Cesarean section and rate of subsequent stillbirth, miscarriage and ectopic pregnancy: a Danish register-based cohort study

Background: With cesarean section rates increasing worldwide, clarity regarding negative effects is essential. This study aimed to investigate the rate of subsequent stillbirth, miscarriage, and ectopic pregnancy following primary cesarean section, controlling for confounding by indication. Methods and Findings: We performed a population-based cohort study using Danish national registry data linking various registers. The cohort included primiparous women with a live birth between January 1, 1982, and December 31, 2010 (n = 832,996), with follow-up until the next event (stillbirth, miscarriage, or ectopic pregnancy) or censoring by live birth, death, emigration, or study end. Cox regression models for all types of cesarean sections, sub-group analyses by type of cesarean, and competing risks analyses for the causes of stillbirth were performed. An increased rate of stillbirth (hazard ratio [HR] 1.14, 95% CI 1.01, 1.28) was found in women with primary cesarean section compared to spontaneous vaginal delivery, giving a theoretical absolute risk increase (ARI) of 0.03% for stillbirth, and a number needed to harm (NNH) of 3,333 women. Analyses by type of cesarean section showed similarly increased rates for emergency (HR 1.15, 95% CI 1.01, 1.31) and elective cesarean (HR 1.11, 95% CI 0.91, 1.35), although not statistically significant in the latter case. An increased rate of ectopic pregnancy was found among women with primary cesarean overall (HR 1.09, 95% CI 1.04, 1.15) and by type (emergency cesarean, HR 1.09, 95% CI 1.03, 1.15, and elective cesarean, HR 1.12, 95% CI 1.03, 1.21), yielding an ARI of 0.1% and a NNH of 1,000 women for ectopic pregnancy. No increased rate of miscarriage was found among women with primary cesarean, with maternally requested cesarean section associated with a decreased rate of miscarriage (HR 0.72, 95% CI 0.60, 0.85). Limitations include incomplete data on maternal body mass index, maternal smoking, fertility treatment, causes of stillbirth, and maternally requested cesarean section, as well as lack of data on antepartum/intrapartum stillbirth and gestational age for stillbirth and miscarriage. Conclusions: This study found that cesarean section is associated with a small increased rate of subsequent stillbirth and ectopic pregnancy. Underlying medical conditions, however, and confounding by indication for the primary cesarean delivery account for at least part of this increased rate. These findings will assist women and health-care providers to reach more informed decisions regarding mode of delivery.

Leisure and surveillance in Irish childhoods: A cross-class study of Cork city

This research provides an interpretive cross-class analysis of the leisure experience of children, aged between six and ten years, living in Cork city. This study focuses on the cultural dispositions underpinning parental decisions in relation to children’s leisure activities, with a particular emphasis on their child-surveillance practices. In this research, child-surveillance is defined as the adult monitoring of children by technological means, physical supervision, community supervision, or adult supervised activities (Nelson, 2010; Lareau, 2003; Fotel and Thomsen, 2004). This research adds significantly to understandings of Irish childhood by providing the first in-depth qualitative analysis of the surveillance of children’s leisure-time. Since the 1990s, international research on children has highlighted the increasingly structured nature of children’s leisure-time (Lareau, 2011; Valentine & McKendrick, 1997). Furthermore, research on child-surveillance has found an increase in the intensive supervision of children during their unstructured leisure-time (Nelson, 2010; Furedi, 2008; Fotel and Thomsen, 2004). This research bridges the gap between these two key bodies of literature, providing a more integrated overview of children’s experience of leisure in Ireland. Using Bourdieu’s (1992) model of habitus, field and capital, the dispositions that shape parents’ decisions about their children’s leisure time are interrogated. The holistic view of childhood adopted in this research echoes the ‘Whole Child Approach’ by analysing the child’s experience within a wider set of social relationships including family, school, and community. Underpinned by James and Prout’s (1990) paradigm on childhood, this study considers Irish children’s agency in negotiating with parents’ decisions regarding leisure-time. The data collated in this study enhances our understanding of the micro-interactions between parents and children and, the ability of the child to shape their own experience. Moreover, this is the first Irish sociological research to identify and discuss class distinctions in children’s agentic potential during leisure-time.

