Health-related quality of life among patients with end-stage renal disease undergoing hemodialysis in Ethiopia: a cross-sectional survey.

BACKGROUND: Measurement of health-related quality of life (HRQOL) enables identification of treatment-related side effects of a disease. Such aspects may negatively impact on patients' lives and should be taken into consideration in medical decision-making. In sub-Saharan Africa, research from the perspective of patients with chronic kidney disease is scarce, and it is almost non-existent in patients undergoing hemodialysis. We aimed to determine HRQOL among end-stage renal disease patients undergoing maintenance hemodialysis in Ethiopia and to identify factors associated with HRQOL. METHODS: A multi-center cross-sectional study was conducted in Addis Ababa, Ethiopia directed to all patients receiving hemodialysis due to kidney failure at 11 randomly-selected government and private hospitals/dialysis centers in the capital of Ethiopia. Data were collected by trained nurses using the KDQOL-36 instrument with five subscales measuring generic and disease-specific HRQOL. Study-specific items were used to collect socio-demographic and clinical data. Factors associated with HRQOL were examined using multivariable linear regression models. RESULTS: Four hundred eighty-one patients completed the survey through face-to-face interviews (response rate 96%; mean age 45.34 ± 14.67). The mean scores of the subscales ranged from 25.6 to 66.68 (range 0-100), with higher scores reflecting better health. Factors associated with low HRQOL included older age, female sex, no formal education, poor medication adherence, > 2 hemodialysis sessions/week, lower body mass index (< 18.5), longer duration of hemodialysis treatment (≥ 12 months), and poor social support. CONCLUSION: Patients with kidney failure undergoing hemodialysis in Addis Ababa, Ethiopia, had low HRQOL across all subscales compared to previous studies. Therefore, the implementation of guidelines is crucial to improve patients' adherence to their prescribed medications. Furthermore, establishing patient support groups and encouraging patients to use the available support resources from family members, neighbors, and friends have the potential to improve patients' HRQOL.

Experience and perceptions of healthcare providers on clinical management and care of near-miss infants: a qualitative content analysis.

INTRODUCTION: Neonatal Near Miss (NNM) refers to neonates with severe complications who almost died but survived immediately after birth. In Ethiopia, the prevalence of NNM has been assessed using a validated Neonatal Near-Miss Assessment Scale. However, understanding the experiences and perceptions of healthcare providers in the clinical management and care of NNM infants remains unexplored. The aim was to investigate the determinants contributing to the survival of neonatal near-miss babies and to identify any barriers encountered, as reported by the experiences of healthcare providers in public hospitals of Amhara Regional State, northwest Ethiopia. METHODS: Semi structured interviews were used to collect data from 25 midwives, nurses, and pediatricians with at least six months of prior experience in one of the labor wards or neonatal intensive care units at one of the four public health hospitals in the Amhara Regional state of northwest Ethiopia included in a large intervention study assessing a NNM scale. Purposeful sampling was used, selecting participants based on their experiences related to the aim of this study. The participants had a varying level of education and years of experience to care for NNM infants. The average age of the healthcare providers was 31 years, with 7 years of work experience. The transcripts of the interviews with the healthcare providers were analyzed using qualitative content analysis. RESULTS: The experience and perceptions of healthcare providers was described in the main category "A sense of hopelessness when caring for the baby" capturing a broader emotional and professional aspect, while the subcategories "Unclear responsibilities discharging one's mission", "Provision of kangaroo mother care" and "Quick action required at birth" are more specific and practical. Healthcare providers perceived a sense of hopelessness when caring for the NNM infant, particularly providing Kangaroo Mother Care (KMC) and quick actions when required at birth to save the life of the infant. CONCLUSION: Unclear responsibilities and a sense of hopelessness could have acted as barriers, hindering the ability of healthcare providers to fulfill their mission of taking swift actions and providing KMC to NNM infants, thus impacting their ability to save the lives of these infants. Healthcare providers' and parents' attitudes must be changed towards hope rather than hopelessness when caring for NNM infants.

