Dissertations / Theses on the topic 'Medical, obstetrics-gynecology'

This thesis included a systematic literature review, yielding studies on three employment categories: hairdressers, cosmetologists and laboratory workers. The original research examined pregnancy outcomes for Finnish singleton births between 1990 and 2010. The parameters were increased male gender, low birth-weight, high birth-weight, pre-term delivery, post-term delivery, small for gestational age, large for gestational age, stillbirth and early neonatal death. Finnish Birth Registry data included 507,659 prima gravida women who delivered singletons with at least 22 weeks’ gestation 1990- 2010. There were 12,854 hairdressers, 1841 cosmetologists and 3587 laboratory workers. Control populations: 40,405 teachers, 1968 musicians and 447,004 women-general population. When hairdressers were compared to the general public, there were three marginally statistically significant results for new-borns: SGA, (OR 1.01, 95% CI 1.00 - 1.02), LGA, (OR 1.02, 95% CI 1.00 - 1.03) and post-term delivery (OR 1.06, 95% CI 1.02 -1.11). Marginal increased statistically significant results for pooled effect size (ES) from the meta-analysis were found for LBW among hairdressers ES 1.083 (95% CI, 1.017-1.153) and SGA infants among hairdressers ES 1.077 (95% CI, 1.006-1.153). Hairdressers may be at a marginally increased risk of low birth weight and small size for gestational age. This may be due to occupational exposure.

Purpose This dissertation focuses at assessing the efficacy of shorter time intervals in the treatment of medical abortions along with the use of various follow up methods. Methods This initial part of dissertation was carried out as an extensive study of literature, followed by observational study on shorter time intervals and follow up methods for the feasibility of the study. The main dissertation met its research aims through an RCT of 121 women comparing shorter to standard time intervals and assessing the various follow up methods at the end of 2 weeks. The qualitative component of the study was achieved by conducting in-depth interviews of women undergoing medical abortion on various aspects of medical abortions with emphasis on shorter time intervals and follow up. Findings This research produced a number of key findings: the RCT showed that both treatments have equal efficacy and acceptability with minor differences in their side effects however the sample size was small to generalise the findings; the follow up methods showed varied responses with preference to confirmatory investigations at 2 weeks follow up. Conclusions The main conclusions drawn from this research were that shorter time intervals can be offered as an alternative to standard treatment intervals in well informed women, however a larger RCT is needed. In order to provide these treatments as outpatient robust follow up methods will need to be incorporated into the abortion services.

Background: Medical student involvement in clinical care of obstetrical emergencies is limited. Wearable technology, namely Google Glass, has been used to enhance the simulation experience for trainees at our institution. We present a pilot study that examines the utility of this technology in medical students’ education through remotely-conducted exercises in obstetric emergencies. Materials & Methods: A total of thirteen medical students accepted the opportunity to participate in an obstetric emergencies training exercise with remote monitoring. Students wore the Google Glass device while participating in two simulated obstetrical emergencies: shoulder dystocia and vaginal breech delivery. A remote instructor monitored the students’ performance and gave verbal instructions during the simulation. Students then filled out a questionnaire grading the effectiveness of the exercise. Results: Of all participating students, 55% reported Glass extremely valuable for their education. None reported it as not being valuable. 15% reported that Glass distracted them in their simulation activity. 100% of participants reported it being more than “successful" in its potential to improve emergency obstetric care. 55% reported that Glass or a similar device is “extremely likely” to be incorporated into medicine. None reported that it is unlikely to be used in the future of medicine. Conclusions: Wearable technology has the potential to provide improved learner experience. This technology can be successfully used to provide student exposure to simulated emergencies. Further studies evaluating the participation of students and other learners in simulated obstetrical emergencies are needed to determine how effective wearable technology can become in medical education and ultimately patient care as well.

Case Report: Krukenberg tumor is a metastatic adenocarcinoma of the ovary that classically arises from the gastrointestinal tract, most often as a metastasis from the stomach as the primary origin, followed by colon. Krukenberg tumors are very rare malignant tumors of the ovary, only accounting for 1-2% of all ovarian malignancies. They tend to present with bilateral involvement. The most common presenting symptoms are abdominal pain, distention, and ascites, secondary to the large ovarian masses. Postmenopausal vaginal bleeding is a rare presenting symptom of a Krukenberg tumor. The diagnosis is commonly delayed until late in the disease progression. We present a case of a 77-year-old woman with stage IV metastatic adenocarcinoma of lower GI with mesenteric involvement and pulmonary nodules. Her disease was confirmed by mesenteric mass biopsy and was histologically CK20 positive, CDX positive, and CK7 negative. She underwent eighteen rounds of palliative chemotherapy with oral capecitabine (Xeloda) over the course of fifteen months. Sixteen months after the initial diagnosis, imaging uncovered a new cystic pelvic mass measuring 15x13x12 cm, decreased mesenteric mass, increasing liver lesion, metastasis to the left adrenal gland, and minimal ascites. She has had vaginal bleeding. Patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and small bowel resection by gynecological oncologist. The left ovary was involved by metastatic adenocarcinoma, 15 cm, consistent with small bowel origin. The small bowel resection showed adenocarcinoma, 3.3 cm in size with serosal invasion arising in an adenoma. Patient is planned for chemotherapy with irinotecan in palliation. Our case demonstrates a rare case of small bowel adenocarcinoma later presenting as a Krukenburg tumor.

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A distribuição eficiente de profissionais médicos é um dos principais problemas enfrentados pelos gestores de políticas públicas. Há vários mecanismos utilizados pelos países para prover profissionais de saúde, que vão desde incentivos salariais até formação continuada. O estado de Pernambuco vem incentivando os programas de residência médica, com aumento das vagas e programas, e também ampliando o número de graduandos de medicina, inclusive de maneira interiorizada, como estratégias para a fixação e provimento do profissional médico. O objetivo desse trabalho foi estimar a necessidade de médicos especialistas em Ginecologia e Obstetrícia para o Sistema Único de Saúde de Pernambuco – SUS/PE e para responder o objetivo da pesquisa foram analisados dados secundários oriundos dos sistemas de informações do SUS (DATASUS) e entrevistas semiestruturadas com gestores de saúde e médicos residentes da especialidade de ginecologia e obstetrícia. Dessa maneira, o estudo observou uma maior procura dos médicos pela especialidade de ginecologia e obstetrícia, ao longo dos anos, contudo ainda existe uma grande concentração de especialistas em algumas áreas do estado, em especial a região metropolitana do Recife. Esse fator demonstrou ser um dos elementos responsáveis pelo alto número de partos encaminhados para realização em outros municípios e um baixo acesso das mulheres ao exame de colposcopia.
Efficient distribution of medical professionals is one of the main problems faced by policymakers. There are several mechanisms used by countries to provide health professionals, ranging from wage incentives to continuing education. The state of Pernambuco is encouraging medical residency programs, an increase of vacancies and programs, and also increasing the number of undergraduate students of medicine, including internalized way, as strategies for the establishment and provision of medical professionals. The aim of this study was to estimate the need for specialists in Obstetrics and Gynaecology for Health System of Pernambuco - SUS / PE and to respond to the objective of the research were analyzed secondary data from the SUS information systems (DATASUS) and interviews semistructured with health managers and resident doctors of obstetrics and gynecology specialty. Thus, the study found a greater demand for doctors in the specialty of obstetrics and gynecology, over the years, yet still there is a large concentration of specialists in some areas of the state, particularly the metropolitan region of Recife. This factor proved to be one of the factors responsible for the high number of deliveries referred to perform in other cities and low access of women to colposcopy examination.

