PRENATAL AND PERINATAL LOSS ENTANGLED IN CZECH INSTITUTIONS Marie Hintnausová ABSTRACT An ethnographic research among women who experienced a loss of child during pregnancy or postpartum aims to expose contexts and backgrounds in which prenatal and perinatal loss emerges in the Czech Republic. This life event is delineated not only by unique biographies of affected mothers, but also by the societal understanding of prenatal life and institutional definitions of human reproduction. This thesis highlights various notions and meanings entangled in the event of prenatal and perinatal death and shows which trajectories women follow in the terrain of societal expectations and governmental and biomedical institutions when they lose a promised assurance of raising a new child.

Title: Psychosocial aspects of intrapartum and postpartum care Author: Mgr. Lea Takács Department: Department of Psychology Supervisor: PhDr. Simona Hoskovcová, Ph.D. Consultant: MUDr. PhDr. Pavel Čepický, CSc. Abstract Background: Satisfaction with perinatal care is largely a result of psychosocial aspects of the care provided. However, despite a considerable body of research, the concept of satisfaction with perinatal care is not sufficiently defined and understood, being often confused with other concepts, particularly with that of satisfaction with childbirth experience. The lack of knowledge concerns especially the psychosocial dimensions and determinants of the care, most importantly for different groups of women, and the level of importance of psychosocial factors for satisfaction compared to biomedical variables. Objective: The aim of the present dissertation is to contribute to the theory of satisfaction by investigating the psychosocial and biomedical factors that affect satisfaction with perinatal care and satisfaction with childbirth experience in different groups of women depending on the mode of delivery (vaginal delivery, emergency caesarean section or elective caesarean section). Method: Ordinal logistic regression was used to identify the key predictors of satisfaction. The data were...

Hintergrund: Ein Schwangerschaftsverlust beziehungsweise das Versterben des Säuglings kurz nach der Geburt stellt eine massive psychische Belastung für die betroffenen Eltern dar (Berth et al., 2009; Ellis et al., 2016). Durch die Trauer ausgelöste Folgeerkrankungen, wie beispielsweise Posttraumatische Belastungsstörungen, Angst- und Panikstörungen, somatoforme Störungen oder Depressionen, entwickeln sich bei 20 - 30 % der Eltern (Klapp, 2017). Die Verhaltensweisen und Handlungen der Klinikmitarbeitenden haben einen bedeutenden Einfluss auf die Eltern (Ellis et al., 2016). Die Verfügbarkeit einer empathischen geburtshilflichen Betreuung ist ein wichtiger Bestandteil für die psychische Gesundheit der Eltern sowie ein wichtiger Beitrag zur Prävention von Folgeerkrankungen (Mills et al., 2014). Die Hälfte aller betroffenen Familien wünscht sich unterstützende Strukturen und Systeme (Ellis et al., 2016). Bei einer Befragung der Betroffenen bezüglich der Qualität der Versorgung nach einem perinatalen Kindstod wurde belegt, dass über die Hälfte der Betroffenen mit der postpartalen Begleitung in der Klinik unzufrieden war (Meier Magistretti et al., 2019). 30 % der Eltern wünschen sich hilfreiche und umfangreiche Informationen für die Zeit nach dem Klinikaufenthalt, wie beispielsweise Kontaktdaten von Selbsthilfegruppen, 13 % wünschen sich, dass ihre Bedenken besprochen werden und 20 %, dass das öffentliche Bewusstsein für den perinatalen Kindstod gestärkt wird (Ellis et al., 2016). Ausgehend von der großen Bedeutung der Trauerverarbeitung nach einem perinatalen Verlust, bildet das Aufgabenmodell von Lammer (2014) die theoretische Grundlage dieser Studie. Das Modell beinhaltet Aspekte der klassischen Phasenmodelle, integriert die Aspekte des Aufgabenmodells von Worden und wird auf die Trauer nach dem perinatalen Kindstod übertragen (Lammer, 2014). Fragestellungen/Hypothesen: Die erste Forschungsfrage untersucht, ob es einen Zusammenhang zwischen der Klinikgröße und dem Angebot an Maßnahmen zur Trauerbewältigung für Eltern von Sternenkindern gibt. Die zweite Forschungsfrage untersucht den Zusammenhang zwischen einem umfangreichen Unterstützungsangebot für das Klinikpersonal im Umgang mit verwaisten Eltern und der Häufung an Informationsangeboten für trauernde Eltern. Bei beiden Fragen wird jeweils ein positiver Zusammenhang