Psychometric properties of the kidney disease quality of life-36 (KDQOL-36) in Ethiopian patients undergoing hemodialysis.

BACKGROUND: Health-related quality of life (HRQOL) has a direct association with increased morbidity and mortality among end stage renal disease patients. Valid and reliable instruments to measure the HRQOL of patients with end stage renal disease are therefore required. This study aimed to translate, culturally adapt and evaluate the psychometric properties of the Amharic version of the Kidney Disease Quality of Life-36 (KDQOL-36) instrument in Ethiopian patients with end stage renal disease undergoing hemodialysis. METHODS: The KDQOL-36 instrument was developed for individuals with kidney disease who are being treated with dialysis and includes both generic and disease-specific components. The KDQOL-36 was translated to Amharic language and distributed to a cross-sectional sample of 292 hemodialysis patients. The psychometric evaluation included construct validity through corrected item-total correlation, confirmatory factor analysis and known group analysis. Convergent validity was evaluated by correlations between each of the three kidney disease targeted scales (symptoms/problems list, burden of kidney disease and effects of kidney diseases) and the European Quality of Life 5D-5L and Visual Analog Scales. Regarding reliability, internal consistency and test-retest reliability were assessed. RESULTS: Two hundred ninety-two patients with a mean age of 48 (SD ± 14.7) completed the questionnaire. Corrected item- total correlation scores were > 0.4 for all items. Confirmatory factor analysis revealed a two χ2 /df was 4.4, Root Mean Square Error of Approximation (RMSEA) = 0.108 (90% CI 0.064-0.095), Comparative Fit Index (CFI) = 0.922, Tucker Lewis Index (TLI) = 0.948 and Standardized Root mean-squared residual (SRMR) = 0.058) and three χ2 /df = 3.1, RMSEA = 0.085 (90% CI 0.064-0.095), CFI = 0.854, TLI = 0.838 and SRMR = 0.067) factor models for the generic and disease specific components respectively. The mean scores of the three kidney disease targeted domains were correlated to the EQ-5D-5L & VAS with correlation coefficients of large magnitude (0.55-0.81). The reliability of the instrument was satisfactory (Cronbach's alpha = 0.81-0.91) and Intra-class correlation (ICC) = 0.90-0.96). CONCLUSION: The Amharic version of the KDQOL-36 is a reliable and valid instrument recommended for assessment of HRQOL of Ethiopian patients on hemodialysis.

Posterior compartment symptoms in primiparous women 1 year after non-assisted vaginal deliveries: a Swedish cohort study.

INTRODUCTION AND HYPOTHESIS: This is a prospective cohort follow-up study based on the hypothesis that primiparous women with non-assisted vaginal deliveries and a second-degree perineal tear have more posterior compartment symptoms 1 year after delivery than those with no or first-degree tears. METHODS: A follow-up questionnaire, including validated questions on pelvic floor dysfunction, was completed 1 year postpartum by 410 healthy primiparas, delivered without instrumental assistance at two maternity wards in Stockholm between 2013 and 2015. Main outcome measures were posterior compartment symptoms in women with second-degree perineal tears compared with women with no or only minor tears. RESULTS: Of 410 women, 20.9% had no or only minor tears, 75.4% had a second-degree tear, and 3.7% had a more severe tear. Of women presenting with second-degree tears, 18.9% had bowel-emptying difficulties compared with 20.0% of women with minor tears. Furthermore, almost 3% of them with second-degree tears complained of faecal incontinence (FI) of formed stool, 7.2% of FI of loose stool compared with 1.2% and 3.5% respectively in women with no or only minor tears. CONCLUSIONS: Symptomatic pelvic floor dysfunction is common among primiparous women within 1 year following uncomplicated vaginal delivery, and there are no significant differences between second-degree perineal tears and minor tears. These symptoms should be addressed in all women after delivery to improve pelvic floor dysfunction and quality of life.

Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study.

BACKGROUND: Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and adverse outcomes, adjusted for population characteristics. METHODS AND FINDINGS: In this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman's rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = -0.71/-0.66), prelabour CS (rho = -0.61/-0.65), overall CS (rho = -0.61/-0.67), and episiotomy (multiparous: rho = -0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = -0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information. CONCLUSIONS: Considerable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.

