Nef harbors a major determinant of pathogenicity for an AIDS-like disease induced by HIV-1 in transgenic mice

The accuracy of antenatal weight data recorded in obstetric notes was investigated in the 45 hospital and community antenatal clinics within a South Thames Region NHS Trust. In order to assess the reliability and validity of all 60 clinic scales triplicate measurements of body weight for low- and high-weight subjects were recorded on each clinical scale and on a calibrated standard scale. The quality of weighing practice during antenatal care was investigated by means of semi-structured interviews conducted with all 33 midwives who currently provide antenatal care within the Trust. Beam balances had the highest reliability and validity, whereas scales with spring mechanisms were the least accurate. Only 40% of the clinics surveyed had access to beam balances, yet most of the maternal weight measurements recorded during antenatal care are likely to be out by no more than 1-1.5% of body weight. Weighing practice was generally inconsistent, and serial measurements of maternal body weight collected during pregnancy are probably too imprecise to provide a sensitive screen for conditions associated with unusual weight gain and too inaccurate to assess compliance with guidelines for weight gain.     

Maternal weight gain patterns and birth weight outcome in twin gestation

OBJECTIVE: To evaluate the association between maternal weight gain patterns, based on pregravid body mass index (BMI) and birth weight outcome in twins, and to make specific recommendations for maternal weight gain during twin gestation. METHODS: One hundred eighty-nine twin pregnancies were reviewed retrospectively. Weekly rates of maternal weight gain before 20 weeks, from 20 weeks to delivery, and for total gestation were calculated. Thresholds of weekly maternal weight gain were determined for underweight and normal-weight women. RESULTS: In underweight women, a higher weekly rate of gain before 20 weeks was associated with the birth of both twins weighing at least 2500 g (1.13 versus 0.70 lb/week, P = .017), when compared with mothers of at least one twin weighing less than 2500 g. A higher rate of weight gain from 20 weeks to delivery was associated with the delivery of twins weighing at least 2500 g in both underweight (1.92 versus 1.29 lb/week, P = .031) and normal weight (1.63 versus 1.29 lb/week, P = .046) women. No significant differences in weight gain patterns were found between overweight women delivering twins weighing less than 2500 g or at least 2500 g. A weekly rate of gain from 20 weeks' gestation to delivery of at least 1.75 lb/week in underweight women and at least 1.50 lb/week in normal-weight women was associated with the birth of both twins weighing at least 2500 g. After controlling for other potential determinants of birth weight, the threshold of 1.75 lb/week in underweight women showed a trend toward significance as an independent predictor of both twins weighing at least 2500 g (P = .06). CONCLUSION: Certain maternal weight gain patterns during twin pregnancy are associated with the birth of each twin weighing at least 2500 g. As with singletons, recommendations for maternal weight gain during twin pregnancy can be based on pregravid BMI.     

Is there an independent association between parity and maternal weight gain?

The independent associations between parity and maternal body mass index (BMI), and between parity and maternal weight gain, were investigated using a combination of cross-sectional and longitudinal analyses based on a retrospective, repeat-pregnancy study that examined the change in maternal body weight from the beginning of one pregnancy to the beginning of the next. A group of 523 multiparous women who had been weighed regularly during pregnancy, and none of whom had fallen pregnant less than 12 months after the birth of their previous child, were examined. Sociodemographic, behavioural, medical, obstetric and perinatal data, together with antenatal measurements of maternal body weight and height, were abstracted from each mother's obstetric notes. Parity was found to be independently associated with maternal BMI (p < 0.001), gestational weight gain (p < 0.001) and interpregnancy weight gain (p = 0.032). Women of different parities were found to be at differential risk of long-term weight gain for two reasons. First, primiparous women are at risk of long-term weight gain because they gain the most weight during pregnancy, and high gestational weight gain is in itself a risk factor for long-term weight gain. Second, women of higher parity (4+) are at risk of long-term weight gain because they gain more weight in association with pregnancy, irrespective of the amount of weight they gain during their pregnancies. For women of parity 3 or less, the association between maternal body weight and parity appears to be the result of cumulative weight gained during successive pregnancies. For women of greater parity, the association between maternal body weight and parity is partly the result of cumulative excess gestational weight gained during successive pregnancies, and partly the result of gaining more weight from the beginning of one pregnancy to the next at later pregnancies.     

