Examining the Intrapersonal, Interpersonal and Community Level Correlates of Access to Medical Care Among Women Employed by Sex Work in Southern Uganda: A cross-sectional Analysis of the Kyaterekera Study.

Women employed by sex work (WESW) experience significant gaps in accessing necessary healthcare services, leading to unmet health needs. Yet, there is a dearth of literature on the barriers to medical care access among WESW in Uganda. We used data from the Kyaterekera baseline to examine the correlates of access to medical care among WESW, defined as the ability of individuals to obtain the necessary healthcare services they require in a timely, affordable, and equitable manner. The Kyaterekera study recruited 542 WESW aged 18-58 years from Southern Uganda. We conducted a multilevel linear regression model to determine the intrapersonal (age, education level, marital status, HIV knowledge, and asset ownership), interpersonal (family cohesion and domestic violence attitudes), and community (community satisfaction, sex work stigma and distance to health facility) level correlates of access to medical care among WESW. Intrapersonal and interpersonal factors were associated with access to medical care among WESW. There was no significant association between community level factors and access to medical care. WESW with secondary education (ß = 0.928, 95% CI = 0.007, 1.849) were associated with increased access to medical care. WESW with high asset ownership (ß = -1.154, 95% CI= -1.903, -0.405), high family cohesion (ß = -0.069, 95% CI= -0.106, -0.031), and high domestic violence attitudes (ß = -0.253, 95% CI= -0.438, -0.068) were associated with decreased access to medical care. The findings emphasize the critical need for targeted family strengthening interventions to enhance family support for WESW and address domestic violence.

What may encourage or deter health services utilization by people living with or at the risk of HIV/AIDS in special health centers? Qualitative evidence from a stigmatized community.

BACKGROUND: Behavioral Diseases Counseling Centers (BDCCs) and Vulnerable Women's Counseling Centers (VWCCs) in Iran are the main peripheral centers that offer educational, counseling, diagnostic, preventive, curative and protective services to individuals living with or at high risk of contracting HIV/AIDS and female sex workers respectively. Due to the social stigma surrounding HIV in Iran, this study aims to identify the factors that may hinder or encourage HIV/AIDS patients and women with risky sexual behaviors from visiting these centers. METHODS: Conducted in 2023, this qualitative study involved individuals visiting BDCCs and VWCCs in two western provinces of Iran, Ilam and Kermanshah. The study participants included 21 health staff members working in BDCCs and VWCCs and 20 HIV/AIDS patients and vulnerable women with unsafe sexual behaviors referring to these centers. Purposive, snowball and maximum variation sampling techniques were applied to interview the participants. Interviews were conducted between January 5th and May 21st, 2023, using a semi-structure guideline. Interviews were transcribed and content analysis approach was applied to analyze data using MAXQDA20 software. RESULTS: According to the findings, the barriers and facilitators of visiting specialized centers for HIV/AIDS patients and vulnerable women were categorized into three main categories, 10 subcategories and 35 sub-subcategories including: Medical and operational processes (4 subcategories and 12 sub-subcategories), mutual interactions between the personnel and visitors (people living with and at the risk of getting HIV/AIDS) (3 subcategory and 13 sub-subcategories), and physical characteristics of the centers (3 subcategories and 10 sub-subcategories). CONCLUSIONS: To improve the performance of BDCCs and VWCCs and encourage people living with and at the risk of contracting HIV/AIDS to visit these centers regularly, health policy makers should consider modifying clinical processes, physical features, personnel behaviors and visitors' concerns raised by the interviewees and the issues identified in this study.

Development and pilot implementation of a novel protocol to assess capacity and readiness of health systems to adopt HPV detection-based cervical cancer screening in Europe.

