Women's experiences of remote video calls with a labour ward midwife during early labour.

BACKGROUND: In an increasingly strained maternity care system with a shortage of midwives and great demands for service, pregnant women in their early labour are at risk of receiving insufficient support. Women make calls and visit the labour ward on multiple occasions before being admitted. A video call with a labour ward midwife during early labour is an unknown practice but could support pregnant women and their partners during this uncertain period. AIM: The study aimed to describe women's experiences of remote video calls with a labour ward midwife during early labour. METHODS: A qualitative study comprising nine semi-structured interviews followed by an inductive thematic analysis was conducted. RESULTS: The results revealed that video calls prepared women and their partners by means of practical support. They received an assessment of early labour and the interaction with labour ward midwives prepared them for the impending birth. The participants reported feeling secure and strengthened by being met at their current stage of labour. Furthermore, they found the service accessible, easy to use and emphasised the need for increased availability and continuity. CONCLUSION: This study highlights the positive impact of video calls in early labour when conducted by competent labour ward midwives. The perceived accessibility and ease of use e-health system underscore a demand for extended availability. These findings indicate the potential benefits of integrating video calls in labour care to enhance support, security, accessibility and overall satisfaction for pregnant women and their partners.

Burnout among midwives-the factorial structure of the burnout assessment tool and an assessment of burnout levels in a Swedish national sample.

BACKGROUND: Many workplaces, within the healthcare sector, experience high rates of mental health problems such as burnout, anxiety, and depression, due to poor psychosocial working conditions and midwives are not an exception. To develop preventive interventions, epidemiologic surveillance of burnout levels, and their relation to professional specific working conditions is needed. Aims of this study is to assess the construct validity of the Burnout Assessment Tool (BAT) in the context of Swedish midwives, to evaluate whether the item responses can be combined into a single score and differential item functioning regarding age. Another aim was to assess the burnout levels of Swedish midwives. METHODS: Data come from a national cohort of Swedish midwives (n = 1664). The construct validity was evaluated using Rasch analysis. Burnout levels were presented by median and first (Q1) and third (Q3) quartiles for the BAT total score and the four subscales (exhaustion, mental distance, cognitive and emotional impairment). RESULTS: In the analysis including all 23 items the fit to the Rasch model was not obtained. Items within each subscale clustered together in a residual correlation matrix in a pattern consistent with the underlying conceptualization of the BAT, indicating multidimensionality. The Rasch analysis was re-run using the four testlets as input variables which resulted in a good fit. The median burnout level was 2.0 (Q1 = 1.6, Q3 = 2.4). The four subscales differentiated the picture (elevated levels on exhaustion and low levels on the other three subscales). CONCLUSIONS: The construct validity of the BAT for use in the context of Swedish midwives was confirmed. The results indicated a strong general factor, meaning that the responses can be combined into a single burnout score. The scale works invariantly for different age groups. The results of this study secure access to a validated instrument to be used for accurate assessment of the burnout levels among midwives in Sweden.

Job satisfaction in midwives and its association with organisational and psychosocial factors at work: a nation-wide, cross-sectional study.