Identifying morbidity in postpartum women

Women with postpartum health problems do not readily initiate consultation, making it necessary for those providing care to devise methods by which problems can be identified. By taking detailed accounts of each woman's labour and delivery details when planning postpartum care, some morbidity could be preempted and its effect limited. Postnatal care requires a planned structure which could be modelled on current antenatal care organisation. All women could routinely be seen at three or six months post-delivery. Care could be given by midwives, with referral to GPs where necessary. Fatigue could put women at greater risk of developing postpartum depression, but few women spontaneously report fatigue as a health problem. Limiting the effects of childbirth on maternal health will have important implications for the future use of the medical services.     

Depression scales in schizophrenia: a critical review

In Sweden, nurse-midwives in primary health care are responsible for taking Papanicolaou smears in population-based cervical cancer screening programs. This article discusses the manner in which a group of nurse-midwives, working with the cervical cancer screening program, view both opportunities and burdens inherent in their work. Semistructured interviews were conducted with 21 nurse-midwives engaged in screening at seven antenatal health care centers in demographically different parts of Stockholm, using a team approach to collect and inductively analyze the interviews. Results indicate discrepancies between ideals guiding the midwives and their practice. Positive aspects described by the midwives appear to be related to an ideology of care, whereas perceived burdens include the midwives' sense of powerlessness, lack of congruence between midwives' ideology and screening organization, and lack of professional familiarity with cancer. Several of these features can be related to issues that are challenges for many health care practitioners today, even in other settings. Our conclusion is that the screening program has latent potential for further development of the role of the nurse-midwife as an advocate for women throughout the lifespan and in a variety of situations.     

Denaturation and reactivation of dimeric human glutathione reductase--an assay for folding inhibitors

In response to a Department of Health, England, circular encouraging policies of named voluntary antenatal HIV antibody testing, one West Midlands health authority in England introduced a policy of raising the issue proactively at the first antenatal attendance. In order to facilitate this policy a short staff education programme was provided for midwives. This paper reports on part of a study which aimed to evaluate the impact of the HIV awareness training programme. A sample of midwives (n = 65) was randomly selected for inclusion in the study. Thirty-three had attended training and 32 had not. Data were collected using a self-administered questionnaire exploring knowledge of aetiology of HIV/AIDS, knowledge of transmission, knowledge of obstetric and paediatric HIV, attitudes to HIV, issues related to antenatal HIV antibody testing and opinions about the HIV awareness training programme. Results indicated no significant difference in levels of knowledge or in attitude between those who had attended the training programme and those who had not. Similarly, no significant difference was found in terms of how midwives would react to women requesting HIV antibody testing. Many of the results contradict the current literature and as a conclusion it is suggested that there is a need to review HIV-related training for midwives.     

Epidemiologic aspects of pre-eclampsia in Saudi Arabia

Pre-eclampsia is pregnancy induced hypertension of unknown aetiology. There is a paucity of maternal data on the disease from this region and this study was undertaken to identify maternal and possible aetiologic factors associated with the disease in the north western region of Saudi Arabia. Seven hundred and five consecutive maternities which delivered from October 1990 till January 1991 at the Armed Forces Hospital were analysed. 2.8% of women in this community study developed pre-eclampsia. Women at extremes of maternal age, the nulliparous and high parity women; women with high body mass index, blood group O and those with no antenatal care or late booking in this study were at greater risk of developing pre-eclampsia when compared with controls who delivered in the same period. Of the babies born to mothers with pre-eclampsia, 46.7% were of low birthweight (< 2500g) while only 10.4% of controls were low birthweight. It is concluded that mothers with pre-eclampsia have to be identified early. Potential modifiable factors include reducing pregnancies at extremes of maternal age, among high parity women and encouraging early booking as well as regular attendance at the antenatal clinic.     