Urinary incontinence after uncomplicated spontaneous vaginal birth in primiparous women during the first year after birth.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is associated with pregnancy and parity and can cause health problems for women. Our objective was to explore risk factors for UI and its effect on women's daily activities, psychological health and wellbeing 9-12 months postpartum in a low-risk primiparous population. METHODS: In this prospective cohort study, first-time mothers in a low-risk population with a spontaneous vaginal birth reported the occurrence of UI and its effect on daily activities and on their psychological health and wellbeing in a questionnaire completed 1 year after birth. Descriptive and comparative statistics were employed for the analysis. RESULTS: A total of 410 women (75.7%) completed the questionnaire. The self-reported rates of stress urinary incontinence, urge urinary incontinence and mixed urinary incontinence were 45.4%, 38.0% and 27.0% respectively. Neither the duration of the second stage of labour, the baby's head circumference or its birth weight were associated with the incidence of UI. There was an association between reported negative impact on daily activities and more negative psychological wellbeing (p < 0.001). CONCLUSIONS: Urinary incontinence was common among primiparous women at 9-12 months postpartum. Women whose symptoms had a negative impact on their daily activities reported more psychological suffering.

A decrease in cesarean sections and labor inductions among Swedish women by awareness of fetal movements with the Mindfetalness method.

BACKGROUND: Maternal perception of decreased fetal movements is commonly used to assess fetal well-being. However, there are different opinions on whether healthcare professionals should encourage maternal observation of fetal movements, as researchers claim that raising awareness increases unnecessary interventions, without improving perinatal health. We aimed to investigate whether cesarean sections and labor induction increase by raising women's awareness of fetal movements through Mindfetalness. Further, we aimed to study perinatal health after implementing Mindfetalness in maternity care. METHODS: In a cluster randomized controlled trial, 67 maternity clinics were allocated to Mindfetalness or routine care. In the Mindfetalness group, midwives distributed a leaflet telling the women to focus on the character, strength and frequency of the fetal movements without counting each movement. The instruction was to do so for 15 min daily when the fetus was awake, from gestational week 28 until birth. In this sub-group analysis, we targeted women born in Sweden giving birth from 32 weeks' gestation. We applied the intention-to-treat principle. RESULTS: The Mindfetalness group included 13,029 women and the Routine-care group 13,456 women. Women randomized to Mindfetalness had less cesarean sections (18.4% vs. 20.0%, RR 0.92, CI 0.87-0.97) and labor inductions (19.2% vs. 20.3%, RR 0.95, CI 0.90-0.99) compared to the women in the Routine-care group. Less babies were born small for gestational age (8.5% vs. 9.3%, RR 0.91, CI 0.85-0.99) in the Mindfetalness group. Women in the Mindfetalness group contacted healthcare due to decreased fetal movements to a higher extent than women in the Routine care group (7.8% vs. 4.3%, RR 1.79, CI 1.62-1.97). The differences remain after adjustment for potential confounders. CONCLUSIONS: Raising awareness about fetal movements through Mindfetalness decreased the rate of cesarean sections, labor inductions and small-for-gestational age babies. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02865759 ). Registered 12 August 2016, www.clinicaltrials.gov .

Older adults' preferences for, adherence to and experiences of two self-management falls prevention home exercise programmes: a comparison between a digital programme and a paper booklet.