BACKGROUND: Midwives report a challenging work environment globally, with high levels of burnout, insufficient work resources and low job satisfaction. The primary objective of this study was to identify factors in the organisational and psychosocial work environment associated with midwives' job satisfaction. A secondary objective was to identify differences in how midwives assess the organisational and psychosocial work environment compared to Swedish benchmarks. METHODS: This nation-wide, cross-sectional web survey study analysed midwives' assessment of their organisational and psychosocial work environment using the COPSOQ III instrument. A multivariable, bi-directional, stepwise linear regression was used to identify association with job satisfaction (N = 1747, 99.6% women). A conventional minimal important score difference (MID ± 5 as a noticeable difference with clinical importance) were used to compare midwives' results with Swedish benchmarks. RESULTS: A multivariable regression model with 13 scales explained the variance in job satisfaction (R2 = .65). Five scales, possibilities for development, quality of work, role conflict, burnout and recognition, explained most of the variance in midwives' job satisfaction (R2 = .63) and had ß values ranging from .23 to .10. Midwives had adverse MID compared to Swedish benchmarks with higher difference in mean values regarding quantitative demands (8.3), work pace (6.0) emotional demand (20.6), role conflicts (7.9) and burnout (8.3). In addition, lower organisational justice (-6.4), self-rated health (-8.8), influence (-13.2) and recognition at work (-5.8). However, variation and meaning of work showed a beneficial difference in mean values with 7.9 and 13.7 respectively. CONCLUSIONS: Midwives reported high levels of meaningfulness in their work, and meaningfulness was associated with job satisfaction. However, midwives also reported adversely high demands and a lack of influence and recognition at work and in addition, high role conflict and burnout compared to Swedish benchmarks. The lack of organisational resources are modifiable factors that can be taken into account when structural changes are made regarding organisation of care, management and resource allocation. Midwives are necessary to a high quality sexual, reproductive and perinatal health care. Future studies are needed to investigate if job satisfaction can be improved through professional recognition and development, and if this can reduce turnover in midwives.

Professional courage to create a pathway within midwives' fields of work: a grounded theory study.

BACKGROUND: The theory of salutogenesis focuses on resources for health and health-promoting processes. In the context of midwives' work, this is not well described despite the importance for occupational health and the intention to remain in the profession. In order to promote a healthy workplace, it is necessary to consider the facilitating conditions that contribute to a sustainable working life. Therefore, the aim of this study was to explore health-promoting facilitative conditions in the work situation on labour wards according to midwives. METHODS: A constant comparative analysis was applied to face-to-face interviews with midwives that constituted the empirical material in this classical grounded theory study. RESULTS: The substantive theory of Professional courage to create a pathway within midwives' fields of work emerged as an explanation of the health-promoting facilitative conditions in midwives' work situation. The theory consists of a four-stage process with prerequisite contextual conditions: visualising midwifery, organisational resources and a reflective and learning environment, that were needed to fulfil the midwives' main concern a Feasibility of working as a midwife. This meant being able to work according to best-known midwifery theory and practice in each situation. Positive consequences of a fulfilled main concern were a professional identity and grounded knowledge that enabled the development of the resistant resource professional courage. The courage made it feasible for midwives to move freely on their pathway within the different fields of work extending between normal and medicalised birth and being autonomous and regulated. CONCLUSIONS: A professional courage was required to create a pathway within midwives' fields of work, to move freely depending on what actions were needed in a particular work situation. Professional courage could be seen as a resistance resource, enabling midwives to become resilient when dealing with the unpredictable work situation. However, there are vital organisational preconditions that needed to be fulfilled for workplaces to become facilitative, organisational resources, visualising midwifery and a reflective environment. The theory can be used to foster health-promoting and sustainable work situations for midwives, which is possible if the organisational preconditions are met. This could be a key factor in retaining midwives in the profession.

Work situation and professional role for midwives at a labour ward pre and post implementation of a midwifery model of care - A mixed method study.

Purpose: To explore and analyse the experience of work situation and professional role for midwives at a labour ward pre and post the implementation of a midwifery model of care (MiMo). Methods: A simultaneous mixed method was used. The qualitative core component departed from three focus group interviews (n = 16 midwives). Secondary inductive and deductive content analysis was performed using an unconstrained matrix to make a corresponding comparison of the different time points. The supplemental component was a quantitative survey about the work situation (n = 58). Results: The qualitative results pre the implementation showed three categories: Balance between Women and Organization, Midwives-Diverse as both Profession and Person, and Strained Work Situation. Post the intervention they transformed to Balance between Midwifery and Organization, Midwives-An Adaptable Profession, Strained Work Situation, and a new category Ability to concretize midwifery was found. There were no significant differences in the measures of work situation in the quantitative analyses. Conclusions: The synthesized findings based on the qualitative part show that MiMo has a potential to strengthen the professional role and midwifery practice. As such, MiMo has the capability to offer benefits to the labour wards with additional considerations.

