'We had conversations we wouldn't have had otherwise'-Exploring home-dwelling people with dementia and family members' experiences of deliberating on ethical issues in a literature-based intervention.

AIM: To explore home-dwelling people with dementia and family members' perceptions of the feasibility and acceptability of an intervention using dementia-related literature excerpts to facilitate conversations on ethical issues related to living with dementia. BACKGROUND: Ethical issues in dementia care emerge throughout the illness. In the early stages, they may involve decisions about disclosing the illness to the family, shifting roles and responsibilities, and considerations of transitioning to a nursing home. Addressing ethical issues and providing adequate support to home-dwelling people with dementia and their families are often lacking. DESIGN: An exploratory-descriptive qualitative study. METHODS: We conducted eight interviews with 14 home-dwelling persons with dementia and their family caregivers. Six were dyadic interviews, and two were individual interviews with family caregivers. We analysed the interview data using template analysis. We adhered to the COREQ checklist in reporting this study. RESULTS: Using excerpts from dementia-related literature was a feasible and acceptable way of initiating discussions on ethical issues among home-dwelling persons with dementia and family caregivers. However, engaging the families of newly diagnosed individuals was challenging due to emotional distress. The intervention provided peer support, including identifying with others and sharing experiences. Moreover, participating couples found intimacy and relational attunement through shared reflections. CONCLUSION: Based on the findings, it appears that the participants in this study felt that using excerpts from dementia-related literature to deliberate on ethical issues was feasible and acceptable. Deliberating on ethical issues with peers and family caregivers offers valuable social support and opportunities for strengthening relationships. IMPLICATIONS FOR PATIENT CARE: This study makes an important contribution by providing valuable insights into how ethical issues related to living with dementia can be addressed using related literature and suggests how the intervention can be integrated into existing care initiatives for home-dwelling people with dementia and their families. REPORTING METHOD: We have adhered to relevant EQUATOR guidelines with the COREQ reporting method. PATIENT OR PUBLIC CONTRIBUTION: A healthcare professional working as a so-called dementia coordinator (a title used in the Danish context) was involved in the conduct of this study by being responsible for the recruitment of home-dwelling people with dementia and their family members. Moreover, she had joint responsibility for facilitating the intervention along with the first author.

Implementing a new birthing room design: a qualitative study with a care provider perspective.

BACKGROUND: Research shows that interventions to protect the sensitive physiological process of birth by improving the birthing room design may positively affect perinatal outcomes. It is, however, crucial to understand the mechanisms and contextual elements that influence the outcomes of such complex interventions. Hence, we aimed to explore care providers' experiences of the implementation of a new hospital birthing room designed to be more supportive of women's birth physiology. METHODS: This qualitative study reports on the implementation of the new birthing room, which was evaluated in the Room4Birth randomised controlled trial in Sweden. Individual interviews were undertaken with care providers, including assistant nurses, midwives, obstetricians, and managers (n = 21). A content analysis of interview data was conducted and mapped into the three domains of the Normalisation Process Theory coding manual: implementation context, mechanism, and outcome. RESULTS: The implementation of the new room challenged the prevailing biomedical paradigm within the labour ward context and raised the care providers' awareness about the complex interplay between birth physiology and the environment. This awareness had the potential to encourage care providers to be more emotionally present, rather than to focus on monitoring practices. The new room also evoked a sense of insecurity due to its unfamiliar design, which acted as a barrier to integrating the room as a well-functioning part of everyday care practice. CONCLUSION: Our findings highlight the disparity that existed between what care providers considered valuable for women during childbirth and their own requirements from the built environment based on their professional responsibilities. This identified disparity emphasises the importance of hospital birthing rooms (i) supporting women's emotions and birth physiology and (ii) being standardised to meet care providers' requirements for a functional work environment. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03948815, 14/05/2019.

People living with HIV in Sweden report high levels of sexual satisfaction in a registry-based cohort study.

Sexual satisfaction can be challenging for people living with HIV (PLWH). To investigate self-reported sexual satisfaction in PLWH and its association with HIV-related biomarkers, a retrospective observational cohort study with data on sociodemographic characteristics and changes in PLWH's assessment of their sexual satisfaction over time were retrieved from the Swedish National Quality Assurance Registry (InfCareHIV) where patient-related outcomes are reported annually. PLWH who had assessed self-reported sexual satisfaction 2011-2016 were included. Sexual satisfaction was dichotomized into sexual "satisfaction and dissatisfaction" and associations were analysed. In total, 3798 patients (66% men) answered 8202 questionnaires. Overall, 67% reported sexual satisfaction, with women more satisfied than men (72% vs 64%, p < 0.0001). Sexual satisfaction did not differ between patients on antiretroviral treatment (ART) >6 months whether the viral load was suppressed or not. Overall, the probability of reporting sexual satisfaction increased by 4% annually (p < 0.001). This increase may be explained by evolving knowledge about the minimal risks of sexual HIV transmission when on ART together with Sweden's concomitant revision of legal restrictions. The use of patient-related outcomes in clinical practice is an important tool for facilitating conversations about sexuality in order to promote the health and well-being of PLWH.

