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Suffocated prone: the iatrogenic tragedy of SIDS.

Epidemiologic research has shown that prone sleeping is a major risk factor for sudden infant death syndrome (SIDS). In a public health review from Sweden, we explored the historical background of the SIDS epidemic, starting with the view of the Catholic Church that sudden infant deaths were infanticides and ending with the slowly disseminated recommendation of a prone sleeping position during the 1960s, 1970s, and 1980s. The story of the SIDS epidemic illustrates a pitfall of preventive medicine--the translation of health care routines for patients to general health advice that targets the whole population. False advice, as well as correct advice, may have a profound effect on public health because of the many individuals concerned. Preventive measures must be based on scientific evidence, and systematic supervision and evaluations are necessary to identify the benefits or the harm of the measures. The discovery of the link between prone sleeping and SIDS has been called a success story for epidemiology, but the slow acceptance of the causal relationship between prone sleeping and SIDS illustrates the weak position of epidemiology and public health within the health care system.

Asphyxia↗

Male or female, we will create them: the ethics of sex selection for non-medical reasons.

The article examines the arguments for and against the practice of sex selection for non-medical reasons (e.g. parental preferences, family balancing, religious reasons) in light of the new technology of Preimplantation Genetic Diagnosis (PGD). It distinguishes between arguments about the risks to the future child, the mother and society, on the one hand, and the inherent wrongness of the practice as an illegitimate interference in the natural course of reproduction, on the other. The article tries to show that at least in the well defined context of sex selection by PGD, when IVF was performed for independent medical reasons, there is no danger to either the child or the mother and hence that the practice should be permitted. Furthermore, the alleged dangers to society are demonstrated to be mostly illusory. On the one hand, the demographic danger is usually overstated and lacks historical support. On the other hand, the feminist claim that sex selection is necessarily discriminatory is found to be both theoretically and empirically groundless. The article's conclusion is that despite widespread intuitive objection to the practice of sex selection, it can be justified in terms of parental autonomy and falls within the value of family planning. This liberal view does not, however, imply that having a child of the desired sex is the parents' right, nor does it apply to sex selection in later phases of gestation (abortions and obviously, infanticide).

Choice Behavior↗

The safety of newer antidepressants in pregnancy and breastfeeding.

The pregnancy and postpartum periods are considered to be relatively high risk times for depressive episodes in women, particularly for those with pre-existing psychiatric illnesses. Therefore, it may be necessary to start or continue the pharmacological treatment of depression during these two timeframes. Hence, the aim of this review is to examine the effects on the fetus and infant of exposure, through the placenta and maternal milk, to the following drugs: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram, mirtazapine, venlafaxine, reboxetine and bupropion. The teratogenic risks, perinatal toxicity and effects on the neurobehavioural development of newborns associated with exposure through the placenta or maternal milk to these medications need to be carefully assessed before starting psychopharmacological treatment in pregnant or lactating women. In spite of the limitations of some of the studies reviewed, the older selective serotonin-reuptake inhibitors (SSRIs) [as we await further data regarding escitalopram] and venlafaxine seem to be devoid of teratogenic risks. By contrast, the data concerning possible consequences related to exposure to SSRIs via the placenta and breastmilk on neonatal adaptation and long-term neurocognitive infant's development are still controversial. Nevertheless, a number of reports have shown that an association between placental exposure to SSRIs and adverse but self-limiting effects on neonatal adaptation may exist. In addition, the information on both teratogenic and functional teratogenic risks associated with exposure to bupropion, mirtazapine and reboxetine is incomplete or absent; at present, these compounds should not be used as first-line agents in the pharmacological treatment of depression in pregnancy and breastfeeding. Untreated depression is not without its own risks since mothers affected by depression have a negative impact on the emotional development of their children and major depression, especially when complicated by a delusional component, may lead to the mother attempting suicide and infanticide. Consequently, clinicians need to help mothers weigh the risks of prenatal exposure to drugs for their babies against the potential risks of untreated depression and abrupt discontinuation of pharmacological treatment. Given these situations, we suggest that choosing to administer psychopharmacological treatment in pregnant or breastfeeding women with depression will result primarily from a careful evaluation of their psychopathological condition; currently, the degree of severity of maternal disease appears to represent the most relevant parameter to take this clinical decision.

