Week 1 of pregnancy – what happens

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This is the first in a series of blogs covering the 40 weeks of pregnancy.

The first week of pregnancy occurs during your last menstrual period. The egg and sperm that will eventually join (or fertilise) to become your baby have not yet fully matured.

Therefore, in week 1 of the pregnancy we explore the maturation of the female egg and male sperm, and then briefly review the future home of the pregnancy, the uterus.

Week 1 of pregnancy – The female egg

Interestingly, a woman’s eggs start their life whilst she is herself an unborn baby, within her own mother’s uterus. As many as 20 million eggs begin to form, but most will degenerate before birth.

As the baby girl is first cuddled by her parents, only 700,000 to 2 million eggs remain within the newborn ovaries.

Yet there is further culling. By the time the young girl reaches the cusp of puberty, and has her first menstrual period, only 400,000 eggs remain in the ovaries.

These are the “potential eggs”, the ones capable of responding to the influx of hormones released from the anterior pituitary in the female brain following puberty, that will enable them to mature and possibly be released from the ovary (ovulation – see week 2 for details). The released egg may then be joined with a sperm (fertilisation – see week 3 for details) to begin the pathway of human development.

Week 1 of pregnancy – Recruiting the egg

So how is one particular egg selected from the awaiting 400,000?

Each month, a hormone in the anterior pituitary of the brain called follicle stimulating hormone (FSH) is released. This hormone acts on the ovary and recruits a small batch of eggs from the waiting thousands, and “activates” them.

Why are some eggs selected each month and not others?

We don’t really know.

There are many theories. One theory is that the activated eggs, by random chance, were more advanced than their peers, and had greater capacity to respond to FSH. Maybe they had a better blood supply, more receptors,or more streamlined internal processes. All we know is that every month, a small group of 5-12 eggs respond to FSH and are recruited for the next menstrual cycle.

Competition continues.

Even amongst the activated 5-12 eggs, only one will eventually ovulate. This selected egg, more advanced by random chance, will become the egg available for fertilisation.

Of course, every now and then a few dead heats emerge in the race and two eggs mature at equal rates and are ovulated, paving the way for non identical twins. Rarer still, three or more eggs may ovulate, leading to the birth of triplets and higher order multiples.

Week 1 of pregnancy -The male sperm

Sperm also take a long time to develop, with the process starting at male puberty.

The male testes begin to secrete the hormone testosterone at puberty. The hormone has many effects, one of which is to promote the growth of the testes and the start of spermatogenesis, or the manufacture of sperm.

A mature sperm consists of a head, a mid piece and a tail. The head contains the nuclei with the genetic material that will become the father’s genetic contribution to the new baby. The mid piece contains the “motor” of the sperm, where energy is generated to enable to sperm to swim through the female reproductive tract and fertilise with the egg. The tail of the sperm contains the propulsion system, that enables the sperm to propel forward on its journey.

Spermatogenesis commences at puberty and continues until a man dies. Sperm are produced in waves, which are synchronised. It takes 64 days to develop a mature sperm.

Week 1 of pregnancy – Recruiting the sperm

After being created in the testes, mature sperm are stored in the epididymis, a coiled duct near the testes. During sex, sperm are ejected into the vas deferens, a communicating channel, supplied with nutritious fluids, and then ejaculated.

During a single ejaculation as many as 200 million sperm may be released. However, only a few hundred sperm survive the journey from the upper vagina, through the cervix and uterine cavity and gain entry into the fallopian tube. The fallopian tube is the ultimate destination of the sperm, as it is the site where fertilisation of the female egg will occur.

Interestingly, the final step to mature sperm doesn’t happen in the male. It happens in the female. As sperm enter the fallopian tube, a chemical reaction between the sperm and female fallopian tube secretions change the sperm and it develops the ability to penetrate an egg and fertilise it. This final step is called “Capacitation”.

Sperm are able to survive and fertilise an egg in the fallopian time for 1-3 days after sex.

Week 1 of pregnancy – Within the uterus

In the first week of pregnancy, the women has her period (or menstrual cycle), shedding the uterine lining (endometrium).