BACKGROUND: Fall prevention exercise programmes are known to be effective, but access to these programmes is not always possible. The use of eHealth solutions might be a way forward to increase access and reach a wider population. In this feasibility study the aim was to explore the choice of programme, adherence, and self-reported experiences comparing two exercise programmes - a digital programme and a paper booklet. METHODS: A participant preference trial of two self-managed fall prevention exercise interventions. Community-dwelling adults aged 70 years and older exercised independently for four months after one introduction meeting. Baseline information was collected at study start, including a short introduction of the exercise programme, a short physical assessment, and completion of questionnaires. During the four months intervention period, participants self-reported their performed exercises in an exercise diary. At a final meeting, questionnaires about their experiences, and post-assessments, were completed. For adherence analyses data from diaries were used and four subgroups for different levels of participation were compared. Exercise maintenance was followed up with a survey 12 months after study start. RESULTS: Sixty-seven participants, with mean age 77 ± 4 years were included, 72% were women. Forty-three percent chose the digital programme. Attrition rate was 17% in the digital programme group and 37% in the paper booklet group (p = .078). In both groups 50-59% reported exercise at least 75% of the intervention period. The only significant difference for adherence was in the subgroup that completed ≥75% of exercise duration, the digital programme users exercised more minutes per week (p = .001). Participants in both groups were content with their programme but digital programme users reported a significantly higher (p = .026) degree of being content, and feeling supported by the programme (p = .044). At 12 months follow-up 67% of participants using the digital programme continued to exercise regularly compared with 35% for the paper booklet (p = .036). CONCLUSIONS: Exercise interventions based on either a digital programme or a paper booklet can be used as a self-managed, independent fall prevention programme. There is a similar adherence in both programmes during a 4-month intervention, but the digital programme seems to facilitate long-term maintenance in regular exercise. TRIAL REGISTRATION: ClinTrial: NCT02916849.

IFN-γ extends the immune functions of Guanylate Binding Proteins to inflammasome-independent antibacterial activities during Francisella novicida infection.

Guanylate binding proteins (GBPs) are interferon-inducible proteins involved in the cell-intrinsic immunity against numerous intracellular pathogens. The molecular mechanisms underlying the potent antibacterial activity of GBPs are still unclear. GBPs have been functionally linked to the NLRP3, the AIM2 and the caspase-11 inflammasomes. Two opposing models are currently proposed to explain the GBPs-inflammasome link: i) GBPs would target intracellular bacteria or bacteria-containing vacuoles to increase cytosolic PAMPs release ii) GBPs would directly facilitate inflammasome complex assembly. Using Francisella novicida infection, we investigated the functional interactions between GBPs and the inflammasome. GBPs, induced in a type I IFN-dependent manner, are required for the F. novicida-mediated AIM2-inflammasome pathway. Here, we demonstrate that GBPs action is not restricted to the AIM2 inflammasome, but controls in a hierarchical manner the activation of different inflammasomes complexes and apoptotic caspases. IFN-γ induces a quantitative switch in GBPs levels and redirects pyroptotic and apoptotic pathways under the control of GBPs. Furthermore, upon IFN-γ priming, F. novicida-infected macrophages restrict cytosolic bacterial replication in a GBP-dependent and inflammasome-independent manner. Finally, in a mouse model of tularemia, we demonstrate that the inflammasome and the GBPs are two key immune pathways functioning largely independently to control F. novicida infection. Altogether, our results indicate that GBPs are the master effectors of IFN-γ-mediated responses against F. novicida to control antibacterial immune responses in inflammasome-dependent and independent manners.

Effect of maternal birth positions on duration of second stage of labor: systematic review and meta-analysis.

BACKGROUND: It is believed that giving birth in an upright position is beneficial for both mother and the infant for several physiologic reasons. An upright positioning helps the uterus to contract more strongly and efficiently, the baby gets in a better position and thus can pass through the pelvis faster. Upright and lateral positions enables flexibility in the pelvis and facilitates the extension of the outlet. Before implementing a change in birthing positions in our clinics we need to review evidences available and context valid related to duration of second stage of labor and birthing positions. Therefore this review aimed to examine the effect of maternal flexible sacrum birth position on duration of second stage of labor. METHOD: The research searched articles using bibliographical Databases: Medline/PUBMED, SCOPUS, Google scholar and Google. All study designs were considered while investigating the impact of maternal flexible sacrum birthing positioning in relation duration of second stage of labor. Studies including laboring mothers with normal labor and delivery. A total of 1985 women were included in the reviewed studies. We included both qualitative and quantitative analysis. RESULTS: We identified 1680 potential citations, of which 8 articles assessed the effect of maternal upright birth positioning on the reduction during the duration of second stage of labor. Two studies were excluded because of incomplete reports for meta analysis. The result suggested a reduction in duration of second stage of labor among women in a flexible sacrum birthing position, with a mean duration from 3.2-34.8. The pooled weighted mean difference with random effect model was 21.118(CI: 11.839-30.396) minutes, with the same significant heterogeneity between the studies (I2 = 96.8%, p < 000). CONCLUSION: The second stage duration was reduced in cases of a flexible sacrum birthing position. Even though the reduction in duration varies across studies with considerable heterogeneity, laboring women should be encouraged to choose her comfortable birth position. Researchers who aim to compare different birthing positions should consider study designs which enable women to choose birthing position. PROSPERO REGISTRATION NUMBER: [CRD42019120618].