At what price? A cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery

Background: Elective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland.Methods: Using a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both "bottom-up" and "top-down" costing estimations.Results: Maternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD ((sic)1,835.06 versus (sic)4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis.Conclusions: Clinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.

Surveillance during pregnancy: methods and response rates from a hospital based pilot study of the Pregnancy Risk Assessment Monitoring System in Ireland

Background: Many European countries including Ireland lack high quality, on-going, population based estimates of maternal behaviours and experiences during pregnancy. PRAMS is a CDC surveillance program which was established in the United States in 1987 to generate high quality, population based data to reduce infant mortality rates and improve maternal and infant health. PRAMS is the only on-going population based surveillance system of maternal behaviours and experiences that occur before, during and after pregnancy worldwide.Methods: The objective of this study was to adapt, test and evaluate a modified CDC PRAMS methodology in Ireland. The birth certificate file which is the standard approach to sampling for PRAMS in the United States was not available for the PRAMS Ireland study. Consequently, delivery record books for the period between 3 and 5 months before the study start date at a large urban obstetric hospital [8,900 births per year] were used to randomly sample 124 women. Name, address, maternal age, infant sex, gestational age at delivery, delivery method, APGAR score and birth weight were manually extracted from records. Stillbirths and early neonatal deaths were excluded using APGAR scores and hospital records. Women were sent a letter of invitation to participate including option to opt out, followed by a modified PRAMS survey, a reminder letter and a final survey.Results: The response rate for the pilot was 67%. Two per cent of women refused the survey, 7% opted out of the study and 24% did not respond. Survey items were at least 88% complete for all 82 respondents. Prevalence estimates of socially undesirable behaviours such as alcohol consumption during pregnancy were high [>50%] and comparable with international estimates.Conclusion: PRAMS is a feasible and valid method of collecting information on maternal experiences and behaviours during pregnancy in Ireland. PRAMS may offer a potential solution to data deficits in maternal health behaviour indicators in Ireland with further work. This study is important to researchers in Europe and elsewhere who may be interested in new ways of tailoring an established CDC methodology to their unique settings to resolve data deficits in maternal health.

A study of the extent to which Irish law, policy and practice allow for Ireland's application of the United Nations Convention on the Rights of the Child, 1989 to pre-natal children

The central research question of this thesis asks the extent to which Irish law, policy and practice allow for the application of the United Nations Convention on the Rights of the Child (CRC) to pre-natal children. First, it is demonstrated that pre-natal children can fall within the definition of ‘child’ under the Convention and so the possibility of applying the Convention to children before birth is opened. Many State Parties to the CRC have interpreted it as applicable to pre-natal children, while others have expressed that it only applies from birth. Ireland has not clarified whether or not it interprets it as being applicable from conception, birth, or some other point. The remainder of the thesis examines the extent to which Ireland interprets the CRC as applicable to the pre-natal child. First, the question of whether Ireland affords to the pre-natal child the right to life under Article 6(1) of the Convention is analysed. Given the importance of the indivisibility of rights under the Convention, the extent to which Ireland applies other CRC rights to pre-natal children is examined. The rights analysed are the right to protection from harm, the right to the provision of health care and the procedural right to representation. It is concluded that Ireland’s laws, policies and practices require urgent clarification on the issue of the extent to which rights such as protection, health care and representation apply to children before birth. In general, there are mixed and ad hoc approaches to these issues in Ireland and there exists a great deal of confusion amongst those working on the frontline with such children, such as health care professionals and social workers. The thesis calls for significant reform in this area in terms of law and policy, which will inform practice.

