Minggu, 22 Maret 2009

A Midwifery Model of Care for Childbearing Women at High Risk: Genuine Caring in Caring for the Genuine

Marie Berg, RNM, MN, MPH, PhD

Abstract
According to this paper's synthesis of research, three constituents of ideal midwifery care emerge. First, a dignity-protective action takes place in a midwife's caring relationship with a childbearing woman at high risk and includes mutuality, trust, ongoing dialogue, enduring presence, and shared responsibility.
Secondly, the midwife's embodied knowledge is based on genuineness to oneself and consists of theoretical, practical, intuitive, and reflective knowledge. Finally, nurse-midwives have a special responsibility to balance the natural and medical perspectives in the care of childbearing women at high risk, especially by promoting the woman's inborn capacity to be a mother and to give birth in a natural manner. This midwifery model of care is labeled “Genuine Caring in Caring for the Genuine.” Here, the word genuine expresses the nature of midwifery care, as well as the nature of each pregnant woman being cared for as a unique individual.

Introducing

The culture focusing on risk rather than the person has followed in the wake of modernity (Giddens, 1991) and influences the organization of health care, including maternity care. With maternity care's goal to reach optimal security and well-being, the childbearing woman is subjected to increased attention and care when the presence of risk factors or complications is apparent for herself or her child. Childbearing is defined here as the period during pregnancy, childbirth, and the early postpartum phase.

The proportion of childbearing women defined as being at high risk is constantly increasing. Today, conditions that previously did not allow women to go through pregnancy and childbirth with a healthy outcome are manageable, owing to medical developments including diagnostic and therapeutic procedures directed to both the woman and her fetus. New obstetric risk factors are constantly being identified. Additionally, interventions—especially of a technical nature—are continuously increasing. However, it is a question of doubt whether the greater frequency of high-risk women corresponds to a real increase. The reason is probably that modern maternity care is organised from a biomedical perspective, which is committed to detecting and treating diseases and complications, and deals with risks even when risks are relatively low. This perspective increases the frequency of interventions. It may also contribute to the fact that the definition of the concepts “normal pregnancy and delivery” has been narrowed over the years. In a Swedish study, only half of childbearing women were found to have a “normal” pregnancy and birth according to current definitions (Berglund & Lindmark, 2000). If normal childbirth should be defined as occurring without medical technique such as pain relief and pharmaceutical induction of labor, the proportion of normal childbirth may be less than 10% (Socialstyrelsen, 2001; World Health Organization, 1996).

Pregnant women labeled as high risk are exposed and vulnerable (Berg, Lundgren, & Lindmark, 2003). Emotionally, they are more anxious, worried, and ambivalent about their pregnancies (Gupton, Heaman, & Cheung, 2001; Hatmaker & Kemp, 1998; Mercer, 1990). Greater total risk is related to lower perceived self-efficacy, which has a negative effect on risk appraisal and emotions (Gray, 2001). Feelings of failure may be paramount (Jones, 1986), and the giving or sacrificing of oneself for the child is intensified. Instead of relying on themselves, the women try to diminish anxiety by turning over their bodies and their experiences to the external technological world. The need for support from others, especially from health-care professionals, is increased (Stainton, McNeil, & Harvey, 1992).

It has been suggested that the risk dimension in health science causes the practice of midwifery to be ever more narrowly circumscribed (Downe, 1996). Ever since Sweden's first midwifery regulation in 1711, Swedish midwives are expected to be responsible for normal childbearing women, while physicians are responsible for childbearing women at high risk (Lundqvist, 1940; Milton, 2001). Even in the care of women at risk, Swedish midwives, who are always registered nurses, have a responsible role. They are specialized in various risk-related fields where they are given delegated responsibility. However, it is important to gain more knowledge about the general, overall features and value of nurse-midwives' care of women at high risk and to investigate the basic motives and meanings in the contexts of midwifery care. Here, caring is defined as “good and ideal caring” and, thus, separated from uncaring, which is defined as a lack of caring or care that causes suffering (Eriksson, 1994, 2001; Halldórsdóttir, 1996). In order to promote ideal caring, the purpose of this study was to describe the essence of the midwifery model of care for women at high risk during childbearing.