Value based maternal and newborn care requires alignment of adequate resources with high value activities.

BACKGROUND: Evidence based practice has been associated with better quality of care in many situations, but it has not been able to address increasing need and demand in healthcare globally and stagnant or decreasing healthcare resources. Implementation of value-based healthcare could address many important challenges in health care systems worldwide. Scaling up exemplary high value care practices offers the potential to ensure values-driven maternal and newborn care for all women and babies. DISCUSSION: Increased use of healthcare interventions over the last century have been associated with reductions in maternal and newborn mortality and morbidity. However, over an optimum threshold, these are associated with increases in adverse effects and inappropriate use of scarce resources. The Quality Maternal and Newborn Care framework provides an example of what value based maternity care might look like. To deliver value based maternal and newborn care, a system-level shift is needed, 'from fragmented care focused on identification and treatment of pathology for the minority to skilled care for all'. Ideally, resources would be allocated at population and individual level to ensure care is woman-centred instead of institution/ profession centred but oftentimes, the drivers for spending resources are 'the demands and beliefs of the acute sector'. We argue that decisions to allocate resources to high value activities, such as continuity of carer, need to be made at the macro level in the knowledge that these investments will relieve pressure on acute services while also ensuring the delivery of appropriate and high value care in the long run. To ensure that high value preventive and supportive care can be delivered, it is important that separate staff and money are allocated to, for example, models of continuity of carer to prevent shortages of resources due to rising demands of the acute services. To achieve value based maternal and newborn care, mechanisms are needed to ensure adequate resource allocation to high value maternity care activities that should be separate from the resource demands of acute maternity services. Funding arrangements should support, where wanted and needed, seamless movement of women and neonates between systems of care.

'Managing pieces of a personal puzzle' - Older people's experiences of self-management falls prevention exercise guided by a digital program or a booklet.

BACKGROUND: Exercise is effective in order to prevent falls in community-dwelling older people. Self-management programs have the potential to increase access and reduce costs related to exercise-based fall prevention. However, information regarding older people's views of participating in such programs is needed to support implementation. The aim of this study was to explore older people's experiences of a self-management fall prevention exercise routine guided either by a digital program (web-based or mobile) or a paper booklet. METHODS: This qualitative study was part of a feasibility study exploring two completely self-managed exercise interventions in which the participants tailored their own program, guided either by a digital program or a paper booklet. Individual face-to-face semi-structured interviews were conducted with a purposeful sample of 28 participants (18 women), mean age 76 yrs. Qualitative content analysis was used to analyse the data. RESULTS: Self-managing and self-tailoring these exercise programs was experienced as 'Managing pieces of a personal puzzle'. To independently being able to create a program and manage exercise was described in the categories 'Finding my own level' and 'Programming it into my life'. The participants experienced the flexibility and independence provided by completely self-managed exercise as positive and constructive although it required discipline. Furthermore, different needs and preferences when managing their exercise were described, as well as varying sources of motivation for doing the exercise, as highlighted in the category 'Defining my source of motivation'. The category 'Evolving my acquired knowledge' captures the participants' views of building their competence and strategies for maintenance of the exercise. It describes a combined process of learning the program and developing reflection, which was more clearly articulated by participants using the digital program. CONCLUSIONS: This study provides new knowledge regarding experiences, preferences and motivations of older people to engage in home-based self-managed fall prevention exercise. They expressed both a capability and willingness to independently manage their exercise. A digital program seems to have strengthened the feeling of support while creating their own exercise program and tailoring it to their preferences and circumstances, which might therefore create better opportunities for adoption and adherence in the long term.

