La période périnatale est particulièrement propice pour que les futures et nouvelles mères consommatrices de substances psychoactives et leur partenaire entrent en relation d’aide avec des intervenants médicaux et psychosociaux. Pour ces mères et ces pères, l’arrivée d’un poupon dans leur vie est une source de motivation pour entreprendre une démarche d’aide basée sur la confiance. Pourtant, plusieurs études soulignent différentes contraintes qui rendent difficile l’entrée en relation d’aide de ces parents avec des intervenants. Ce mémoire à donc pour objectif d’explorer, à partir du point de vue de mères consommatrices et de leur partenaire, la façon dont se vivent leurs expériences relationnelles avec des intervenants médicaux et psychosociaux au cours de la période périnatale, tout en identifiant des éléments qui ont influencé leurs rapports. Nous avons fait une analyse secondaire du discours de vingt mères consommatrices et de leur partenaire, recrutés au moment de la naissance dans le cadre d’une recherche de Morissette, Devault et Rondeau (2006-2010). Les résultats obtenus indiquent que les parents semblent généralement satisfaits de leurs relations avec les intervenants médicaux et psychosociaux qu’ils ont rencontrés à cette période, même s’ils rapportent vivre des peurs importantes qui nuisent à la relation d’aide. Nos résultats révèlent également plusieurs éléments qui influencent les relations relevant autant des contextes d’intervention que des intervenants eux-mêmes et de leurs rôles. Nous constatons d’après les résultats qu’en dépit de certains aspects qui nuisent aux relations avec des intervenants, le cumul des éléments qui les favorisent semble susciter une satisfaction des mères consommatrices et de leur partenaire. Dans les situations où plusieurs éléments nuisent à la relation d’aide, il se créer une dynamique de méfiance réciproque entre ces parents et les intervenants. Néanmoins, comme les relations ne sont pas immuables, il est possible de transformer les relations difficiles pour les rendre plus satisfaisantes pour les mères consommatrices, leur partenaire et les intervenants médicaux et psychosociaux. / The perinatal period is especially prone for future and new mothers who use or abuse of psychoactives substances and their partners to enter helping relationships with medical and psychosocial workers. For these mothers and their partner, the birth of a child is a source of motivation to begin a helping process based on trust. However, studies underline multiple obstacles that restrain those parents to enter helping relationships with workers. This research aims to explore, from the substance-using mothers and their partners’ point of view, the ways in which they have experienced their relationships with the medical and psychosocial workers during the perinatal period, while pointing to elements that have influenced those relationships. Twenty substances-using mothers and their partner were recruited at the time of birth and interviewed as part of a research conducted by Morissette, Devault and Rondeau (2006-2010). We have made a secondary analysis of the interviews. The results indicate that, despite their fears to establish helping interactions with workers, parents seem generally satisfied of the relationships they have had with the medical and psychosocial workers met. Our results also point to many elements that have an influence on the helping relationships pertaining to the context in which the interactions took place, to the workers themselves and their roles. We notice from the results that the combination of elements favorably influencing their relationships with the worker conveys a sense of satisfaction to the substance-using mothers and their partners about the helping relationships experienced, despite some aspects that hinder these relationships. A mutual mistrust dynamic is created between the parents and the workers in situations where many elements hinder the helping relations. However, as the relationships are not static, it is possible to transform difficult relations to make them more satisfying for substance-using mothers, their partners and the medical and psychosocial workers.