A Lifestyle Intervention During Pregnancy and Its Effects on Child Weight 2.5 Years Later.

AIM: The aim of this study was to evaluate if overweight and obesity in the offspring is reduced by a low-intensity antenatal primary care intervention with focus on diet and physical activity for pregnant women with obesity, comparing children to mothers receiving the intervention with children to mothers who did not. METHODS: This study is a follow-up of children 2.5 years of age after their mothers' participation in a non-randomised controlled intervention intending to limit gestational weight gain. All study participants received standard antenatal care. The intervention group received lifestyle support via motivational talks with midwife and support from dietician. Data on child weight were collected by medical records, letter and phone. RESULTS: There was no significant difference between the groups 2.5 years after intervention (International Obesity Task Force ISO-BMI 25 (child BMI corresponding to adult BMI of 25): 20% vs. 21%; ISO-BMI 30: 4.6% vs. 1.3%). The mother's BMI at the beginning of pregnancy significantly influenced child BMI at 2.5 years (r = 0.13, p = 0.014, r2 = 0.017). For each unit of increase in maternal BMI at enrollment, the probability of child ISO-BMI ≥ 25 increased by 7.5% (p = 0.021) and of ≥ 30, by 12.9% (p = 0.017). CONCLUSION: The frequency of overweight and obesity of the children at 2.5 years of age was significantly correlated to the mother's BMI, but not correlated to the mothers' participation in the antenatal lifestyle intervention. Thus, it seems important to address obesity and lifestyle issues before and between pregnancies. Trial registration The study has been registered at ClinicalTrials.gov, Identifier: NCT03147079.

Cost effectiveness of a controlled lifestyle intervention for pregnant women with obesity.

BACKGROUND: The Mighty Mums antenatal lifestyle intervention is a person-centered behavioral intervention focusing on nutrition and physical activity for pregnant women with obesity (body mass index [BMI] ≥30). The aim of this study was to evaluate the costs and clinical outcomes of adding the Mighty Mums intervention to standard antenatal care. METHODS: Participants in the intervention group (n = 434) received motivational talks with their midwife and a selection of physical and/or nutritional activities in addition to antenatal care. Control participants (n = 867) from adjacent geographic areas received standard antenatal care. Costs for staff, unit costs for specific activities, and registered costs for specialized antenatal care were analyzed for associations with gestational weight gain and self-reported health. Results are reported for the intention-to-treat (ITT) population and a per protocol (PP) population identified by participation in the intervention. Analyses included bootstrapped linear regressions adjusted for background characteristics that differed significantly between groups. RESULTS: The average costs were SEK 9727 higher (95% confidence interval [CI]: 6677 to 12,777) among participants in the intervention group than in the control ITT population and SEK 8655 (95% CI 4586 to 12,724) higher than in the PP population. The cost increase per 1 kg reduction in gestational weight gain was SEK 12,369 in the ITT population and SEK 7209 for the PP population. CONCLUSION: Participation in the Mighty Mums intervention was associated with higher costs, but also reduced gestational weight gain. The cost per kilogram reduction in gestational weight gain was low, particularly in the PP population. A future decision to implement this behavioral intervention in standard care should take into account society's willingness to pay per unit reduction in gestational weight gain. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov , Identifier: NCT03147079 .

Dosage of oxytocin for augmentation of labor and women's childbirth experiences: A randomized controlled trial.

INTRODUCTION: The aim of this study was to compare childbirth experiences and experience of labor pain in primiparous women who had received high- vs low-dose oxytocin for augmentation of delayed labor. MATERIAL AND METHODS: A multicenter, parallel, double-blind randomized controlled trial took place in six Swedish labor wards. Inclusion criteria were healthy primiparous women at term with uncomplicated singleton pregnancies, cephalic fetal presentation, spontaneous onset of labor, confirmed delayed labor progress and ruptured membranes. The randomized controlled trial compared high- vs low-dose oxytocin used for augmentation of a delayed labor progress. The Childbirth Experience Questionnaire version 2 (CEQ2) was sent to the women 1 month after birth. The CEQ2 consists of 22 items in four domains: Own capacity, Perceived safety, Professional support and Participation. In addition, labor pain was reported with a visual analog scale (VAS) 2 hours postpartum and 1 month after birth. The main outcome was the childbirth experience measured with the four domains of the CEQ2. The clinical trial number is NCT01587625. RESULTS: The CEQ2 was sent to 1203 women, and a total of 1008 women (83.8%) answered the questionnaire. The four domains of childbirth experience were scored similarly in the high- and low-dose oxytocin groups of women: Own capacity (P = .36), Perceived safety (P = .44), Professional support (P = .84), Participation (P = .49). VAS scores of labor pain were reported as similar in both oxytocin dosage groups. Labor pain was scored higher 1 month after birth compared with 2 hours postpartum. There was an association between childbirth experiences and mode of birth in both the high- and low-dose oxytocin groups. CONCLUSIONS: Different dosage of oxytocin for augmentation of delayed labor did not affect women's childbirth experiences assessed through CEQ2 1 month after birth, or pain assessment 2 hours or 1 month after birth.