Placental glucocorticoid receptors are not affected by maternal depression or SSRI treatment.

Background: Prenatal depression is common, with an estimate that up to one in five pregnant women suffers from depressive symptoms. Maternal depression is associated with poor pregnancy outcomes such as preterm birth and low birth-weight. Such outcomes possibly affect offspring development. Previous studies suggest placental RNA levels of the glucocorticoid receptor are altered by maternal depression or anxiety; this stress may affect the placenta of male and female foetuses differently. However, it is unknown if the protein levels and activity of this receptor are additionally affected in women with depressive symptoms or being pharmacologically treated for depression.Methods: In this study, we investigated whether the glucocorticoid receptor (NR3C1) in the placenta is affected by maternal depression and/or selective serotonin reuptake inhibitor (SSRIs) treatment. Placentas from 45 women with singleton, term pregnancies were analysed by Western blot to determine glucocorticoid receptor levels, and by DNA-binding capacity to measure glucocorticoid receptor activation.Results: There were no differences in levels of the glucocorticoid receptor or activity between groups (control, depressive symptoms, and SSRI treatment; n = 45). Similarly, there was no difference in placental glucocorticoid receptor levels or activity dependent upon foetal sex.Conclusion: Maternal depression and SSRI treatment do not affect the glucocorticoid receptors in the placenta.

Veiled midwifery in the baby factory - A grounded theory study.

BACKGROUND: Midwives' professional role has been changing drastically over time, from handling births in home settings to being part of a team in labour wards in hospitals. This demands a greater effort of interprofessional collaboration in childbirth care. AIM: Explore midwives' work in a hospital-based labour ward from the perspectives of other professions, working in the same ward. METHOD: Classical grounded theory, using a constant comparative analysis, was applied to focus group interviews with obstetricians, assistant nurses and managers to explore their views of midwifery work during childbirth. FINDINGS: The substantive theory of 'veiled midwifery' emerged as an explanation of the social process between the professions in the 'baby factory' context. The other professionals perceive midwifery through a veil that filters the reality and only permits fragmentary images of the midwives' work. The main concern for the other professions was that the midwives were 'marching to own drum'. The midwives were perceived as both in dissonance with the baby factory, and therefore hard to control, or, alternatively more compliant with the prevailing rhythm. This caused an unpredictability and led to feelings of frustration and exclusion. Which in turn resulted in attempts to cooperate and gain access to the midwifery world, by using three unveiling strategies: Streamlining, Scrutinising and Collaborating admittance. CONCLUSIONS: Findings provide a theoretical conceptualisation of a 'veiled midwifery 'that causes problems for the surrounding team. This generates a desire to streamline and control midwifery in order to increase interprofessional collaboration.

DC-LAMP+ dendritic cells are recruited to gastric lymphoid follicles in Helicobacter pylori-infected individuals.

Infection with Helicobacter pylori is associated with development of ulcer disease and gastrointestinal adenocarcinoma. The infection leads to a large infiltration of immune cells and the formation of organized lymphoid follicles in the human gastric mucosa. Still, the immune system fails to eradicate the bacteria, and the substantial regulatory T cell (Treg) response elicited is probably a major factor permitting bacterial persistence. Dendritic cells (DCs) are professional antigen-presenting cells that can activate naive T cells, and maturation of DCs is crucial for the initiation of primary immune responses. The aim of this study was to investigate the presence and localization of mature human DCs in H. pylori-infected gastric mucosa. Gastric antral biopsy specimens were collected from patients with H. pylori-associated gastritis and healthy volunteers, and antrum tissue was collected from patients undergoing gastric resection. Immunohistochemistry and flow cytometry showed that DCs expressing the maturation marker dendritic cell lysosome-associated membrane glycoprotein (DC-LAMP; CD208) are enriched in the H. pylori-infected gastric mucosa and that these DCs are specifically localized within or close to lymphoid follicles. Gastric DC-LAMP-positive (DC-LAMP(+)) DCs express CD11c and high levels of HLA-DR but little CD80, CD83, and CD86. Furthermore, immunofluorescence analyses demonstrated that DC-LAMP(+) DCs are in the same location as FoxP3-positive putative Tregs in the follicles. In conclusion, we show that DC-LAMP(+) DCs with low costimulatory capacity accumulate in the lymphoid follicles in human H. pylori-infected gastric tissue, and our results suggest that Treg-DC interactions may promote chronic infection by rendering gastric DCs tolerogenic.