BACKGROUND: Cervical cancer remains a significant public health concern in Europe. Effective introduction and scaling up of human papillomavirus (HPV) detection-based cervical cancer screening (CCS) requires a systematic assessment of health systems capacity. However, there is no validated capacity assessment methodology for CCS programmes, especially in European contexts. Addressing this gap, our study introduces an innovative and adaptable protocol for evaluating the capacity of CCS programmes across varying European health system settings. METHODS: Our research team developed a three-step capacity assessment framework, incorporating a health policy review checklist, a facility visit survey, and key informants' interview guide followed by a strengths, weaknesses, opportunities and threats (SWOT) analysis. Piloting this comprehensive approach, we explored the CCS capacity in three countries: Estonia, Portugal and Romania. These countries were selected due to their contrasting healthcare structures and resources, providing a diverse overview of the European context. RESULTS: Conducted over a period of 9 months, the capacity assessment covered multiple resources, 27 screening centres, 16 colposcopy and treatment centres and 15 key informant interviews. Our analysis highlighted both shared and country-specific challenges. A key common issue was ensuring high compliance to follow-up and management of screen-positive women. We identified considerable heterogeneity in resources and organization across the three countries, underscoring the need for tailored, rather than one-size-fits-all, solutions. CONCLUSIONS: Our study's novelty lies in the successful development of this capacity assessment methodology implementable within a relatively short time frame, proving its feasibility for use in various contexts and countries. The resulting set of materials, adaptable to different cancer types, is a ready-to-use toolkit to improve cancer screening processes and outcomes. This research marks a significant stride towards comprehensive capacity assessment for CCS programmes in Europe. Future directions include deploying these tools in other countries and cancer types, thereby contributing to the global fight against cancer.

Household food insecurity is prevalent in a cohort of postpartum women who registered in the Canada Prenatal Nutrition Program in Toronto.

OBJECTIVE: To assess the prevalence, severity and socio-demographic predictors of household food insecurity among vulnerable women accessing the Canada Prenatal Nutrition Program (CPNP) and to examine associations between household food insecurity and breastfeeding practices to 6 months. DESIGN: Cohort investigation pooling data from two studies which administered the 18-item Household Food Security Survey Module at 6 months postpartum and collected prospective infant feeding data at 2 weeks and 2, 4 and 6 months. Household food insecurity was classified as none, marginal, moderate or severe. Logistic regression analyses were performed to assess predictors of household food insecurity and associations between household food security (any and severity) and continued and exclusive breastfeeding. SETTING: Three Toronto sites of the CPNP, a federal initiative targeting socially and/or economically vulnerable women. PARTICIPANTS: 316 birth mothers registered prenatally in the CPNP from 2017 to 2020. RESULTS: Household food insecurity at 6 months postpartum was highly prevalent (44 %), including 11 % in the severe category. Risk of household food insecurity varied by CPNP site (P < 0·001) and was higher among multiparous participants (OR 2·08; 95 % CI 1·28, 3·39). There was no association between the prevalence or severity of food insecurity and continued or exclusive breastfeeding to 6 months postpartum in the adjusted analyses. CONCLUSIONS: Household food insecurity affected nearly half of this cohort of women accessing the CPNP. Further research is needed on household food insecurity across the national CPNP and other similar programmes, with consideration of the implications for programme design, service delivery and policy responses.

Using mindfulness-based stress reduction group therapy to reduce perceived stress of vulnerable women in south of Iran.

Provision of educational and health services to vulnerable women in drop-in centers can reduce their traumas. Mindfulness-Based Stress Reduction (MBSR) group therapy is a psychological intervention to reduce perceived stress these women. This quasi-experimental study aimed to evaluate the effectiveness of MBSR group therapy in the perceived stress of 63 vulnerable women who referred to two drop-in centers in southeastern Iran. The participants were assigned into the intervention (n = 30) and control (n = 33) groups. The intervention group members were required to attend the MBSR intervention held in eight 90-minute sessions. Perceived Stress Scale (PSS) was administered to collect data before and one month after the MBSR. Based on the findings, the pre-test scores of perceived stress were not significantly different between the intervention (38.16 ± 6.04) and control (39.06 ± 5.30) groups (t = -0.62, p = 0.53). However, the perceived stress scores reduced significantly in the intervention group (30.20 ± 2.89) than the control group scores (37.96 ± 4.18) in the posttest (t = -8.35, P = 0.001). Given the significant reduction of perceived stress in participants after attending the MBSR group therapy, expert counselors, psychologists, and psychiatrists are recommended to conduct this therapy to reduce perceived stress in vulnerable women.