vermutet. Material und Methode: In dieser Arbeit wird mittels einer empirischen Studie die psychosoziale Betreuung rund um den perinatalen Verlust in Geburtskliniken untersucht. Ziel der vorliegenden Studie ist es, die aktuellen Vorgehensweisen der psychosozialen Betreuung in deutschen Kliniken zu erheben, um daraus Handlungsempfehlungen für Kliniken beziehungsweise Fachkräfte zum empathischen Umgang mit Betroffenen abzuleiten. Angewendet auf die Trauerbegleitung wurde ein konzeptionelles Modell entworfen, aus dem zwei Forschungsfragen generiert wurden, die mittels einer quantitativen Querschnittsstudie in Form einer Vollerhebung an deutschen Kliniken mit Entbindungsstation untersucht wurden. Das Sample umfasst Chefärzt*innen, geeignete Fachkräfte, Krankenpfleger*innen, Entbindungshelfer*innen, Seelsorger*innen, Psycholog*innen, Sozialarbeiter*innen und Angehörige unspezifischer Professionen. Das Datenerhebungsinstrument ist ein Fragebogen bestehend aus 5 Frageblöcken mit insgesamt 13 Fragen. Erhoben wurden die Daten mit der Software LimeSurvey (LimeSurvey GmbH). Die Auswertung der Daten zur Überprüfung der Hypothesen erfolgte mittels einer Regressionsanalyse. Ergebnisse: 206 (33.2 %) Klinken haben an der Befragung teilgenommen, am häufigsten Ärzt*innen (69.5 %) und Entbindungshelfer*innen (19 %). Die deskriptiven Ergebnisse zeigen, dass die Kliniken den Eltern unter anderem Verabschiedung (99.5 %), Kontaktaufnahme (95.1 %), Anfertigung von Erinnerungsstücken (98.5 %), Anfertigung von Fotos (99 %) und Kontaktaufnahme mit Sternenkindfotograf*innen (81.8 %) anbieten. Die Zufriedenheit des Klinikpersonals bei der psychosozialen Betreuung sowie dessen Relevanz wird sehr hoch eingeschätzt. Die Analysen bestätigen beide Hypothesen. Die Überprüfung der Hypothese 1: Je größer die Klinik ist, desto größer ist das Angebot an Maßnahmen zur Trauerbewältigung für Eltern von Sternenkindern zeigt, dass die Größe der Klinik einen höchst signifikant positiven Effekt auf die Anzahl der Angebote hat, um die Trauer der Eltern von Sternenkindern zu verarbeiten. Die Überprüfung der Hypothese 2: Je umfangreicher die Unterstützungsangebote für das Klinikpersonal im Umgang mit verwaisten Eltern ausfallen, desto größer ist das Informationsangebot für trauernde Eltern ergibt, dass sich die Anzahl unterschiedlicher Angebote für Krankenhauspersonal positiv und hoch signifikant auf die Anzahl der Informationsangebote für Eltern von Sternenkindern auswirkt. Das lineare Regressionsmodell mit der Erweiterung um die Anzahl der Geburten, die Anzahl der perinatalen Säuglingstodesfälle und die Situationsvariablen in Ost- oder Westdeutschland zeigt, dass die Anzahl der Angebote für das Krankenhauspersonal einen sehr positiven und signifikanten Einfluss auf die Anzahl der den Eltern zur Verfügung stehenden Informationen hat. Schlussfolgerungen: Eine mögliche Handlungsempfehlung, die sich aus dieser Studie ableiten lässt, ist, dem Klinikpersonal spezielle Fortbildungen rund um das Thema des perinatalen Kindstods anzubieten. Die Thematisierung von Ärzt*in-Patient*innen-Beziehung in Balint- oder Supervisionsgruppen können ebenfalls zu einer verbesserten Situation zwischen diesen führen, werden derzeit allerdings nur in 27 % der Kliniken angeboten. Um eine bessere psychosoziale Betreuung der trauernden Eltern zu etablieren, ist sowohl die interne interdisziplinäre Zusammenarbeit als auch die Kooperation mit externen Beratungsstellen förderlich. Darüber hinaus könnte es für die Eltern nach einem perinatalen Verlust wichtig sein, sich mit Gleichgesinnten auszutauschen, wobei bisher lediglich 40 % der Kliniken den Eltern den Hinweis auf Online-Selbsthilfegruppen geben.:Einleitung 1 1. Hintergrund 3 1.1 Begriffliche Bestimmung des perinatalen Kindstodes 3 1.2 Formale Regelungen zum Begriff des perinatalen Kindstodes 4 1.3 „Anhaltende Trauerstörung“ als Krankheitsbild 5 1.4 Trauer als Verlustreaktion und die daraus resultierenden Aufgaben der Trauerbewältigung 5 1.5 Unterstützung im Trauerprozess durch das Fachpersonal 9 1.5.1 Unterstützungsbedarfe der Betroffenen 9 1.5.2 Aufgaben der Trauerbegleitung 10 1.6 Psychosoziale Versorgungsstrukturen in der Geburtshilfe und Frauenheilkunde 16 1.6.1 Gynäkologische und neonatale Versorgungsstrukturen in Deutschland 16 1.6.2 Psychosoziale Betreuung im klinischen Kontext 19 2. Fragestellung und Hypothese 22 3. Material und Methode 27 3.1 Studienpopulation und Sample 27 3.2 Operationalisierung und