Evaluation of bowel function in healthy children: untreated constipation is common.

AIM: We evaluated bowel function in healthy children with regard to gender and age. METHODS: The study was carried out in 2016 at a tertiary children's hospital. Healthy children aged 3.5 years to 15 years who were admitted to the hospital, siblings to patients or offspring of staff members were included. Validated self-report questionnaires and internally developed questions regarding obstructive outlet- and gas-related symptoms were used. RESULTS: A total of 310 participants (50% girls) were included, which corresponded to a 94% answer frequency. Respondents were divided into a younger age group (3.5 years to seven years), consisting of 135 children, and an older age group (eight years to 15 years), consisting of 175 children. Younger children reported more foul odours than older children (50% vs. 29%, p = 0.001) and more obstructive symptoms (21% vs. 10%, p = 0.01). There was no difference between the age groups regarding constipation (19% vs 16%, NS). Overall, 55% of those with constipation had no treatment for the condition, although they reported abdominal pain (51%) and problems with foul odours (57%). CONCLUSION: Healthy children frequently reported constipation, abdominal pain and gas-related problems, but treatment was rare. Overall, bowel function seemed to improve during childhood, although constipation remained largely untreated.

Women's attitudes, experiences and compliance concerning the use of Mindfetalness- a method for systematic observation of fetal movements in late pregnancy.

BACKGROUND: Maternal perception of decreased fetal movements and low awareness of fetal movements are associated with a negative birth outcome. Mindfetalness is a method developed for women to facilitate systematic observations of the intensity, character and frequency of fetal movements in late pregnancy. We sought to explore women's attitudes, experiences and compliance in using Mindfetalness. METHODS: We enrolled 104 pregnant women treated at three maternity clinics in Stockholm, Sweden, from February to July of 2016. We educated 104 women in gestational week 28-32 by providing information about fetal movements and how to practice Mindfetalness. Each was instructed to perform the assessment daily for 15 min. At each subsequent follow-up, the midwife collected information regarding their perceptions of Mindfetalness, and their compliance. Content analyses, descriptive and analytic statistics were used in the analysis of data. RESULTS: Of the women, 93 (89%) were positive towards Mindfetalness and compliance was high 78 (75%). Subjective responses could be binned into one of five categories: Decreased worry, relaxing, creating a relationship, more knowledge about the unborn baby and awareness of the unborn baby. Eleven (11%) women had negative perceptions of Mindfetalness, citing time, and the lack of need for a method to observe fetal movements as the most common reasons. CONCLUSION: Women in late pregnancy are generally positive about Mindfetalness and their compliance with daily use is high. The technique helped them to be more aware of, and create a relationship with, their unborn baby. Mindfetalness can be a useful tool in antenatal care. However, further study is necessary in order to determine whether the technique is able to reduce the incidence of negative birth outcome.

Midwives' Management during the Second Stage of Labor in Relation to Second-Degree Tears-An Experimental Study.

INTRODUCTION: Most women who give birth for the first time experience some form of perineal trauma. Second-degree tears contribute to long-term consequences for women and are a risk factor for occult anal sphincter injuries. The objective of this study was to evaluate a multifaceted midwifery intervention designed to reduce second-degree tears among primiparous women. METHODS: An experimental cohort study where a multifaceted intervention consisting of 1) spontaneous pushing, 2) all birth positions with flexibility in the sacro-iliac joints, and 3) a two-step head-to-body delivery was compared with standard care. Crude and Adjusted OR (95% CI) were calculated between the intervention and the standard care group, for the various explanatory variables. RESULTS: A total of 597 primiparous women participated in the study, 296 in the intervention group and 301 in the standard care group. The prevalence of second-degree tears was lower in the intervention group: [Adj. OR 0.53 (95% CI 0.33-0.84)]. A low prevalence of episiotomy was found in both groups (1.7 and 3.0%). The prevalence of epidural analgesia was 61.1 percent. Despite the high use of epidural analgesia, the midwives in the intervention group managed to use the intervention. CONCLUSION: It is possible to reduce second-degree tears among primiparous women with the use of a multifaceted midwifery intervention without increasing the prevalence of episiotomy. Furthermore, the intervention is possible to employ in larger maternity wards with midwives caring for women with both low- and high-risk pregnancies.