This thesis analyzes medical manuals published in England between 1500 and 1770 to trace developing medical understandings and prescriptive approaches to conception, pregnancy, and childbirth. While there have been plenty of books written regarding social and religious changes in the reproductive process during the early modern era, there is a dearth of scholarly work focusing on the medical changes which took place in obstetrics over this period. Early modern England was a time of great change in the field of obstetrics as physicians incorporated newly-discovered knowledge about the male and female body, new fields and tools, and new or revived methods into published obstetrical manuals. As men became more prominent in the birthing chamber, instructions in the manuals began to address these men as well. Overall these changes were brought about by changes in the medical field along with changes in culture and religion and the emergence of print culture and rising literacy rates.

Chlamydia is the most reported sexually transmitted infection in the US and is caused by the obligate intracellular bacterium Chlamydia trachomatis. Typically, this presents as a lower genital tract infection (cervicitis or urethritis), but can ascend to the upper genital tract, causing pelvic inflammatory disease, tubal infertility, epididymitis, or ectopic pregnancy. While chlamydia infections can be cured with a single-dose oral antibiotic, repeat infections are common and having multiple chlamydial infections increases a woman’s risk of developing serious chronic conditions. Previous research has shown that estrogen has a positive effect on C. trachomatis infections—an important finding, connecting fluctuating estrogen levels in females to variance in pathogenesis.The mechanism behind this hormonal influence remains unknown; however, previous work in our laboratory indicates that estrogen-stimulated stromal cell effectors play a role in enhancing C. trachomatis infections in a polarized endometrial epithelial Ishikawa (IK)/stromal (SHT-290) cell co-culture model. Specifically, our data indicate that estrogen exposure stimulates osteopontin and vimentin release from stromal cells in co-culture with endometrial epithelial cells. Furthermore, we noted that Chlamydia-infected, polarized Ishikawa cells exposed to a combination of recombinant osteopontin and estrogen released significantly more infectious chlamydia than cultures exposed to estrogen alone. Most tissue culture models being used today employee non-polarized cells. Given the fact that epithelial cell polarization is known to impact C. trachomatis serovar E development, in the current study we sought to determine if the estrogen-induced stromal cell effectors, osteopontin and vimentin, affect C. trachomatis viability and infectivity in non-polarized Ishikawa cells. Non-polarized Ishikawa cells were exposed to osteopontin or vimentin in the presence or absence of estrogen, infected with C. trachomatis serovar E, and collected for examination of chlamydial infectivity and progeny production. Our initial data show that osteopontin and vimentin impact chlamydial progeny production in a concentration dependent fashion, with higher concentrations of recombinant effectors +/- estrogen significantly decreasing progeny production. These data suggest that polarization of host cells influences the way hormone-stimulated effectors interact with the cell to impact on chlamydial infection. Future research goals are to explore other stromal effectors such as fibronectin with estrogen and to study the cell signaling mechanism osteopontin and vimentin use to affect chlamydial infections in polarized epithelial cell cultures.

Preterm birth (PTB) is defined as birth before 37 weeks gestational age. PTB is a common outcome and one that may be increasing in prevalence with serious individual and public health implications both immediately and long term. While PTB is a pregnancy specific outcome it is more appropriately viewed as the culmination of risk factors present both before pregnancy and possibly in past generations. This thesis attempts to review the implications, risk factors and current prevention strategies directed at PTB while placing it in an intergenerational and life cycle context. Three novel investigations are presented and their consequences are discussed. These investigations cover the lifespan and relate to identifying PTB and treating its immediate health outcomes. The first examines mitochondrial genetics and it's relation to PTB. There is a strong a priori hypothesis that mitochondrial genetics, being maternally inherited, may contribute to an individual's risk for PTB. However, in two genome wide association studies, no evidence is found for any mitochondrial polymorphisms being related to PTB. The second investigation reports an attempt to identify women at risk for PTB within a given pregnancy. Using routinely collected maternal information and serum screening data a potentially useful screening method is derived. While the algorithm does not have ideal performance characteristics it compares favorably to other population wide screening techniques and could be improved through future validation and data collection. The third and final investigation attempts to address quality of care for infants born preterm. In a network of neonatal intensive care units, wide variations in mortality outcomes are observed. Intensity of medical intervention appears to be an important predictor of mortality for the lowest gestational age infants. However, this intensity of intervention does not fully explain the observed differences in mortality outcomes. Finally, these study are discussed in context with one another and a new framework for considering PTB is presented that may help to guide future investigation into predicting, preventing and caring for those at risk for or experiencing a PTB.

Bakgrund: Avbrytande av graviditet innebär att fostret utförskaffas ur livmodern innan graviditetsvecka 22, spontant eller genom induktion. En inducerad abort kan ske medicinskt eller kirurgiskt. Cirka 56 miljoner aborter sker årligen i ett globalt perspektiv. Barnmorskan ska stödja kvinnan i abortvården samt verka för att ge jämställd och rättvis vård baserad på vetenskap och beprövad erfarenhet utifrån ett socialt-, ekonomiskt- och kulturellt perspektiv. Barnmorskan utvecklas i sin yrkesroll genom kunskap och erfarenhet. Syfte: Syftet med studien är att belysa kvinnors erfarenheter av medicinsk- eller kirurgisk abort i ett globalt perspektiv. Metod: Studien genomfördes som en metasyntes med kvalitativ ansats. Femton (15) vetenskapliga artiklar utgör resultatet. Resultat: Fyra huvudkategorier identifierades otillgänglighet och konsekvenser för kvinnan, ekonomiska faktorer, stigma samt autonomi. Resultatet visar att kvinnorna upplever att restriktiv lagstiftning skapar en stor oro och kan ge desperation. Detta kan innebära att många kvinnor söker sig till osäkra alternativ om tillgången på säker abortvård inte finns tillgänglig. Aborten hade negativa ekonomiska konsekvenser för kvinnorna. Att få bestämma över sin egen kropp och känslan av kontroll var en viktig del i abortbeslutet för kvinnan. Slutsats: Brist på ekonomiska tillgångar och stigma gör att många kvinnor söker sig till osäkra abortalternativ. Den enskilda kvinnan bör få ta beslut som rör hennes egen kropp och själv besluta om när hon önskar skaffa barn vilket innebär att tillgängligheten på säker abortvård måste öka. Klinisk tillämpbarhet: Studien kan användas för att ge ökad kunskap om kvinnors upplevelser och erfarenheter vilket kan leda till en mer tillgänglig abortvård för kvinnor i ett globalt perspektiv.
Background: Termination of pregnancy is when a fetus is removed from the uterus before pregnancy week 22, spontaneously or through induction. An induced abortion can be performed either medical or surgical. In a global perspective, each year around 56 million abortions are performed. The role of the Midwife in abortion care is to support the woman aiming to offer equal and equitable care based on proven experience and with a social-, economical- and cultural perspective. The professional skills of the midwife is developing through knowledge and experience. Objective: The aim of the study was to identify womens experiences of medical- or surgical abortion in a global perspective. Method: The study was conducted as a qualitative metasynthesis. Fifteen (15) scientific articles were included in the result. Result: Four main categories were identified inaccessibility and consequences for the woman, economical factors, stigma and autonomy. The result shows that the women experience that restrictive legislations makes women anxious and instill feelings of desperation. Many women are considering unsafe alternatives when safe abortion care isn’t accessible. The abortion had negative financial consequences for the women. To decide about their own body and having a feeling of control was an important part in the decision of abortion for the woman. Conclusion: Lack of financial assets and stigma means that many women seek unsafe abortion options. The individual woman should be able to make decisions concerning her own body and decide for herself when she wants to have children, which means that access to safe abortion care must increase. Clinical applicability: The study can be used to provide increased knowledge about womens experiences which can lead to a more accessible abortion care for women in a global perspective.

