Women's views on moderate and low alcohol consumption: stages of the subjective transition from pregnancy to postpartum.

BACKGROUND: Alcohol consumption during pregnancy and breastfeeding is associated with a risk for the child's healthy development. Nevertheless, about 16 to 25% of all women in the European region, including Switzerland, consume alcohol during pregnancy and probably even more during breastfeeding. Little is known about how women perceive this risk and how risk perception changes during the transition to motherhood. The present study aims to explore the subjective transition from the woman's perspective, focusing on perceptions of alcohol as a risk, changes in alcohol consumption in daily life and experienced support from health professionals in this period. METHODS: The longitudinal qualitative, semi-structured interview study was jointly designed and conducted by health sociologists and midwifery researchers. Using the theoretical framework of sociocultural risk and life course transition, we interviewed 46 women from the French and German speaking part of Switzerland during pregnancy and until six months after birth. RESULTS: In our study, we found that pregnant and breastfeeding women perceive alcohol consumption as a risk to the health of the child. Abstinence is sought especially during pregnancy, but this does not preclude occasional and low-level consumption according to some women. Alcohol consumption and risk perception change during the transition to motherhood. We identified five stages that characterise this transition in terms of alcohol consumption and risk perception. From the women's perspective, there was a lack of counselling from health professionals, and the women expressed a desire for respectful and more individualised counselling. CONCLUSION: Many women express a need for guidance and counselling by health care professionals at some stages of the transition to motherhood. The stages identified can be used as pointers to address the subject of alcohol consumption in professional practice. The stage around conception and early pregnancy should be taken more into account, as women experience themselves as particularly vulnerable during this time. Low-threshold counselling services should be therefore offered to women before or in the stage around conception and be continued until the end of the breastfeeding period.

French-speaking Africa and translation: From midwifery to maïeutique?

INTRODUCTION: In the French version of The Lancet Series (2014) midwifery has been translated as maïeutique. Likewise, the term maïeuticien has recently been introduced in some countries to name (male) midwives. This change of terminology has not been the subject of broad stakeholder consultation. The aim of this study is to explore the opinion of African midwives on the use of the terminologies pratique de sage-femme/maïeutique (midwifery) and sage-femme/maïeuticien (midwife). METHODS: A quantitative study was conducted using an online survey among members of francophone professional midwifery associations in 17 French-speaking African countries. RESULTS: From 140 invited midwives, 82 responses were received. The respondents represented 12 francophone African countries. Respondents obviously prefer the terms pratique de sage-femme and sage-femme above maïeutique and maïeuticien. The sage-femme is acknowledged and deeply rooted in African society. Midwifery is comprehensive, while maïeutique does not describe the full scope of midwifery. Though, some respondents believe that maïeutique has the potential to differentiate sages-femmes from other health professionals, can diminishing role ambiguity, and value midwifery practice. Respondents in favor of the term maïeutique are referring to the modernization of the midwifery profession and its scientific evolution. CONCLUSIONS: Internationally, midwives closely follow the developments on the linguistic subject of maïeutique. The results of this study may support current discussion about the evolution and modernization of terminology in the francophone community worldwide. Midwives need to be actively involved in these discussions. Nevertheless, at all times we need to be cautious not to break away from midwives' cherished historical, social, and cultural roots.

Giving birth: A hermeneutic study of the expectations and experiences of healthy primigravid women in Switzerland.

Switzerland experiences one of the highest caesarean section rates in Europe but it is unclear why and when the decision is made to perform a caesarean section. Many studies have examined from a medical and physiological point of view, but research from a women's standpoint is lacking. Our aim was to develop a model of the emerging expectations of giving birth and the subsequent experiences of healthy primigravid women, across four cantons in Switzerland. This longitudinal study included 30 primigravidae from the German speaking, 14 from the French speaking and 14 from the Italian speaking cantons who were purposively selected. Data were collected by semi-structured interviews taking place around 22 and 36 weeks of pregnancy and six weeks and six months postnatally. Following Gadamer's hermeneutic, which in this study comprised 5 stages, a model was developed. Four major themes emerged: Decisions, Care, Influences and Emotions. Their meandering paths and evolution demonstrate the complexity of the expectations and experiences of women becoming mothers. In this study, women's narrated mode of birth expectations did not foretell how they gave birth and their lived experiences. A hermeneutic discontinuity arises at the 6 week postnatal interview mark. This temporary gap illustrates the bridge between women's expectations of birth and their actual lived experiences, highlighting the importance of informed consent, parent education and ensuring women have a positive birth and immediate postnatal experiences. Other factors than women's preferences should be considered to explain the increasing caesarean section rates.

