Perinatal Context Research Articles

Male-Partnered Sexual Minority Women: Sexual Identity Disclosure to Health Care Providers During the Perinatal Period.

Male-partnered sexual minority women (SMW) have received little research attention, despite the fact that they represent a large proportion of SMW - particularly child-bearing SMW. Male-partnered SMW are less "out" than female-partnered SMW and will likely be "read" as heterosexual by perinatal providers. Given this, and evidence that pregnant women have unique mental health care needs, the current study focuses on male-partnered SMW (n = 28) during the perinatal period, recruited from Toronto, Canada and Massachusetts, USA, in an effort to understand disclosure and concealment processes in general and to perinatal heath care providers specifically. Women generally reported that they did not disclose (but made no effort to conceal) their sexual identities and histories in new or unfamiliar relationships, largely because the topic rarely came up, although some women highlighted bisexual invisibility and fear of biphobia as reasons for non-disclosure. Despite overall positive experiences with perinatal providers, less than one-quarter of the sample (n = 6) had disclosed their sexual identities and histories to them. Most women felt that this information was generally not relevant to their health care, and particularly their reproductive/obstetric care, although some believed that disclosure would be appropriate under conditions of sexual health risk (n = 8). Others noted that although they did not feel the need to disclose, they did prefer an LGBQ-affirming provider (n = 7). Findings provide insight into male-partnered SMW's views and patterns of disclosure during the perinatal period, and have implications for providers, organizations, and scholars who interface with SMW. Pregnant sexual minority women with male partners are often assumed to be heterosexual, raising questions about whether and when these women disclose their sexual minority status in the perinatal context. This qualitative study of 28 women found that most participants did not share their sexual identity or sexual histories with their perinatal health care providers because this information was perceived as not relevant to their care, although some women nevertheless valued having LGBTQ friendly providers.

The ethical issues regarding consent to clinical trials with pre-term or sick neonates: a systematic review (framework synthesis) of the analytical (theoretical/philosophical) research.

BackgroundConducting clinical trials with pre-term or sick infants is important if care for this population is to be underpinned by sound evidence. Yet, approaching the parents of these infants at such a difficult time raises challenges to obtaining valid informed consent for such research. In this study, we asked, What light does the analytical literature cast on an ethically defensible approach to obtaining informed consent in perinatal clinical trials?MethodsIn a systematic search, we identified 30 studies. We began our analysis by applying philosophical frameworks, which were then refined as concepts emerged from the analytical studies, to present a coherent picture of a broad literature.ResultsBetween them, the studies addressed four themes. The first three were the ethical basis for parental informed consent for neonatal and/or perinatal research, the validity of parental consent in this context, and the range of possible options in methods for gaining consent. The last was the issue of risk and the possibility of a double-standard or asymmetry in the current approaches to the requirement for consent for research and consent for clinical treatment.ConclusionsIn addressing these issues, the analysed studies showed that, whilst there are a variety of possible defences for seeking parental ‘consent’ to neonatal and/or perinatal clinical trials, these are all consistent with the strongly and widely held view that it is important that parents do give (or decline) consent for such research. So far as the method of obtaining consent is concerned, none of the existing consent processes reviewed by the research is satisfactory, and there are philosophical reasons for supposing that at least some parents will fail to give valid consent in a neonatal context. Furthermore, in giving parental ‘consent’ in a perinatal context, parents are authorising infant participation, not giving ‘proxy consent’. Finally, there are reasons for giving weight to both parental ‘consent’ and the infant’s best interests in both research and clinical treatment. However, there are also reasons to treat these factors differently in the two contexts, and this may be partly due to the differing relevance of risk in each case. A significant gap is the lack of any detailed discussion of a process of emergency and/or urgent ‘assent’, in which parents assent or refuse their baby’s participation as best they can during the emergency and later give full consent to continuing participation and follow-up.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1562-3) contains supplementary material, which is available to authorized users.