Antidepressive Agents↗

Who decides? The connecting thread of euthanasia, eugenics, and doctor-assisted suicide.

Throughout recorded history, a series of seemingly unrelated ideas have been consistently intertwined: suicide, euthanasia, infanticide, eugenics, genocide and, most recently, the practice termed physician-assisted suicide. From Plato and Hippocrates to a pair of twentieth-century American physicians named Haiselden and Kevorkian, an examination of history shows these disparate notions always involve two troublesome questions: Which lives are not worth living? And who will decide? The same examination of history teaches that separating the worthy from the not worthy is a very dangerous proposition, especially for those whose lives are deemed marginal.

Decision Making↗

Son preference, sex selection, and the "new" new reproductive technologies.

Throughout recorded history, humans have tried to influence the sex of their offspring, through pregnancy injunctions, infanticide, and infant/child neglect. Reproductive technologies developed in the late 20th century allow determination of the sex of the offspring during pregnancy, making "sex selection" through abortion possible. Especially in parts of East and South Asia, sex selection against female fetuses has had dramatic consequences for male/female sex ratios. However, "newer" new reproductive technologies, such as prenatal genetic diagnosis and DNA-weighted semen selection, can now be applied for sex selection; eventually, the latter technology may become easily accessible as a noninvasive method. The prospects of these new technologies for sex selection must be considered in the light of cultural values surrounding son preference / daughter discrimination in many parts of the world, most notably Asia, as well as preferences for a "gender-balanced" family in much of the West. The ethical issues surrounding these technologies, such as the right to life and the equal treatment of female children, are potentially profound, but legislating the appropriate use of these "newest" new reproductive technologies will be difficult.

Asia↗

Effects of postpartum psychiatric illnesses on family planning.

OBJECTIVE: We investigated the relationship between postpartum psychiatric episodes and subsequent family planning. Our hypothesis was that women who had a postpartum illness would plan to have fewer children. METHOD: We conducted a mail survey of members of the self-help group Depression After Delivery (DAD). The membership was asked about changes in family planning after a postpartum illness. Two groups were defined: women who took action to prevent further pregnancies after the illness (CHANGE) and women who did not take action to prevent future pregnancies (NO CHANGE). RESULTS: Among respondents 32 percent changed their family plans after suffering a postpartum illness. Fear of recurrence, effects on the family, treatment costs and severity of the episode manifested by suicide or infanticide attempt, hospitalization, and prescribed medication were reasons given for altering plans. CONCLUSIONS: The postpartum illness dramatically changed some women's reproductive plans. Prevention strategies for these illnesses need to be addressed when women are making decisions about having other children.

Adult↗

Ethical issues in high-risk infant care.

Much controversy exists today regarding the "salvaging" of high-risk infants. There are many ethical concerns surrounding these children. The advancement of technology has had a profound effect on the treatment of preterm infants or infants with deformities. In this article the authors address selected ethical concerns regarding personhood, autonomy, beneficence, parental authority, quality of life, sanctity of life, and optional, obligatory, and wrong forms of treatment. The article begins with an overview of the history of infanticide as well as the history of neonatal intensive care units. Financial and legal issues are also discussed. In addition, the nurse's role in working with high-risk infants and their families is briefly explored.

Beneficence↗

Honor your father and your mother.