Cramps may accompany the bleeding of the menstrual cycle, as arteries in the uterine lining constrict and deprive the lining tissues of oxygen. This process releases chemicals such as prostaglandins, that trigger painful cramps in some women.This is why medication that blocks the actions of prostaglandins, can help the pain and discomfort of menstrual cramps, which in severe cases is called “primary dysmenorrhoea”.

As the first week ends, the arteries in the uterus begin to open and grow again, sending oxygen, nutrients and hormones to enable a new endometrium to grow over the next month.

Week 1 of pregnancy – Summary

In the first week of pregnancy a woman has her period, or menstrual cycle. The old lining of the uterus is shed, and a new lining begins to grow.

In the mother, a hormone called follicle stimulating hormone is released by the brain, and activates a small group of 5-12 eggs within her ovary.

In the father, sperm were created over the preceding 64 days, and are now stored in the epididymus. Of the 200 million sperm may be released during ejaculation. However, only a few hundred will complete the journey from vagina to the fallopian tube, and undergo capacitation, to enable fertilisation of an egg.

For more reading

Brskov AG. Differentiation of the mammalian embryonic gonad. Physiol Rev 1986, 66: 71.

Clermone Y. Kinetics of spermatogenesis in mammals: seminiferous epithelium cycle and spermatogonial renewal. Physiol Rev 1972; 52:198.

Larsen WJ. Human Embryology 3rd edition. Churchill Livingston, 2002, Pennsylvania.

Wasserman PM. Elements of mammalian fertilisation Vol 1 Basic concepts 1991, CRC Press, Boca Raton, FL.

Larsen WJ. Human Embryology 3rd edition. Churchill Livingston, 2002, Pennsylvania

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40 weeks of pregnancy – overview

IMG_0077When you see your doctor or midwife, they will talk about your pregnancy in terms of “weeks”. Your estimated date of delivery is based on the “40th week”. A term pregnancy is one where the baby is born between “weeks 37 to 42”.

This series within pregnancyandwomenshealth will inform you about the growth and development of your baby in each week of pregnancy.

If you read an embryology textbook things rapidly become complicated. Hopefully this blog will explain development in a simpler way. Then again, maybe not. It really does get complicated at times, especially around weeks 8-20. My colleagues and I have observed many medical and midwifery students develop glazed eyes once we embark on fetal folding. But that comes later. For now, start at week 1 of pregnancy – what happens…

 

 

 

 

 

 

 

Five reasons we are closer to preventing preterm birth

 

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Most pregnant women assume they will deliver a healthy baby at term. However, 8% of women deliver their baby preterm (before 37 weeks of pregnancy). This figure is higher in the developing world and in certain subgroups of women with medical conditions affecting their health or that of their baby.

Impact of preterm birth

Preterm birth can devastate families. Seeing your baby in an intensive care unit, wondering if they will survive, and if so, whether there has been lifelong damage to their vision, hearing, movement or capacity to learn is every parent’s nightmare.

Sadly, in many cases involving early preterm birth (less than 34 weeks of pregnancy), fears are justified. World-wide, preterm birth remains the leading cause of death and disability in children under five years of age (1,2,3,4).

However, recent developments in our understanding of preterm birth now offer hope to families.

This blog briefly covers a few simple interventions that have been proven to lower rates of preterm birth and some other strategies under investigation.

Causes of preterm birth

Nearly half of all preterm births are spontaneous. The other 50% of cases arise due to a need for elective early delivery due to a pregnancy complication. These may include hypertensive disorders, multiple pregnancy, placental bleeding and diabetes.

The greatest hopes to reduce the devastation of preterm birth lies in discovering why so many babies spontaneously deliver early.

New technologies, spontaneous preterm birth and infection

One common link identified in many spontaneous preterm births is infection (3). Our published systematic review identified infection as a common final pathway in many cases of preterm birth and as a causal factor in long term neurological damage in children (3).

Infection leads to preterm birth in a complex way (5).

Bacteria can enter the intra-uterine space directly by ascending from the vagina. They can also access the intra-uterine space by the blood stream or rarely through invasion from a source of infection elsewhere in the abdominal space or by being directly inoculated following an invasive procedure such as an amniocentesis. (5,6).

