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Empowerment is acknowledged as a process facilitating those who are less powerful to be engaged in their problem identification, decision making and actions to gain control over their life. This is an important goal for women during the perinatal period in their transition to motherhood. A concept analysis of women's empowerment during the perinatal period found that psychological and social dimensions play a role in women's perinatal empowerment and identified several defining attributes. The aim of this study was to identify robust validated instruments that measure all the attributes of women's empowerment during the perinatal period. We did a scoping review of scientific literature following the methodology of the JBI Reviewer's Manual. We searched the database MEDLINE, CINAHL, PsycINFO, PsycARTICLES and SocINDEX and selected papers meeting the inclusion criteria. Instruments measuring empowerment or related concepts were identified in the selected papers. Two authors independently cross referenced the items of each instrument against the defining attributes for empowerment. Our search resulted in 9771 unique hits of which 36 papers were finally included. Studies were from various countries with a wide variety of aims, demographics of cohorts and timepoints across the perinatal period. Twenty-one different instruments were used to measure empowerment, of which 11 were validated among women during the perinatal period. However, no identified instrument was developed specifically for women during the perinatal period or included all the dimensions of empowerment and the defining attributes. There is a need for a theoretically sound valid and reliable instrument measuring all the dimensions of empowerment of women during the perinatal period. Once developed this instrument needs testing with a broad range of women. Results from such a study will inform the development of appropriate interventions that have a coherent theoretical basis and are empirically informed to enhance women's empowerment during the perinatal period.

Background Twinning collaborations, where two groups — from educational institutions, hospitals or towns — work together cross-culturally on joint goals, are increasingly common worldwide. Pairing up individuals, so-called twin pairs, is thought to contribute to successful collaboration in twinning projects, but as yet, there is no empirical evidence or theory that offers insight into the value of the pair relationship for twinning. Aim To explore the contribution of one-to-one relationships between twins to twinning projects, as exemplified in projects between Dutch and Moroccan, and Dutch and Sierra Leone midwives. Methods We conducted thirteen in-depth interviews with midwives from two twinning collaborations. Interviews were transcribed and analysed using an iterative, grounded theory process, yielding a theoretical understanding of one-to-one twinning relationships for twinning collaborations. Findings Participant comments fell into four substantive categories: 1) Being named a twin, 2) moving beyond culture to the personal level, 3) searching for common ground to engage, 4) going above and beyond the twinning collaboration. Their interplay demonstrates the value of twin pairs in paving the way for successful twinning. Discussion A complex combination of contextual inequities, personality, and cultural differences affect the twin relationship. Trusting relationships promote effective collaboration, however, as ‘trust’ cannot be mandated, it must be built by coaching twins in personal flexibility and (cultural) communication. Conclusion By offering original insights into the ways twinning relationships are built, our research explores how twin pairs can enhance the success of twinning projects.

Background: In order to internalize the midwifery philosophy of care and to learn how to advocate for physiological childbirth, student midwives in the Netherlands need learning experiences that expose them to physiological childbirth practices. Increased hospital births, wide variation in non-urgent referrals and escalating interventions impact on learning opportunities for physiological childbirth. Midwifery educators need to find ways to support student agency in becoming advocates of physiological childbirth.Objective: To gather students' opinions of what they need to become advocates of physiological childbirth.Methods: Focus groups with student midwives (n = 37), examining attitudes regarding what educational programs must do to support physiological childbirth advocacy.Results: Students reported feelings of personal power when the midwifery philosophy of care is internalized and expressed in practice. Students also identified dilemmas associated with supporting woman-centered care and promoting physiological childbirth. Perceived hierarchy in clinical settings causes difficulties, leading students to practice in accordance with the norms of midwife preceptors. Students are supported in the internalization and realization of the midwifery philosophy of care, including physiological childbirth, if they are exposed to positive examples of care in practice and have opportunities to discuss and reflect on these in the classroom.Key conclusion: Midwifery education should focus on strategies that include navigating dilemmas in practice and helping students to express the midwifery philosophy of care in communication with other professionals and with women. Preceptors need to be supported in allowing student midwives opportunities to realize the midwifery philosophy of care, also when this differs from preceptor practice. (C) 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Perinatal audits in the Netherlands showed that stillbirth was nearly always preceded by a period of reduced fetal movements. Patient or caregiver delay was identified as a substandard care factor.To determine whether the use of a new information brochure for pregnant women on fetal movements results in less patient delay in contacting their maternity caregiver.A pre- and post-survey cohort study in the Netherlands, including 140 women in maternity care with a singleton pregnancy, expecting their first child. All participating women filled out a baseline questionnaire, Cambridge Worry Scale and pre-test questionnaire at the gestational age of 22-24 weeks. Subsequently, the intervention group received a newly developed information brochure on fetal movements. At a gestational age of 28 weeks, all women received the post-test questionnaire. Multiple regression analyses were used.Per-protocol analysis showed less patient delay in the intervention group compared to the control group (Odds Ratio 0.43; 95% Confidence Interval 0.17-0.86, p=0.02). A significant linear relation was observed between reading the information brochure and an increase of knowledge about fetal movements (B=1.2, 95% Confidence Interval 1.0-1.4, p0.001). Maternal concerns did not affect patient delay to report reduced fetal movements.Use of an information brochure regarding fetal movements has the potential to reduce patient delay and increase knowledge about reduced fetal movements. A national survey to determine the effect of an information brochure about reduced fetal movements on patient delay and stillbirth rates is needed.