While on the one hand there is much mutual love and care in the relationship between parents and their offspring, there may, on the other hand, be also much mutual 'sound and fury', which sometimes is far from 'signifying nothing' (William Shakespeare, Macbeth). Indeed, from conception on, individuals are confronted with parent-offspring conflicts of all kinds. Initially these conflicts concern physiological matters (implantation, nutrition, weaning, etc.), but later in life the accent is on psychological ('you must this', 'you must that', 'don't do that' etc.) and social affairs, and phenomena such as child abuse, infanticide and incest may occur. It is, therefore, certainly not self-evident that children honor their parents. To reinforce their position, parents (societies) may appeal to a 'divine' commandment which helps them make their children suppress any tendency to conflict toward them (and hence to their culture), so that children conform to their parents' norms and values. When such psychological and sociological parent-offspring conflicts are not resolved satisfactorily, it can be suggested, children may (consciously or unconsciously) have aggressive feelings toward their parents: Freud's 'Oedipus complex'. This complex, it is argued, can also be seen as a parent-offspring conflict. Given their biological basis, parent-offspring conflicts can hardly be considered as abnormal. Conflicts between adults and their offspring have always existed and will always exist, simply because it is inherent in our genetic make-up: parents and offspring of sexually reproducing species--humans included--are only about 50% genetically related and hence have different interests at all levels of being. Indeed, parent-offspring conflicts are such stuff as we are made on, and our little life is rounded with its consequences (adapted from William Shakespeare, The Tempest).

Adult↗

Denial of pregnancy: obstetrical aspects.

Between 1987 and 1990 27 women were observed who professed they did not know they were pregnant until term or until premature contractions set in. The aim of this study was to evaluate obstetric history and pregnancy outcomes and assess defence mechanisms and coping strategies which contribute to negation of pregnancy. In 11 women pregnancy was denied until delivery, five of these had breech presentations. In nine women denial ended between 27 and 36 weeks and in seven women between 21 and 26 weeks of gestation. Three of the four fetal deaths that occurred and two of the three cases of prematurity occurred in the last group. There was no infanticide but one woman delivered her infant alone and concealed. Most women reported irregular, sometimes menstruation-like bleedings during pregnancy, three women had taken oral contraceptives during pregnancy. Few women reported actual symptoms of pregnancy, such as nausea and weight gain. Denial of pregnancy is a heterogeneous condition with different meanings and different psychiatric diagnoses in different women. Stressors (e.g. separation from partner, interpersonal problems etc.) do play an important role as precipitating factors for the development of an adjustment disorder with maladaptive denial of pregnancy. There is a fluid transition between conscious coping strategies and unconscious defence mechanisms.

Adult↗

Reduced reproductive efficiency in mice with schistosomiasis mansoni and in uninfected pregnant mice injected with antibodies against Schistosoma mansoni soluble egg antigens.

Female CBA/J mice were infected with approximately 15 cercariae of Schistosoma mansoni and mated with normal syngeneic males 7 weeks later. Uninfected mice were bred in parallel, and both groups were subsequently bred several more times. Pregnancies were documented by formation of vaginal plugs, and daily records were kept concerning the status of the pregnancies, delivery, and offspring. One hundred thirty-two pregnancies in uninfected mice resulted in 101 (77%) viable litters. In contrast, 133 pregnancies in mice infected with S. mansoni lead to 45 (34%) viable litters. The decreased number of viable litters born or raised by infected mothers resulted from maternal death during pregnancy (5%), spontaneous abortion (20%), and infanticide (42%). Observations of multiparous infected mice indicated that this reduced rate of production of viable, surviving offspring was not different in subsequent pregnancies nor influenced by the duration of the infection. At 2 weeks of age, offspring of infected mice weighed significantly less than offspring of equal-sized litters from uninfected mice, but this weight differential was not sustained beyond 2 weeks of age. Subsequent studies compared the effects on uninfected pregnant mice of injections of antibodies against S. mansoni soluble egg antigens (immunoaffinity-purified from sera of mice with 16 week S. mansoni infections) vs. normal mouse immunoglobulin. After repeated injections of these antibodies during multiple pregnancies, lowered reproductive efficiencies (37%) were observed as compared to parallel studies of pregnant mice injected with normal mouse immunoglobulin (67%).

Animals↗

Management of ectopia vesica in Ibadan: an 8-year review.