Measuring women's experiences of decision-making and aspects of midwifery support: a confirmatory factor analysis of the revised Childbirth Experience Questionnaire.

BACKGROUND: Women's experiences of labour and birth can have both short- and long-term effects on their physical and psychological health. The original Swedish version of the Childbirth Experience Questionnaire (CEQ) has shown to have good psychometric quality and ability to differentiate between groups known to differ in childbirth experience. Two subscales were revised in order to include new items with more relevant content about decision-making and aspects of midwifery support. The aim of the study was to develop new items in two subscales and to test construct validity and reliability of the revised version of CEQ, called CEQ2. METHOD: A total of 11 new items (Professional Support and Participation) and 14 original items from the first CEQ (Own capacity and Perceived safety), were answered by 682 women with spontaneous onset of labour. Confirmatory factor analysis was used to analyse model fit. RESULTS: The hypothesised four-factor model showed good fit (CMIN = 2.79; RMR = 0.33; GFI = 0.94; CFI = 0.94; TLI = 0.93; RMSEA = 0.054 and PCLOSE = 0.12) Cronbach's alpha was good for all subscales (0.82, 0.83, 0.76 and 0.73) and for the total scale (0.91). CONCLUSIONS: CEQ2, like the first CEQ, yields four important aspects of experience during labour and birth showing good psychometric performance, including decision-making and aspects of midwifery support, in both primiparous and multiparous women.

Midwives' challenges and factors that motivate them to remain in their workplace in the Democratic Republic of Congo-an interview study.

BACKGROUND: The Democratic Republic of Congo (DRC) has high maternal mortality and a low number of midwives, which undermines the achievement of goal 3 of the Sustainable Development Goals (SDGs) for 2030, specifically the health of the mother and newborn. Scaling up the midwifery workforce in relation to number, quality of healthcare, and retention in service is therefore critical. The aim of this study was to investigate midwives' challenges and factors that motivate them to remain in their workplace in the DRC. METHODS: Data were collected in two out of 26 provinces in the DRC through ten focus group discussions with a total of 63 midwives working at ten different healthcare facilities. Transcribed discussions were inductively analysed using content analysis. RESULTS: The midwives' challenges and the factors motivating them to remain in their workplace in the DRC are summarised in one main category-Loving one's work makes it worthwhile to remain in one's workplace, despite a difficult work environment and low professional status-consisting of three generic categories: Midwifery is not just a profession; it's a calling is described in the subcategories Saving lives through midwifery skills, Building relationships with the women and the community, and Professional pride; Unsupportive organisational system is expressed in the subcategories Insufficient work-related security and No equitable remuneration system, within Hierarchical management structures; and Inadequate pre-conditions in the work environment includes the subcategories Lack of resources and equipment and Insufficient competence for difficult working conditions. CONCLUSION: Midwives in the DRC are driven by a strong professional conscience to provide the best possible care for women during childbirth, despite a difficult work environment and low professional status. To attract and retain midwives and ensure that they are working to their full scope of practice, we suggest coordinated actions at the regional and national levels in the DRC and in other low-income countries with similar challenges, including (i) conducting midwifery education programmes following international standards, (ii) prioritising and enforcing policies to include adequate remuneration for midwives, (iii) involving midwives' associations in policy and planning about the midwifery workforce, and (iv) ensuring that midwives' working environments are safe and well equipped.

Maternal plasma levels of oxytocin during physiological childbirth - a systematic review with implications for uterine contractions and central actions of oxytocin.