Helicobacter pylori infection in children

BACKGROUND: Although immigrants to the United States are usually ethnic minorities and socioeconomically disadvantaged, foreign-born women generally have lower rates of low birth weight infants than do US-born women. OBJECTIVE: To measure the relationship between maternal birthplace, ethnicity, and low birth weight infants. DESIGN: Retrospective cohort study of birth certificate data. SETTING: California, 1992. SUBJECTS: Singleton infants (n = 497 868) born to Asian, black, Latina, and white women. MAIN OUTCOME MEASURES: Very low birth weight (500-1499 g), moderately low birth weight (1500-2499 g), and normal birth weight (2500-4000 g, reference category). RESULTS: Foreign-born Latina women generally had less favorable maternal characteristics than US-born Latinas, yet foreign-born Latina women were less likely to have moderately low birth weight infants (odds ratio, 0.91; 95% confidence interval, 0.86-0.96) than US-born Latinas after adjusting for maternal age, education, marital status, parity, tobacco use, use of prenatal care, and gestational age. While foreign-born Asian women generally had a less favorable profile of maternal characteristics than US-born Asians, there was no statistically significant difference in the odds of very low birth weight or moderately low birth weight infants between foreign- and US-born Asian women. Foreign-born black women had more favorable maternal characteristics than US-born women, but there was no significant nativity difference in very low birth weight or moderately low birth weight between foreign- and US-born black women after adjusting for maternal and infant factors. CONCLUSIONS: The relationship between maternal birthplace and low birth weight varies by ethnicity. Further study is needed to understand the favorable pregnancy outcomes of foreign-born Latina women.     

Effects of long-term pravastatin treatment on spermatogenesis and on adrenal and testicular steroidogenesis in male hypercholesterolemic patients

STUDY OBJECTIVE: To determine if there are significant differences in birth outcomes and survival for infants delivered by certified nurse midwives compared with those delivered by physicians, and whether these differences, if they exist, remain after controlling for sociodemographic and medical risk factors. DESIGN: Logistic regression models were used to examine differences between certified nurse midwife and physician delivered births in infant, neonatal, and postneonatal mortality, and risk of low birthweight after controlling for a variety of social and medical risk factors. Ordinary least squares regression models were used to examine differences in mean birthweight after controlling for the same risk factors. STUDY SETTING: United States. PATIENTS: The study included all singleton, vaginal births at 35-43 weeks gestation delivered either by physicians or certified nurse midwives in the United States in 1991. MAIN RESULTS: After controlling for social and medical risk factors, the risk of experiencing an infant death was 19% lower for certified nurse midwife attended than for physician attended births, the risk of neonatal mortality was 33% lower, and the risk of delivering a low birthweight infant 31% lower. Mean birthweight was 37 grams heavier for the certified nurse midwife attended than for physician attended births. CONCLUSIONS: National data support the findings of previous local studies that certified nurse midwives have excellent birth outcomes. These findings are discussed in light of differences between certified nurse midwives and physicians in prenatal care and labour and delivery care practices. Certified nurse midwives provide a safe and viable alternative to maternity care in the United States, particularly for low to moderate risk women.     

