Epidural Analgesia With or Without Oxytocin, but Not Oxytocin Alone, Administered During Birth Disturbs Infant Pre-feeding and Sucking Behaviors and Maternal Oxytocin Levels in Connection With a Breastfeed Two Days Later.

Aims This work aimed to study consequences of medical interventions in connection with birth on infant pre-feeding and feeding behaviors and on maternal oxytocin levels in connection with a breastfeed 2 days later. Materials and Methods Mothers and their full-term newborns (n = 41) were videotaped during a breastfeed 2 days after birth. Duration and quality of rooting [Infant Breastfeeding Assessment Tool (IBFAT)] were assessed. Maternal blood samples were collected, oxytocin levels were analyzed, and mean oxytocin level and variance were calculated. Data on medical interventions during birth, number of breastfeedings, and infant weight loss since birth were recorded. Data were analyzed using logistic regression models. Results The duration of infant rooting was significantly shorter when the mother had received epidural analgesia. The shorter the duration of infant rooting, the more often infants had breastfed and the greater was the infant weight loss since birth. Mothers with epidural analgesia with oxytocin had the lowest oxytocin mean levels in connection with a breastfeed. Oxytocin variance correlated positively with quality of rooting and correlated negatively with infant weight loss. In the control group alone, we found similar patterns of associations with oxytocin levels. Conclusion Epidural analgesia and epidural analgesia with oxytocin infusion in connection with birth negatively influenced infant rooting behavior and maternal mean oxytocin levels, respectively. Oxytocin infusion alone was without effect. The data also suggest that infants who suck well stimulate oxytocin release more efficiently, as expressed by a high oxytocin variance, leading to a better stimulation of milk production and consequently to a reduced infant weight loss 2 days after birth.

Weight loss and low age are associated with intensity of rooting behaviours in newborn infants.

AIM: Little is known about the developing breastfeeding behaviour of newborn infants. This study describes infants' prebreastfeeding behaviour during the second day of life and explores possible associations with infant characteristics. METHODS: We studied 13 mothers and healthy full-term infants after normal births. At 24-48 hours of life, the newborns were placed in skin-to-skin contact with their mothers for breastfeeding and were video-filmed. The order, frequency and duration of predefined infant prefeeding behaviours and suckling were coded and analysed using computer-based video software. RESULTS: Prefeeding behaviours occurred in the following order: rooting, hand to mouth movements, licking of the nipple and hand to breast to mouth movements. The infants started to suckle at a median of one to two minutes. Rooting was the most common behaviour, observed in 12 infants. The duration of rooting movements during the last minute before breastfeeding was inversely related to neonatal age (p ≤ 0.001) and positively related to neonatal weight loss (p = 0.02) after birth. CONCLUSION: Infants exhibited a distinct sequence of prefeeding behaviours during the second day of life, and our findings suggest that rooting movements were governed by mechanisms involved in the regulation of food intake and weight gain.

Influence of common birth interventions on maternal blood pressure patterns during breastfeeding 2 days after birth.

OBJECTIVE: This study investigated possible influences of medical interventions during labor on maternal blood pressure during a breastfeed 2 days postpartum. SUBJECTS AND METHODS: Sixty-six primiparae with normal deliveries were consecutively recruited. Blood pressure was measured at -5, 10, 30, and 60 minutes during a morning breastfeed 2 days postpartum. Five treatment groups were formed based on the medical interventions received during labor: Non-medicated mothers (Control group, n=21); mothers receiving epidural analgesia (EDA) with oxytocin (OT) stimulation (EDA(OT) group, n=14); mothers receiving EDA without OT stimulation (EDA(non-OT) group, n=7); mothers receiving OT stimulation only (OT intravenously [iv] group, n=9); and mothers receiving 10 IU of OT intramuscularly (im) only (OT im group, n=15). RESULTS: Baseline diastolic, but not systolic, blood pressure differed between the groups as displayed by significantly lower diastolic blood pressure in the EDA(non-OT) group compared with the Control group, the OT iv group, and the EDA(OT) group (p=0.045, p=0.041, and p=0.024, respectively). Both systolic and diastolic blood pressure fell significantly during the breastfeeding session in the Control group (p=0.001 and p=0.004, respectively), the OT im group (p=0.006 and p=0.001, respectively), and the EDA(OT) group (p=0.028 and p=0.002, respectively), and the fall in diastolic blood pressure tended to be significant in the OT iv group (p=0.050). The duration of skin-to-skin contact before breastfeeding correlated positively with the decrease in systolic blood pressure in the OT im group (R(s)=0.540, p=0.046). CONCLUSION: Administration of EDA during labor lowers baseline diastolic blood pressure and abolishes the fall in blood pressure in response to a breastfeed 2 days after birth.

