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Kristine Selvik Jacobsen, 1 Eline Skirnisdottir Vik, 2 Bente Dahl 1 1Centre for Women’s, Family and Child Health, Faculty of Health and Social Sciences, University of South-Eastern Norway, Kongsberg N-3603, Norway; 2Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, NorwayCorrespondence: Bente DahlFaculty of Health and Social Sciences, University of South-Eastern Norway, P.O. Box 235, Kongsberg N-3603, NorwayTel +47 906 26 991Email bente.dahl@usn.noPurpose: To explore solo mothers’ postnatal caring experiences.Patients and Methods: A qualitative interview study including nine solo mothers living in six different counties in Norway. The mothers had a total of twelve children conceived through assisted fertilization and donor sperm. Systematic text condensation was used to analyze the data.Results: The first theme described how the decision to be a solo mother entailed responsibility and rendered solo mothers vulnerable. Secondly, it was valuable, but sometimes surprising, to be met with care and interest, but, and finally, bending standard rules and regulation of the postnatal ward proved necessary to fit the needs of solo mothers.Conclusion: Solo mothers see themselves as different from other mothers, and the results of this study underline that solo mothers’ individual needs are not always met in postnatal care.Keywords: assisted fertilization, donor sperm, postnatal, single mothers by choice, systematic text condensation, solo mothers

Introduction: Maternal-neonatal healthcare services were severely disrupted during the COVID-19 pandemic in even high-income countries within the World Health Organization (WHO) European Region. The objective of this study was to compare trends in the quality of maternal and neonatal care (QMNC) in Sweden and Norway to 12 other countries from the WHO European Region during the COVID-19 pandemic, and to identify domains for improvement., Material and Methods: This cross-sectional study included women giving birth in Europe from March 1, 2020 to December 31, 2022. Women answered an online, anonymous questionnaire which included 40 WHO Standard-based Quality Measures collectively scored as the total QMNC index (0-400) and separately in four subdomains (0-100): provision of care, experience of care, availability of human and physical resources, and reorganizational changes due to COVID-19. To assess reported QMNC changes over time, we used adjusted quantile regression models., Clinicaltrials: gov Identifier: NCT04847336., Results: Of the 45151 women included in the study, 13 117 (29.1%) were from Sweden and Norway and 32034 (70.9%) from the 12 WHO European countries. The total QMNC index for Sweden and Norway (median: 325, IQR: 285-355) was higher than the 12 WHO European countries (median: 315, IQR: 265-350, p < 0.001) as were trends in QMNC index over time (Sweden and Norway median: 310-345; 12 WHO European countries median: 305-340). Sweden and Norway also had higher scores in three-of-four QMNC subdomains, with the 12 WHO European countries scoring higher only for reorganizational changes due to COVID-19. In adjusted quantile models of the total QMNC index, Sweden and Norway had higher scores, with largest differences in the lower quantiles (p < 0.001 in all percentiles)., Conclusions: Across Europe, there are significant gaps in the quality of maternal-neonatal healthcare services. Although women giving birth in Sweden and Norway reported higher QMNC scores in all subdomains except for "reorganizational changes due to COVID-19," there is room for improvement and shared learning across Europe. Policymakers should prioritize long-term investments in maternal and neonatal healthcare, ensuring that facilities are adequately equipped during public health crises and that all women have access to high-quality, evidence-based, equitable, and respectful care., (© 2024 The Author(s). Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Introduction: This study assessed prevalence and time trends of pre-pregnancy obesity in immigrant and non-immigrant women in Norway and explored the impact of immigrants' length of residence on pre-pregnancy obesity prevalence., Material and Methods: Observational data from the Medical Birth Registry of Norway and Statistics Norway for the years 2016-2021 were analyzed. Immigrants were categorized by their country of birth and further grouped into seven super regions defined by the Global Burden of Disease study. Pre-pregnancy obesity was defined as a body mass index ≥30.0 kg/m 2 , with exceptions for certain Asian subgroups (≥27.5 kg/m 2 ). Statistical analysis involved linear regressions for trend analyses and log-binomial regressions for prevalence ratios (PRs)., Results: Among 275 609 pregnancies, 29.6% (N = 81 715) were to immigrant women. Overall, 13.6% were classified with pre-pregnancy obesity: 11.7% among immigrants and 14.4% among non-immigrants. Obesity prevalence increased in both immigrants and non-immigrants during the study period, with an average yearly increase of 0.62% (95% confidence interval [CI]: 0.55, 0.70). Obesity prevalence was especially high in women from Pakistan, Chile, Somalia, Congo, Nigeria, Ghana, Sri Lanka, and India (20.3%-26.9%). Immigrant women from "Sub-Saharan Africa" showed a strong association between longer residence length and higher obesity prevalence (≥11 years (23.1%) vs. <1 year (7.2%); adjusted PR = 2.40; 95% CI: 1.65-3.48), particularly in women from Kenya, Eritrea, and Congo., Conclusions: Prevalence of maternal pre-pregnancy obesity increased in both immigrant and non-immigrant women from 2016 to 2021. Several immigrant subgroups displayed a considerably elevated obesity prevalence, placing them at high risk for adverse obesity-related pregnancy outcomes. Particular attention should be directed towards women from "Sub-Saharan Africa", as their obesity prevalence more than doubled with longer residence., (© 2024 The Author(s). Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background: Health workers' (HWs') perspectives on the quality of maternal and newborn care (QMNC) are not routinely collected. In this cross-sectional study, we aimed to document HWs' perspectives on QMNC around childbirth in 12 World Health Organization (WHO) European countries., Methods: HWs involved in maternal/neonatal care for at least one year between March 2020 and March 2023 answered an online validated WHO standards-based questionnaire collecting 40 quality measures for improving QMNC. A QMNC index (score 0-400) was calculated as a synthetic measure., Results: Data from 4143 respondents were analysed. For 39 out of 40 quality measures, at least 20% of HWs reported a 'need for improvement', with large variations across countries. Effective training on healthy women/newborns management (n = 2748, 66.3%), availability of informed consent job aids (n = 2770, 66.9%), and effective training on women/newborns rights (n = 2714, 65.5%) presented the highest proportion of HWs stating 'need for improvement'. Overall, 64.8% (n = 2684) of respondents declared that HWs' numbers were insufficient for appropriate care (66.3% in Portugal and 86.6% in Poland), and 22.4% described staff censorship (16.3% in Germany and 56.7% in Poland). The reported QMNC index was low in all countries (Poland median (MD) = 210.60, interquartile range (IQR) = 155.71, 273.57; Norway MD = 277.86; IQR = 244.32, 308.30). The 'experience of care' domain presented in eight countries had significantly lower scores than the other domains (P < 0.001). Over time, there was a significant monthly linear decrease in the QMNC index (P < 0.001), lacking correlation with the coronavirus disease 2019 (COVID-19) pandemic trends (P > 0.05). Multivariate analyses confirmed large QMNC variation by country. HWs with <10 years of experience, HWs from public facilities, and midwives rated QMNC with significantly lower scores (P < 0.001)., Conclusions: HWs from 12 European countries reported significant gaps in QMNC, lacking association with COVID-19 pandemic trends. Routine monitoring of QMNC and tailored actions are needed to improve health services for the benefit of both users and providers., Registration: ClinicalTrials.gov NCT04847336., Competing Interests: Disclosure of interests: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

Introduction: The integration of technology within teaching offers efficient and diverse learning opportunities. Studies have shown that the use of virtual reality (VR), improves anatomical knowledge and spatial understanding. The aim of this pilot study was to examine whether the utilization of immersive virtual reality goggles as a learning tool for anatomy increase midwifery students' knowledge, and to explore the potential of replacing traditional classroom teaching with VR., Methods: We conducted a pre-post pilot study using a questionnaire before and after the use of VR as a learning tool in two cohorts of midwifery students in higher education. Cohort one had completed eight hours of classroom teaching of anatomy before participating in the VR session., Results: The study included 44 midwifery students from two different classes at the same Master's program in midwifery at a university college in Norway. Student in both cohorts were in their first semester of midwifery studies and possessed a Bachelor's degree in nursing. Both cohorts had an increased average mean score in anatomical knowledge immediate after and 14 days after attending the learning session in VR. Students from the cohort that did not participate in anatomy lectures scored high on knowledge, both before and after the session in VR compared to the cohort that had additional classroom teaching in anatomy., Conclusions: Implementing VR as a learning tool, can contribute to increase spatial understanding and anatomical knowledge. By focusing on student learning in combination with learning activities and collaboration, the technology helps students gain understanding and knowledge., Competing Interests: The authors have completed and submitted the ICMJE Form for disclosure of Potential Conflicts of Interest and none was reported., (© 2024 Aasekjær K. et al.)