CONTEXT: The management of children with ectopia vesica is intricate and complex. Repair of the bladder soon after delivery is desirable, particularly in our environment as the social stigma associated with such an anomaly can lead to child abandonment or infanticide. OBJECTIVE: To report our experience in the management of children with ectopia vesica at the University College Hospital (UCH), Ibadan, over an 8-year period. STUDY DESIGN, SETTING AND SUBJECTS: All children who presented at the UCH, Ibadan between January 1995 and December 2002 with ectopia vesica had the bladder closed primarily. The children that presented between 1995 and 1998 had the symphysial diastasis approximated with no. 1 nylon suture, while those that presented subsequently had the muscle and fascial layer closed with a darning suture of no. 1 nylon. RESULT: A total of 13 children presented with ectopia vesica during the period of the study. The bladder was closed in all cases. Abdominal wound dehiscence occurred less frequently in patients who had darning suture approximation of the muscle and fascial layer, compared with those who had simple symphysial approximation with nylon suture. CONCLUSION: The result of immediate bladder closure in children with ectopia vesica can be satisfactory in this environment. There is a need for continuing experience in the management of these children to improve outcome.

Bladder Exstrophy↗

Improving perinatal mental health care.

Pregnancy and the puerperium can bring many emotional, physical and social changes to the mother, her partner and the rest of the family. While many mothers find these changes--such as the experience of pregnancy or the addition of a new member to the family--joyous, some do not share these positive feelings and often undergo emotional upheaval resulting in severe biopsychosocial distress. This period of distress does not only subject the mother and her family to increased risk of psychological crisis, mental illness and developmental disturbances, but may also, if untreated, result in the fatalistic outcomes of infanticide or suicide. In this article, the author calls for a more robust, co-ordinated and interdisciplinary approach to perinatal mental health services.

Female↗

Abortions in Byzantine times (325-1453 AD).

The legislation and the texts of the most important medical writers of Byzantine times have been studied with reference to abortions, the ethical aspect of this social and medico-legal problem, the theological and the scientific approach. The theoretical basis of the permanent and absolute condemnation of all kinds of abortions except those permitted for medical reasons, is greatly influenced by the spirit of Christianity. In fact, religion supported the view that the reception of the seed in the uterus and the conception of the embryo means the beginning of life and accepted that the foetus is already a living creature. All legislation of Byzantium from the earliest times also condemned abortions. Consequently, foeticide was considered equal to murder and infanticide and the result was severe punishments for all persons who participated in an abortive technique reliant on drugs or other methods. The punishments could extend to exile, confiscation of property and death. The physicians followed the tradition of Ancient Greece, incorporated in the Hippocratic Oath, representative of the ideas of previous philosophers. According to this famous document, it is forbidden them to give a woman "an abortive suppository". The Orthodox faith reinforced this attitute, protective of every human life. On the other hand, the Church and the State accepted selective abortion based on medical data, such as prevention of dangerous conditions in pregnancy or anatomical difficulties involved. In conclusion, science, church and legislation had a common attitude to matters concerning abortion and this fact reveals an effort to apply a fair policy for the rights of the embryo and the protection of human life in Byzantine society.

Abortion, Spontaneous↗

[Not Available].

The pain of childbirth, whose description often link it closely to death phantasies, paralyzing fright and the fear of being torn apart, was integrated into a complex network of meanings in which ghosts and demons, personal misdemeanour, guilt, purification and initiation all had their place. Each individual interpretation of pain was supported by a variety of cultural meanings related to symbolic, metaphoric, popular religious, gender-specific, social and emotional significances. The meaningful components of these various meanings were not so much analyzed and discussed as incorporated into a code of conduct and creative practical application. On the one hand, by means of collective care and a staged joint overcoming of the pain, they robbed the experience of pain of its isolating prong and of the feeling of being at the mercy of a body both physically and imaginarily defenceless. At the same time they provided model interpretations for a variety of contexts; up as far as the mid-eighteenth century statements made while suffering from the pain of childbirth were assigned a high degree of truth; when assessing the quality and quantity of pain at childbirth, 'natural' pain was considered as initiation into motherhood, while excessive pain was seen as a punishment for concrete individual faults (violation of rules for pregnant women due to give birth) and a complete lack of pain as an indication of not wanting or not being able to be a mother (infanticides).

