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Abstract Aim To analyse the transfer of knowledge on how to detect physical abuse, especially shaken baby syndrome/abusive head trauma (SBS/AHT), and its association to trends in infant abuse diagnoses (maltreatment and assault). Methods Design: retrospective population-based and quasi-experimental. Setting: Sweden 1987–2019. Patients: Children below age 1 year, selected from the National Patient Register (n = 1150). Exposures: Literature search for transfer of knowledge by diffusion, dissemination and implementation, and whether supportive or disruptive of the SBS/AHT paradigm. Main outcome measure: Abuse diagnoses (maltreatment or assault). Analyses: Incidence rate, incidence rate ratio (IRR). Results The overall incidence rate of abuse was 32.23 per 100,000 during the years 1987–2019. It was rather stable 1987–2000. The SBS diagnosis was introduced in the late 1990s. A comprehensive increase of transfer of knowledge on physical abuse, specifically on SBS/AHT and dangers of shaking, took place from 2002 and onward through diffusion, dissemination and implementation. Maltreatment diagnoses, but not assault diagnosis, increased steeply during 2002–2007, peaking in 2008–2013 [IRR 1.63 (95% confidence interval 1.34–1.98)]. Transfer of disruptive knowledge on SBS/AHT during the period 2014–2019 was associated with a decline in maltreatment diagnoses [IRR 0.84 (95% confidence interval 0.71–0.99)]. Conclusion An increase in maltreatment diagnoses was associated with transfer of supportive knowledge of the SBS/AHT paradigm, while a decline occurred toward the end of the study period, which might indicate a burgeoning de-implementation process.

Abstract Background The purpose of this population-based registry study was to analyze both birth-related femur and humerus shaft fractures and diagnosed later in infancy, as regards incidence, perinatal characteristics, other diagnoses, and reported accidents. Methods Children born in 1997–2014, diagnosed with a femur or humerus shaft fracture before age 1 year, were identified in the Swedish Health Registries. Rate of birth fractures were estimated by combining femur and humerus shaft fractures coded as birth-related with femur and humerus shaft fractures diagnosed during day 1–7 without registered trauma or abuse. Incidence was computed by comparing infants with femur or humerus shaft fractures to the total at-risk population. Results The incidence for birth-related femur shaft fractures was 0.024 per 1000 children (n = 45) and that for birth-related humerus shaft fractures was 0.101 per 1000 children (n = 188). The incidence was 0.154 per 1000 children for later femur shaft fractures (n = 287) and 0.073 per 1000 children for later humerus shaft fractures (n = 142). Birth-related femur shaft fracture was associated with shoulder dystocia, cesarean, multiple birth, breech, preterm, and small-for-gestational age, while humerus shaft fracture was associated with maternal obesity, dystocic labor, shoulder dystocia, vacuum-assisted delivery, male sex, multiple birth, breech, preterm, large-for-gestational age, birth weight > 4000 g, and injury of brachial plexus. A bone fragility diagnosis was recorded in 5% of those with birth-related or later femur shaft fractures. Among infants with birth-related humerus shaft fractures, 1% had a bone fragility diagnosis; the figure for later fractures was 6%. Maltreatment diagnosis was associated with later fractures of both types, especially among those aged