Early detection and treatment of infection can reduce preterm birth. Meta-analyses of antibiotic administration to women with bacterial vaginosis have found significant decreases in the rate of preterm birth  (7).

However, many bacteria cannot be cultured, so identifying infectious causes of preterm birth can be difficult. However, the use of innovative new technologies is creating new opportunities.Our research group have been employing 16S rRNA gene technology to identify bacterial taxa in the vagina of women with complicated pregnancy. Our recent case reports have identified unusual bacterial taxa such as Acinetobacter, Bacteroides, Hafnia, Campylobacter and Haemophilus as being implicated in extremely preterm, very preterm and preterm births (8-10)

There is hope modern technologies will help unravel the infectious precursors and causes of preterm birth.

Fish oil to prevent preterm birth

Another large research project we have underway is called ORIP (11). This is one of the largest randomised research trials in the world in pregnancy and is designed to reduce early preterm birth using a nutritional supplement called DHA that is found in some fish oils.

Our previous trial DOMINO (12) involving more than 2500 women, found DHA supplements in pregnancy were associated with lower rates of spontaneous early preterm birth. In order to formally determine if DHA can prevent early preterm birth, we have embarked on the ORIP trial. Currently we have recruited over 3000 women into ORIP. Eventually we plan to recruit more than 5500 women to confirm whether DHA supplements are effective.

If you want to read more, we have published a review article on this subject (11).

Immunisation

It is important to also understand that some very simple measures significantly reduce the risk of preterm birth.

The first of these is immunisation against influenza virus infection in pregnancy.

Sadly, many pregnant women are either not offered vaccination, or else decline vaccination (13). These women remain vulnerable to a severe viral infection that can precipitate preterm birth.

QUIT Stopping smoking

Another simple and obvious fix to preterm birth is to quit smoking. Smoking is a leading independent risk factor for preterm birth. It can act as a direct risk, and also indirectly, through damage to the placenta, resulting in poor growth of the baby or bleeding that means babies must be delivered early to avoid death in utero.

All pregnant women who smoke should ask for help to stop smoking. Many services are available to help – just ask.

Cervical length screening and treating with progesterone

Another new strategy to prevent preterm birth is to measure the length of the cervix using ultrasound. This measurement can be easily undertaken when women have their 18-20 week ultrasound of the baby’s anatomy.

If the cervix is shorter than expected, there is an increased risk of preterm birth (14). A number of studies have linked the length of the cervix in mid pregnancy to the risk of preterm birth. For population purposes, women with a cervix of 15mm or less at 18 to 24 weeks gestation, have a 50% chance of having a preterm delivery at less than 33 weeks of gestation (14-17).

Women identified with a short cervix on ultrasound can be offered intervention with progesterone therapy or cerclage to reduce the risk of preterm birth.

The evidence for progesterone therapy is promising. Several trials have reported a reduction in preterm birth in women with a short cervix (14-17). The largest trial was called the PREGNANT trial.  In this trial 30,000 women were screened for cervical length and women with a short cervix were prescribed  vaginal progesterone gel (90 mg). There was a  45% reduction in the rate of early preterm birth (18).

Cervical cerclage has also been reported to be effective in treating women with short cervical length (19,20).Cervical cerclage is a small surgical procedure where a tape is inserted and tied around the cervix to strengthen the cervix and prevent premature dilation.

Summary

Preterm birth is a terrifying reality for many families. However, we now have several promising interventions that can hopefully reduce this devastating outcome. Any woman who has had a preterm baby should seek help early in her next pregnancy in order to take advantage of emerging therapies.

References

1. Lawn, J. E., Cousens, S. & Zupan, J. (2005). 4 million neonatal deaths: When? Where? Why? Lancet 365, 891-900.

2. Goldenberg, R. L., Culhane, J. F., Iams, J. D. & Romero, R. (2008). Preterm birth 1: Epidemiology and causes of preterm birth. Lancet 371, 75-84.

3. Shatrov, J. G., Birch, S. C., Lam, L. T., Quinlivan, J. A., McIntyre, S. & Mendz G. L. (2010). Chorioamnionitis and cerebral palsy. Obstet Gynecol 116, 387-392.

