Normal Physiologic Birth Research Articles

Factors influencing midwives’ intentions to facilitate normal physiological birth: A qualitative study

BackgroundWhilst most women desire to birth vaginally, research highlights reducing rates of normal physiological birth worldwide. Previous studies have focussed largely on clinical practices associated with vaginal birth however health care professionals’ intentions are also known to effect behaviour; a factor not well understood within the context of midwifery and normal physiological birth. Question/AimTo explore factors influencing midwives’ intentions to facilitate normal physiological birth. MethodsA qualitative study using individual interviews was conducted. The Theory of Planned Behaviour was used to develop a semi-structured interview guide to gather perceptions, thoughts, knowledge, and experience of normal physiological birth from participants. Data were analysed thematically within the theoretical constructs: attitudes, subjective norms, and perceived behavioural control. FindingsFourteen midwives from various practice settings, models, and locations in Australia were interviewed. Major factors influencing midwives’ intentions to facilitate normal physiological birth were influenced by workplace culture, values and influence of leaders, the need to prioritise collaborative interdisciplinary relationships and support autonomy in midwifery. DiscussionFactors influencing the midwives’ intentions of facilitating normal physiological birth were multifaceted. Some influences are more obvious and observable through practice, while others were rooted in underlying beliefs and attitudes that were hidden in the subconscious of those involved. However, all contributing influences ultimately shape midwives’ intentions and the way in which they facilitate normal physiological birth. ConclusionsMidwives intend to support normal physiological birth; however multiple factors influence their intentions over time. Prioritising collaborative interdisciplinary relationships and supporting autonomy in midwifery could address known barriers.

O49 - How the intentions of maternity care providers influence normal physiological birth

O49 - How the intentions of maternity care providers influence normal physiological birth

The impact on midwives and their practice after caring for women who have a traumatic childbirth: A systematic review.

Women's birth experiences can range from positive and satisfying to negative and traumatizing. Midwives caring for women can also be exposed to these traumatic childbirth experiences. There is a paucity of research on the impact these experiences have on midwives and their practice. The PEO framework guided the research review question. Seven electronic databases were systematically searched. The quality of each included study was assessed using the tool appropriate to the study's methodological approach; Critical Appraisal Skills Program (CASP) criteria and the Mixed Methods Appraisal Tool (MMAT) Version 2018. The Consolidated Criteria for Reporting Qualitative Research (COREQ) tool was utilized to assess reported findings. Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to grade the confidence in the evidence of the qualitative research. Data were thematically analyzed to formalize the identification and development of themes. A total of 12 studies were included. Synthesis of the evidence generated one overarching theme, "Midwives, the forgotten victims", and three themes describing the essences of midwives' experiences: "Bruised and battered but still smiling"; "Wearing armour to protect my soul"; "Members of my team are holding me up, others are pulling me down". Midwives expressed feelings of shock, fear, responsibility, and powerlessness which may contribute to some experiencing serious mental illness. They reported a shaken belief in the normal physiologic birth process which consequently led to more defensive practice. Research is needed to identify high-quality interventions to support midwives after these events. This systematic review protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO; Registration CRD42021252033).

Does the ARRIVE trial merit changing obstetric practice? Some reflections four-year postrelease.

It has been 4 years since the release of the study Labor Induction versus Expectant Management in Low-Risk Nulliparous Women, also known as the ARRIVE trial. As researchers and speakers who frequently present to the United States and international audiences about models of care and strategies to support normal physiologic labor and birth, we have had ample opportunity to engage with practitioners who consistently ask about our perspectives on the ARRIVE trial's findings and methods. Many note the marked increase in pressure they feel to induce at 39 weeks since the study's publication in 2018. In this commentary, we discuss some of the concerns that have been brought up during these conversations. We focus on the trial's key findings and reflect on factors critical to consider as translation into clinical practice is negotiated.