Resumo em Português Antecedentes A fístula obstétrica continua a ser um problema de saúde comum em países de baixa e média renda, apesar das tendências de aumento dos partos institucionais nesses países. As circunstâncias socio-comportamentais em que a fístula ocorre, assim como suas consequências, são pouco documentadas, principalmente do ponto de vista das próprias mulheres com fístula obstétrica. Este estudo descreveu as experiências das mulheres em relação aos cuidados pré-natais, de parto e pós-parto no sul de Moçambique e identificou as experiências particulares das mulheres com fístula, a fim de compreender as circunstâncias em que a procura e oferta de cuidados poderiam ter sido modificadas para evitar ou mitigar a contracção ou as consequências da fístula. Métodos Este estudo foi realizado nas províncias de Maputo e Gaza, sul de Moçambique, em 2016–2017. Os dados qualitativos foram colhidos através de entrevistas em profundidade realizadas com 14 mulheres com diagnóstico positivo de fístula e um número igual de mulheres sem fístula. Todas as entrevistas foram gravadas em áudio e transcritas na íntegra para posterior análise temática utilizando NVivo11. Conclusão Embora as mulheres procurem cuidados pré-natais e peri-parto nas unidades sanitárias, deficiências e atrasos na assistência ao parto, referência e na indicação e aplicação de intervenções vitais foram experiências comumente relatadas por mulheres com fístula. Além disso, foram evidentes fragilidades na qualidade da assistência, não só em relação à prevenção, mas também à resolução dos danos. É crucial melhorar a qualidade da assistência ao parto, tanto ao nível primário como nos de referência. Existe a necessidade de aumentar a conscientização e desenvolver diretrizes para prevenção, detecção precoce e manejo da fístula obstétrica, incluindo tratamento pós-parto precoce, disponibilidade de reparo da fístula para casos complexos e reabilitação, juntamente com a promoção do conhecimento da comunidade sobre o problema.

Background: Vulvodynia is defined as vulvar pain for at least 3 months without a clear cause. To the best of our knowledge, there are no trials investigating the effects of internet treatment using CBT (Cognitive behavioural therapy) treatment with Acceptance and Commitment Therapy (ACT) components for women with vulvodynia. The aim of this study is to examine the effects of such a guided internet-based intervention on provoked vulvar pain during the waiting period before clinical treatment. Methods: We will randomise 52 patients to either guided internet-based intervention with CBT with (ACT) components or no intervention during the waiting period for treatment as usual. Online assessments are conducted at baseline, posttreatment, and at follow-up after 9 months. The primary outcome measure is provoked vulvar pain. Secondary outcomes are depression, anxiety, sexual function, and quality of life. Linear-mixed effect models will be used to assess the effect of the internet-based intervention on vulvar pain, pain acceptance, depression, anxiety, sexual function, and quality of life over time, by applying the intention-to-treat approach. Continuous data will be analysed with general linear models using intention-to-treat and also per protocol approaches to assess the effects of the intervention at different time points. Ordinal and binary data will be analysed with Mann Whitney's test, Fischer's exact test and multivariate logistic regression, respectively. Discussion: As a randomised controlled trial with short- and long-term follow-up points, the EMBLA study intends to provide a novel and better understanding regarding the treatment of vulvodynia and the role of internet-based treatment as a complement to standard care for women suffering from vulvodynia. The effects of vulvodynia on pain, sexual function, quality of life, depression, and anxiety are investigated. The study's results are expected to be of value in the planning of clinical care in the medical area. High dropout rates and technical difficulties associated with using the platform are common in similar studies. Trial registration number: NCT02809612

Abstract Background Client satisfaction is an essential component of quality of care. Health system factors, processes of care as well as mothers’ characteristics influence the extent to which care meets the expectations of mothers and families. In our study, we specifically aimed to address the mothers’ experiences of, and satisfaction with, care during childbirth. Methods A population-based cross-sectional study, using structured interviews with published sequences of questions assessing satisfaction, including 4358 mothers who gave birth during the 12 months before June 2016 to estimate satisfaction with childbirth care. Regression analysis was used to determine the predictors of client satisfaction. Results Most mothers (92.5%) reported being satisfied with care during childbirth and would recommend that a family member to deliver at the same facility. Specifically, 94.7% were satisfied with the cleanliness of the facility, 92.0% reported being satisfied with the interaction with the healthcare providers, but only 49.8% felt satisfied with the assistance to feed their baby. Mothers who had negative experiences during the process of care, such as being abandoned when needing help, disrespect, humiliation, or physical abuse, reported low levels of satisfaction when compared to those who had not had such experiences (68.5% vs 93.5%). Additionally, they reported higher levels of dissatisfaction (20.1% vs 2.1%). Regression analysis revealed that mothers who gave birth in primary level facilities tended to be more satisfied than those who gave birth in hospitals, and having a companion increased, on average, the overall satisfaction score, with 0.06 in type II health centres (CI 0.03–0.10) and with 0.05 in type I health centres (CI − 0.02 – 0.13), compared to − 0.01(CI -0.08 – 0.07) in the hospitals, irrespective of age, education and socio-economic background. Conclusion Childbirth at the primary level facilities contributes to the level of satisfaction. The provision of childbirth care should consider women’s preferences and needs, including having a companion of choice. We highlight the challenge in balancing safety of care versus satisfaction with care and in developing policies on the optimum configuration of childbirth care. Interventions to improve the interaction with providers and the provision of respectful care are recommended.

