| 1. |
- Åhman, Annika, et al.
(author)
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Midwives’ and obstetricians’ views on appropriate obstetric sonography in Norway
- 2018
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In: Sexual & Reproductive HealthCare. - : Elsevier. - 1877-5756 .- 1877-5764. ; 16, s. 1-5
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Research review (peer-reviewed)abstract
- Introduction: The primary aim of this study was to investigate midwives' and obstetricians' views on how many ultrasound examinations should be part of standard care during pregnancy in Norway.Material and methods: This study is a part of a larger study, the CROss-Country Ultrasound Study (CROCUS), an international investigation of midwives' and obstetricians' experiences of and views on the use of ultrasound. We distributed 400 questionnaires to respondents in all five health regions in Norway: 40 to municipal midwives, 180 to midwives working in hospitals and 180 to obstetricians. The questionnaire included specific questions about the appropriate number of examinations during pregnancy, examinations without medical indication, non-medical ultrasound, commercialisation and safety.Results: The response rate was 45%. Of the respondents, 58% reported satisfaction with the offer of one scheduled ultrasound examination during pregnancy, as recommended in the Norwegian guidelines. Health care professionals who used ultrasound themselves were significantly more likely to want to offer more ultrasound examinations: 52% of the ultrasound users wanted to offer two or more ultrasound examinations vs. 16% of the non-users (p < .01). The majority of obstetricians (80%) reported that pregnant women expect to undergo ultrasound examination, even in the absence of medical indication.Conclusion: The majority of Norwegian health care professionals participating in this study supported the national recommendation on ultrasound in pregnancy. Ultrasound users wanted to offer more ultrasound examinations during pregnancy, whereas non-users were generally content with the recommendation. The majority of respondents thought that commercialisation was not a problem at their institution, and reported that ultrasound is often performed without a medical indication. The ultrasound users thought that ultrasound is safe.
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| 2. |
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| 3. |
- Björkander, Sophia, et al.
(author)
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Staphylococcus aureus-derived factors induce IL-10, IFN-gamma and IL-17A-expressing FOXP3(+)CD161(+) T-helper cells in a partly monocyte-dependent manner
- 2016
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In: Scientific Reports. - : Springer Science and Business Media LLC. - 2045-2322. ; 6
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Journal article (peer-reviewed)abstract
- Staphylococcus aureus (S. aureus) is a human pathogen as well as a frequent colonizer of skin and mucosa. This bacterium potently activates conventional T-cells through superantigens and it is suggested to induce T-cell cytokine-production as well as to promote a regulatory phenotype in T-cells in order to avoid clearance. This study aimed to investigate how S. aureus impacts the production of regulatory and pro-inflammatory cytokines and the expression of CD161 and HELIOS by peripheral CD4(+)FOXP3(+) T-cells. Stimulation of PBMC with S. aureus 161:2-cell free supernatant (CFS) induced expression of IL-10, IFN-gamma and IL-17A in FOXP3(+) cells. Further, CD161 and HELIOS separated the FOXP3(+) cells into four distinct populations regarding cytokine-expression. Monocyte-depletion decreased S. aureus 161:2-induced activation of FOXP3(+) cells while pre-stimulation of purified monocytes with S. aureus 161:2-CFS and subsequent co-culture with autologous monocyte-depleted PBMC was sufficient to mediate activation of FOXP3(+) cells. Together, these data show that S. aureus potently induces FOXP3(+) cells and promotes a diverse phenotype with expression of regulatory and pro-inflammatory cytokines connected to increased CD161-expression. This could indicate potent regulation or a contribution of FOXP3(+) cells to inflammation and repression of immune-suppression upon encounter with S. aureus.
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| 4. |
- Edvardsson, Kristina, et al.