Cette étude avait pour but d’évaluer, à partir d’un processus de co-construction avec les personnes concernées, dans un contexte de 1ère ligne, la mise en application d’interventions infirmières inspirées du Guide des meilleures pratiques de soins pour les endeuillés (GMPSE) auprès d’un couple ayant vécu une perte périnatale au cours des six dernier mois. Un devis de recherche d’étude de cas basé sur la démarche d’évaluation de la quatrième génération de Guba et Lincoln (1989) a été utilisé. Une infirmière expérimentée auprès des familles endeuillées, s’est inspirée de la guidance du GMPSE pour intervenir auprès d’un couple lors de cinq rencontres thérapeutiques, dont quatre ont été précédées d’une entrevue avec les personnes concernées . Ces entrevues ont permis à ces personnes d’identifier ensemble les interventions les plus utiles et les moins utiles. Le verbatim des rencontres et entrevues ont été enregistrées et transcrites à des fins d’analyses qualitatives, Les résultats de ces analyses font ressortir la pertinence des interventions inspirées du GMPSE et l’apport spécifique de la pratique infirmière auprès de la population visée. Il appert que la sensibilisation des décideurs et des cliniciens aux enjeux des personnes endeuilles soit nécessaire pour favoriser l’implantation du Guide dans les milieux de soins. Enfin, une meilleure appropriation du GMPSE est recommandée autant dans le cadre de la formation, que de la recherche et de la pratique en sciences infirmières. / The purpose of this study was to evaluate from a constructivist perspective, partnering with the stakeholders , the usefulness of nursing interventions inspired from The Best Practice Guidelines in Bereavement Care (BPGBC) in a first line context, during the follow up a couple whom had experienced a prenatal lost in the last six months. A case study design was used along with The Fourth Evaluation’s methodological approach designed by Guba and Lincoln (1989). An experienced nurse in the care of bereaved families, used the BPGBC to guide her interventions in five therapeutic meetings with the couple, followed by four interviews with the stakeholders. The interventions considered the most helpful and the less useful were identified. The gathering of the data and their analysis followed an interactive and ongoing process. The results support the pertinence of the nursing interventions inspired from the BPGBC, as well as the specific contribution of the nursing profession in the bereavement work. Implementing the BPGBC becomes a realistic goal when the managers and the clinical professionals are made aware of the issues encompassed by the grieving population. The nursing profession could incorporate the BPGBC in its training curriculum, in the research field and in the care offered to the bereaved population in different care settings.

This paper explores a Master of Social Work (MSW) student's experiences in engagement with structural social work during an advanced practicum with a perinatal mental health project in Northeastern Ontario. The goals of the advanced practicum were to: (a) improve reflexive practice, (b) improve understanding of structural social work, specific to social justice, and (c) improve understanding of the role of structural social workers within inter-organizational collaborations. Deconstruction of the engagement with each of the goals and the challenges in facilitation of the objectives are reviewed. Though there are issues and dilemmas facing those who wish to engage in structural social work, this advanced practicum experience was successful in improving the student's engagement with structural social work praxis.