BACKGROUND: Oxytocin is a key hormone in childbirth, and synthetic oxytocin is widely administered to induce or speed labour. Due to lack of synthetized knowledge, we conducted a systematic review of maternal plasma levels of oxytocin during physiological childbirth, and in response to infusions of synthetic oxytocin, if reported in the included studies. METHODS: An a priori protocol was designed and a systematic search was conducted in PubMed, CINAHL, and PsycINFO in October 2015. Search hits were screened on title and abstract after duplicates were removed (n = 4039), 69 articles were examined in full-text and 20 papers met inclusion criteria. As the articles differed in design and methodology used for analysis of oxytocin levels, a narrative synthesis was created and the material was categorised according to effects. RESULTS: Basal levels of oxytocin increased 3-4-fold during pregnancy. Pulses of oxytocin occurred with increasing frequency, duration, and amplitude, from late pregnancy through labour, reaching a maximum of 3 pulses/10 min towards the end of labour. There was a maximal 3- to 4-fold rise in oxytocin at birth. Oxytocin pulses also occurred in the third stage of labour associated with placental expulsion. Oxytocin peaks during labour did not correlate in time with individual uterine contractions, suggesting additional mechanisms in the control of contractions. Oxytocin levels were also raised in the cerebrospinal fluid during labour, indicating that oxytocin is released into the brain, as well as into the circulation. Oxytocin released into the brain induces beneficial adaptive effects during birth and postpartum. Oxytocin levels following infusion of synthetic oxytocin up to 10 mU/min were similar to oxytocin levels in physiological labour. Oxytocin levels doubled in response to doubling of the rate of infusion of synthetic oxytocin. CONCLUSIONS: Plasma oxytocin levels increase gradually during pregnancy, and during the first and second stages of labour, with increasing size and frequency of pulses of oxytocin. A large pulse of oxytocin occurs with birth. Oxytocin in the circulation stimulates uterine contractions and oxytocin released within the brain influences maternal physiology and behaviour during birth. Oxytocin given as an infusion does not cross into the mother's brain because of the blood brain barrier and does not influence brain function in the same way as oxytocin during normal labour does.

Health care professional's communication through an interpreter where language barriers exist in neonatal care: a national study.

BACKGROUND: A number of parents in neonatal care are foreign-born and do not speak the local language, which makes communication between healthcare professionals and parents more difficult. Interpreters can be used when language barriers exist - parent interactions, medical communication and communication about the care of the child. The aim in this study was to examine healthcare professionals' use of interpreters and awareness of local guidelines for interpreted communication in neonatal care. METHOD: A survey was distributed to all 2109 employees at all 38 neonatal units in Sweden, thus to all physicians, registered nurses and nurse assistants in active service. Data were analysed with descriptive statistics and dichotomized so the professionals were compared in groups of two using the Mantel-Haenszel Chi Square test and Fisher's Non Parametric Permutation test. RESULTS: The survey was answered by 41% (n = 858) representing all neonatal units. The study showed a difference between the professional groups in awareness of guidelines, availability of interpreters, and individual resources to communicate through an interpreter. Nurse assistants significantly lesser than registered nurses (p < .0001) were aware of guidelines concerning the use of interpreters. In emergency communications nurse assistants used authorized interpreters to a significantly lesser extent than physicians (p < .0001) and registered nurses (p < .0001). Physicians used authorized interpreters to a significantly higher extent than registered nurses (p 0.006) and non-authorized interpreters to a significantly lesser extent than registered nurses (p 0.013). In planned communications, nurse assistants used authorized interpreters to a significantly lesser extent than physicians (p < .0001) and registered nurses (p < .0001). Nurse assistants rated their ability to communicate with parents through an interpreter to a significantly lesser extent than physicians (p 0.0058) and registered nurses (p 0.0026). No other significant differences were found. CONCLUSION: The results of the study show insufficient awareness of guidelines in all neonatal units in Sweden. Clinical implications might be to provide healthcare professionals with guidelines and training clinical skills in using interpreters and increasing the availability of interpreters by having interpreters employed by the hospital.

Maternal probiotic supplementation for prevention of morbidity and mortality in preterm infants.