Ghana is identified among the developing countries with high maternal mortality ratio in Africa. This study unpacked the Demographic and Health Survey data by examining the maternal health indicators at the district level using GIS methods. Understanding the geographic patterns of antenatal care, place of delivery, and skilled birth attendants at the small scale will help to formulate and plan for location-specific health interventions that can improve maternal health care behavior among Ghanaian women. Districts with high rates and low rates were identified. Place of residence, Gini-Coefficient, wealth status, internet access, and religious affiliation were used to explore the underlying factors associated with the observed patterns. Economic inequality was positively associated with increased use of maternal health care services. The ongoing free maternal health policy serves as a cushion effect for the economic inequality among the districts in the Northern areas. Home delivery is common among the rural districts and is more prominent mostly in the western part of Northern Region and southwest of Upper West. Educating women about the free maternal health policy remains the most viable strategy for positive maternal health outcomes and in reducing MMR in Ghana.

During roughly forty years of a woman’s life-span, the fertile female human body prepares itself monthly for the possibility of pregnancy. Science has shown that the fluctuation of the sex steroids progesterone and estrogen have a crucial role in the female body's physiology, determining the menstrual cycle and its general phases. This biological dance of hormones governing the cycle influences a lot of physical, mental and cognitive aspects of life for a fertile ovulating woman. Although the question of whether these changes also affect women's cognitive performance is still unclear, some evidence has been gathered that could bring us closer to answers. Recent research findings show that this hormonal interplay might have a significant role in cognitive and psychological development - modulating brain activity, cognitive performance, higher cognition, emotional status, sensory processing, appetite and more. This thesis aims to uncover to what extent the menstrual cycle affects brain functions, neurobiology, mood, well-being and cognitive performance in menstruating cisgender women.

Chlamydia trachomatis is the most prevalent agent of bacterial sexually transmitted infections in the world. However, a profuse number of cases are unreported, as the infection is often asymptomatic. Sequelae such as pelvic inflammatory disease, an increased risk of cervical cancer, premature birth, and perinatal infections in pregnant women can occur. Inflammation occurs in the body in response to infection or injury. Although inflammation can lead to some unwanted secondary effects, such as pain, it serves to return the body to homeostasis by restoring injured tissues and eliminating pathogens. One recently identified connection between the central nervous system and the immune system that regulates inflammation is the cholinergic anti-inflammatory pathway (CAP). In the CAP, pathogen-associated molecular patterns stimulate the vagus nerve to activate the pathway, which ultimately results in acetylcholine (ACh) release, which down regulates inflammation. We hypothesized that genital chlamydial infection would increase the expression of choline acetyltransferase (ChAT), the enzyme that synthesizes ACh, in the female murine genital tract, therefore down regulating inflammation and promoting chlamydial infection. Transgenic female mice carrying a ChAT-promoter driven GFP reporter gene were vaginally infected with C. muridarum. Mice were sacrificed on days 3, 9, 15, and 21 post infection; cervical, uterine horn, and ovarian tissues were removed and embedded in paraffin. Small sections of each tissue were cut and mounted onto slides. The tissue sections were then stained for the expression of ChAT using immunohistochemical techniques. Finally, tissue sections were viewed under a microscope for positive staining and the data was analyzed. The results indicated that there is a significant increase in the number of cells that express ChAT in genital tract of chlamydia-infected mice versus non-infected mice.

Chlamydia trachomatis is the most common sexually transmitted bacterial disease agent worldwide, and, though frequently asymptomatic, can cause extreme pathology including infertility. Chlamydial species exhibit a unique biphasic developmental cycle. Once attached to a cell surface, infectious elementary bodies (EB) are internalized within an inclusion, the membrane-bound structure in which EB transform to noninfectious, replicable reticulate bodies (RB). After multiple rounds of division, RB condense to form EB, which are released and can infect new host cells. In culture, exposure to stressors, such as beta-lactam antibiotics, induce chlamydiae to reversibly detour from normal development into a noninfectious, viable state termed persistence. Cell culture data suggest that persistent forms are resistant to azithromycin (AZM), a front-line antibiotic, and are able to alter the host transcriptome. Though persistence has been described in culture for over 50 years, whether or not it: i) occurs in vivo; and ii) influences chlamydial pathogenesis, transmission and therapy has remained unresolved. To address these questions, we developed an animal model of persistent chlamydial infection using amoxicillin (AMX) treatment. AMX exposure decreased shedding of infectious chlamydiae in C. muridarum-infected mice without affecting chlamydial viability, demonstrating the presence of persistent chlamydiae. Shedding of infectious EB resumed following AMX cessation. Shedding data and microarray analyses suggested that host immunity might limit chlamydia’s exit from persistence in our model. Thus, we hypothesized that cyclophosphamide (CTX) treatment would increase the magnitude of chlamydial shedding observed after AMX-treatment cessation. CTX treatment increased post-AMX shedding by more than 10-fold compared to AMX-only controls. To determine whether persistent chlamydiae are resistant to antibiotic eradication in vivo, we induced persistence by administering AMX and treated mice with various AZM dosing regimes. Persistently infected mice demonstrated increased treatment failure following AZM therapy compared to productively infected controls. These data suggest that persistent chlamydiae are refractory to treatment in vivo and provide an explanation for the observation that treatment fails in some patients. In addition to creating the first fully characterized, experimentally tractable, in vivo model of chlamydial persistence, these experiments provide evidence that persistent/stressed chlamydial forms may serve as a long-term reservoir of infectious organisms in vivo.

The purpose of this dissertation was to examine patterns of antenatal stressful life events (SLEs) experienced by women in the United States (U.S.) and their association with postpartum depression (PPD). It further explored the role of women's state-level socio-economic status (SES) on PPD; the racial/ethnic dispartites in SLE-PPD relationship; and the role of provider communication on perinatal depression. Data from 2009–11 Pregnancy Risk Assessment Monitoring System (PRAMS) and SES indicators published by the Institute of Women’s Policy Research (IWPR) were used. Latent class analysis (LCA) was performed to identify unobserved class membership based on antenatal SLEs. Multilevel generalized linear mixed models examined whether state-level SES moderated the antenatal SLE-PPD relationship. Of 116,595 respondents to the PRAMS 2009-11, the sample size for our analyses ranged from 78% to 99%. The majority (64%) of participants were in low-stress class. The illness/death related-stress class (13%) had a high prevalence of severe illness (77%) and death (63%) of a family member or someone very close to them, while those in the multiple-stress (22%) class endorsed most other SLEs. Eleven percent had PPD; women who experienced all types of stressors, had the highest odds (adjusted odds ratio [aOR]: 5.43; 95% confidence interval [CI]: 5.36, 5.51) of PPD. The odds of PPD decreased with increasing state-level social/economic autonomy index (aOR: 0.75; 95% CI: 0.64, 0.88), with significant cross-level interaction between stressors and state-level SES. Among non-Hispanic blacks and non-Hispanic whites, husband/partner not wanting the pregnancy (aOR: 1.47; 95% CI: 1.14, 1.90) and drug/drinking problems of someone close (aOR: 1.37; 95% CI: 1.21, 1.55) were respectively associated with PPD. Provider communication was protective. That 1 out of every 5 and 1 out of every 8 women were in the high- and emotional-stress classes suggests that SLEs are common among pregnant women. Our results suggest that screening for antenatal SLEs might help identify women at risk for PPD. The finding that the odds of PPD decrease with increasing social/economic autonomy, could have policy implications and motivate efforts to improve these indices. This study also indicates the benefits of antenatal health care provider communication on perinatal depression.