Method
A research synthesis of three qualitative interview studies (of which the author served as primary investigator) was performed with the purpose of creating a general structure of the phenomenon known as “midwifery caring of childbearing women at high risk.” High risk is defined here as it was in the original three studies. All three previous studies are published. In the first study (I), a phenomenological study, 10 women with any kind of complicated childbirth were interviewed about their experience of childbirth (Berg & Dahlberg, 1998). In the second study (II), a hermeneutic phenomenological study, the researchers performed 44 interviews with 14 women who had diabetes type 1 during the course of their pregnancy (Berg & Honkasalo, 2000). The intent of this study was to search for the essential core of these women's experiences. In the third study (III), a phenomenological study, the researchers interviewed 10 midwives from four Swedish hospitals caring for pregnant women at high risk (Berg & Dahlberg, 2001). All three studies focused on the everyday world of experience (i.e., lifeworld experience) without prior application of any theoretical framework. (See Tables 1 and 2 for an overview of each study.) The method of data collection and analysis for each study is detailed elsewhere.

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Maternal Antibodies, Childhood Infections, and Autoimmune Diseases

Rolf M. Zinkernagel, M.D.
Recovery from an infectious disease or an encounter with a nonmicrobial antigen is usually followed by the development of resistance to that disease or a rapid and heightened immune response on reexposure to the antigen.
These effects, termed immunologic memory, are explainable by the generation of increased numbers of precursor lymphocytes during the initial encounter and the induction of a special "memory" quality of individual T and B cells.1,2,3,4 Alternatively, memory could result from the persistence of low levels of antigen in lymphoid tissues, which keep T cells activated and maintain protective amounts of antibodies.5,6 In this article, I will discuss how the antibody repertoire of the mother influences the susceptibility of her child to infectious agents and autoimmune diseases.7,8,9,10 Her immune repertoire reflects not only her cumulative immunologic memory but also the protective immunity present in her neighbors — herd immunity. I will argue that a mother's immunologic memory can influence the ability of early childhood infections to serve as physiological vaccines not only in her own child but also in generations to come.

Transferable Maternal Immune Protection

The period shortly before and after birth may be the key to understanding immunologic memory.6,8,9,10 During this phase of development the immune system is relatively incompetent. For this reason, transferable maternal immunologic memory is essential for the survival of the fetus, newborn, and infant. Moreover, the attenuation of infection by transferable maternal immunity permits microbial agents to immunize the child under optimal conditions (this key function of transferred maternal antibodies is also essential for the survival of birds and fish). Although maternal antibodies can protect the offspring, maternal T cells cannot, because of differences in tissue antigens (HLA in particular) between the mother and her fetus. These differences raise the possibility of an attack on the fetus by maternal T cells, but this danger is avoided by the absence of HLA antigens in areas of placental contact11,12; conversely, the risk that fetal lymphocytes will attack the mother is likewise low, because of the incompetence of fetal T cells. Thus, antibodies alone serve to transmit the mother's immunologic experience to the fetus and infant; these, and not T cells, protect the child while its own immune system matures.

The importance of the protection afforded by maternal antibodies is clearly seen in agammaglobulinemia.8,9,13 Infants incapable of producing immunoglobulins are protected by maternal antibodies for the first 3 to 12 months after birth (Figure 1). Maternal IgG antibodies enter the fetal circulation through the placenta, whereas IgA antibodies in milk remain largely within the infant's gut, where they influence the intestinal flora. How can antibody levels in plasma and milk be kept high enough to protect the child?9,10 Various mechanisms cause a constant boosting of the immune responses by microbes. Examples are periodic reinfection by polioviruses,14 the persistence of low levels of disabled measles virus,15,16 and controlled subclinical infection by persistent hepatitis B virus (HBV).17

Protective antibodies against all relevant infectious agents cannot be produced during pregnancy without harming the fetus. In fact, infections that threaten the survival of the fetus or newborn are rare not only because of transferred maternal immunity but also because of herd immunity. Herd immunity reflects the equilibrium between susceptible and immune individuals in a population or species.5 It reduces the probability that an infected person will spread the infection widely to susceptible, uninfected people. By evolutionary necessity, women must become immune to life-threatening infectious agents before they become pregnant if they are to transfer their protective antibodies to the next generation during pregnancy. Therefore, the outcome in a given child of any of the classic infectious diseases of childhood depends on the mother's history of infectious disease before pregnancy — her accumulated immunologic experience — which in turn is partly dependent on herd immunity 5,14,18.