Rumination and postnatal depression: A systematic review and a cognitive model

Postnatal depression (PND) confers risk for a range of negative child developmental outcomes, at least in part through its impact on parenting behaviour. Whilst the behavioural effects of depression on parenting are well established, the cognitive mechanisms that may mediate this effect are less well understood. The current paper proposes that rumination may be a key cognitive mechanism through which parenting is affected in PND, and provides a systematic review of the existing literature on rumination in the context of perinatal depression. The review identifies ten relevant papers. Eight are questionnaire-based studies examining the role of rumination in predicting future depression and/or mother-infant relationship outcomes, such as bonding. Two are experimental studies examining the effects of induced rumination on parenting behaviours. The results of the review are discussed, and remaining questions highlighted. We then present a new theoretical model, developed specifically for the perinatal context, and informed by existing models of rumination and worry. Our cognitive model emphasises the relationship between rumination, cognitive biases and cognitive control, and the impact of these variables on infant cue processing and subsequent parenting responses. The model provides a potential framework for future work in this area, and to guide the development of treatment interventions.

The pathway not taken: understanding ‘omics data in the perinatal context

'Omics analysis of large datasets has an increasingly important role in perinatal research, but understanding gene expression analyses in the fetal context remains a challenge. We compared the interpretation provided by a widely used systems biology resource (ingenuity pathway analysis [IPA]) with that from gene set enrichment analysis (GSEA) with functional annotation curated specifically for the fetus (Developmental FunctionaL Annotation at Tufts [DFLAT]). Using amniotic fluid supernatant transcriptome datasets previously produced by our group, we analyzed 3 different developmental perturbations: aneuploidy (Trisomy 21 [T21]), hemodynamic (twin-twin transfusion syndrome [TTTS]), and metabolic (maternal obesity) vs sex- and gestational age-matched control subjects. Differentially expressed probe sets were identified with the use of paired t-tests with the Benjamini-Hochberg correction for multiple testing (P < .05). Functional analyses were performed with IPA and GSEA/DFLAT. Outputs were compared for biologic relevance to the fetus. Compared with control subjects, there were 414 significantly dysregulated probe sets in T21 fetuses, 2226 in TTTS recipient twins, and 470 in fetuses of obese women. Each analytic output was unique but complementary. For T21, both IPA and GSEA/DFLAT identified dysregulation of brain, cardiovascular, and integumentary system development. For TTTS, both analytic tools identified dysregulation of cell growth/proliferation, immune and inflammatory signaling, brain, and cardiovascular development. For maternal obesity, both tools identified dysregulation of immune and inflammatory signaling, brain and musculoskeletal development, and cell death. GSEA/DFLAT identified substantially more dysregulated biologic functions in fetuses of obese women (1203 vs 151). For all 3 datasets, GSEA/DFLAT provided more comprehensive information about brain development. IPA consistently provided more detailed annotation about cell death. IPA produced many dysregulated terms that pertained to cancer (14 in T21, 109 in TTTS, 26 in maternal obesity); GSEA/DFLAT did not. Interpretation of the fetal amniotic fluid supernatant transcriptome depends on the analytic program, which suggests that >1 resource should be used. Within IPA, physiologic cellular proliferation in the fetus produced many "false positive" annotations that pertained to cancer, which reflects its bias toward adult diseases. This study supports the use of gene annotation resources with a developmental focus, such as DFLAT, for 'omics studies in perinatal medicine.

89: The pathway not taken: understanding ‘omics data in the perinatal context

Understanding 'omics data is important for perinatal research, but data analysis is challenging because most programs are curated for adult biology. Here we compared interpretation of fetal gene expression by Ingenuity Pathway Analysis (IPA) to Gene Set Enrichment Analysis (GSEA) with specific fetal functional annotation (Developmental FunctionaL Annotation at Tufts [DFLAT], http://dflat.cs.tufts.edu/).

