Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis.

Background: Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care. Objectives: Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services. Methods: Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders. Data sources: Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews. Review methods: In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway. Results: Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women's economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels. Limitations: In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English. Conclusions: The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services. Recommendations for health policy and practice: These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it. Future work: Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries. Trial registration: This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Mental health problems affect one in five women during pregnancy and the first year after birth (the perinatal period). These include anxiety, depression and stress-related conditions. Mental health problems can have a negative effect on women, their partners and their children. They are also a leading cause of maternal death. It is therefore important that women who experience mental health problems get the care and treatment they need. However, only about half of women with perinatal mental health problems are identified by health services and even fewer receive treatment. This research aimed to understand what factors help or prevent women getting care or treatment for perinatal mental health problems. We did this by pulling together the findings from existing research in three phases. In phase 1 we reviewed the evidence from research studies to understand why it has been difficult for health services to assess, care for and treat women with perinatal mental health problems. In phase 2 we reviewed evidence from women's perspectives on all of the factors that prevent women from being able to get the care and treatment they need. In phase 3 we worked with a panel of women, health professionals (such as general practitioners and midwives) and health service managers to look at the findings from phases 1 and 2. We then developed frameworks that give a clear overview of factors that help or prevent women getting care and treatment. These frameworks show 39 factors that help women access services, and 66 factors that prevent access. Based on these results we have developed guidance for government, NHS service managers and health professionals, such as general practitioners, midwives, health visitors, nurses and wider teams such as receptionists. This will be shared widely with health services and professionals who support women during pregnancy and after birth to improve perinatal mental health services so that care meets women's needs.

Pediatric pulmonary thromboembolism: a 3-year Canadian Pediatric Surveillance Program study.

BACKGROUND: Pediatric pulmonary embolism (PE) is a rare event associated with significant morbidity and mortality. Awareness of clinical presentation and practices unique to children may aid clinicians in prompt identification and treatment. OBJECTIVES: To describe the incidence, risk factors, clinical presentation, diagnostic and therapeutic practices, and short-term outcomes of pediatric PE. METHODS: We conducted a 3-year national surveillance study through the Canadian Pediatric Surveillance Program. Over 2800 pediatric specialists and subspecialists were contacted monthly from 2020 to 2022 and requested to report all new cases of PE in patients up to 18 years of age. Case-specific data were obtained through voluntary completion of a detailed questionnaire. RESULTS: Fifty-eight cases (78% female, n = 45) were reported (2.4 cases per million children), with rates highest in adolescents 15 to 18 years (6.6 cases per million). Detailed information, available for 31 (53%) cases, documented at least 1 risk factor in 28 (90%) cases; 24 (77%) patients presented with 2 or more symptoms. Computed tomography pulmonary angiography was used for diagnostic confirmation in 25 (81%) cases. Anticoagulation was initiated in 24 (77%) of 31 cases; fewer than 5 patients underwent thrombolysis or surgical interventions. Of 28 patients who received therapeutic interventions, 8 (29%) experienced treatment-related complications. Fewer than 5 mortalities were reported. CONCLUSION: Pediatric PE is a rare event, with female adolescents at the highest risk. Although the presentation is often nonspecific, clinicians should maintain a high index of suspicion, particularly in patients with risk factors and when other diagnoses that may explain symptoms have been excluded.

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: A prioritisation nominal group technique.