4. Hussein, J., Ugwumadu, A, & Witkin, S. S. (2011). Editor’s choice. Brit J Obst Gynaecol 118, i-ii. doi: 10.1111/j.1471-0528.2010.02829.x

5. Kaakoush NO, Mendz GL, Quinlivan JA. New techniques to characterize the vaginal microbiome in pregnancy. AIMS Microbiology 2016, 2(1);55-68.

6. Romero, R, & Mazor, M. (1988). Infection and preterm labor. Clin Obstet Gynecol 31, 553-584.

7. Smaill. F. (2001). Antibiotics for asymptomatic bacteriuria in pregnancy. Chocrane Database Syst. Rev 2, CD000490.

8. Mendz, G. L., Petersen, R., Quinlivan, J. A. & Kaakoush, N. O. (2014). Potential involvement of Campylobacter curvus and Haemophilus parainfluenzae in preterm birth. Br Med J Case Rep pii, bcr2014205282. doi: 10.1136/bcr-2014-205282.

9. Kaakoush, N. O., Quilivan, J. A. & Mendz, G. L. (2014). Bacteroides and Hafnia Infections associated with chorioamnionitis and preterm birth. J Clin Gynecol Obstet 3, 76-79.

10. Quinlivan, J. A., Kaakoush, N. O. & Mendz, G. L. (2014). Acinetobacter species associated with spontaneous preterm birth and histological chorioamnionitis. Br J Med Med Res 4, 5293-5297.

11. Quinlivan JA, Pakmehr S. Fish Oilsas a Population Based Strategy to Reduce Early Preterm Birth. Reproductive System and Sexual Disorders 2013; 2: 116. http://dx.doi.org/10.4172/2161-038X.1000116

12. Makrides M, Gibson RA, McPhee AJ, Yelland L, Quinlivan J, Ryan P, DOMInO Investigative Team, Effect of DHA supplementation during pregnancy on maternal depression and neurodevelopment of young children: a randomized controlled trial. JAMA: The Journal Of The American Medical Association, 2010 Oct 20; Vol. 304 (15), pp. 1675-83; PMID: 20959577 ISSN: 1538-3598.

13. White SW, Petersen RW, Quinlivan JA. Pandemic (H1N1) 2009 influenza vaccine uptake in pregnant women entering the 2010 influenza season in Western Australia MJA 2010; 193 (7): 405-407

14. Hassan SS, Romero R, Berry SM et al. Patients with an ultrasonographic cervical lengh < or = 15 mm have nearly 50% risk of early spontaneous preterm delivery. Am J Obstet Gynecol 2000; 82(6): 1458-1467

15. Heath VC, Southall TR, Souka AP et al. Cervical length at 23 weeks of gestation: prediction of spontaneous preterm delivery. Ultrasound Obstet Gynecol1998; 12(5),312-317.

16. Grimes D, Berghella V. Cervical length and prediction of preterm delivery. Curr Opin Obstet Gynecol 2007; 19(2): 191-195.

17. Romero R. Vaginal progesterone to reduce the rate of preterm birth and neonatal morbidity: a solution at last. Women’s Health 2011; 7(5): 501-4.

18. Hassan SS, Romero R, Vidyadhari D et al. Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomised, double blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2011; 38(1): 18-31.

19. Bennett P. Preterm Labour. In: Dewhurst’s Textbook of Obstetrics & Gynaecology, Blackwell Publishing, 2008.

20. Alfirevic Z, Owen J, Carreras Moratonas E et al. Vaginal progesterone, cerclage or cervical pessary for preventing preterm birth in asymptomatic singleton pregnant women with history of preterm birth and a sonographic short cervix. Ultrasound Obstet Gynecol 2012 18 sept epub ahead of print. DOI : 10.1002/uog.12300.

 

 

 

 

 

 

 

 

 

 

What’s new about gestational diabetes?

IMG_0675.JPGGestational diabetes is a common medical complication of pregnancy (1-5). It is an important condition as failure to diagnose and treat gestational diabetes can lead to poor pregnancy outcomes, and in severe cases, fetal death in utero may occur. However, with accurate diagnosis and management, outcomes are excellent.

There have been some changes in the way gestational diabetes is diagnosed and managed.