Pregnancy as a transition: First-time expectant couples' experience with alcohol consumption.

INTRODUCTION AND AIMS: Most official healthcare guidelines apply the precautionary principle by recommending that pregnant women abstain from any alcohol consumption. However, a number of women continue drinking alcohol while pregnant. The aim of this study was to investigate couples' experiences of the issue of alcohol consumption during pregnancy as a transitional process. DESIGN AND METHODS: Thirty semi-directive joint interviews were conducted with couples expecting their first child in Switzerland. Interviews were analysed thematically with the help of ATLAS.ti. RESULTS: Couples endorsed the imperative of changing drinking habits and all the women reduced their alcohol consumption, although some reported difficulties. First, we identified three themes describing how couples experienced the woman's change of drinking habits as a smooth transition: Internalisation of risk discourses, abstinence as a social norm and embodiment of alcohol aversion. Second, we emphasised four kinds of difficulties that couples encountered in their everyday lives: burden of risk discourses, conflicting advice, social occasions and desire for alcohol. DISCUSSION AND CONCLUSIONS: This paper makes a significant contribution by examining prenatal drinking change as a transition. In this conceptualisation, the change of alcohol consumption is a relational process that is shaped by multiple changes and social norms. Our findings have important implications for practice. First, health professionals should be aware of the difficulties women experience when they abstain from alcohol during pregnancy. Second, our findings suggest the importance of a patient-centred approach that considers the role of the partner in supporting a pregnant woman's change of alcohol consumption.

Integrative power in Swiss home-like childbirths: A qualitative multiple case study.

OBJECTIVE: To increase understanding of integrative power in decision-making in home-like childbirth from midwives' and women's perspectives. DESIGN: A qualitative multiple case study. SETTING: Two regions of Switzerland, a French and a German-speaking. PARTICIPANTS: Twenty interviews with midwives and 20 with women and some partners who had experienced complications in home-like births. METHODS: Data were collected from in-depth interviews relevant for casestudy. Four cases during second stage of labour were carefully selected using literal replication logic. Interview transcripts were analysed in developing case descriptions and in interpreting mechanisms related to perception of power in making decision. FINDINGS: The analysis of each case and a cross-case comparison showed that mechanisms for building integrative power, such as creation of relationships, cooperation, loyalty, legitimacy and respect, were highly visible in midwifery decision-making activities. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The study highlighted the visibility of integrative power mechanisms in decision-making in homelike settings. Until now, mechanisms of positive power in midwifery have been poorly described in literature. Integrative power could be a promising strategy to reinforce decision-making strategies. Therefore, clinical and policy measures explicitly addressing the positive aspects of power should be developed and evaluated.

Decision-making in Swiss home-like childbirth: A grounded theory study.

BACKGROUND: Decision-making in midwifery, including a claim for shared decision-making between midwives and women, is of major significance for the health of mother and child. Midwives have little information about how to share decision-making responsibilities with women, especially when complications arise during birth. AIM: To increase understanding of decision-making in complex home-like birth settings by exploring midwives' and women's perspectives and to develop a dynamic model integrating participatory processes for making shared decisions. METHODS: The study, based on grounded theory methodology, analysed 20 interviews of midwives and 20 women who had experienced complications in home-like births. FINDINGS: The central phenomenon that arose from the data was "defining/redefining decision as a joint commitment to healthy childbirth". The sub-indicators that make up this phenomenon were safety, responsibility, mutual and personal commitments. These sub-indicators were also identified to influence temporal conditions of decision-making and to apply different strategies for shared decision-making. Women adopted strategies such as delegating a decision, making the midwife's decision her own, challenging a decision or taking a decision driven by the dynamics of childbirth. Midwives employed strategies such as remaining indecisive, approving a woman's decision, making an informed decision or taking the necessary decision. DISCUSSION AND CONCLUSION: To respond to recommendations for shared responsibility for care, midwives need to strengthen their shared decision-making skills. The visual model of decision-making in childbirth derived from the data provides a framework for transferring clinical reasoning into practice.