Female↗

[A study of the organizing process of the modern midwifery system in Yamagata Prefecture focusing on the enactment of "Midwifery Regulation" in the 32th year of Meiji].

The Japanese modern midwifery system was provided at the start by the "Medical regulation" in the 7th year of Meiji and was organized to national unity by the Imperial Ordinance "Midwifery Regulation" in the 32th year of Meiji (1899). During these twenty-five years, Hokkaido and each of the prefectures enacted their own "Midwifery Regulation" to conform with the "Midwifery Regulation," and they organized the original midwifery system. This study focuses on the Yamagata Prefecture and midwifery system in the Tohoku district, and considers the organizing process of the system. Because the Yamagata district continued the Edo Period custom of infanticide, the Yamagata prefectual administration maintained strict control of that custom. At the same time it repeatedly enacted and revised the "Mid-wifery Regulation" to adjust it to the conditions of farm and mountain villages. Finally, it established the original "Registered Midwife System" in the 22th year of Meiji. That organizing process was classified into four stages. The present study shows that the system was not contradictory to the Imperial Ordinance "Midwifery Regulation" enacted in the 32th year of Meiji, which was amended to the unified national midwife system.

History, 19th Century↗

[Value of a consultation center and crisis intervention in addressing psychiatric disorders in the perinatal period].

The Psychiatry department of the University Hospital Centre of Lille has developed, over the last 10 years, a treatment network for psychiatric disorders during pregnancy or in the post-partum period. There are liaison consultations in the maternity department, screening and management of psychopathological disorders in the perinatal period, training of midwives, support of patients seeking genetic counselling, collaboration with teams providing "medically-assisted procreation", etc. For severe disorders of the post-partum period (severe depression, serious alteration of mother-child interaction, puerperal psychosis), the Psychiatry department has a specialized unit where 3 "mother-child" groups can be admitted. This unit is particularly effective if the patients and their family understand this healthcare system and stick to it to a certain extent. Even if improvements are always possible, cases in which situations occur as an emergency, are when dysfunctions are most frequently seen. On 7th December 1998, a Crisis Intervention Unit (CIU) was created with 15 short-term beds, for stays up to 72 hours. The CIU was opened in the Psychiatry department, close to the main Accident and Emergency department, with 2 aims: firstly to provide a setting and resources for a number of emergency psychiatric situations, and secondly to provide a place and time for crisis situations which we admit to the unit, with a view to facilitating interaction and to propose in certain cases a process of crisis intervention, which later continues on an outpatient basis. After being open for a year, the CIU has proved to be an improvement to all of the healthcare services which are available. It should be noted that the situations which need highly specialized resources in such a short time, are those which cause the most acute problems. This is at times when the emergency services network, with its internal logic, require another network based on a different logic, that the interface problems are at their most acute. The situations reported here, which require a fluid interface between the emergency services and the "mother-child" networks, are examples. We report 3 clinical situations, which illustrate 3 possibilities of action: the first, in which 2 successive stays in the CIU allowed an admission to the "mother-child" unit in satisfactory conditions, the second, in which overall management was based on hospitalization in the Obstetrics department and several visits to our Unit, and the last one, in which the whole medico-psycho-social approach was set up after a single stay of 3 days. Since the opening of Crisis Intervention Unit, around 1,000 patients have been treated there; 37 were women with difficulties with their pregnancy, 17 of whom required direct intervention by the "mother-child" team. The contexts were: 5 prenatal depressions, 4 post-partum depressions, 3 cases of hyperemesis gravidarum, 5 rejections of pregnancy and/or situations at risk of infanticide. The almost constant suicidal risk should be noted, or even attempted suicide, at the time of admission to the CIU. The other 20 women had psychopathological disorders linked to sterility, medically-assisted pregnancy, termination of pregnancy or pregnancy in women suffering from long-term somatic illnesses (insulin-dependent diabetes, lupus, etc.). When a psychopathological episode occurs during pregnancy, it is essential to preserve the developing relationship with the child in an intermediate place, in a healthcare perspective and to prevent any future impairment of the quality of the mother-child relationship by the psychiatric disorder. The Crisis Intervention Unit is not an emergency "mother-child" unit. Other French experiences have been reported, an example being mother-baby hospitalization in a crisis centre. The aim of our interventions is not the same, and our local context, together with the availability of a healthcare network on different floors, which is specific and close-by, allows this approach. Also, the contribution of Liaison Psychiatry in emergency situations should not be minimized. It is necessary to work in collaboration with the obstetricians. In fact, the chance to work with us was given by asking for a hospitalization in the Obstetric unit, during the prepartum period of pregnancies with a psychiatric risk. This way of proceeding allows somatic monitoring in hospital to be performed, whenever the risk run by the mother and/or the child requires it. This "analogue" procedure, however preventative it may be, does not always allow specific treatment of the psychiatric disorders to be given, despite liaison psychiatry interventions. Our interventions are not a specialized "mother-child" unit, or a substitute for Liaison Psychiatry, but they are specifically aimed at the context of the crisis. Obviously, it is precisely this dimension of the crisis which makes the other types of management temporarily unsuitable. This new working framework, with the simple possibility of admitting women and interacting with them in a crisis situation, with the aid of the competence of "mother-child" teams, most often seems to allow an alternative to hospitalization in the Psychiatry department, at the same time keeping up quality management of problems linked to the pregnancy or post-partum period. The specificity of the CIU, with its project of taking the special psychiatric vulnerability of pregnancy into account, makes sure that the psychopathological aspects of the crisis situation and the physiological aspects of adaptation reactions to the perinatal period are not neglected, but that are respected by this type of interaction/intervention.

