Breastfeeding challenges and the impact of social support in Iranian Muslim mothers: A cross-sectional study.

Breast milk is the perfect food during infancy. Adequate support from family and health systems can be helpful to continue breastfeeding. This study aimed to determine the status of breastfeeding challenges and its relationship with social support and socio-demographic factors. In this correlational-descriptive study, 348 breastfeeding mothers were recruited using cluster random sampling from health care centers in Tabriz, Iran in 2022. Socio-demographic, breastfeeding challenges and social support questionnaires were used for data collection. Data were analyzed for descriptive and inferential statistics (Pearson correlation tests, independent t-test, one-way ANOVA and general linear model) using SPSS version 16. Difficulty in completing household tasks and breastfeeding at the same time (32.5 percent) was the most common challenge reported by mothers. There was an inverse and significant correlation between perceived social support and experiencing challenges (r = -0.199؛ p = .001). Based on the adjusted general linear model, with increasing social support, the score of breastfeeding challenges decreased (B = -0.165; 95 percent CI: -0.07-0.25, p < .001). Considering the relationship between perceived social support and the challenges experienced during breastfeeding, it can be concluded that adequate support from family along with training and guidance from health care providers can lead women to have better breastfeeding experiences and overcome breastfeeding problems.

Clinical and oncological outcomes of pelvic exenteration surgery for anal squamous cell carcinoma.

AIM: Anal cancer incidence and mortality rates are rising in the United Kingdom (UK). Surgery is an important treatment modality for persistent or recurrent disease. There is a paucity of data on outcomes for patients undergoing pelvic exenteration for anal squamous cell carcinoma (SCC) for persistent or recurrent disease. The aim of this study was to investigate the outcomes for patients who were treated with pelvic exenteration for anal SCC from two high-volume, high-complexity pelvic exenteration units in the UK. METHOD: A retrospective review of prospectively maintained databases from 2011 to 2020 was undertaken. Primary endpoints included R0 resection rates, overall and disease-free survival at 2 and 5 years. RESULTS: From 2011 to 2020, 35 patients with anal SCC were selected for exenteration. An R0 resection was achieved in 26 patients (77%). Of the remaining patients, seven patients had an R1 resection and one had a R2 resection. One further patient was excluded from additional analysis as the disease was inoperable at the time of laparotomy. With a median follow-up of 19.5 months (interquartile range 7.9-53.5 months), overall survival was 50% (17/34). Patients with an R1/2 resection had a significantly poorer overall survival [0.27 (0.09-0.76), p = 0.021] than those patients in whom R0 resection was achieved. Disease-free survival was 38.2% (13/34) and an R1/R2 resection was associated with a significantly reduced disease-free survival [0.12 (0.04-0.36), p < 0.001]. CONCLUSION: Complete R0 resection for recurrent or persistent anal SCC is possible in the majority of patients and improves overall and disease-free survival compared with R1/R2 resection.

Breastfeeding after return to work: An Australian national workplace survey.

Breastfeeding initiation rates in Australia are high but duration rates fall well below the World Health Organization targets. Return to work is a known factor impacting 6 months exclusive breastfeeding and continuation into the infants second year of life. Work related factors can influence a woman's confidence in maintaining breastmilk supply after return to employment and determine whether she meets her personal breastfeeding goals. This cross-sectional online survey is the first Australian study to explore women's experience of maintaining breastfeeding after return to work, in all work sectors. Results revealed variations across work sectors reflected in worker autonomy and confidence in speaking up about breastfeeding rights. Women who had autonomy or flexibility in planning their workday were more likely to be confident in maintaining breastmilk supply. The main predictors for milk supply confidence and meeting personal breastfeeding goals included having: a suitable place to express milk; confidence in speaking out about rights; a formal return-to-work plan; a supportive workplace; and returning to work after the period of exclusive breastfeeding. This study reveals that supportive workplace environments can lead to increased confidence in maintaining milk supply, extending durations of breastfeeding. Women who are confident in their rights to express breastmilk, or breastfeed at work, are more likely to meet their own breastfeeding goals. Education, and awareness raising, on the rights of breastfeeding women in the workplace, is a gender equity imperative that can improve experiences for breastfeeding women, and, increase manager and co-worker knowledge for creating enabling workplace environments for breastfeeding employees.

The prevalence of breastfeeding aversion response in Australia: A national cross-sectional survey.