Undue burdens created by the Texas Abortion Law for vulnerable pregnant women.

The new Texas abortion law requires the physician to determine whether a fetal heartbeat is present and prohibits abortion after a heartbeat has been documented. An exception is allowed when a "medical emergency necessitated the abortion." These and other provisions of the statute are to be enforced through "civil actions" brought by private citizens. This article identifies 3 populations of vulnerable women who will experience undue burdens created by the Texas abortion law. We begin with an account of the concept of undue burden in the jurisprudence of abortion, as expressed in the 1992 US Supreme Court case, Planned Parenthood v. Casey of Southeastern Pennsylvania. We then provide an evidence-based account of the predictable, undue burdens for 3 populations of vulnerable women: pregnant women with decreased freedom of movement; pregnant minors; and pregnant women with major mental disorders and cognitive disabilities. The Texas law creates an undue burden on these 3 populations of vulnerable women by reducing or even eliminating access to abortion services outside of Texas. The Texas law also creates an undue burden by preventably increasing the risks of morbidity, including loss of fertility, and mortality for these 3 populations of vulnerable women. For these women, it is indisputable that the Texas law will create undue burdens and is therefore not compatible with the jurisprudence of abortion as set forth in Planned Parenthood v. Casey because a "significant number of women will likely be prevented from obtaining an abortion." Federal courts should therefore strike down this law.

Implementation barriers and enablers of midwifery group practice for vulnerable women: a qualitative study in a tertiary urban Australian health service.

BACKGROUND: Maternity services have limited formalised guidance on planning new services such as midwifery group practice for vulnerable women, for example women with a history of substance abuse (alcohol, tobacco and other drugs), mental health challenges, complex social issues or other vulnerability. Continuity of care through midwifery group practice is mostly restricted to women with low-risk pregnancies and is not universally available to vulnerable women, despite evidence supporting benefits of this model of care for all women. The perception that midwifery group practice for vulnerable women is a high-risk model of care lacking in evidence may have in the past, thwarted implementation planning studies that seek to improve care for these women. We therefore aimed to identify the barriers and enablers that might impact the implementation of a midwifery group practice for vulnerable women. METHODS: A qualitative context analysis using the Consolidated Framework for Implementation Research was conducted at a single-site tertiary health facility in Queensland, Australia. An interdisciplinary group of stakeholders from a purposeful sample of 31 people participated in semi-structured interviews. Data were analysed using manual and then Leximancer computer assisted methods. Themes were compared and mapped to the Framework. RESULTS: Themes identified were the woman's experience, midwifery workforce capabilities, identifying "gold standard care", the interdisciplinary team and costs. Potential enablers of implementation included perceptions that the model facilitates a relationship of trust with vulnerable women, that clinical benefit outweighs cost and universal stakeholder acceptance. Potential barriers were: potential isolation of the interdisciplinary team, costs and the potential for vicarious trauma for midwives. CONCLUSION: There was recognition that the proposed model of care is supported by research and a view that clinical benefits will outweigh costs, however supervision and support is required for midwives to manage and limit vicarious trauma. An interdisciplinary team structure is also an essential component of the service design. Attention to these key themes, barriers and enablers will assist with identification of strategies to aid successful implementation. Australian maternity services can use our results to compare how the perceptions of local stakeholders might be similar or different to the results presented in this paper.

Factors associated with participation in the organized cervical cancer screening program in the greater Paris area (France): An analysis among more than 200,000 women.

We aimed to identify the contextual factors associated with participation in the organized Cervical Cancer Screening (CCS) pilot program, which includes specific interventions to reach vulnerable women, in the Greater Paris region. Study population consisted of 231,712 women aged 25-65 years, who were not up to date to their smear test and had been invited to take part in the program from July 2014 to September 2017. Using a multilevel mixed logistic regression with random effects, we investigated the effect of grassroots interventions targeting vulnerable women, healthcare provider accessibility, social environment and municipal policy-related factors. The CCS rate was two times higher in women who had received their first invitation to the program during the study period (32·9%) compared to those who were already invited before the study period (15·3%). In both populations, there were no significant trends in participation with regards to the type of grassroots interventions, level of accessibility of healthcare services or municipal commitment to healthcare. Among women invited previously and aged above 35 increased participation was seen in neighborhoods with low proportion of single women or in less deprived neighborhoods. Our results identified groups of women who participated less in the organized CCS program and suggested that additional interventions targeting the barriers faced by vulnerable women, especially those aged 35-45 years old, are needed.