Color, light, and birth space design: An integrative review

AbstractThis integrative review sought knowledge across a broad spectrum of literature concerning the role of color and light in maternity environments. Today it is acknowledged that the clinical nature of birth spaces is detrimental to maintaining normal physiological birth rates. Significantly, “clinical” spaces are often described as white, pale, monochromatic, and/or overlit. Attempts to make maternity settings more “home‐like” have promoted use of “warm” or “soft” colors. Ambience or spatial atmosphere is known to impact birth hormones, affecting labor commencement and progress. Today, efforts to improve birth spaces include “sensory rooms” (offering pain distraction via dark spaces and illuminated color elements); programmable colored light installations; and immersive image projections. Yet, as this paper shows, there is little specific study of the physical and psychological impact of color and light within birth settings. However, there are significant findings on colored light's impact upon birth processes, including the contraindication of bright blue light. And there is valuable knowledge embedded in old and new literature from diverse disciplines. This review thus exposes the strong need for further research and literature focused directly on how color and light in birth environment design impact birth experience for all involved. It is clear that environmental color and light need to be taken seriously as potent interrelated environmental factors that are directly implicated in the health and wellness of mothers and their infants during labor and birth. Thus, it is crucial to bring deeper awareness and comprehensive knowledge into use by designers, developers and managers of birth spaces.

Implementing an Undergraduate Nursing Elective Advanced Perinatal Course and Its Effect on Perceived Perinatal Nursing Knowledge and Self-Efficacy Levels of Students Who Aim to Enter a Perinatal Specialty as New Graduate Nurses

Nursing schools face challenges within maternal/newborn practicum courses for undergraduate nursing students, such as a lack of consistent clinical sites or experiences that capture the high acuity needs of perinatal environments. Additionally, perinatal units face challenges in orienting and retaining new graduate nurses, while new graduate nurses entering perinatal units may be likely to experience feelings of insecurity or self-doubt due to perceived inadequate preparation for such specialties (Lesher et al., 2021). There are multiple negative impacts that may stem from a lack of confident and competent novice perinatal nurses. The rise in maternal morbidity and mortality rates in the United States are of particular concern, and knowledge gaps on behalf of novice perinatal nurses may result in the lack of skills and confidence in recognizing complications and intervening appropriately, potentially jeopardizing patient safety. The literature suggests that perinatal units face challenges in effectively orientating new graduate nurses, leading to burnout and financial burdens (Dickerson et al., 2022). Recognizing the potential benefits of improving preparation for students interested in entering a perinatal specialty as new graduates, such as improved patient outcomes and increased staff retention, this study aims to analyze the impact of an elective advanced perinatal course on student perception of knowledge and self-efficacy levels for those who aim to enter a perinatal specialty as a new graduate nurse. Content will be focused on advancing knowledge of normal physiologic birth, high-risk obstetrical and newborn considerations, obstetric emergencies, perinatal mood and anxiety disorders, bereavement care, diversity/equity/inclusion care, and resiliency tips.

Effects of Labor Support Education on Nursing Knowledge, Confidence, and Cesarean Rates

Despite physical, psychological, and financial consequences, nulliparous, term, singleton, vertex (NTSV) cesareans have continued to rise. A goal of Healthy People 2020 was to reduce NTSV cesarean rates to 24.7%. In 2020, Carilion New River Valley Medical Center (CNRVMC) reported a monthly NTSV cesarean rate of 50%, with a yearly mean of 30.4%. Research suggests that registered nurses can significantly contribute to the reduction of cesareans through evidence-based labor support (EBLS). To reach the Healthy People 2020 goal at CNRVMC, an EBLS education program was implemented to reinforce nurse-led interventions that support normal physiological birth.

Investigating active versus expectant management of third stage labour in a midwife-led unit

Little is known regarding third stage management approaches and the incidence of and treatment of postpartum haemorrhage in women giving birth solely in midwife-led units. This systematic literature review identified nine studies of varying quality that investigated active versus expectant management of the third stage of labour and any related blood loss in women, who had a normal physiological birth and gave birth or intended to give birth in a midwife-led unit. The results identified a need for further research studies into this area of practice, as birth settings are becoming increasingly more important. This is because of research studies that have reported many beneficial outcomes for healthy women at low risk of obstetric complications, who plan to give birth in midwife-led units.

Factors Associated With Normal Physiologic Birth for Women Who Labor In Water: A Secondary Analysis of A Prospective Observational Study.

