to construct a decision analysis modeling the risk of lymphatic spread and the effects of treatment on patients with endometrial cancer. This model was then applied to previous trials as well as other future trial designs that might be used to address this subject.

Results

Comparing the predicted and actual results in the ASTEC trial, the model closely mimics the survival results with and without lymph node dissection for the low and high risk groups. The model suggests a survival difference of less than 2% between the experimental and control arms of the ASTEC trial under all circumstances. Sensitivity analyses reveal that these conclusions are robust. Future trial designs were also modeled with hysterectomy only, hysterectomy with radiation in intermediate risk patients, and staging with radiation only with node positive patients. Predicted outcomes for these approaches yield survival rates of 88%, 90%, and 93% in clinical stage I patients who have a risk of pelvic node involvement of approximately 7%. These estimates were 78%, 82%, and 89% in intermediate risk patients who have a risk of nodal spread of approximately 15%.

Conclusions

This model accurately predicts the outcome of previous trials and demonstrates that even if lymph node dissection was therapeutic, these trials would have been negative due to study design. Furthermore, future trial designs that are being considered would need to be conducted in high-intermediate risk patients to detect any difference.