1. The diagnosis of gestational diabetes has changed

The original diagnosis of gestational diabetes was developed nearly 50 years ago (3). In 2010 there was a recommendation by the International Diabetes and Pregnancy Study Groups that the diagnosis of gestational gestational diabetes should change (4,5). The recommendation arose from a study called HAPO (Hyperglycaemia and pregnancy outcomes)(5). The HAPO tidy correlated blood sugar levels in pregnancy with poor outcomes in mothers and babies and formulated new cut off values for blood sugar levels in pregnancy (4,5).

Six years later, not all countries and clinicians have adopted the new recommendations. However, our research suggests the new diagnostic criteria are associated with improved outcomes (6).

Gestational diabetes is diagnosed on a blood test performed between 24 and 30 weeks of pregnancy. The diagnostic test is called a glucose tolerance test and involves an overnight fast, followed by a fasting blood sugar test. Women then drink a measured amount of glucose syrup and 1 and 2 hours later have further blood sugar tests.

The new diagnostic criteria are (4):

fasting level greater than 5 mmol/l

1 hour sugar level greater than 10mmol/l

2 hour sugar level greater than or equal to 8.5mmol/l.

2. Importance of diet

The importance of diet in the management of gestational diabetes has never been clearer.

The majority of women who adopt a diabetic diet will require no additional treatment.

Many maternity units will refer women diagnosed with gestational diabetes to a dietician for advice on a diabetic diet. However, information is also widely available on the Internet, and in libraries and from diabetes associations.

Monitoring blood sugar levels in conjunction with diet is important as no two people respond to a food source in the same way.

As a clinician I have seen women eat the same meal and one will have a normal blood sugar level and the second an elevated level. Therefore it is important to monitor your sugar levels along with your diet to assess how your body responds to particular foods. This will help you identify safe foods and those you should avoid.

Blood sugar levels are monitored using a finger prick test. Machines to record the blood sugar level may be hired from chemists.

3. Medication for gestational diabetes

If medication is required (about 30% of women) then traditionally this would have been Insulin.

However, increasingly Metformin, an oral medication, is prescribed. There are good safety studies for Metformin.

Your specialist will advise whether Metformin, Insulin or a combination of the two is required.

4. Monitoring the pregnancy

Because gestational diabetes is associated with an increased risk of pregnancy complications, additional monitoring of the pregnancy is required. This is usually in the form of ultrasound examinations and fetal cardiotocograph tests (CTGs).

Ultrasound examinations are ordered to assess fetal growth and placental health. The pathology in gestational diabetes arises in the placenta. High blood sugar levels damage the delicate blood vessels in the placenta, causing sugar to flood across into the baby. The baby’s developing hormone system responds to the high sugar level by releasing growth factors. This causes abnormal growth of the baby which is detected on ultrasound as an increase in the abdominal circumference.

In more severe cases, the delicate placental blood vessels are so damaged that the placental circulation shuts down, and the baby ends up being starved of nutrients, and becomes growth restricted.

Medical staff will usually plot the developing baby’s growth on a chart to assess if the overall growth of the baby, and the relative growth of the head, abdomen and femur bones are in proportion.

The ultrasound examination will also inform medical staff about blood flow in the placenta and if growth is abnormal, will record the blood flow within the baby’s head. Blood flow readings are called doppler studies. The results of doppler studies can assist in guiding  delivery management.

Cardiotocograph tests may also be ordered to monitor the well being of the developing baby. We are currently finalising a study to investigate the optimal strategy to use CTGs in pregnancy complicated by gestational diabetes. However, our preliminary results suggest the tests should be reserved for pregnancies where medication is required in addition to diet, or where other complications have been noted.

5. Timing of delivery

There is no agreed gestation at which women with gestational diabetes should deliver. However, many people now believe that if the pregnancy has been managed with diet alone, and blood sugar levels have been controlled, and the baby’s growth is normal, then the pregnancy can progress to term and normal birth without the need for intervention. However, many centres still offer delivery at 40 weeks.

If the pregnancy is complicated because medication was required in addition to diet, or the baby’s growth was abnormal, or a CTG was abnormal, then earlier delivery is required.

