A cross-sectional survey of the mental health of midwives in Ontario, Canada: Burnout, depression, anxiety, stress, and associated factors.

PROBLEM: Burnout and the psychological co-morbidities stress, anxiety and depression have a significant impact on healthcare providers, including midwives. These conditions impact the quality of care provided to women, and midwives' ability to remain in the profession. BACKGROUND: There is growing concern regarding the retention of maternity care providers in Canada, particularly midwives. Nationally, 33% of Canadian midwives are seriously considering leaving practice; impacts of the profession on work-life-balance and mental health being commonly cited reasons. Burnout has been shown to contribute to workplace attrition, but little is known concerning burnout among Canadian midwives. AIM: To assess levels of stress, anxiety, depression, and burnout among midwives in Ontario, Canada and potential factors associated with these conditions. METHODS: A cross-sectional survey of Ontario midwives incorporating a series of well-validated tools including the Copenhagen Burnout Inventory and the Depression, Anxiety and Stress Scale. FINDINGS: Between February 5, and April 14, 2021, 275 Ontario midwives completed the survey. More than 50% of respondents reported depression, anxiety, stress, and burnout. Factors associated with poor mental health outcomes included having less than 10-years practice experience, identifying as a midwife with a disability, the inability to work off-call, and having taken a prior mental health leave. DISCUSSION & CONCLUSION: A significant proportion of Ontario midwives are experiencing high levels of stress, anxiety, depression, and burnout, which should be a serious concern for the profession, its leaders, and regulators. Investment in strategies aimed at retaining midwives that address underlying factors leading to attrition should be prioritized.

Spontaneous, idiopathic granulomatous mastitis in a pregnant patient: A case report and review of the literature.

Idiopathic granulomatous mastitis is a rare breast condition of unclear etiology. Its course is often rapidly progressive, slow to resolve, and can have a high rate of recurrence. Clinical presentation can mimic breast abscess, infectious mastitis, and carcinoma of the breast, generating a diagnostic challenge. Histopathological analysis is required to make the diagnosis after common conditions are excluded. There is no standard treatment, however surgical excision, steroid treatment, and observation are commonly reported approaches. Here, we describe a complex case of a multiparous patient presenting with idiopathic granulomatous mastitis at 32 weeks gestation. In this review, we highlight the importance of collaboration amongst a multidisciplinary team for effective diagnosis and treatment. We discuss the use of oral corticosteroids in the antenatal period and illustrate the patient support required to both facilitate successful breastfeeding in the postpartum period and promote recovery.

A mixed-method study exploring barriers and facilitators to midwives' mental health in Ontario.

BACKGROUND: There is a paucity of information regarding the mental health of midwives working in Ontario, Canada. Many studies have investigated midwives' mental health around the world, but little is known about how the model of midwifery care in Ontario contributes to or negatively impacts midwives' mental health. The aim of the study was to gain a deeper understanding of factors that contribute to and negatively impact Ontario midwives' mental health. METHODS: We employed a mixed-methods, sequential, exploratory design, which utilized focus groups and individual interviews, followed by an online survey. All midwives in Ontario who had actively practiced within the previous 15 months were eligible to participate. FINDINGS: We conducted 6 focus groups and 3 individual interviews, with 24 midwives, and 275 midwives subsequently completed the online survey. We identified four broad factors that impacted midwives' mental health: (1) the nature of midwifery work, (2) the remuneration model, (3) the culture of the profession, and (4) external factors. DISCUSSION: Based on our findings and the existing literature, we have five broad recommendations for improving Ontario midwives' mental health: (1) provide a variety of work options for midwives; (2) address the impacts of trauma on midwives; (3) make mental health services tailored for midwives accessible; (4) support healthy midwife-to-midwife relationships; and (5) support improved respect and understanding of midwifery. CONCLUSION: As one of the first comprehensive investigations into midwives' mental health in Ontario, this study highlights factors that contribute negatively to midwives' mental health and offers recommendations for how midwives' mental health can be improved systemically.

Lyme borreliosis in pregnancy and associations with parent and offspring health outcomes: An international cross-sectional survey.

