Introduction. Today women comprise 15% of the U.S. active-duty military, but are often overlooked in research of the Armed Forces. While some of the challenges faced by women are similar to men, they encounter unique stressors related to childcare while deployed, sexual harassment and assault, and gynecological needs. Women are also more likely than men to develop post-traumatic stress disorder (PTSD). Both stress and PTSD have been linked to the development of chronic hypertension and some adverse birth outcomes. We hypothesized that post-9/11/2001 era military women who deployed or who had indicators of PTSD would be at greater risk of developing a hypertensive disorder of pregnancy (HDP) than non-deployed or non-PTSD military women. Methods. We conducted a retrospective cohort study using a U.S. Department of Defense database comprised of all active-duty women who gave birth to their first, live-born singleton infant using Tricare from January 1, 2004 to December 31, 2008. The database included maternal and infant birth hospitalization records, maternal mental health visits, and post-9/11/2001 deployment information which included Post-Deployment Health Assessment (PDHA) and Reassessment (PDHRA) screening responses. HDP was defined with ICD-9-CM codes in the maternal birth hospitalization record. We evaluated the risk of HDP associated with overall deployment and timing of deployment ending compared to non-deployed women, in addition to cumulative months of deployment. We also conducted Classification Tree Analysis (CART) to determine appropriate cut-points for categorization of deployment variables among mothers who deployed: cumulative weeks of deployment, percent of study time spent deployed, and dwell time between two most recent pre-birth deployments. We explored effect modification by covariates postulated to potentially modify the relationship between deployment history and risk of HDP. New variables were defined and used in multivariable logistic regression models for each deployment measure. Women fit into four PTSD case-definition categories: confirmed (ICD-9-CM diagnosis), probable (possible plus endorsement of “high risk” items on the PDHA), possible (endorsement of ≥3 PTSD items on the PDHA), or none (no PTSD indicators). We compared mothers with PTSD to non-cases using multivariable logistic regression to quantify the risk of HDP, and repeated the analyses using a ≥2 PTSD item endorsement case-definition criteria. All logistic regression models were adjusted for known confounders and important covariates. Results. There were a total of 36,675 births, 13.4% of mothers experienced at least one HDP, and 35% of mothers deployed. No increased risk of HDP was observed for deployment overall (OR=1.02, 95% CI: 0.95-1.09), but black mothers who deployed were 13% more likely to develop an HDP (OR=1.13, 95% CI: 1.00-1.27). CART revealed an important cut-point for cumulative deployment length of ≥1 year, which was statistically significant among mothers <35 years old. Mothers with ≥1 year cumulative deployment were 17% more likely to have an HDP than mothers deployed <1 year (OR=1.17, 95% CI: 1.01-1.36). The prevalence of confirmed PTSD was 1.6% in the overall cohort. The prevalence of any PTSD among deployed mothers who completed a PDHA was 6.2%. Overall, PTSD was not significantly associated with HDP except among probable PTSD cases using the ≥2 item criteria (OR=1.30, 95% CI: 1.01-1.67) and among confirmed PTSD mothers identifying as “other” race (OR=6.62, 95% CI: 1.72-25.47). Conclusion. Results are suggestive of an elevated risk of HDP among the military population among women who deployed for a year or longer and for black mothers. Although PTSD did not clearly confer additional risk in the overall cohort, there is evidence to support further research using more thorough screening especially across racial/ethnic groups. Our study likely underestimated PTSD and possibly attenuated results since individuals may purposely report inaccurately on the PDHA in order to go home sooner after deployment. Future studies should include information related to deployment-specific experiences and screen all participants for evidence of PTSD.

This thesis deals with the topic of providing perinatal care from the patient's point of view. The aim of the thesis is to use national legislation and decisions of Czech and international courts to determine under what conditions a woman has the right to decide on the provided health services. From the legal point of view the area of perinatal care brings many questions where it is not easy, also with regard to the ethical aspect of things, to find an answer. During the pregnancy and childbirth, there are situations in which two constitutionally guaranteed rights conflict and with regard to the health services provided, it is necessary to evaluate the situation individually. In the introductory chapters the thesis summarizes the legal regulation including the constitutional law of the provision of health services. Emphasis is placed on the rights of the patient, especially the possibility to decide on the provided health care in different situations. A separate chapter is devoted to the institute of previously expressed wish and its application to the period of delivery. In the context of postnatal care, the legal regulation of parents' decisions about the health services provided to their child is mentioned. The field of healthcare law requires the introduction of legislation into the context of...