OBJECTIVES:To explore parents' experiences of seeking health care for their children and instead being accused by healthcare professionals of Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT), being reported to Social Services, undergoing judiciary processing, and the impact of these events on family (dis)integration. METHODS:Design: A qualitative study based on qualitative content analysis. Participants: Twelve parents in Sweden, mothers and fathers, seeking health care for their infants, encountering allegations of SBS/AHT, losing custody of their infants, and being subjected to a judiciary process, and finally regaining custody of their children. Data collection: In-depth interviews. RESULTS:An overarching theme 'Fighting for protection of their child after being trapped by doctors' and four sub-themes were developed to reflect the parents' experiences, reactions and interpretations. The first sub-theme, 'Being accused of injuring the child', illuminated the shock experienced when seeking care and instead being accused of being a perpetrator. The second, 'Chaos and powerlessness', refers to the emotions experienced when losing custody of the child and being caught in the enforcement of legislation by the authorities. The third, ´The unified fight against the doctors' verdict´, illustrates the parents' fight for innocence, their worry for the lost child, and their support and resistance. The fourth, 'The wounded posttraumatic growth', describes the emotions, grief, panic, anxiety, and challenges in reuniting the family, but also the parents' reflections on personal growth. Unanimously, they had experienced the authorities' inability to reconsider, and expressed a deep mistrust of paediatric care. CONCLUSIONS:Being wrongly accused of child abuse and alleged SBS/AHT evoked emotions of intense stress, but parents endured because of a successful fight to regain custody of their child. However, the trauma had a long-term impact on their lives with residual posttraumatic stress symptoms and mistrust towards healthcare services and the authorities. The results provide important inferences for restoring system failures within child protection services.

BackgroundMany physicians regard the combination of encephalopathy, subdural haemorrhage (SDH), retinal haemorrhage (RH), rib fractures, and classical metaphyseal lesions (CML) as highly specific for abusive head trauma (AHT). However, without observed abuse or other criteria that are independent of these findings, bias risk is high.MethodsInfants subjected for examination under the suspicion of maltreatment during the period 1997-2014 were identified in the National Patient Registry, International Classification of Diseases (ICD-10 SE). The medical records were scrutinized for identification of cases of witnessed or admitted physical abuse by shaking. The main outcome measures were occurrence of SDH, RH, fractures and skin lesions.ResultsAll identified 36 infants had been shaken, and for 6, there was information indicating blunt force impact immediately after shaking. In 30 cases, there were no findings of SDH or RH, rib fractures, or CMLs. Six infants had finding(s) suggestive of physical abuse, two with possible acute intracranial pathology. One infant with combined shaking and impact trauma had hyperdense SDH, hyperdense subarachnoid haemorrhage, suspected cortical vein thrombosis, RH, and bruises. Another infant abused by shaking had solely an acute subarachnoid haemorrhage. Both had pre-existing vulnerability. The first was born preterm and had non-specific frontal subcortical changes. The other had bilateral chronic SDH/hygroma.ConclusionsThe present findings do not support the hypothesis that acute SDH or RH can be caused by isolated shaking of a healthy infant. However, they do suggest that abuse by shaking may cause acute intracranial haemorrhage with RH in infants with certain risk factors.