The field of prenatal screening and diagnosis has developed rapidly over the past half-century, enabling possibilities for detecting anomalies in reproduction that were never before contemplated. A simple blood sample can aid in the identification of several conditions in the fetus early in the pregnancy. If a fetus is found to be affected by Down syndrome, anencephalus, spina bifida, or Edward's syndrome, a decision must then be made whether to continue or terminate the pregnancy. As prenatal screening becomes increasingly commonplace and part of routine maternal care, researchers are faced with the challenge of understanding its effects at the level of the population and monitoring trends over time. Greater uptake of prenatal screening, when followed by prenatal diagnosis and termination, has important implications for both congenital anomaly surveillance and infant and fetal mortality indicators. Research in Canada suggests that this practice has led to reductions in the congenital-anomaly specific infant mortality rate and increases in the stillbirth rate.(1, 2) The current study is a population-based, epidemiological exploration of demographic predictors of maternal serum screening (MSS) and amniocentesis uptake, with special attention to variations in birth outcomes resulting from different patterns of use. To accomplish our objectives, multiple data sources (vital statistics, hospital and physician services, cytogenetic and MSS laboratory information) were compiled to create a comprehensive maternal-fetal-infant dataset. Data spanned a six-year period (2000-2005) and involved 93,171 pregnancies. A binary logistic regression analysis found that First Nations status, rural-urban health region of residence, maternal age group, and year of test all significantly predicted MSS use. Uptake was lower in women living in a rural health region, First Nations women, and those under 30 years of age. The study dataset identified ninety-four terminations of pregnancy following detection of a fetal anomaly (TOPFA), which led to a lower live birth prevalence of infants with Down syndrome, Trisomy 18, and anencephalus. While a significant increasing trend was observed for the overall infant mortality rate in Saskatchewan between 2001-2005, a clear trend in one direction or the other could not be seen in regards to infant deaths due to congenital anomaly. First Nations status and maternal age were important predictors of both MSS and amniocentesis testing, and appeared to influence the decision to continue or terminate an affected pregnancy. The fact that First Nations women were less likely to screen (9.6% vs. 28.4%) and to have diagnostic follow-up testing (18.5% vs. 33.5%), meant that they were less likely to obtain a prenatal diagnosis when the fetus had a chromosomal anomaly compared to other women (8.3% vs. 27.0%). This resulted in a lower TOPFA rate compare to the rest of the population (0.64 vs. 1.34, per 1,000 pregnancies, respectively) and a smaller difference between the live birth prevalence and incidence of Down syndrome and Trisomy 18 for First Nations women. Women under 30 years of age were much less likely to receive a prenatal diagnosis when a chromosomal anomaly was present (18.4% vs. 31.8%). While risk for a chromosomal anomaly is considerably lower for younger mothers, 53.5% of all pregnancies with chromosomal anomalies and 40.7% of DS pregnancies belonged to this group. Consistent with other studies pregnancy termination rates following a prenatal congenital anomaly diagnosis are high (eg. 74.1% of prenatally diagnosed Down syndrome or Trisomy 18 cases), but these rates may be misleading in that they are based on women who chose to proceed to prenatal diagnosis. The fact that two-thirds (67.3%) of Saskatchewan women who received an increased-risk result declined amniocentesis, helps to put this finding into context. Strong surveillance systems and reasonable access to research datasets will be an on-going challenge for the province of Saskatchewan and should be viewed as a priority. Pregnancies and congenital anomalies are two particularly challenging outcomes to study in the absence of perinatal and congenital anomaly surveillance systems. Still pregnancies that never reach term must be accounted for, in order to describe the true state of maternal-fetal-infant health and to study its determinants. While our study was able to identify some interesting trends and patterns, it is only a snapshot in time. Key to the production of useful surveillance and evaluation is timely information. The current system is not timely, nor is it user-friendly for researchers, health regions or governments. Data compilation for the current study was a gruelling and cumbersome process taking more than five years to complete. A provincial overhaul is warranted in both the mechanism by which researchers access data and in the handling of data. The Better Outcomes Registry & Network (BORN) in Ontario is an innovative perinatal and congenital anomaly surveillance system worthy of modelling.(3) Academic papers in non-ethics' journals typically focus on the technical or programmatic aspects of screening and do not effectively alert the reader to the complex and profound moral dilemmas raised by the practice. A discussion of ethics was felt necessary to ensure a well-rounded portrayal of the issue, putting findings into context and helping to ensure their moral relevance did not remain hidden behind the scientific complexities. Here I lay out the themes of the major arguments in a descriptive manner, recognizing that volumes have been written on the ethics of both screening and abortion. A major ethical tension arising within the context of population based prenatal screening is the tension between community morality and the principle of respect for personal autonomy. Prenatal screening and selective termination have been framed as a purely private or medical matter, thereby deemphasizing the social context in which the practice has materialized and the importance of community values. I consider how a broader sociological perspective, one that takes into account the relevance of community values and limitations of the clinical encounter, could inform key practice and policy issues involving prenatal screening. It is my position that the community's voice must be invited to the conversation and public engagement processes should occur prior to any additional expansion in programming. I end with a look at how the community’s voice might be better heard on key issues, even those issues that at first glance seem to be the problems of individuals. As Rayna Rapp (2000) (4) poignantly observed, women today are 'moral pioneers' not by choice, but by necessity. By elucidating the effects of prenatal screening and the extent of the practice of selective termination in the province, the true occurrence of important categories of congenital anomalies in our province can be observed. Without this knowledge it is very difficult to identify real increases or decreases in fetal and infant mortality over time as the etiologies are complex. Evidence suggests a large and increasing impact of TOPFA on population-based birth and mortality statistics nationally, whereas in Saskatchewan the effect appears to be less pronounced. Appreciation of the intervening effect of new reproductive technologies will be increasingly important to accurate surveillance, research, and evaluation as this field continues to expand.

This thesis investigates long-term cognitive outcome in two cohorts of adolescents and young adults exposed to stressors during the perinatal period: one group born preterm (&lt;37 weeks of gestation and birth weight &lt;1,500 g); one group exposed to two or more courses of antenatal corticosteroids (ACS), to stimulate lung maturation in the face of threatening preterm birth. In fetal life the brain undergoes dramatic growth, and a disruption to the early establishment of functional neural networks may interrupt development in ways that are difficult to predict. Executive function refers to a set of cognitive processes that are important for purposeful regulation of thought, emotion, and behavior, and even a subtle depreciation may influence overall functioning. Study I investigated the stability of executive function development after preterm birth. Executive functions were differentiated into working memory and cognitive flexibility. Both components were highly stable from preschool age to late adolescence. In Study II, we identified subgroups within the group of children born preterm with respect to cognitive profiles at 5½ and 18 years, and identified longitudinal streams. Outcome after preterm birth was diverse, and insufficiently predicted by perinatal and family factors. Individuals performing at low levels at 5½ years were unlikely to improve over time, while a group of individuals performing at or above norm at 5½ years had improved their performance relative to term-born peers by age 18. Studies I and II pointed to the need for developmental monitoring of those at risk, prior to formal schooling. Study III investigated long-term cognitive outcome after repeat ACS treatment. The study did not provide support for the concern that repeat ACS exposure will have an adverse impact on cognitive function later in life. In sum, exposure to perinatal stressors resulted in great variation in outcome. However, for many, their rough beginnings had not left a lasting mark. / <p>At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 1: Submitted.</p>

