Turning Around Talipes: Nursing Considerations

The management of congenital talipes equinovarus (TEV) has received much clinical and research attention within the disciplines of medicine and physiotherapy. However, few articles have been published about the role of the registered nurse in contributing to the optimum health and wellbeing of the child and family presenting for assessment and treatment of the condition. Much of the most intense treatment for TEV occurs in the first few weeks of the child’s life; a time of critical growth and development when the infant is both sensitive and vulnerable to the environment within which it is nurtured. This is also a crucial time for developing a secure attachment to the caregiver and nurses can assist parents in optimising their infant’s opportunities for a secure attachment relationship. This paper thus provides an overview of the medical and physiotherapy management of TEV and highlights the role nurses have in providing nursing care and psycho-social support to parents of infants with TEV, in areas such as the maintenance of skin integrity and circulation, providing effective pain relief, and optimising growth, development, and a secure attachment relationship. Congenital TEV or 'club foot' is one of the most common congenital orthopaedic anomalies of infants. In Queensland in 2000, in approximately 50,000 births, 244 infants were born with talipes; almost five infants per 1000 births. National statistics are not as specific, with coding providing only 'other lower limb' as the category that would encompass talipes; the 1997 national incidence of such lower limb congenital malformations is reported as 1.7 per 10,000 births 1.

Birthing practices of traditional birth attendants in south Asia in the context of training programmes

Traditional Birth Attendants (TBA) training has been an important component of public health policy interventions to improve maternal and child health in developing countries since the 1970s. More recently, since the 1990s, the TBA training strategy has been increasingly seen as irrelevant, ineffective or, on the whole, a failure due to evidence that the maternal mortality rate (MMR) in developing countries had not reduced. Although, worldwide data show that, by choice or out of necessity, 47 percent of births in the developing world are assisted by TBAs and/or family members, funding for TBA training has been reduced and moved to providing skilled birth attendants for all births. Any shift in policy needs to be supported by appropriate evidence on TBA roles in providing maternal and infant health care service and effectiveness of the training programmes. This article reviews literature on the characteristics and role of TBAs in South Asia with an emphasis on India. The aim was to assess the contribution of TBAs in providing maternal and infant health care service at different stages of pregnancy and after-delivery and birthing practices adopted in home births. The review of role revealed that apart from TBAs, there are various other people in the community also involved in making decisions about the welfare and health of the birthing mother and new born baby. However, TBAs have changing, localised but nonetheless significant roles in delivery, postnatal and infant care in India. Certain traditional birthing practices such as bathing babies immediately after birth, not weighing babies after birth and not feeding with colostrum are adopted in home births as well as health institutions in India. There is therefore a thin precarious balance between the application of biomedical and traditional knowledge. Customary rituals and perceptions essentially affect practices in home and institutional births and hence training of TBAs need to be implemented in conjunction with community awareness programmes.

Determinants of infant and young child feeding practices in Nepal : secondary data analysis of demographic and health survey 2006

Background: Childhood undernutrition and mortality are high in Nepal, and therefore interventions on infant and young child feeding practices deserve high priority. Objective. To estimate infant and young child feeding indicators and the determinants of selected feeding practices. Methods: The sample consisted of 1,906 children aged 0 to 23 months from the Demographic and Health Survey 2006. Selected indicators were examined against a set of variables using univariate and multivariate analyses. Results. Breastfeeding was initiated within the first hour after birth in 35.4% of children, 99.5% were ever breastfed, 98.1% were currently breastfed, and 3.5% were bottle-fed. The rate of exclusive breastfeeding among infants under 6 months of age was 53.1%, and the rate of timely complementary feeding among those 6 to 9 months of age was 74.7%. Mothers who made antenatal clinic visits were at a higher risk for no exclusive breastfeeding than those who made no visits. Mothers who lived in the mountains were more likely to initiate breastfeeding within 1 hour after birth and to introduce complementary feeding at 6 to 9 months of age, but less likely to exclusively breastfeed. Cesarean deliveries were associated with delay in timely initiation of breastfeeding. Higher rates of complementary feeding at 6 to 9 months were also associated with mothers with better education and those above 35 years of age. Risk factors for bottle-feeding included living in urban areas and births attended by trained health personnel. Conclusions: Most breastfeeding indicators in Nepal are below the expected levels to achieve a substantial reduction in child mortality. Breastfeeding promotion strategies should specifically target mothers who have more contact with the health care delivery system, while programs targeting the entire community should be continued.