Some women who breastfeed will experience complex ongoing difficulties, such as breastfeeding aversion response (BAR). This recently named breastfeeding challenge is defined as feelings of aversion while breastfeeding for the entire time that the child is latched. This study provides the first prevalence data for the experience of BAR in Australian breastfeeding women. A national online survey investigated the breastfeeding experience of Australian women including data on (1) participant demographics, (2) breastfeeding experience with up to four children, (3) breastfeeding challenges and prevalence of BAR, and (4) the value of available breastfeeding support. This study found that of the Australian breastfeeding women who participated (n = 5511), just over one in five self-identified as having experienced a BAR (n = 1227, 22.6%). Most reported experiencing some breastfeeding challenges, with only 4.5% (n = 247) having had no breastfeeding complications. Importantly, despite these difficulties, 86.9% of the total women in this study rated their overall breastfeeding experience as good (n = 2052, 37.6%), or very good (n = 2690, 49.3%), and 82.5% of those who experience BAR as good (n = 471, 38.7%) or very good (n = 533, 43.8%). BAR reporting was decreased in higher education and income groups. Women who are breastfeeding for the first time are more likely to encounter difficulties with breastfeeding such as BAR. Complications with breastfeeding are pervasive, but women who can overcome breastfeeding issues often report a positive overall breastfeeding experience.

Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications.

AIM: Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis. METHOD: The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted. RESULTS: Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2 years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%). CONCLUSION: The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.

From coercion to respectful care: women's interactions with health care providers when planning a VBAC.

BACKGROUND: In many countries caesarean section rates are increasing and this impacts on choices made around mode of birth in subsequent pregnancies. Having a vaginal birth after caesarean (VBAC) can be a safe and empowering experience for women, yet most women have repeat caesareans. High caesarean section rates increase maternal and neonatal morbidity, health costs and burden on hospitals. Women can experience varied support from health care providers when planning a VBAC. The aim of this paper is to explore the nature and impact of the interactions between women planning a VBAC and health care providers from the women's perspective. METHODS: A national Australian VBAC survey was undertaken in 2019. In total 559 women participated and provided 721 open-ended responses to six questions. Content analysis was used to categorise respondents' answers to the open-ended questions. RESULTS: Two main categories were found capturing the positive and negative interactions women had with health care providers. The first main category, 'Someone in my corner', included the sub-categories 'belief in women birthing', 'supported my decisions' and 'respectful maternity care'. The negative main category 'Fighting for my birthing rights' included the sub-categories 'the odds were against me', 'lack of belief in women giving birth' and 'coercion'. Negative interactions included the use of coercive comments such as threats and demeaning language. Positive interactions included showing support for VBAC and demonstrating respectful maternity care. CONCLUSIONS: In this study women who planned a VBAC experienced a variety of positive and negative interactions. Individualised care and continuity of care are strategies that support the provision of positive respectful maternity care.

The pouch behaving badly: management of morbidity after ileal pouch-anal anastomosis.

AIM: Ileal pouch-anal anastomosis (IPAA), or a 'pouch', allows restoration of intestinal continuity after proctocolectomy for ulcerative colitis or familial adenomatous polyposis. Most patients have a good long-term outcome after IPAA, but in a significant proportion the functional outcome and quality of life are unsatisfactory. We term this outcome 'the pouch behaving badly'. Managing this, especially one is when unfamiliar with the possible underlying pathologies, is a challenge for both patient and clinician. We aim to outline the clinical approach to the pouch behaving badly, highlighting key aspects of investigation and management. METHOD: This is a narrative review of the literature covering the investigation and management of postoperative complications and morbidity after IPAA. RESULTS: Management of the pouch behaving badly requires a careful clinical assessment. The patient may present with multiple symptoms and a clear picture of the symptomatology and past history should be constructed before thorough examination and specialist investigation. We divide the pathology that underlies this clinical scenario into surgical, inflammatory, mechanical, functional and dysplastic causes and outline the investigation and management of each one. CONCLUSION: The pouch behaving badly is a challenging problem for both patient and clinician. A detailed clinical assessment with careful specialist investigation is key to diagnosing the underlying pathology. We stress the importance of patient-centred care - the aim is to improve quality of life.

Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia.

BACKGROUND: Vaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women's experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women's experiences when planning a VBAC in Australia. METHODS: The Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor. RESULTS: In total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC. CONCLUSION: This study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC.

A narrative analysis of women's experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory.