The effect of mindfulness-based stress reduction on resilience of vulnerable women at drop-in centers in the southeast of Iran.

BACKGROUND: Female sex workers and addicted women are among the vulnerable groups who impose high costs on the health system of every society. They are prone to psychological problems such as anxiety, stress, and reduced resilience due to their lifestyles. Since mindfulness-based stress reduction (MBSR) has been applied frequently by many psychotherapists to treat stress and anxiety, the present study investigated the effectiveness of MBSR on resilience of the vulnerable women. METHODS: The statistical population of this quasi-experimental study consisted of all eligible women who referred to the drop-in centers in Kerman in the southeast of Iran. Followed by random sampling, 63 vulnerable women were randomly assigned into the intervention (n = 30) and control (n = 33) groups. The MBSR intervention was conducted for the intervention group in eight 90-min sessions. Demographic information questionnaire and Connor-Davidson resilience scale were administered to collect data prior to and one month after the MBSR intervention. RESULTS: The pre-test resilience score was not significantly different between the intervention (53.40 ± 10.49) and the control (54.5 ± 9.27) groups (t = 0.43, p = 0.66). However, the posttest resilience score in the intervention group (60.66 ± 6.71) was significantly higher than the control group (53.88 ± 7.54) (t = 3.58, P = 0.001). Moreover, a comparison between the pretest and posttest scores revealed a significant decrease in resilience scores of the control group (t = 2.81, p = 0.009). CONCLUSION: Since MBSR intervention increased resilience of the vulnerable women in the intervention group, researchers, managers, counselors, community health nurses, and psychiatric nurses are suggested to implement related interventions to promote the health of women, especially vulnerable ones.

Pregnancy outcomes in asylum seekers in the North of the Netherlands: a retrospective documentary analysis.

BACKGROUND: With more than 20,000 asylum seekers arriving every year, healthcare for this population has become an important issue. Pregnant asylum seekers seem to be at risk of poor pregnancy outcomes. This study aimed to assess the difference in pregnancy outcomes between asylum seekers and the local Dutch population and to identify potential substandard factors of care. METHODS: Using a retrospective study design we compared pregnancy outcomes of asylum-seeking and Dutch women who gave birth in a northern region of the Netherlands between January 2012 and December 2016. The following data were compared: perinatal mortality, maternal mortality, gestational age at delivery, preterm delivery, birth weight, small for gestational age children, APGAR score, intrauterine foetal death, mode of delivery and the need for pain medication. Cases of perinatal mortality in asylum seekers were reviewed for potential substandard factors. RESULTS: A total of 344 Asylum-seeking women and 2323 Dutch women were included. Asylum seekers had a higher rate of perinatal mortality (3.2% vs. 0.6%, p = 0.000) including a higher rate of intrauterine foetal death (2.3% vs. 0.2%, p = 0.000), higher gestational age at birth (39 + 4 vs. 38 + 6 weeks, p = 0.000), labour was less often induced (36.9 vs. 43.8, p = 0.016), postnatal hospitalization was longer (2.24 vs. 1.72 days p = 0.006) and they received more opioid analgesics (27.3% vs. 22%, p = 0.029). Babies born from asylum-seeking women had lower birth weights (3265 vs. 3385 g, p = 0.000) and were more often small for gestational age (13.9% vs. 8.4%, p = 0.002). Multivariate analysis showed that the increased risk of perinatal mortality in asylum-seeking women was independent of parity, birth weight and gestational age at birth. Review of the perinatal mortality cases in asylum seekers revealed possible substandard factors, such as late initiation of antenatal care, missed appointments because of transportation problems, not recognising alarm symptoms, not knowing who to contact and transfer to other locations during pregnancy. CONCLUSION: Pregnant asylum seekers have an increased risk of adverse pregnancy outcomes. More research is needed to identify which specific risk factors are involved in poor perinatal outcomes in asylum seekers and to identify strategies to improve perinatal care for this group of vulnerable women.