À l'heure actuelle, les résultats périnataux en France demeurent parmi les moins satisfaisants en Europe malgré une très forte médicalisation. Les autorités de santé affirment reconnaître l'influence de la prise en charge et de l'accompagnement pendant la grossesse, l'accouchement et la période néonatale sur l'état de santé de la mère et de l'enfant mais l'offre de soins peine à s'élargir. Contrairement à ce que prévoient les lois concernant le libre choix du praticien en France, les parturientes ne sont pas à même de choisir le professionnel de santé qui les accompagnera lors de leur accouchement. De même, les sages-femmes, contrairement à ce qu'impose leur code de déontologie, ne sont pas en mesure de garantir à leurs patientes ni les conditions, ni le lieu de leur accouchement. De surcroît, peu d'entre elles exercent leur profession de façon autonome tout en pratiquant le plein exercice de leur fonction. En centrant cette recherche anthropologique sur l'expérience des femmes et des sages-femmes dans leurs relations autour de la naissance et de l'accouchement, l'objectif de cette étude qualitative est de faire la lumière sur les tenants et les aboutissants de l'uniformisation de l'offre de soins. Dans un premier temps sont abordés les différents types d'accompagnement proposés aux femmes aujourd'hui ainsi que la place qu'y occupent les sages-femmes. Dans un second temps, l'étude de l'accompagnement global permet l'examen de la prise en charge des patientes et de ses liens de causalité avec les relations interprofessionnelles. Ainsi sont révélés les impacts de cette pratique sur le soutien à la parentalité et la nécessité d'une diversification de l'offre de soins. / Currently, the perinatal results in France remain among the least satisfactory in Europe in spite of a very strong medicalization. However, health authorities acknowledge the influence of maternity care during pregnancy, childbirth and neonatal period on the state of health of the mother and the child but health services hardly increase. Contrary to what French law says on free choice of practitioner, parturient women cannot choose the health professional who will assist them during labor. Likewise, midwives cannot guarantee their patients the place and conditions of childbirth, contrary to their code of ethics. In addition, few of them have the opportunity to work in an independent way and at the same time fully practice their profession. By focusing this anthropological research on women's and midwives' experience in their relationships around childbirth, the aims of this qualitative study are to clarify the ins and outs of the standardization of health services. Initially, the various types of care provided to women today and the place granted to midwives are discussed. Secondly, possible causal links between interprofessional relations and maternity care are searched for through the study of comprehensive care. So are revealed the impacts of a close and trusting relationship in supporting parenthood and of a diversification of health services.

Determina la eficacia de los indicadores de morbilidad materna extrema y mortalidad materna para medir la calidad de atención en los servicios obstétricos de hospitalización de los hospitales Dr. Teodoro Maldonado Carbo y Enrique C. Sotomayor. Realiza un estudio con enfoque cuantitativo de nivel investigativo observacional y diseño transversal. El estudio se efectuó en hospitales de tercer nivel con atención a mujeres embarazadas internadas. Se escogió instituciones del sector privado y de la seguridad social con atención a más de 2000 nacimientos anuales. Utiliza una muestra de 414 mujeres. Encuentra que en el Hospital Materno Enrique C. Sotomayor se estableció 531% (163 casos) de MME y 37,7% (52 casos) en el Hospital Teodoro Maldonado Carbo. En el Hospital Materno Enrique C. Sotomayor se encontró 7,5% (23 casos) MM y el Hospital Teodoro Maldonado Carbo 2,2% (3 casos). La relación morbilidad materna extrema/mortalidad materna fue 6,3, lo que significa la calidad de atención brindada fue satisfactoria. Conclusiones. En el Hospital Enrique C. Sotomayor la tasa de morbilidad materna extrema fue mayor que en el Hospital Teodoro Maldonado Carbo. El Hospital Enrique C. Sotomayor tuvo mayor número de casos de mortalidad materna que el Hospital Teodoro Maldonado Carbo. La relación morbilidad materna extrema/mortalidad maternal (6,3) indica que la calidad de atención brindada fue satisfactoria. / Tesis