INTRODUCTION: Carers of people with mental illness may face distinct challenges, including navigating fragmented health and social services during discharge from mental health hospitals. Currently, limited examples of interventions that support carers of people with mental illness in improving patient safety during transitions of care exist. We aimed to identify problems and solutions to inform future carer-led discharge interventions, which is imperative for ensuring patient safety and the well-being of carers. METHODS: The nominal group technique was used which combines both qualitative and quantitative data collection methods in four distinct phases: (1) problem identification, (2) solution generation, (3) decision making and (4) prioritisation. The aim was to combine expertise from different stakeholder groups (patients, carers and academics with expertise in primary/secondary care, social care or public health) to identify problems and generate solutions. RESULTS: Twenty-eight participants generated potential solutions that were grouped into four themes. The most acceptable solution for each was as follows: (1) 'Carer Involvement and Improving Carer Experience' a dedicated family liaison worker, (2) 'Patient Wellness and Education' adapting and implementing existing approaches to help implement the patient care plan, (3) 'Carer Wellness and Education' peer/social support interventions for carers and (4) 'Policy and System Improvements' understanding the co-ordination of care. CONCLUSION: The stakeholder group concurred that the transition from mental health hospitals to the community is a distressing period, where patients and carers are particularly vulnerable to safety and well-being risks. We identified numerous feasible/acceptable solutions to enable carers to improve patient safety and maintain their own mental wellbeing. PATIENT AND PUBLIC CONTRIBUTION: Patient and public contributors were represented in the workshop and the focus of the workshop was to identify the problems they faced and co-design potential solutions. Patient and public contributors were involved in the funding application and study design.

Health-care practitioners' assessment and observations of birth trauma in mothers and partners.

BACKGROUND: Evidence shows that traumatic childbirth can cause ongoing distress, often referred to as birth trauma. This can have an impact on parents and the couple relationship, and consequently identifying and supporting parents with birth trauma is important to practice. AIM: To investigate the experiences of health-care practitioners from the United Kingdom (UK) in assessment for birth trauma, perceived occurrence of birth trauma and observed impact on parents and the couple relationship. METHODS: An online survey of UK health-care practitioners working with parents in the first postnatal year. RESULTS: A sample of 202 practitioners reported identifying birth trauma in 34.4% of mothers and 25.0% of partners. Assessment for birth trauma was only conducted for 50.3% of mothers and 25.9% of partners. The most observed symptoms were re-experiencing among mothers (87.1%) and avoidance among partners (50.9%). Birth trauma was perceived as impacting on the couple relationship for 29.8% of mothers and 26.9% of partners. Written responses provided more detailed observations of the impact of birth trauma. CONCLUSION: Understanding how birth trauma may present differently in mothers and partners could support effective assessment. Once birth trauma is identified, parents require personalised support to help them cope with the impact.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries.

BACKGROUND: Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning. AUTHORS' CONCLUSIONS: PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Organ Donation at the End of Life: Experiences From the 3 Wishes Project.

PURPOSE: The 3 Wishes Project (3WP) promotes holistic end-of-life care in the intensive care unit (ICU) to honor dying patients, support families, and encourage clinician compassion. Organ donation is a wish that is sometimes made by, or on behalf of, critically ill patients. Our objective was to describe the interface between the 3WP and organ donation as experienced by families, clinicians, and organ donation coordinators. METHODS: In a multicenter evaluation of the 3WP in 4 Canadian ICUs, we conducted a thematic analysis of transcripts from interviews and focus groups with clinicians, organ donation coordinators, and families of dying or died patients for whom donation was considered. RESULTS: We analyzed transcripts from 26 interviews and 2 focus groups with 18 family members, 17 clinicians, and 6 organ donation coordinators. The central theme describes the mutual goals of the 3WP and organ donation-emphasizing personhood and agency across the temporal continuum of care. During family decision-making, conversations encouraged by the 3WP can facilitate preliminary discussions about donation. During preparation for donation, memory-making activities supported by the 3WP redirect focus toward personhood. During postmortem family care, the 3WP supports families, including when donation is unsuccessful, and highlights aspirational pursuits of donation while encouraging reflections on other fulfilled wishes. CONCLUSIONS: Organ donation and the 3WP provide complementary opportunities to engage in value-based conversations during the dying process. The shared values of these programs may help to incorporate organ donation and death into a person's life narrative and incorporate new life into a person's death narrative.

Health care practitioners' views of the support women, partners, and the couple relationship require for birth trauma: current practice and potential improvements.