(author)
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Norwegian obstetricians' experiences of the use of ultrasound in pregnancy management : a qualitative study
- 2018
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In: Sexual & Reproductive HealthCare. - : Elsevier. - 1877-5756 .- 1877-5764. ; 15, s. 69-76
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Journal article (peer-reviewed)abstract
- Objective: To explore obstetricians' experiences and views of the use of obstetric ultrasound in clinical management of pregnancy. Methods: A qualitative interview study was undertaken in 2015 with obstetricians (N = 20) in Norway as part of the CROss Country Ultrasound Study (CROCUS). Results: Three categories developed during analyses. 'Differing opinions about ultrasound and prenatal diagnosis policies' revealed divergent views in relation to Norwegian policies for ultrasound screening and prenatal diagnosis. Down syndrome screening was portrayed as a delicate and frequently debated issue, with increasing ethical challenges due to developments in prenatal diagnosis. 'Ultrasound's influence on the view of the fetus' illuminated how ultrasound influenced obstetricians' views of the fetus as a 'patient' and a 'person'. They also saw ultrasound as strongly influencing expectant parents' views of the fetus, and described how ultrasound was sometimes used as a means of comforting women when complications occurred. The complexity of information and counselling' revealed how obstetricians balanced the medical and social aspects of the ultrasound examination, and the difficulties of 'delivering bad news' and counselling in situations of uncertain findings. Conclusion: This study highlights obstetricians' experiences and views of ultrasound and prenatal diagnosis in Norwegian maternity care and the challenges associated with the provision of these services, including counselling dilemmas and perceived differences in expectations between caregivers and expectant parents. There was notable diversity among these obstetricians in relation to their support of, and adherence to Norwegian regulations about the use of ultrasound, which indicates that the care pregnant women receive may vary accordingly.
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| 5. |
- Haileselassie, Yeneneh, et al.
(author)
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Lactobacilli Regulate Staphylococcus aureus 161:2-Induced Pro-Inflammatory T-Cell Responses In Vitro
- 2013
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In: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 8:10
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Journal article (peer-reviewed)abstract
- There seems to be a correlation between early gut microbiota composition and postnatal immune development. Alteration in the microbial composition early in life has been associated with immune mediated diseases, such as autoimmunity and allergy. We have previously observed associations between the presence of lactobacilli and Staphylococcus (S.) aureus in the early-life gut microbiota, cytokine responses and allergy development in children. Consistent with the objective to understand how bacteria modulate the cytokine response of intestinal epithelial cell (IEC) lines and immune cells, we exposed IEC lines (HT29, SW480) to UV-killed bacteria and/or culture supernatants (-sn) from seven Lactobacillus strains and three S. aureus strains, while peripheral blood mononuclear cells (PBMC) and cord blood mononuclear cells (CBMC) from healthy donors were stimulated by bacteria-sn or with bacteria conditioned IEC-sn. Although the overall IEC response to bacterial exposure was characterized by limited sets of cytokine and chemokine production, S. aureus 161: 2-sn induced an inflammatory response in the IEC, characterized by CXCL1/GROa and CXCL8/IL-8 production, partly in a MyD88-dependent manner. UV-killed bacteria did not induce a response in the IEC line, and a combination of both UV-killed bacteria and the bacteria-sn had no additive effect to that of the supernatant alone. In PBMC, most of the Lactobacillus-sn and S. aureus-sn strains were able to induce a wide array of cytokines, but only S. aureus-sn induced the T-cell associated cytokines IL-2, IL-17 and IFN-gamma, independently of IEC-produced factors, and induced up regulation of CTLA-4 expression and IL-10 production by T-regulatory cells. Notably, S. aureus-sn-induced T-cell production of IFN-gamma and IL-17 was down regulated by the simultaneous presence of any of the different Lactobacillus strains, while the IEC CXCL8/IL-8 response was unaltered. Thus these studies present a possible role for lactobacilli in induction of immune cell regulation, although the mechanisms need to be further elucidated.
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| 6. |
- Holmlund, Sophia, et al.
(author)
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Health professionals' experiences and views on obstetric ultrasound in Rwanda : A cross-sectional study
- 2018
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In: PLOS ONE. - : PUBLIC LIBRARY SCIENCE. - 1932-6203. ; 13:12
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Journal article (peer-reviewed)abstract
- Objectives: Implementation of ultrasound in antenatal care (ANC) in low-income countries has been shown to increase pregnant women’s compliance with ANC visits, and facilitate detection of high-risk pregnancies. In Rwanda, as in other low-income countries, access to ultrasound has increased significantly, but lack of training is often a barrier to its use. The aim of this study was to investigate Rwandan health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.Methods: A cross-sectional questionnaire study was undertaken between November 2016 and March 2017, as part of the CROss Country UltraSound Study (CROCUS). Data were collected at 108 health facilities located in both rural and urban areas of Rwanda, including provincial, referral, district and private hospitals as well as health centres. Participants were obstetricians (n = 29), other physicians (n = 222), midwives (n = 269) and nurses (n = 387).Results: Obstetricians/gynecologists/other physicians commonly performed ultrasound examinations but their self-rated skill levels implied insufficient training. Access to ultrasound when needed was reported as common in hospitals, but available to a very limited extent in health centres. The vast majority of participants, independent of health profession, agreed that maternity care would improve if midwives learned to perform basic ultrasound examinations.Conclusions: Barriers to provision of high quality ultrasound services include variable access to ultrasound depending on health facility level and insufficient skills of ultrasound operators. Physicians in general need more training to perform ultrasound examinations. Implementation of a general dating ultrasound examination seems to be a relevant goal as most health professionals agree that pregnant woman would benefit from this service. To further improve maternity care services, the possibility of educating midwives to perform ultrasound examinations should be further explored.