Women-centered care: Implementation of CenteringPregnancy® in The Netherlands.

INTRODUCTION: In response to a relatively high perinatal mortality rate in The Netherlands, the Dutch Health Ministry recommended changes to maternity care, opening a pathway toward more integrated woman-centered services. Because of its potential to positively influence risk factors for adverse pregnancy outcomes, CenteringPregnancy (CP) group prenatal care was implemented. METHODS: We performed a retrospective cohort study (n = 2318) and survey on women's experiences (n = 222) in eight primary care midwifery practices to investigate outcome differences between CP and traditional individual prenatal care. Data from the period 2011-2013 were analyzed. RESULTS: Primiparous and multiparous CP women attended more prenatal care visits compared with women who received individual care (adjusted odds ratio [aOR] 1.23 [95% confidence interval [CI] 1.18-1.29] and 1.29 [1.21-1.36]). Fewer primiparous CP women used pain relief during labor (0.56 [0.43-0.73]), and they initiated breastfeeding more often (1.74 [1.15-2.62]). Women participating in CP were more likely to feel that their wishes with respect to medication use (69.1% vs 54.4%, P = 0.039), physical activities (72.8% vs 52.5%, P = 0.008), and relaxation exercises (67.9% vs 35.6%, P ≤ 0.001) were listened to by care providers. They also felt more supported to actively participate in their care (89.6% vs 68.5%, P = 0.001) and felt more able to voice opinions about care (92.7% vs 73.9%, P = 0.002). CONCLUSIONS: The CP model is a good approach aligning with Dutch policy calling for women-centered care and responding to the needs of pregnant women. This study supports CP scale-up in The Netherlands and adds to the pool of international knowledge about CP implementation.

Vulnerable Women's Perceptions of Individual Versus Group Prenatal Care: Results of a Cross-Sectional Survey.

Introduction Vulnerable pregnant women (e.g. women with low socio-economic status or recent immigrants) are less likely to receive adequate prenatal care or to attend perinatal education classes. CenteringPregnancy (CP) is a model of group prenatal care which combines assessment, education and support. This study aimed to assess patient experience among vulnerable women in group prenatal care compared to individual care. Methods Women participating in CP at a community-based health centre in urban Alberta were eligible to participate. A convenience sample of women who received individual care at a low-risk maternity clinic served as comparison. Women were asked a series of questions on their prenatal care experience. Demographic and patient responses were compared using Chi square, fisher's exact and t tests. Results Forty-five women accessing CP and 92 women accessing individual care participated. Women in CP were younger, more likely to be single and having their first baby than women in individual care. Women in CP were significantly more likely to report having received enough information on exercise during pregnancy (92 vs. 66%, p = 0.002), breastfeeding (95 vs. 70%, p = 0.002) and baby care (95 vs. 67%, p = 0.001). Women in CP were more likely to report that they felt their prenatal care providers were interested in how the pregnancy was affecting their life (100 vs. 93%, p ≤ 0.001). Discussion Group prenatal care provides a positive experience and improved information exchange among vulnerable populations. Programs interested in engaging, educating and empowering vulnerable pregnant women may benefit from implementation of group care.

A qualitative study of the experience of doula support to women in socially disadvantaged positions in Sweden: The voices of women and doulas.