Background: Young childbearing women have an increased risk of experiencing perinatal depression when compared to adult childbearing women. Perinatal depression has been associated with adverse life events in the literature and conceptually, in frameworks such as the Lifecycle Approach to Risk Factors for Mental Disorders Model. Purpose: The purpose of this manuscript-based thesis was to (1) determine the prevalence of: (i) adverse life events that have been associated with depression and (ii) depressive symptoms among the young pregnant and parenting women who access specialized services in an urban centre in Ontario, Canada; (2) determine which adverse life events are predictive of depression during the perinatal period, in this population; and (3) examine the psychometric properties of the Edinburgh Postnatal Depression Scale (EPDS) for use in a population of young childbearing women who access specialized services in an urban centre in Ontario, Canada. Methods: A survey was conducted with 102 young women from two agencies that provide specialized services to young parents. The interviewer-administered questionnaire included demographic questions, the Edinburgh Postnatal Depression Scale, the Antenatal Psychosocial Health Assessment, the Centers for Epidemologic Studies Depression Scale, Brown’s Support Behaviour Inventory. Results: 31.4% of the sample screened positive for perinatal depression. The only adverse life events found to predict perinatal depression were satisfaction with support from ‘others’ and intimate partner violence. Another predictor was very young maternal age (14 – 17 years). The EPDS was found to be psychometrically sound when used in this population of young childbearing women. Conclusion: In this study of young childbearing women in Ontario, Canada, we found a high prevalence rate of perinatal depression and adverse life events. Furthermore, we identified specific factors that predict the development of perinatal depression in this group. Nurses can use these findings to help prioritize perinatal screening efforts to identify this condition early on in order to lessen the adversities related to perinatal depression.

Background: In Pakistan, the prevalence of perinatal depression is high and is associated with adverse outcomes in both the mothers and their infant. Although effective psychosocial interventions have been developed for such settings, the scarcity of trained mental health professionals means that the majority of such women do not receive any intervention. The aim of this study was to explore the acceptability of peer volunteers (PVs) - volunteer lay women from the community with shared socio-demographic and life experiences with the target population – as delivery agents of a psychosocial intervention for perinatal depression in a rural area of Pakistan. Methods: This qualitative study was embedded in the pilot phase of a cluster randomised control trial. Participants included the entire sample of the pilot study: mothers (n=21), PVs (n=8), primary health care staff (n=5), husbands (n=5) and mothers-in-law (n=10). Data were collected, from these key stakeholders, through in-depth interviews and focus group discussions. Data analysis was underpinned by Framework Analysis involving five key stages: familiarisation, development of thematic framework, indexing, charting and interpretation. Results: All stakeholders viewed the PVs as acceptable delivery agents of a psychosocial intervention for perinatal depression. The PV’s personal attributes such as being local, empathic, trustworthy, approachable and of good reputation within their communities contributed to their acceptability. Their linkage with the primary health care system was vital to their legitimacy and credibility. Factors such as appropriateness of the intervention, effective training and supervision, perception of personal gain from the programme, and endorsement from their families and the community were motivational for them. Likely barriers to their work were women’s lack of autonomy, cultural beliefs around the perinatal period, stigma of depression, lack of some mothers’ engagement and resistance from some families. Conclusion: PVs are a potential human resource for the delivery of a psychosocial intervention for perinatal depression in this rural area of Pakistan. The use of such delivery agents could be considered for other under-resourced settings globally, and for other mental health conditions.