Background: Dutch maternity care is based on the principle that pregnancy and childbirth are physiological processes. However, the last decade an increase of intra-partum referrals to obstetric-led care has been observed. Most of these referrals are among nulliparous women, non-urgent and occur during the first stage of labour. The increase in referrals seems not associated with better perinatal outcomes.Objective: Gain understanding of underlying factors in the decision-making process prior to referral to obstetric-led care among midwives attending childbirth in midwifery-led care.Method: A qualitative study based on in-depth interviews with Dutch midwives (n = 10) working in midwifery-led care. We performed a thematic analysis based on the hypothetico-deductive and the intuitive-humanist theory.Results: Midwives mentioned knowledge as the basis of a reasoned decision. This included both theoretical knowledge, and knowledge from clinical experience. Influences of others, like the needs and wishes of labouring womenwere another factor influencing the decision-making, especially in non-urgent situations. Under subjective factors, the fear of being held responsible for professional choices emerged.Key conclusion: The decision-making process during childbirth is multi-factorial. The women's needs and wishes are recognized as of great influence on the decision-making process during childbirth, which is not included as a factor in the hypothetico-deductive or the intuitive-humanist theory.Implication for practice: The influence of women's needs and wishes should be part of models about the intrapartum decision-making process. Midwives should find strategies to support women to make well-informed choices that include adequate information on the consequences of medicalisation in obstetric-led care. (c) 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Objective The aim of this study is to explore the lived experience of Flemish midwifery students undertaking an internship in Suriname. Design Hermeneutic phenomenological method as described by van Manen. Methods Seven midwifery students from one University College were selected purposefully for an in-depth interview during their internship abroad within the period October–November 2014. All interviews were audio-taped, transcribed verbatim and analysed thematically. Findings The study revealed five overarching themes: (1) A time to reconsider the time, (2) a time of connection and disconnection, (3) spatiality for thought and rethinking, (4) a body to undergo or a body to respond and (5) the other(s) among the others. Conclusion The experience of an internship in Suriname presents itself in each individual as: ‘A process of awareness from the self with a main focus on the professional'. Meaning that it was a process of ‘disconnection' from their own culture towards ‘connection' with another culture. Both, the ‘ rethinking' of their role as a midwife, as well as, balancing between guarding one's own authenticity by ‘responding' or being the friendly stranger through ‘undergoing', was noticeably striking.

Background Instruction in ethics is an essential component of midwifery education. However, the evidence for how midwifery students experience ethics instruction in the classroom and via clinical experience is limited. Objective This study explores midwifery students' perceptions of ethics education and their opinions about essential components of ethics education. Design This was a qualitative descriptive thematic study, exploring student midwives' experiences of ethics education in their midwifery programs. We conducted focus group interviews with students from three midwifery programs in the United States (U.S.). Setting Graduate midwifery educational programs in the United States. Participants Thirty-nine students from three graduate midwifery programs participated in four focus group discussions. Results Thematic analysis identified three primary themes and associated subthemes: 1) current experience and identified needs, 2) the preceptor dilemma, with subthemes the critical role of modeling ethics and powerlessness within interprofessional conflicts, and 3) complicated relationships: advocacy, autonomy and choice. Students relied primarily upon clinical preceptors rather than classroom discussion as a significant source of learning ethics content and ethical behavior. Students called for explicit identification of ethics learning when it occurs, particularly midwifery-specific content, as well as increased opportunities for reflection and integration of their experiences. Conclusion This study shows the need for intentional inclusion of midwifery-specific ethics content into the overall midwifery education program content, in both classroom and clinical experiences. Midwifery programs should integrate ethics content in their curricula in a way that complements other midwifery content. This study also demonstrates the key role of clinical preceptors in student ethics learning.