Swedish midwives' rating of risks during labour progress and their attitudes toward performing intrapartum interventions: a web-based survey.

OBJECTIVE: to study how Swedish midwives working in low-risk labour ward units rate intrapartum risks compared to their midwifery colleagues working in standard care labour wards. A second aim was to describe midwives' attitudes toward performing different types of interventions during a normal labour. DESIGN: an explorative study was carried out in 2009, using a web-based questionnaire containing 31 questions on midwives' risk ratings and attitudes to interventions during labour, as well as personal comments. SETTING: four labour ward units in Stockholm, Sweden. Two labour ward units with expected normal deliveries ('low-risk') and two standard care units with all types of deliveries. PARTICIPANTS: seventy-seven registered clinically practicing midwives. FINDINGS: midwives in all units stated that factors to be considered for risk estimation were: previous delivery outcome, result of cardiotocography test (CTG) on admission to labour ward and quality of amniotic fluid. Midwives working at the low-risk units preferred to be more expectant during normal birth than their colleagues working at the standard care units. Examples of this were regarding second vaginal examination during labour (p=0.001) and/or amniotomy (p=0.012). Furthermore, midwives working at the low-risk units more often considered that first-time mothers could give birth without epidural analgesia during labour (p=0.019) and that the labouring woman should be encouraged to push according to her own spontaneous urge (p=0.040). Midwives at low-risk units were more reluctant to use an intravenous vein catheter than their colleagues at standard care units (p=0.001) and also to use oxytocin in order to augment contractions (p=0.013). Further, the open-ended question showed that attitudes to different types of interventions differed between midwives working at low-risk units or the standard care units working with all types of deliveries. CONCLUSION: the Swedish midwives estimated risks similarly regardless of whether they worked in low-risk or in standard care units, but midwives working at low-risk units reported that they perform less routine interventions and have a more expectant attitude towards performing interventions.

Chilean midwives and midwifery students' views of women's midlife health-care needs.

OBJECTIVE: to determine Chilean midwives' views with regard to Chilean women's health-care needs in midlife. The aim was also to explore Chilean midwifery students' views on the clinical care provided to women in midlife. DESIGN: a qualitative study using focus group discussions and narratives which were analysed using thematic manifest and latent content analysis. SETTING: 10 different primary health care (PHC) centres in Santiago, Chile. PARTICIPANTS: 22 midwives, working in PHC clinics and 13 (n = 13) midwifery students with PHC clinical experience, attending their fourth or fifth year of midwifery education at the School of Midwifery in Santiago. FINDINGS: the midwives felt that women in midlife have special health-care service needs. They also considered themselves to be the most appropriate health staff to provide health care for women in midlife, but recognised that they lacked competence in attending psychological and social health-care needs of women in midlife such as violence, abuse and sexuality issues. The midwifery students remarked that many midwives focused their attention on fulfilling the biomedical requirements. Even if the midwives had knowledge about recent research on menopause, they had difficulties in approaching this issue and including it in their counselling. Some students also questioned the sometimes disrespectful attitude shown, especially towards Peruvian immigrants and women with psychosocial problems. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the findings suggest that midwives need more education about women's health-care needs in midlife, and that more focus should be placed on the psychosocial aspects of midwifery. More reflections about the quality of the client-provider relationship in clinical practice are needed. Gender issues, the structure of power relationships, and empowerment should be incorporated and critically discussed during midwifery education and training, and also in clinics.

"We are always asked; 'where are you from?'": Chilean women's reflections in midlife about their health and influence of migration to Sweden.

