Providers' experiences with abortion care: A scoping review.

BACKGROUND: Induced abortion is one of the most common gynecological procedures in the world, with as many as three in every ten pregnancies ending in abortion. It, however, remains controversial. The objective of this scoping review was to explore and map existing literature on the experiences of those who provide abortion care. METHODS AND FINDINGS: This exploratory review followed the Levac et al. guidelines and was reported in accordance with the PRISMA-ScR checklist. CINAHL, Cochrane, EMBASE, PsycInfo, PubMed, and Web of Science were used to identify peer-reviewed, original research articles published on providers' experience of abortion. We identified 106 relevant studies, which include a total sample of 4,250 providers from 28 countries and six continents. Most of the studies were qualitative (n = 83), though quantitative (n = 15) and mixed methods (n = 8) studies were also included. We identified two overarching themes: (1) Providers' experiences with abortion stigma and (2) Providers' reflections on their abortion work. Our findings suggest that providers from around the world experience challenges within society and their communities and workplaces which reinforce the stigmatization and marginalization of abortion and pose questions about the morality of this work. Most, however, are proud of their work, believe abortion care to be socially important and necessary, and remain committed to the provision of care. CONCLUSIONS: The findings of this review provide a comprehensive overview on the known experiences of providing abortion care. It is a key point of reference for international providers, researchers, and advocates to further this area of research or discussion in their own territories. The findings of this review will inform future work on how to support providers against stigmatization and will offer providers the chance to reflect on their own experiences.

The experiences and outcomes of Gypsy, Roma, and Traveller pregnant people in pregnancy: A scoping review.

BACKGROUND: Within Europe, Roma, Gypsy, and Traveller groups have been marginalized and discriminated against by larger society. Persecution and displacement have resulted in high rates of unemployment, reduced access to education, and poorer health, with significantly increased risk of poverty compared with the general population. In pregnancy, there appears to be a gap in the literature surrounding the experiences and outcomes of pregnant people within these ethnic groups. OBJECTIVES: The aim of this study was therefore to scope published research, specifically questioning "What is the experience of Roma Gypsy and Traveller pregnant people who access maternity care?" and "What are the obstetric outcomes within these groups?" SEARCH STRATEGY: This review followed frameworks proposed by Arksey and O'Malley, Levac, and the Joanna Brigg's Institute. The PRISMA extension for Scoping Reviews (PRISMA-ScR) tool was used. The search strategy and specific terms were chosen using the population-concepts-context framework. SELECTION CRITERIA: Titles and abstracts were reviewed independently by two reviewers. Inclusion and exclusion criteria were defined to set clear guidance for reviewers to identify appropriate studies. DATA COLLECTION AND ANALYSIS: Five electronic databases were searched (CINAHL, EMBASE, MEDLINE [OVID] Web of Science and SCOPUS). A charting form was developed to record key characteristics systematically and uniformly from the studies. MAIN RESULTS: Five themes were identified: systemic issues, antenatal care, complications of pregnancy, birth experience, and postnatal care. Systemic issues included racism, barriers to care, and adapted antenatal care. Antenatal issues included teenage pregnancy, smoking, risk of venous thrombus embolism, dietary issues, risk of communicable diseases, domestic violence, and mental health concerns. Increased risks of congenital abnormalities, growth restriction, premature labor, and perinatal and early childhood mortality were identified. For Roma women, negative birth experiences were reported, whereas the experiences of Traveller women varied. CONCLUSIONS: The findings identified in this study serve to create a framework upon which healthcare providers can tailor the way in which pregnant people from a Roma, Gypsy, or Irish Traveller background are cared for. Using such a framework would hopefully begin to reduce the systematic marginalization and discrimination of these minorities.

Attitudes of women with gestational diabetes toward diet and exercise: a qualitative study.