In this thesis, by being motivated from the challenges in perinatal networks, we address design, evaluation and flow control of a stochastic healthcare network where there exist multiple levels of hospitals and different types of patients. Patients are supposed urgent; thus they can be rejected and overflow to another facility in the same network if no service capacity is available at their arrival. Rejection of patients due to the lack of service capacity is the common phenomenon in overflow networks. We approach the problem from both strategic and operational perspectives. In strategic part, we address a location & capacity planning problem for adjusting the network to better meet demographic changes. In operational part, we study the optimal patient admission control policies to increase flexibility in allocation of resources and improve the control of patient flow in the network. Finally, in order to evaluate the performance of the network, we develop new approximation methodologies that estimate the rejection probabilities in each hospital for each arriving patient group, thus the overflow probabilities among hospitals. Furthermore, an agent-based discrete-event simulation model is constructed to adequately represent our main applicationarea: Nord Hauts-de-Seine Perinatal Network. The simulation model is used to evaluate the performance of the complex network and more importantly evaluate the strength of the optimal results of our analytical models. The developed methodologies in this thesis are combined in a decision support tool, foreseen under the project "COVER", which aims to assist health system managers to effectively plan strategic and operational decisions of a healthcare network and evaluate the performance of their decisions.

[Truncated abstract] Periodontal disease is a common and underdiagnosed disease in humans that may have adverse effects on pregnancy outcomes. The aim of this thesis was to investigate the effects of periodontal disease in pregnancy by means of two observational human studies and the development of animal models of fetal and uterine exposure to periodontopathic bacteria and lipopolysaccharide. I performed a prospective study examining the rates of preterm birth, small for gestational age neonates and neonatal inflammation in 277 women who had undergone a detailed antenatal periodontal examination and oral health questionnaire. Periodontal disease was associated with small for gestational age neonates, and increased CRP levels in umbilical cord blood, but no effect was seen on the rate of preterm birth. Maternal oral health symptoms predicted both periodontal disease and newborn biometry. In a retrospective case control study, I examined the role of periodontal disease in perinatal mortality. Participants included 53 women who had experienced a perinatal loss for which no cause could be found after thorough investigation, and 111 control women. Women who had experienced a perinatal loss were more than twice as likely as controls to have periodontal disease. The incidence of periodontal disease was even higher in women in whom the perinatal loss was due to extreme prematurity. In contrast to my prospective study, risks to the pregnancy could not be predicted by maternal oral health behaviours or oral health symptoms. In order to better understand the mechanisms regulating the associations described in the human studies, two animal models were developed; one to investigate acute exposure and the second to investigate long-term exposure to periodontal pathogens. The first study examined the effects of administration of a bolus of periodontopathic bacteria and lipopolysaccharide to the pregnant sheep. Injection of bacteria and lipopolysaccharide in the amniotic fluid of the pregnant preterm sheep caused a high rate of fetal lethality, disturbance of fetal acid base status and inflammation of the fetus and membranes. Given the circumstances of exposure to periodontopathic pathogens in human periodontal disease, a model investigating long-term exposure to periodontopathic lipopolysaccharide on pregnancy outcomes was developed. ... Overall, I have demonstrated that maternal periodontal disease is associated with adverse pregnancy outcomes including fetal growth restriction and possibly perinatal loss. Mechanisms regulating these effects are likely to be mediated by fetal adaptations to intrauterine inflammation resulting in altered fetal development, growth or survival. Randomised controlled trials that are currently in progress will provide further information on the effects of periodontal disease in human pregnancy, and the efficacy of treatment to reduce these adverse outcomes.

Diss. (sammanfattning) Uppsala : Sveriges lantbruksuniv., 2002. / Härtill 6 uppsatser.

Thesis (M.N.)--Memorial University of Newfoundland, School of Nursing, 2000. / Typescript. Bibliography: p. 100-112.

Mestre -- Universidade de Sao Paulo. Faculdade de Saude Publica. Departamento de Nutricao, Sao Paulo, 1996.