6. Follow up after delivery

All women who were diagnosed with gestational diabetes should have a follow up assessment within six months of delivery. This should involve a repeat glucose tolerance test. In our clinic, we also screen for thyroid and cholesterol abnormalities. We have found women with gestational diabetes have an elevated risk of developing type 2 diabetes, thyroid and cholesterol problems (7).

Sadly, many women fail to receive postnatal follow up and a valuable opportunity to improve their long term health through early diagnosis of chronic disease is wasted.

In summary

Gestational diabetes is easy to diagnose and manage. Most women will only require dietary changes, monitoring of blood sugar levels and some additional investigations.

It is important to screen and treat as otherwise pregnancy complications can harm mother and baby.

References

1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes care 2009; 32(S1): S62-S67.

2. Metzger BE, Coustan DR: The organizing committee. Summary and recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes care 1998; 21(S2): B161-B167.

3. O’Sullivan JB, Mahan CM. Criteria for oral glucose tolerance test in pregnancy. Diabetes 1964;13: 278-285.

4. International Association of Diabetes and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of Hyperglycemia in pregnancy. Diabetes Care 2010; 33: 676-682.

5. Metzger BE, Lowe LP, Dyer AR et al. The HAPO Study Cooperative Research Group. Hyperglycemia and Adverse pregnancy outcomes. N Engl J Med 2008; 358: 1991-2002.
6. Silbartie P, Quinlivan JA. Implementation of the International Association of Diabetes and Pregnancy Study Groups Criteria: Not Always a Cause for Concern. Journal of pregnancy 12/2015; 2015(2):1-5. DOI: 10.1155/2015/754085

7. Quinlivan JA, Lam D. Cholesterol abnormalities are common in women with prior gestational diabetes. J Diabetes Metab 2013; 4(4): 255. doi: 10.4172/2155-6156.10000255.

Strong fathers, strong families: How to beat depression

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There has been considerable attention given to postnatal depression and its impact upon the health of mothers and babies.  Less attention has been given to the effect of depression in fathers. However, research evidence suggests depressed fathers adversely impact upon family health to a similar degree to maternal depression (1,2,3).

Depression in fathers is a major health problem

A recent meta-analysis estimated depression in fathers impacted upon one in ten families (1). As with depression in mothers, the adverse effects included poorer outcomes in children across a range of areas (2).

Depression in fathers was also associated with adverse financial and emotional outcomes for the entire family (2). As with maternal depression, depressed fathers reported poorer engagement with their children (3).

How can we help depressed fathers?

Employment and education help fight depression in fathers.

Employment has been shown to protect fathers from depression. Having a job is a stabilising force, and provides meaning to the father’s life as the person who brings home a family income (3,4,5). Employment is most protective against depression in disadvantaged families. The vicious cycle of  unemployment and unrecognised or untreated depression results in fathers distancing themselves from children (3,4,5). High levels of stress, aggravation and violence can occur (3,4,5).

Education can also protect fathers from depression, especially in families facing socioeconomic disadvantage (6,7).

Helping teenage fathers

We recently explored whether employment and education to a vulnerable group of fathers would reduce depression.

We selected fathers in the setting of a maternal teenage pregnancy as our target group.

We already knew depression was particularly common in teenage fathers (8,9,10,11,12). However, most studies had come from regions where employment and educational opportunities are poor.

What would happen if we could help these vulnerable fathers engage in employment or education. Would the same levels of depression be seen?

The answer is no!

Findings from the Australian Father’s Study

When we assessed depression in teenage fathers in Western Melbourne, we found the same high rates of depression reported elsewhere in the world (13). Western Melbourne has poor opportunities for employment and education for teenage fathers.

In contrast, when we evaluated rates of depression in fathers in the setting of teenage pregnancy in northern Perth, where educational and employment opportunities were greater, we found rates of depression similar to those for other older fathers (14).

If you would like to read our full paper please click here.

So it appears that vulnerable groups of fathers who are able to secure employment or further education, are likely to experience lower rates of depression.

Social determinants of health

Our findings, and those of others, reinforce how important social factors are to the health of families (16). Higher rates of many diseases are found in areas of social disadvantage. The link with depression in fathers is a strong and obvious association, but many other more subtle associations exist.