AIM: This study explored how Chilean immigrant women living in Sweden perceived and related their life situations and health status during midlife to their migration experiences. METHOD: Three focus group discussions (FGDs) were performed with 21 middle-aged Chilean women (40-60 years) who had lived in Stockholm for at least 15-20 years. In-depth interviews were held with three key informants. A combination of manifest and latent content analysis was performed to structure and categorize the tape-recorded and transcribed data. FINDINGS: Three main themes emerged from the data: (i) Chilean women's reflections about migration and resettlement; (ii) Health during midlife; perceptions of Chilean women living in Sweden; and (iii) Strategies to manage their lives and to gain social acceptance and position. The Chilean women reflected about the discrimination they had met in the Swedish society and within the health care system along with health changes they had had during midlife. They connected some of their health related problems to their hardships of migration. They also expressed confusion about the health care they had received in Sweden including conflicting and mistrusting relationship with some health care providers. Important for their way of coping with their own health seemed to be a recognition of their own space, level of independence, self-acceptance and awareness of power relationships. CONCLUSION: The results illuminate the importance of awareness of influence of gender and socio-cultural aspects, power relationships and communication skills among health care providers on women's health. Complementary interventions to the biomedical paradigm are needed and should be addressed in Swedish health staff educational programmes as well as in clinical training.

Pregnancy loss: spontaneous and induced abortions among young women in Lusaka, Zambia.

An estimated 60% of all adolescent pregnancies in low-income countries are unintended. The present study was carried out at the university hospital in Lusaka, Zambia over a four-month period in 2005. The aim was to explore experiences of pregnancy loss and to ascertain the girl's contraceptive knowledge and use and their partner's involvement in the pregnancy/abortion. Eighty-seven girls aged 13-19 years admitted to hospital for incomplete abortions were interviewed. Of these girls, 53 (61%) had had a spontaneous abortion and 34 (39%) had undergone an unsafe induced abortion. Significantly more girls with an unsafe induced abortion were single, students, had completed more years in school and were in less stable relationships. Girls' overall contraceptive knowledge and use was low and most pregnancies were unplanned. Partners played a decisive role in terminating pregnancy through unsafe induced abortion. Traditional healers, girls themselves and health professionals were the main abortion providers. Young women's health risks due to unprotected sex and lack of contraceptive services should urgently be addressed. The existence of the abortion law and access to emergency contraception should be better publicized in Zambia.

Chilean women's reflections about womanhood and sexuality during midlife in a Swedish or Chilean context.

In order to learn about Chilean women's reflections about womanhood and sexuality during midlife, we held focus group discussions (FGDs) with middle-aged Chilean women living in Stockholm, Sweden, or in Santiago, Chile. We used thematic content analysis for the qualitative data. Emerging themes follow; societal expectations on women, perceptions about sexual relationships, and women's social stigmatization. The women had since childhood been strongly influenced by a gender-imbalanced world, which had made them socially, economically, and biologically at higher risk for exploitation during life. More focus should be directed to middle-aged women's life situation and promotion of gender equity in society.

Effects of sucking and skin-to-skin contact on maternal ACTH and cortisol levels during the second day postpartum-influence of epidural analgesia and oxytocin in the perinatal period.

BACKGROUND AND AIMS: In this study we made a detailed analysis of the mothers' release pattern of adrenocorticotropic hormone (ACTH) and cortisol during a breastfeeding session during the second day postpartum and related these patterns to maternal oxytocin levels as well to the duration of sucking and the duration of skin-to-skin contact before sucking the breast. Furthermore, we investigated if epidural analgesia and oxytocin administration during and after labor influenced the release pattern of ACTH and cortisol. METHODS: Sixty-three primiparae were included in the study. Fourteen received oxytocin intramuscularly postpartum, nine received oxytocin infusion, 14 received epidural analgesia combined with oxytocin infusion, and six received epidural analgesia alone. Twenty mothers did not receive any of these medical interventions. Blood samples were analyzed for ACTH and cortisol by enzyme-linked immunoassay. RESULTS: Both ACTH and cortisol levels fell significantly during the breastfeeding session. A significant negative relationship was found between oxytocin and ACTH levels, but not between oxytocin and cortisol levels. A positive and significant relationship was found between ACTH and cortisol levels. The duration of skin-to-skin contact before onset of sucking was significantly and negatively associated with lower cortisol levels, but not with ACTH levels. Cortisol levels differed significantly between mothers having received epidural analgesia with and without oxytocin. CONCLUSIONS: Breastfeeding is associated with a decrease of ACTH and cortisol levels. Skin-to-skin contact contributes to this effect. ACTH correlated negatively with the duration of sucking and with median oxytocin levels, whereas cortisol levels correlated inversely with the duration of skin-to-skin contact preceding sucking, suggesting a partial dissociation between the mechanisms regulating ACTH and cortisol release. In addition, medical interventions in connection with birth influence the activity of the hypothalamic-pituitary-adrenal axis 2 days after birth.