Neighborhood Adversity, Ethnic Diversity, and Weak Social Cohesion and Social Networks Predict High Rates of Maternal Depressive Symptoms: A Critical Realist Ecological Study in South Western Sydney, Australia

The aim of the study reported here is to explore ecological covariate and latent variable associations with perinatal depressive symptoms in South Western Sydney for the purpose of informing subsequent theory generation of perinatal context, depression, and the developmental origins of health and disease. Mothers (n = 15,389) delivering in 2002 and 2003 were assessed at two to three weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were Edinburgh Postnatal Depression Scale (EPDS)> 9 and > 12. Aggregated EPDS > 9 was analyzed for 101 suburbs. Suburb-level variables were drawn from the 2001 Australian Census, New South Wales Crime Statistics, and aggregated individual-level risk factors. Analysis included exploratory factor analysis, univariate and multivariate likelihood, and Bayesian linear regression with conditional autoregressive components. The exploratory factor analysis identified six factors: neighborhood adversity, social cohesion, health behaviors, housing quality, social services, and support networks. Variables associated with neighborhood adversity, social cohesion, social networks, and ethnic diversity were consistently associated with aggregated depressive symptoms. The findings support the theoretical proposition that neighborhood adversity causes maternal psychological distress and depression within the context of social buffers including social networks, social cohesion, and social services.

Troubles de santé mentale, recours aux soins et au soutien social chez une population vulnérable : l’exemple des centres maternels de Paris

The negative effect of social deprivation and poverty on mental health has been the subject of numerous publications since the 1960s, with studies generally showing a higher prevalence of mental health disorders in homeless, unemployed or low income populations. Women in perinatal contexts are also at greater risk for psychopathology: the relative risk for being hospitalised is up to 60% higher in the perinatal period than during the two years preceding pregnancy. Access to social care and informal support is therefore particularly important for pregnant women in vulnerable social conditions. In France, socially excluded mothers access shelter and accommodation in maternal centres. Over the last few years, staff in these centers report what they perceive to be as an increase in the prevalence of mental health problems in the mothers using these services. The current study, CEMAT, set out to examine this question. Based on a participatory research method, a qualitative and epidemiological study was carried out in order to evaluate the reality and needs in terms of mental health care in this population, as well as to evaluate available care and support networks. The study took place in 2005. All stakeholder groups in six maternal centres agreed to participate in focus groups and, in addition, residents were invited to respond to epidemiological and qualitative questionnaires, including the Mini International Neuropsychiatric Interview (MINI 5.0.0) and its qualitative questions aimed at evaluating use of medical and social network resources. Overall, 95 women took part in this study, representing 61% of all residents. Subjects were young (64% under 26) and 57% had been living in their centre for over 12 months. A percentage of 68% (N=65) of the participants were identified as having a mental health disorder, according to the MINI. Of these 65 women, 55 (85%) had consulted a physician (mainly general practitioners and gynecologists) during the preceding two months. Ninety seven per cent of women validating one or more MINI diagnoses had specifically looked for help for these disorders, 17% seeking only professional help (GP, psychiatrist, psychologist, social worker, expert in non conventional medicine or traditional care), 23%looking for an informal source of support (partner, family, friends) and 57% using both professional care and informal support. High rates of satisfaction (69% for professional services, 81% for informal support) showed the capacity of this population to request relevant social and medico-social support. Results tend to confirm the links between psychosocial vulnerability and mental health disorders. On the other hand, the women's ability to ask for and to access specific psychological care, whether it be from professionals or informally from friends and family is to be underlined. The high satisfaction rates tend to prove that, though psychologically vulnerable, this population has coping capacities that should be recognized and valorized. Options open to such structures do not necessarily involve the sole development of internal mental health resources, but need to acknowledge and strengthen existing support networks.