Giving birth: Expectations of first time mothers in Switzerland at the mid point of pregnancy.

PROBLEM AND BACKGROUND: Despite a generally affluent society, the caesarean section rate in Switzerland has steadily climbed in recent years from 22.9% in 1998 to 33.7% in 2014. Speculation by the media has prompted political questions as to the reasons. However, there is no clear evidence as to why the Swiss rate should be so high especially in comparison with neighbouring countries. AIM: To describe the emerging expectations of giving birth of healthy primigravid women in the early second semester of pregnancy in four Swiss cantons. METHODS: Qualitative individual interviews with 58 healthy primigravid women, were audio recorded, transcribed and subjected to thematic analysis. Recruitment took place through public and private hospitals, birth centres, obstetricians and independent midwives. The main ethical issues were informed consent, autonomy, confidentiality and anonymity. FINDINGS: The three main themes identified were taking or avoiding decisions, experiencing a continuum of emotions and planning the care. DISCUSSION: Being pregnant was part of a project women had mapped out for their lives. Only three women in our sample expressed a wish for a caesarean section. One of the strongest emotions was that of fear but in contrast some participants expressed faith that their bodies would cope with the experience. CONCLUSION: Bringing together the three languages and cultures produced a truly "Swiss" study showing contrasts between a matter of fact approach to pregnancy and the concept of fear. Such a contrast is worthy of further and deeper exploration by a multi-disciplinary research team.

Risk perception by healthcare professionals related to drug use during pregnancy: a Swiss survey.

PRINCIPLE: Healthcare professionals' (HCPs') perception of risk associated with drug use in pregnancy may have an impact on the pharmacological treatment of some women. The aim of this study was to examine this risk perception in a sample of Swiss HCPs with a special focus on their knowledge and use of available specialised information sources. METHOD: An online, French and German, questionnaire was e-mailed to 7,136 members of four Swiss professional societies (gynaecologists, paediatricians, midwives and pharmacists). The questionnaire was designed (a) to collect demographic characteristics, (b) to evaluate the frequency of use of several specialised sources of information on drugs in pregnancy in their daily practice, and (c) to examine the perception of risk associated with drug use during pregnancy. RESULTS: A total of 1,310 questionnaires were collected (response rate of 18.4%). More than 80% of the respondent HCPs use the Swiss Drug Reference Book (Compendium) to assess the risk associated with drugs during pregnancy and are not aware of available specialised information sources (books, websites or information centres). Despite some disparities between HPCs, the risk related to drug intake was overall highly misperceived. Blinded reading of three product monographs in the Compendium was associated with an overestimated perception of risk (e.g., after reading the "paracetamol" monograph, 38% of the participants stated they would probably not advise the use of this drug to a pregnant patient). CONCLUSION: Overall, an overestimation of the risk associated with drug use during pregnancy has been observed in our sample of HCPs, which might be related to the underuse of specialised information source among other factors. These findings evidenced the need for increased training for HCPs in order to optimise medication use during pregnancy. Further studies are needed to confirm these results and identify causes.

Epidermal expression of neuropilin 1 protects murine keratinocytes from UVB-induced apoptosis.