OBJECTIVE: Gestational diabetes (GDM) refers to glucose intolerance of varying severity first occurring in pregnancy. Following a diagnosis of GDM, exercise and dietary modification has a positive effect on improving glycemic control. Lifestyle changes affected in pregnancies affected by GDM have beneficial effects on long-term health if continued following birth. In addition, the psychological impact of a diagnosis of GDM should not be overlooked. Reports of maternal stress, anxiety, and fear are commonly reported issues in the literature. Support, both socially and from health care professionals, is also linked with higher rates of success in GDM management. Research to date had focused on women's reaction to a diagnosis of GDM, their mood and quality of life following a diagnosis, and their knowledge or opinions on the management of GDM. This qualitative study explored the attitudes of women with GDM toward these lifestyle changes, specifically diet and exercise. Women were also asked to identify advice that would be useful for other women newly diagnosed with GDM. METHODS: With ethical approval a qualitative study was conducted using semi-structured interviews which were examined using Thematic Analysis. Patients were invited to participate and gave written consent after a discussion with a study researcher. The question plan for semi-structured interviews was designed with the advice of patient advocates. Recurrent themes were developed until the saturation of data. RESULTS: Thirty-two women took part in the study. Time, convenience, and lack of educational awareness were common barriers to healthy eating and physical activity plans. Enablers for change included meal planning and organization. Women regarded their diets pre-diagnosis as healthy, with small "tweaks" (such as portion control) required to comply with recommendations. Another significant facilitator to change was support from the woman's partner. This also set a benchmark for plans of diet maintenance within the family structure after pregnancy. Unlike dietary changes, a consistent theme was that exercise was considered a "chore" in managing GDM and was unlikely to be continued in the long term. Practical advice offered by participants for other women with GDM included organization, realistic approaches, and lack of self-blame. CONCLUSION: Women reported that changes in diet would be more achievable in the long term than changes in exercise patterns. Partners and the clinical team were significant sources of support. Women's views are crucial to providing clinicians with a comprehensive and holistic understanding of disease management. Involving women in self-care decisions and empowering women to manage their own health are key contributors to long-term behavior change as well as service provision and policy implementation.

Validation of a questionnaire exploring patient attitudes towards bedside teaching.

BACKGROUND: Bedside teaching (BST) facilitates medical education and has reduced in practice, often due to patient-related concerns. This study aimed to validate a questionnaire exploring patients attitudes towards BST. METHODS: International guidelines for questionnaire development were followed. Seven steps were included: literature review, patient interviews, development of clear and understandable items, expert validation, cognitive interviewing and pilot testing. Statistical analyses included exploratory factor analysis, internal consistency, investigation of demographic influences and discriminant validity across subscales. RESULTS: Following the literature review, 32 interviews were conducted. Potential items were developed, reviewed and adapted. Experts in medical education and statistics reviewed the draft questionnaire. Fifteen patients consented to cognitive testing and 401 consenting patients completed the final version. The median age of participants was 35 years of age (range: 18 to 70 years). Participants included women attending for antenatal (40%), postnatal (32%) and gynaecology issues (28%). Just under one third (29%) had taken part in medical student teaching previously. Statistical analyses found a two-factor solution, consisting of Educate medical professionals and Conditions for participation subscales with good internal consistency; responses did not vary by age or education. Participants who had opted-in for teaching in the ward and bedside endorsed higher levels of Educate medical professionals, suggesting discriminant validity. A majority of patients (> 92%) reported that they were happy to be involved in BST. Patients believed that they should not be asked to participate in BST should they feel stressed or unwell (68.2%). CONCLUSION: This study shows extensive patient support for BST, independent of age or education. The desire to educate is a strong motivating factor. This strong support by patients for BST is an area that medical schools and universities can potentially develop. Future versions of this questionnaire may include virtual bedside teaching, in the context of social distancing.

Providers' Experience of Abortion Care: Protocol for a Scoping Review.