Background: Although giving birth is a positive experience for many, some 10% of pregnant Swedish women suffer from severe fear of childbirth (FOC), which impairs their daily functioning and poses a risk for a negative delivery experience. This thesis focuses on the mental and health-economic effects of severe FOC, and explores new treatment options for childbirth-related anxiety. Aims: (i) to investigate the prevalence of and variables associated with severe FOC, (ii) to estimate the cost of illness of severe FOC and (iii) to explore whether Internetbased cognitive behaviour therapy (ICBT) is feasible for treating pregnant women with severe FOC and those with childbirth-related symptoms of posttraumatic stress disorder (PTSD). Design and Results: Study 1: In a cross-sectional study 1635 pregnant women were asked about their FOC via the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), and provided socio-demographic data and information of their preferred mode of delivery. It was found that 15.6% of the participants had a severe FOC, which also strongly correlated with the preference of a caesarean section. Study 2: In a prospective case-control cohort study we mapped all visits, in-patient care, sick leave and delivery variables from medical records and estimated the societal costs in two groups of women; one group with severe FOC and one with low FOC. The costs for the group with severe FOC were 38% higher than for the low FOC group. Study 3: Twenty-eight nulliparous women with severe FOC were self-recruited to an eight weeks ICBT program for severe FOC. Fifteen women followed the entire program. Their FOC decreased significantly after treatment (Cohen’s d=0.95, p<0.0001), which means that ICBT is feasible and an option for treating women with severe FOC. Study 4: Fifteen participants in Study 3 wrote narratives of the imminent delivery before as well as after therapy. After treatment, the women had a more realistic attitude towards childbirth, more self-confidence and more active coping strategies. Partners and staff were perceived as more helpful, and the women were more aware of the child they were bearing. Study 5: Fifty-six women with a traumatic delivery experience were included in a randomized wait-list controlled study (RCT) of the effects of an eight week long ICBT program for childbirth-related PTSD symptoms. These symptoms decreased in both groups during active therapy, while the between-group effect size varied depending on measurements. Psychiatric comorbidity decreased in both groups after active treatment. Conclusion: Severe FOC is prevalent among Swedish pregnant women, and the cost of illness of this marker of peripartum psychological vulnerability is considerable when treated using standard care. A new treatment option for this group with ICBT seems feasible and is associated with more realistic attitudes towards the imminent delivery. An RCT with eight weeks of ICBT for parous women with PTSD symptoms also had promising results. As severe FOC is prevalent and associated with mental and economic burdens for the individual and the society, there is an urgent need to expand the research field. It is important to find feasible and effective treatments that can be applied on a large scale.
Denna avhandling undersöker (i) hur vanligt det är att svenska gravida kvinnor lider av rädsla för förlossningen, och (ii) hur detta påverkar kvinnornas sjukvårdskonsumtion under denna period samt vilka kostnader detta innebär för samhället; testar och utvärderar (iii) nya behandlingsmetoder för rädsla för förlossningen och för posttraumatiska stressymptom efter en traumatisk förlossning. Avhandlingen består av fem delstudier: Studie 1 var en studie bland 1635 gravida kvinnor och visade att mer än var tionde gravid kvinna har svår förlossningsrädsla. Denna hade samband med kvinnornas önskemål om planerat snitt som förlossningssätt, och hos omföderskor, med tidigare negativa upplevelser av förlossningen. Studie 2 jämförde sjukvårdskonsumtion och sjukskrivning under graviditet och den första tiden efter förlossningen hos förstföderskor med svår respektive lindrig förlossningsrädsla, vilka omhändertagits i den ordinarie förlossningsvården. Gruppen med svår förlossningsrädsla visade sig ha avsevärt högre kostnader orsakade av att de i genomsnitt hade högre sjukskrivningstal under graviditet och fler besök på grund av psykiska besvär, samt oftare förlöstes med kejsarsnitt och hade komplicerade förlossningar. I Studie 3 testade 28 förstföderskor med svår förlossningsrädsla en ny behandlingsmetod med kognitiv beteendeterapi (KBT) via internet. Behandlingen medförde att kvinnornas rädsla kraftigt minskade från företill efter behandling. I Studie 4 skickade 15 av kvinnorna i Studie 3 in berättelser via nätet om hur de föreställde sig att deras förlossning skulle bli, såväl innan terapin startade som när den var avslutad. Efter genomförd terapi hade kvinnorna en mer realistisk attityd till förlossningen än före terapin och visade tecken på att ha ett bättre självförtroende och mer aktiva strategier att hantera den kommande förlossningen. Studie 5 utforskade om kvinnor, som upplevt en traumatisk förlossning, kan bli hjälpta av behandling med KBT via internet. Traumatiserade kvinnor slumpades till att antingen få behandling direkt eller få behandlingen efter en väntetid (kontrollgruppen). I båda grupperna minskade kvinnornas posttraumatiska stressymtom, liksom förekomsten av depression och andra ångestproblem. Sammanfattning: Avhandlingen visar att svår förlossningsrädsla är vanligt förekommande och medför lidande för kvinnor och ökade kostnader för samhället i samband med graviditet och förlossning, när detta problem hanteras i den vanliga vården. Två internetbaserade studier testar kognitiv beteendeterapi som behandling för svår förlossningsrädsla och för problem efter en traumatisk förlossning och visar att dessa behandlingsformer tycks fungera väl och i framtiden skulle kunna utgöra ett alternativ som medför att vård görs tillgänglig också för kvinnor som inte har tillgång till kvalificerade hjälpinsatser på andra sätt. Svår förlossningsrädsla och ångestproblem efter en traumatisk förlossning föreligger ofta tillsammans med annan psykisk sjuklighet varför diagnostik och behandling behöver utföras av personer med tillräcklig kompetens för dessa uppgifter. Otillräckligt behandlad/icke behandlad svår förlossningsrädsla ökar riskerna för att kvinnan upplever en kommande förlossning som traumatisk. Avhandlingens slutsatser behöver undersökas i fler och större studier, och, avseende behandlingsstudierna, i undersökningar som har tillräckligt stora kontrollgrupper. Om sådana studier bekräftar dessa preliminära fynd, blir frågan om screening för svår förlossningsrädsla aktuell eftersom det då finns såväl bra screeninginstrument som behandling som skulle kunna göras tillgänglig för stora grupper. Kommer samhället i denna situation att ha råd att inte försöka förebygga individuellt lidande och stora merkostnader för kvinnor med svår förlossningsrädsla?
Tämän tutkimuksen tavoitteena on tutkia (i) kuinka yleinen synnytyspelko on ruotsalaisten raskaana olevien naisten keskuudessa ja (ii) kuinka se vaikuttaa heidän terveyden‐ ja sairaanhoitopalveluiden kulutukseen raskauden aikana ja sen jälkeen, sekä selvittää miten synnytyspelko vaikuttaa yhteiskunnan kustannuksiin; kehittää, testata ja arvioida (iii) uusia hoitomuotoja synnytyspelon sekä synnytyksestä johtuvien psykologisen trau man (posttraumaattinen stressi, PTSD) hoitoon.' Tämä väitöskirja koostuu viidestä osatyöstä: 1. Ensimmäinen osatyö tutki synnystyspelon yleisyyttä 1635 raskaana olevan naisen keskuudessa. Tutkimus osoitti että joka seitsemäs raskaana oleva nainen Ruotsissa kärsii vakavasta synnytyspelosta. Keisarinleikkaus toiveen takana on usein vakava synnystyspelko. Uudelleen synnyttäjillä synnytyspelkoon vaikuttaa myös aiempi traumaattinen synnytyskokemus. 2. Toisessa osatyössa verrattiin ensisynnyttäjien terveyden- ja sairaanhoitokustannuksia sekä sairaslomapäiviä raskauden aikana, synnyksen yhteydessä sekä sitä seuraavan kolmen ensimmäisen kuukauden aikana. Vertailuryhmät seurasivat tavallista äitiysneuvolaohjelmaa, ryhmistä toisella oli vakava ja toisella lievä synnytyspelko. Vakavasta synnytyspelosta kärsivien naisten terveyden ja sairaanhoitopalvelujen käyttö osoittautui huomattavasti korkeammaksi kuin vertailuryhmässä. 3. Kolmannessa osatyössa 28 vakavasta synnytyspelosta kärsivää ensisynnyttäjää, testasi uutta ratkaisukeskeiseen terapiaan (KBT) pohjautuvaa Internetin kautta ohjattua psykologista hoito-ohjelmaa. Hoito lievensi huomattavasti osallistujien synnytyspelkoa. 4. Neljännessä osatyössä 15 naista (edellisestä osatyöstä 3) kirjoittivat osana terapiaansa kertomuksen tulevan synnytyksensä odotuksista. Sama tehtävä kertautui ennen terapian alkua sekä sen jälkeen. Kertomusten yhtäläiset teemat tunnistettiin minkä jälkeen ennen ja jälkeen hoitoohjelmaa kirjoitettujen kertomusten teemoja vertailtiin. Hoidon jälkeen naisten odotukset pohjautuivat suuremmassa määrin tietoon, he kuvailivat itsensä varmemmiksi sekä paremmin  valmistautuneiksi tulevaa synnytystä ajatellen. 5. Viides osatyö tutki Internetin kautta ohjatun ratkaisukeskeisen terapian (KBT) vaikutusta naisiin jotka kärsivät synnytyksen jälkeisestä henkisestä traumasta. Naiset satunnaistettiin tutkimuksessa joko välittömän hoidon ryhmään tai odotuslista ryhmään, joka sai saman hoidon myöhemmin. Hoidon jälkeen PTSD oireet vähenivät sekä hoitoettä kontrolliryhmässä. Myös masentuneisuus ja ahdistusoireet väheniväthoidon myötä. Yhteenvetona voidaan oheisista tutkimuksista todeta että synnytyspelko on yleinen ruotsalaisten raskaana olevien naisten keskuudessa. Synnytyspelko aiheuttaa kärsimystä sekä raskaana olevalle naiselle mutta myös lisäkustannuksia yhteiskunnalle. Kahdessa Internetin kautta ohjatussa ratkaisukeskeisessä hoito-ohjelmassa testattiin uusia hoitomuotoja raskaana oleville ensisynnyttäjille sekä synnytyksen jälkeisistä traumaoireista kärsiville naisille. Tulokset osoittavat, että Internetin kautta ohjattu hoito toimii näissä ryhmissä hyvin ja saattaisi tulevaisuudessa olla vaihtoehto kohderyhmille, joille sopivaa terapeuttista hoitoa nykytilanteessa ei voida tarjota. Koska vaikea synnytyspelko ja synnytystä seuraavat PTSD oireet esiintyvät usein muiden mielialahäiriöiden rinnalla, on tärkeää, että näitä naisia hoitavalla henkilökunnalla on tarpeellinen pätevyys hoitaa myös mielenterveysongelmia. Hoitamatta jätetty tai puutteelisesti hoidettu synnytyspelko lisää raskaana olevan naisen riskiä kokea synnytyksensä traumaattisena. Tulevissa tutkimuksissa tämän tutkimusprojektin tulokset ja johtopäätökset on syytä toistaa useammissa ja ennen kaikkea suuremmissa ryhmissä. Jos tutkimustemme alustaville tuloksille löytyy tukea, nousee kysymys synnystyspelon seulonnasta äitiysneuvoloissa ajankohtaiseksi; sekä seulontamenetelmä että tehokas hoitotapa ovat olemassa ja voitaisiin tarjota suuremmille kohderyhmille. Onko yhteiskunnalla sellaisessa tilanteessa varaa olla ennaltaehkäisemättä synnystyspelkoisten naisten kärsimystä?