AIM: To examine health care practitioners' views of the support women, partners, and the couple relationship require when affected by birth trauma, barriers to gaining such support, and potential improvements. BACKGROUND: Ongoing distress following psychologically traumatic childbirth, also known as birth trauma, can affect women, partners, and the couple relationship. Birth trauma can lead to post traumatic stress symptoms (PTSS) or disorder (PTSD). Whilst there is a clear system of care for a PTSD diagnosis, support for the more prevalent experience of birth trauma is not well-defined. METHOD: An online survey of health care practitioners' views of the support parents require for birth trauma, barriers to accessing support, and potential improvements. Practitioners were recruited in 2018 and the sample for the results presented in the article ranged from 95 to 110. RESULTS: Practitioners reported differing needs of support for women, partners, and the couple as a unit. There was correlation between practitioners reporting having the skills and knowledge to support couples and feeling confident in giving support. The support most commonly offered by practitioners to reduce the impact on the couple relationship was listening to the couple. However practitioners perceived the most effective support was referral to a debriefing service. Practitioners observed several barriers to both providing support and parents accessing support, and improvements to birth trauma support were suggested. CONCLUSIONS: Practitioners indicate that some women, partners, and the couple as a unit require support with birth trauma and that barriers exist to accessing effective support. The support that is currently provided often conflicts with practitioners' perception of what is most effective. Practitioners indicate a need to improve the identification of parents who need support with birth trauma, and more suitable services to support them.

Expanding the 3 Wishes Project for compassionate end-of-life care: a qualitative evaluation of local adaptations.

BACKGROUND: The 3 Wishes Project (3WP) is an end-of-life program that honors the dignity of dying patients by fostering meaningful connections among patients, families, and clinicians. Since 2013, it has become embedded in the culture of end-of-life care in over 20 ICUs across North America. The purpose of the current study is to describe the variation in implementation of 3WP across sites, in order to ascertain which factors facilitated multicenter implementation, which factors remain consistent across sites, and which may be adapted to suit local needs. METHODS: Using the methodology of qualitative description, we collected interview and focus group data from 85 clinicians who participated in the successful initiation and sustainment of 3WP in 9 ICUs. We describe the transition between different models of 3WP implementation, from core clinical program to the incorporation of various research activities. We describe various sources of financial and in-kind resources accessed to support the program. RESULTS: Beyond sharing a common goal of improving end-of-life care, sites varied considerably in organizational context, staff complement, and resources. Despite these differences, the program was successfully implemented at each site and eventually evolved from a clinical or research intervention to a general approach to end-of-life care. Key to this success was flexibility and the empowerment of frontline staff to tailor the program to address identified needs with available resources. This adaptability was fueled by cross-pollination of ideas within and outside of each site, resulting in the establishment of a network of like-minded individuals with a shared purpose. CONCLUSIONS: The successful initiation and sustainment of 3WP relied on local adaptations to suit organizational needs and resources. The semi-structured nature of the program facilitated these adaptations, encouraged creative and important ways of relating within local clinical cultures, and reinforced the main tenet of the program: meaningful human connection at the end of life. Local adaptations also encouraged a team approach to care, supplementing the typical patient-clinician dyad by explicitly empowering the healthcare team to collectively recognize and respond to the needs of dying patients, families, and each other. TRIAL REGISTRATION: NCT04147169 , retrospectively registered with clinicaltrials.gov on October 31, 2019.

Protocol for a two-arm feasibility RCT to support postnatal maternal weight management and positive lifestyle behaviour in women from an ethnically diverse inner city population: the SWAN feasibility trial.