Abstract Background Obstetric fistula is one of the most devastating consequences of unmet needs in obstetric services. Systematic reviews suggest that the pooled incidence of fistulae in community-based studies is 0.09 per 1000 recently pregnant women; however, as facility delivery is increasing, for the most part, in Africa, incidence of fistula should decrease. Few population-based studies on fistulae have been undertaken in Sub-Saharan Africa, including Mozambique. This study aimed to estimate the incidence of obstetric fistulae in recently delivered mothers, and to describe the clinical characteristics and care, as well as the outcome, after surgical repair. Methods We selected women who had delivered up to 12 months before the start of the study (June, 1st 2016). They were part of a cohort of women of reproductive age (12–49 years), recruited from selected clusters in rural areas of Maputo and Gaza provinces, Southern Mozambique, who were participating in an intervention trial (the Community Level Interventions for Pre-eclampsia trial or CLIP trial). Case identification was completed by self-reported constant urine leakage and was confirmed by clinical assessment. Women who had confirmed obstetric fistulae were referred for surgical repair. Data were entered into a REDCap database and analysed using R software. Results Five women with obstetric fistulae were detected among 4358 interviewed, giving an incidence of 1.1 per 1000 recently pregnant women (95% CI 2.16–0.14). All but one had Caesarean section and all of the babies died. Four were stillborn, and one died very soon after birth. All of the patients identified and reached the primary health facility in reasonable time. Delays occurred in the care: in diagnosis of obstructed labour, and in the decision to refer to the secondary or third-level hospital. All but one of the women were referred to surgical repair and the fistulae successfully closed. Conclusion This population-based study reports a high incidence of obstetric fistulae in an area with high numbers of facility births. Few first and second delays in reaching care, but many third delays in receiving care, were identified. This raises concerns for quality of care.

Abstract Background Maternal exposure to adversity during the perinatal period has been associated with increased susceptibility for psychiatric symptoms in the offspring. The aim of this study was to investigate a possible developmental effect of maternal perinatal stressors on emotional and behavioural symptoms in the offspring in a developing country. Methods We followed an Ethiopian birth cohort (N = 358), assessing intimate partner violence (IPV) and maternal psychiatric symptoms during the perinatal period and at follow-up 10 years later, as a proxy for adversity, and maternal ratings on the Child Behavior Checklist (CBCL) 10 years later as the outcome. Results Among the women, exposure to IPV was common (60.6%) during the perinatal period and predicted IPV (29.9% of the mothers) at follow-up (ρ = 0.132; p = 0.012). There was also an association between maternal psychiatric symptoms at the two time points (ρ = 0.136; p = 0.010) and between maternal symptoms and IPV. Current maternal symptoms of anxiety and depression (β = 0.057; p

Abstract Background Most women who choose to terminate a pregnancy cope well following an abortion, although some women experience severe psychological distress. The general interpretation in the field is that the most consistent predictor of mental disorders after induced abortion is the mental health issues that women present with prior to the abortion. We have previously demonstrated that few women develop posttraumatic stress disorder (PTSD) or posttraumatic stress symptoms (PTSS) after induced abortion. Neuroticism is one predictor of importance for PTSD, and may thus be relevant as a risk factor for the development of PTSD or PTSS after abortion. We therefore compared Neuroticism-related personality trait scores of women who developed PTSD or PTSS after abortion to those of women with no evidence of PTSD or PTSS before or after the abortion. Methods A Swedish multi-center cohort study including six Obstetrics and Gynecology Departments, where 1294 abortion-seeking women were included. The Screen Questionnaire-Posttraumatic Stress Disorder (SQ-PTSD) was used to evaluate PTSD and PTSS. Measurements were made at the first visit and at three and six month after the abortion. The Swedish universities Scales of Personality (SSP) was used for assessment of Neuroticism-related personality traits. Multiple logistic regression analyses were performed to investigate the risk factors for development of PTSD or PTSS post abortion. Results Women who developed PTSD or PTSS after the abortion had higher scores than the comparison group on several of the personality traits associated with Neuroticism, specifically Somatic Trait Anxiety, Psychic Trait Anxiety, Stress Susceptibility and Embitterment. Women who reported high, or very high, scores on Neuroticism had adjusted odds ratios for PTSD/PTSS development of 2.6 (CI 95% 1.2–5.6) and 2.9 (CI 95% 1.3–6.6), respectively. Conclusion High scores on Neuroticism-related personality traits influence the risk of PTSD or PTSS post abortion. This finding supports the argument that the most consistent predictor of mental disorders after abortion is pre-existing mental health status.