Background Advances in medical treatment during the last 50 years have resulted in more individuals with congenital heart disease (CHD) and Marfan syndrome reaching childbearing age. The substantial physiological changes during pregnancy result in a high-risk situation, and pregnancy is a major concern in women with these conditions. Aims To describe the socio-demographic characteristics, birth characteristics and reproductive patterns of individuals with CHD and women with Marfan syndrome. To investigate obstetric and neonatal outcomes in the firstborn children of individuals with CHD and women with Marfan syndrome. To study long-term cardiovascular outcomes after childbirth in women with Marfan´syndrome. Methods The studies are population-based register studies. The study population in the first paper included all women born between 1973 and 1983 who were alive and resident in Sweden at the age of 13 (494 692 women, of whom 2 216 were women with CHD). In the second paper, the same definition of the study population was chosen, except that it involved all men born between 1973 and 1983 (522 216 men, of whom 2 689 men with CHD). The third and fourth papers involved a study population of all Swedish women born between 1973 and 1993 who were still living in Sweden at age 13. This population consisted of 1 017 538 women, 273 of whom had been diagnosed with Marfan syndrome. Results and conclusions The individuals studied were more often born preterm, and were small-for-gestational age babies. They were more likely to have been born by cesarean section. In women with CHD, these characteristics were repeated in their firstborn children. No increased risks were found in children of men with CHD or in children of women with Marfan syndrome. There was no increased risk of aortic dissection in women with Marfan syndrome during pregnancy compared to women with Marfan syndrome who did not give birth. Higher frequencies of cardiac arrhythmia and valvular heart disease were found after childbirth in women with Marfan syndrome. Pregnancy in women with CHD is a high-risk situation associated with increased risk of adverse neonatal outcomes for the expected child. Pregnancy in women without CHD, but where the father has CHD is not so associated with increased risk of adverse obstetric or neonatal outcomes. Pregnancy in women with Marfan syndrome is not associated with adverse outcomes for the expected child.

Background: One in ten people in the U.S. are affected by a substance use disorder (SUD), roughly one third of whom are women. Rates of unintended pregnancy are higher in this population than in the general public. Little is understood about how women with SUD use prescription contraception and think about pregnancy. Methods: By analyzing Medicaid claims data and conducting qualitative interviews with women with SUD, this doctoral thesis seeks to: 1) compare any use of and consistent, continued coverage by prescription contraceptives between women with and without SUD; 2) determine the extent to which SUD is associated with pregnancy, abortion, and adverse feto-maternal outcomes in women who use prescription contraception; and 3) explore facilitators of and barriers to contraceptive utilization by women with SUD, using qualitative interviews. Results: Compared to women without SUD, women with SUD are less likely to use any prescription contraceptive, particularly long-acting reversible methods. Among women who do use long-acting methods, SUD is associated with less continued, consistent coverage by a prescription contraceptive. Among women who use contraception, SUD is also associated with increased odds of abortion. When interviewed, women with SUD report fatalistic attitudes towards pregnancy planning, and have difficulty conceptualizing how susceptibility to pregnancy may change over time. Women with SUD also report that pregnancy has substantial impact on their drug treatment prospects. Conclusions: This study is the first to examine contraceptive utilization by women with SUD who are enrolled in Medicaid or state-subsidized insurance. Our study may help to inform clinical practice and policy development to improve the reproductive health and wellbeing of women with SUD.

Background: One in ten people in the U.S. are affected by a substance use disorder (SUD), roughly one third of whom are women. Rates of unintended pregnancy are higher in this population than in the general public. Little is understood about how women with SUD use prescription contraception and think about pregnancy. Methods: By analyzing Medicaid claims data and conducting qualitative interviews with women with SUD, this doctoral thesis seeks to: 1) compare any use of and consistent, continued coverage by prescription contraceptives between women with and without SUD; 2) determine the extent to which SUD is associated with pregnancy, abortion, and adverse feto-maternal outcomes in women who use prescription contraception; and 3) explore facilitators of and barriers to contraceptive utilization by women with SUD, using qualitative interviews. Results: Compared to women without SUD, women with SUD are less likely to use any prescription contraceptive, particularly long-acting reversible methods. Among women who do use long-acting methods, SUD is associated with less continued, consistent coverage by a prescription contraceptive. Among women who use contraception, SUD is also associated with increased odds of abortion. When interviewed, women with SUD report fatalistic attitudes towards pregnancy planning, and have difficulty conceptualizing how susceptibility to pregnancy may change over time. Women with SUD also report that pregnancy has substantial impact on their drug treatment prospects. Conclusions: This study is the first to examine contraceptive utilization by women with SUD who are enrolled in Medicaid or state-subsidized insurance. Our study may help to inform clinical practice and policy development to improve the reproductive health and wellbeing of women with SUD.

