[Maternal-fetal therapy: from saving the fetus towards a better life for the future child]. / Ontwikkelingen in maternale-foetale therapie.

Maternal-fetal therapy (MFT) is special because treatment of the fetus is exclusively possible through the body of another person, the pregnant woman. MFT is a broad specialty with diverse interventions. In this manuscript several examples of innovations in MFT are discussed to illustrate the shift of lifesaving interventions to interventions aiming to improve morbidity of the future child. The broadening of the scope and shift towards prenatal treatments improving morbidity result in new ethical challenges. Particularly attention is needed for counseling and (the risk of) therapeutic misconception.

Fetal medicine specialist experiences of providing a new service of termination of pregnancy for fatal fetal anomaly: a qualitative study.

OBJECTIVE: To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time. DESIGN: Qualitative study. SETTING: Fetal medicine units in the Republic of Ireland. POPULATION: Ten fetal medicine specialists from five of the six fetal medicine units. METHODS: nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews. MAIN OUTCOME MEASURES: Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA. RESULTS: Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'. CONCLUSIONS: Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service. TWEETABLE ABSTRACT: The implementation of termination services for fatal fetal anomaly is complex and requires institutional support.

Desafios do processo gestacional de mulheres negras: uma revisão narrativa / Challenges in the gestational process of black women: hia narrative review

Esta revisão narrativa procura discutir aspectos concernentes ao processo gestacional de mulheres negras, quais sejam: se existem diferenças de tratamento entre mulheres brancas e negras durante a gravidez e nos momentos do parto e pós-parto, como essas diferenças são influenciadas pelos aspectos fisiológicos de cada grupo étnico e como isso afeta as taxas de morbimortalidade. Para esta revisão, quatro bases de dados foram usadas (SciELO, LILACS, PubMed e MEDLINE) e 23 artigos foram lidos na íntegra, depois de selecionados por data de publicação, língua, país da pesquisa e análise dos títulos e resumos. Como principais resultados, os autores encontraram diferenças claras entre mulheres brancas e negras quanto ao acesso à saúde, sendo as negras mais propensas a usar os sistemas públicos e ter menos consultas pré-natal. Também foi observado que as mulheres negras reportaram maus-tratos mais vezes, tinham maiores chances de serem proibidas de ter um acompanhante durante o parto e recebiam menos anestesia para episiotomias. As características fisiológicas também foram apontadas várias vezes. Nesse sentido, altas taxas de anemia ferropriva e hipertensão durante a gravidez foram mais comuns entre as negras. Além disso, em se tratando de taxas de morbimortalidade, mulheres negras tinham uma chance consideravelmente maior de serem readmitidas pós-parto e maiores taxas de mortalidade, quando comparadas com mulheres brancas.(AU)

This review aims to discuss aspects related to the gestational process of black women, namely: if there is a difference in how black and white women are treated throughout pregnancy, partum and postpartum moments, how this difference is influenced by the physiological aspects of each ethnical group and how it affects their morbidity and mortality rates. For this review, four databases were used (SciELO, LILACS, PubMed and MEDLINE) and 23 articles were fully read, after being selected by publishing date, language, country of research, title and abstract analysis. The authors found as the main results clear differences between black women's and white women's access to health care, as black women are more likely to use public health care systems and have fewer prenatal appointments. It was also noticed that black women reported maltreatment more frequently, had a higher chance of being prohibited from keeping a companion during labor and suffering from less local anesthesia for episiotomy. The physiological characteristics were also pointed out several times, with high rates of iron deficiency anemia and hypertension during pregnancy being more common among black women. Moreover, when it comes to morbidity and mortality rates, black women had an extremely higher chance of being readmitted postpartum, and a higher mortality rate, when compared to white women.(AU)

Voices of the vulnerable: Exploring the livelihood strategies, coping mechanisms and their impact on food insecurity, health and access to health care among Syrian refugees in the Beqaa region of Lebanon.