Aim: To explore midwives' experiences with providing home-based postpartum care during the COVID-19 pandemic in Norway., Design: A descriptive and explorative qualitative study., Methods: The study is based on semi-structured individual interviews with 11 midwives experienced in offering home-based postpartum care. We explored their experiences of such care during the first wave of the COVID-19 pandemic. Data collection occurred from October through November 2020. An inductive thematic analysis was performed using Systematic Text Condensation (STC) by Malterud (2012)., Results: The following two main results emerged from the analyses: (1) the midwives adapted quickly to changes in postpartum care during the pandemic and (2) midwives saw the experience as an opportunity to re-evaluate their practices., Conclusion: This study highlights midwives' resilience and adaptability during the first wave of COVID-19 pandemic. It emphasises the crucial role of face-to-face interactions in postpartum care, while recognising the value of technology when direct access is limited. By shedding light on midwives' experiences, this research contributes to improving postpartum care in unforeseen circumstances. It underscores the significance of interdisciplinary integration in planning postpartum care services and the lasting influence of lessons learned on addressing future challenges., Implications for Practice: The valuable insights gained from lessons learned during the COVID-19 pandemic may have a lasting influence on the postpartum care system, empowering it to tackle unforeseen challenges both today and in the future., Impact: The current study addressed midwives' experience with providing home-based postpartum care during the COVID-19 pandemic in Norway. Midwives received an opportunity to re-evaluate their own practices and valued being included when changes were implemented. The current findings should alert policy makers, leaders and clinicians in postpartum care services when planning future practice., (© 2023 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Background: Little is known about women's experience of care and views on early breastfeeding during the COVID-19 pandemic in Norway., Methods: Women (n = 2922) who gave birth in a facility in Norway between March 2020 and June 2021 were invited to answer an online questionnaire based on World Health Organization (WHO) Standard-based quality measures, exploring their experiences of care and views on early breastfeeding during the COVID-19 pandemic. To examine associations between year of birth (2020, 2021) and early breastfeeding-related factors, we estimated odds ratios (ORs) with 95% confidence intervals (CIs) using multiple logistic regression. Qualitative data were analysed using Systematic Text Condensation., Results: Compared to the first year of the pandemic (2020), women who gave birth in 2021 reported higher odds of experiencing adequate breastfeeding support (adjOR 1.79; 95% CI 1.35, 2.38), immediate attention from healthcare providers when needed (adjOR 1.89; 95% CI 1.49, 2.39), clear communication from healthcare providers (adjOR 1.76; 95% CI 1.39, 2.22), being allowed companion of choice (adjOR 1.47; 95% CI 1.21, 1.79), adequate visiting hours for partner (adjOR 1.35; 95% CI 1.09, 1.68), adequate number of healthcare providers (adjOR 1.24; 95% CI 1.02, 1.52), and adequate professionalism of the healthcare providers (adjOR 1.65; 95% CI 1.32, 2.08). Compared to 2020, in 2021 we found no difference in skin-to-skin contact, early breastfeeding, exclusive breastfeeding at discharge, adequate number of women per room, or women's satisfaction. In their comments, women described understaffed postnatal wards, early discharge and highlighted the importance of breastfeeding support, and concerns about long-term consequences such as postpartum depression., Conclusions: In the second year of the pandemic, WHO Standard-based quality measures related to breastfeeding improved for women giving birth in Norway compared to the first year of the pandemic. Women's general satisfaction with care during COVID-19 did however not improve significantly from 2020 to 2021. Compared to pre-pandemic data, our findings suggest an initial decrease in exclusive breastfeeding at discharge during the COVID-19 pandemic in Norway with little difference comparing 2020 versus 2021. Our findings should alert researchers, policy makers and clinicians in postnatal care services to improve future practices., (© 2023. The Author(s).)