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| 7. |
- Holmlund, Sophia, et al.
(author)
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Health professionals’ experiences and views on obstetric ultrasound in Vietnam : a regional, cross-sectional study
- 2019
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In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 9
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Journal article (peer-reviewed)abstract
- Objectives: Obstetric ultrasound is an important part of antenatal care in Vietnam, although there are great differences in access to antenatal care and ultrasound services across the country. The aim of this study was to explore Vietnamese health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.Design: A cross-sectional questionnaire study was performed as part of the CROss Country UltraSound study.Setting: Health facilities (n=29) in urban, semiurban and rural areas of Hanoi region in Vietnam.Participants: Participants were 289 obstetricians/ gynaecologists and 535 midwives.Results: A majority (88%) of participants agreed that ‘every woman should undergo ultrasound examination’ during pregnancy to determine gestational age. Participants reported an average of six ultrasound examinations as medically indicated during an uncomplicated pregnancy. Access to ultrasound at participants’ workplaces was reported as always available regardless of health facility level. Most participants performing ultrasound reported high-level skills for fetal heart rate examination (70%), whereas few (23%) reported being skilled in examination of the anatomy of the fetal heart. Insufficient ultrasound training leading to suboptimal pregnancy management was reported by 37% of all participants. ‘Better quality of ultrasound machines’, ‘more physicians trained in ultrasound’ and ‘more training for health professionals currently performing ultrasound’ were reported as ways to improve the utilisation of ultrasound.Conclusions: Obstetric ultrasound is used as an integral part of antenatal care at all selected health facility levels in the region of Hanoi, and access was reported as high. However, reports of insufficient ultrasound training resulting in suboptimal pregnancy management indicate a need for additional training of ultraso
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| 8. |
- Holmlund, Sophia, 1980-
(author)
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Health professionals’ experiences and views related to obstetric ultrasound in Rwanda and Vietnam
- 2019
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Doctoral thesis (other academic/artistic)abstract
- BackgroundObstetric ultrasound has become an indispensable part of maternity care in high-income countries, where it is universally used for screening, diagnostic and surveillance purposes. In low-income countries, insufficient numbers of trained health professionals’ is commonly a barrier to obstetric ultrasound use. Globally, health professionals’ encounter complex clinical situations in which rapid technical improvements in fetal surveillance and pregnancy interventions are components that influence clinical decisions, thereby implicating maternal and fetal health outcomes.AimsThe overall aim of this thesis was to explore health professionals’ experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects, in two low-to-middle-income countries with different characteristics, cultures, religions and health care systems.MethodsStudy I (Rwanda) and Study III (Vietnam) are based on focus group discussions in which data were analysed using content analysis. Study I included six focus group discussions with 23 midwives recruited from six different hospitals in the area of Kigali and in the Southern province. Study III included four focus group discussions with 25 midwives working at three different hospitals in the Hanoi area. Study II (Rwanda) and Study IV (Vietnam) are cross-sectional studies using descriptive statistics, Pearson’s chi-square test and logistic regression analyses. A questionnaire, including items based on the results from previous qualitative studies, was used as the data collection tool. For Study II, health professionals (midwives, nurses, obstetricians, other physicians; N=907) working at 108 health facilities representing all provinces of Rwanda were recruited. Study IV constituted a regional sample of 824 health professionals (midwives, obstetricians/gynecologists) working at 29 health facilities in urban, semi-urban and rural parts of Hanoi, Vietnam.Main findingsObstetric ultrasound was regarded as a highly valued tool for pregnancy management in Rwanda as well as in Vietnam (Papers I–IV). In Rwanda, access to ultrasound was described as poor, especially for women living in rural areas (Paper I). In contrast, access to obstetric ultrasound was described as being very high in all health facilities in urban, semi-urban and rural areas of Hanoi (Paper III & Paper IV). In Rwanda, if a pregnancy was considered normal, obstetric ultrasound was not routinely performed (Paper I), while pregnant women in Vietnam were reported as undergoing several further ultrasound examinations in addition to the three examinations recommended by the Ministry of Health (Paper III). Midwives in Rwanda expressed a need to be trained in ultrasound, particularly those working at health centres in rural areas where ultrasound was rarely available (Paper I). A majority of health professionals (91%) also agreed that maternity care in Rwanda would improve if midwives were qualified to perform basic ultrasound examinations (Paper II). Sub-optimal pregnancy management due to a lack of or insufficient ultrasound training was reported by health professionals in both Rwanda (65%; Paper II) and Vietnam (37%; Paper IV). The use of obstetric ultrasound without medical indication was described as a troubling phenomenon, especially in Vietnam, where participants also reported that pregnant women sometimes replaced antenatal care surveillancewith ultrasound examinations (Paper III).ConclusionObstetric ultrasound plays a significant role in pregnancy management in Rwanda, although access varies significantly. The findings indicate that physicians in Rwanda are in need of additional formal ultrasound training in order to increase the quality of ultrasound surveillance and to improve maternal and fetal health outcomes. To increase ultrasound access for all pregnant women in Rwanda, midwives could potentially be trained to perform basic ultrasound examinations. In the Hanoi area of Vietnam, ultrasound is a well-integrated tool in pregnancy management and access was high. However, overuse and commercialisation of obstetric ultrasound examinations were described as common and need to be addressed to achieve adequate allocation of resources. The rapid development of technology in maternity care needs to be accompanied by medical guidelines stating the appropriate indications for ultrasound surveillance.