Background: Lyme disease (LD) is a complex tick-borne pathology caused by Borrelia burgdorferi sensu lato bacteria. Currently, there are limited data regarding the health outcomes of people infected during pregnancy, the potential for perinatal transmission to their fetus, and the long-term effects on these children. Therefore, the primary objective of this survey study was to investigate the impact of LD in pregnancy on both the parent and their offspring. Methods: A seven-section survey was developed and administered in REDCap. Although recruitment was primarily through LD-focused organizations, participation was open to anyone over the age of 18 who had been pregnant. Participant health/symptoms were compared across those with "Diagnosed LD," "Suspected LD," or "No LD" at any time in their lives. The timing of LD events in the participants' histories (tick bite, diagnosis, treatment start, etc.) were then utilized to classify the participants' pregnancies into one of five groups: "Probable Treated LD," "Probable Untreated LD," "Possible Untreated LD," "No Evidence of LD," and "Unclear." Results: A total of 691 eligible people participated in the survey, of whom 65% had Diagnosed LD, 6% had Suspected LD, and 29% had No LD ever. Both the Diagnosed LD and Suspected LD groups indicated a high symptom burden (p < 0.01). Unfortunately, direct testing of fetal/newborn tissues for Borrelia burgdorferi only occurred following 3% of pregnancies at risk of transmission; positive/equivocal results were obtained in 14% of these cases. Pregnancies with No Evidence of LD experienced the fewest complications (p < 0.01) and were most likely to result in a live birth (p = 0.01) and limited short- and long-term offspring pathologies (p < 0.01). Within the LD-affected pregnancy groups, obtaining treatment did not decrease complications for the parent themselves but did ameliorate neonatal health status, with reduced rates of rashes, hypotonia, and respiratory distress (all p < 0.01). The impact of parent LD treatment on longer-term child outcomes was less clear. Conclusion: Overall, this pioneering survey represents significant progress toward understanding the effects of LD on pregnancy and child health. A large prospective study of pregnant people with LD, combining consistent diagnostic testing, exhaustive assessment of fetal/newborn samples, and long-term offspring follow-up, is warranted.

Effectiveness of oral intake of Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 on Group B Streptococcus colonization during pregnancy: a midwifery-led double-blind randomized controlled pilot trial.

OBJECTIVE: Group B streptococcus (GBS) vaginal/rectal colonization in pregnancy has been associated with early-onset GBS disease (EOGBSD), a leading cause of neonatal morbidity and mortality. In Canada, universal screening for GBS colonization is offered to pregnant people at 35-37 weeks' gestation and those who test positive are offered intrapartum antibiotic prophylaxis (IAP). Universal screening and treatment with IAP have not eradicated all cases of EOGBSD, and IAP has documented side effects. Probiotic supplements have been proposed as a possible way to reduce GBS colonization. MATERIALS AND METHODS: Pregnant midwifery clients >18 years of age and <45 years of age and with a gestational age of <25 weeks at the time of enrolment were randomly assigned to receive two capsules of probiotics (Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14) or placebo orally daily for 12 weeks at 23-25 weeks' gestation. The primary aim was to determine the feasibility of a larger study. The rate of GBS vaginal/rectal colonization at 35-37 weeks' gestation was also assessed in both groups. RESULTS: In total, 139 pregnant midwifery clients were randomized (probiotic group [N = 73] and placebo group [N = 66]). Of these, 113 were included in the final analysis (probiotic group [N = 57] and placebo group [N = 56]). Baseline characteristics between groups were similar with the exception of gestational age (p < .01). The recruitment rate was low at 12%, but the mean compliance rate was 87%. The eligibility/ineligibility criteria were too strict and changes to the study design will be required for the larger proposed study. The rates of vaginal/rectal GBS colonization did not differ significantly between groups (15.8 versus 21.43%; p = .48). No adverse effects were documented in the probiotic group. CONCLUSION: This was the first midwifery-led trial involving a natural health product in the province of Ontario. Although treatment with oral probiotics is feasible, the results were not superior to placebo in reducing the rate of GBS colonization. An adequately powered, randomly controlled trial is required to assess the effectiveness of the two probiotic strains.

Modeling responses to respiratory house dust mite exposure.

House dust mite (HDM) is the most pervasive indoor aeroallergen source worldwide. Allergens derived from HDM are associated with sensitization and allergic asthma. Allergic asthma is an immunologically driven disease characterized by a Th2-polarized immune response, eosinophilic inflammation, airway hyperreactivity, and remodeling. Animal models of asthma utilizing ovalbumin (OVA) exposure have afforded us considerable insight with respect to the mediators and cell types involved in allergic airway inflammation. However, OVA preparations and HDM are two vastly different materials. This chapter is specifically concerned with modeling responses to HDM exposure in mice. These studies have furnished new information and unlocked new lines of inquiry regarding biological responses to common aeroallergens. The complexity of HDM as an allergen source, with its plethora of protein and nonprotein immunogenic components, may influence the mechanisms underlying sensitization, inflammation and remodeling. Here, we will discuss this issue, along with giving critical thought to the use of experimental models.

Defibrinated bovine plasma inhibits retroviral transcription by blocking p52 activation of the NFkappaB element in the long terminal repeat.