Lebanon has approximately one million Syrian refugees (SR) registered with the United Nations High Commission on Refugees (UNHCR) and an unknown number of unregistered SR, who cannot benefit from formal assistance. This study aimed to examine the livelihoods, coping strategies, and access to healthcare among SR based on registration status and accompanying formal assistance. A mixed-method approach with more emphasis on the qualitative design was adopted. A purposive convenient sampling approach was used to recruit SR from informal tented settlements (ITS) in the Beqaa region in Lebanon. Data collection included 19 focus group discussions (FGDs) that were conducted with participants, who were further divided into three groups: registered refugees with assistance, registered without assistance and unregistered. Twelve in-depth interviews were conducted with key informants from humanitarian organizations. All interviews and FGDs were audio recorded, transcribed, and thematically analyzed. SR were highly dependent on formal assistance when received, albeit being insufficient. Regardless of registration status, refugees resorted to informal livelihood strategies, including informal employment, child labor, early marriage, and accruing debt. Poor living conditions and food insecurity were reported among all SR. Limited healthcare access and high out-of-pocket costs led to limited use of antenatal care services, prioritizing life-threatening conditions, and resorting to alternative sources of healthcare. Severity of these conditions and their adverse health consequences were especially pronounced among unregistered refugees. Our findings shed light on the economic and health disparities among marginalized SR, with the lack of registration and formal assistance increasing their vulnerability. More tailored and sustainable humanitarian programs are needed to target the most vulnerable and hard-to-reach groups.

Ethical considerations relevant to infections in pregnancy: Application to Sars-Covid-19.

Despite wide diversity and scope, the ethical dimensions relevant to infections in pregnancy remain little explored. Important questions span topics with personal or wider societal and public health impact. The conceptualization of the status and responsibilities of the pregnant woman and the legitimate limits of third-party interests are key determinants of our appreciation of applicable ethical obligations.

Professionally responsible counseling about birth location during the COVID-19 pandemic.

If the worries about the coronavirus disease 2019 (COVID-19) pandemic are not already enough, some pregnant women have been questioning whether the hospital is a safe or safe enough place to deliver their babies and therefore whether they should deliver out-of-hospital during the pandemic. In the United States, planned out-of-hospital births are associated with significantly increased risks of neonatal morbidity and death. In addition, there are obstetric emergencies during out-of-hospital births that can lead to adverse outcomes, partly because of the delay in transporting the woman to the hospital. In other countries with well-integrated obstetric services and well-trained midwives, the differences in outcomes of planned hospital birth and planned home birth are smaller. Women are empowered to make informed decisions when the obstetrician makes ethically justified recommendations, which is known as directive counseling. Recommendations are ethically justified when the outcomes of one form of management is clinically superior to another. The outcomes of morbidity and mortality and of infection control and prevention of planned hospital birth are clinically superior to those of out-of-hospital birth. The obstetrician therefore should recommend planned hospital birth and recommend against planned out-of-hospital birth during the COVID-19 pandemic. The COVID-19 pandemic has increased stress levels for all patients and even more so for pregnant patients and their families. The response in this difficult time should be to mitigate this stress and empower women to make informed decisions by routinely providing counseling that is evidence-based and directive.

[Prenatal vulnerabilities, ethical issues of prevention: French regional practice survey] / Vulnérabilités prénatales, enjeux éthiques de la prévention : enquête de pratiques.

OBJECTIVE: Some prenatal situations may be characterized as concerning on the medico-psycho-social level, leaving a risk of danger to the unborn child, raising different issues between prevention and protection, legal and justified. The objectives were to evaluate the professionals' perceptions with respect to the most worrying prenatal situations, to assess the practices of care, and to identify potential measures for improvement. METHOD: The research was based on a qualitative-quantitative methodology: Semi-directed interviews with experts who allowed the construction of a questionnaire, validated according to a Delphi-type methodology, and a regional survey based on the questionnaire, which was directed to the maternities and the departmental councils. RESULTS: The participation rate was 69%. The survey revealed a willingness to create regional perinatal partnerships, an awareness of ethical issues (information sharing, conflict of values, ethics of Care, vulnerability…), and a lack of knowledge of the regulatory framework (legal, ethical). Different possibilities of improvement have been proposed. CONCLUSION: Simultaneously, this study participates in the observatory missions of the ethical committee, as well as in public policies of perinatal prevention.

Vaginal delivery in the 30+4 weeks of pregnancy and organ donation after brain death in early pregnancy.