BACKGROUND: Inflammation may contribute to preterm birth and to morbidity of preterm infants. Preterm infants are at risk for alterations in the normal protective microbiome. Oral probiotics administered directly to preterm infants have been shown to decrease the risk for severe necrotizing enterocolitis (NEC) as well as the risk of death, but there are safety concerns about administration of probiotics directly to preterm infants. Through decreasing maternal inflammation, probiotics may play a role in preventing preterm birth and/or decreasing the inflammatory milieu surrounding delivery of preterm infants, and may alter the microbiome of the preterm infant when given to mothers during pregnancy. Probiotics given to mothers after birth of preterm infants may effect infant bacterial colonization, which could potentially reduce the incidence of NEC. OBJECTIVES: 1. To compare the efficacy of maternal probiotic administration versus placebo or no intervention in mothers during pregnancy for the prevention of preterm birth and the prevention of morbidity and mortality of infants born preterm.2. To compare the efficacy of maternal probiotic administration versus placebo, no intervention, or neonatal probiotic administration in mothers of preterm infants after birth on the prevention of mortality and preterm infant morbidities such as NEC. SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 2), MEDLINE via PubMed (1966 to 21 March 2017), Embase (1980 to 21 March 2017), and CINAHL (1982 to 21 March 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. SELECTION CRITERIA: We included randomized controlled trials in the review if they administered oral probiotics to pregnant mothers at risk for preterm birth, or to mothers of preterm infants after birth. Quasi-randomized trials were eligible for inclusion, but none were identified. Studies enrolling pregnant women needed to administer probiotics at < 36 weeks' gestation until the trimester of birth. Probiotics considered were of the genera Lactobacillus, Bifidobacterium or Saccharomyces. DATA COLLECTION AND ANALYSIS: We used the standard methods of the Cochrane Collaboration and Cochrane Neonatal to determine the methodologic quality of studies, and for data collection and analysis. MAIN RESULTS: We included 12 eligible trials with a total of 1450 mothers and 1204 known infants. Eleven trials administered probiotics to mothers during pregnancy and one trial administered probiotics to mothers after birth of their preterm infants. No studies compared maternal probiotic administration directly with neonatal administration. Included prenatal trials were highly variable in the indication for the trial, the gestational age and duration of administration of probiotics, as well as the dose and formulation of the probiotics. The pregnant women included in these trials were overall at low risk for preterm birth. In a meta-analysis of trial data, oral probiotic administration to pregnant women did not reduce the incidence of preterm birth < 37 weeks (typical risk ratio (RR) 0.92, 95% confidence interval (CI) 0.32 to 2.67; 4 studies, 518 mothers and 506 infants), < 34 weeks (typical risk difference (RD) 0.00, 95% CI -0.02 to 0.02; 2 studies, 287 mothers and infants), the incidence of infant mortality (typical RD 0.00, 95% CI -0.02 to 0.02; 2 studies, 309 mothers and 298 infants), or the gestational age at birth (mean difference (MD) 0.15, 95% CI -0.33 to 0.63; 2 studies, 209 mothers with 207 infants).One trial studied administration of probiotics to mothers after preterm birth and included 49 mothers and 58 infants. There were no significant differences in the risk of any NEC (RR 0.44, 95% CI 0.13 to 1.46; 1 study, 58 infants), surgery for NEC (RR 0.15, 95% CI 0.01 to 2.58; 1 study, 58 infants), death (RR 0.66, 95% CI 0.06 to 6.88; 1 study, 58 infants), and death or NEC (RR 0.53, 95% CI 0.19 to 1.49; 1 study, 58 infants). There was an improvement in time to reach 50% enteral feeds in infants whose mothers received probiotics, but the estimate is imprecise (MD -9.60 days, 95% CI -19.04 to -0.16 days; 58 infants). No other improvement in any neonatal outcomes were reported. The estimates were imprecise and do not exclude the possibility of meaningful harms or benefits from maternal probiotic administration. There were no cases of culture-proven sepsis with the probiotic organism. The GRADE quality of evidence was judged to be low to very low due to inconsistency and imprecision. AUTHORS' CONCLUSIONS: There is insufficient evidence to conclude whether there is appreciable benefit or harm to neonates of either oral supplementation of probiotics administered to pregnant women at low risk for preterm birth or oral supplementation of probiotics to mothers of preterm infants after birth. Oral supplementation of probiotics to mothers of preterm infants after birth may decrease time to 50% enteral feeds, however, this estimate is extremely imprecise. More research is needed for post-natal administration of probiotics to mothers of preterm infants, as well as to pregnant mothers at high risk for preterm birth.

Fathers' experiences of care when their partners suffer from peripartum cardiomyopathy: a qualitative interview study.

BACKGROUND: Peripartum cardiomyopathy (PPCM), a potentially life-threatening condition in women, can have a profound impact on the family. Although structured support systems are developed, these systems tend to be based on the healthcare providers' perceptions and focus mainly on mothers' care. Fathers' vital role in supporting their partners has been advocated in previous research. However, the impact of PPCM on the male partners of women is less understood. The aim of this study was to explore the experiences of healthcare in fathers whose partner was suffering from peripartum cardiomyopathy. METHODS: The data from interviews with fourteen fathers were analysed using inductive content analysis. RESULTS: An overarching category "The professionals could have made a difference" was identified from the data, characterised by the sub-categories: 'To be informed/not informed,' 'To feel secure/insecure,' 'To feel visible/invisible' and 'Wish that it had been different'. Lack of timely information did not allow fathers to understand their partner´s distress, and plan for the future. The birth of the child was an exciting experience, but a feeling of helplessness was central, related to seeing their partner suffering. A desire for follow-up regarding the effect of PPCM on themselves was expressed. CONCLUSIONS: When men, as partners of women with PPCM, get adequate information of their partner´s condition, they gain a sense of security and control that gives them strength to handle their personal and emotional life-situation during the transition of becoming a father, along with taking care of an ill partner with PPCM. Hence, maternity professionals should also focus on fathers' particular needs to help them fulfil their roles. Further research is urgently required in this area.

Web-Based Intervention for Women With Type 1 Diabetes in Pregnancy and Early Motherhood: Critical Analysis of Adherence to Technological Elements and Study Design.