INTRODUCTION: A high BMI during and after pregnancy is linked to poor pregnancy outcomes and contributes to long-term maternal obesity, hypertension, and diabetes. Evidence of feasible, effective postnatal interventions is lacking. This randomised controlled trial will assess the feasibility of conducting a future definitive trial to determine effectiveness and cost-effectiveness of lifestyle information and access to Slimming World® (Alfreton, UK) groups for 12 weeks commencing from 8 to 16 weeks postnatally, in relation to supporting longer-term postnatal weight management in women in an ethnically diverse inner city population. METHODS/ANALYSIS: Women will be recruited from one maternity unit in London. To be eligible, women will be overweight (BMI 25-29.9 kg/m2) or obese (BMI ≥ 30 kg/m2) as identified at their first antenatal contact, or have a normal BMI (18.5-24.9 kg/m2) at booking but gain excessive gestational weight as assessed at 36 weeks gestation. Women will be aged 18 and over, can speak and read English, expecting a single baby, and will not have accessed weight management groups in this pregnancy. Women will be randomly allocated to standard care plus lifestyle information and access to Slimming World® (Alfreton, UK) groups or standard care only. A sample of 130 women is required.Feasibility trial objectives reflect those considered most important inform a decision about undertaking a definitive future trial. These include estimation of impact of lifestyle information and postnatal access to Slimming World® (Alfreton, UK) on maternal weight change between antenatal booking weight and weight at 12 months postbirth, recruitment rate and time to recruitment, retention rate, influence of lifestyle information and Slimming World® (Alfreton, UK) groups on weight management, diet, physical activity, breastfeeding, smoking cessation, alcohol intake, physical and mental health, infant health, and health-related quality of life 6 and 12 months postnatally. An embedded process evaluation will assess acceptability of study processes and procedures to women. ETHICS/DISSEMINATION: London-Camberwell St Giles Research Ethics Committee, reference: 16/LO/1422. Outcomes will be disseminated in peer-reviewed journals and presentations at national and international conferences. TRIAL REGISTRATION: Trial registration number: ISRCTN 39186148. Protocol version number: v7, 13 August 17. Trial sponsor: King's College London.

A systematic review and meta-synthesis of the impact of becoming parents on the couple relationship.

BACKGROUND: the transition to parenthood (TTP) is associated with changes to a couple's relationship. Quantitative evidence shows the TTP is associated with reduced satisfaction and quality of a couples' relationships. Qualitative research provides information on the lived experience of couples in the TTP so can provide a more in-depth understanding of the impact. This review therefore aimed to synthesise qualitative research of the perceived impact of the TTP on a couple's relationship in contemporary Western society. DESIGN: a systematic search was conducted of nine databases and grey literature. Key author, citation and reference searches were also undertaken. Papers were included if they presented qualitative data of romantic partner relationships during the TTP with parents aged 18 or over. Studies were restricted to those conducted from 1996 in Western societies. Analysis was conducted using meta-ethnography. FINDINGS: searches identified 5256 papers. After applying inclusion criteria 12 papers were included in the meta-synthesis. Six main themes were identified: (1) Adjustment Phase (a period of change in the relationship), (2) Focus on the Baby (with a sub-theme of feeling unprepared for the relationship impact), (3) Communication (shifts in communication patterns and importance), (4) Intimacy (changes to sexual relations, romance and closeness), (5) Strain on the Relationship (short-term or prolonged), and (6) Strengthened Relationships (deepening of connection and new affinity). Except for the themes of Strain on the Relationship and Strengthened Relationships, the findings showed the TTP had positive and negative impacts on couples' relationships. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the review highlights a range of TTP relationship issues that couples experience and may require help with. Health care professionals working with parents in the TTP may be able to provide support through antenatal education that includes preparation for relationship changes, and provision of postnatal support to identify and overcome problems.

Antenatal weight management: Diet, physical activity, and gestational weight gain in early pregnancy.

OBJECTIVE: to investigate women's physical activity levels, diet and gestational weight gain, and their experiences and motivations of behavior change. DESIGN: analysis of cross-sectional data collected during a longitudinal, cohort study examining physiological, psychological, sociodemographic, and self-reported behavioural measures relating to bodyweight. SETTING: women recruited from routine antenatal clinics at the Nottingham University Hospitals NHS Trust. PARTICIPANTS: 193 women ≤27 weeks gestation and aged 18 years or over. MEASUREMENTS & FINDINGS: measurements included weight and height, the Dietary Instrument for Nutrition Education (Brief Version), the International Physical Activity Questionnaire (Short Form), and open questions of perceptions of behaviour change. 50.3% (n=97) were overweight/obese, and women gained 0.26kg/wk (IQR 0.34kg/wk) since conception. The majority consumed low levels of fat (n=121; 63.4%), high levels of unsaturated fat (n=103; 53.9%), and used a dietary supplement (n=166; 86.5%). However, 41% (n=76) were inactive, 74.8% (n=143) did not consume high levels of fibre, and 90.0% (n=171) consumed less than 5 portions of fruit and vegetables a day. Body mass index category was not associated with diet, physical activity levels, or gestational weight gain. Themes generated from open-questions relating to behaviour change were: (1) Risk management, (2) Coping with symptoms, (3) Self-control, (4) Deviation from norm, (5) Nature knows best. CONCLUSIONS: early pregnancy is a period of significant and heterogeneous behaviour change, influenced by perceptions of risk and women's lived experience. Behaviour was influenced not only by perceptions of immediate risk to the fetus, but also by the women's lived experience of being pregnant. IMPLICATIONS FOR PRACTICE: There are exciting opportunities to constructively reframe health promotion advice relating to physical activity and diet in light of women's priorities. The need for individualized advice is highlighted, and women across all body mass index categories would benefit from improved diet and physical activity levels.