Early contact versus separation: effects on mother-infant interaction one year later.

BACKGROUND: A tradition of separation of the mother and baby after birth still persists in many parts of the world, including some parts of Russia, and often is combined with swaddling of the baby. The aim of this study was to evaluate and compare possible long-term effects on mother-infant interaction of practices used in the delivery and maternity wards, including practices relating to mother-infant closeness versus separation. METHODS: A total of 176 mother-infant pairs were randomized into four experimental groups: Group I infants were placed skin-to-skin with their mothers after birth, and had rooming-in while in the maternity ward. Group II infants were dressed and placed in their mothers' arms after birth, and roomed-in with their mothers in the maternity ward. Group III infants were kept in the nursery both after birth and while their mothers were in the maternity ward. Group IV infants were kept in the nursery after birth, but roomed-in with their mothers in the maternity ward. Equal numbers of infants were either swaddled or dressed in baby clothes. Episodes of early suckling in the delivery ward were noted. The mother-infant interaction was videotaped according to the Parent-Child Early Relational Assessment (PCERA) 1 year after birth. RESULTS: The practice of skin-to-skin contact, early suckling, or both during the first 2 hours after birth when compared with separation between the mothers and their infants positively affected the PCERA variables maternal sensitivity, infant's self-regulation, and dyadic mutuality and reciprocity at 1 year after birth. The negative effect of a 2-hour separation after birth was not compensated for by the practice of rooming-in. These findings support the presence of a period after birth (the early "sensitive period") during which close contact between mother and infant may induce long-term positive effect on mother-infant interaction. In addition, swaddling of the infant was found to decrease the mother's responsiveness to the infant, her ability for positive affective involvement with the infant, and the mutuality and reciprocity in the dyad. CONCLUSIONS: Skin-to-skin contact, for 25 to 120 minutes after birth, early suckling, or both positively influenced mother-infant interaction 1 year later when compared with routines involving separation of mother and infant.

Epidural analgesia: breast-feeding success and related factors.

OBJECTIVE: to compare the early breast-feeding behaviours of full-term newborns whose mothers had received epidural analgesia (EDA) during an uncomplicated labour, with a group of newborns whose mothers had not received EDA. DESIGN AND SETTING: a retrospective comparative study design was used and the study was carried out in a labour ward in Stockholm, Sweden between January 2000 and April 2000. The ward has about 5500 deliveries per year. PARTICIPANTS: all maternity records of women who had received EDA during labour (n=585) were included in the study. For each EDA record, a control record was selected, matched for parity, age and gestational age at birth. Women with emergency caesarean section, vacuum extraction/forceps, twin pregnancy, breech presentation or an intra-uterine death, as well as neonates with an Apgar score <7 at 5 mins were excluded. After exclusion, the study population consisted of 351 healthy women and babies in each group. METHOD: logistic regression was performed. The dependent variables: (1) initiation of breast feeding after birth; (2) artificial milk given during hospital stay; and (3) breast feeding at discharge were studied in response to: (a) parity; (b) gestational age at birth; (c) length of first and second stage of labour; (d) administration of oxytocin; (e) administration of EDA; and (f) neonatal weight, as independent variables. FINDINGS: significantly fewer babies of mothers with EDA during labour suckled the breast within the first 4 hours of life [odds ratio (OR) 3.79]. These babies were also more often given artificial milk during their hospital stay (OR 2.19) and fewer were fully breast fed at discharge (OR 1.79). Delayed initiation of breast feeding was also associated with a prolonged first (OR 2.81) and second stage (OR 2.49) and with the administration of oxytocin (OR 3.28). Fewer newborns of multiparae received artificial milk during their hospital stay (OR 0.58). It was also, but to a lesser extent, associated with oxytocin administration (OR 2.15). Full breast feeding at discharge was also positively associated with multiparity (OR 0.44) and birth weight between 3 and 4 kg (OR 0.42). KEY CONCLUSIONS: the study shows that EDA is associated with impaired spontaneous breast feeding including breast feeding at discharge from the hospital. Further studies are needed on the effects of EDA on short- and long-term breast-feeding outcomes.

Sexuality and health: a study of Tanzanian men's experiences of living with HIV/AIDS.