Quality of the intimate and sexual relationship in first-time parents - a longitudinal study.

OBJECTIVES: To describe experienced relationship quality, and in particular sensuality and sexuality, in first-time parents over time from when the firstborn is six months (T1), four years (T2) and eight years (T3) of age, to describe gender differences and the factors which may affect experienced relationship quality. METHOD: A longitudinal design with repeated measures using the self-reporting questionnaire Quality of Dyadic Relationship, QDR36, which was answered by 258 parents at all three occasions. Data was analysed primarily using Friedman's test and multiple regression analysis. RESULTS: The relationship quality statistically significantly decreased at T2 and then significantly increased again at T3 but not back to the level of origin at T1 (p<0.000). Both sexes showed a similar change over time in the QDR-index. The dimension Dyadic Sensuality statistically significantly decreased at all three occasions (p<0.000) and Dyadic Sexuality showed no significant differences over time but remained at a low level at all three occasions. Sexual Frequency and Contentment decreased at T3 after a small increase at T2. Four covariates of perceived relationship quality at T3 were statistically significant; strained relationship with the child, strained health, Sense of Coherence and strained economy. Cronbach's alpha showed a high reliability (0.95) at T3 and indicates a development of the QDR 36. CONCLUSION: The results showing low intimacy in the relationship indicate a need of support from professionals, e.g. midwives, to couples with small children, for instance by enhancing communication skills and emphasizing the role of sensuality and sexuality.

DC-derived IL-18 drives Treg differentiation, murine Helicobacter pylori-specific immune tolerance, and asthma protection.

Persistent colonization with the gastric bacterial pathogen Helicobacter pylori causes gastritis and predisposes infected individuals to gastric cancer. Conversely, it is also linked to protection from allergic, chronic inflammatory, and autoimmune diseases. We demonstrate here that H. pylori inhibits LPS-induced maturation of DCs and reprograms DCs toward a tolerance-promoting phenotype. Our results showed that DCs exposed to H. pylori in vitro or in vivo failed to induce T cell effector functions. Instead, they efficiently induced expression of the forkhead transcription factor FoxP3, the master regulator of Tregs, in naive T cells. Depletion of DCs in mice infected with H. pylori during the neonatal period was sufficient to break H. pylori-specific tolerance. DC depletion resulted in improved control of the infection but also aggravated T cell-driven immunopathology. Consistent with the mouse data, DCs infiltrating the gastric mucosa of human H. pylori carriers exhibited a semimature DC-SIGN(+)HLA-DR(hi)CD80(lo)CD86(lo) phenotype. Mechanistically, the tolerogenic activity of H. pylori-experienced DCs was shown to require IL-18 in vitro and in vivo; DC-derived IL-18 acted directly on T cells to drive their conversion to Tregs. CD4(+)CD25(+) Tregs from infected wild-type mice but not Il18(-/-) or Il18r1(-/-) mice prevented airway inflammation and hyperresponsiveness in an experimental model of asthma. Taken together, our results indicate that tolerogenic reprogramming of DCs ensures the persistence of H. pylori and protects against allergic asthma in a process that requires IL-18.