BACKGROUND: Women in socially disadvantaged positions face increased risk of fear of birth, birth complications, and postpartum depression, highlighting the need for targeted interventions for this group. Doula support is associated with positive emotional and medical outcomes for mother and child. Experience of doula support for women in socially disadvantaged positions in Sweden remains unexplored. AIM: To describe experiences of doula support within a project for women in socially disadvantaged positions in Sweden. METHODS: In-depth interviews with seven women and focus group discussions with twelve doulas in a Doula support project were conducted. Data was analysed with inductive content analysis. RESULTS: Women and doulas described experiences of doula support as a significant relationship with challenges, due to unclear boundaries for the support, and the time and trust needed to establish the relationship. The support was perceived as comprehensive, far exceeding traditional doula support, with extensive assistance provided postpartum. The project was regarded as meaningful, and that it led to positive birth experiences. CONCLUSIONS: Women in socially disadvantaged positions may benefit from doula support during the perinatal period. The support fosters feelings of calmness, security and empowerment, and alleviates feelings of isolation, which is crucial for a positive birth experience. Support for these women is complex due to increased social needs, leading to unclear expectations of the doula's role. Support from colleagues is deemed crucial. Future projects should establish clear frameworks and a supportive structure for doulas.

Interventions to improve enablers and/or overcome barriers to seeking care during pregnancy, birthing and postnatal period for women living with vulnerabilities in high-income countries: A systematic review and meta-analysis.

OBJECTIVE: To reduce maternal morbidity and mortality, World Health Organization recommendations include: commencing pregnancy care before 12-weeks', at least eight antenatal and four postnatal visits, and attendance of skilled care at birthing. While lower adherence to the recommendation predominates in low- and middle-income countries, it also occurs in some settings in high-income countries. Globally, various strategies are used to optimise maternity care, in line with these recommendations. This systemic review aimed to determine if enhanced care improves maternal care-seeking, thus improving clinical outcomes for women and babies living with vulnerabilities, in high-income countries. DESIGN, SETTING AND PARTICIPANTS: We searched the Cochrane Central Registers of Controlled Trials and Cochrane Pregnancy and Childbirth, MEDLINE, CINAHL, Proquest Dissertation and Thesis and reference lists of relevant articles. The latest search was performed June 20, 2022. Randomised controlled trials, non-randomised intervention trials and cohort studies comparing effects of interventions designed to increase utilisation of maternal health services with routine care, for women at increased risk of maternal mortality and severe maternal morbidity in high-income countries were included. Two authors selected, extracted, assessed and analysed data. Additional information was sought from study authors. This systematic review and meta-analysis was registered with PROSPERO(CRD42021256811). FINDINGS: Nine studies with 5,729 participants were included. Interventions to enhance care significantly increased utilisation of health services, increasing attendance at antenatal classes (Odds Ratio[OR]=15·23, 95%Confidence Interval[CI] 10·73-21·61, p<0·0001) and postnatal visits by 6-8 weeks (OR=2·66, 95%CI 1·94-3·64, p<0·0001), compared to routine care. Infants in the intervention groups were significantly less likely to be: born preterm (OR=0·68, 95%CI 0·56-0·82, p<0·0001); low birthweight (OR=0·78, 95%CI 0·64-0·95, p = 0·01) or; require neonatal intensive care (OR=0·80, 95%CI 0·66-0·96, p = 0·02). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Among women living with vulnerabilities in high-income countries, interventions to enhance care increases utilisation of maternal health services and improves outcomes.

Pandemic within a pandemic! Policy Implications of community-based Interventions to mitigate violence against women during COVID-19 in Urban Slums of Lucknow, India.

Background: The COVID-19 pandemic has brought an unprecedented adverse impact on women's health. Evidence from the literature suggests that violence against women has increased multifold. Gender-based violence in urban slums has worsened due to a lack of water and sanitation services, overcrowding, deteriorating conditions and a lack of institutional frameworks to address gender inequities. Methods: The SAMBHAV (Synchronized Action for Marginalized to Improve Behaviors and Vulnerabilities) initiative was launched between June 2020 to December 2020 by collaborating with the Uttar Pradesh state government, UNICEF and UNDP. The program intended to reach 6000 families in 30 UPS (Urban Poor settlements) of 13 city wards. These 30 UPS were divided into 5 clusters. The survey was conducted in 760 households, 397 taken from randomly selected 15 interventions and 363 households from 15 control UPS. This paper utilized data from a baseline assessment of gender and decision-making from a household survey conducted in the selected UPS during July 03-15, 2020. A sample size of 360 completed interviews was calculated for intervention and control areas to measure changes attributable to the SAMBHAV intervention in the behaviours and service utilization (pre- and post-intervention). Results: The data analysis showed a significant difference (p-value < 0.001) between respondents regarding women's freedom to move alone in the control and intervention area. It also reflected a significant difference between control and intervention areas as the respondents in the intervention area chose to work for the cause of gender-based violence. Conclusion: The SAMBHAV initiative brought an intersectional lens to gender issues. The community volunteers were trained to approach issues based on gender-based violence with the local public, and various conferences and meetings were organized to sensitize the community. The initiative's overall impact was that it built momentum around the issue of applying the concept of intersectionality for gender issues and building resilience in the community. There is still a need to bring multi-layered and more aggressive approaches to reduce the prevalence of gender-based violence in the community.