IntroductionResearch to understand factors associated with normal physiologic birth (unassisted vaginal birth, spontaneous labor onset without epidural analgesia, spinal, or general anesthetic, without episiotomy) is required. Laboring and/or giving birth in water has been shown to be associated with a high proportion of physiologic birth but with little understanding of factors that may influence this outcome. This study explored factors associated with normal physiologic birth for women who labored in water.MethodsWe conducted a secondary analysis of a UK‐based prospective observational study of 8064 women at low risk of childbirth complications who labored in water. Consecutive women were recruited from birth settings in England, Scotland, and Northern Ireland. Planned place of birth, maternal characteristics, intrapartum events, and maternal and neonatal outcomes were measured. Univariable and multivariable logistic regression modelling explored factors associated with normal physiologic birth.ResultsIn total, 5758 (71.4%) of women who labored in water had a normal physiologic birth. Planned birth in the community (adjusted odds ratio [aOR], 2.58; 95% CI, 2.22‐2.99) or at an alongside midwifery unit (aOR, 1.21; 95% CI, 1.04‐1.41) was positively associated with normal physiologic birth compared with planned birth in an obstetric unit. Duration of second stage (aOR, 0.66; 95% CI, 0.62‐0.70), duration in the pool [aOR, 0.93; 95% CI, 0.90‐0.96), and birth weight of the neonate (aOR, 0.74; 95% CI, 0.65‐0.85) were negatively associated with normal physiologic birth. Parity was not associated with normal physiologic birth in multivariate analyses.DiscussionOur findings largely reflected wider research, both in and out of water. We found midwifery‐led birth settings may increase the likelihood of normal physiologic birth among healthy women who labor in water, irrespective of parity. This association supports growing evidence demonstrating the importance of planned place of birth on reducing intervention rates and adds to research on labor and birth in water.

Особенности центральной гемодинамики, функционального состояния вен нижних конечностей и перинатальные исходы у беременных женщин с начальными формами флебопатий

Objective. To study the features of functional status of veins and central hemodynamics in women with early stages of phlebopathy during pregnancy and their role in perinatal outcomes. Patients and methods. Seventy pregnant women with early manifestations of chronic venous disorders were examined. The study group included 30 patients who gave birth to children with signs of ante-, intra-, postnatal hypoxia; the control group included 40 patients with normal physiological birth outcomes for newborns. When assessing the status of venous system, the elasticity index was calculated, and the severity of sludge syndrome was identified. Volumetric compression oscillometry was used to measure several central hemodynamic parameters in the second trimester. The relative gene expression of HIF1α transcription factor was calculated in the second and third trimesters. Morphological examination of the placenta was performed with determining the fetoplacental ratio and placental weight (g). Results. There was a statistically significant increase in the elasticity index during gestation in pregnant women in the study group. The first stage of sludge syndrome in the second trimester was detected in 70% of pregnant women in the study group, and the second stage of sludge syndrome was detected in 16.6% of patients. The relative expression of HIF1α in patients in the study group increased more than 2.5-fold in the second trimester and more than 3.5-fold in the third trimester. Pregnant women in the study group had statistically significant changes in all central hemodynamic parameters as compared with the control group. All women required emergency delivery. Fetal weight in the study group was statistically lower than in the control group. Apgar score at 1 minute of life in the study group was 6.5 (6; 7) and at 5 minutes – 7.5 (7; 8), in the control group it was 8 (8; 8) and 9 (8; 9), respectively (p > 0.001). The revealed changes in the placentas from women in the study group corresponded to hypoxic tissue injuries. Conclusion. Pregnant women with early stages of phlebopathy have specific features of central hemodynamics and venous functional status, which determine perinatal outcomes. Key words: pregnancy, phlebopathy, hemodynamics in pregnant women, placental morphology

‘Stories of distress versus fulfilment’: A narrative inquiry of midwives’ experiences supporting alternative birth choices in the UK National Health Service