Maternal exposure to ambient temperature and the risk of preterm birth and stillbirth in Brisbane, Australia

Almost 10% of all births are preterm and 2.2% are stillbirths globally. Recent research has suggested that environmental factors may be a contributory cause to these adverse birth outcomes. The authors examined the relationship between ambient temperature and preterm birth and stillbirth in Brisbane, Australia between 2005 and 2009 (n = 101,870). They used a Cox proportional hazard model with live birth and stillbirth as competing risks. They also examined if there were periods of the pregnancy where exposure to high temperatures had a greater effect. Exposure to higher ambient temperatures during pregnancy increased the risk of stillbirth. The hazard ratio for stillbirth was 0.3 at 12 °C relative to the reference temperature at 21 °C. The temperature effect was greatest for fetuses of less than 36 weeks of gestation. There was an association between higher temperature and shorter gestation, as the hazard ratio for live birth was 0.96 at 15 °C and 1.02 at 25 °C. This effect was greatest at later gestational ages. The results provide strong evidence of an association between increased temperature and increased risk of stillbirth and shorter gestations.

The impact of nonlinear exposure risk relationships on seasonal time series data: modelling danish neonatal birth anthropometric data

Background Birth weight and length have seasonal fluctuations. Previous analyses of birth weight by latitude effects identified seemingly contradictory results, showing both 6 and 12 monthly periodicities in weight. The aims of this paper are twofold: (a) to explore seasonal patterns in a large, Danish Medical Birth Register, and (b) to explore models based on seasonal exposures and a non-linear exposure-risk relationship. Methods Birth weight and birth lengths on over 1.5 million Danish singleton, live births were examined for seasonality. We modelled seasonal patterns based on linear, U- and J-shaped exposure-risk relationships. We then added an extra layer of complexity by modelling weighted population-based exposure patterns. Results The Danish data showed clear seasonal fluctuations for both birth weight and birth length. A bimodal model best fits the data, however the amplitude of the 6 and 12 month peaks changed over time. In the modelling exercises, U- and J-shaped exposure-risk relationships generate time series with both 6 and 12 month periodicities. Changing the weightings of the population exposure risks result in unexpected properties. A J-shaped exposure-risk relationship with a diminishing population exposure over time fitted the observed seasonal pattern in the Danish birth weight data. Conclusion In keeping with many other studies, Danish birth anthropometric data show complex and shifting seasonal patterns. We speculate that annual periodicities with non-linear exposure-risk models may underlie these findings. Understanding the nature of seasonal fluctuations can help generate candidate exposures.

The influence of ambient temperature on birth outcomes in Brisbane, Australia

Lately, there has been increasing interest in the association between temperature and adverse birth outcomes including preterm birth (PTB) and stillbirth. PTB is a major predictor of many diseases later in life, and stillbirth is a devastating event for parents and families. The aim of this study was to assess the seasonal pattern of adverse birth outcomes, and to examine possible associations of maternal exposure to temperature with PTB and stillbirth. We also aimed to identify if there were any periods of the pregnancy where exposure to temperature was particularly harmful. A retrospective cohort study design was used and we retrieved individual birth records from the Queensland Health Perinatal Data Collection Unit for all singleton births (excluding twins and triplets) delivered in Brisbane between 1 July 2005 and 30 June 2009. We obtained weather data (including hourly relative humidity, minimum and maximum temperature) and air-pollution data (including PM10, SO2 and O3) from the Queensland Department of Environment and Resource Management. We used survival analyses with the time-dependent variables of temperature, humidity and air pollution, and the competing risks of stillbirth and live birth. To assess the monthly pattern of the birth outcomes, we fitted month of pregnancy as a time-dependent variable. We examined the seasonal pattern of the birth outcomes and the relationship between exposure to high or low temperatures and birth outcomes over the four lag weeks before birth. We further stratified by categorisation of PTB: extreme PTB (< 28 weeks of gestation), PTB (28–36 weeks of gestation), and term birth (≥ 37 weeks of gestation). Lastly, we examined the effect of temperature variation in each week of the pregnancy on birth outcomes. There was a bimodal seasonal pattern in gestation length. After adjusting for temperature, the seasonal pattern changed from bimodal, to only one peak in winter. The risk of stillbirth was statistically significant lower in March compared with January. After adjusting for temperature, the March trough was still statistically significant and there was a peak in risk (not statistically significant) in winter. There was an acute effect of temperature on gestational age and stillbirth with a shortened gestation for increasing temperature from 15 °C to 25 °C over the last four weeks before birth. For stillbirth, we found an increasing risk with increasing temperatures from 12 °C to approximately 20 °C, and no change in risk at temperatures above 20 °C. Certain periods of the pregnancy were more vulnerable to temperature variation. The risk of PTB (28–36 weeks of gestation) increased as temperatures increased above 21 °C. For stillbirth, the fetus was most vulnerable at less than 28 weeks of gestation, but there were also effects in 28–36 weeks of gestation. For fetuses of more than 37 weeks of gestation, increasing temperatures did not increase the risk of stillbirth. We did not find any adverse affects of cold temperature on birth outcomes in this cohort. My findings contribute to knowledge of the relationship between temperature and birth outcomes. In the context of climate change, this is particularly important. The results may have implications for public health policy and planning, as they indicate that pregnant women would decrease their risk of adverse birth outcomes by avoiding exposure to high temperatures and seeking cool environments during hot days.