The prevalence of opioid use has increased in many populations including pregnant women, which has led to a substantial rise in infants born dependent on opioids due to in utero exposure. Many women use multiple substances aside from opioids during pregnancy, and their infants therefore present with a variety of symptoms. With increasing legalization and changing perception of marijuana, it has become one of the most commonly used substances during pregnancy. Few studies have evaluated concomitant use of marijuana and opioids in pregnancy despite both being implicated in adverse newborn outcomes. The primary aim of this study was to determine the association between marijuana use and pregnancy outcomes in opioid-exposed pregnancies. The secondary aim was to identify, in a sample of women already using opioids, maternal characteristics associated with marijuana use during pregnancy. A retrospective chart review was conducted from July 2011 to June 2016 of all births from 6 delivery hospitals in South-Central Appalachia to determine pregnancy and neonatal outcomes of pregnancies exposed to any form of opioid and positive urine drug screen for marijuana at the time of delivery. 2375 pregnancies met the inclusion criteria with 108 pregnancies positive for marijuana. Student t-test and Chi-Square test were used for group comparison for presence and absence of marijuana. Logistic regression was done for significant confounding variables to find aOR for marijuana exposure for neonatal abstinence syndrome diagnosis, premature birth, and low birth weight. Among opioid using women, marijuana positive women were more likely to be unmarried, nulliparous, and use tobacco and benzodiazepines. Infants born to the marijuana users were likely to be of earlier gestational age (3 days), lower birth weight, and preterm; with preterm birth and low birth weight (mean difference = 265 gms) increased two fold even after controlling for parity, marital status, tobacco and benzodiazepine use with aOR of 2.35 (1.30-4.23) and 2.02 (1.18-3.47) respectively. Ultimately, prenatal use of marijuana in opioid-exposed pregnancies carries significant risk of prematurity and low birth weight. For pregnant women continuing their American College of Obstetricians and Gynecologists recommended medical assisted treatment for opioid use disorder, providers should counsel women to abstain from marijuana during pregnancy.

BACKGROUND: The United States maternal mortality ratio (MMR) has increased in the past few decades and disparities that negatively impact birthing individuals of color persist. While there are many potential causes for health inequity, distinct factors such as obstetric racism, lack of informed and shared decision-making approaches, and lack of continuous birthing support can prevent positive birthing outcomes. The present study investigates the impact of doula support on perinatal mood disorders while also evaluating potential differences in racial/cultural concordance and cultural competence in the context of the doula-patient relationship, in a Northeastern U.S. urban setting. METHODS: Seven focus group discussions (FGDs) were conducted amongst prenatal and postpartum patients (n=9) and actively practicing doulas (n=18). Participants shared their thoughts and lived experiences related to doula support during the perinatal period through open-ended questions. Researchers transcribed qualitative data from FGDs and analyzed them using a modified grounded theory approach. RESULTS: Five major themes emerged from qualitative data analysis: (1) doula support can reduce stress during the perinatal period, (2) doulas can make the process of seeking out mental health support more efficient, (3) cultural competency in doula care is a learning process (4) racial concordance does not guarantee successful doula-patient relationships, and (5) doulas play an important role in the decision-making process. CONCLUSIONS: The presence of doula support can combat perinatal mood disorders through two pathways identified in the present study. Although there may be distinct differences between culturally competent versus culturally congruent doula-patient relationships, matching by race or culture is not the solution to a fulfilling relationship. Doulas practicing cultural competence and cultural humility – regardless of client background – can make a meaningful impact on the perinatal experience and long-term mental health outcomes. / 2022-11-10T00:00:00Z