Impact of gonadectomy on blood pressure regulation in ageing male and female rats.

BACKGROUND: Sexual dimorphism in blood pressure has been associated with differential expression of the angiotensin II (AII) receptors and with activity of the nervous system. It is generally accepted that ageing affects kidney function as well as autonomic nervous system and hormonal balance. Given that hypertension is more prevalent in men than women until women reach their seventh decade, we hypothesised that females would be relatively protected from adverse effects of ageing compared to males and that this would be mediated by the protective effect of ovarian steroids. METHODS: Intact and gonadectomised male and female normotensive Wistar rats aged 6, 12 and 18 months were used to study renal function, blood pressure, heart rate, and blood pressure variability. RESULTS: We observed that intact females had lower levels of proteinuria and higher (12.5%) creatinine clearance compared to intact males and that this difference was abolished by castration but not by ovariectomy. Ovariectomy resulted in a change by 9% in heart rate, resulting in similar cardiovascular parameters to those observed in males or gonadectomised males. Spectral analysis of systolic blood pressure revealed that high-frequency power spectra were significantly elevated in the females vs. males and were reduced by ovariectomy. CONCLUSIONS: Taken altogether, the results show that females are protected from age-related declining renal function and to a lesser extent from rising blood pressure in comparison to males. Whilst ovariectomy had some deleterious effects in females, the strongest effects were associated with gonadectomy in males, suggesting a damaging effect of male hormones.

Modelling maternal obesity: the effects of a chronic high-fat, high-cholesterol diet on uterine expression of contractile-associated proteins and ex vivo contractile activity during labour in the rat.

Maternal obesity is associated with prolonged and dysfunctional labour and emergency caesarean section, but the mechanisms are unknown. The present study investigated the effects of an adiposity-inducing high-fat, high-cholesterol (HFHC) diet on uterine contractile-associated protein (CAP) expression and ex vivo uterine contractility in term non-labouring (TNL) and term labouring (TL) rats. Female rats were fed either control chow (CON n=20) or HFHC (n=20) diet 6 weeks before conception and during pregnancy. On gestational day 21 (TNL) or day 22 (TL) CON and HFHC (n=10) rats were killed to determine plasma cholesterol, triacylglycerol and progesterone concentrations and collection of myometrium for contractility studies and expression of CAPs caveolin-1 (Cav-1), connexin-43 (CX-43) and it's phosphorylated form (pCX-43), oxytocin receptor (OXTR) and cyclooxygenase-2 (COX-2). HFHC feeding increased visceral fat (P≤0.001), plasma cholesterol (P≤0.001) and triacylglycerol (P=0.039) concentrations. Stage of labour effected uterine expression of CAV-1 (P<0.02), pCX43 and COX-2 (both P<0.03). CAV-1 and pCX43 decreased but COX-2 increased with parturition. Significant diet- and labour-stage interactions were evident for CX-43 and pCX43 (P<0.03 and P<0.004 respectively). CX-43 decreased with TL in HFHC animals but was unaltered in CON. pCX-43 fell with labour in CON but remained high in HFHC. OXTR expression was significantly higher in HFHC compared with CON animals (P<0.03). Progesterone was higher in HFHC rats at term (P<0.014) but fell significantly with labour to similar concentrations as CON. Contractility studies identified synchronous contractions of stable amplitude in lean animals, but unstable asynchronous contractions with obesity. Uterine dose response to oxytocin was blunted during labour in HFHC rats with a log EC50 of -8.84 compared with -10.25 M in CON for integral activity (P<0.05). In conclusion, our adiposity model exhibits adverse effects on contractile activity during labour that can be investigated further to unravel the mechanisms causing uterine dystocia in obese women.