碩士
中山醫學大學
醫療產業科技管理學系碩士班
102
With the advances in medical technologies, almost all medical facilities are now equipped with comprehensive medical hardware. While a majority of the industries nowadays are guided by “customer-oriented” service, the main business goal set by every business operator is to improve customer satisfaction. This is more so for medical service teams. As the patients’ demand for quality medical services increases, programs concerning how to improve healthcare quality, and how to enhance patients’ satisfaction with hospital services, which in turn improves patients’ loyalty to the hospital, have become major business operating targets. The research target of this paper is the OB/GYN outpatient clinic of a medical center in central Taiwan. This paper adopted the Discrete-Event Orientation Simulation method to deduce the overall clinic-visit process based on the real-life clinic visit data to the department, and to construct a clinic-visit process simulation. The improvement factors of the research were used to formulate improvement solutions, of which the optimal solution was found to reduce time spent for the average clinic-visit and to lower average manpower costs. The result is offered to hospital management as a reference base for decision-making. Findings of this paper show that clinic-visit process time of Average Clinic-visit Process Time Y1 is the shortest, i.e. when there are 5 outpatient rooms (approx. 7 minutes for a clinic visit), 5 registration/cashier counters (approx. 5 minutes for registration and payment), 3 pharmacy counters (approx. 8 minutes for obtaining medicine) in operation, and a Short Time for health education (approx. 8 minutes for health education). Average Clinic-visit Process Time Y1 is the shortest The best solution for Average Manpower Cost is the genetic algorithm of Y2, i.e. when there are 3 outpatient rooms, 3 registration/cashier counters, and one pharmacy counter in operation, the lowest average manpower cost can be achieved. The best solution of Ideal Function Y3 is, when there are 3 outpatient rooms (approx. 11 minutes for clinic visit), 5 registration/cashier counters (approx. 5 minutes for registration and payment), 3 pharmacy counters (approx. 8 minutes for obtaining medicine) in operation, and a Short Time for health education (approx. 8 minutes for health education). The Function in question incorporates the idea of weighted average, which is the optimal compromise between Average Clinic-visit Process Time Y1 and Average Manpower Cost Y2. Therefore, the optimal solution of Ideal Function Y3 is a better choice.

碩士
逢甲大學
公共政策所
98
How promotes the medical service quality, the increase sickness degree of satisfaction to become between the medical establishment the competitive advantage the important attribute, this research take the gynecology and obstetrics department sterility sickness as the object of study, its discussion sickness when accepts each medical the service, how affects sickness whole to go see a doctor the degree of satisfaction, uses the sense of purpose random sampling, establishes in decides the sample the way investigation, and continues the material analysis moreover to carry on the real feeling experience thoroughly, understands sterility patient to between the medical service quality expectation and the degree of satisfaction relations, and related essential factor.The research knew that, discovered the medical service quality is in order highest to degree of satisfaction of the medical officer by the doctor''s scope of specialized ability degree of satisfaction promotion, next the medical care personnel manner, treats an illness the interaction relations.Sterility sickness to goes see a doctor the time length which degree of satisfaction of the process waits for, goes see a doctor the flow feeling, sickness right of privacy, medical officer''s technical fluency, causes scope of the overall degree of satisfaction promotion for least.Not most satisfactory partial sterility sickness is unsatisfied to the medical environment in order for the environmental equipment feeling, environment neat comfortableness, the consummation independent medical service space, the participant to “the reliability”, “the concern” two construction surface has the high expectation, the medical service quality heavy visual degree, take “reliability” as most important, “the concern” is the next best, expected lowest is “the efficiency”, “visible”, “the integrity”. Interviewee of cure background, just got in touch with an infertility treatment, while coming to hospital to seek medical advice with age more the big, lived a nearer and farther region, the first foetus, Gao educational background, chose other infertility center in houses and sought medical advice for the first time for just got in touch with expectation and satisfaction of medical treatment service quality higher, have have no occupation and barren year count of factor then to expectation and satisfaction of medical treatment service quality is without the notable influence.

碩士
中原大學
建築研究所
105
With the rise of feminism, people have gradually paid greater attention to women’s doctor-patient relationship and physical autonomy. Female patients are allowed to express opinions about their medical benefits. In fact, women have a higher demand for a gender-friendly medical environment, particularly regarding medical items such as outpatient service, physical examination, and palpation in the obstetrics and gynecology department. Through a gender-friendly concept and the design and space of the medical process, a comfortable space should be created for women. Based on a gender-friendly medical environment and from data collection, classification, and analysis, this study investigates and explores the literature related to hospital buildings in Taiwan and gender-friendly issues and reorganizes the measures of privacy, safety, convenience, and comfort in order to examine space in the obstetrics and gynecology department. In terms of architecture design, it attempts to find how a gender-friendly medical environment can adhere to hospital policies. Aside from studying foreign and domestic cases, this study treats Landseed Hospital as the subject. By a questionnaire and by measures of a gender-friendly medical environment, it conducts interviews on current spatial use and the problems of the obstetrics and gynecology department in the hospital. The questionnaire passed the examination of the hospital’s Institutional Review Board (IRB) so as to develop a structural questionnaire survey on patients and medical personnel. In the process, the researcher explains the research purposes and process to the subjects, and the samples are collected after the subjects sign an agreement. The findings can be criteria for hospital and architecture designers when setting up a gender-friendly space in hospitals that result in patients’ privacy, safety, comfort, and convenience. The research findings present spatial use and the policy of patients and nursing personnel in the obstetrics and gynecology department toward a gender-friendly medical environment as follows: (1) privacy of patients’ space: it must maintain the independence of personal space. Patients’ must be protected on anything that is personal, such as an independent room for private diagnosis and privacy during registration; (2) safety: medical personnel should offer protection measures at all times and pay attention to patients’ safety. A complete medical environment should be provided, such as wheelchairs and a barrier-free facility design; (3) comfort: patients should be emotionally relaxed in a hospital. For instance, chairs in waiting room should be comfortable and the temperature in the wards can be regulated according to personal feelings; (4) convenience: specific personnel assistance should be provided like smooth route planning and convenient and immediate health education information, such as digital route presentation and health education information. Therefore, a gender-friendly medical environment can provide services that do match patients’ needs and offer space and facilities that are modern. The quality of architecture design in the medical field can thus be upgraded.