The aim of this study was to explore Tanzanian men's experiences regarding their health and sex life after they had been diagnosed with HIV. In-depth interviews were performed with a purposive sample of ten men living in an urban area in Tanzania and who had been HIV positive for more than one year. A phenomenological-hermeneutic approach was used for analyzing the transcribed interviews. Three themes emerged from the texts; "awareness of HIV infection", "perceived and ideal health", and "sex life a source of happiness and caring". Living with HIV meant profound adjustments to daily life activities for the participants. HIV forced them to learn new ways of having sexual intercourse and new ways of acting as a man. The meaning of being a "real man" had changed from being a man with great sexual prowess to being a "caring man" within one relationship.

Maternal axillar and breast temperature after giving birth: effects of delivery ward practices and relation to infant temperature.

BACKGROUND: Little is known about the development and control of skin temperature in human mothers after birth. The purpose of this study was to explore the effects of delivery ward practices and early suckling on maternal axillar and breast temperatures during the first 2 hours postpartum and to relate them to the infant's foot and axillar temperatures. METHODS: Three groups of 176 mother-infant pairs were randomized as follows--group I: infants lying prone in skin-to-skin contact on their mother's chest, named the "skin-to-skin group" (n = 44), group II: infants who were dressed and lying prone on their mother's chest, named the "mother's arms group" (n = 44), and group III: infants who were dressed and kept in the nursery, named the "nursery group" (n = 88). Maternal axillar and breast temperatures and infants' axillar and foot temperatures were measured at 15-minute intervals from 30 to 120 minutes after birth. Episodes of early suckling were noted. RESULTS: The axillar and breast temperatures rose significantly in all mothers. The rise of temperature over time was significantly higher in multiparas than in primiparas but was influenced only slightly by group assignment. The variation in breast temperature was highest in mothers in the skin-to-skin group and lowest in mothers in the nursery group. In the mother's arms group, variation in breast temperature was larger in those mothers exposed to early suckling than in those not exposed. A positive relationship was found between the maternal axillar temperature and the infant foot and axillar temperature 90 minutes after the start of the experiment (120 min after birth) in the skin-to-skin and mother's arms groups. The rise in temperature in the infant's foot was nearly twice that in the axilla. No such relationship was established in the nursery group. In addition, foot temperature in infants from the skin-to-skin group was nearly 2 degrees C higher than that in infants from the mother's arms group. CONCLUSIONS: Maternal temperature rose after birth, and the rise was higher in multiparas than in primiparas. Skin-to-skin contact and early suckling increased temperature variation. Maternal temperature was related to infant foot and axillar temperatures.

Poverty and devastation of intimate relations: Tanzanian women's experience of living with HIV/AIDS.

In Tanzania, women of reproductive age constitute the largest group infected by HIV. This study aimed to explore the lived experiences related to health and sexuality of Tanzanian women who had known their positive serostatus for 1 year. In-depth interviews with 10 women were analyzed using a phenomenological-hermeneutic approach and showed frustration and despair at not having resources to maintain daily life. The women needed regular medical treatment for themselves and for their HIV-positive children. Their sexual desires had declined or vanished, and they had come to view sexuality as a source of transmittable disease. For some women, casual sex was an option to solve urgent financial needs. Happiness was something for their children, not for them. Access to social support from the women's community would help prevent further HIV transmission and enhance survival so the children could grow up with at least one devoted parent.

Unsafe induced abortions among adolescent girls in Lusaka.

Our aim in this study was to describe adolescent girls' circumstances underlying the decision to resort to unsafe induced abortions. Thirty-four Zambian girls aged 13 to 19 years admitted to University Teaching Hospital (UTH) in Lusaka were interviewed using a semistructured questionnaire with both closed and open-ended questions. Results revealed that most of the girls were single, in school, reached higher grades, mainly nulliparous, and had very low knowledge of contraceptive use. Reasons given for performing unsafe abortions were fear of facing personal shame and social stigma following premarital pregnancies, such as parental disapproval, abandonment by partner, and expulsion from school. A blend of traditional and modern methods and medicines were used to abort. Limited access to contraception and the stigma attached to premarital pregnancies and abortions are likely to continue to compel girls to rely on clandestine abortions if comprehensive adolescent reproductive health services are not provided. The necessity to give adolescent girls more attention and advocacy is obvious.

Early lactation performance in primiparous and multiparous women in relation to different maternity home practices. A randomised trial in St. Petersburg.