UK women's experiences of breastfeeding and additional breastfeeding support: a qualitative study of Baby Café services.

BACKGROUND: Whilst 81 % of UK women initiate breastfeeding, there is a steep decline in breastfeeding rates during the early postnatal period, with just 55 % of women breastfeeding at six weeks. 80 % of these women stopped breastfeeding sooner than they intended, with women citing feeding difficulties and lack of adequate support. As part of efforts to increase breastfeeding continuation rates, many public and voluntary organisations offer additional breastfeeding support services, which provide practical support in the early postnatal period and beyond. This paper focuses on the qualitative experiences of UK users of Baby Café services to examine their experiences of breastfeeding and breastfeeding support. METHODS: The study was based upon in-depth interviews and focus groups with users of eight Baby Café breastfeeding support groups across the UK. Thirty-six interviews and five focus groups were conducted with a total of fifty-one mothers using the service. Interviews and group discussions were analysed using N Vivo software to draw out key themes and discussions. RESULTS: Whilst each mother's infant feeding journey is unique, reflecting her own personal circumstances and experiences, several themes emerged strongly from the data. Many women felt that they had been given unrealistic expectations of breastfeeding by professionals keen to promote the benefits. This left them feeling unprepared when they encountered pain, problems and relentlessness of early infant feeding, leading to feelings of guilt and inadequacy over their feeding decisions. Mothers valued the combination of expert professional and peer support provided by Baby Café services and emphasised the importance of social support from other mothers in enabling them to continue feeding for as long as they wished. CONCLUSIONS: The research emphasises the need for realistic rather than idealistic antenatal preparation and the importance of timely and parent-centred breastfeeding support, particularly in the immediate postnatal weeks. The findings suggest that effective social support, combined with reassurance and guidance from skilled practitioners, can help women to overcome difficulties and find confidence in their own abilities to achieve their feeding goals. However, further work is needed to make sure such services are readily accessible to women from all sectors of the community.

Protective role of female gender in programmed accelerated renal aging in the rat.

The aging kidney exhibits a progressive decline in glomerular filtration rate, accompanied by inflammatory and oxidative damage. We hypothesized that accelerated, age-related progression of renal injury is ovarian hormones-dependant. To address this we used an established model of developmentally programmed accelerated renal aging in the rat, superimposed by ovariectomy to assess interactions between ovarian hormones and the aging process. Under our experimental conditions, we found that kidney function worsens with age, that is GFR reduces over 18 month analyzed time-course and this was worsened by fetal exposure to maternal low-protein diet and absence of estrogen. Reduction in GFR was followed by increases in albuminuria, proteinuria, inflammatory markers, and tissue carbonyls, all suggesting inflammatory response and oxidative stress. This was associated with changes in AGTR2 expression which was greater at 18 months of age compared to earlier time points, but in MLP offspring only. Our studies show an influence of ovarian hormones on programmed accelerated renal aging and the AGTR2 across the lifespan. The main findings are that ovariectomy is a risk factor for increased aging-related renal injury and that this and oxidative damage might be related to changes in AGTR2 expression.

Maternal age effects on myometrial expression of contractile proteins, uterine gene expression, and contractile activity during labor in the rat.