Gallium Potentiates the Antibacterial Effect of Gentamicin against Francisella tularensis.

The reasons why aminoglycosides are bactericidal have not been not fully elucidated, and evidence indicates that the cidal effects are at least partly dependent on iron. We demonstrate that availability of iron markedly affects the susceptibility of the facultative intracellular bacterium Francisella tularensis strain SCHU S4 to the aminoglycoside gentamicin. Specifically, the intracellular depots of iron were inversely correlated to gentamicin susceptibility, whereas the extracellular iron concentrations were directly correlated to the susceptibility. Further proof of the intimate link between iron availability and antibiotic susceptibility were the findings that a ΔfslA mutant, which is defective for siderophore-dependent uptake of ferric iron, showed enhanced gentamicin susceptibility and that a ΔfeoB mutant, which is defective for uptake of ferrous iron, displayed complete growth arrest in the presence of gentamicin. Based on the aforementioned findings, it was hypothesized that gallium could potentiate the effect of gentamicin, since gallium is sequestered by iron uptake systems. The ferrozine assay demonstrated that the presence of gallium inhibited >70% of the iron uptake. Addition of gentamicin and/or gallium to infected bone marrow-derived macrophages showed that both 100 µM gallium and 10 µg/ml of gentamicin inhibited intracellular growth of SCHU S4 and that the combined treatment acted synergistically. Moreover, treatment of F. tularensis-infected mice with gentamicin and gallium showed an additive effect. Collectively, the data demonstrate that SCHU S4 is dependent on iron to minimize the effects of gentamicin and that gallium, by inhibiting the iron uptake, potentiates the bactericidal effect of gentamicin in vitro and in vivo.

Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth.

BACKGROUND: Whether certain birth positions are associated with perineal injuries and severe perineal trauma (SPT) is still unclear. The objective of this study was to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal injuries, SPT and episiotomy in different birth positions in four Nordic countries. METHODS: A population-based prospective cohort study of planned home births in four Nordic countries. To assess medical outcomes a questionnaire completed after birth by the attending midwife was used. Descriptive statistics, bivariate analysis and logistic regression were used to analyze the data. RESULTS: Two thousand nine hundred ninety-two women with planned home births, who birthed spontaneously at home or after transfer to hospital, between 2008 and 2013 were included. The prevalence of SPT was 0.7 % and the prevalence of episiotomy was 1.0 %. There were differences between the countries regarding all maternal characteristics. No association between flexible sacrum positions and sutured perineal injuries was found (OR 1.02; 95 % CI 0.86-1.21) or SPT (OR 0.68; CI 95 % 0.26-1.79). Flexible sacrum positions were associated with fewer episiotomies (OR 0.20; CI 95 % 0.10-0.54). CONCLUSION: A low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No associations were found between flexible sacrum positions and SPT. Flexible sacrum positions were associated with fewer episiotomies.

Transfers to hospital in planned home birth in four Nordic countries - a prospective cohort study.