Objective: To describe the perception of quality of maternal and newborn care (QMNC) around the time of childbirth among migrant and nonmigrant women in Europe., Methods: Women who gave birth at a health facility in 11 countries of the WHO European Region from March 2020 to July 2021 were invited to answer an online questionnaire including demographics and childbirth experience. Data were analyzed and compared for 1781 migrant and 20 653 nonmigrant women., Results: Migrant women who experienced labor perceived slightly more difficulties in attending routine antenatal visits (41.2% vs 39.4%; P = 0.001), more barriers in accessing facilities (32.9% vs 29.9%; P = 0.001), lack of timely care (14.7% vs 13.0%; P = 0.025), inadequate room comfort and equipment (9.2% vs 8.5%; P = 0.004), inadequate number of women per room (9.4% vs 8.6%; P = 0.039), being prevented from staying with their baby as they wished (7.8% vs 6.9%; P = 0.011), or suffering abuse (14.5% vs 12.7%; P = 0.022) compared with nonmigrant women. For women who had a prelabor cesarean, migrant women were more likely not to receive pain relief after birth (16.8% vs.13.5%; P = 0.039) and less likely to provide informal payment (1.8% vs 4.4%; P = 0.005) compared with nonmigrant women. Overall, the QMNC index was not significantly different for migrant compared with nonmigrant women., Conclusion: Gaps in overall QMNC were reported by both migrant and nonmigrant women, with improvements to healthcare necessary for all., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: To describe maternal perception of the quality of maternal and newborn care (QMNC) in facilities in Norway during the first year of COVID-19 pandemic., Methods: Women who gave birth in a Norwegian facility from March 1, 2020, to October 28, 2021, filled out a structured online questionnaire based on 40 WHO standards-based quality measures. Quantile regression analysis was performed to assess changes in QMNC index over time., Results: Among 3326 women included, 3085 experienced labor. Of those, 1799 (58.3%) reported that their partner could not be present as much as needed, 918 (29.8%) noted inadequate staff numbers, 183 (43.6%) lacked a consent request for instrumental vaginal birth (IVB), 1067 (34.6%) reported inadequate communication from staff, 78 (18.6%) reported fundal pressure during IVB, 670 (21.7%) reported that they were not treated with dignity, and 249 (8.1%) reported experiencing abuse. The QMNC index increased gradually over time (3.68 points per month, 95% CI, 2.83-4.53 for the median), with the domains of COVID-19 reorganizational changes and experience of care displaying the greatest increases, while provision of care was stable over time., Conclusion: Although several measures showed high QMNC in Norway during the first year of the COVID-19 pandemic, and a gradual improvement over time, several findings suggest that gaps in QMNC exist. These gaps should be addressed and monitored., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Competing Interests: ES has no commercial contracts. She has received research funding from WHO, UNICEF, and USAID for work related to quality of maternal and pediatric care. All other authors have none to declare.