Fragebogenentwicklung 33 3.3 Datenerhebungsmethode 38 3.4 Datenauswertungsmethoden 39 3.4.1 Quantitative Datenanalyse 39 3.4.2 Qualitative Inhaltsanalyse 41 3.5 Ethische und rechtliche Aspekte der Studie 42 4. Ergebnisse 43 4.1 Hypothese 1 43 4.1.1 Deskriptive Statistik zu Hypothese 1 43 4.1.2 Hypothesentest 44 4.2 Hypothese 2 46 4.2.1 Deskriptive Statistik zu Hypothese 2 47 4.2.2 Hypothesentest 49 4.3 Weitere explorative Datenanalysen 51 4.3.1 Angebote für betroffene Eltern 51 4.3.2 Bewertung der Zufriedenheit 52 4.3.3 Bewertung der Themenrelevanz 52 4.3.4 Standardisierte Vorgehensweise 53 4.3.5 Begriffe für Totgeburten und Kindstode in den Kliniken 54 4.3.6 Unerwähnte Angebote 55 4.3.7 Wünsche des Personals bezüglich der Unterstützung 56 4.3.8 Weitere Kommentare zur Begleitung der Eltern 57 5. Schlussfolgerungen 58 5.1 Zusammenfassung und Interpretation der Ergebnisse 58 5.2 Ergebniseinordnung in den aktuellen Forschungsstand und Handlungsempfehlungen 60 5.3 Kritische Reflexion der eigenen Untersuchung 64 5.4 Resümee und Zukunftsperspektiven 65 Zusammenfassung (Deutsch) 67 Abstract (English) 70 Quellenverzeichnis 73 Anhang 82 A. Abkürzungsverzeichnis 82 B. Abbildungsverzeichnis 83 C. Tabellenverzeichnis 84 D. Operationalisierung der Variablen 85 E. Fragebogen 88 F. Anschreiben Kliniken 96 G. Reminderanschreiben Kliniken (I) 98 H. Reminderanschreiben Kliniken (II) 100 I. Ethikkommission 102 J. Danksagung 107 K. Erklärung zur Eröffnung des Promotionsverfahrens (Anlage 1) 108 L. Erklärung zur Einhaltung gesetzlicher Vorgaben (Anlage 2) 109 / Background: A pregnancy loss or the death of the infant shortly after birth represents a massive psychological burden for the parents affected (Berth et al., 2009; Ellis et al., 2016). Consequential illnesses triggered by the grief, such as post-traumatic stress disorder, anxiety and panic disorders, somatoform disorders or depression, develop in 20 - 30 % of parents (Klapp, 2017). The behaviours and actions of clinic staff have a decisive influence on parents (Ellis et al., 2016). The availability of empathic obstetric care is an important component for parents' mental health as well as an important contribution to the prevention of sequelae (Mills et al., 2014). Half of all affected families want support structures and systems (Ellis et al., 2016). In a survey regarding the quality of care after a perinatal infant death, it was documented that over half of those affected were dissatisfied with the postpartum support in the clinic (Meier Magistretti et al., 2019). 30 % of parents would like helpful and comprehensive post-hospital information, such as contact details for support groups, 13 % would like their concerns to be discussed and 20 % would like public awareness of perinatal death to be raised (Ellis et al., 2016). Based on the great importance of grief processing after a perinatal loss, Lammer's (2014) task model forms the theoretical basis of this study. The model includes aspects of the classical phase models, integrates the aspects of Worden's task model and is applied to grief after perinatal infant death (Lammer, 2014). Research questions/hypotheses: The first research question investigates whether there is a correlation between clinic size and the availability of grief management interventions for parents of infants who have died. The second research question examines the correlation between an extensive offer of support for the clinic staff in dealing with orphaned parents and the number of information offers for grieving parents. For each research question, a positive correlation is hypothesised. Material and method: In this study, the psychosocial care around perinatal loss in maternity hospitals is investigated by means of an empirical study. The aim of this study is to survey the current procedures of psychosocial care in German clinics in order to derive recommendations for action for clinics or professionals on how to deal empathetically with those affected. Applied to grief counselling, a conceptual model was designed from which two research questions were generated, which were investigated by means of a quantitative cross-sectional study in the form of a full survey of German hospitals with maternity wards. The sample includes head physicians, appropriate specialists, nurses, maternity assistants, pastoral workers, psychologists, social workers and members of non-specific professions. The data collection instrument is a questionnaire