Abstract Background and aims Identification of child abuse involves a medical investigation and assessment of problems related to social environment and upbringing and might necessitate out‐of‐home care. The objective of this study was to analyse infants placed in out‐of‐home care in Sweden by incidence, medical diagnoses, and perinatal factors. Methods This was a population‐based register study of infants born in Sweden 1997 to 2014. Data were retrieved from registers at the Swedish National Board of Health and Welfare and Statistics Sweden. Outcome measures were out‐of‐home care categories: (a) “Problems Related to Social Environment/Upbringing”, (b) “Abuse diagnoses without SDH (subdural haemorrhage), RH (retinal haemorrhage), rib fracture, or long bone fracture”, and (c) “SDH, RH, rib fracture, or long bone fracture.” As a reference population, we randomly selected infants without medical diagnoses born the same year. Results Overall incidence of out‐of‐home care was 402 per 100 000. For subcategories (a), (b), and (c), the incidences were 14.8 (n = 273), 3.77 (n = 70), and 9.83 (n = 182) per 100 000, respectively. During the study period, the first remained unchanged; the latter two have been increasing. Compared with other reasons for out‐of‐home care, children in category (c), “SDH, RH, rib fracture, or long bone fracture”, had increased odds of being boys (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI], 1.08‐2.38) and decreased odds of having a mother being single (aOR 0.49; 95% CI, 0.32‐0.75) and a smoker (aOR 0.60; 95% CI, 0.37‐0.96). Compared with the reference population, children in this category were more often twin born (7.7% versus 2.8%), preterm (18.5% versus 5.5%), and small‐for‐gestational age (5.2% versus 2.1%). Conclusion SDH, RH, rib fracture, or long bone fracture constitute a minor part of medical diagnoses for infants entered in out‐of‐home care, but have been increasing, both in numbers and proportion. Overdiagnosis of abuse might be a possible reason but cannot be ascertained by this study design.

Causality in abusive head trauma has never been fully established and hence no gold standard exists for the diagnosis. Implications hereof include bias introduced by circular reasoning and a shift from a trustful doctor patient relationship to a distrustful one when the caregiver statement is questioned. In this paper we examine seven recent abusive head trauma studies including 476 diagnosed abuse cases for circular reasoning as well as the role of the caregiver statement in the diagnosis. Secondly, we present a novel ranking scale for the diagnosis of abusive head trauma designed to minimize circular reasoning. We found circularity to be a potential source of bias in all seven studies. The caregiver statement (lack of trauma mechanism or trauma mechanism considered incompatible with clinical findings) was listed as a diagnostic item in 329 (69%) of 476 cases. Applying our ranking scale to the abuse cases showed that the demands of our ranking scale were not fulfilled in 440 (92%) cases. We conclude that most abuse cases in the studies were, to some extent, diagnosed on criteria based on circular reasoning. The caregiver statement was one of the most frequently used diagnostic items. Hypothetically, caregivers offer no or inadequate explanation to the clinical findings in assumed abuse cases. Thus, when this feature is encountered, it is regarded as indicative of abuse adding further to the risk of circularity bias. We propose the use of our novel ranking scale in abusive head trauma research in an effort to minimize circular reasoning.