BackgroundSome childbearing women/birthing people prioritize out of maternity care organizational guidelines’ approaches to childbirth as a way of optimizing their chances of a normal physiological birth. Currently, there is little known about the experiences of midwives who support their choices. AimTo explore the experiences of UK midwives employed by the NHS, who self-defined as supportive of women’s alternative physiological birthing choices. MethodsA narrative inquiry was used to collect and analyse professional stories of practice via self-written narratives and interviews. Forty-five midwives from across the UK were recruited. FindingsThree overarching storylines were developed with nine sub-themes. ‘Stories of distress’ highlights challenging experiences due to poor supportive working environments, ranging from small persistent challenges to extreme situations. Conversely, ‘Stories of fulfilment’ offers a positive counter-narrative where midwives worked in supportive working environments enabling woman-centred care unencumbered by organisational constraints. ‘Stories of transition’ abridge these two polarized themes. ConclusionThe midwives’ experiences were mediated by their socio-cultural working contexts. Negative experiences were characterised by a misalignment between the midwives’ philosophy and organisational cultures, with significant consequences for the midwives. Conversely, examples of good organisational culture and practice reveal that it is possible for organisations to fulfil their obligations for safe and positive maternity care for both childbearing women who make alternative birthing choices, and for attending staff. This highlights what is feasible and achievable within maternity organisations and offers transferable insights for organisational support of out-of-guideline care that can be adapted across the UK and beyond.

Normal Physiologic Birth Continuing Professional Development: From a National Health Priority to Expanded Capacity.

Background:The Republic of Liberia has experienced many barriers to maintaining the quality of its healthcare workforce. The Resilient and Responsive Health Systems (RRHS) Initiative supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has responded to Liberian identified health priorities. Liberia’s maternal morbidity and mortality rates continue to rank among the highest in the world. Recent country regulations have put forth required continuing professional development (CPD) for all licensed healthcare workers for re-licensure.Methods:The Model for Improvement was the guiding framework for this CPD to improve midwifery and nursing competencies in assisting birthing women. Two novel activities were used in the CPD. We tested the formal CPD application and approval process as this is a recent regulatory body policy. We also included the use of simulation and its processes as a pedagogical method. Over a two-year period, we developed a two-day CPD module, using didactic training and clinical simulation, for Liberian midwives. We then piloted the module in Liberia, training a group of 21 participants, including midwives and nurses, including pre- and post-test surveys as well as observational evaluation of participant skills.Findings:There were no significant changes in knowledge acquisition noted in the post-test. Small tests of change were implemented during the program, supporting the stages of the Model of Improvement. Observation of skill acquisition was done; however, using a formal observation checklist, such as an Observed Structured Clinical Evaluation (OSCE), would add more robust findings. The CPD and follow-up activity highlighted the need for human and financial support to maintain the simulation kits and to create sustainability for future trainings. Videotaping the didactic and simulation two-day continuing professional development train-the-trainer workshop expands the sustainability beyond newly prepared trainers. Simultaneous with this CPD, the Liberian Board for Nursing and Midwifery (LBNM) worked with a partner to create a CPD portal. The CPD partners created modules from the videos and have uploaded these modules to the LBNM’s new CPD portal.Conclusions:Using a quality improvement model as a framework for developing and implementing CPDs provides a clear structure and supports the dynamic interactions in learning and clinical care. It is too soon to determine measurable health outcomes resulting from this project. Anecdotal feedback from clinicians and leaders was not directly related to the content of the CPD; however, it does demonstrate an increased awareness of examining changes in practice to support expanded health outcomes. Further research to examine methods and processes to determine the quality and safety outcomes of CPD trainings is necessary.

Does midwifery-led care demonstrate care ethics: A template analysis

Ethical care in maternity is fundamental to providing care that both prevents harm and does good, and yet, there is growing acknowledgement that disrespect and abuse routinely occur in this context, which indicates that current ethical frameworks are not adequate. Care ethics offers an alternative to the traditional biomedical ethical principles. The aim of the study was to determine whether a correlation exists between midwifery-led care and care ethics as an important first step in an action research project. Template analysis was chosen for this part of the action research. Template analysis is a design that tests theory against empirical data, which requires pre-set codes. A priori codes that represent midwifery-led care were generated by a stakeholder consultative group of nine childbearing women using nominal group technique, collected in Perth, Western Australia. The a priori codes were applied to a predesigned template with four domains of care ethics. Ethics approval was granted by the Edith Cowan University research ethics committee REMS no. 2019-00296-Buchanan. The participants generated eight a priori codes representing ethical midwifery care, such as: 1.1 Relationship with Midwife; 1.2 Woman-centred care; 2.1 Trust women's bodies and abilities; 2.2. Protect normal physiological birth; 3.1. Information provision; 3.2. Respect autonomy; 4.1. Birth culture of fear (midwifery-led care counter-cultural) and 4.2. Recognition of rite of passage. The a priori codes were mapped to the care ethics template. The template analysis found that midwifery-led care does indeed demonstrate care ethics. Care ethics takes into consideration what principle-based bioethics have previously overlooked: relationship, context and power. Midwifery-led care has been determined in this study to demonstrate care ethics, which suggest that further research is defensible with the view that it could be incorporated into the ethical codes and conduct for the midwifery profession.