碩士
弘光科技大學
健康事業管理研究所
107
Clinics and hospitals in Taiwan are becoming more and more competitive, and the quality of quality medical services has become an important element in attracting medical professionals and improving satisfaction. With the rise of consumer awareness, the medical practitioners have certain requirements for the satisfaction of medical service quality, the comfort of the medical environment, and the location and convenience of medical institutions. The purpose of this study is to understand the factors that influence the quality of medical services, environmental facilities, and loyalty of hospitals in a grassroots obstetrics and gynaecology clinic in a township. This study adopted a convenient sampling and closed structural questionnaire survey method for cross-sectional research. The study subjects were 532 questionnaires issued by a township-type grassroots obstetrics and gynaecology clinic in the central part of China. The effective questionnaire recovery rate was 96%. The collected data were analyzed by SPSS statistical software, descriptive statistics, inferential statistics, single factor analysis, and linear regression. The reasons why the respondents chose to come to the hospital were mostly recommended by relatives and friends. Secondly, the traffic was convenient. The average scores of the “medical service quality”, “environmental facilities” and “medical loyalty” of the respondents were all above 4 points. The perceptions of the "medical service quality", "environmental facilities" and "medical loyalty" of the respondents will be significantly different due to differences in personal traits such as age, education level and hospitalization style; different types of medical care for the environment The perception of facilities is significantly different; there is a significant difference in the loyalty of "medical loyalty" depending on the occupation. In addition, there is a significant positive correlation between "medical service quality", "environmental facilities" and "medical loyalty". The results of this study show that the reputation and location of medical institutions are indeed important considerations for people to choose medical treatment. In addition, the medical practitioners obviously have certain requirements and knowledge for good medical service quality and comfortable environmental facilities. It is recommended that medical institutions should continue to pay attention to the improvement of medical service quality and environmental facilities, so as to enhance the loyalty of the medical practitioners.

碩士
國防醫學院
公共衛生學研究所
90
As people’s knowledge grows, patients’ demand for more comprehensible medical information is increasing when they are receiving medical treatment. Previous to studies suggested that patients usually do not get sufficient medical information to help them undergoing the treatment, and this may jeopardize the quality of medical services and the relationship between physicians and patients. However, it is not clear that what kind of information is important but insufficient from patients’ point of view. The goals of this study are to gather patients’ opinions about the importance and obtainment of the medical information and further to discuss the factors influencing patients in obtaining the medical information. A 38-item questionnaire was developed from interviewing patients of obstetrics and gynecology and reviewing related articles. With help of factor analysis, the 38 items were grouped into four categories─ core medical information, associated medical information, perimeter medical information, and non-medical information. Patients came to Ob/ Gyn clinic for check up or treatment were asked to fill out the questionnaire. Base on 624 effective questionnaires, the results show that “core medical information” is the most important part of information that a patient would like to know, whereas “non-medical information” is least important part. A sample of Ob/ Gyn Physicians’ opinions was also collected. There are significant differences between physicians’ opinions and patients’ opinions. Physicians value “non-medical information” much higher than patients do. On the other hand, the importance of “associated medical information” is ranked much higher by patients than by physicians. Since both patients and physicians think highly of “core medical information”, physicians tend to provide such information to patients automatically; as the same time, and patients tend to ask more about “core medical information” than other kind of information. Consequently, the completeness of medical information that patients obtained varies according to its closeness to the core, such that core medical information, 87.3%, associated medical information, 77.2%, and perimeter medical information, 58.2%. The obtainment of medical information when patients undergo the medical treatment depends not only on physicians’ automatic provision, but also on patients’ aggressiveness of consulting to their physicians, especially for perimeter medical information. As long as the patient ask for the information, more than 80% of the chance they will get it. Patients’ characteristics may also influence their obtainment of medical information. Patients with older age and without health insurance tend to consider “core medical information” and “associated medical information” less important, and less aggressive on obtaining such information. On the other hand, patient with younger age and without health insurance care less about perimeter medical information.

A research report submitted to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Public Health in the field of Hospital Management, Johannesburg, 2011
Mecklenburg Hospital provides a comprehensive package of promotive, preventive, curative and rehabilitative reproductive health services for women which are not available in primary health care clinics and community health centres. These services require special equipment (such as cardiotochograph machine) and personnel (such as medical doctors) that are not available in these health facilities. The availability of medical equipment is one of the crucial components of effective maternal health services. Specific life saving medical equipment must be available for routine and emergency management of maternal and neonatal complications. This study is undertaken since no formal study has been done to systematically study the availability and related cost of medical equipment in a district Hospital maternity ward.

碩士
臺北醫學大學
護理學研究所
95
This study was a cross-sectional, descriptive study. Research aims were: (a) investigating women’s menopause symptoms and quality of life (QOL), (b) exploring relationships between women’s individual characteristics, menopause symptoms and QOL, and (c) identifying possible predictors of women’s QOL among a sample of women 45-60 years of age. A structured questionnaire was used to collect information about women’s individual characteristics, menopause symptoms, lower urinary tract symptoms (LUTS) and QOL. Sample of this study were 138 women 45-60 years of age who visited the gynecology/obstetrics clinic in a medical center and currently experienced one or more than one menopause symptom(s). The mean age of menopause was 50.35±3.27 years for the women in this study. Mean value of the menopause symptoms was 19.50±10.00 (range = 0-63); feeling tired or lacking in energy, loss of interest in sex, muscle and joint pains, difficulty in sleeping, and difficulty in concentrating were the five menopause symptoms that women were more likely to experience. About 82% women experienced one or more than one LUTS, the mean value of LUTS was 1.93±1.79 (range = 0-9). The mean value of QOL (range = 0-100) measured by the SF-36 questionnaire in eight domains were: physical functioning 78.09±17.16, role limitations due to physical problems 58.15±43.05, bodily pain 66.67±23.23, general health perceptions 58.33±19.94, vitality 54.16±19.50, social functioning 76.53±21.27, role limitations due to emotional problems 69.08±39.18, and mental health 61.01±18.78. Spouse, religion, occupation, chronic disease(s), and hormone treatment were significantly related to women’s QOL in several domains. Menopause symptom(s) and LUTS were significantly related to women’s QOL at eight domains. Women who experienced severer menopause symptoms or LUTS reported lower QOL. Menopause somatic symptom(s) were a significant predictor of physical functioning QOL; hormone treatment and menopause somatic symptom(s) were significant predictors of bodily pain QOL. General health QOL was associated with chronic disease(s), menopause psychological symptom(s) and LUTS; vitality QOL was associated with menopause psychological symptom(s). Menopause psychological and somatic symptom(s) were related to social functioning QOL; menopause psychological symptom(s) was related to mental health QOL. Study results demonstrated that menopause psychological and somatic symptom(s) were related to women’s QOL in six domains. Health care providers and health-related policy decision makers should pay attention to these important predictors and generate related strategies or interventions. Counseling services or related exercise/diet treatments can be provided to this population to improve their menopause symptom(s) and QOL.

碩士
東海大學
工業工程與經營資訊學系
96
As healthy insurance policy changed, the competition between hospitals of the same district becomes more intense. In order to consolidate health care market share, it is important to know the medical market and patient characteristics for developing suitable business strategies. With hundreds of hospitals and clinics, Taichung city has an intense medical market competition. Via data mining and cluster analysis with National Health Insurance Research Database (NHIRD), a study on patients’ characteristics and treatments of Obstetrics and Gynecology is presented as a reference for Taichung city’s hospitals to develop business strategy. By analyzing the NHIRD in 2004 for two medical centers in Taichung city, the results are as below. First, by using descriptive analysis, we can conclude that (1) the patients of Obstetrics and Gynecology are concentrated in the 26 to 45 age bracket; (2) the main diagnoses are “normal delivery” and “cancer chemotherapy”. Second, with cluster analysis, we found that: (1) Cluster analysis method is useful to divide patients into three groups, Case Payment Group, Gynecological Disease Group, and Gynecological Cancer Group. (2) The characteristics of major diseases’ patients are different between groups. In Gynecological Disease Group, the main diagnoses are “malignant neoplasm of cervix uteri” and the main treatment is “radical abdominal hysterectomy”. In Gynecological Cancer Group, The most main diagnoses and treatments are “cancer chemotherapy” and “radiotherapeutic procedure.” (3) The characteristics of Obstetrics and Gynecology inpatients appear differences between the two medical centers. There are at least three differences in the study: (a) In Case Payment Group, Situn District medical center has older patients and more complications or merge sickness at its Obstetrics patients. In North District medical center, the amount of Obstetrics patients is more than Gynecology’s. (b) In Gynecological Disease Group, Situn District medical center has older patients with “malignant neoplasm of cervix uteri” as its popular main diagnoses. The number of patients with “carcinoma in situ of cervix uteri” is the largest in North District medical center. (c) In Gynecological Cancer Group, more patients of Situn District medical center were treated with “cancer chemotherapy”, and patients of the North District medical center were commonly treated with “cancer chemotherapy” and “radiotherapeutic procedure.”