BACKGROUND:The aim of this study was to assess the incidence of fractures in infancy, overall and by type of fracture, its association with accidents, metabolic bone disease risk factors, and abuse diagnosis. METHODS:The design was a population-based register study in Sweden. Participants: Children born 1997-2014, 0-1 years of age diagnosed with fracture-diagnosis according to International Classification of Diseases (ICD10) were retrieved from the National Patient Register and linked to the Swedish Medical Birth Register and the Death Cause Register. Main outcome measures were fractures of the skull, long bone, clavicle and ribs, categorized by age (younger or older than 6 months), and accident or not. FINDINGS:The incidence of fractures during infancy was 251 per 100 000 infants (n = 4663). Major fracture localisations were long bone (44·9%), skull (31·7%), and clavicle (18·6%), while rib fractures were few (1·4%). Fall accidents were reported among 71·4%. One-third occurred during the first 6 months. Metabolic bone disease risk factors, such as maternal obesity, preterm birth, vitamin D deficiency, rickets, and calcium metabolic disturbances, had increased odds of fractures of long bones and ribs in early infancy (0-6 months): birth 32-36 weeks and long bone fracture [AOR 2·13 (95%CI 1·67-2·93)] and rib fracture [AOR 4·24 (95%CI 1·40-12·8)]. Diagnosis of vitamin D deficiency/rickets/disorders of calcium metabolism had increased odds of long bone fracture [AOR 49·5 (95%CI 18·3-134)] and rib fracture [AOR 617 (95%CI 162-2506)]. Fractures without a reported accident had higher odds of metabolic risk factors than those with reported accidents. Abuse diagnosis was registered in 105 infants, with overrepresentation of preterm births, multiple births and small-for-gestational age. INTERPRETATION:Metabolic bone disease risk factors are strongly associated with fractures of long bone and ribs in early infancy. Fracture cases with abuse diagnosis had a metabolic bone risk factor profile.

OBJECTIVES:To analyse subdural haemorrhage (SDH) during infancy in Sweden by incidence, SDH category, diagnostic distribution, age, co-morbidity, mortality, and maternal and perinatal risk factors; and its association with accidents and diagnosis of abuse. METHODS:A Swedish population-based register study comprising infants born between 1997 and 2014, 0-1 years of age, diagnosed with SDH-diagnoses according to the (International Classification of Diseases, 10th version (ICD10), retrieved from the National Patient Register and linked to the Medical Birth Register and the Death Cause Register. Outcome measures were: 1) Incidence and distribution, 2) co-morbidity, 3) fall accidents by SDH category, 4) risk factors for all SDHs in the two age groups, 0-6 and 7-365 days, and for ICD10 SDH subgroups: S06.5 (traumatic SDH), I62.0 (acute nontraumatic), SDH and abuse diagnosis. RESULTS:Incidence of SDH was 16·5 per 100 000 infants (n = 306). Median age was 2·5 months. For infants older than one week, the median age was 3·5 months. Case fatality was 6·5%. Male sex was overrepresented for all SDH subgroups. Accidental falls were reported in 1/3 of the cases. One-fourth occurred within 0-6 days, having a perinatal risk profile. For infants aged 7-365 days, acute nontraumatic SDH was associated with multiple birth, preterm birth, and small-for-gestational age. Fourteen percent also had an abuse diagnosis, having increased odds of being born preterm, and being small-for-gestational age. CONCLUSIONS:The incidence was in the range previously reported. SDH among newborns was associated with difficult birth and neonatal morbidity. Acute nontraumatic SDH and SDH with abuse diagnosis had similar perinatal risk profiles. The increased odds for acute nontraumatic SDH in twins, preterm births, neonatal convulsions or small-for-gestational age indicate a perinatal vulnerability for SDH beyond 1st week of life. The association between prematurity/small-for-gestational age and abuse diagnosis is intriguing and not easily understood.

Preeclampsia is associated with low birth weight, both because of increased risks of preterm and of small-for-gestational-age (SGA) births. Low birth weight is associated with accelerated childhood height gain and cardiovascular diseases later in life. The aim was to investigate if prenatal exposure to preeclampsia is associated with accelerated childhood height gain, also after adjustments for SGA-status and gestational age at birth.In a cohort of children prenatally exposed to preeclampsia (n = 865) or unexposed (n = 22,898) we estimated height gain between birth and five years of age. The mean difference in height gain between exposed and unexposed children was calculated and adjustments were done with linear regression models.Children exposed to preeclampsia were on average born shorter than unexposed. Exposed children grew on average two cm more than unexposed from birth to five years of age. After adjustments for maternal characteristics including socioeconomic factors, height, body mass index (BMI) and diabetes, as well as for parents smoking habits, infant's breastfeeding and childhood obesity, the difference was 1.6 cm (95% CI 1.3-1.9 cm). Further adjustment for SGA birth only slightly attenuated this estimate, but adjustment for gestational age at birth decreased the estimate to 0.5 cm (95% CI 0.1-0.7 cm).Prenatal exposure to preeclampsia is associated with accelerated height gain in early childhood. The association seemed independent on SGA-status, but partly related to shorter gestational age at birth.