As medical diagnostic and therapeutic intervention costs rise well above the rate of inflation each year, it pays to reflect on how strengthening the economy, enabling people to find work, and implementing public health approaches may represent better value for money to achieve healthy families.

References

  1. Paulson JF, Bazemore SD. Prenatal and postpartum depression in fathers and its association with maternal depression; A meta-analysis. Journal of the American Medical Association 2010; 303: 1961-1969
  2. Ramchandani P, Stein A, Evans J, O’Connor TG; ALSPAC Study Team. Paternal depression in the post- natal period and child development: a prospective population study. Lancet 2005; 3: 2201- 2205.
  3. Bronte-Tinkew J, Moore KA, Matthews G, Carrano J. Symptoms of major depression in a sample of fathers of infants; Sociodemographic correlates and links to father involvement. Journal of Family Issues 2007; 28: 61-99.
  4. Dooley D, Prause J, Ham-Rowbottom KA. Underemployment and depression: longitudinal relationships. Journal of Health and Social Behaviour 2000; 41: 421-436.
  5. Taris TW, Bok IA, Calje DG. On the relation between job characteristics and depression: A longitudinal study. International Journal of Stress Management 1998; 5: 157-167
  6. Alio AP, Mbah AK, Grunsten RA, Salihu HM. Teenage pregnancy and the influence of paternal involvement on fetal outcomes. Journal of Pediatric and Adolescent Gynecology 2011; 24: 404-409.
  7. Holden GW, Nelson PB, Velasquez J, Ritchie KL. Cognitive, psychosocial, and reported sexual behavior differences between pregnant and non-pregnant adolescents. Journal of Adolescence 1993; 28: 557-72.
  8. Bauldry S. Variation in the protective effect of higher education against depression. Journal of Society and Mental Health 2015; 5: 145-161.
  9. Jeffery T, Luo K, Kueh B, Petersen RW, Quinlivan JA. Australian Father’s Study: What influences paternal engagement with antenatal care? The Journal of Perinatal Education 2015; 24(3):181-187(7)
  10. Quinlivan JA, Tan LH. Domestic violence, single parenthood, and fathers in the setting of teenage pregnancy. Journal of Adolescent Health 2006; 38:201-7.
  11. Lorant V, Deliege D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. American Journal of Epidemiology 2003; 157: 98-112.
  12. Taylor DJ, Chavez GF, Adams EJ, Chabra A, Shah RS. Demographic characteristics in adult paternity for first births to adolescents under 15 years of age. Journal of Adolescent Health 1999; 24:251-258.
  13. Quinlivan J, Condon J. Anxiety and depression in fathers in teenage pregnancy. Australian and New Zealand Journal of Psychiatry 2005; 39: 915-920.
  14. Atkinson AG, Petersen RW, Quinlivan JA. Employment may protect fathers in the setting of maternal teenage pregnancy from anxiety and depression: Findings from the Australian Father’s Study. Repro System Sexual Disorders. 2016 5:1 http://dx.doi.org/10.4172/2161-038X.1000161

Are your women’s health records secure?

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A recent scandal making headlines in Australia involved unauthorised access of a healthcare record by 13 clinical staff. Worse, the issue of unauthorised access only came to media attention because the individual whose privacy was breached was a central figure in a murder trial linked to Australia’s favourite sporting past-time. The AFL.

How private are your electronic health records?

Not as private as you might like them to be!

Apart from the risk of healthcare staff gaining unauthorised access, there is the bigger risk of hackers. Several hospitals have now faced payouts as a result of privacy and data security breaches of patient records (1). One US FBI investigation into the hacking of a computer system at a medical facility found that “the system had been hacked into by 11 other groups before the breach under investigation had been identified” (1).

How concerned are patients about privacy?

Some US patients are sufficiently concerned over loss of privacy they have transferred their healthcare contracts to companies that do not use electronic health records (2). Data from a New Zealand consumer patient survey reported high levels of concern about hackers (79.4%), vendor access (72.7%) and malicious software (68%) (3).