Upon recognition of auto-antigens, thymocytes are negatively selected or diverted to a regulatory T cell (Treg) fate. CCR7 is required for negative selection of auto-reactive thymocytes in the thymic medulla. Here, we describe an unanticipated contribution of CCR7 to intrathymic Treg generation. Ccr7(-/-) mice have increased Treg cellularity because of a hematopoietic but non-T cell autonomous CCR7 function. CCR7 expression by thymic dendritic cells (DCs) promotes survival of mature Sirpα(-) DCs. Thus, CCR7 deficiency results in apoptosis of Sirpα(-) DCs, which is counterbalanced by expansion of immature Sirpα(+) DCs that efficiently induce Treg generation. CCR7 deficiency results in enhanced intrathymic generation of Tregs at the neonatal stage and in lymphopenic adults, when Treg differentiation is critical for establishing self-tolerance. Together, these results reveal a complex function for CCR7 in thymic tolerance induction, where CCR7 not only promotes negative selection but also governs intrathymic Treg generation via non-thymocyte intrinsic mechanisms. ispartof: Cell Reports vol:21 issue:1 pages:168-180 ispartof: location:United States status: published

Recombination activating genes (RAGs), consisting of RAG1 and RAG2, are stringently regulated lymphoid-specific genes, which initiate V(D)J recombination in developing lymphocytes. We report the regulation of RAG1 through a microRNA (miRNA), miR-29c, in a B cell stage-specific manner in mice and humans. Various lines of experimentation, including CRISPR-Cas9 genome editing, demonstrate the target specificity and direct interaction of miR-29c to RAG1. Modulation of miR-29c levels leads to change in V(D)J recombination efficiency in pre-B cells. The miR-29c expression is inversely proportional to RAG1 in a B cell developmental stage-specific manner, and miR-29c null mice exhibit a reduction in mature B cells. A negative correlation of miR-29c and RAG1 levels is also observed in leukemia patients, suggesting the potential use of miR-29c as a biomarker and a therapeutic target. Thus, our results reveal the role of miRNA in the regulation of RAG1 and its relevance in cancer. ispartof: CELL REPORTS vol:36 issue:2 ispartof: location:United States status: published

Objective: to study the effect of body mass index (BMI) on the use of antenatal care by women in midwife-led care.Design: an explorative cohort study.Setting: 11 Dutch midwife-led practices.Participants: a cohort of 4421 women, registered in the Midwifery Case Registration System (VeCaS), who received antenatal care in midwife-led practices in the Netherlands and gave birth between October 2012 and October 2014.Findings: the mean start of initiation of care was at 9.3 (SD 4.6) weeks of pregnancy. Multiple linear regression showed that with an increasing BMI initiation of care was significantly earlier but BMI only predicted 0.2% (R-2) of the variance in initiation of care. The mean number of face-to-face antenatal visits in midwife-led care was 11.8 (SD 3.8) and linear regression showed that with increasing BMI the number of antenatal visits increased. BMI predicted 0.1% of the variance in number of antenatal visits. The mean number of antenatal contacts by phone was 2.2 (SD 2.6). Multiple linear regression showed an increased number of contacts by phone for BMI categories 'underweight' and 'obese class I'. BMI categories predicted 1% of the variance in number of contacts by phone.Key conclusions: BMI was not a relevant predictor of variance in initiation of care and number of antenatal visits. Obese pregnant women in midwife-led practices do not delay or avoid antenatal care. Implications for practice: Taking care of pregnant women with a high BMI does not significantly add to the workload of primary care midwives. Further research is needed to more fully understand the primary maternal health services given to obese women.

Iceland and the Netherlands both have a long history of midwifery education and midwifery practice. Starting as a midwife requires a direct entry BSc program in midwifery in The Netherlands, where Iceland requires a nurse-midwife model. This paper presents an overview of midwifery education and its dynamic in these countries. Subsequently, we explore two most notable components that were identified as important for the future of midwifery education. In the concluding section, we reflect how these components support the scope of practice as presented in the Lancet framework for quality maternal and newborn care.

Objective: to examine the effect of gestational weight gain (GWG) on likelihood of referral from midwife led to obstetrician-led care during pregnancy and childbirth for women in primary care at the outset of their pregnancy. Design: secondary analysis of data from a prospective cohort study. Setting: Dutch midwife-led practices. Participants: a cohort of 1288 women of Northern European descent, with uncomplicated, singleton pregnancy at antenatal booking who consequently were eligible for primary, midwife-led care. Measurements: because of the absence of an established GWG guideline in the Netherlands, we compared the effect of inadequate and excessive GWG according to two GWG guidelines: the criterion traditionally used, which is based on knowledge of the physiological components of GWG, advising 1015 kg as a normal GWG irrespective of a woman's BMI category, and the 2009 Institute of Medicine recommendations (IOMr) on GWG, which provide BMI related advice. Outcome measures were: number of women referred from midwife-led to obstetrician-led care during pregnancy and during childbirth; indications of referral and birth outcomes. Findings: GWG above traditional criteria (Tc; > 15 kg between 12 and 36 weeks) was associated with increased odds for referral during childbirth (adjusted odds ratio (aOR) 1.88; 95% confidence interval (CI) 1.22-2.90), but had no effect on referral during pregnancy (aOR .86; 95% CI .57-1.30). No associations were established between GWG below Tc (