BACKGROUND: Neuropilin 1 (NRP1) is expressed on several cell types including neurons and endothelial cells, where it functions as an important regulator in development and during angiogenesis. As a cell surface receptor, NRP1 is able to bind to members of the VEGF family of growth factors and to secreted class 3 semaphorins. Neuropilin 1 is also highly expressed in keratinocytes, but the function of NRP1 in epidermal physiology and pathology is still unclear. METHODS AND RESULTS: To elucidate the role of NRP1 in skin in vivo we generated an epidermis-specific neuropilin 1 knock out mouse model by using the Cre-LoxP-System. Mice were viable and fertile and did not display any obvious skin or hair defects. After challenge with UVB irradiation, we found that deletion of epidermal NRP1 leads to increased rates of apoptosis both in vitro and in vivo. NRP1-deficient primary keratinocytes cultured in vitro showed significantly higher rates of apoptosis 24 hours after UVB. Likewise, there is a significant increase of active caspase 3 positive cells in the epidermis of Keratin 14-Cre-NRP1 (-/-) mice 24 hours after UVB irradiation. By Western Blot analysis we could show that NRP1 influences the cytosolic levels of Bcl-2, a pro-survival member of the Bcl-2 family. After UVB irradiation the amounts of Bcl-2 decrease in both protein extracts from murine epidermis and in NRP1-deficient keratinocytes in vitro, whereas wild type cells retain their Bcl-2 levels. Likewise, levels of phospho-Erk and Rac1 were lower in NRP1-knock out keratinocytes, whereas levels of pro-apoptotic p53 were higher. CONCLUSION: NRP1 expression in keratinocytes is dispensable for normal skin development. Upon UVB challenge, NRP1 contributes to the prevention of keratinocyte apoptosis. This pro-survival function of NRP1 is accompanied by the maintenance of high levels of the antiapoptotic regulator Bcl-2 and by lower levels of pro-apoptotic p53.

[Clinical forensic examination findings and legal outcome in cases of suspected physical child abuse]. / Klinisch-forensische Untersuchungsergebnisse und rechtliche Folgen bei körperlicher Kindesmisshandlung.

Clinical forensic examinations performed at the Institute of Legal Medicine of the Hanover Medical School between 1999 and 2008 in cases of suspected physical abuse of children were analyzed retrospectively with special emphasis on the legal consequences. Altogether, 192 children (85 girls, 107 boys) with a median age of 4.4 years were examined. In 47 cases (24.5 %), the clinical forensic examination findings were interpreted as accidental injuries, birth traumas or unspecific findings. 29 victims (20.0 %) had suffered a shaken baby syndrome. Only part of the presented cases ended with conviction, which was more likely if the victims were aged between 7 and 11 years. Prison terms of 2 years and more were imposed only if the child suffered potentially or acute life-threatening injuries or if additional anogenital lesions were diagnosed indicating sexual child abuse.

Dendritic cell vaccination with xenogenic polypeptide hormone induces tumor rejection in neuroendocrine cancer.

PURPOSE: No relevant breakthrough has yet been achieved in the identification of tumor antigens in many neuroendocrine cancer types that exist, such as malignant gastrinoma, insulinoma, or medullary thyroid carcinoma. The aim of this study was to proof the concept of dendritic cell immunization with a tumor cell-specific polypeptide hormone as a target molecule in a transgenic mouse model for medullary thyroid carcinoma (Ret/Cal mice). EXPERIMENTAL DESIGN: Ret/Cal mice were repeatedly immunized for up to 6 months with amino acid-modified (xenogenic) calcitonin-pulsed dendritic cells. Xenogenic calcitonin was chosen for immunization due to its higher immunogenicity as compared with murine calcitonin. RESULTS: Lymph nodes from control protein-immunized mice did not show any macroscopic abnormalities, whereas tumor peptide-treated mice revealed in general profoundly enlarged lymph nodes. In tetramer analysis of paratumorous lymph nodes, 1.9% to 3.1% of all infiltrating CD8(+) T cells were specific for one of three tumor epitopes tested. Analysis of the activated IFN-gamma-secreting component in splenic cells revealed an average of 2.8% tumor epitope-specific CD8(+) cells. Immunohistochemistry revealed strong CD8(+) tumor infiltration in calcitonin-vaccinated mice. In addition, these cells also showed strong in vitro lysis capacity at up to 63.3%. Most importantly, calcitonin-immunized mice revealed largely diminished tumor outgrowth (-74.3%) compared with control mice (P < 0.0001). Likewise, serum calcitonin levels in calcitonin-vaccinated Ret/Cal mice were lower than in the control group. CONCLUSION: These results have a major effect, as they are the first to establish a role for xenogenic polypeptide hormones as target molecules for immunotherapy in endocrine malignancies.