Our own Australian research found pregnant women shared these concerns (4). We conducted a survey study of 528 pregnant women asking about their preferences in medical record systems. Despite the surveyed women having high levels of familiarity with computers, and using them on an almost daily basis, nearly half preferred a hospital held paper-based system. Only a third ranked electronic records first (4).

One key finding in our research was that pregnant women had concerns over loss of privacy with an electronic health record compared to a paper-based hospital system.

One woman stated:

“You hear about people breaking into computers and stealing information. You know, like Wikileaks, only they just want to cause trouble. I’m not sure I want all my medical information out there to be discovered. Who reads it? I also don’t want my husband or kids seeing things either and if its (sic) there they might want to see. I’m not convinced it would be safe.”

How concerned are patients about loss of control?

Our research also found patients were concerned about a loss of control of their record (4).

One woman stated:

“They say that only you can see it, but in a few years that will change. All those politicians will want to ransack our records for things and you won’t get a say in how they use them. Once somethings (sic) on-line you’ve lost control.”

One way that loss of control might occur is through data entry errors. This could happen if information from one source is merged with another without the “safety check” of consumer involvement.

Instances of inaccurate data ending up in patient’s records were identified in an evaluation of the English Summary Care Record (5). Patients were found to have drugs listed that they were not prescribed and in other cases medications they used were omitted from the record (5).

Some positive aspects to electronic health records

Our research did identify some strong positive findings in favour of electronic health records (4). Pregnant women found then to be less likely to be lost, and they felt they were the “way of the future”.

One woman wrote:

“Everything is on line now. I find a lot of it easier, like banking. Why should medical records be different?”

And another said:

“By the time my kids are my age paper will old fashioned. In school now they don’t use paper. Why should hospitals be different?” 

Electronic healthcare records are inevitable

The move to fully integrated electronic healthcare records is inevitable.

Governments around the world are spending billions (literally) on electronic health record systems. By example, in 2012 the Australian government spent $766 million for a new personally controlled e-health record (PCEHR) system (6,7).

Electronic health records should improve access to patient information by bringing together information from multiple sources into a single record. There are real benefits to bringing together pathology, radiology and clinical notes from community, private and public healthcare services into one site. Research studies have documented benefits in greater adherence to guideline-based care, enhanced surveillance and monitoring and fewer medication errors (8,9,10).

The key to electronic healthcare records will be to ensure patients do not lose their privacy and retain control of their records.

In women’s health, where sensitive issues such as domestic violence, sexual assault, and sexually transmitted infections are common, the right to privacy and control remain critical.

References

  1. Gupta A. Hackers, Breaches and other threats to electronic records. Health Data Management 2011; 19: 54-55.
  2. Chanabhai P, Holt A. Consumers are ready to accept the transition to online and electronic records if they can be assured of the security measures. Med Gen Med 2007; 9(1): 8
  3. Gaylin DS, Moiduddin A, Mohamoud S, Lundeen K, Kelly JA. Public attitudes about health information technology, and its relationship to health care quality, costs and privacy. Health Services Research 2011; 46(3): 920-938.
  4. Quinlivan JA, Lyons S, Petersen RW. Attitudes of pregnant women towards personally controlled electronic (PCEHR), hospital held and patient held medical record systems: a survey study. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 07/2014. DOI: 10.1089/tmj.2013.0342
  5. Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HW. Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study. BMJ 2010;340:c3111.
  6. Avery B. Opinion: Why national e-health is not for everyone. Authoritative. Strategic, IDG Communication, published 13 May 2013. Accessed on 21 July 2013 at http://www.cio.com.au/article/461628/opinion_why_national_e-health_everyone,
  7. Haikerwal M. PCEHR set to make life easier for doctors, improve care. Australian Medicine, Australian Medical Association, published 4 May 2013. Accessed on 21 July 2013 at https://ama.com.au/ausmed/pcehr-set-make-life-easier-doctors-improve-care
  8. Sheikh A, Cornford T, Barber N, Avery A, Takian A, Lichtner V et al. Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in ‘early adopter’ hospitals. BMJ 2011; 343: d6054 doi:10.1136/bmj.d6054
  9. Jha AK. The promise of electronic health records. JAMA 2011; 306(8): 880-881
  10. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E et al. Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine 2006; 144: 742-752.