Implementing the MAMAACT intervention in Danish antenatal care: a qualitative study of non-Western immigrant women's and midwives' attitudes and experiences.

INTRODUCTION: Immigrant women have an increased risk of negative pregnancy and birth outcomes compared to women from European host populations. Similar trends are seen in Denmark, where especially some groups of non-Western immigrant women have an increased risk of stillbirth and infant mortality. This study reports on an implementation analysis of The MAMAACT Intervention, which was developed to increase midwives' and women's responses to pregnancy complications (trial registration number: NCT03751774). The intervention consisted of a training session and two dialogue meetings for midwives, and a leaflet and mobile application for women. OBJECTIVE: To explore midwives' and non-Western immigrant women's attitudes towards and experiences of using the MAMAACT intervention to enhance mutual interactions and improve responses to potential pregnancy complications. DESIGN: A multi-method qualitative study was used to collect data. Data consisted of non-participant observations of midwifery visits, field notes, focus group interviews with midwives and in-depth interviews with non-Western immigrant women. Data were initially analysed using systematic text condensation according to Malterud. Subsequently, Shim's concept of cultural health capital was applied to the data analysis. SETTING: Data were collected from ten Danish antenatal care facilities affiliated with five maternity care wards. PARTICIPANTS: Twenty-three midwives participated in observations of 40 midwifery visits, and 27 midwives participated in nine focus group interviews. Twenty-one non-Western immigrant women each participated in one in-depth interview. FINDINGS: Two main themes were identified: 'the MAMAACT intervention as a tool to build knowledge and skills' and 'intervention experiences'. Training sessions and dialogue meetings promoted midwives' reflection on practice, however, at the visits, habitual ways of interacting impacted encounters between midwives and non-Western immigrant women. Among midwives, informing was a more dominant communication strategy than the use of dialogue, and competing tasks affected their follow-up on women's use of the information material. Women seemed hesitant to use the MAMAACT leaflet and app to actively engage with midwives at the visits although they used this material to distinguish between normal and abnormal conditions in pregnancy and to contact emergency maternity care services when at home. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The acceptability and usability of the intervention were high among participants. The leaflet and app showed potential in prompting women to contact emergency care maternity services. Despite midwives' increased reflections on immigrant women's care provision, this did not appear to increase their use of a needs-based dialogue at the antenatal visits. Institutional structures, especially power relationships between midwives and non-Western immigrant women, affected mutual interactions. Attention to midwives' task loads and time resources are needed if midwives are to have the necessary space to adapt their interactional styles to immigrant women's individual needs.

Organisational barriers to implementing the MAMAACT intervention to improve maternity care for non-Western immigrant women: A qualitative evaluation.

BACKGROUND: In Europe, the number of children born by non-Western immigrant women is rising and these women have an increased risk of negative pregnancy and birth outcomes, compared to the host populations. Several individual and system barriers are associated with immigrant women's access to maternity care. Scientific evaluations of interventions to enhance the health of immigrant women in the maternity setting are lacking, and there is a need for further development of the evidence base on how health care system initiatives may mitigate ethnic inequities in reproductive health. In Denmark, the MAMAACT intervention was developed to improve midwives' as well as non-Western immigrant women's response to pregnancy complications and to promote midwives' intercultural communication and cultural competence. The intervention included a training course for midwives as well as a leaflet and a mobile application. This study focuses on the significance of the antenatal care context surrounding the implementation of the MAMAACT intervention (Id. No: SUND-2018-01). OBJECTIVES: To explore the main organisational barriers, which impacted the intended mechanisms of the MAMAACT intervention in Danish antenatal care. DESIGN: A qualitative study design was used for data collection and analysis. SETTING: Midwifery visits at ten antenatal facilities affiliated to five Danish maternity wards formed the setting of the study. PARTICIPANTS AND METHODS: Data consisted of nine focus group interviews with midwives (n = 27), twenty-one in-depth interviews with non-Western immigrant women, forty observations of midwifery visits, and informal conversations with midwives at antenatal care facilities (50 h). Data were initially analysed using systematic text condensation. The candidacy framework was applied for further interpretation of data. RESULTS: Analysis of data revealed three main categories: 'Permeability of antenatal care services', 'The interpreter as an aid to candidacy´, and 'Local conditions influencing the production of candidacy'. CONCLUSIONS: Several organisational barriers impacted the intended mechanisms of the MAMAACT intervention. Major barriers were incomplete antenatal records, insufficient referrals to specialist care, inadequate interpreter assistance, and lack of local time resources for initiating a needs-based dialogue with the women. Immigrant targeted interventions must be understood as events within complex systems, and training midwives in intercultural communication and cultural competence cannot alone improve system responses to pregnancy complications among immigrant women. Changes in the legal, social, and political context of the health care system are needed to support organisational readiness for the MAMAACT intervention.