Advanced maternal age of first time pregnant mothers is associated with prolonged and dysfunctional labor and significant risk of emergency cesarean section. We investigated the influence of maternal age on myometrial contractility, expression of contractile associated proteins (CAPs), and global gene expression in the parturient uterus. Female Wistar rats either 8 (YOUNG n = 10) or 24 (OLDER n = 10) weeks old were fed laboratory chow, mated, and killed during parturition. Myometrial strips were dissected to determine contractile activity, cholesterol (CHOL) and triglycerides (TAG) content, protein expression of connexin-43 (GJA1), prostaglandin-endoperoxide synthase 2 (PTGS2), and caveolin 1 (CAV-1). Maternal plasma concentrations of prostaglandins PGE2, PGF2α, and progesterone were determined by RIA. Global gene expression in uterine samples was compared using Affymetrix Genechip Gene 2.0 ST arrays and Ingenuity Pathway analysis (IPA). Spontaneous contractility in myometrium exhibited by YOUNG rats was threefold greater than OLDER animals (P < 0.027) but maternal age had no significant effect on myometrial CAP expression, lipid profiles, or pregnancy-related hormones. OLDER myometrium increased contractile activity in response to PGF2α, phenylephrine, and carbachol, a response absent in YOUNG rats (all P < 0.002). Microarray analysis identified that maternal age affected expression of genes related to immune and inflammatory responses, lipid transport and metabolism, steroid metabolism, tissue remodeling, and smooth muscle contraction. In conclusion YOUNG laboring rat myometrium seems primed to contract maximally, whereas activity is blunted in OLDER animals and requires stimulation to meet contractile potential. Further work investigating maternal age effects on myometrial function is required with focus on lipid metabolism and inflammatory pathways.

Development and verification of a hydrostatic pressure chamber for determining the efffect of pressure on liver progenitor cells.

Hepatic progenitor cells (HPCs) have regenerative properties that could aid the development of treatments for severe liver disease. To study how pressure influences HPC fate, a hydrostatic pressure-controlled cell culture chamber was developed. The design incorporates custom LabView scripting for enhanced pressure regulation and data acquisition. Pressure can be controlled within ±0.2mmHg. Continuous airflow permits gas exchange, and CO2 is maintained at 5%±0.2%. Applied pressures range from 5 to 20 mmHg, reflecting interstitial pressure conditions in healthy and diseased livers, respectively. Bipotential Murine Oval Liver (BMOL) cells, an HPC-like cell line, were cultured in the chamber to test for maintenance of cell viability, adequate CO2 regulation, and maintenance of adequate media volume over 24 hours. Cultured cells were exposed to 5 or 19 mmHg. After 24 hours, media pH was measured, viable cells were counted (Trypan Blue, n=3), and plates were weighed to assess fluid loss. The number of live cells cultured under pressure vs. control conditions was not statistically different (p>.05). The pH remained constant at 7.0 for all conditions, suggesting adequate gas exchange. Evaporation of media was minimal at 3.97%. Results indicate that the pressure chamber provides appropriate environmental conditions for future studies on HPC pressure sensitivity.

Childhood obesity: the impact on long-term risk of metabolic and CVD is not necessarily inevitable.

The worldwide prevalence of overweight and obesity in the adult population is estimated to be 35%. These trends are reflected in childhood obesity prevalence, and the potential impact of early-onset obesity is of great concern. The aim of this review was to investigate the long-term implications of childhood obesity for metabolic and cardiovascular health, focusing on the independent contribution of childhood obesity to adult disease risk, as distinct from associations mediated by tracking of obesity across the lifespan. The data systematically reviewed provide little evidence to suggest that childhood overweight and obesity are independent risk factors for metabolic and cardiovascular risk during adulthood. Instead, the data demonstrate that the relationships observed are dependent on tracking of BMI between childhood and adulthood, alongside persistence of dietary patterns and physical activity. Adjustment for adult BMI uncovers unexpected negative associations between childhood BMI and adult disease, suggesting a protective effect of childhood obesity at any given level of adult BMI. Further work is required to explain these findings, both in terms of pathways and statistical artefacts. To conclude, it must be stressed that it is not suggested that childhood obesity is without negative consequence. Childhood obesity is clearly associated with a range of adverse physical and psychological outcomes. However, the data are important in supporting a positive message that the long-term consequences of childhood obesity are avoidable; and that there remains opportunity for intervention across the lifespan. This nuance in understanding long-term risk is important when considering the effectiveness of interventions at different stages of the lifespan.