consisting of 5 question blocks with a total of 13 questions. The data was collected with the software LimeSurvey (LimeSurvey GmbH). Regression analysis was used to analyse the data to test the hypotheses. Results: 206 (33.2 %) clinics participated in the survey, most frequently physicians (69.5 %) and maternity nurses (19 %). The descriptive results show that the clinics offer parents, among other things, goodbyes (99.5 %), contact (95.1 %), making mementos (98.5 %), taking photos (99 %), and contacting still born infant photographers (81.8 %). The satisfaction of the clinic staff with the psychosocial support and its relevance are rated very high. The analyses confirm both hypotheses. The test of hypothesis 1 The larger the clinic, the greater the range of grief management measures for parents of still born infants shows that the size of the clinic has a highly significant positive effect on the number of offers to help parents of still born infants cope with their grief. Testing hypothesis 2 The more extensive the support services for hospital staff in dealing with orphaned parents, the greater the information available for bereaved parents shows that the number of different services for hospital staff has a positive and highly significant effect on the number of information services for parents of still born infant. The linear regression model with the extension to include the number of births, the number of perinatal infant deaths and the situation variables in East or West Germany shows that the number of services offered to hospital staff has a very positive and significant influence on the amount of information available to parents. Conclusions: One possible recommendation for action that can be derived from this study is to offer hospital staff special training on the topic of perinatal infant death syndrome. Addressing the doctor-patient relationship in balint or supervision groups can also lead to an improved situation, but is currently only offered in 27% of the clinics. In order to establish better psychosocial care for bereaved parents, both internal interdisciplinary cooperation and cooperation with external counselling centres are beneficial. In addition, it could be important for parents after a perinatal loss to exchange information with like-minded people, although so far only 40 % of the clinics refer parents to online self-help groups.:Einleitung 1 1. Hintergrund 3 1.1 Begriffliche Bestimmung des perinatalen Kindstodes 3 1.2 Formale Regelungen zum Begriff des perinatalen Kindstodes 4 1.3 „Anhaltende Trauerstörung“ als Krankheitsbild 5 1.4 Trauer als Verlustreaktion und die daraus resultierenden Aufgaben der Trauerbewältigung 5 1.5 Unterstützung im Trauerprozess durch das Fachpersonal 9 1.5.1 Unterstützungsbedarfe der Betroffenen 9 1.5.2 Aufgaben der Trauerbegleitung 10 1.6 Psychosoziale Versorgungsstrukturen in der Geburtshilfe und Frauenheilkunde 16 1.6.1 Gynäkologische und neonatale Versorgungsstrukturen in Deutschland 16 1.6.2 Psychosoziale Betreuung im klinischen Kontext 19 2. Fragestellung und Hypothese 22 3. Material und Methode 27 3.1 Studienpopulation und Sample 27 3.2 Operationalisierung und Fragebogenentwicklung 33 3.3 Datenerhebungsmethode 38 3.4 Datenauswertungsmethoden 39 3.4.1 Quantitative Datenanalyse 39 3.4.2 Qualitative Inhaltsanalyse 41 3.5 Ethische und rechtliche Aspekte der Studie 42 4. Ergebnisse 43 4.1 Hypothese 1 43 4.1.1 Deskriptive Statistik zu Hypothese 1 43 4.1.2 Hypothesentest 44 4.2 Hypothese 2 46 4.2.1 Deskriptive Statistik zu Hypothese 2 47 4.2.2 Hypothesentest 49 4.3 Weitere explorative Datenanalysen 51 4.3.1 Angebote für betroffene Eltern 51 4.3.2 Bewertung der Zufriedenheit 52 4.3.3 Bewertung der Themenrelevanz 52 4.3.4 Standardisierte Vorgehensweise 53 4.3.5 Begriffe für Totgeburten und Kindstode in den Kliniken 54 4.3.6 Unerwähnte Angebote 55 4.3.7 Wünsche des Personals bezüglich der Unterstützung 56 4.3.8 Weitere Kommentare zur Begleitung der Eltern 57 5. Schlussfolgerungen 58 5.1 Zusammenfassung und Interpretation der Ergebnisse 58 5.2 Ergebniseinordnung in den aktuellen Forschungsstand und Handlungsempfehlungen 60 5.3 Kritische Reflexion der eigenen Untersuchung 64 5.4 Resümee und Zukunftsperspektiven 65 Zusammenfassung (Deutsch) 67 Abstract (English) 70 Quellenverzeichnis 73 Anhang 82 A. Abkürzungsverzeichnis 82 B. Abbildungsverzeichnis 83 C. Tabellenverzeichnis 84 D. Operationalisierung der Variablen 85 E. Fragebogen 88 F. Anschreiben Kliniken 96 G. Reminderanschreiben Kliniken (I) 98 H. Reminderanschreiben Kliniken (II) 100 I. Ethikkommission 102 J. Danksagung 107 K. Erklärung zur Eröffnung des Promotionsverfahrens (Anlage 1) 108 L. Erklärung zur Einhaltung gesetzlicher Vorgaben (Anlage 2) 109