BACKGROUND: Numerous Web-based interventions have been implemented to promote health and health-related behaviors in persons with chronic conditions. Using randomized controlled trials to evaluate such interventions creates a range of challenges, which in turn can influence the study outcome. Applying a critical perspective when evaluating Web-based health interventions is important. OBJECTIVE: The objective of this study was to critically analyze and discuss the challenges of conducting a Web-based health intervention as a randomized controlled trial. METHOD: The MODIAB-Web study was critically examined using an exploratory case study methodology and the framework for analysis offered through the Persuasive Systems Design model. Focus was on technology, study design, and Web-based support usage, with special focus on the forum for peer support. Descriptive statistics and qualitative content analysis were used. RESULTS: The persuasive content and technological elements in the design of the randomized controlled trial included all four categories of the Persuasive Systems Design model, but not all design principles were implemented. The study duration was extended to a period of four and a half years. Of 81 active participants in the intervention group, a maximum of 36 women were simultaneously active. User adherence varied greatly with a median of 91 individual log-ins. The forum for peer support was used by 63 participants. Although only about one-third of the participants interacted in the forum, there was a fairly rich exchange of experiences and advice between them. Thus, adherence in terms of social interactions was negatively affected by limited active participation due to prolonged recruitment process and randomization effects. Lessons learned from this critical analysis are that technology and study design matter and might mutually influence each other. In Web-based interventions, the use of design theories enables utilization of the full potential of technology and promotes adherence. The randomization element in a randomized controlled trial design can become a barrier to achieving a critical mass of user interactions in Web-based interventions, especially when social support is included. For extended study periods, the technology used may need to be adapted in line with newly available technical options to avoid the risk of becoming outdated in the user realm, which in turn might jeopardize study validity in terms of randomized controlled trial designs. CONCLUSIONS: On the basis of lessons learned in this randomized controlled trial, we give recommendations to consider when designing and evaluating Web-based health interventions.

Measuring women's childbirth experiences: a systematic review for identification and analysis of validated instruments.

BACKGROUND: Women's childbirth experience can have immediate as well as long-term positive or negative effects on their life, well-being and health. When evaluating and drawing conclusions from research results, women's experiences of childbirth should be one aspect to consider. Researchers and clinicians need help in finding and selecting the most suitable instrument for their purpose. The aim of this study was therefore to systematically identify and present validated instruments measuring women's childbirth experience. METHODS: A systematic review was conducted in January 2016 with a comprehensive search in the bibliographic databases PubMed, CINAHL, Scopus, The Cochrane Library and PsycINFO. Included instruments measured women's childbirth experiences. Papers were assessed independently by two reviewers for inclusion, and quality assessment of included instruments was made by two reviewers independently and in pairs using Terwee et al's criteria for evaluation of psychometric properties. RESULTS: In total 5189 citations were screened, of which 5106 were excluded by title and abstract. Eighty-three full-text papers were reviewed, and 37 papers were excluded, resulting in 46 included papers representing 36 instruments. These instruments demonstrated a wide range in purpose and content as well as in the quality of psychometric properties. CONCLUSIONS: This systematic review provides an overview of existing instruments measuring women's childbirth experiences and can support researchers to identify appropriate instruments to be used, and maybe adapted, in their specific contexts and research purpose.

Associations between perceptions of care and women's childbirth experience: a population-based cross-sectional study in Rwanda.

BACKGROUND: In recent years Rwanda has achieved remarkable improvement in quality of maternity care services but there is evidence of deficiencies in care quality in terms of disrespectful care. Women's overall childbirth experience is an important outcome of childbirth and a factor in assessing quality of care. The aim of this study was to investigate how women's overall childbirth experience in Rwanda was related to their perceptions of childbirth care. METHODS: A cross-sectional household study of women who had given birth 1-13 months earlier (n = 921) was performed in the Northern Province and in the capital city. Data was collected via structured interviews following a questionnaire. Significant variables measuring perceptions of care were included in a stepwise forward selection logistic regression model with overall childbirth experience as a dichotomised target variable to find independent predictors of a good childbirth experience. RESULTS: The majority of women (77.5%) reported a good overall childbirth experience. In a logistic regression model five factors of perceived care were significant independent predictors of a good experience: confidence in staff (Adjusted OR 1.73, 95% CI 1.20-2.49), receiving enough information (AOR 1.44, 95% CI 1.03-2.00), being treated with respect (AOR 1.69, 95% CI 1.18-2.43), getting support from staff (AOR 1.75, 95% CI 1.20-2.56), and having the baby skin-to-skin after birth (AOR 2.21, 95% CI 1.52-3.19). CONCLUSIONS: To further improve childbirth care in Rwanda and care for women according to their preferences, it is important to make sure that the childbirth care includes the following quality aspects in national and clinical guidelines: build confidence, provide good information, treat women and families with respect, provide good professional support during childbirth and put the newborn baby skin-to-skin with its mother early after birth.

A Holistic, Person-Centred Care Model for Victims of Sexual Violence in Democratic Republic of Congo: The Panzi Hospital One-Stop Centre Model of Care.

Denis Mukwege and Marie Berg describe the One Stop Centre at Panzi Hospital in Eastern Democratic Republic of Congo that provides care for girls and women who have been raped in combination with extreme bodily harm.

Prophylactic barbiturate use for the prevention of morbidity and mortality following perinatal asphyxia.