The birthing room and its influence on the promotion of a normal physiological childbirth - a qualitative interview study with midwives in Sweden

ABSTRACT The birthing room is a major workplace for midwives but how it influences them in practice is not enough investigated. Purpose: This study aimed to explore midwives´ experiences of how the birthing room affects them in their work to promote a normal physiological birth. Methods: A phenomenological reflective lifeworld research approach was used and included individual interviews with 15 midwives working at four different hospitals in western Sweden, and of which two also assisted at homebirths. The analysis focused on the meanings of the study phenomenon. Results: A birthing room can by its design either support a normal physiological birth or support a risk approach to childbirth. Four opposing constituents complete the essential meaning of the birthing rooms, and to which the midwives need to relate in their roles as guardians for normal birth: i) a private or a public room; ii) a home-like or hospital-like room; iii) a room promoting activity or passivity; iv) a room promoting the midwife´s presence or absence. Conclusions: The birthing room mirrors a pathogenic-oriented care approach. A presupposition for the work to keep the birth bubble intact is to protect the mother from disturbing elements both inside and outside the room.

Birth Outcomes Associated With Induction and Augmentation: A Population Health Perspective

Normal physiological birth occurs when biological and psychological conditions support intended vaginal births and reduce primary cesarean births. Induction and augmentation of labor are hospital interventions associated with disrupting normal physiological birth. The purpose of this study was to examine the association between induction and augmentation of labor with childbirth outcomes in low-risk nulliparous women. A secondary data analysis was conducted using birth registry data from two diverse northeastern states in the United States from 1992 to 2014. Chi-square tests were used to evaluate the relationship between use of induction and augmentation of labor with childbirth outcomes. After evaluating these relationships and adjusting for potential confounders, multivariable logistic regression models were used to estimate the odds ratio of childbirth outcomes with induction and augmentation of labor. Of the 3.5 million births in the two states, 650,237 deliveries met the inclusion criteria of nulliparous, low-risk, singleton pregnancy at term and not breech. After adjusting for potential confounders, induction at 39 weeks gestation in State 1 was associated with a 50% greater likelihood of having a primary cesarean compared with no induction from 39 to 41 weeks gestation (adjusted odds ratio, 1.50 [95% CI 1.40–1.62]). In State 2, induction during gestational week 39 was associated with a 71% greater likelihood of having a primary cesarean birth compared with no induction between 39 to 41 completed weeks gestation (adjusted odds ratio1.71 [95% CI 1.65–1.77]). Augmentation of labor was associated with increased assisted vaginal birth in both states compared with births that were not augmented. Less reliance on induction or augmentation in low-risk nulliparous women could result in better birth outcomes and support women in their endeavor to achieve a normal physiological birth.

Normal Birth: Position Statement

Here at All4Maternity: The Practising Midwife and The Student Midwife, we are strong advocates of women and birthing people’s rights to make and enact their preferred birthing decisions. We are, however, concerned with the lack of equitable services meeting the needs of women seeking a normal physiological birth. Compelling evidence highlights the long term biopsychosocial benefits of normal birth for the mother-baby dyad, within relational care models.1 Evidence also shows that the majority of women hope for and anticipate a normal birth; expecting that their care providers are knowledgeable and skilled to facilitate safe effective care.2 Indeed, it is the core function of the midwife3– a protected title with an inherent responsibility to optimise the normal physiological and psychological processes of childbirth,4 as captured in the Lancet Midwifery series1 and ICM scope of midwifery practice.4