SammanfattningBakgrund: Tidig separation i samband med födseln av ett för tidigt fött och svårt sjukt barn kan leda till att anknytningen mellan föräldrar och barn påverkas. För att ett barn ska få en god känslomässig och psykosocial utveckling behövs en trygg anknytning. Barnsjuksköterskan har i sitt ansvarsområde att arbeta främjande för att anknytningsprocessen ska bli så god som möjligt.Syfte: Beskriva barnsjuksköterskors erfarenheter av att stötta föräldrar i anknytningsprocessen efter att de separerats från sitt för tidigt födda eller sjuka nyfödda barn.Metod och tillvägagångssätt: En kvalitativ metod med en induktiv ansats tillämpades. Elva barnsjuksköterskor på fyra olika neonatalavdelningar i Mellansverige intervjuades och innehållet analyserades därefter enligt Graneheim och Lundmans innehållsanalys.Resultat: Det framkom att barnsjuksköterskorna främjade anknytning mellan förälder och barn genom att göra anpassningar i miljön för att möjliggöra närhet och hud mot hudkontakt. Barnsjuksköterskan lade vikt i arbetet på att ge föräldrar emotionellt stöd för att främja anknytningsprocessen. Resultatet presenterades i två huvudkategorier med tillhörande subkategorier: Betydelsen av att skapa förutsättningar för noll-separation (Arbeta för att främja fysisk närhet mellan förälder och barn efter tidig separation, Optimera miljön kring barnet för att öka chanserna att främja anknytning, Att ha tillräckligt med resurser) och Betydelsen av att stärka föräldrarna i deras föräldraroll (Ge föräldrarna emotionellt stöd, Stötta föräldrarna i att de är huvudansvariga för barnets omvårdnad).Slutsats: Det finns fysiska och emotionella hinder som kan påverka anknytningsprocessen mellan föräldrar och barn. Barnsjuksköterskan spelar en viktig roll i att ge föräldrar det stöd de behöver för att främja anknytningsprocessen. / SummaryBackground: Early separation in connection with the birth of a premature and seriously ill child can lead to the attachment between parents and children being affected. In order for a child to have a good emotional and psychosocial development, a secure attachment is needed. The pediatric nurse has in her area of responsibility to work to promote the attachment process to be as good as possible.Purpose: Describe pediatric nurses' experiences of supporting parents in the attachment process after they have been separated from their premature or sick newborn child.Method and approach: A qualitative method with an inductive approach. Eleven pediatric nurses at four different Neonatal wards in middle of Sweden were interviewed and the content was then analyzed according to Graneheim and Lundman's content analysis.Results: It emerged that the pediatric nurses promoted attachment between parent and child by making adjustments in the environment to promote closeness and skin to skin contact. The pediatric nurse placed emphasis in the work on giving parents emotional support to promote the attachment process. The results were presented in two main categories: The importance of creating the conditions for zero separation (Working to promote physical closeness between parent and child after early separation, Optimizing the environment around the child to increase the chances of promoting attachment, Having enough resources) and The importance of empowering parents in their parental role (Give the parents emotional support, Support the parents in being primarily responsible for the child's care). Conclusion: There are physical and emotional barriers that can affect the attachment process between parents and children. The pediatric nurse plays an important role in giving parents the support they need to promote the attachment process.