Bovine leukemia virus (BLV) induces a persistent but latent infection in cattle. Viral latency is invoked by a protein known as plasma blocking factor (PBF) that is found in both bovine and human plasma. We report here on pathways that mediate latency in the presence of PBF. Reporter-gene constructs driven by the promoters of 6 retroviruses were used to measure the production of chloramphenicol acetyl transferase (CAT) in cell lines cultured with or without defibrinated bovine plasma. Plasma inhibited CAT production only in constructs containing an NFkappaB-binding element proximal to the initiation site (BLV, human immunodeficiency virus, and human T-cell leukemia virus). The promoters of Bovine immunodeficiency virus, Feline immunodeficiency virus, or Feline leukemia virus were not inhibited in the presence of bovine plasma. Using gel mobility shift assays, we demonstrated that activation of viral transcription upon stimulation with phorbol esters and ionomycin was mediated through the NFkappaB element and that this was abrogated in the presence of plasma. Furthermore, analysis of individual NFkappaB proteins in nuclear extracts of mononuclear cells or Jurkat cells showed that all 5 members of the NFkappaB family were upregulated in response to stimulation, but only p52 was significantly downregulated in the presence of bovine plasma. Thus, we infer that plasma effects are mediated through interference with either p52 translocation to the nucleus or p52 synthesis.

Intranasal exposure of mice to house dust mite elicits allergic airway inflammation via a GM-CSF-mediated mechanism.

It is now well established that passive exposure to inhaled OVA leads to a state of immunological tolerance. Therefore, to elicit allergic sensitization, researchers have been compelled to devise alternative strategies, such as the systemic delivery of OVA in the context of powerful adjuvants, which are alien to the way humans are exposed and sensitized to allergens. The objectives of these studies were to investigate immune-inflammatory responses to intranasal delivery of a purified house dust mite (HDM) extract and to evaluate the role of GM-CSF in this process. HDM was delivered to BALB/c mice daily for 10 days. After the last exposure, mice were killed, bronchoalveolar lavage was performed, and samples were obtained. Expression/production of Th2-associated molecules in the lymph nodes, lung, and spleen were evaluated by real-time quantitative PCR and ELISA, respectively. Using this exposure protocol, exposure to HDM alone generated Th2 sensitization based on the expression/production of Th2 effector molecules and airway eosinophilic inflammation. Flow cytometric analysis demonstrated expansion and activation of APCs in the lung and an influx of activated Th2 effector cells. Moreover, this inflammation was accompanied by airways hyper-responsiveness and a robust memory-driven immune response. Finally, administration of anti-GM-CSF-neutralizing Abs markedly reduced immune-inflammatory responses in both lung and spleen. Thus, intranasal delivery of HDM results in Th2 sensitization and airway eosinophilic inflammation that appear to be mediated, at least in part, by endogenous GM-CSF production.

Effect of GM-CSF on immune, inflammatory, and clinical responses to ragweed in a novel mouse model of mucosal sensitization.

BACKGROUND: Conventional models of allergic airway inflammation involve intraperitoneal administration of ovalbumin in conjunction with a chemical adjuvant (generally aluminum hydroxide) to generate allergic airways inflammation. Here we have investigated the effect of respiratory mucosal exposure to a ragweed extract in the absence of chemical adjuvant on the generation of allergic responses. OBJECTIVES: We sought to develop a mouse model of ragweed-induced allergic airway inflammation through mucosal sensitization and to investigate the role of GM-CSF in this process. METHODS: Ragweed was delivered intranasally to an airway microenvironment enriched with GM-CSF, which was achieved by means of either multiple coadministrations of recombinant GM-CSF or a single delivery of an adenoviral vector carrying the GM-CSF transgene. RESULTS: Administration of a purified ragweed extract leads to T(H)2 sensitization (and not inhalation tolerance) accompanied by mild airway inflammation, modest clinical symptoms, and moderate production of T(H)2 cytokines by splenocytes on ragweed restimulation. The administration of anti-GM-CSF antibodies in conjunction with ragweed diminished T(H)2-associated cytokine production. These responses were amplified by enriching the airway microenvironment with GM-CSF. Under these conditions, all T(H)2-associated immune-inflammatory responses, as well as the clinical responses, were considerably enhanced. To investigate the mechanism underlying these effects, we examined lung mononuclear cells by means of flow cytometry and detected a substantial expansion of antigen-presenting cells, particularly dendritic cells, as well as a substantially increased activation of these antigen-presenting cells, as demonstrated by the expression of B7 molecules, particularly B7.2. CONCLUSION: GM-CSF plays an important role in the generation of allergic immune-inflammatory responses to ragweed.