Adult↗

[Medical and legal involvement of the antisocial aggressive behaviour of the under-age person].

The aggressive behaviour of the child, both the physical and the verbal one, appears due to the conflicts between the environments in which the child is incorporated, but also due to the difficulty of accommodation in a new one. The aggressive behaviour of the child could be a part of the normal way of the child development (for obtain the respect of the group or the autonomy in front of his parents or other persons), but also could be one of the elements, which denote the personality of the juvenile delinquent. The factors which are associated with the aggressive behaviour are: the disorganized family, with many children, the poor family, the alcoholism or drug-dependence of the parents, penal acts of the family members, but also factors which depends on the child: the age between 15 and 17 years old, male, sex head injuries, mental diseases. The facts produced by them could be: theft, burglary, robbery, arson, hitting, rape, sexual perversity, maiming, infanticide, murder.

Adolescent↗

Women--an endangered species.

Throughout India and China, South Korea and Taiwan, Pakistan and Malaysia, the same sentiment recurs: "The birth of girl is an occasion for gloom, not cheer, for bitterness, not pleasure." In all these countries "patriarchal traditions and social stigmas" make females the unwanted sex, reports Asiaweek. The tragic result: prenatal gender tests are flourishing. And for many women, if the test indicates a female, they abort. In India, sex tests and abortions are legal, cheap and readily available. Some 1500 sex-tested girls are aborted annually in Bombay alone. In China, abortions are legal, but gender tests strictly forbidden. Says one official: We cannot afford to let people know what sex the fetus is because all the girls would be aborted." Yet the numbers of baby girls in China have been reduced--and illicit gender tests and female infanticide are considered partly to blame. In South Korea, gender tests have been banned and most abortions are illegal, but "clandestine tests" are available, and according to the government some 30,000 pregnancies are terminated annually. The number of aborted females is not known, but birth ratios have shown "an alarming swing towards males" in recent years. Can laws and education change the social attitudes against girls in these Asian countries? Indian activist Vibhuti Patel, a lobbyist for stronger controls over sex-testing, hopes so. She urges a "continuous campaign" to fight the "centuries-old values" that encourages gender tests. Says Patel: Nothing less than the very survival of women is at stake."

Abortion, Induced↗