Introduction: Obsessive-compulsive disorder (OCD) is a complex disorder that is associated with significantly impaired functioning. The current prevailing model of OCD implicates dysfunction of the serotonergic neurotransmitter system and fronto-striatal neural networks, but challenges in replicating findings within OCD samples are often attributed to clinical heterogeneity. OCD symptoms that develop or worsen within the perinatal period appears to reflect a distinct subtype of the disorder, but the genetic and neurobiological factors that contributes to its presentation in women is poorly understood. In this dissertation, we aimed to review the literature on the genetic architecture of OCD, identify potential gene candidates for perinatal OCD and analyze one serotonin system gene according to OCD and possible subtypes using meta-analytic techniques. Based on these findings, we then tested the association of serotonergic candidate gene polymorphisms with the presence of infant-related obsessive-compulsive symptoms (OCS). Lastly, we investigated the cortical morphological features associated with perinatal OCD and OCS symptom severity in postpartum mothers. Results: From prior reports in the literature and our own meta-analytic investigation, polymorphic variants in genes coding for the serotonergic transporter and serotonin 2A receptor subtype (SLC6A4 and HTR2A, respectively) appear to be candidates for perinatal OCD due to their association in female samples. However, upon investigation in our perinatal sample (n=107), we found no evidence to support the association of the 5-HTTLPR polymorphism of SLC6A4 with perinatal-related OCS, but larger samples are needed to confirm this finding. Due to technical challenges, the HTR2A polymorphism remains to be tested. Our novel whole-brain explorations revealed distinct cortical morphology associated with symptom worsening across the perinatal period, irrespective of diagnosis. Cortical parameters were not able to differentiate mothers with and without OCD; however, OCD mothers displayed positive correlations between cortical surface area and symptom severity in widespread regions, including the frontal, parietal, temporal and occipital cortex. Conclusions: Overall, this body of work aimed to fill the gap in the literature by exploring the possible genetic and cortical correlates of perinatal-related OCS and OCD. While 5-HTTLPR or HTR2A are candidates for perinatal OCD, it is not yet clear whether they increase susceptibility for the development of infant-related OCS in the perinatal period. Distinct cortical alterations in surface area appeared alongside OCS exacerbation in the postpartum period in regions that extend beyond the frontoparietal network. This suggests that additional neural networks may be contributing to symptom severity and that the cortical plasticity that occurs across the perinatal period may predispose women for risk of OCD. Future studies should continue to use a multiple perspective approach, that utilizes genetic and neurobiological techniques, in order to provide greater insight into the etiology of perinatal OCD. / Dissertation / Doctor of Philosophy (PhD) / Women are at greater risk for the development of mental illness in the time surrounding pregnancy and postpartum, known as the perinatal period. In the case of perinatal obsessive-compulsive disorder (OCD), mothers may experience unique worries in regard to their parenting or fears that their baby may be harmed. While these worries are common, they can become disruptive when persistent and impact the mother’s mood and ability to bond with the infant. Our current understanding of OCD includes the influence of genetic factors and brain changes, but little is understood about what factors may increase risk for OCD in the perinatal period. In this thesis, we aimed to review whether certain alterations within DNA segments, known as gene variants, may be linked to the development of OCD in females and if these gene changes, as well as differences in brain structures in postpartum mothers, are associated with OCD symptoms during the perinatal period. The genes we examined are important for regulating a chemical signaling substance in the brain known as serotonin. Based on our results, we did not find a relationship between serotonin gene variants and OCD symptoms in perinatal women. We also found no differences when comparing the cortical brain structures between mothers with OCD and healthy mothers; however, we observed that measures of surface area across several cortical brain regions were related to symptom worsening from pregnancy to postpartum, and also with symptom severity in postpartum mothers with OCD. These results suggest that there are widespread brain changes during the postpartum period that may increase a mother’s risk for developing OCD. Overall, the work in this thesis provides the first glimpse into potential risk factors for perinatal OCD.