Anxiety Disorders During Pregnancy and the Postpartum Period

The postpartum period is recognized as a time of vulnerability to affective disorders, particularly postpartum depression. In contrast, the prevalence and clinical presentation of anxiety disorders during pregnancy and the postpartum period have received little research attention. In this article, we review the medical literature as it relates to the prevalence and clinical presentation of panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder during pregnancy and the postpartum period. MEDLINE (1966 to July 2005 week 1) and PsycInfo (1840 to July 2005 week 1) were searched using combinations of the following search terms: pregnancy, childbirth, postpartum, panic disorder, phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. All relevant papers published in English and reporting original data related to perinatal anxiety disorders were included. Studies were examined for data related to the prevalence, presentation, predictors/risk factors, new onset, course, and treatment of anxiety disorders during pregnancy and the postpartum period. Anxiety disorders are common during the perinatal period, with reported rates of obsessive-compulsive disorder and generalized anxiety disorder being higher in postpartum women than in the general population. The perinatal context of anxiety disorders presents unique issues for detection and management. Future research is needed to estimate the prevalence of perinatal anxiety disorders more precisely, to identify potential implications of maternal anxiety disorders for maternal quality of life and child development, and to determine safe and effective treatment methods.

Preference-based approaches to measuring the benefits of perinatal care.

Studies that measure benefits of health care interventions in natural or physical units cannot incorporate the several health changes that might occur within a single measure, and they overlook individuals' preferences for those health changes. This paper discusses and critically appraises the application of preference-based approaches to the measurement of the benefits of perinatal care that have developed out of economic theory. These include quality adjusted life year (QALY)-based approaches, monetary-based approaches, and discrete choice experiments. QALY-based approaches use scaling techniques, such as the rating scale, standard gamble approach, and time trade-off approach, or multi-attribute utility measures, to measure the health-related quality of life weights of health states. Monetary-based approaches include the revealed preference approach, which involves observing decisions that individuals actually make concerning health risks, and the willingness-to-pay approach, which provides a framework for investigating individuals' willingness to pay for benefits of health care interventions. Discrete choice experiments describe health care interventions in terms of their attributes, and elicit preferences for scenarios that combine different levels of those attributes. Empirical examples are used to illustrate each preference-based approach to benefit measurement, and several methodological issues raised by the application of these approaches to the perinatal context are discussed. Particular attention is given to identifying the relevant attributes to incorporate into the measurement instrument, appropriate respondents for the measurement exercise, potential sources of bias in description and valuation processes, and the practicality, reliability, and validity of alternative measurement approaches. The paper's conclusion is that researchers should be explicit and rigorous in their application of preference-based approaches to benefit measurement in the context of perinatal care.

A theory of caring and dementia

This paper explores the applicability of Swanson's mid-range theory of caring to work with persons with dementing illness. The definition of caring and the caring process inductively derived by Swanson from research with samples of women in a perinatal context have relevance for both formal and informal caregivers of persons with dementia. The nature of severe dementia necessitates modifications in applying the theory. However, the well-being of this vulnerable population may be enhanced when practice and research are based on this rich conception of caring. This theory of caring provides structure to the sometimes amorphous characterization of an ethic of care and gives meaning and direction for work with persons affected by dementia.

Empirical Development Of a Middle Range Theory of Caring

A middle-range theory of caring was inductively derived and validated through phenomenological investigations in three separate perinatal contexts. Caring was described in Study I by 20 women who had recently miscarried, in Study II by 19 careproviders in the newborn intensive care unit, and in Study III by 8 young mothers who had been the recipients of a long-term public health nursing intervention. The empirical development and refinement of the theory is discussed. The five caring processes and an overall definition of caring are presented. Finally, study findings are compared and contrasted with Cobb's (1976) definition of social support, Watson's (1979, 1985) "carative" factors, and Benner's (1984) description of the helping role of the nurse.

Perinatal risk, attachment, and family context

Perinatal risk, attachment, and family context