Effect on breastfeeding practices of providing in-home lactation support to vulnerable women through the Canada Prenatal Nutrition Program: protocol for a pre/post intervention study.

BACKGROUND: Only one-third of Canadian infants are exclusively breastfed for the first 6 months of life as recommended. Skilled lactation support in the early postpartum period is one strategy for improving breastfeeding outcomes by building breastfeeding self-efficacy and resolving difficulties. Access to such support is limited among vulnerable women, including those who are new immigrants, low income, under-educated, young or single. The Canada Prenatal Nutrition Program (CPNP) aims to improve birth and breastfeeding outcomes among vulnerable women, but currently lacks a formal framework for providing postpartum lactation support. METHODS: This pre/post intervention study will examine the effect on breastfeeding outcomes of an evidence-based in-home lactation support intervention provided through the CPNP. We will enrol 210 pregnant women who intend to breastfeed and are registered CPNP clients at two sites in Toronto, Canada. During the intervention phase, postpartum home visits by International Board Certified Lactation Consultants (IBCLCs) will be pro-actively offered to registered clients of the two sites. Double-electric breast pumps will also be provided to those who meet specific criteria. Infant feeding data will be collected prospectively at seven time points from 2 weeks to 6 months postpartum. Descriptive and regression analyses will be conducted to measure intervention effects. The primary outcome is exclusive breastfeeding at 4 months postpartum. Secondary outcomes include the duration of any and exclusive breastfeeding, timing of introduction of breastmilk substitutes and timing of introduction of solid foods. Breastfeeding self-efficacy will be assessed prenatally and at 2 weeks and 2 months postpartum. Other measures include maternal socio-demographics, infant feeding intentions, maternal depression and anxiety, and household food insecurity. Monitoring data will be used to assess the reach, uptake and fidelity of intervention delivery. DISCUSSION: Increasing access to skilled lactation support through the CPNP may be an effective means of improving breastfeeding practices among vulnerable women and thereby enhancing health and development outcomes for their infants. This pre/post intervention study will contribute evidence on both the effectiveness and feasibility of this approach, in order to guide the development and further testing of appropriate models of integrating lactation support into the CPNP. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03589963 ) registered July 18, 2018.

Methamphetamine use in pregnancy, child protection, and removal of infants: Tertiary centre experience from Western Australia.

The aim of this study is to explore factors that determine infant removal by Child Protective Services and placement in out of home care, for methamphetamine-using women receiving pregnancy care with Western Australia Women and Newborn Drug and Alcohol Service. METHOD: A prospective cohort study of 112 methamphetamine-using women attending Women and Newborn Drug and Alcohol Service for pregnancy care from 2015 to 2018 was undertaken. Maternal methamphetamine use was assessed during each trimester of pregnancy using a standardised assessment tool. Drug use was by maternal self-report. Involvement of Western Australia's Department for Child Protection and Family Support and removal from maternal care were recorded. Infant development was formally assessed at 12 months with Griffiths Mental Development Scales. The comparison was made between three groups: those women who had no involvement with Child Protection, those for whom Child Protection was involved but the child remained in maternal care and those women who had their infants removed from their care. A comparison between Aboriginal and non-Aboriginal women was also undertaken. RESULTS: Of the 110 infants born to 112 women, 33 (30.3%) of infants were removed from maternal custody after delivery. Overall 60 (53.5%) of women had Child Protection involvement. Aboriginal women were overrepresented in our population 59 (52.7%) and 24 out of the 33 infants were Aboriginal were removed and placed into out of home care. Infants were removed from women with a high level of risk factors associated with MA use including those who were homeless, in prison, unemployed or continued high use of MA, mental health issues. Aboriginal infants were at increased risk of removal. Children removed from maternal care had a trend towards poorer developmental attainment at around 12 months compared to those who remained with their mother. Infants who were removed by the Child protection had lower general quotients (p = 0.132) than infants who had no involvement or some involvement. CONCLUSION: Infants removed from maternal care were more likely to be from women with high use, adverse social factors and born to mothers who identified as being Aboriginal. Resources are required that work intensively with families to reduce the number of infants being removed from maternal care to overcome the risks and challenges of addiction. IMPLICATIONS FOR PRACTICE: Resources that provide long term support and community-based models that offer a comprehensive range of maternal-child services and in-home-support would be more effective in keeping families together.