Epidemiology and detection of HIV-1 among pregnant women in the United Kingdom: results from national surveillance 1988-96

OBJECTIVE: To describe the epidemiology of HIV-1 infection in pregnant women in the United Kingdom. DESIGN: Serial unlinked serosurveillance for HIV-1 in neonatal specimens and surveillance through registers of diagnosed maternal and paediatric infections from reporting by obstetricians, paediatricians, and microbiologists. SETTING: United Kingdom, 1988-96. SUBJECTS: Pregnant women proceeding to live births and their children. MAIN OUTCOME MEASURES: Time trends in prevalence of HIV-1 seropositivity in newborn infants (as a proxy for infection in mothers); the proportions of mothers with diagnosed HIV-1 infections, and their characteristics. RESULTS: HIV-1 prevalence among mothers in London rose sixfold between 1988 and 1996 (0.19% of women tested; 1 in 520 in 1996). Apart from in Edinburgh and Dundee, levels remained low in Scotland (0.025%; 1 in 3970) and elsewhere in the United Kingdom (0.016%; 1 in 1930). Over a third of births to infected mothers in 1996 occurred outside London. In London the reported infections were predominantly among black African women, whereas in Scotland most were associated with drug injecting. The contribution of reported infection among African women increased over time as that of drug injecting declined. In Scotland 51% of mothers' infections were diagnosed before the birth. In England, despite a national policy initiative in 1992 to increase the antenatal detection rate of HIV, no improvement in detection was observed, and in 1996 only 15% of previously unrecognised HIV infections were diagnosed during pregnancy. CONCLUSIONS: HIV-1 infection affects mothers throughout the United Kingdom but is most common in London. Levels of diagnosis in pregnant women have not improved. Surveillance data can monitor effectively the impact of initiatives to reduce preventable HIV-1 infections in children.     

Developing effective interactions to improve breastfeeding outcomes

The objective of this replicated research was to assess the effectiveness of antenatal Breastfeeding Workshops (Jamieson 1990) in improving breastfeeding outcomes. It was a longitudinal study using a pre-test/post-test design to evaluate any increase in the confidence, skill and knowledge of women and midwives. The research was carried out in the maternity section of a large Tasmanian teaching hospital. Fifty-six midwives who attended the workshops became the research group with 49 non-attendees as the control. Of the 159 women who indicated an interest in attending, 107 who attended formed the research group, and the remaining 52 were used as the control. The paper is in two parts. The first describes responses from midwives. The results show those midwives who attended a workshop perceived an increase in their confidence level in supporting mothers to breastfeed, altered their perception of those factors most important in successful breastfeeding, and acknowledged that updating of breastfeeding knowledge is necessary on an annual basis. The second part analyses breastfeeding outcomes in respondent women. The results show that women who attended the workshops had a significant increase in confidence levels associated with breastfeeding, and were more likely (p < 0.01) to breastfeed for an extended time even though they experienced difficulties.     

Single pre-delivery symphysis-fundal height measurement as a predictor of birthweight and multiple pregnancy

OBJECTIVE: To compare the value of different pre-delivery maternal indices for predicting birthweight, and to examine the usefulness of a single pre-delivery symphysis-fundal height measurement for the detection of low birthweight and twin pregnancy or macrosomia. DESIGN: Symphysis-fundal height measurements were gathered from 1509 women who had both a singleton delivery and available data of pre-delivery weight, height and mid-upper arm circumference, and from 73 women who had a twin delivery. SETTING: A district hospital in rural Tanzania. RESULTS: Symphysis-fundal height, pre-delivery weight and mid-upper arm circumference, respectively, explain 41%, 13% and 4% of the observed variation in birthweight. At a cut-off level of 30 cm for symphysis-fundal height, the detection rate for birthweight below 2500 g and 2000 g was 66% and 68%, respectively, and the false positive rate was 9% and 14%, respectively. At a cut-off level of 38 cm for symphysis-fundal height the detection rate for twin pregnancy or birthweight > or = 4000 g was 76%, and the false positive rate was 4%. CONCLUSION: Symphysis-fundal height was a better predictor of birthweight than maternal height, pre-delivery weight or mid-upper arm circumference. It seems justified to investigate the value of a simple tricoloured symphysis-fundal height measuring tape for use in antenatal care in developing countries at village level.     