INTRODUCTION: Women planning a home birth are transferred to hospital in case of complications or elevated risk for adverse outcomes. The aim of the present study was to describe the indications for transfer to hospital in planned home births, and the proportion of cases in which this occurs. MATERIAL AND METHODS: Women in Norway, Sweden, Denmark and Iceland who had opted for, and were accepted for, home birth at the onset of labor, were included in the study. Data from 3068 women, 572 nulliparas and 2446 multiparas, were analyzed for proportion of transfers during labor and within 72 h after birth, indications for transfer, how long before or after birth the transfer started, time from birth to start of transfer, duration and mode of transfer, and whether the transfer was classified as potentially urgent. Analyses were stratified for nulliparity and multiparity. RESULTS: One-third (186/572) of the nulliparas were transferred to hospital, 137 (24.0%) during labor and 49 (8.6%) after the birth. Of the multiparas, 195/2446 (8.0%) were transferred, 118 (4.8%) during labor and 77 (3.2%) after birth. The most common indication for transfers during labor was slow progress. In transfers after birth, postpartum hemorrhage, tears and neonatal respiratory problems were the most common indications. A total of 116 of the 3068 women had transfers classified as potentially urgent. CONCLUSIONS: One-third of all nulliparous and 8.0% of multiparous women were transferred during labor or within 72 h of the birth. The proportion of potentially urgent transfers was 3.8%.

Induced Labor in Sweden, 1999-2012: A Population-Based Cohort Study.

BACKGROUND: Previous studies show contradictory results about the impact of induced labor on the cesarean delivery rate and few studies have investigated the risk of vacuum extraction subsequent to induced labor. The aims of the present study were to describe the rate of induced labor in Sweden from 1999 to 2012, and to assess the risk of unplanned cesarean delivery and vacuum extraction after induced labor in relation to medical complications and length of gestation. METHODS: A register-based cohort study was conducted, including 1,078,536 women with spontaneous or induced onset of labor who gave birth by noninstrumental vaginal delivery, unplanned cesarean delivery, or vacuum extraction in gestational week 37 + 0 to 41 + 6. Logistic regression was used to study the association between induced labor and instrumental delivery. RESULTS: The rate of induced labor increased from 7.7 to 12.9 percent among primiparous and from 7.5 to 11.8 percent among multiparous women. Induced labor was associated with 2-3 times greater risk of unplanned cesarean delivery among all women, except multiparas in gestational week 37-38, and with a 20-50 percent higher risk of vacuum extraction after the adjustment for confounding factors. Among women without a recognized medical complication, induced labor was associated with a threefold increased risk of cesarean delivery in gestational week 39-41 and a 40 percent increase in gestational week 37-38 compared with women with spontaneous onset of labor. CONCLUSIONS: The proportion of induced labors increased substantially during the 14-year study period and was associated with an increased risk of both cesarean delivery and vacuum extraction, even in women without a documented medical complication. The increased risk of instrumental delivery should be taken into account when counseling about the risks and benefits of induced labor.

Roles of reactive oxygen species-degrading enzymes of Francisella tularensis SCHU S4.

Francisella tularensis is a facultative intracellular bacterium utilizing macrophages as its primary intracellular habitat and is therefore highly capable of resisting the effects of reactive oxygen species (ROS), potent mediators of the bactericidal activity of macrophages. We investigated the roles of enzymes presumed to be important for protection against ROS. Four mutants of the highly virulent SCHU S4 strain with deletions of the genes encoding catalase (katG), glutathione peroxidase (gpx), a DyP-type peroxidase (FTT0086), or double deletion of FTT0086 and katG showed much increased susceptibility to hydrogen peroxide (H2O2) and slightly increased susceptibility to paraquat but not to peroxynitrite (ONOO(-)) and displayed intact intramacrophage replication. Nevertheless, mice infected with the double deletion mutant showed significantly longer survival than SCHU S4-infected mice. Unlike the aforementioned mutants, deletion of the gene coding for alkyl-hydroperoxide reductase subunit C (ahpC) generated a mutant much more susceptible to paraquat and ONOO(-) but not to H2O2. It showed intact replication in J774 cells but impaired replication in bone marrow-derived macrophages and in internal organs of mice. The live vaccine strain, LVS, is more susceptible than virulent strains to ROS-mediated killing and possesses a truncated form of FTT0086. Expression of the SCHU S4 FTT0086 gene rendered LVS more resistant to H2O2, which demonstrates that the SCHU S4 strain possesses additional detoxifying mechanisms. Collectively, the results demonstrate that SCHU S4 ROS-detoxifying enzymes have overlapping functions, and therefore, deletion of one or the other does not critically impair the intracellular replication or virulence, although AhpC appears to have a unique function.