BACKGROUND: There are not many studies exploring parity differences in early lactation performance and the results obtained are fairly often contradictory. The present study investigated the effect of different maternity home practices in St. Petersburg, Russia, as well as of physiological breast engorgement and maternal mood, on milk production in primi- and multiparous women on day four. The amount of milk was studied in relation to the duration of "nearly exclusive" breastfeeding. METHODS: 176 mother-infant pairs were randomised into four groups according to an experimental two-factor design taking into account infant location and apparel. Data were recorded in the delivery ward at 25-120 minutes postpartum and later in the maternity ward. Group I infants (n = 37) were placed skin-to-skin in the delivery ward while Group II infants (n = 40) were dressed and placed in their mother's arms. Both groups later roomed-in in the maternity ward. These infants had the possibility of early suckling during two hours postpartum. Group III infants (n = 38) were kept in a cot in the delivery and maternity ward nurseries with no rooming-in. Group IV infants (n = 38) were kept in a cot in a delivery ward nursery and later roomed-in in the maternity ward. Equal numbers per group were either swaddled or clothed. Episodes of early suckling were noted. Number of breastfeeds, amount of milk ingested (recorded on day 4 postpartum) and duration of "nearly exclusive" breastfeeding were recorded. Intensity of breast engorgement was recorded and a Visual Analogue Scale measured daily maternal feelings of being "low/blue". RESULTS: On day four, multiparas had lower milk production than primiparas when they were separated from their infants and breastfeeding according to the prescriptive schedule (7 times a day; Group III). In contrast, there was no difference in milk production between multi- and primiparous mothers in the groups rooming-in and feeding on demand (Groups I, II and IV), although multiparas had higher numbers of feedings than primiparas. In addition during the first three days postpartum, multiparous mothers had higher perception of physiological breast engorgement and lower intensity of feeling "low/blue" than primiparous mothers. Early suckling was shown to positively affect milk production irrespective of parity. Thus Group I and II infants who suckled within the first two hours after birth ingested significantly more milk on day 4 than those who had not (284 and 184 ml respectively, SE = 14 and 27 ml, p = 0.0006).Regression analyses evaluated factors most important for milk production and found in Groups I and II for primiparous women that early suckling, intensity of breast engorgement and number of breastfeeds on day 3 were most important. Intensity of feeling "low/blue" was negatively related to amount of milk ingested. The significant factor for multiparous women was early suckling. Similar results were obtained in Groups III and IV; however, in primiparous mothers, engorgement was the most important factor and in multiparous women it was rooming-in. Amount of milk produced on day 4 was strongly correlated to a duration of "nearly exclusive" breastfeeding (p < 0.0001). CONCLUSION: The present data show that ward routines influence milk production. As our data suggest that milk production in primi- and multiparous women may be differently influenced or regulated by complex factors, further research is needed.

Ethics of justice and ethics of care. Values and attitudes among midwifery students on adolescent sexuality and abortion in Vietnam and their implications for midwifery education: a survey by questionnaire and interview.

UNLABELLED: Adolescent's sexuality and related reproductive health and rights problems are sensitive issues in Vietnam. Globalisation has had an impact on the lifestyles of young people, and rising numbers of abortion and STI/HIV risks among youth are posing major health concerns in the country. These problems need to be addressed. Midwives belong to a key category of health personnel in Vietnam, whose task it is to promote adolescents' sexual and reproductive health and prevent reproductive ill health. It is important to understand future midwives' perceptions and attitudes in order to improve their education and training programmes. AIM: The aim of this study was to investigate Vietnamese midwifery students' values and attitudes towards adolescent sexuality, abortion and contraception and their views on professional preparation. METHODS: A quantitative survey including 235 midwifery students from four different secondary medical colleges in northern Vietnam was carried out in 2003. A qualitative study addressing similar questions was performed and 18 midwifery students were individually interviewed. FINDINGS: Findings revealed a general disapproval of adolescent pre-marital sexual relations and abortion-'an ethics of justice'-but also an empathic attitude and willingness to support young women, who bear the consequences of unwanted pregnancies and social condemnation-'an ethics of care'. Gender-based imbalance in sexual relationships, limited knowledge about reproductive health issues among youth, and negative societal attitudes were concerns expressed by the students. The students saw their future tasks mainly related to childbearing and less to other reproductive health issues, such as abortion and prevention of STI/HIV. CONCLUSION: Midwifery education in Vietnam should encourage value-reflective thinking around gender inequality and ethical dilemmas, in order to prepare midwives to address adolescents' reproductive health needs.