Significance of philosophy, bio-mathematics, biometry and model theory for medicine]

STUDY OBJECTIVE: Poor attendance to antenatal visits was studied to identify risk factors and to analyse the association with adverse pregnancy outcome. DESIGN: All poor attenders and a sample of good attenders were compared within three groups of women: women < 20 years, French women > or = 20 years, and foreigners > or = 20 years. SETTING: 20 French districts including 85,000 births from January to June 1993. SUBJECTS: 848 poor attenders and 759 good attenders. Poor attenders made fewer than four antenatal visits or began care during or after the sixth month. Good attenders made at least four visits and began care before the sixth month. MAIN RESULTS: 1.1% of the women were poor attenders. Risk factors for poor attendance were single status and lack of health insurance in the group under 20; young age, high parity, and single status in the French group aged over 20; and single status and lack of health insurance in the foreign group aged over 20. For poor attenders, the odds ratios for preterm delivery were 5.8 (95% CI: 3.2, 10.5) among French women and 3.3 (95% CI: 1.5, 7.4) among foreign women with health insurance. Poor attendance was not associated with poor pregnancy outcome in the group under 20, and among foreign women over 20 without health insurance, but both groups had high rates of preterm delivery and low birth weight. CONCLUSION: Lack of health insurance is an important barrier to health care during pregnancy. Poor antenatal care is an important risk factor for adverse pregnancy outcome among women who have easy access to health care services.     

Maternal and perinatal mortality due to eclampsia

Forty-four mothers with eclampsia and their newborns managed during the year 1988 at the University Hospital of Banaras Hindu University, Varanasi were analyzed. The incidence of eclampsia was 2.2% of all hospital deliveries. Eclampsia was more common in women (below 20 years) and at gestation of 36 weeks and below, and amongst the mothers deprived of antenatal care. The maternal mortality amongst cases of eclampsia was 31.8% and perinatal loss was 38.6%. A relatively high incidence of eclampsia and maternal and perinatal loss was considered to be related to lack of antenatal care and late referral to the hospital. Our findings suggest that more frequent use of properly timed cesarean section can improve the maternal outcome.     

What does postnatal care do for women's health?

In developed countries, postpartum care begins in the hospitals where most women give birth. In the UK, midwives continue postpartum care with home visits up to the 10th day, which can be extended to the 28th day if necessary. Then care is transferred to the health visitor who performs child health surveillance to age 5 years. Family physicians usually perform the 6-week postpartum maternal check-up. This routine, which was more appropriate in days when serious postpartum maternal infection was prevalent, seeks to promote and monitor maternal and infant health but its ability to meet these goals is questionable (this includes the value of a 6-week vaginal exam). Common and persistent maternal problems such as backache, perineal pain, urinary or bowel incontinence, sexual problems, hemorrhoids, depression, or exhaustion are not addressed by this routine. Research in Australia suggests that the timing as well as the content of maternal care should be reexamined. In this case/control study, no differences were found in health outcomes at 3- and 6-month follow-up among women who received their postpartum exam at 1 week from those who were examined at 6 weeks. It may be beneficial to base postpartum care on women's individual needs rather than on routine, but this must be investigated in order to devise proper guidelines and distinguish the roles of various health professionals. Reorganization of the delivery of postpartum care to improve its impact on women's health is a priority in the UK, and several research trials are in progress.     

Women's midlife health. Reframing menopause

In primary care and gynecologic settings, midwives will manage the care of women during the perimenopause transition as well as throughout the postmenopausal period. As such, they will need to understand the issues that are at the heart of the debate regarding menopause and aging. This article reviews the endocrinology of menopause, the history of menopause treatment in this century, and the various physical, psychological, and role changes that accompany the developmental processes of menopause. Bleeding pattern changes, hot flashes, sleep disturbances, and genital, skin, and weight changes are discussed. Sexuality, breast, cardiovascular, skeletal, as well as hormone therapy issues are examined. The basics of the midlife health office visit are included.     