Introduction: The first contact with the labor ward is a crucial moment in any birth and can be especially challenging when the woman has a migrant background. The aim of the study was to explore migrant Somali women's experiences with their first contact with the labor ward prior to admission, in Norway., Methods: In this qualitative study, data were collected through semi-structured individual interviews and Systematic Text Condensation was the method used to analyze the data. Ten Somali-born women who had given birth in Norway were included., Results: The migrant Somali women's first contact with the labor ward prior to admission was challenging, due to one-way communication, poor health literacy, and a fear of interventions or adverse outcomes. To improve care, the migrant Somali women highlighted a need for: 1) flexibility, tailored information and practical guidance before birth; and 2) face-to-face assessment in early labor., Conclusions: The findings in this study indicate that the needs of laboring migrant Somali women are not fully met by antenatal or pre-hospital maternity care services. To improve the critical first contact with the labor ward for migrant Somali women, this study suggests that antenatal care services offer practical guidance on whom to contact and what to expect at the hospital in early labor. Face-to-face assessment of maternal and fetal well-being should be the first choice of care for Somali women in early labor who are unfamiliar with the healthcare system after immigration. Interpretation services need strengthening and our findings support a need for increased continuity of care., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2022 Vik E. S. et al.)

Introduction: The length of postpartum hospital stays is decreasing internationally. The ongoing organizational change from hospital to home-based postpartum care implies the promotion of family-centered care for healthy women, their babies and families. The aim of the study was to explore midwives' experiences of an organizational change in early postpartum care services from hospital to home-based care in Norway., Methods: Ten midwives participated in two separate focus-group interviews. Systematic Text Condensation (STC) was the method used to analyze the data., Results: The midwives in the current study described that the organizational change in early postpartum care services from hospital to home-based care was characterized by: 1) unclear leadership, 2) increased continuity of care and professional growth, and 3) the midwives being solution-oriented., Conclusions: The midwives had both positive and negative experiences of an organizational change in early postpartum care services from hospital to home-based care in Norway. The study indicates a need for increased resources, training in new tasks and employees being more included when changes in midwifery practice are planned and implemented. The current study contributes knowledge of relevance to those planning to start home-based postpartum care, which may contribute to improving quality of care, employees' satisfaction and prevent burnout., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2022 Vik E. S. et al.)

Objectives: Develop and validate a WHO Standards-based online questionnaire to measure the quality of maternal and newborn care (QMNC) around the time of childbirth from the health workers' perspective., Design: Mixed-methods study., Setting: Six countries of the WHO European Region., Participants and Methods: The questionnaire is based on lessons learnt in previous studies, and was developed in three sequential phases: (1) WHO Quality Measures were prioritised and content, construct and face validity were assessed through a Delphi involving a multidisciplinary board of experts from 11 countries of the WHO European Region; (2) translation/back translation of the English version was conducted following The Professional Society for Health Economics and Outcomes Research guidelines; (3) internal consistency, intrarater reliability and acceptability were assessed among 600 health workers in six countries., Results: The questionnaire included 40 items based on WHO Standards Quality Measures, equally divided into four domains: provision of care, experience of care, availability of human and physical resources, organisational changes due to COVID-19; and its organised in six sections. It was translated/back translated in 12 languages: Bosnian, Croatian, French, German, Italian, Norwegian, Portuguese, Romanian, Russian, Slovenian, Spanish and Swedish. The Cronbach's alpha values were ≥0.70 for each questionnaire section where questions were hypothesised to be interrelated, indicating good internal consistence. Cohen K or Gwet's AC1 values were ≥0.60, suggesting good intrarater reliability, except for one question. Acceptability was good with only 1.70% of health workers requesting minimal changes in question wording., Conclusions: Findings suggest that the questionnaire has good content, construct, face validity, internal consistency, intrarater reliability and acceptability in six countries of the WHO European Region. Future studies may further explore the questionnaire's use in other countries, and how to translate evidence generated by this tool into policies to improve the QMNC., Trail Registration Number: NCT04847336., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