The Host–Parasite Equilibrium

It is not surprising that all protective vaccines induce long-lasting neutralizing-antibody responses. Current vaccines that are not sufficiently protective include those against mycobacteria, most parasites, and herpesviruses and human papillomaviruses. Neutralizing antibodies alone are not sufficient to eliminate infections with these kinds of microbes, since these agents can persist outside lymphoid tissues in neurons, epithelial cells, or granulomas. Moreover, such infectious agents are often only weakly cytopathic, if at all, and the infections they cause are chronic and are usually not lethal. In almost all these instances, immunologic control of the invader requires both antibodies and T cells.19,20,21,22,23,24,25 Chronic HBV infection is an exception, because neutralizing antibodies alone protect efficiently; a carrier mother who lacks neutralizing antibodies readily transfers the virus to her infant during labor and delivery.

In many cases, the microbe and its host are in a delicate equilibrium: an ongoing immune response results in low levels of the infectious agent, and a low level of the microbe helps maintain protective immunity. This balanced state of chronic infection and concomitant immunity is accompanied by a heightened degree of macrophage activation by cytokines (e.g., interferon-{gamma} and tumor necrosis factor) and activation of natural killer cells.22,23 The result is the enhancement of innate immunity — the initial nonspecific disposal of infectious agents. For some agents, such as mycobacteria and many parasites, a chronic low-level infection may represent an exquisite coevolutionary balance of mutual benefit.

The Role of Hygiene

The neutralizing antibodies that a mother transfers to her fetus may not always eliminate a particular infectious agent, but they do attenuate infection during the initial months of life, thereby creating optimal conditions for the natural immunization of the child against that agent as a result of infection. However, the development during the past century of high standards of hygiene in the developed world has decreased the level of exposure to common infectious agents during childhood to the extent that many infections now occur only after maternal antibodies in the child have waned. Moreover, hygienic conditions may hamper the induction and maintenance of protective maternal antibodies before pregnancy. This situation will be aggravated if vaccination programs are inadequate and thus reduce opportunities to boost immunity to important pathogens. The failure to maintain high levels of neutralizing antibodies will eventually diminish herd immunity, thereby increasing the risk of the spread of an infectious agent, and reduced levels of neutralizing antibodies during pregnancy in one generation will influence the initial host–parasite equilibrium in succeeding generations. The latter change will, over time, increase susceptibility to serious childhood infections among populations and exacerbate other infections that are currently mild.

Transferred maternal immune protection can have an important influence on emerging or new infectious diseases in susceptible populations. The excessive morbidity and mortality of emerging infections may be due largely to the lack of transferred maternal antibodies during infancy, when they could attenuate the infection.14,26 For this reason, the relation between maternal immunity and emerging infections may be of general importance now and in the future. If the transmission of immunologic memory from mother to offspring does indeed influence disease susceptibility in the next generation, then the use of vaccines that are as efficient as wild-type infections in evoking protective immunity, at least during the reproductive period, may be crucial, because they will have a species-wide influence.

The experience with poliovirus may be instructive here (Figure 2). 14 Because levels of neutralizing antibodies against poliovirus are determined by infection and vaccination, better hygiene has delayed the occurrence of natural infection with the virus in both the developed and developing worlds.14 The consequence of this delay is that antibodies in maternal serum and milk (poliovirus infections occur through the gut) do not protect adequately against infection for a sufficient length of time; hence, infections late in childhood are not attenuated and can result in severe, acute disease. Similar problems may be anticipated in the case of measles, mumps, and other infections, for which levels of maternal antibody are insufficient to attenuate late infection in children. The effectiveness and influence of many types of childhood vaccinations across more than one or two generations have not yet been established.26,27,28,29,30,31,32,33 Goals of global vaccination and breast-feeding of infants are therefore relevant not only in the developing world but also in developed countries, and vaccines must be improved, many more vaccines must be developed, and vaccination schedules must be stringently followed.

