Involuntary Treatment of Psychosis in Pregnancy.

When a patient with acute psychosis refuses antipsychotic medication despite a clear need for treatment, involuntary medication is often considered. When the patient is both pregnant and acutely unwell, an additional layer of analysis enters the picture. This analysis then also includes the health of the mother and fetus, rights of the mother and fetus, and whose rights take precedence when choosing treatment options in event of a conflict. Antipsychotic agents are frequently the medications prescribed as involuntary treatment. Typical and atypical antipsychotic agents are often used in both emergent and nonemergent situations during pregnancy. Despite a lack of randomized, double-blind, controlled, prospective studies in pregnancy, available data regarding the safety of antipsychotic agents in pregnancy are relatively reassuring. At the same time, the risks of untreated psychosis, for both the mother and the fetus, are not negligible. Such cases merit ethics-related and legal analyses. Forensic psychiatrists involved in such cases need to consider the patient's capacity to make medical decisions and be able to discuss the potential risks, benefits, and alternatives with patients and in court, as part of initiation of involuntary treatment.

Village midwives and their changing roles in Brunei Darussalam: A qualitative study.

BACKGROUND: There are lay midwives worldwide, interchangeably and universally called traditional birth attendants or traditional midwives by organisations such as the World Health Organization and the International Confederation of Midwives. AIM: This study aimed to explore the history of lay midwives (village midwives) in Brunei, describe the evolution from their previous to current roles and determine if they are still needed by women today. METHODS: This qualitative, descriptive study included in-depth, semi-structured interviews with eight women who had received care from village midwives. Data analysis was based on the principles underpinning thematic analysis and used a constant comparative method. FINDINGS: Village midwives have been popular in Brunei since the 1900s, with their major role being to assist women with childbirth. However, since the 1960s, their roles and practices have changed to focus on pre-conception, antenatal, postnatal and women's general healthcare. Traditional practices were influenced by religion, culture and the social context of and within Brunei. DISCUSSION: The major changes in village midwives' roles and practices resulted from the enforcement of the Brunei Midwives' Act in 1956. Village midwives' traditional practices became juxtaposed with modern complementary alternative medicine practices, and they began charging a fee for their services. CONCLUSION: Brunei village midwives are trusted by women, and their practices may still be widely accepted in Brunei. Further research is necessary to confirm their existence, determine the detailed scope and appropriateness of their practices and verify the feasibility of them working together with healthcare professionals.

Court-ordered caesareans.

Court-ordered caesarean sections are in the news after a number of recent legal decisions authorising surgery for women who lack mental capacity to consent. The decisions have not always been based on good evidence and they raise serious concerns about the protection of the rights of mentally ill women. The authors explain the legal process and question the wisdom of recent judgements.

Leveraging the Affordable Care Act to improve the health of mothers and newborns.

Health insurance in the United States is a patchwork system whereby opportunities for coverage are strongly associated with life circumstances (ie, age, income, pregnancy, parental status). For pregnant women, this situation contributes to unstable coverage before, between, and after pregnancies. The Affordable Care Act has the potential to make coverage for women of reproductive age more stable and create new opportunities to intervene on conditions associated with maternal and neonatal morbidity. In this article, we discuss the health economics of the Affordable Care Act, its implications for maternal and neonatal health, specific challenges associated with implementation, and opportunities for obstetricians to leverage the Affordable Care Act to improve the care of women.

The 2013 review of the Children's Health Insurance Program Reauthorization Act: a call to action.

In September 2013, Congress again will review the Children's Health Insurance Program Reauthorization Act of 2009. Fourteen states cover the fetus only (and not the pregnant woman) under the "unborn child" provision of the current law. That the Children's Health Insurance Program Reauthorization Act continues to make it possible for states to provide health insurance coverage to the fetus only has been critiqued for unnecessarily politicizing the law, dragging abortion and personhood debates into the matter of children's health insurance and creating unacceptable tensions between maternal and fetal health. Although the 2009 reauthorization attempted to remedy this issue by also providing coverage for the pregnant mother, it is imperative to review these changes and their effect before the 2013 reauthorization. To ensure optimum health care for both the fetus and the woman, we urge for removal of the "unborn child" pathway and promote coverage of both the fetus and the pregnant woman.

Targeted interventions for improved equity in maternal and child health in low- and middle-income settings: a systematic review and meta-analysis.

BACKGROUND: Targeted interventions to improve maternal and child health is suggested as a feasible and sometimes even necessary strategy to reduce inequity. The objective of this systematic review was to gather the evidence of the effectiveness of targeted interventions to improve equity in MDG 4 and 5 outcomes. METHODS AND FINDINGS: We identified primary studies in all languages by searching nine health and social databases, including grey literature and dissertations. Studies evaluating the effect of an intervention tailored to address a structural determinant of inequity in maternal and child health were included. Thus general interventions targeting disadvantaged populations were excluded. Outcome measures were limited to indicators proposed for Millennium Development Goals 4 and 5. We identified 18 articles, whereof 15 evaluated various incentive programs, two evaluated a targeted policy intervention, and only one study evaluated an intervention addressing a cultural custom. Meta-analyses of the effectiveness of incentives programs showed a pooled effect size of RR 1.66 (95% CI 1.43-1.93) for antenatal care attendance (four studies with 2,476 participants) and RR 2.37 (95% CI 1.38-4.07) for health facility delivery (five studies with 25,625 participants). Meta-analyses were not performed for any of the other outcomes due to scarcity of studies. CONCLUSIONS: The targeted interventions aiming to improve maternal and child health are mainly limited to addressing economic disparities through various incentive schemes like conditional cash transfers and voucher schemes. This is a feasible strategy to reduce inequity based on income. More innovative action-oriented research is needed to speed up progress in maternal and child survival among the most disadvantaged populations through interventions targeting the underlying structural determinants of inequity.

Human rights approach to maternal & child health: has India fared well?

BACKGROUND & OBJECTIVES: The objectives of the study were to examine: right to access maternal health; right to access child health; and right to access improved water and sanitation in India. METHODS: We used large-scale data sets like District Level Household Survey conducted in 2007-08 and National Family Health Surveys conducted during 1992-93, 1998-99, and 2005-06 to fulfil the objectives. The selection of the indicator variables was guided by the Human Rights' Framework for Health and Convention of the Rights of the Child- Articles 7, 24 and 27. We used univariate and bivariate analysis along with ratio of access among non-poor to access among poor to fulfil the objectives. RESULTS: Evidence clearly suggested gross violation of human rights starting from the birth of an individual. Even after 60 years of independence, significant proportions of women and children do not have access to basic services like improved drinking water and sanitation. INTERPRETATION & CONCLUSIONS: There were enormous socio-economic and residence related inequalities in maternal and child health indicators included in the study. These inequalities were mostly to the disadvantage of the poor. The fulfilment of the basic human rights of women and children is likely to pay dividends in many other domains related to overall population and health in India.