Microbial Synthesis of Human-Hormone Melatonin at Gram Scales.

Melatonin is a commercially attractive tryptophan-derived hormone. Here we describe a bioprocess for the production of melatonin using Escherichia coli to high titers. The first engineered strain produced 0.13 g/L of melatonin from tryptophan under fed-batch fermentation conditions. A 4-fold improvement on melatonin titer was further achieved by (1) protein engineering of rate-limiting tryptophan hydroxylase to improve 5-hydroxytryptophan biosynthesis and (2) chromosomal integration of aromatic-amino-acid decarboxylase to limit byproduct formation and to minimize gene toxicity to the host cell. Fermentation optimization improved melatonin titer by an additional 2-fold. Deletion of yddG, a tryptophan exporter, exhibited an additive beneficial effect. The final engineered strain produced ∼2.0 g/L of melatonin with tryptophan supplemented externally and ∼1.0 g/L with glucose as the sole carbon source for tryptophan supply. This study lays the foundation for further developing a commercial melatonin-producing E. coli strain.

Contextual Factors Influencing the MAMAACT Intervention: A Qualitative Study of Non-Western Immigrant Women's Response to Potential Pregnancy Complications in Everyday Life.

In western countries, immigrant women have an increased risk of negative birth outcomes. Immigrant women's and maternity care system's delayed response to pregnancy complications contribute to ethnic inequities in reproductive health. The MAMAACT intervention was developed to improve midwives' and women's response to pregnancy complications in Denmark. The study examines the context of the implementation of the MAMAACT intervention and investigates how the intended intervention mechanisms regarding response to pregnancy complications were affected by barriers in non-Western immigrant women's everyday life situations. Twenty-one interviews with non-Western immigrant women were undertaken. Systematic text condensation and the situational-adaptation framework by Alonzo were used to analyze data. Four main categories were identified: 'Sources of knowledge during pregnancy', 'Containment of pregnancy warning signs', 'Barriers during the onset of acute illness' and 'Previous situations with maternity care providers'. Attention to potential pregnancy complications may conflict with immigrant women's everyday life situations and result in the containment of symptoms as well as causing delays in seeking medical assistance. It is probable that barriers in women's everyday life will impact the intended intervention mechanisms and thus the full potential of the intervention may not be reached.

Addressing ethnic disparity in antenatal care: a qualitative evaluation of midwives' experiences with the MAMAACT intervention.

BACKGROUND: In Denmark, 13% of all children are born by non-Western immigrant women. The public antenatal care has not adapted to this increased diversity of women. Compared to women coming from Western countries, non-Western immigrant women have an increased prevalence of severe maternal morbidity and higher risks of maternal death, stillbirth and infant death. Suboptimal care is a contributing factor to these ethnic disparities, and thus the provision of appropriate antenatal care services is pivotal to reducing these disparities and challenges to public health. Yet, little is known about the targeted interventions which have been developed to reduce these inequities in reproductive health. The MAMAACT intervention, which included a training course for midwives, a leaflet and a mobile application, as well as additional visit time, was developed and tested at a maternity ward to increase responses to pregnancy warning signs among midwives and non-Western immigrant women. AIM: To explore the feasibility and acceptability of the MAMAACT intervention among midwives and identify factors affecting midwives' delivery of the intervention. METHODS: Eight mini-group interviews with midwives (n = 18) were undertaken. Systematic text condensation was used to analyse data. RESULTS: Three main categories were identified, which were 'Challenges of working with non-Western immigrant women', 'Attitudes towards and use of the leaflet and mobile application', and 'Organisational factors affecting the use of the MAMAACT intervention'. CONCLUSIONS: The MAMAACT intervention was found to be feasible as well as acceptable among midwives. Women turning to relatives for pregnancy-related advice, time constraints during midwifery visits, incomplete clinical records and lack of professional interpreter assistance impacted midwives' delivery of the MAMAACT intervention. Midwives displayed a readiness for the MAMAACT intervention; however, there is a need to further examine how contextual factors may impact the use of the intervention in antenatal care. TRIAL REGISTRATION: ClinicalTrials.gov, Retrospective Registration (07/2/2020), registration number NCT04261400.