BACKGROUND: Despite being one of the most common gynecological procedures in the world, abortion care remains highly stigmatized. Internationally, providers have noted negative impacts related to their involvement in the services, and abortion care has been described as "dirty work." Though much of the existing research focuses on the challenges of providing, many have also highlighted the positive aspects of working in abortion care. Despite the steadily increasing interest in this area over the past decade, however, no one has sought to systematically review the literature to date. OBJECTIVE: The aim of this review is to systematically explore published studies on the experiences of abortion care providers to create a narrative review on the lived experience of providing abortion care, reflecting on what is already known and what areas require further exploration. METHODS: This review will be conducted according to the framework outlined by Levac et al, which expanded on the popular Arksey and O'Malley framework. We will systematically search for peer-reviewed articles in 6 electronic databases: CINAHL, the Cochrane Library, EMBASE, PsycInfo, PubMed, and Web of Science. Following a pilot exercise, we devised a search strategy to identify relevant studies. In this protocol, we outline how citations will be assessed for eligibility and what information will be extracted from the included articles. We also highlight how this information will be combined in the review. RESULTS: As of December 2021, at the time of writing, we have searched for articles in the electronic databases and identified 6624 unique citations. We intend to fully assess these citations for eligibility by the end of January 2022, chart and analyze data from the eligible citations by the end of March 2022, and submit a journal article for peer review by late spring 2022. CONCLUSIONS: The findings of this review will provide a comprehensive overview on the known experiences of providing abortion care. We also anticipate that the findings will identify aspects of care and experiences that are not reflected in the available literature. We will disseminate the results via a publication in a peer-reviewed academic journal and by presenting the findings at conferences in the areas of abortion care, obstetrics, and midwifery. As this review is a secondary analysis of published articles, ethical approval was not required. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35481.

Antenatal prediction of fetal macrosomia in pregnancies affected by maternal pre-gestational diabetes.

AIMS: Higher rates of fetal macrosomia may occur in infants of women with pre-gestational diabetes compared with non-diabetic controls. Antenatal predication of fetal macrosomia remains challenging. Ultrasound over-estimated fetal weight could result in over-classification of fetuses as macrosomic with corresponding inappropriate clinical interventions. Previously we had studied a measurement - the anterior abdominal wall measurement (AAW) - to predict fetal macrosomia in fetal estimation of weight. The purpose of the study was to study whether specific third trimester ultrasound measurements with measures of glycaemic control (HbA1c) predicted macrosomia in babies born to women with pre-gestational diabetes. In particular, a new variant of this measurement (fetal anterior abdominal wall thickness (AAW), abdominal circumference (AC) ratio: AAW:AC) was investigated. METHODS: This was a prospective cohort study in a tertiary referral maternity hospital. Serial growth scans including measurement of AAW and AC: AAW ratio was performed at 30, 33- and 36-weeks' gestation. Birth-weight data was collected, and macrosomia was defined as >90th centile based on gestational age and gender of the baby. Serial HbA1c as measured at the first antenatal visit, 14, 20- and 36-weeks' gestation were reported for this study. RESULTS: Of the 416 pregnancies analyzed, mean maternal age was 33.3 years. One in five women were primigravida's. The mean birthweight was 3548 g (+/- 581 g), of which 142 (34%) babies were classified as macrosomic. The median gestational age at delivery was 383 weeks (314 - 402 weeks). There were 37 (9%) babies born preterm at <37 weeks' gestation. Mean AC measurements in fetuses that would be born with macrosomia compared with those with a non-macrosomic birth weight were 282 mm vs. 266 mm at 30 weeks, 318.3 mm vs. 297 mm at 33 weeks and 350 mm vs. 325 mm at 36 weeks' gestation (all p < .001). Mean AAW measurements in macrosomic fetuses compared with normal size fetuses were 3.7 mm vs. 3.3 mm at 30 weeks, 4.9 mm vs 4.3 mm at 33 weeks and 5.9 mm vs. 5.3 mm at 36 weeks' gestation (all p < .001). The mean AC: AAW was 0.01 for both normal and macrosomic fetuses at 30 weeks. There was no clinical or statistical difference in AC:AAW ratios between non-macrosomic and macrosomic infants. Binary logistic regression showed that AC at 36 weeks was most predictive of macrosomia (76.5%), followed by AAW at 30 weeks (68.5%). Using a combination of HbA1c booking, 14, 20, 36 weeks and AAW 30, 33, 36 weeks and AC 30, 33, 36 weeks predicted macrosomia in 80.9%. The ratio of AC: AAW did not act as a useful antenatal clinical predictor of macrosomia at birth. CONCLUSIONS: Abdominal circumference at 36 weeks was the single best predictor of fetal macrosomia. A combined model of HbA1c, AC and AAW was the best antenatal predictor of macrosomia, with intriguing clinical possibilities in the possible prevention of maternal and fetal complications of macrosomia.