BACKGROUND: Most women who have a caesarean can safely have a vaginal birth after caesarean (VBAC) for their next birth, but more women have an elective repeat caesarean than a VBAC. METHODS: The aim of this qualitative study was to explore the experiences of women planning a vaginal birth after caesarean (VBAC) in Australia, the interactions with their health care providers and their thoughts, feelings and experiences after an antenatal appointment and following the birth. The study explored the effect of different models of care on women's relationships with their health care provider using a feminist theoretical lens. Eleven women who had previously experienced a caesarean section and were planning a VBAC in their current pregnancy used the 'myVBACapp' to record their thoughts after their antenatal appointments and were followed up with in-depth interviews in the postnatal period. RESULTS: Fifty-three antenatal logs and eleven postnatal interviews were obtained over a period of eight months in 2017. Women accessed a variety of models of care. The four contextual factors found to influence whether a woman felt resolved after having a VBAC or repeat caesarean were: 'having confidence in themselves and in their health care providers', 'having control', 'having a supportive relationship with a health care provider' and 'staying active in labour'. CONCLUSIONS: The findings highlight that when women have high feelings of control and confidence; have a supportive continual relationship with a health care provider; and are able to have an active labour; it can result in feelings of resolution, regardless of mode of birth. Women's sense of control and confidence can be undermined through the impact of paternalistic and patriarchal maternity systems by maintaining women's subordination and lack of control within the system. Women planning a VBAC want confident, skilled, care providers who can support them to feel in control and confident throughout the birthing process. Continuity of care (CoC) provides a supportive relationship which some women in this study found beneficial when planning a VBAC.

Expectations and experiences of nursing students in supporting new mothers to breastfeed: A descriptive qualitative study.

BACKGROUND: Improving breastfeeding support to mothers has been the focus of several national and international health organisations. There is evidence that theoretical and clinical education improves breastfeeding knowledge and attitudes among nursing and other health professional students prior to clinical placement, to support women who are breastfeeding. AIMS AND OBJECTIVES: To explore the expectations and experiences of Taiwanese nursing students in supporting breastfeeding on clinical placement. To gain additional insight into student experience, we also sought the perspectives of mothers, nursing staff and teachers about the role of nursing students in supporting breastfeeding mothers. DESIGN: A qualitative descriptive approach guided this study. METHODS: Focus groups and small group interviews were conducted with four participant groups in southern Taiwan. Ethical approval was obtained prior to data collection. The consolidated criteria for reporting qualitative research checklist was used. FINDINGS: Three main themes emerged from the data that captured the nursing students' experiences during clinical practice, which were "High expectations"; "The reality is different"; and "Improving confidence in students." The study found that students lacked confidence in supporting breastfeeding in the clinical setting. Students were expected to support women to achieve their breastfeeding goals under the supervision. The students highlighted the importance of establishing trust to effectively support mothers, and for the students to feel confident to provide the breastfeeding information. CONCLUSIONS: Despite structured theoretical breastfeeding education prior to clinical placement, students did not feel they were adequately prepared to support women who are breastfeeding during their clinical placement. The findings demonstrated the need for further support in developing effective communication skills and building confidence prior to clinical placement. RELEVANCE TO CLINICAL PRACTICE: Enhancing the content of theoretical and simulated breastfeeding education to incorporate women's breastfeeding experience combined with realistic clinical student allocation could serve to improve students' confidence in supporting breastfeeding.

Migrant Burmese women living in southern Thailand and motherhood: An ethnographic study.

Migrants to Thailand come from low-income border countries, such as Burma (Myanmar). Generally, migrant women experience difficulties obtaining high-quality health care due to socioeconomic barriers and conflicts with their practices. The aim of this study was to explore migrant Burmese women's experiences of becoming a mother while living in Thailand and their perceptions of motherhood, family support, and traditional postpartum practices. The study used an ethnographic design. In 2015, data were gathered through individual interviews with 10 migrant Burmese women before and after birth. Interview and field note data were analyzed using thematic analysis. Four themes emerged from the data: (i) the more children, the stronger the family; (ii) finding ways to promote baby's health and growth; (iii) sharing responsibility to fulfill parenting role; and (iv) peer and family support. Becoming a mother was important to the Burmese women interviewed; however, as migrants in Thailand, they had to juggle work and care for young children. Most decided that once their child was school age they would be sent to Burma to live with relatives. They engaged in a range of traditional practices to support their infant's health and well-being and protect their baby from evil spirits. Support from family, and the ability to participate in postpartum practices, were important for Burmese migrant women becoming mothers in Thailand.

What is the impact of rerouting a cancer diagnosis from emergency presentation to GP referral on resource use and survival? Evidence from a population-based study.