An expression tag toolbox for microbial production of membrane bound plant cytochromes P450.

Membrane-associated Cytochromes P450 (P450s) are one of the most important enzyme families for biosynthesis of plant-derived medicinal compounds. However, the hydrophobic nature of P450s makes their use in robust cell factories a challenge. Here, we explore a small library of N-terminal expression tag chimeras of the model plant P450 CYP79A1 in different Escherichia coli strains. Using a high-throughput screening platform based on C-terminal GFP fusions, we identify several highly expressing and robustly performing chimeric designs. Analysis of long-term cultures by flow cytometry showed homogeneous populations for some of the conditions. Three chimeric designs were chosen for a more complex combinatorial assembly of a multigene pathway consisting of two P450s and a redox partner. Cells expressing these recombinant enzymes catalyzed the conversion of the substrate to highly different ratios of the intermediate and the final product of the pathway. Finally, the effect of a robustly performing expression tag was explored with a library of 49 different P450s from medicinal plants and nearly half of these were improved in expression by more than twofold. The developed toolbox serves as a platform to tune P450 performance in microbial cells, thereby facilitating recombinant production of complex plant P450-derived biochemicals. Biotechnol. Bioeng. 2017;114: 751-760. © 2016 Wiley Periodicals, Inc.

Healing a vulnerable self: exploring return to work for women with mental health problems.

Mental health problems (MHPs) such as stress and depression are among the leading causes of work disability. In this article we explore how women with MHPs experience sickness absence and subsequent return to work. We conducted 16 semistructured interviews and employed constructivist grounded theory for the analysis. We found that whereas sickness absence constituted a major threat to positive self-images, the experience had potential as a personal growth experience: Although some women felt handicapped, others became stronger and more self-confident. The core of the experience was not the return to work but a process of healing a vulnerable self--the ability both to refocus attention from symptoms to other life goals and to maintain or reconstruct a positive self-image. Supportive health care and acknowledgment from others facilitated the healing process.

Structural and biochemical studies elucidate the mechanism of rhamnogalacturonan lyase from Aspergillus aculeatus.

We present here the first experimental evidence for bound substrate in the active site of a rhamnogalacturonan lyase belonging to family 4 of polysaccharide lyases, Aspergillus aculeatus rhamnogalacturonan lyase (RGL4). RGL4 is involved in the degradation of rhamnogalacturonan-I, an important pectic plant cell wall polysaccharide. Based on the previously determined wild-type structure, enzyme variants RGL4_H210A and RGL4_K150A have been produced and characterized both kinetically and structurally, showing that His210 and Lys150 are key active-site residues. Crystals of the RGL4_K150A variant soaked with a rhamnogalacturonan digest gave a clear picture of substrate bound in the -3/+3 subsites. The crystallographic and kinetic studies on RGL4, and structural and sequence comparison to other enzymes in the same and other PL families, enable us to propose a detailed reaction mechanism for the ß-elimination on [-,2)-α-l-rhamno-(1,4)-α-d-galacturonic acid-(1,-]. The mechanism differs significantly from the one established for pectate lyases, in which most often calcium ions are engaged in catalysis.

Thermodynamic and kinetic characterization of duplex formation between 2'-O, 4'-C-methylene-modified oligoribonucleotides, DNA and RNA.

2'-O,4'-C-methylene-linked ribonucleotide derivatives, named LNA (locked nucleic acid) and BNA (bridged nucleic acid) are nucleic acid analogoues that have shown high-affinity recognition of DNA and RNA, and the employment of LNA oligomers for antisense activity, gene regulation and nucleic acid diagnostics seems promising. Here we show kinetic and thermodynamic results on the interaction of a series of 10 bases long LNA-DNA mixmers, gabmers as well as full length LNA's with the complementary DNA, RNA and LNA oligonucleotides in the presence and absence of 10 mM Mg(2+)- ions. Our results show no significant differences in the reaction thermodynamics and kinetics between the LNA species, only a tendency to stronger duplex formation with the gabmer and mixmer. Introduction of a few LNA's thus may be a better strategy, than using full length LNA's to obtain an oligonucleotide that markedly increases the strength of duplexes formed with the complementary DNA and RNA.