BACKGROUND: Seizures are common following perinatal asphyxia and may exacerbate secondary neuronal injury. Barbiturate therapy has been used for infants with perinatal asphyxia in order to prevent seizures. However, barbiturate therapy may adversely affect neurodevelopment leading to concern regarding aggressive use in neonates. OBJECTIVES: To determine the effect of administering prophylactic barbiturate therapy on death or neurodevelopmental disability in term and late preterm infants following perinatal asphyxia. SEARCH METHODS: We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 11), MEDLINE via PubMed (1966 to 30 November 2015), EMBASE (1980 to 30 November 2015), and CINAHL (1982 to 30 November 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials (RCT) and quasi-RCTs. SELECTION CRITERIA: We included all RCTs or quasi-RCTs of prophylactic barbiturate therapy in term and late preterm infants without clinical or electroencephalographic evidence of seizures compared to controls following perinatal asphyxia. DATA COLLECTION AND ANALYSIS: Three review authors independently selected, assessed the quality of, and extracted data from the included studies. We assessed methodologic quality and validity of studies without consideration of the results. The review authors independently extracted data and performed meta-analyses using risk ratios (RR) and risk differences (RD) for dichotomous data and mean difference for continuous data with 95% confidence intervals (CI). For significant results, we calculated the number needed to treat for an additional beneficial outcome (NNTB) or for an additional harmful outcome (NNTH). MAIN RESULTS: In this updated review, we identified nine RCTs of any barbiturate therapy in term and late preterm infants aged less than three days old with perinatal asphyxia without evidence of seizures. Eight of these studies compared prophylactic barbiturate therapy to conventional treatment (enrolling 439 infants) and one study compared barbiturate therapy to treatment with phenytoin (enrolling 17 infants). Prophylactic barbiturate therapy versus conventional treatment: one small trial reported a decreased risk of death or severe neurodevelopmental disability for barbiturate therapy (phenobarbital) versus conventional treatment (RR 0.33, 95% CI 0.14 to 0.78; RD -0.55, 95% CI -0.84 to -0.25; NNTB 2, 95% CI 1 to 4; 1 study, 31 infants) (very low quality evidence).Eight trials comparing prophylactic barbiturate therapy with conventional treatment following perinatal asphyxia demonstrated no significant impact on the risk of death (typical RR 0.88, 95% CI 0.55 to 1.42; typical RD -0.02, 95% CI -0.08 to 0.05; 8 trials, 429 infants) (low quality evidence) and the one small trial noted above reported a significant decrease in the risk of severe neurodevelopmental disability (RR 0.24, 95% CI 0.06 to 0.92; RD -0.43, 95% CI -0.73 to -0.13; NNTB 2, 95% CI 1 to 8; 1 study, 31 infants) (very low quality evidence).A meta-analysis of the six trials reporting on seizures in the neonatal period demonstrated a statistically significant reduction in seizures in the prophylactic barbiturate group versus conventional treatment (typical RR 0.62, 95% CI 0.48 to 0.81; typical RD -0.18, 95% CI -0.27 to -0.09; NNTB 5, 95% CI 4 to 11; 6 studies, 319 infants) (low quality evidence). There were similar results in subgroup analyses based on type of barbiturate and Sarnat score. Prophylactic barbiturate therapy versus other prophylactic anticonvulsant therapy: one study reported on prophylactic barbiturate versus prophylactic phenytoin. There was no significant difference in seizure activity in the neonatal period between the two study groups (RR 0.89, 95% CI 0.07 to 12.00; 1 trial, 17 infants). AUTHORS' CONCLUSIONS: We found only low or very low quality evidence addressing the use of prophylactic barbiturates in infants with perinatal asphyxia. Although the administration of prophylactic barbiturate therapy to infants following perinatal asphyxia did reduce the risk of seizures, there was no reduction seen in mortality and there were few data addressing long-term outcomes. The administration of prophylactic barbiturate therapy for late preterm and term infants in the immediate period following perinatal asphyxia cannot be recommended for routine clinical practice. If used at all, barbiturates should be reserved for the treatment of seizures. The results of the current review support the use of prophylactic barbiturate therapy as a promising area of research. Future studies should be of sufficient size and duration to detect clinically important reductions in mortality and severe neurodevelopmental disability and should be conducted in the context of the current standard of care, including the use of therapeutic hypothermia.

Bipolar disorder in pregnancy and childbirth: a systematic review of outcomes.