Maternal obesity has significant consequences on the lifelong health of the developing child and rising global incidences make it one of the most common comorbidities during pregnancy. Offspring of obese mothers are at an increased risk of hospitalization for respiratory infections throughout childhood, which predispose these children to non-communicable respiratory diseases in later life. Animal models of maternal high fat diet (mHFD) feeding have observed common inflammatory outcomes with obesogenic models, but the effect on offspring varies with timing of the nutritional challenge and diet composition across studies. These studies demonstrate significant alterations to circulating and lung specific immune cells but the sequence of events that link maternal diet to these fetal outcomes are unclear, nor have they been tested in the context of a bacterial respiratory infection. Streptococcus pneumonaie is the most common causative pathogen of bacterial pneumonia and meningitis, making it of high clinical relevance. We aimed to investigate the effect of a mHFD (45% kcal from fat) during gestation and lactation, on offspring outcome and recovery from Streptococcus pneumoniae infection. Immunophenotyping, both before and after infection, revealed a hypo-inflammatory phenotype in circulating monocytes of the mHFD offspring with a decreased capacity to both initiate and terminate inflammatory responses. These offspring had significantly higher bacterial counts in lung tissues during infection and sustained cellular inflammation in survivors. In this thesis, we present foundational work on the detrimental influence of excess maternal nutrition on offspring immune function and infection outcomes, which may be involved in susceptibility to inflammatory and chronic disease in later life. A better understanding of this deep and lasting influence of the maternal environment will allow us to target preconception health as a form of harm reduction, informing stake holders and institutions to direct efforts towards DOHaD knowledge translation. / Thesis / Master of Science (MSc)

Introduction: Multiple sclerosis (MS) is an autoimmune disorder of the CNS that typically affects young women of childbearing age. Due to the international published data, safety for pregnant women with MS can be assumed. However, no study has been published in the Czech Republic to address the effect of MS on pregnancy and perinatal outcomes. Objective: Analysis of the clinical course of patients with MS during and after pregnancy, and perinatal outcomes in comparison with healthy pregnant women. Methods: A single centre prospective observational study in the period 2006-2015 was conducted. Complete data from 68 patients with MS were analyzed (85 deliveries) and were compared with a control cohort of 68 age- and parity - matched healthy pregnancies. Results: The comparison between relapse rate and EDSS before, during and after delivery showed no statistically significant difference (relapse in 7.4% and 9.5%, EDSS 1.27 and 1.49). Perinatal outcomes were comparable in both cohorts. The weight of newborns differed by 159 g, (p = 0.295), complications in pregnancy were represented in 16.2% in the group with MS and in 27.9% in controls (p = 0.295), caesarean section was performed in 16.2% in patients with MS and in 23.5% of controls (p = 0.629), 79.4% of patients with MS were breast-feeding. In the MS...