Embodied sexualities: Exploring accounts of Irish women's sexual knowledge and sexual experiences, 1920-1970

This chapter explores the ways in which sexuality has been understood, embodied and negotiated by a cohort of Irish women through their lives. It is based on qualitative data generated as part of an oral history project on Irish women’s experiences of sexuality and reproduction during the period 1920–1970.1 The interviews, which were conducted with 21 Irish women born between 1914 and 1955, illustrate that social and cultural discourses of sexuality as secretive, dangerous, dutiful and sinful were central to these women’s interpretative repertoires around sexuality and gender. However, the data also contains accounts of behaviours, experiences and feelings that challenged or resisted prevailing scripts of sexuality and gender. Drawing on feminist conceptualisations of sexuality and embodiment (Holland et al., 1994; Jackson and Scott, 2010), this chapter demonstrates that the women’s sexual subjectivities were forged in the tensions that existed between normative sexual scripts and their embodied experiences of sexual desires and sexual and reproductive practices. While recollections of sexual desire and pleasure did feature in the accounts of some of the women, it was the difficulties experienced around sexuality and reproduction that were spoken about in greatest detail. What emerges clearly from the data is the confusion, anxiety and pain occasioned by the negotiation of external demands and internal desires and the contested, unstable nature of both cultural power and female resistance.

Prophets of the beast: the modernist esotericism of D.H. Lawrence and W.B. Yeats

This thesis analyses the influence of the esoteric tradition on D.H. Lawrence and W.B. Yeats’ thought and examines both authors’ writings in light of the antidemocratic political religions that emerged during and after their respective careers. While a number of extant studies investigate the connection between modernism and the occult and a number of critics have discussed the importance of antidemocratic politics to modernism, this study is unique in its emphasis on the relationship between modernist esotericism and antidemocratic politics, and in its insistence that the interconnection between the two constitutes a fundamental part of both authors’ world-views. This study calls for the development of a multivalent understanding of modernism, which appears as neither a “cultural movement identifiable with bourgeois, capitalist, paternalist, ethnocentrist, phallocentrist, and logocentrist ideologies” (Surette 5) nor entirely the opposite; Romantic, feministic, primitivistic and countercultural. Rather, modernism will be shown to have encompassed both of these ideological orientations, effectively operating on a double front in its crusade to establish a new age. This complexity is visible in both Lawrence and Yeats’ work, as both authors advocate a return to traditional structures while simultaneously endeavouring to usher Western civilisation into a new modern paradigm. Although they primarily grounded their writings in a mythico-pastoral discourse that masked the practical implications of their revolutionary agendas, both authors possessed an attraction to Futurist thought and, albeit rarely, showed an awareness that the change they envisioned could not be brought about without a radical intervention in the political and economic sectors – an intervention that would necessarily take place through the medium of the “machine” from which they were often so adamant to distance themselves. This fusion of technophilic and Arcadian thought-currents – dubbed “archeofuturism” by the French right-wing intellectual Guillaume Faye – constitutes the central focus of this discussion of Lawrentian and Yeatsian thought.

The Celtic dragon slayer - a literary analysis of Tochmarc Emire in connection with Tristan et Iseut

As Celtic scholars have long noted, the medieval Irish tale Tochmarc Emire “The Courtship of Emer” is heavily indebted to other medieval Irish texts. In this tale of courtship and otherworldly quests, the Irish hero Cú Chulainn must prove himself worthy of the hand of the noblewoman Emer. Among his overseas adventures, Cú Chulainn rescues a princess from three attackers of the Fomoire. This episode may represent the only medieval Irish example of AT300 “The Dragon Slayer”, a story pattern known from classical models such as the stories of Perseus and Andromeda; and Hercules and Hesione. Moreover, in the company of Cú Chulainn we find a character otherwise unknown to Irish tradition by the name of Drust mac Seirb. This has led scholars to argue that Tochmarc Emire may preserve a Celtic precursor of the Continental Tristan legend, seeing in Drust the Pictish origin of the character Tristan, himself a famous dragon slayer. In this interdisciplinary dissertation, a number of questions are addressed. If the redactor of Tochmarc Emire drew on material from outside Irish tradition, what does this tell us about medieval Irish concepts of literature and genre? Further, what evidence do we have for tracing the origin of the Continental Tristan legend back to Pictland, and what explanation might we offer for a putative Pictish prince featuring in an Irish Dragon Slayer story? Finally, what place does the Dragon Slayer episode occupy within Tochmarc Emire and can we find other narratives, Celtic or classical or other, fitting the pattern of AT300, which may strengthen the link between Tochmarc Emire and Tristan?