Factors affecting confidence and competence of doctors in performing operative vaginal births: A qualitative study.

OBJECTIVES: Operative vaginal birth (OVB) is an important skill for obstetricians. It is the most common emergency intervention in obstetrics and requires a high degree of skill. While there is a lot of data available on technical and non-technical factors affecting the outcome of OVBs little work has been done to investigate the factors that make obstetricians feel confident and competent when performing such a procedure. The objective of this study was therefore to identify the common factors that affect confidence and competence of obstetricians in operative vaginal births (OVB). Our hypothesis was that a qualitative research method would provide a rich approach where themes would be developed that the participants themselves identify as important. STUDY DESIGN: Qualitative research within two University Hospitals and one District Hospital in Ireland. Participants interviewed ranged from first year trainees to consultant obstetricians. Interviews using open ended questions. Interviews were recorded on audio and later transcribed. Thematic analysis was performed until saturation. RESULTS: 35 obstetricians were interviewed. The median number of years of experience was 5 years (range 3-20 years). The median number of OVB was 200 (range 20-1000+). Vacuum was the preferred choice amongst junior trainees. Preference shifted to forceps with increasing clinical experience. Seven clear themes emerged. Three themes were common to all participants: firstly, that all clinicians reported respect for the primiparous OVB in anticipation of possible complications, secondly the wish for senior midwifery support and finally the importance of clinical experience and exposure. Four themes were common to trainees only. Female clinicians in training reported significant self-doubt in their ability to perform an OVB and had concerns about causing harm. Clinicians in training wished to be trained by consultants during their first year on the labour ward. Experience was important. The final theme was a wish for more training in forceps OVB by clinicians in training. CONCLUSION: This qualitative study identified factors that can be used to design education and training in OVB in order to support trainees and ultimately improve care for the woman and baby.

The Profile of Women Attending the National Maternity Hospital Emergency Out Of Hours Service ­ Two Decades On. A Retrospective Review

Introduction This study aimed to review the profile of women attending an out of hours emergency service (OHS) in a maternity hospital and compare it to a previous study. Methods Retrospective study. Demographic information was recorded including timing of presentation, reason and outcome. Results In 2017, 9,020 women attended the OHS, a 334% increase since 1993. On detailed review of 2,143 charts, most (84.7%, n=1,815) were antenatal. The most common reason for presenting to the OHS then was first trimester bleeding. In 2017, over half of antenatal women (51%, n=1,092) presented with "other" reasons, such as vomiting, hypertension or suspected pre-eclampsia. Admission rates significantly decreased from 1993 (38% (n=1,053) in 1993 vs. 16% (n=338) in 2017; p<0.05). Discussion Numbers attending for emergency maternity care have increased in both numbers and variety of presentations. It is important that women are seen and cared for in a compassionate, kind and evidence based manner.

The Second Victim: a Review.