FOXP3-expressing CD4(+) T-cell numbers increase in areas of duodenal gastric metaplasia and are associated to CD4(+) T-cell aggregates in the duodenum of Helicobacter pylori-infected duodenal ulcer patients.

BACKGROUND: We have previously demonstrated that Helicobacter pylori infection is associated with an increased number of CD4(+)CD25(high) regulatory T cells in the gastric and duodenal mucosa. In this study, we determined the number and localization of CD4(+) cells expressing the regulatory T-cell-specific transcription factor FOXP3 in the antrum and duodenum of duodenal ulcer patients, asymptomatic carriers, and uninfected individuals. We also determined gene expression levels of FOXP3 as well as anti- and proinflammatory cytokines before and after H. pylori eradication. METHODS: Cellular FOXP3 expression was studied by immunofluorescence and flow cytometry, and transcription levels of FOXP3, interleukin (IL)-10, transforming growth factor-beta, CD4, and interferon-gamma were analyzed by real-time reverse transcription-polymerase chain reaction. RESULTS: We found an increased (6-fold) frequency of CD4(+)FOXP3(+) T cells in H. pylori-infected gastric mucosa; interestingly 26% of these cells did not co-express CD25. The increase of FOXP3-expressing T cells in the antrum of infected individuals was dependent on the presence of H. pylori, since eradication therapy resulted in 4-fold lower levels of FOXP3 and IL-10 mRNA in the antrum. Furthermore, higher numbers of CD4(+)FOXP3(+) T cells were found in areas of duodenal gastric metaplasia in the duodenum of duodenal ulcer patients compared to duodenal gastric metaplasia of asymptomatic individuals and healthy mucosa in both patient groups. In duodenal ulcer patients, the CD4(+)FOXP3(+) T cells were more highly associated to aggregates in the duodenal mucosa. CONCLUSION: The numbers of CD4(+)FOXP3(+) T cells are increased and localized in CD4(+) T-cell aggregates in areas of duodenal gastric metaplasia in duodenal ulcer patients.

Selective upregulation of endothelial E-selectin in response to Helicobacter pylori-induced gastritis.

Helicobacter pylori is one of the most common bacterial pathogens, infecting up to 50% of the world's population. The host is not able to clear the infection, leading to life-long chronic inflammation with continuous infiltration of lymphocytes and granulocytes. The migration of leukocytes from the blood into inflamed tissue is dependent on adhesion molecules expressed on the vascular endothelium. The aim of this study was to characterize the effect of H. pylori-induced gastritis with regard to the expression of endothelial adhesion molecules in the gastric mucosa and compare this to other types of chronic mucosal inflammations. Our results demonstrate an increased level of expression of the adhesion molecule E-selectin, but not of intracellular adhesion molecule 1, vascular adhesion molecule 1, or vascular adhesion protein 1, in H. pylori-induced gastritis but not in gastritis induced by acetylsalicylic acid or pouchitis. The upregulated E-selectin expression was determined to be localized to the gastric mucosa rather than being a systemic response to the infection. Moreover, the H. pylori type IV secretion system encoded by the cag pathogenicity island (cagPAI) was found to be an important determinant for the upregulation of human endothelial E-selectin expression in vitro, and this process is probably dependent on the CagL protein, mediating binding to alpha5beta1 integrins. Thus, endothelial E-selectin expression induced by H. pylori probably contributes to the large influx of neutrophils and macrophages seen in infected individuals, and our results suggest that this process may be more pronounced in patients infected with cagPAI-positive H. pylori strains and may thereby contribute to tissue damage in these individuals.

Decreased IgA antibody production in the stomach of gastric adenocarcinoma patients.