Background: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence. Objectives: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique. Methods: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach’s α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique. Results: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed. Conclusions: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants’ responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

Background: Epidemiological transition (ET) theory, first postulated in 1971, has developed alongside changes in population structures over time. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners. Here, we review the concept and development of ET theory, contextualising this in empirical evidence, which variously supports and contradicts the original theoretical propositions. Design: A Medline literature search covering publications over four decades, from 1971 to 2013, was conducted. Studies were included if they assessed human populations, were original articles, focused on mortality and health or demographic or ET and were in English. The reference lists of the selected articles were checked for additional sources. Results: We found that there were changes in emphasis in the research field over the four decades. There was an increasing tendency to study wide-ranging aspects of the determinants of mortality, including risk factors, lifestyle changes, socio-economics, and macro factors such as climate change. Research on ET has focused increasingly on low- and middle-income countries rather than industrialised countries, despite its origins in industrialised countries. Countries have experienced different levels of progress in ET in terms of time, pace, and underlying mechanisms. Elements of ET are described for many countries, but observed transitions have not always followed pathways described in the original theory. Conclusions: The classic ET theory largely neglected the critical role of social determinants, being largely a theoretical generalisation of mortality experience in some countries. This review shows increasing interest in ET all over the world but only partial concordance between established theory and empirical evidence. Empirical evidence suggests that some unconsidered aspects of social determinants contributed to deviations from classic theoretical pathways. A better-constructed, revised ET theory, with a stronger basis in evidence, is needed.

Background: Experiencing domestic violence is considered a chronic and stressful life event. A theoretical framework of coping strategies can be used to understand how women deal with domestic violence. Traditional values strongly influenced by religious teachings that interpret men as the leaders of women play an important role in the lives of Javanese women, where women are obliged to obey their husbands. Little is known about how sociocultural and psychosocial contexts influence the ways in which women cope with domestic violence. Objective: Our study aimed to deepen our understanding of how rural Javanese women cope with domestic violence. Our objective was to explore how the sociocultural context influences coping dynamics of women survivors of domestic violence in rural Purworejo. Design: A phenomenological approach was used to transform lived experiences into textual expressions of the coping dynamics of women survivors of domestic violence. Results: Experiencing chronic violence ruined the women's personal lives because of the associated physical, mental, psychosocial, and financial impairments. These chronic stressors led women to access external and internal resources to form coping strategies. Both external and internal factors prompted conflicting impulses to seek support, that is, to escape versus remain in the relationship. This strong tension led to a coping strategy that implied a long-term process of moving between actively opposing the violence and surrendering or tolerating the situation, resembling an elastic band that stretches in and out. Conclusions: Women survivors in Purworejo face a lack of institutional support and tend to have traditional beliefs that hamper their potential to stop the abuse. Although the women in this study were educated and economically independent, they still had difficulty mobilizing internal and external support to end the abuse, partly due to internalized gender norms.

OBJECTIVES:To explore the association between postpartum haemorrhage (PPH) and postpartum depression (PPD), taking into account the role of postpartum anaemia, delivery experience and psychiatric history. METHODS:A nested cohort study (n = 446), based on two population-based cohorts in Uppsala, Sweden. Exposed individuals were defined as having a bleeding of ≥1000 ml (n = 196) at delivery, and non-exposed individuals as having bleeding of