Prepregnant weight in relation to risk of neural tube defects

OBJECTIVE: To examine the relation between prepregnant weight and the risk of neural tube defects (NTDs). DESIGN: Data were collected from 1988 to 1994 in a case-control surveillance program of birth defects. SETTING: Study subjects were ascertained at tertiary care centers and birth hospitals in the greater metropolitan areas of Boston, Mass, and Philadelphia, Pa, and in southeastern Ontario. PARTICIPANTS: Cases were 604 fetuses or infants with an NTD identified within 6 months of delivery. Controls were 1658 fetuses or infants with other major malformations identified within 6 months of delivery. For 1992 to 1994, there were 93 control infants without major malformations. MAIN OUTCOME MEASURE: Relative risk of NTDs in infants or fetuses for different maternal weights. RESULTS: Relative to women who weighed 50 to 59 kg, risk of NTDs increased from 1.9 (95% confidence interval [CI], 1.2 to 2.9) for women weighing 80 to 89 kg to 4.0 (95% CI, 1.6 to 9.9) for women weighing 110 kg or more. When women were classified according to daily intake above or below the recommended level of 400 micrograms of folate, approximate threefold increases in risk were estimated for the heaviest weights in both groups. Intakes of 400 micrograms of folate or more reduced risk of NTDs by 40% among women weighing less than 70 kg, but no risk reduction was observed among heavier women. CONCLUSION: The risk of NTDs increased with increasing prepregnant weight, independent of the effects of folate intake.     

Population-based primary health care for women. An overview for midwives

This home study program has as its focus population-based care for women. Although clearly significant, concentrating effort solely on the individual does not ensure that the population as a whole is healthier. Experts are encouraging health care providers to consider the population as their "patient" and to begin documenting the incidence and prevalence of its disease. This article addresses the following issues: the definition of population-based health care; the relationship between primary care, women's health care, and population-based health care; the importance of a population-based approach or perspective for midwives; the use of population-based care in the provision of prenatal care; the definition of the populations to whom midwives have historically provided care and the documentation of how those populations are changing; and the research and policy issues for midwives related to population-based health care.     

Using the ALPHA form in practice to assess antenatal psychosocial health. Antenatal Psychosocial Health Assessment

BACKGROUND: The assessment of the psychosocial health of pregnant women and their families, although recommended, is not carried out by most practitioners. One reason is the lack of a practical and evidence-based tool. In response, a multidisciplinary group created the Antenatal Psychosocial Health Assessment (ALPHA) form. This article describes the development of this tool and experience with it in an initial field trial. METHODS: A systematic literature review revealed 15 antenatal psychosocial risk factors associated with poor postpartum family outcomes of woman abuse, child abuse, postpartum depression, marital/couple dysfunction and increased physical illness. The ALPHA form, incorporating these risk factors, was developed and refined through several focus groups. It was then used by 5 obstetricians, 10 family physicians, 7 midwives and 4 antenatal clinic nurses in various urban, rural and culturally diverse locations across Ontario. After 3 months, these health care providers met in focus groups to discuss their experiences. A sample of pregnant women assessed using the ALPHA form were interviewed about their experience as well. Results were analysed according to qualitative methods. RESULTS: The final version of the ALPHA form grouped the 15 risk factors into 4 categories--family factors, maternal factors, substance abuse and family violence--with suggested questions for each area of enquiry. The health care providers uniformly reported that the form helped them to uncover new and often surprising information, even when the women were well known to them. Incorporating the form into practice was usually accomplished after a period of familiarization. Most of the providers said the form was useful and would continue to use it if it became part of standard care. The pregnant women in the sample said they valued the enquiry and felt comfortable with the process, unless there were large cultural barriers. INTERPRETATION: The ALPHA form appears to be an important tool in assessing psychosocial health in pregnancy and to be readily integrated into practice. More study is required to quantify the number of risks identified and resources used, to determine the form's reliability and validity and, ultimately, to assess the effect of its use on postpartum outcomes.