BACKGROUND: Bipolar Disorder (BD) is a mental disorder usually diagnosed between 18 and 30 years of age; this coincides with the period when many women experience pregnancy and childbirth. As specific problems have been reported in pregnancy and childbirth when the mother has BD, a systematic review was carried out to summarise the outcomes of pregnancy and childbirth, in mother and child, when the mother has BD diagnosed before pregnancy. METHODS: An a priori protocol was designed and a systematic search conducted in PubMed, CINAHL, Scopus, PsycINFO and Cochrane databases in March 2015. Studies of all designs were included if they involved women with a diagnosis of bipolar disorder prior to pregnancy, who were pregnant and/or followed up to one year postpartum. All stages of inclusion, quality assessment and data extraction were done by two people. All maternal or infant outcomes were examined, and narrative synthesis was used for most outcomes. Meta-analysis was used to achieve a combined prevalence for some outcomes and, where possible, case and control groups were combined and compared. RESULTS: The search identified 2809 papers. After screening and quality assessement (using the EPHPP and AMSTAR tools), nine papers were included. Adverse pregnancy outcomes such as gestational hypertension and antepartum haemorrhage occur more frequently in women with BD. They also have increased rates of induction of labour and caesarean section, and have an increased risk of mood disorders in the postnatal period. Women with BD are more likely to have babies that are severely small for gestational age (<2nd-3rd percentile), and it appears that those women not being treated with mood stabilisers in pregnancy might not have an increased risk of having a baby with congenital abnormalities. DISCUSSION: Due to heterogeneity of data, particularly the use of differing definitions of bipolar disorder, narrative synthesis was used for most outcomes, rather than a meta-analysis. CONCLUSIONS: It is evident that adverse outcomes are more common in women with BD and their babies. Large cohort studies examining fetal abnormality outcomes for women with BD who are not on mood stabilisers in pregnancy are required, as are studies on maternal-infant interaction.

Experiences of health care in women with Peripartum Cardiomyopathy in Sweden: a qualitative interview study.

BACKGROUND: Peripartum cardiomyopathy is often associated with severe heart failure occurring towards the end of pregnancy or in the months following birth with debilitating, exhausting and frightening symptoms requiring person-centered care. The aim of this study was to explore women's experiences of health care while being diagnosed with peripartum cardiomyopathy. METHOD: Qualitative interviews were conducted with 19 women with peripartum cardiomyopathy in Sweden, following consent. Data were analysed using qualitative content analysis. Confirmability was ensured by peer-debriefing, and an audit trail was kept to establish the credibility of the study. RESULTS: The main theme in the experience of health care was, 'Exacerbated Suffering', expressed in three subthemes; 'not being cared about', 'not being cared for' and 'not feeling secure.' The suffering was present in relation to the illness with failing health symptoms, but most of all in relation to not being taken seriously and adequately cared for by healthcare professionals. Women felt they were on an assembly line in midwives' routine work where knowledge about peripartum cardiomyopathy was lacking and they showed distrust and dissatisfaction with care related to negligence and indifference experienced from healthcare professionals. Feelings of being alone and lost were prominent and related to a sense of insecurity, distress and uneasiness. CONCLUSIONS: This study shows a knowledge gap of peripartum cardiomyopathy in maternity care personnel. This is alarming as the deprecation of symptoms and missed diagnosis of peripartum cardiomyopathy can lead to life-threatening consequences. To prompt timely diagnosis and avoid unnecessary suffering it is important to listen seriously to, and respect, women's narratives and act on expressions of symptoms of peripartum cardiomyopathy, even those overlapping normal pregnancy symptoms.

Adopting a healthy lifestyle when pregnant and obese - an interview study three years after childbirth.

BACKGROUND: Obesity during pregnancy is increasing and is related to life-threatening and ill-health conditions in both mother and child. Initiating and maintaining a healthy lifestyle when pregnant with body mass index (BMI) ≥ 30 kg/m(2) can improve health and decrease risks during pregnancy and of long-term illness for the mother and the child. To minimise gestational weight gain women with BMI ≥ 30 kg/m(2) in early pregnancy were invited to a lifestyle intervention including advice and support on diet and physical activity in Gothenburg, Sweden. The aim of this study was to explore the experiences of women with BMI ≥ 30 kg/m(2) regarding minimising their gestational weight gain, and to assess how health professionals' care approaches are reflected in the women's narratives. METHODS: Semi-structured interviews were conducted with 17 women who had participated in a lifestyle intervention for women with BMI ≥ 30 kg/m(2) during pregnancy 3 years earlier. The interviews were digitally recorded and transcribed in full. Thematic analysis was used. RESULTS: The meaning of changing lifestyle for minimising weight gain and of the professional's care approaches is described in four themes: the child as the main motivation for making healthy changes; a need to be seen and supported on own terms to establish healthy routines; being able to manage healthy activities and own weight; and need for additional support to maintain a healthy lifestyle. CONCLUSIONS: To support women with BMI ≥ 30 kg/m(2) to make healthy lifestyle changes and limit weight gain during pregnancy antenatal health care providers should 1) address women's weight in a non-judgmental way using BMI, and provide accurate and appropriate information about the benefits of limited gestational weight gain; 2) support the woman on her own terms in a collaborative relationship with the midwife; 3) work in partnership to give the woman the tools to self-manage healthy activities and 4) give continued personal support and monitoring to maintain healthy eating and regular physical activity habits after childbirth involving also the partner and family.