Maternal Immunity and Autoimmune Diseases

With the advent of the era of increased hygiene, we humans have entered a dramatic new environment. The characteristics of an infection differ depending on whether it occurs early in life or later, after maternal protection has disappeared. Moreover, maternal protection influences infections with typical pathogens as well as with agents that are not usually life-threatening, particularly gastrointestinal and respiratory viruses that are not cytopathic or only poorly cytopathic. If such an infection is not noticed clinically, then the immune response it evokes may well be regarded as an autoimmune disease (Figure 2).
Let us assume that type 1 diabetes or cardiomyopathies are caused by coxsackievirus B, at least in some patients. Let us also postulate that levels of maternal antibodies are insufficient to protect the child against this virus.34 Since coxsackievirus B infections are not usually lethal, the virus may spread from the gastrointestinal tract to other sites, including pancreatic islet cells or cardiac myocytes, depending on the degree of protection offered by the mother's neutralizing antibodies in plasma or milk (Figure 2). Coxsackievirus B can be cytopathic to islet cells or indirectly cause their destruction in the course of an antiviral immune response. In any case, prolonged release of islet-cell or myocyte antigens into lymphoid tissues may induce autoimmune T-cell and autoantibody responses that eventually become self-perpetuating, particularly if lymph follicles form in the target organ.35 Perhaps this kind of mechanism explains the increased incidence of juvenile diabetes, cardiomyopathies, and other autoimmune diseases in industrialized countries in the 20th century.

The host–parasite relations that evolved over thousands of years, when life expectancy was 30 years or less, may have changed too rapidly in the past 100 years. Perhaps the prolongation of life, coupled with the occurrence of many fewer infectious diseases during childhood, will, on balance, have disadvantages that are revealed not only later in life but also in coming generations.

Conclusions

The protection against infection afforded by vaccination is one of the great successes of medicine. Vaccines have prevented more deaths than any other medical measure so far. Protective immunity is about survival within an evolutionary context. It is particularly important early in life, because the immune system is immature at birth. Successful vaccines induce optimal levels of neutralizing antibodies against acutely cytopathic agents. In contrast, long-lasting cell-mediated immunity is much more difficult to induce through vaccination: the required balance between attenuation and persistent stimulation of effector T cells by microbial antigens has not yet been achieved with vaccines. The aim should be to develop strategies that create a persistent low level of infection and of infectious antigens in order to maintain sufficient levels of activated T cells and IgG antibodies. This may not be easy to achieve, but the development of DNA-based vaccines may bring us closer to the goal.


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Rabu, 11 Maret 2009

Hasil Poling 25/01/09 - 11/03/09

Akhirnya polling yang ditancapkan diblog ini menunjukkan hasil yang cukup signifikan, dimana dari pertanyaan yang diajukan kepada pengunjung blog ini yaitu: "Apakah anda setuju jika tugas akhir seperti KTI/Skripsi dihilangkan dan diganti dengan Studi Kasus?" diperoleh sebanyak 47 pengunjung yang memiliki jawaban berbeda-beda, yakni 21 pengunjung (44%) menyatakan setuju jika tugas akhir seperti KTI/Skripsi dihilangkan dan diganti dengan studi kasus, 16 (34%) menyatakan tidak setuju, 8 pengunjung (17%) menyatakan ragu-ragu dan 2 pengunjung (4%) tidak tahu.

Hasil tersebut memperlihatkan bahwa hampir separuh pengunjung blog ini menyatakan ketidakpuasannya terhadap adanya tugas akhir seperti Karya Tulis Ilmiah (KTI) atau Skripsi, kemungkinan alasan pertama yang dapat digambarkan adalah masih minimnya materi tentang Metodologi Penelitian yang diperoleh oleh mahasiswa, baik keterbatasan/kemampuan kognitif, afektif maupun konatif setiap mahasiswa. Alasan kedua adalah kurangnya informasi mendalam mengenai seberapa penting tugas akhir tersebut, sehingga masih banyak kalangan mahasiswa (bahkan tidak menutup kemungkinan para rekan dosen) yang mengganggap bahwa tugas akhir seperti KTI/Skripsi tidak layak untuk dimasukkan sebagai salah satu mata kuliah (maaf agak sedikit ngelantur...).