A 28-year-old woman suffered a traffic accident resulting in severe head injuries with deleterious prognosis. Diagnostics further revealed a hitherto unknown pregnancy, at suspected week 9. Based on the patient's wish to donate organs, brain death protocol confirmed irreversible loss of brain function. Yet, vital pregnancy rendered organ transplantation impossible. Multiple ethical and legal issues arose, from invalidation of established legal care after brain death to the delivery of a healthy child after trauma and long-term critical care. After medicolegal and ethical counselling, pregnancy was sustained, and the goal of organ donation postponed. Critical care focused on foetal homeostasis. At 30+4 weeks, a viable girl was born via assisted vaginal delivery. Postpartal organ donation resulted in heart, kidney and pancreas transplantation. The case emphasises the medical, legal and ethical challenges to combine two apparently diametrical goals: the successful full-term pregnancy and the fulfilment of a patient's wish to donate organs.

Prenatal Care for Undocumented Immigrants: Professional Norms, Ethical Tensions, and Practical Workarounds.

This paper examines the practice implications of various state policies that provide publicly funded prenatal care to undocumented immigrants for health care workers who see undocumented patients. Data were collected through in-depth interviews with purposively sampled health care workers at safety net clinics in California, Maryland, Nebraska, and New York. Health care workers were asked about the process through which undocumented patients receive prenatal care in their health center and the ethical tensions and frustrations they encounter when providing or facilitating this care under policy restrictions. Respondents discussed several professional practice norms as well as the ethical tensions they encountered when policy or institutional constraints prevented them from living up to professional norms. Using Nancy Berlinger's "workarounds" framework, this paper examines health care workers' responses to the misalignment of their professional norms and the policy restrictions in their state. These findings suggest that the prenatal policies in each state raise ethical and professional challenges for the health care workers who implement them.

Why Physicians Should Advocate for Undocumented Immigrants' Unimpeded Access to Prenatal Care.

Nearly 7% of US citizens born each year have at least one undocumented parent, but many pregnant undocumented immigrants are ineligible for public insurance covering prenatal care due to their immigration status. This article reviews national-level and state-level policies affecting access to prenatal care for members of this population. This article also considers ethical challenges posed by some policies that create obstacles to patients' accessing health care that is universally recommended by professional guidelines.

[25 years of work: The Interdisciplinary Team for Fetal Malformation at the Institute of Mother and Child in Warsaw - from counselling to clinical ethics].

Perinatology is a dynamically developing field of medicine. The progress of technology in recent decades has made it possible to recognize birth defects very early, including those which are lethal or genetically determined. In many clinical situations, it is no longer possible to work alone to reach a definitive diagnosis, plan treatment or predict the clinical course of the affected fetus/newborn. There is a need for teamwork, which ensures the proper, early care starting in the fetal period, not only in the delivery room or NICU. This paper discusses the ethical foundations of creating interdisciplinary teams, taking as an example the Interdisciplinary Team for Fetal Malformation at the Institute of Mother and Child in Warsaw, which has been active for 25 years, and presents how it works in practice. On the basis of the clinical cases that are examined, practical guidelines were formulated for both the work of medical teams and the way parents are informed about the clinical situation of their child and about sharing the care after the birth of the child. A document was also proposed with information on prenatal diagnosis, decisions made by the interdisciplinary team regarding the mother and child, as well as the conclusions resulting from discussions with parents.

Ultrasound in rural India: a failure of the best intentions.

The Pre-Conception and Pre-Natal Diagnostic Techniques Act was written to prevent societally unacceptable harms including intentional sex selection. The pragmatism required to enforce this law has profound effects on the ability of rural Indians to access diagnostic ultrasonography. In so doing, it may have inadvertently placed a heavier burden on the poorest and worsened health inequity in India, creating serious ethical and justice concerns. It is time to re-examine and update the law such that diagnostic ultrasonography is widely available in even the most peripheral primary health and community health centres. Shorter, more accessible ultrasonography training courses should be offered; collaboration between radiologists and rural practitioners and facilities should be encouraged. Finally, modern ultrasound machines can carefully record all images via a "silent observer" modality. With some modifications to previously used silent observer modalities, this technology allows both greater access and better policing of potential misuse of ultrasound technology.

ACOG Committee Opinion No. 763 Summary: Ethical Considerations for the Care of Patients With Obesity.