Objective: This study explores violence against women in a low-income setting in relation to residency and literacy. Setting: The study was conducted within the Butajira Rural Health Programme (a Health and Demographic Surveillance Site), which includes rural and semi-urban settings in south-central Ethiopia. Design: This is a community-based cross-sectional study and is part of the WHO Women's Health and Life Events multi-country study. It included 1,994 randomly selected married women. Methods: A standardised WHO questionnaire was used to measure physical violence, residency, literacy of the woman and her spouse, and attitudes of women about gender roles and violence. Analyses present prevalence with 95% confidence intervals and odds ratios derived from bivariate and multivariate logistic regression models. Results: In urban and rural areas of the study area, the women were of varying ages, had varying levels of literacy and had spouses with varying levels of literacy. Women in the overall study area had beliefs and norms favouring violence against women, and women living in rural communities and illiterate women were more likely to accept such attitudes. In general, violence against women was more prevalent in rural communities. In particular, violence against rural literate women and rural women who married a literate spouse was more prevalent. Literate rural women who were married to an illiterate spouse had the highest odds (Adj. OR=3.4; 95% CI: 1.7–6.9) of experiencing physical violence by an intimate partner. Conclusion: Semi-urban lifestyle and literacy promote changes in attitudes and norms against intimate partner violence; however, within the rural lifestyle, literate women married to illiterate husbands were exposed to the highest risks of violence.

BACKGROUND: Due to scanty individual health data in low- and middle-income countries (LMICs), health planners often use imperfect data sources. Frequent national-level data are considered essential, even if their depth and quality are questionable. However, quality in-depth data from local sentinel populations may be better than scanty national data, if such local data can be considered as nationally representative. The difficulty is the lack of any theoretical or empirical basis for demonstrating that local data are representative where data on the wider population are unavailable. Thus these issues can only be explored empirically in a complete individual dataset at national and local levels, relating to a LMIC population profile. METHODS AND FINDINGS: Swedish national data for 1925 were used, characterised by relatively high mortality, a low proportion of older people and substantial mortality due to infectious causes. Demographic and socioeconomic characteristics of Sweden then and LMICs now are very similar. Rates of livebirths, stillbirths, infant and cause-specific mortality were calculated at national and county levels. Results for six million people in 24 counties showed that most counties had overall mortality rates within 10% of the national level. Other rates by county were mostly within 20% of national levels. Maternal mortality represented too rare an event to give stable results at the county level. CONCLUSIONS: After excluding obviously outlying counties (capital city, island, remote areas), any one of the remaining 80% closely reflected the national situation in terms of key demographic and mortality parameters, each county representing approximately 5% of the national population. We conclude that this scenario would probably translate directly to about 40 LMICs with populations under 10 million, and to individual states or provinces within about 40 larger LMICs. Unsubstantiated claims that local sub-national population data are "unrepresentative" or "only local" should not therefore predominate over likely representativity.

Ideas of socialdarwinism and eugenics in combination with German nationalism and antisemitism paved the way for doctors joining the Nazi party, 45 per cent of all German doctors became party members. In the early 20th century Swedish medicine and medical education were much influenced by German basic and clinical sciences as well as German eugenics. Early Swedish officials opposed the antisemitic German policy of "rassenhygien". Few Swedish doctors were active antagonists to the nazis, although just a small percentage were members in nazi- or nazisympathizing Swedish organisations, but still many of those sympathizers were influential. The moral catastrophe for the Swedish doctors and medical undergraduates was that a majority opposed asylum for jewish doctors escaping Third Reich. The turn towards a humanistic attitude came when Norwegian and Danish jewish doctors fled from the occupation of their countries. The attitude among Swedish doctors and medical students against jewish refugees have during the last years been on the agenda.

How is research and teaching on Nazism best conducted? Despite the nearly universal condemnation of an unsanctioned "lecture" by a member of a Swedish Nazi party held at Umeå University in December 1997, a number of complex questions have been raised about the role of the researcher and the research object, as well as about the qualitative difference between conducting thorough-going research into Nazism, past and present, and allowing Nazi ideologies to penetrate the universities. An important way of countering the latter is to do more research into Nazism and the Holocaust and produce better, more accessible presentations of the wealth of research already extant. Insight into the nature and essence of Neo-Nazi ideology can hardly be expected to be won through highly-censored and propagandistic "lectures", but rather by closely studying the undergrowth of Nazi rhetoric and White Power music, the internal jargon and propaganda directed toward sympathizers and prospective members. It would be a fateful mistake to try and ignore Nazism, but neither can an open discussion be conducted on its own conditions. Recurring conferences and symposia and interdisciplinary efforts at designing improved study courses on Nazism are important contributions to maintaining the very fundament of our society which these movements reject — the equal rights of all mankind.