Interaction of myxomatosis and Rabbit Haemorrhagic Disease in wild rabbit

Increasing resistance of rabbits to myxomatosis in Australia has led to the exploration of Rabbit Haemorrhagic Disease, also called Rabbit Calicivirus Disease (RCD) as a possible control agent. While the initial spread of RCD in Australia resulted in widespread rabbit mortality in affected areas, the possible population dynamic effects of RCD and myxomatosis operating within the same system have not been properly explored. Here we present early mathematical modelling examining the interaction between the two diseases. In this study we use a deterministic compartment model, based on the classical SIR model in infectious disease modelling. We consider, here, only a single strain of myxomatosis and RCD and neglect latent periods. We also include logistic population growth, with the inclusion of seasonal birth rates. We assume there is no cross-immunity due to either disease. The mathematical model allows for the possibility of both diseases to be simultaneously present in an individual, although results are also presented for the case where co infection is not possible, since co-infection is thought to be rare and questions exist as to whether it can occur. The simulation results of this investigation show that it is a crucial issue and should be part of future field studies. A single simultaneous outbreak of RCD and myxomatosis was simulated, while ignoring natural births and deaths, appropriate for a short timescale of 20 days. Simultaneous outbreaks may be more common in Queensland. For the case where co-infection is not possible we find that the simultaneous presence of myxomatosis in the population suppresses the prevalence of RCD, compared to an outbreak of RCD with no outbreak of myxomatosis, and thus leads to a less effective control of the population. The reason for this is that infection with myxomatosis removes potentially susceptible rabbits from the possibility of infection with RCD (like a vaccination effect). We found that the reduction in the maximum prevalence of RCD was approximately 30% for an initial prevalence of 20% of myxomatosis, for the case where there was no simultaneous outbreak of myxomatosis, but the peak prevalence was only 15% when there was a simultaneous outbreak of myxomatosis. However, this maximum reduction will depend on other parameter values chosen. When co-infection is allowed then this suppression effect does occur but to a lesser degree. This is because the rabbits infected with both diseases reduces the prevalence of myxomatosis. We also simulated multiple outbreaks over a longer timescale of 10 years, including natural population growth rates, with seasonal birth rates and density dependent(logistic) death rates. This shows how both diseases interact with each other and with population growth. Here we obtain sustained outbreaks occurring approximately every two years for the case of a simultaneous outbreak of both diseases but without simultaneous co-infection, with the prevalence varying from 0.1 to 0.5. Without myxomatosis present then the simulation predicts RCD dies out quickly without further introduction from elsewhere. With the possibility of simultaneous co-infection of rabbits, sustained outbreaks are possible but then the outbreaks are less severe and more frequent (approximately yearly). While further model development is needed, our work to date suggests that: 1) the diseases are likely to interact via their impacts on rabbit abundance levels, and 2) introduction of RCD can suppress myxomatosis prevalence. We recommend that further modelling in conjunction with field studies be carried out to further investigate how these two diseases interact in the population.

Methodological challenges when estimating the effects of season and seasonal exposures on birth outcomes

Background Many previous studies have found seasonal patterns in birth outcomes, but with little agreement about which season poses the highest risk. Some of the heterogeneity between studies may be explained by a previously unknown bias. The bias occurs in retrospective cohorts which include all births occurring within a fixed start and end date, which means shorter pregnancies are missed at the start of the study, and longer pregnancies are missed at the end. Our objective was to show the potential size of this bias and how to avoid it. Methods To demonstrate the bias we simulated a retrospective birth cohort with no seasonal pattern in gestation and used a range of cohort end dates. As a real example, we used a cohort of 114,063 singleton births in Brisbane between 1 July 2005 and 30 June 2009 and examined the bias when estimating changes in gestation length associated with season (using month of conception) and a seasonal exposure (temperature). We used survival analyses with temperature as a time-dependent variable. Results We found strong artificial seasonal patterns in gestation length by month of conception, which depended on the end date of the study. The bias was avoided when the day and month of the start date was just before the day and month of the end date (regardless of year), so that the longer gestations at the start of the study were balanced by the shorter gestations at the end. After removing the fixed cohort bias there was a noticeable change in the effect of temperature on gestation length. The adjusted hazard ratios were flatter at the extremes of temperature but steeper between 15 and 25°C. Conclusions Studies using retrospective birth cohorts should account for the fixed cohort bias by removing selected births to get unbiased estimates of seasonal health effects.