Implementation of midwifery continuity of care models for Indigenous women in Australia: Perspectives and reflections for the United Kingdom.

Maternity models that provide midwifery continuity of care have been established to increase access to appropriate services for Indigenous Australian women. Understanding the development and implementation of continuity models for Indigenous women in Australia provides useful insights for the development and implementation of similar models in other contexts such as those for vulnerable and socially disadvantaged women living in the United Kingdom. To ensure better health outcomes for mothers and babies, it is crucial to promote culturally competent and safe public health models in which midwives work collaboratively with the multidisciplinary team.

Vulnerable, single and living in poverty: Women's challenges to accessing food in the Australian Capital Territory.

OBJECTIVE: To explore challenges to food access faced by vulnerable women living in the Australian Capital Territory and surrounds. METHOD: Qualitative study comprising semi-structured interviews supplemented with quantitative demographic data. RESULTS: Forty-one women, mean age of 43 years, living in government and community housing who had an income of <$300 per week participated. A total of 78% of women had completed Year 10 or above and 93% had accessed food from at least one charitable organisation. Women requested greater and reliable access to meat, dairy and quality fruit and vegetables. Primary challenges to accessing food included: limited income, distance to food outlets, lack of nutritious, safe and healthy food, limited knowledge of services and opening hours. CONCLUSION: Access to safe, nutritious and healthy food is difficult for women living in poverty. Acknowledgement of challenges that contribute to women's food insecurity by all stakeholders is essential to address the problem and build sustainable actions and solutions. Implications for public health: Collaboration from all stakeholders within our food system is required to address current inequities to accessing reliable, nutritious and safe food and to reduce individual food insecurity.

'They'll be judging us' a qualitative study of pregnant women's experience of being offered participation in a supportive intervention.

OBJECTIVE: to explore pregnant women's experience of being offered participation in a supportive intervention and how their experience influenced the outcome of the intervention. DESIGN AND SETTING: a qualitative, phenomenological hermeneutic study based on semi-structured interviews with eight Danish first-time mothers. FINDINGS: the study revealed a divergence between the professional's and the women's perception of their vulnerability. The women typically felt the offer of participation as a stigma, which they met with anxiety and confusion. Insufficient information led to uncertainty and a feeling of being evaluated as inadequate mothers or parents. The information offered failed to provide the basis of informed choice. However, the development of a trusting, supportive and non-judgemental relationship with the health professionals ensured most women a positive outcome of the intervention. KEY CONCLUSION: being invited to participate in an intervention targeting vulnerable women may induce unintended feelings in relation to stigmatization and judgement, leading to doubt about own ability to cope with motherhood. Inadequate information and explication about aims and contents of the intervention are likely to cause confusion and anxiety and a feeling of being judged as parents. Information combined with establishing a trusting and non-judgemental relationship between women and professionals appears to have significant impact on outcomes. IMPLICATIONS FOR PRACTICE: care providers should be aware of the induced negative feelings and sense of judgement and stigmatization as a result of being categorized as vulnerable and perceived in need of help to cope with motherhood, and that they may play a key role in helping women cope with this. Furthermore, detailed information about the intervention and the background of the offer should be ensured as well as an informed choice of participation.