BACKGROUND: Studies on alternative routes to diagnosis stimulated successful policy interventions reducing the number of emergency diagnoses and associated mortality risk. A dearth of evidence on the costs of such interventions might prevent new policies from achieving more ambitious targets. METHODS: We conducted a retrospective cohort study on the population of colorectal (88,051), breast (90,387), prostate (96,219), and lung (97,696) cancer patients diagnosed after a GP referral or an emergency presentation and reported in the Cancer Registry of England. Resource use and survival were compared 1 year before and 5 years after diagnosis (3 years for lung), including the costs of GP referrals not converted into a positive diagnosis. Risk-adjusted statistical models were used to calculate the effect of rerouting patient' diagnoses from emergency presentation to GP referral. RESULTS: Rerouting a cancer diagnosis results in a relatively small additional costs to the National Health System against additional years of life saved to the patient. The cost per year of life saved is £6456 in colorectal, £1057 in breast, -£662 in prostate (savings), and £819 in lung cancer. Reducing the overall prevalence of emergency presentations to the level achieved by the 20% of Clinical Commissioning Groups with the lowest prevalence would result in £11,481,948 against 1863 years of life saved for Colorectal, £847,750 against 889 years for breast, -£943,434 (cost savings) against 1195 years for prostate, and £609,938 against 1011 years for lung cancer. CONCLUSION: Redirecting diagnoses from emergency presentation to GP referral appears an achievable target that can produce large benefits to patients against modest additional costs to the National Health System.

The Design, Development, and Evaluation of a Qualitative Data Collection Application for Pregnant Women.

PURPOSE: This article explores the development and evaluation of a smartphone mobile software application (app) to collect qualitative data. The app was specifically designed to capture real-time qualitative data from women planning a vaginal birth after caesarean delivery. This article outlines the design and development of the app to include funding, ethics, and the recruitment of an app developer, as well as the evaluation of using the app by seven participants. ORGANIZING CONSTRUCT: Data collection methods used in qualitative research include interviews and focus groups (either online, face-to-face, or by phone), participant diaries, or observations of interactions. This article identifies an alternative data collection methodology using a smartphone app to collect real-time data. CONCLUSIONS: The app provides real-time data and instant access to data alongside the ability to access participants from a variety of locations. This allows the researcher to gain insight into the experiences of participants through audio or video recordings in longitudinal studies without the need for constant interactions or interviews with participants. CLINICAL RELEVANCE: Using smartphone applications can allow researchers to access participants who are traditionally hard to reach and access their data in real time. Evaluating these apps before use in research is invaluable.

Video ethnography during and after caesarean sections: methodological challenges.

AIMS AND OBJECTIVES: To describe the challenges of, and steps taken to successfully collect video ethnographic data during and after caesarean sections. BACKGROUND: Video ethnographic research uses real-time video footage to study a cultural group or phenomenon in the natural environment. It allows researchers to discover previously undocumented practices, which in-turn provides insight into strengths and weaknesses in practice. This knowledge can be used to translate evidence-based interventions into practice. DESIGN: Video ethnographic design. METHODS: A video ethnographic approach was used to observe the contact between mothers and babies immediately after elective caesarean sections in a tertiary hospital in Sydney, Australia. Women, their support people and staff participated in the study. Data were collected via video footage and field notes in the operating theatre, recovery and the postnatal ward. CONCLUSIONS: Challenges faced whilst conducting video ethnographic research included attaining ethics approval, recruiting vast numbers of staff members and 'vulnerable' pregnant women, and endeavouring to be a 'fly on the wall' and a 'complete observer'. There were disadvantages being an 'insider' whilst conducting the research because occasionally staff members requested help with clinical tasks whilst collecting data; however, it was an advantage as it enabled ease of access to the environment and staff members that were to be recruited. Despite the challenges, video ethnographic research enabled the provision of unique data that could not be attained by any other means. RELEVANCE TO CLINICAL PRACTICE: Video ethnographic data are beneficial as it provides exceptionally rich data for in-depth analysis of interactions between the environment, equipment and people in the hospital environment. The analysis of this type of data can then be used to inform improvements for future care.

Cost of care for cancer patients in England: evidence from population-based patient-level data.