Pregnancy losses in young Australian women : findings from the Australian Longitudinal Study on Women's Health

INTRODUCTION: Little research has examined recognized pregnancy losses in a general population. Data from an Australian cohort study provide an opportunity to quantify this aspect of fecundity at a population level. METHOD: Participants in the Australian Longitudinal Study on Women's Health who were aged 28-33 years in 2006 (n = 9,145) completed up to 4 mailed surveys over 10 years. Participants were categorized according to the recognized outcome of their pregnancies, including live birth, miscarriage/stillbirth, termination/ectopic, or no pregnancy. RESULTS: At age 18-23, more women reported terminations (7%) than miscarriages (4%). By 28-33 years, the cumulative frequency of miscarriage (15%) was as common as termination (16%). For women aged 28-33 years who had ever been pregnant (n = 5,343), pregnancy outcomes were as follows: birth only (50%); loss only (18%); and birth and loss (32%), of which half (16%) were birth and miscarriage. A comparison between first miscarriage and first birth (no miscarriage) showed that most first miscarriages occurred in women aged 18-23 years who also reported a first birth at the same survey (15%). Half (51%) of all first births and first miscarriages in women aged 18-19 ended in miscarriage. Early childbearers (<28 years) often had miscarriages around the same time period as their first live birth, suggesting proactive family formation. Delayed childbearers (32-33 years) had more first births than first miscarriages. CONCLUSION: Recognized pregnancy losses are an important measure of fecundity in the general population because they indicate successful conception and maintenance of pregnancy to varying reproductive endpoints.

Changing patterns of contraceptive use in Australian women

Background: This longitudinal analysis examines how patterns of contraceptive use changed over 11 years among Australian women born between 1973 and 1978. Study Design: The analysis included 6708 women sampled from the Australian universal health insurance database who completed four self-report postal surveys between 1996 and 2006. Change over time in use of any method of contraception and the common single methods of the oral contraceptive pill and condom was examined using a longitudinal logistic regression model. Results: The oral contraceptive pill was the most commonly used single method at each survey (27-44%) but decreased over time. Over time, contraceptive users were increasingly more likely to be single or in a de facto relationship or to have had two or more births. Conclusions: Women's contraceptive use and the factors associated with contraceptive use change over time as women move into relationships, try to conceive, have babies and complete their families.

Infertility resolved with or without fertility treatment in Australian women aged 31-36 years: A prospective, population-based study [abstract]

Birth outcomes during a three year period were compared for women with a history of infertility who did or did not use fertility treatment with hormones and/or in vitro fertilisation. Participants in the Australian Longitudinal Study on Women’s Health born in 1973-78 were randomly selected from the universal public health insurance database and completed up to five mailed surveys (1996-2009). Participants reported on their infertility and use of treatment at age 28-33 years (survey 4 (S4) in 2006) and 31-36 years (survey 5 (S5) in 2009). The odds of resolved infertility at S5 were estimated using logistic regression with adjustment for age, area of residence, private health insurance and male infertility. Among 7280 women who responded to both S4 and S5, 18.6% (n=1378) reported infertility. More than half (n=804, 56.8%) of these women did not use treatment and 43.9% (n=347) gave birth between S4 and S5. Compared to infertile women who did not use treatment, women who used treatment were more likely at S5 to have recently given birth (odds ratio (OR) = 1.59, 95% CI 1.26-2.00) or be pregnant (OR = 1.77, 1.27-2.46). Further, women who used treatment were more likely to have twins (3.37, 1.18-9.62), premature births (1.52, 0.95-2.43), or low birthweight babies (1.83, 0.70-2.53) compared to women who gave birth without using treatment. Many women aged up to 36 years with a history of infertility can conceive naturally over a three year period without the use of treatment.Women who have never had a prior birth may need to use treatment to resolve their infertility but they are at higher risk of poorer perinatal outcomes, such as premature or low birthweight babies.