Maternal Confidence for Physiologic Birth: Instrument Development and Testing

IntroductionMaternal confidence is associated with enhanced birth experiences through a greater sense of control, feeling more informed, and less pain during labor. A valid and reliable measure of prenatal confidence for physiologic birth for clinical use to identify areas where confidence might be enhanced has not yet been developed.MethodsThis was a multi‐phased instrument development study. Qualitative analysis from a study with 14 women who had a normal physiologic birth, along with concept analysis on maternal confidence, informed the development of a 22‐item Likert scale, the Preparation for Labor and Birth (P‐LAB) instrument. Content validity and face validity were evaluated by a panel of 10 experts including midwives, physicians, and women who had a normal physiologic birth. Psychometric testing of the instrument was performed with a sample of 206 women who were between 34 0/7 to 38 6/7 weeks’ gestation from 5 Midwestern clinics.ResultsThe P‐LAB demonstrated content validity, internal consistency, stability over time, and beginning construct validity. All items had content validity index (CVI) scores greater than or equal to 0.8 and total instrument CVI of 0.95. Four subscales were identified: planned use of pain medication, trusted relationship with care provider and care environment, confidence or fear for childbirth, and support (eg, partner, provider, environment). Cronbach's coefficients alpha for the 4 extracted factors were 0.93, 0.76, 0.73, and 0.74, accordingly. Intraclass correlation (95% CI) for the total questionnaire was 0.92 (0.88 ‐ 0.94).DiscussionExploratory findings demonstrate that the P‐LAB instrument exhibits beginning validity and reliability in the measurement of prenatal maternal confidence for normal physiologic birth. The P‐LAB instrument is a potentially clinically useful instrument to measure maternal confidence for normal physiologic birth, however, more testing is required for continuing to establish construct validity.

Associations among cervical dilatation at admission, intrapartum care, and birth mode in low‐risk, nulliparous women

Admission in early labor is associated with increased likelihood of cesarean birth, but the context in which this occurs is unclear. Previous research has explored the relationship between dilatation at admission and the use of single intrapartum interventions; however, the majority of women in the United States receive multiple intrapartum interventions. The objective of this study was to examine the associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women with spontaneous onset of labor. This was a cross-sectional, observational study of 21858 nulliparous, singleton, term vertex births that occurred from 2002 to 2007 across nine hospitals in the Consortium on Safe Labor. Outcome measures included the individual and combined use of intrapartum interventions (amniotomy, epidural anesthesia, oxytocin augmentation) and birth mode. In this sample, 92.0% of women received at least one intrapartum intervention and 22.7% received all three interventions. After propensity score adjustment, women were more than twice as likely to receive the combination of amniotomy-epidural-oxytocin when admitted at 0-3cm (RR 2.83 [95% CI 2.45-3.27]) and 4-5cm (2.49 [2.15-2.89]) compared to 6-10cm. Adjusted likelihood of cesarean birth was five times greater for women admitted at 0-3cm (5.26 [4.36-6.34]) and two times greater for women admitted at 4-5cm (2.27 [1.86-2.77]) compared to 6-10cm. To promote normal physiologic birth, low-risk, nulliparous women should be engaged in shared decision-making about timing of admission after spontaneous onset of labor.

Working Together to Promote Perineal Integrity in Normal Physiologic Birth: A Joint Collaboration between Women and Midwives

Perineal trauma during childbirth is mainly connected with pain and complications. Episiotomy is a surgical incision of the perineum and the posterior vaginal wall. Before setting up motherfriendly care in Iran, mediolateral episiotomy was a traditional and routine component of vaginal childbirth. The aim was to keep away from damage to the anal sphincter and to limit the risk of traumatic birth for the fetus.

Management of the Perineum in Normal Physiologic Birth: A Joint Collaboration of Women and Midwives

Open Access Research in Anatomy Management of the Perineum in Normal Physiologic Birth: A Joint Collaboration of Women and Midwives Somayeh Makvandi1 and Khadigeh Mirzaiinajmabadi2* 1PhD candidate on reproductive health, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran 2Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran *Corresponding author: Khadigeh Mirzaiinajmabadi, PhD, Associate Professor, Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran Submission: February 21, 2018; Published: February 27, 2018 DOI: 10.31031/OARA.2017.01.000518 ISSN: 2577-1922 Volume1 Issue4