Perspectives of midwives and doctors on adolescent sexuality and abortion care in Vietnam.

BACKGROUND: Vietnam has one of the highest abortion rates in the world and adolescent abortions are thought to constitute at least one-third of all cases. Lack of balanced reproductive health information and services to adolescents and negative social attitudes towards adolescent sexuality are contributing factors to the high abortion rates. Health providers are important in guiding and counselling adolescents on how to protect their reproductive health. There is a lack of studies on health providers' perspectives on their work in adolescent reproductive health care. AIM: To explore the perspectives of midwives and doctors on adolescent sexuality and abortion, and what they considered to be quality abortion care for adolescents and the barriers to it, as well as to their own training needs. METHODS: Observations of care in abortion clinics and focus-group discussions (FGD) were used to collect data. Doctors and midwives from three healthcare facilities in Quang Ninh province in Northern Vietnam participated in a total of eight FGDs. Data were analysed using latent content analysis. FINDINGS: Major barriers identified for quality abortion care were of technical and managerial nature. Participants considered that counselling unmarried clients in connection with abortion should focus on warning against the risks and dangers of abortion and pre-marital sexual relations, which they strongly disapproved of. However, they also expressed a pragmatic and caring attitude towards the unmarried girls and couples coming for abortion. Adolescent sexuality and abortion are morally sensitive issues in the Vietnamese culture. The contradictions between cultural norms and the reality facing health providers while counselling unmarried adolescents need to be addressed in education and training programmes.

Zambian male adolescents' perceptions about premarital sexual relationships.

The role adolescent boys play in premarital sexual activities, gender power relations, and the reproductive health risks they are exposed to, has received little attention in research. This qualitative study has aimed to explore Zambian male adolescents' perceptions and expectations about premarital sexual relationships. Seven focus group discussions were conducted between November 2000 and May 2001, in George and Chimwemwe compounds, with 53 boys aged 15 to 19. The findings reveal that adolescent premarital sexual relationships are common and considered by many boys as a prerequisite to achieving an adult male's autonomy and status. The boys viewed themselves as the privileged gender, with greater freedom than girls, and were the major decision-makers on sexual matters in relationships. The results indicate that traditional values and stereotypical gender roles continue to influence Zambian boys' male identity. However, a sense of ambiguity among the boys on issues of gender imbalance in premarital relationships indicates a potential and preparedness to break with traditional trends - a true challenge for public health priorities and interventions.

Cultural childbirth practices and beliefs in Zambia.

BACKGROUND: Zambia, one of the world's poorest countries, also has one of the highest maternal mortality rates in the world. Most pregnant women in Zambia (96%) attend antenatal care, while 53% deliver at home. This may be related to socio-economic and cultural factors, but cultural childbirth practices and beliefs in Zambia have been little documented. AIM: The aim of this study was to explore cultural childbirth practices and beliefs in Zambia as related by women accompanying labouring women to maternity units. These social support women were also interviewed about their views on providing companionship to labouring women. METHODS: Thirty-six women accompanying labouring women to urban and rural maternity units in Zambia were interviewed A thematic guide with closed and open-ended questions was used. EPI INFO, an epidemiological statistical software package, was used to analyse the quantitative data; qualitative data were analysed using content analysis. FINDINGS: Eighteen of the women considered themselves to be mbusas, or traditional birth assistants and the rest said that they followed labouring women to maternity units. Those who considered themselves traditional birth assistants advised childbearing women on appropriate cultural childbirth practices and assisted with deliveries at home. They also advised women on the use of traditional medicine, for example, to widen the birth canal and to precipitate labour. If something went wrong during labour, they relied on traditional beliefs and witchcraft to explain the mishap and expected the woman in labour to confess her purported 'bad' behaviour. Twelve of the women were in favour of providing support to labouring women in maternity units and learning about childbirth care from midwives. CONCLUSION: These social support women, including those who considered themselves as mbusas, lacked understanding of the causes of obstetric complications during childbirth, and had inadequate knowledge of the appropriate management of labour. Culturally-specific knowledge from this study should be used to guide policy-makers and health planners in the future development of safe motherhood initiatives in developing countries. Midwives have a unique opportunity to ensure that care given during childbirth is clinically safe and culturally sensitive.