Recent studies highlight surprising roles for granulocyte-macrophage colony-stimulating factor (GM-CSF) production by T cells. T-cell–derived GM-CSF is required for the differentiation of monocyte-derived inflammatory dendritic cells during inflammation and for the pathogenicity of IL-17 producing T helper cells in autoimmunity. To gain further insight into these findings, we engineered in vivo overexpression of GM-CSF specifically in T cells, under the control of the Lck promoter. Lck -GM-CSF transgenic mice displayed a dramatic phenotype, characterized by splenomegaly, lymphadenopathy, thymic atrophy, and multiple abnormalities in blood cell populations. Thymocyte differentiation was severely affected, and there was a dramatic increase in regulatory T cells in the thymus and peripheral lymphoid organs. Lck -GM-CSF transgenic mice developed a disseminated histiocytosis and had increased circulating IL-17 producing T helper cells–related cytokines. The pathological characteristics in Lck -GM-CSF transgenic mice resemble those of histiocytic human diseases, such as Langerhans cell histiocytosis. The etiology of many histiocytic disorders is unknown, but our findings suggest that over-production of GM-CSF by T cells could be a pathogenic factor and raise the possibility that GM-CSF may represent a novel therapeutic target.

to explores preferences, characteristics and motives regarding place of birth of low-risk nulliparous women in the Netherlands.a prospective cohort study of low-risk nulliparous women and their partners starting their pregnancy in midwifery-led care or in obstetric-led care. Data were collected using a self-administered questionnaire, including questions on demographic, psychosocial and pregnancy factors and statements about motives with regard to place of birth. Depression, worry and self-esteem were explored using the Edinburgh Depression Scale (EDS), the Cambridge Worry Scale (CWS) and the Rosenberg Self Esteem Scale (RSE).participants were recruited in 100 independent midwifery practices and 14 hospitals from 2007 to 2011.550 low-risk nulliparous women; 231 women preferred a home birth, 170 women a hospital birth in midwifery-led care and 149 women a birth in obstetric-led care.Significant differences in characteristics were found in the group who preferred a birth in obstetric-led care compared to the two groups who preferred midwifery-led care. Those women were older (F (2,551)=16.14, p0.001), had a higher family income (χ(2) (6)=18.87, p=0.004), were more frequently pregnant after assisted reproduction (χ(2)(2)=35.90, p0.001) and had a higher rate of previous miscarriage (χ(2)(2)=25.96, p0.001). They also differed significantly on a few emotional aspects: more women in obstetric-led care had symptoms of a major depressive disorder (χ(2)(2)=6.54, p=0.038) and were worried about health issues (F (2,410)=8.90, p0.001). Women's choice for a home birth is driven by a desire for greater personal autonomy, whereas women's choice for a hospital birth is driven by a desire to feel safe and control risks.the characteristics of women who prefer a hospital birth are different than the characteristics of women who prefer a home birth. It appears that for women preferring a hospital birth, the assumed safety of the hospital is more important than type of care provider. This brings up the question whether women are fully aware of the possibilities of maternity care services. Women might need concrete information about the availability and the characteristics of the services within the maternity care system and the risks and benefits associated with either setting, in order to make an informed choice where to give birth.

Objective to explore low-risk pregnant women's views on their preferences for psychosocial support from midwives during their transition to motherhood. Design a qualitative design with focus-group interviews and thematic analysis of the discussions. Settings and respondents 21 Dutch participants were included in three focus groups. Groups 1 ( n =7) and 3 ( n =8) consisted of pregnant women from four semi-urban midwifery practices, and group 2 ( n =6) included participants from three urban midwifery practices. Findings the women wanted to take responsibility for their own well-being during pregnancy. In addition to informal support, they explicitly expressed a need for professional support from their midwives when undergoing the transition to motherhood. They wanted informational and emotional support from their midwives that addressed psychological and physical changes during pregnancy. They expressed a strong desire to be informed during pregnancy of how to prepare physically and psychologically for birth, recovery and motherhood. They also wanted help with sifting and interpreting information and, ultimately, wanted to make their own choices. Key conclusions and implications for practice during their transition to motherhood, healthy low-risk pregnant women want attentive, proactive, professional psychosocial support from midwives. They expect their midwives to oversee the transition period and to be capable of supporting them in dealing with changes in pregnancy and in preparing for birth and motherhood.