Amongst the lay and media population there is a perception that pregnancy, labour and delivery is always physiological, morbidity and mortality should be "never events" and that error is the only cause of adverse events. Those working in maternity care know that it is an imperfect art, where adverse outcomes and errors will occur. When errors do occur, there is a domino effect with three groups being involved - the patient (first victim), the staff (second victims) and the organization (third victims). If the perceived expectation of patients on all clinicians is that of perfection, then clinicians may suffer the consequences of adverse outcomes in isolation and silence. More recently identification and discussion on the phenomenon of the second victim has become a popular research topic. This review aimed to study not only the phenomenon of second victim in general medical care but to also concentrate on maternity care where the expectation of perfection may be argued to be greater. Risk factors, prevalence and effect of second victims were identified from a thorough search of the literature on the topic. The review focuses on the recent research of the effect on maternity staff of adverse outcomes and discusses topical issues of resilience, disclosure, support systems as well as Learning from Excellence. It is now well documented that when staff members are supported in their disclosure of errors this domino effect is less traumatic. It is the responsibility of everyone working in healthcare to support all the victims of an error, as an ethical duty and to have a supportive culture of disclosure. In addition, balance can be provided by developing a culture of learning from excellence as well as from errors.

An international assessment of trainee experience, confidence, and comfort in operative vaginal delivery.

AIM: The aim of this study was to assess Irish and Canadian obstetricians in training ("trainees") experience, confidence, and comfort in performing operative vaginal delivery (OVD). STUDY DESIGN: Trainees in Obstetrics and Gynaecology in the University of Toronto and the Royal College of Physicians of Ireland (RCPI) were invited to participate in an anonymous online survey reviewing experience as primary operator of OVD. Trainee confidence and comfort was self-assessed based upon their last few OVDs. RESULTS: The response rate was 55% amongst Canadian trainees (31/56) and 44% amongst Irish trainees (21/48). When comparing Irish with Canadian trainee experience, the median numbers of vacuum and forceps deliveries performed by Irish trainees as primary operator were reported to be higher [125 (range 10-150) vs 20 (range 5-40); p < 0.0001 (ventouse), 45 (range 10-150) vs 6 (range 1-12); p = 0.0001 (forceps)]. Despite this, trainee confidence between the groups did not differ [confidence score: 18.7 (SD 3.2) vs 17.8 (SD 3.5), p = 0.3]. There were some differences regarding comfort in certain aspects of OVD, most notably increased comfort in Irish trainees in pre-procedure assessment skills of OVD. CONCLUSION: With falling OVD rates worldwide, training experience is declining. Despite higher numbers of OVD within the Irish trainee group, there was no difference in trainee confidence between the two groups. These results suggest that a high number of cases as primary operator may not be required to establish operator confidence in performing a procedure. Irish trainees self-reported more comfort in non-technical skills of OVD, suggesting a step-wise effect of experience on first technical and then non-technical skills.

Familiarisation to and reproducibility of cycling at 110% peak power output.

AIM: This study investigated the familiarisation to and test re-test reproducibility of constant load cycling at 110% peak power output (WPEAK). METHODS: Eleven healthy, but not cycle trained, males performed a graded incremental exercise test to ascertain WPEAK followed by three trials (T1, T2 and T3) at 110% WPEAK to exhaustion. Trials were separated by ~7 days. RESULTS: Although there was no difference in time to exhaustion (TLIM) between T1 and T2 (P=0.100) and T2 and T3 (P=0.095) respectively, a difference was observed between T1 and T3 (P=0.046). Correlation coefficients, coefficients of determination, limits of agreement (LoA) and within-subject coefficient of variation (CV) improved across trials demonstrating T2 and T3 had the strongest relationship (T1 vs. T3: r=0.73; r2=0.53; Bias=40 s; CV=14%; T1 vs. T2: r=0.66; r2=0.43; Bias=24 s; CV=10%; T2 vs. T3: r=0.97; r2=0.95; Bias=16 s; CV=7%). There was no difference across trials for HR (P=0.12), BLa (P=0.76), RER (P=0.52), VE, (P=0.32), VO2, (P=0.33), local RPE (RPEL; P=1) and overall RPE (RPEO; P=0.91) at exhaustion or BLa (P=0.76) and pH (P=0.47) 5-minutes post-exercise. CONCLUSION: Constant load cycling at 110% WPEAK is a reliable protocol when assessing supramaximal exercise performance after completion of two familiarisation trials.