Obesity is a medical condition that may be associated with bias among health care professionals, and this bias may result in disrespectful or inadequate care of patients with obesity. Obstetrician-gynecologists regularly care for patients with obesity and play an integral role in advocating for best practices in health care and optimizing health outcomes for patients with obesity. Obstetrician-gynecologists should be prepared to care for their patients with obesity in a nonjudgmental manner, being cognizant of the medical and societal implications of obesity. This Committee Opinion has been updated from its previous version to focus on obesity bias within the medical community and to provide practical guidance using people-first language instead of labels (ie, "patients with obesity" versus "obese patients") to help obstetrician-gynecologists deliver effective, compassionate medical care that meets the needs of patients with obesity.

ACOG Committee Opinion No. 763: Ethical Considerations for the Care of Patients With Obesity.

Obesity is a medical condition that may be associated with bias among health care professionals, and this bias may result in disrespectful or inadequate care of patients with obesity. Obstetrician-gynecologists regularly care for patients with obesity and play an integral role in advocating for best practices in health care and optimizing health outcomes for patients with obesity. Obstetrician-gynecologists should be prepared to care for their patients with obesity in a nonjudgmental manner, being cognizant of the medical and societal implications of obesity. This Committee Opinion has been updated from its previous version to focus on obesity bias within the medical community and to provide practical guidance using people-first language instead of labels (ie, "patients with obesity" versus "obese patients") to help obstetrician-gynecologists deliver effective, compassionate medical care that meets the needs of patients with obesity.

A qualitative study on the voluntariness of counselling and testing for HIV amongst antenatal clinic attendees: do women have a choice?

BACKGROUND: Mother-to-child transmission (MTCT) of the Human Immunodeficiency -Virus (HIV) is a serious public health problem, contributing up to 90% of childhood HIV infections. In Tanzania, the prevention-of-mother-to-child-transmission (PMTCT) feature of the HIV programme was rolled out in 2000. The components of PMTCT include counselling and HIV testing directed at antenatal clinic attendees. It is through the process of Provider Initiated Counseling and Testing (PITC) that counselling is offered participant confidentiality and voluntariness are upheld and valid consent obtained. The objective of the study was to explore antenatal clinic attendees' experiences of the concept of voluntariness vis- a- vis the implementation of prior counseling and subsequent testing for HIV under the PITC as part of their antenatal care. METHODS: In-depth interviews were conducted with17 antenatal clinic attendees and 6 nursing officers working at the Muhimbili National Hospital (MNH) antenatal clinic. The study data were analyzed using qualitative content analysis. RESULTS: Antenatal clinic attendees' accounts suggested that counselling and testing for HIV during pregnancy was voluntary, and that knowledge of their HIV status led them to access appropriate treatment for both mother and her newborn baby. They reported feeling no pressure from nursing officers, and gave verbal consent to undergo the HIV test. However, some antenatal clinic attendees reported pressure from their partners to test for HIV. Healthcare providers were thus faced with a dilemma of disclosure/ nondisclosure when dealing with discordant couples. CONCLUSION: Antenatal clinic attendees at MNH undertook the PITC for HIV voluntarily. This was enhanced by their prior knowledge of HIV, the need to prevent mother- to- child transmission of HIV, and the effectiveness of the voluntary policy implemented by nursing officers.

Research in Obstetric Fistula: Addressing Gaps and Unmet Needs.

Although obstetric fistula has likely plagued women since the beginning of time, very little research proportionally exists. This article summarizes the most substantial research on the topic and delineates research gaps and future needs. Existing research demonstrates that access to care is the underlying cause of obstetric fistula and that the first attempt at closure holds the highest chance at success, ranging between 84% and 94%. For simple cases, 10 days of a catheter is sufficient, although what constitutes as simple is unclear. Circumferential fistulas are at high risk for ongoing urethral continence. Psychosocial programs are helpful for all women, but those who are "dry" tend to reintegrate into society, whereas those still leaking need additional support. Prenatal care and scheduled cesarean delivery are recommended to avoid another fistula. Gaps in research include accurate prevalence and incidence, interventions to improve access to care, surgical technique, especially for complex cases, and ways to prevent ongoing incontinence, among many others. In all areas, more rigorous research is needed.