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Purpose: This study was initiated to verify whether a remarkably high rate of postpartum depression (PPD), previously found in immigrant Hispanic women receiving health care at a community clinic, would also be found in a community sample with a similar demographic. Data Sources: Sixty immigrant Hispanic women who had recently given birth were recruited from local community settings. The Beck Postpartum Depression Screening Scale-Spanish version (PPDS-S) and the General Acculturation Index (GAI) were used to screen for PPD symptoms and to collect demographic data. These data were then compared with previously published data from the community clinic sample. Conclusions: Sixty percent of the immigrant Hispanic women in our community sample showed significant PPD symptoms as scored on the Beck PPDS-S. There was no significant difference found in demographics or in types of PPD symptoms between the clinic sample and the community sample. Of all the demographic data, the only statistically significant positive predictive factor for increased PPD symptoms was having a previous history of depression. In addition, 54% of the sample had an elevated symptom content profile score for suicidal thinking. Implications for Practice: Health practitioners should be aware of a potentially high rate of PPD in this population, especially in light of previously studied increased rates of suicide attempts in Latinas. If a prior history of depression is predictive of PPD, it is possible that many of the mothers in our sample suffered from depression prior to the postpartum period, but were not appropriately diagnosed or treated. Recommendations for outreach and further research are discussed. In particular, further research regarding the prenatal prevalence of depression in immigrant Hispanic women is recommended in order to further understand the high incidence of PPD.

En 2019, 31 % et 14 % des jeunes femmes et hommes mondialement ont déclaré de n’être pas engagé en emploi, en études ou en formation (NEET). Cette étude a examiné les voies de développement menant au statut NEET chez les jeunes adultes en étudiant l'association entre les adversités périnatales et le statut NEET et le rôle médiateur de comportements extériorisés. Les données proviennent de l'Étude Longitudinale du Développement des Enfant du Québec (ÉLDEQ, n = 974). L'analyse des classes latentes a identifié quatre profils d'exposition: faible adversité; adversité de la croissance fœtale, qui incluent les participants rencontrant des problèmes de croissance in utero et après la naissance ; les complications d’accouchement, qui incluent les participantes qui connaissent des complications pendant l'accouchement; l’adversité familiale, qui se compose de participants qui ont vécu l'adversité dans leur vie familiale. Les associations entre les profils périnatals, le statut NEET et le rôle médiateur présumé de comportements extériorisés ont été étudiées à l'aide de la modélisation par équation structurelle. Le risque de devenir NEET était plus élevé pour les enfants ayant subi une adversité familiale (OR = 3,19 [IC 95 % : 2,31-4,40], p < 0,001) et de croissance fœtale (2,03 [1,11-3,71], p = 0,022). Les problèmes d’extériorisation ont médié l'association entre l'adversité familiale et le statut de NEET (1,03 [1,01-1,06], p=0,003). La prévention du statut NEET devrait englober les facteurs de risque lié à la croissance fœtale et l’adversité familiale, qui peuvent aider les efforts de prévention pendant la période périnatale. / In 2019, 31% and 14% of young women and men worldwide – respectively – reported being Not engaged in Employment, Education, or Training (NEET), an important indicator of long-term socioeconomic vulnerability. This study examined the developmental pathways leading to NEET status in young adulthood by investigating the association between perinatal adversities and NEET status and the mediating role of externalizing behaviours. Data were from the Québec Longitudinal Study of Child Development (QLSCD, n = 974). Latent Class Analysis identified four profiles of exposures to 32 perinatal adversities: Low adversity, the reference profile; Fetal growth adversity, which includes participants experiencing adversity related to growth problems in utero and after birth; Delivery complications, which includes participants – or their mothers – who experience complications during birth; Familial adversity, consists of participants who experienced adversity related to their family life. The associations between the perinatal profiles, NEET status which was self-reported at age 21 years old and the putative mediating role of externalizing symptoms that were self-reported at age 15 and 17 were investigated using structural equation modeling. The risk of becoming NEET was higher for children who experienced perinatal familial (OR = 3.19 [95% CI: 2.31-4.40], p < 0.001) and fetal growth (2.03 [1.11-3.71], p = 0.022) adversity. Externalizing problems mediated the association between familial adversity and NEET status (1.03 [1.01-1.06], p=0.003). Prevention of NEET status in young adulthood should encompass familial and fetal growth- related risk factors, which can help inform early prevention efforts in the perinatal period.