Sedangkan jika dilihat hasil jawaban pengunjung yang menjawab tidak setuju, ragu-ragu dan tidak tahu lebih sedikit dari yang menjawab setuju, maka saya menyimpulkan bahwa (dilihat berdasarkan polling) KTI/Skripsi sebaiknya dihapus. Namun jika dilihat berdasarkan grafik ShinyStat di bawah ini:



Maka KTI/Skripsi sebaiknya tidak dihapus/dihilangkan. Karena meskipun rata-rata per hari pengunjung blog ini adalah mahasiswa, namun sangat sedikit yang memberikan jawaban 'Ya' dibandingkan 'Tidak'. Artinya 44% pengunjung yang menyatakan 'Ya' tidak semua dari kalangan mahasiswa melainkan dari blogger umum atau sejenis.

Jumat, 06 Maret 2009

Tiga Langkah Mudah Menyelesaikan KTI/Skripsi Anda!

Langkah pertama cari judul dengan tema apa saja yang anda miliki.
Kedua Ikuti langkah-langkah ini.
dan Ketiga kami siap melayani anda selama masa bimbingan.

Kamis, 05 Maret 2009

OLAH DATA (OD) SPSS ONLINE

PENGOLAHAN DATA (OD)
(Menggunakan Program Statistik SPSS)
Atas banyaknya permintaan untuk pengolahan data KTI dan Skripsi,

saat ini kami melayani jasa pengolahan data khusus untuk kesehatan dengan program statistik SPSS. Yaitu:
(1) Skripsi Kedokteran
(2) Skripsi Keperawatan
(3) Skripsi FKM (Semua Peminatan)
(4) Skripsi Kebidanan
(5) KTI Keperawatan
(6) KTI Kebidanan
(7) KTI Kesehatan Lingkungan
(8) KTI Analis Kesehatan
(9) KTI Farmasi
(10) KTI Gizi

Caranya sangat mudah, silahkan ikuti petunjuk di bawah ini:
(1) Kirim SMS dengan format REG333 spasi OD spasi NAMA spasi E-MAIL spasi NO HP ANDA. Contoh: (REG333 OD RENIAGUSTIN august_girl@yahoo.com 0812698777xx)
(2) Setelah registrasi anda kami terima, silahkan mengirim data mentah (tabulasi excel) atau proposal lengkap anda melalui alamat e-mail kami di ryan75800@gmail.com.
(3) Sebelum kami mengirimkan hasil OLAH DATA anda, anda diharuskan mentransfer Rp.50.000,- ke Bank Mandiri Norek: 114-00-0598247-8 a/n: Rudi Yanto. Setelah anda mentransfer konfirmasikan melalui sms ke No HP kami di 0813 798 19 333.
(4) Jika anda telah melakukan langkah 1-3, maka kami akan segera mengirimkan olahan data melalui alamat e-mail anda


Selasa, 03 Maret 2009

Kampanye Damai Pemilu Indonesia 2009

Sejak awal terus terang saya tidak suka dengan hal yang berbau "POLITIK", namun karena mendengar bahwa ada bonus-nya (alias hadiah) coba-coba ah ikutan... mumpung gratis.
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Jadi di Kontes SEO ini tidak hanya mengejar kata kunci, kita sekalian ikut mensukseskan Kampanye Pemilihan Presiden Langsung 2009. Mudah-mudahan Kampanye Damai Pemilu Indonesia 2009 dapat terwujud.

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Kontes SEO ini berlangsung kurang lebih 3 bulan, cukup waktu buat para peserta yang sedang sama-sama belajar seo, untuk melakukan optimasi di Data Center Indonesia (www.google.co.id).

Selamat berlomba para peserta Kontes SEO dengan Keyword "kampanye damai pemilu Indonesia 2009".

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