碩士
東海大學
工業工程與經營資訊學系
95
It is the responsibility of medical care providers to provide good quality of medical care. Since the implementation of national health insurance scheme in Taiwan, promoting service quality and increasing consumers satisfaction have become more important topics for the medical care managers because of the keen competition in medical business. Via researching and analyzing people’s medical care seeking behavior to understand what consumers need is an indispensable method to promote service quality. Such studies have been widely reported in literature. However, obstetrics and gynecology patients may differ from general patients in terms of the unique nature of this discipline. It is therefore necessary to investigate this specific topic. The aim of the study is to find out whether different scale of medical institutes and personal characteristics will influence women’s concern on selecting obstetrical and gynecological service. We hope this study can provide some helpful information to the obstetrical and gynecological care providers. Through a structural interview to the patients of obstetrical and gynecological clinics at three scales of medical institutes in Taichung city (medical centers, regional hospitals, and private clinics) we have the following findings: 1. Single women and women with lower education level are more deliberate in selecting obstetrical and gynecological doctors and medical institutes than married women and women with higher education level, respectively. 2. Generally, occupation and family income do not affect women’s choice for obstetrical and gynecological doctors and medical institutes. 3. Women in urban region have a bi-polar tendency in selecting medical institutes for their obstetrical and gynecological care, i.e., either hospital or private clinic, few mixture of the two. 4. In spite of the difference in selecting medical institutes, urban women have similar concerns on the factors that they think important in obstetrical and gynecological care. For selecting physicians, their experience, attitude, and professional expertise are the prioritized concerned factors. For selecting medical institutes, their environment, facility, and service quality are most important. 5. Physician’s gender, age, and religion background are the factors that are thought least important to concern. We therefore suggest that the physicians and medical institutes offering obstetrical and gynecological service should strengthen the items that women are most concerned. In addition, interval interview to the consumers may gain more information about what they really need and so that better medical care can be provided.

Background: To date, little information exists about contraception counselling, unplanned pregnancy counselling, and abortion services curricula in Ontario medical schools. Identifying existing curricula, including influences on whether and how curricula are delivered, is an essential starting point for evaluative processes. Purpose and Objectives: The purpose of this study was to explore contraception counselling, unplanned pregnancy counselling, and abortion services curricula in Ontario medical schools. The objectives were to 1) identify the existence of such curricula in undergraduate (preclinical, obstetrics and gynecology clerkship, and family medicine clerkship) and post-graduate (obstetrics and gynecology and family medicine) programs; and 2) explore factors influencing the existence and form of these curricula from the perspective of program directors. Design: An exploratory qualitative approach was used for this study whereby, Ontario program directors responsible for contraception counselling, unplanned pregnancy counselling, and abortion services curricula were interviewed. Results: Overall, the inclusion of routine curricula in contraception counselling, unplanned pregnancy counselling, and abortion services was limited and variable between schools, as well as within clerkship and post-graduate programs. Program directors were often uncertain about iii whether such routine curricula were present in their programs. Four factors were found to influence whether these curricula were included in a program: 1) program structure, 2) program resources, 3) the interests of residents/students, and 4) personal philosophy of the program director. A typology was developed to understand how program directors resolved uncertainty when asked about the existence of these curricula in their programs. The emergent sensemaking typology revealed strategies used by directors to either justify the current system of medical teaching (i.e., defending the status quo) or support change (i.e., responsive). Program directors were consistent across programs in terms of the factors they identified as influencing the curriculum offered. The perceived impact of these factors varied according to the sensemaking processes employed by each director. Conclusions: This study provides an outline of curriculum variability within and between medical school programs. Further, if offers a typology of the ways program directors explain their uncertainty regarding the inclusion of these curricula in their programs. In so doing, program director sensemaking as a key influence on the curriculum is revealed.

This thesis presents a single witness edition of The Knowing of Woman’s Kind in Childing, which is a 14th century vernacular obstetrical and gynaecological treatise found in British Library MS Additional 12195. Purported to be emulating medical texts of French and Latin origin, The Knowing of Woman's Kind in Childing is “a novel fusing of several different texts and theoretical traditions into a single work” (Green, “Obstetrical” 64). The Knowing of Woman’s Kind in Childing is an important and significant medieval medical text because it has a self-identified female audience and a female-orientated medical focus. Accompanying notes and emendations from the four other extant witnesses are also presented: Oxford Bodley MS Douce 37 (SC 21611), Oxford MS Bodley 483 (SC 2062), Cambridge University Library MS Ii. 6. 33, and British Library MS Sloane 421A. This thesis explores the folklore of the traditional herbs, medicinals, and compounds used in the treatise. A comparison of the material appended to all five of the extant witnesses is presented in Appendix A; Appendix B lists the incidence of rubrication found in this edition; originating source material for the Knowing of Woman’s Kind in Childing is presented in Appendix C; and an alphabetical catalogue of medicinals, in four tables, can be found in Appendix D.

Afin de lutter contre la mortalité maternelle dont les taux restent encore élevés avec 401 pour 100 000 naissances vivantes en 2005, le Sénégal a mis en œuvre dans la continuité de ses stratégies novatrices de délégation de compétences pour renforcer l’accès aux soins obstétricaux et néonataux d’urgence, un programme alternatif de formation au D.E.S de Gynécologie et Obstétrique de médecins généralistes basés dans les zones éloignées. A partir du curriculum du programme classique, ce programme allie l’enseignement à distance à l’aide des Nouvelles Technologies de l’Information et de la Communication, des stages pratiques dans les sites du CHU, le coaching par les enseignants du CHU dans les Centres de santé où officient les médecins apprenants, des évaluations en ligne et les évaluations annuelles formelles du programme de formation classique. Il a été mis en œuvre dans deux districts du Sénégal par la Chaire de Gynécologie et d’Obstétrique du CHU de Dakar. Ce travail présente l’évaluation à mi-parcours de ce programme en analysant son implantation et ses effets à travers une étude de cas, grâce à des données qualitatives et quantitatives. Les résultats montrent : une évolution favorable des indicateurs sanitaires dans les deux sites du programme comparativement aux sites témoins, une augmentation du niveau de connaissance et de compétence des apprenants, et un niveau de satisfaction élevé des deux apprenants, des enseignants et des bénéficiaires. Cependant, des améliorations sont à apporter dans la mise en œuvre du programme en particulier en termes d’opérationnalisation des innovations pédagogiques, de coordination et de pérennisation par le Ministère de la Santé.
In order to reduce high level of maternal mortality rate estimated in 2005 at 401/100 000 live births, and following task shifting innovative strategies already initiated in the country to increase access to emergency obstetric care in Senegal, an alternative training program has been implemented for general medical doctors working in remote areas, to be effective obstetricians gynecologists. Adapted from the normal curriculum, this program combines distance learning using new information and communication technology, practical training in university facilities, coaching and mentoring by university teachers in learners’ heath centers, on line evaluations and also formal annual evaluations such as the normal program. The program has been implemented in two districts in Senegal by Obstetrics and Gynecology Unit of Dakar University. This midterm evaluation analyzes the program implementation and effects using case study with qualitative and quantitative data. Results show a positive evolution of emergency obstetric care indicators compared with two control districts, an increased level of trainees’ knowledge and skills, and also satisfaction of trainees, trainers and beneficiaries. However, some weaknesses have been identified in the program implementation particularly regarding implementation of new training innovations, coordination and sustainability by Ministry of Health.