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| 9. |
- Holmlund, Sophia, et al.
(author)
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Improved maternity care if midwives learn to perform ultrasound : a qualitative study of Rwandan midwives' experiences and views of obstetric ultrasound
- 2017
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In: Global Health Action. - : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 10:1
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Journal article (peer-reviewed)abstract
- Background: Obstetric ultrasound has become an indispensable part of antenatal care worldwide. Although the use of ultrasound has shown benefits in the reduction of maternal and foetal morbidity and mortality, it has also raised many ethical challenges. Because of insufficient numbers of midwives in Rwanda, uncomplicated pregnancy care is usually provided by nurses in local health centres. Obstetric ultrasound is generally performed by physicians at higher levels of healthcare, where midwives are also more likely to be employed.Objectives: To explore Rwandan midwives’ experiences and views of the role of obstetric ultrasound in relation to clinical management, including ethical aspects.Methods: A qualitative study design was employed. Six focus group discussions were held in 2015 with 23 midwives working in maternity care in rural and urban areas of Rwanda, as part of the CROss Country Ultrasound Study (CROCUS).Results: Obstetric ultrasound was experienced as playing a very important role in clinical management of pregnant women, but participants emphasised that it should not overshadow other clinical examinations. The unequal distribution of ultrasound services throughout Rwanda was considered a challenge, and access was described as low, especially in rural areas. To increase the quality of maternity care, some advocated strongly for midwives to be trained in ultrasound and for physicians to receive additional training. In general, pregnant women were perceived both as requesting more ultrasound examinations than they received, and as not being satisfied with an antenatal consultation if ultrasound was not performed.Conclusions: Obstetric ultrasound plays a significant role in maternity care in Rwanda. Increasing demand for ultrasound examinations from pregnant women needs to be balanced with medical indication and health benefits. Training of midwives to perform obstetric ultrasound and further training for physicians would help to address access to ultrasound for greater numbers of women across Rwanda.
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| 10. |
- Holmlund, Sophia, et al.
(author)
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Sub-optimal use of ultrasound examinations may result in underperformance of Vietnamese maternity care : A qualitative study of midwives’ experiences and views
- 2020
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In: Sexual & Reproductive HealthCare. - : Elsevier. - 1877-5756 .- 1877-5764. ; 24
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Journal article (peer-reviewed)abstract
- Objective: To explore Vietnamese midwives’ experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects.Methods: Using a qualitative design, content analysis of focus group discussions with midwives (N = 25) working at Departments of Obstetrics and Gynecology at three hospitals in urban, semi-urban and rural parts of Hanoi were performed.Results: Obstetric ultrasound was reported as being a highly valuable tool, although replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication was perceived as troubling. Participants generally viewed the fetus as a human being already at an early stage of pregnancy. However, when complications occurred, the pregnant woman’s health was mostly prioritised.Conclusion: Although the use of ultrasound has many benefits during pregnancy, replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication is concerning and needs to be addressed. There is also a need to communicate the benefits of adequate antenatal care to pregnant women and caution about the non-beneficial use of repeated ultrasound examinations without medical indication. Additionally, non-medical ultrasounds consume limited healthcare resources and its use needs to be better regulated in Vietnam.
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