Depression and 'crises of meaninglessness' in the political-economic theology of the money-God

The thesis starts with a historical analysis of the development of depression as a concept. Through this inquiry, the controversies behind the apparent consensus about depression’s etiology and treatment are illuminated, suggesting that the understanding of the climbing rates of depression in contemporary Western civilization is still up for grabs. That’s what the thesis sets out to investigate. In order to accomplish this aim, the study builds upon the classical accounts of Georg Simmel, Émile Durkheim and the more contemporary ideas of Dany-Robert Dufour, in dialogue with an array of supplementary theoretical sources. Navigating through this ‘sea’ of extraordinary and different theories, a new avenue of reflections arises, contributing for the sophistication of the questions made about the phenomenon of depression’s rates. The fundamental argument emerging from this theoretical undertaking is that ‘crises of meaninglessness’ that pervade the collective body of Western contemporary societies have, as one of its consequences, the expansion of depression rates. Meaninglessness in contemporary times is the primary object of investigation of the thesis. The concept, in the context of this study, is not understood as merely an effect of the historical decline of shared social norms due to processes of individualization. Rather, it is claimed, it originates from and is reinforced by the ‘political-economic theology of neo-liberalism’ which becomes virtually generalized in the West, erecting money as a God. The study concludes that by undermining culturally established values, ideals, institutions and principles that may block the dissemination of commodities this new transcendence has been challenging the task of signifying life, potentializing – among other subjective difficulties – the diffusion of depression.

Valuing maternity care: a comparison of stated preference methods with an application to cost-benefit analysis

This research investigates whether a reconfiguration of maternity services, which collocates consultant- and midwifery-led care, reflects demand and value for money in Ireland. Qualitative and quantitative research is undertaken to investigate demand and an economic evaluation is performed to evaluate the costs and benefits of the different models of care. Qualitative research is undertaken to identify women’s motivations when choosing place of delivery. These data are further used to inform two stated preference techniques: a discrete choice experiment (DCE) and contingent valuation method (CVM). These are employed to identify women’s strengths of preferences for different features of care (DCE) and estimate women’s willingness to pay for maternity care (CVM), which is used to inform a cost-benefit analysis (CBA) on consultant- and midwifery-led care. The qualitative research suggests women do not have a clear preference for consultant or midwifery-led care, but rather a hybrid model of care which closely resembles the Domiciliary Care In and Out of Hospital (DOMINO) scheme. Women’s primary concern during care is safety, meaning women would only utilise midwifery-led care when co-located with consultant-led care. The DCE also finds women’s preferred package of care closely mirrors the DOMINO scheme with 39% of women expected to utilise this service. Consultant- and midwifery-led care would then be utilised by 34% and 27% of women, respectively. The CVM supports this hierarchy of preferences where consultant-led care is consistently valued more than midwifery-led care – women are willing to pay €956.03 for consultant-led care and €808.33 for midwifery-led care. A package of care for a woman availing of consultant- and midwifery-led care is estimated to cost €1,102.72 and €682.49, respectively. The CBA suggests both models of care are cost-beneficial and should be pursued in Ireland. This reconfiguration of maternity services would maximise women’s utility, while fulfilling important objectives of key government policy.