Les difficultés psychologiques pouvant apparaître chez les mères au cours de la périodepérinatale se révèlent fréquentes et potentiellement graves pour la mère et l’enfant. Ces troublessemblent être insuffisamment repérés et l’accès aux soins psychiques des femmes en périodepérinatale reste un enjeu de santé publique majeur. Peu de travaux se sont intéressés auxinterrelations et processus sous jacents entre des facteurs de risque de survenue de symptômesdépressifs postnataux. L’objectif principal de notre travail était d’étudier l’impact de diversfacteurs de risque de survenue de difficultés psychologiques au cours de la grossesse et/ou lepostpartum, au sein d’un vaste échantillon de mères en population générale. Le second objectifétait de développer un « modèle multifactoriel de la symptomatologie dépressive postnatale »,basé sur les travaux théoriques de Milgrom, Martin & Negri (1999).Deux études ont été menées à partir des données de la cohorte ELFE (Etude LongitudinaleFrançaise depuis l’Enfance). La première étude (n=15 143) a permis de mettre en évidence quedes vulnérabilités socioéconomiques et un ensemble de caractéristiques de la grossesse,notamment celles concernant le suivi prénatal et les complications obstétricales, étaientindépendamment associées à la présence de difficultés psychologiques prénatales. Environ 13%des femmes déclaraient avoir présenté de telles difficultés et un quart d’entre elles avaientconsulté un spécialiste de la santé mentale. Le jeune âge, un niveau éducatif intermédiaire et êtrenée à l’étranger étaient indépendamment associés à une plus faible probabilité d’accéder à dessoins de santé mentale. La seconde étude (n=11 643) a permis le développement d’un modèlemultifactoriel de la symptomatologie dépressive maternelle postnatale. Les résultats montrent uneffet direct du soutien anténatal de la part du conjoint et des capacités d’autorégulation du bébésur l’intensité de la symptomatologie dépressive postnatale. Des effets indirects du niveausocioéconomique et de la compréhension maternelle des pleurs du bébé médiés respectivementpar le soutien anténatal et les capacités d’autorégulation du bébé sont démontrés.En dépit des stratégies de santé publique visant à promouvoir un dépistage organisé et desstratégies de prévention des vulnérabilités psychosociales périnatales, le manque d’accès auxsoins psychiques au cours de la période périnatale demeure un enjeu majeur de santé publique.Notre travail confirme l’hypothèse que les symptômes dépressifs postnataux ont des originesmultifactorielles, qui évoluent au sein d’un modèle interactif complexe. Le soutien anténatal de lapart du conjoint et les caractéristiques liées au bébé semblent avoir une place centrale. / Mother’s psychological problems during the perinatal period are frequent and potentiallyserious for both mother and child. Depressive disorders appear to be particularly poorly identifiedand access to mental health care for women in the perinatal period remains a major public healthissue. Few studies have focused on interrelationships between risk factors for occurence ofpostpartum depressive symptoms. The main objective of our work was to study the impact ofvarious risk factors for occurrence of psychological problems during pregnancy and / orpostpartum, in a large sample of mothers in general population. The second objective was todevelop a "multifactorial model of postnatal depressive symptoms" based on the theoretical workof Milgrom, Martin & Negri (1999).Two studies were conducted using data from the ELFE cohort (Etude LongitudinaleFrançaise depuis l’Enfance - French longitudinal study from childhood). The first study (n=15143) showed that socioeconomic vulnerabilities and some characteristics of pregnancy,particularly those concerning antenatal care and obstetrical complications, were independentlyassociated with prenatal psychological distress. About 13% of women report having presentedsuch difficulties and a quarter of them had consulted a mental health specialist. Young age,intermediate educational level and being foreign-born were independently associated with a lowerprobability of access to mental health care. The second study (n=11 643) enabled the developmentof a multifactorial model of postnatal maternal depressive symptomatology. The results show adirect effect of prenatal support from the spouse and baby's self-regulatory capacities on theintensity of postnatal depressive symptoms. Indirect effects of socioeconomic status and maternalunderstanding of the baby’s crying mediated by respectively prenatal support and baby’s selfregulationcapacity are shown.Despite public health strategies to promote an organized screening and psychosocialvulnerabilities perinatal prevention strategies, lack of access to mental health care during theperinatal period remains a major public health issue. Our work confirms the hypothesis thatpostnatal depressive symptoms have multifactorial origins, evolving within a complex interactivemodel. Prenatal support from the spouse and baby-related characteristics seem to have a central

The aim of this study has been to examine eight Afro-Swedish women's lived experiences of perinatal care in Sweden. The material has been produced through qualitative interviews to investigate the extent to which colonial stereotypes continue to affect Afro-Swedish women in perinatal care. The questions to be answered were "What aspects are recurring in the womens stories about perinatal care in Sweden?" and “In what way are stereotypes created and maintained in perinatal care? Most of the women had encountered various forms of malpractice in perinatal care. At some point the women neither felt seen nor heard and the healthcare staff tended to speak condescendingly to them. Stereotypes in perinatal care can be maintained and created through birth stories by Swedish midwives who have practiced in poor countries such as in Africa. Through these birth stories, a perception is created of how black women give birth versus white women.