Contraceptive changes after reproductive events among Australian women born in 1973 to 1978: A longitudinal study from 1996 to 2009

Background Women change contraception as they try to conceive, space births, and limit family size. This longitudinal analysis examines contraception changes after reproductive events such as birth, miscarriage or termination among Australian women born from 1973 to 1978 to identify potential opportunities to increase the effectiveness of contraceptive information and service provision. Methods Between 1996 and 2009, 5,631 Australian women randomly sampled from the Australian universal health insurance (Medicare) database completed five self-report postal surveys. Three longitudinal logistic regression models were used to assess the associations between reproductive events (birth only, birth and miscarriage, miscarriage only, termination only, other multiple events, and no new event) and subsequent changes in contraceptive use (start using, stop using, switch method) compared with women who continued to use the same method. Results After women experienced only a birth, or a birth and a miscarriage, they were more likely to start using contraception. Women who experienced miscarriages were more likely to stop using contraception. Women who experienced terminations were more likely to switch methods. There was a significant interaction between reproductive events and time indicating more changes in contraceptive use as women reach their mid-30s. Conclusion Contraceptive use increases after the birth of a child, but decreases after miscarriage indicating the intention for family formation and spacing between children. Switching contraceptive methods after termination suggests these pregnancies were unintended and possibly due to contraceptive failure. Women’s contact with health professionals around the time of reproductive events provides an opportunity to provide contraceptive services.

Birth outcomes after spontaneous or assisted conception among infertile Australian women aged 28 to 36 years: A prospective, population-based study

Objective To examine the extent to which the odds of birth, pregnancy, or adverse birth outcomes are higher among women aged 28 to 36 years who use fertility treatment compared with untreated women. Design Prospective, population-based. Setting Not applicable. Patient(s) Participants in the ALSWH born in 1973 to 1978 who reported on their infertility and use of in vitro fertilization (IVF) or ovulation induction (OI). Intervention(s) Postal survey questionnaires administered as part of ALSWH. Main Outcome Measure(s) Among women treated with IVF or OI and untreated women, the odds of birth outcomes estimated by use of adjusted logistic regression modeling. Result(s) Among 7,280 women, 18.6% (n = 1,376) reported infertility. Half (53.0%) of the treated women gave birth compared with 43.8% of untreated women. Women with prior parity were less likely to use IVF compared with nulliparous women. Women using IVF or OI, respectively, were more likely to have given birth after treatment or be pregnant compared with untreated women. Women using IVF or OI were as likely to have ectopic pregnancies, stillbirths, or premature or low birthweight babies as untreated women. Conclusion(s) More than 40% of women aged 28–36 years reporting a history of infertility can achieve births without using treatment, indicating they are subfertile rather than infertile.

Miscarriage, preterm delivery, and stillbirth: Large variations in rates within a cohort of Australian women

Objectives We aimed to use simple clinical questions to group women and provide their specific rates of miscarriage, preterm delivery, and stillbirth for reference. Further, our purpose was to describe who has experienced particularly low or high rates of each event. Methods Data were collected as part of the Australian Longitudinal Study on Women's Health, a national prospective cohort. Reproductive histories were obtained from 5806 women aged 31–36 years in 2009, who had self-reported an outcome for one or more pregnancy. Age at first birth, number of live births, smoking status, fertility problems, use of in vitro fertilisation (IVF), education and physical activity were the variables that best separated women into groups for calculating the rates of miscarriage, preterm delivery, and stillbirth. Results Women reported 10,247 live births, 2544 miscarriages, 1113 preterm deliveries, and 113 stillbirths. Miscarriage was correlated with stillbirth (r = 0.09, P<0.001). The calculable rate of miscarriage ranged from 11.3 to 86.5 miscarriages per 100 live births. Women who had high rates of miscarriage typically had fewer live births, were more likely to smoke and were more likely to have tried unsuccessfully to conceive for ≥12 months. The highest proportion of live preterm delivery (32.2%) occurred in women who had one live birth, had tried unsuccessfully to conceive for ≥12 months, had used IVF, and had 12 years education or equivalent. Women aged 14–19.99 years at their first birth and reported low physical activity had 38.9 stillbirths per 1000 live births, compared to the lowest rate at 5.5 per 1000 live births. Conclusion Different groups of women experience vastly different rates of each adverse pregnancy event. We have used simple questions and established reference data that will stratify women into low- and high-rate groups, which may be useful in counselling those who have experienced miscarriage, preterm delivery, or stillbirth, plus women with fertility intent.