Gastric adenocarcinoma is closely associated with Helicobacter pylori infection. It is also much more frequent in patients with common variable immunodeficiency or selective IgA-deficiency than in the general population. To investigate a possible link between local antibody production and gastric tumors, we studied gastric B cell infiltration and local IgA production in patients with H. pylori induced gastric adenocarcinomas. These studies showed that total and H. pylori-specific IgA antibody levels were substantially lower in gastric tissue from the cancer patients compared to those from asymptomatic H. pylori carriers. However, serum IgA levels were similar in the cancer patients and asymptomatic carriers. As could be expected, H. pylori infected asymptomatic carriers had considerably increased IgA antibody levels compared to uninfected subjects. We conclude that patients suffering from gastric adenocarcinoma have a dramatically decreased local IgA production in the stomach compared to asymptomatic H. pylori infected individuals.

CCL28 is increased in human Helicobacter pylori-induced gastritis and mediates recruitment of gastric immunoglobulin A-secreting cells.

Human Helicobacter pylori infection gives rise to an active chronic gastritis and is a major risk factor for the development of duodenal ulcer disease and gastric adenocarcinoma. The infection is accompanied by a large accumulation of immunoglobulin A (IgA)-secreting cells in the gastric mucosa, and following mucosal immunization only H. pylori-infected volunteers mounted a B-cell response in the gastric mucosa. To identify the signals for recruitment of gastric IgA-secreting cells, we investigated the gastric production of CCL28 (mucosa-associated epithelial chemokine) and CCL25 (thymus-expressed chemokine) in H. pylori-infected and uninfected individuals and the potential of gastric B-cell populations to migrate toward these chemokines. Gastric tissue from H. pylori-infected individuals contained significantly more CCL28 protein and mRNA than that from uninfected individuals, while CCL25 levels remained unchanged. Chemokine-induced migration of gastric lamina propria lymphocytes isolated from patients undergoing gastric resection was then assessed using the Transwell system. IgA-secreting cells and IgA(+) memory B cells from H. pylori-infected tissues migrated toward CCL28 but not CCL25, while the corresponding cells from uninfected patients did not. Furthermore, IgG-secreting cells from H. pylori-infected patients did not migrate to CCL28 but instead to CXCL12 (SDF-1alpha). However, chemokine receptor expression did not correlate to the migratory pattern of the different B-cell populations. These studies are the first to show increased CCL28 production during gastrointestinal infection in humans and provide an explanation for the large influx of IgA-secreting cells to the gastric mucosa in H. pylori-infected individuals.

Dendritic cells express CCR7 and migrate in response to CCL19 (MIP-3beta) after exposure to Helicobacter pylori.

Helicobacter pylori infection induces chronic inflammation in the gastric mucosa with a marked increase in the number of lymphoid follicles consisting of infiltrating B and T cells, neutrophils, dendritic cells (DC) and macrophages. It has been suggested that an accumulation of mature DC in the tissue, resulting from a failure of DC to migrate to lymph nodes, may contribute to this chronic inflammation. Migration of DC to lymph nodes is regulated by chemokine receptor CCR7, expressed on mature DC, and the CCR7 ligands CCL19 and CCL21. In this study we analysed the maturation, in vitro migration and cytokine production of human DC after stimulation with live H. pylori. For comparison, DC responses to non-pathogenic Escherichia coli bacteria were also evaluated. Stimulation with H. pylori induced maturation of DC, i.e. up-regulation of the chemokine receptors CCR7 and CXCR4 and the maturation markers HLA-DR, CD80 and CD86. The H. pylori-stimulated DC also induced CD4(+) T-cell proliferation. DC stimulated with H. pylori secreted significantly more interleukin (IL)-12 compared to DC stimulated with E. coli, while E. coli-stimulated DC secreted more IL-10. Despite low surface expression of CCR7 protein following stimulation with H. pylori compared to E. coli, the DC migrated equally well towards CCL19 after stimulation with both bacteria. Thus, we could not detect any failure in the migration of H. pylori stimulated DC in vitro that may contribute to chronic gastritis in vivo, and our results suggest that H. pylori induces maturation and migration of DC to lymph nodes where they promote T cell responses.