Amino acid-modified calcitonin immunization induces tumor epitope-specific immunity in a transgenic mouse model for medullary thyroid carcinoma.

Up to now, no relevant tumor antigen has been identified in medullary thyroid carcinoma (MTC). The aim of the present study was to prove the concept of an immunization with an amino acid-modified calcitonin (CT) for the treatment of MTC in a transgenic mouse model. Amino acid-modified (human) CT has been chosen for vaccination because of its higher binding affinity to the murine H2-Kb-MHC molecule. Mice were immunized over 6 months with monthly injections of amino acid-modified CT-pulsed dendritic cells. For enumeration of tumor epitope-specific CD8+ cytotoxic T cells, tetramer analyses were performed. CT peptide-treated mice revealed a mean 0.73 +/- 0.45 and 0.91 +/- 0.59% positive cells, depending on the two tetramers tested, whereas no increase was seen in control protein-immunized mice (0.08-0.12% tetramer-positive cells). Importantly, the subset of CT-specific CD8+ T cells also showed a high expression of interferon-gamma. In line with these results, CT-immunized mice also showed an intratumor infiltration with CD8+ T lymphocytes. Importantly, we also found a diminished tumor outgrowth of -57% and a decrease of the serum CT levels (2.0 +/- 0.1 pg/ml) compared with control protein-immunized Ret/Cal mice (3.0 +/- 0.4 pg/ml). In summary, we show that amino acid-modified CT is recognized from the immune system leading to a specific antitumor immune response and a diminished tumor outgrowth in transgenic MTC mice. The results are of potential importance because they might be applicable to patients with metastatic spread of a MTC.

Functional and genetic analysis of coronavirus replicase-transcriptase proteins.

The coronavirus replicase-transcriptase complex is an assembly of viral and cellular proteins that mediate the synthesis of genome and subgenome-sized mRNAs in the virus-infected cell. Here, we report a genetic and functional analysis of 19 temperature-sensitive (ts) mutants of Murine hepatitis virus MHV-A59 that are unable to synthesize viral RNA when the infection is initiated and maintained at the non-permissive temperature. Both classical and biochemical complementation analysis leads us to predict that the majority of MHV-A59 ORF1a replicase gene products (non-structural proteins nsp1-nsp11) form a single complementation group (cistron1) while the replicase gene products encoded in ORF1b (non-structural proteins nsp12-nsp16) are able to function in trans and comprise at least three, and possibly five, further complementation groups (cistrons II-VI). Also, we have identified mutations in the non-structural proteins nsp 4, nsp5, nsp10, nsp12, nsp14, and nsp16 that are responsible for the ts phenotype of eight MHV-A59 mutants, which allows us to conclude that these proteins are essential for the assembly of a functional replicase-transcriptase complex. Finally, our analysis of viral RNA synthesis in ts mutant virus-infected cells allows us to discriminate three phenotypes with regard to the inability of specific mutants to synthesize viral RNA at the non-permissive temperature. Mutant LA ts6 appeared to be defective in continuing negative-strand synthesis, mutant Alb ts16 appeared to form negative strands but these were not utilized for positive-strand RNA synthesis, and mutant Alb ts22 was defective in the elongation of both positive- and negative-strand RNA. On the basis of these results, we propose a model that describes a pathway for viral RNA synthesis in MHV-A59-infected cells. Further biochemical analysis of these mutants should allow us to identify intermediates in this pathway and elucidate the precise function(s) of the viral replicase proteins involved.