BACKGROUND: Health systems are facing the challenge of providing care to an increasing population of patients with cancer. However, evidence on costs is limited due to the lack of large longitudinal databases. METHODS: We matched cost of care data to population-based, patient-level data on cancer patients in England. We conducted a retrospective cohort study including all patients age 18 and over with a diagnosis of colorectal (275 985 patients), breast (359 771), prostate (286 426) and lung cancer (283 940) in England between 2001 and 2010. Incidence costs, prevalence costs, and phase of care costs were estimated separately for patients age 18-64 and ⩾65. Costs of care were compared by patients staging, before and after diagnosis, and with a comparison population without cancer. RESULTS: Incidence costs in the first year of diagnosis are noticeably higher in patients age 18-64 than age ⩾65 across all examined cancers. A lower stage diagnosis is associated with larger cost savings for colorectal and breast cancer in both age groups. The additional costs of care because of the main four cancers amounts to £1.5 billion in 2010, namely 3.0% of the total cost of hospital care. CONCLUSIONS: Population-based, patient-level data can be used to provide new evidence on the cost of cancer in England. Early diagnosis and cancer prevention have scope for achieving large cost savings for the health system.

A Systematic Review of the Impact of Dedicated Emergency Surgical Services on Patient Outcomes.

OBJECTIVE: This review aims to assess the impact of implementing dedicated emergency surgical services, in particular acute care surgery, on clinical outcomes. BACKGROUND: The optimal model for delivering high-quality emergency surgical care remains unknown. Acute Care Surgery (ACS) is a health care model combining emergency general surgery, trauma, and critical care. It has been adopted across the United States in the management of surgical emergencies. METHOD: A systematic review was performed after PRISMA recommendations using the MEDLINE, Embase, and Psych-Info databases. Studies assessing different care models and institutional factors affecting the delivery of emergency general surgery were included. RESULTS: Twenty-seven studies comprising 744,238 patients were included in this review. In studies comparing ACS with traditional practice, mortality and morbidity were improved. Moreover, time to senior review, delays to operating theater, and financial expenditure were often reduced. The elements of ACS models varied but included senior clinicians present onsite during office hours and dedicated to emergency care while on-call. Referrals were made to specialist centers with primary surgical assessments taking place on surgical admissions units rather than in the emergency department. Twenty-four-hour access to dedicated emergency operating rooms was also described. CONCLUSIONS: ACS models as well as centralized units and hospitals with dedicated emergency operating rooms, access to radiology and intensive care facilities (ITU) are all factors associated with improved clinical and financial outcomes in the delivery of emergency general surgery. There is, however, no consensus on the elements that constitute an ideal ACS model and how it can be implemented into current surgical practice.

Linked Hospital and Primary Care Database Analysis of the Incidence and Impact of Psychiatric Morbidity Following Gastrointestinal Cancer Surgery in England.

OBJECTIVE: To evaluate risk of psychiatric morbidity and its impact on survival in gastrointestinal surgery. BACKGROUND: Psychiatric morbidity related to surgery is poorly understood, and may be evaluated using linked hospital and primary care data. METHODS: Patients undergoing gastrointestinal surgery from 2000 to 2011 with linkage of Clinical Practice Research Datalink (CPRD), Hospital Episodes Statistics (HES), Office of National Statistics (ONS), and National Cancer Intelligence Network (NCIN) databases were studied. Psychiatric morbidity was defined as a diagnosis code in CPRD or HES, or a prescription code for psychiatric medication in the 36 months before (preoperative) or 12 months after (postoperative) surgery. Newly diagnosed psychiatric morbidity was measured in patients without preoperative psychiatric morbidity. RESULTS: In our study, 14,797 (23.8%) and 47,279 (76.2%) patients had surgery for cancer and benign disease, respectively. Postoperative psychiatric morbidity was observed in 10.1% (1500/14797) of patients undergoing cancer surgery. Logistic regression revealed that when adjusted for other factors, cancer diagnosis [odds ratio (OR) = 1.19] independently predicted postoperative psychiatric morbidity (P < 0.05). Hepatopancreaticobiliary resection (OR = 2.40) and esophagogastrectomy (OR = 2.55) carried the highest risks of postoperative psychiatric morbidity (P < 0.05). Preoperative psychiatric morbidity (OR = 1.16) and newly diagnosed psychiatric morbidity (OR = 1.87) were associated with increased 1-year mortality in cancer patients only (P < 0.05). CONCLUSIONS: Postoperative psychiatric morbidity affected a tenth of patients who underwent gastrointestinal cancer surgery and was associated with increased mortality. Strategies to identify patients at risk preoperatively and to reduce the observed adverse impact of postoperative psychiatric morbidity should be part of perioperative care in complex cancer patients.