TCR-like antibodies represent a unique type of engineered antibodies with specificity toward pHLA, a ligand normally restricted to the sensitive recognition by T cells. Here, we report a phage display-based sequential development path of such antibodies. The strategy goes from initial lead identification through in silico informed CDR engineering in combination with framework engineering for affinity and thermostability optimization, respectively. The strategy allowed the identification of HLA-DQ2.5 gluten peptide-specific TCR-like antibodies with low picomolar affinity. Our method outlines an efficient and general method for development of this promising class of antibodies, which should facilitate their utility including translation to human therapy., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID-19 pandemic, as defined by WHO Standards, are lacking., Methods: Women who gave birth in 12 countries of the WHO European Region from March 1, 2020 - March 15, 2021 answered an online questionnaire, including 40 WHO Standard-based Quality Measures., Findings: 21,027 mothers were included in the analysis. Among those who experienced labour (N=18,063), 41·8% (26·1%- 63·5%) experienced difficulties in accessing antenatal care, 62% (12·6%-99·0%) were not allowed a companion of choice, 31·1% (16·5%-56·9%) received inadequate breastfeeding support, 34·4% (5·2%-64·8%) reported that health workers were not always using protective personal equipment, and 31·8% (17·8%-53·1%) rated the health workers' number as "insufficient". Episiotomy was performed in 20·1% (6·1%-66·0%) of spontaneous vaginal births and fundal pressure applied in 41·2% (11·5% -100%) of instrumental vaginal births. In addition, 23·9% women felt they were not treated with dignity (12·8%-59·8%), 12·5% (7·0%-23·4%) suffered abuse, and 2·4% (0·1%-26·2%) made informal payments. Most findings were significantly worse among women with prelabour caesarean birth (N=2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significant lower QMNC Indexes and Luxemburg showing a significantly higher QMNC Index than the total sample. Younger women and those with operative births also reported significantly lower QMNC Indexes., Interpretation: Mothers reports revealed large inequities in QMNC across countries of the WHO European Region. Quality improvement initiatives to reduce these inequities and promote evidence-based, patient-centred respectful care for all mothers and newborns during the COVID-19 pandemic and beyond are urgently needed., Funding: The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy., Study Registration: ClinicalTrials.gov Identifier: NCT04847336., Competing Interests: Céline Miani's position as a post-doctoral researcher is funded by Bielefeld University. Catarina Barata had a PhD grant FCT/FSE (SFRH/BD/128600/2017) while she was voluntarily writing this article. She is board member, unpaid collaboration, of Associação Portuguesa pelos Direitos da Mulher na Gravidez e Parto (APDMGP). Daniela Drandić received a salary during the time she was volunteer-writing this article was from a grant from the Erasmus+ programme of the European Commission, regarding a project on parenting support and from a grant from the UNICEF Croatia, regarding a project on online education for pregnant women during COVID. She is a board member of an NGO called Human Rights in Childbirth, and has been for the entire time she worked on this paper. Dr Emma Sacks has received research funding from the World Health Organization related to the mistreatment of women and newborns in health facilities. The project has no impact on the present manuscript outside of similar topics. She is the former co-chair of the Newborn Health Working Group of the Global Respectful Maternity Care Council. Other authors have none to declare., (© 2021 The Author(s).)

Antibodies specific for peptides bound to human leukocyte antigen (HLA) molecules are valuable tools for studies of antigen presentation and may have therapeutic potential. Here, we generated human T cell receptor (TCR)-like antibodies toward the immunodominant signature gluten epitope DQ2.5-glia-α2 in celiac disease (CeD). Phage display selection combined with secondary targeted engineering was used to obtain highly specific antibodies with picomolar affinity. The crystal structure of a Fab fragment of the lead antibody 3.C11 in complex with HLA-DQ2.5:DQ2.5-glia-α2 revealed a binding geometry and interaction mode highly similar to prototypic TCRs specific for the same complex. Assessment of CeD biopsy material confirmed disease specificity and reinforced the notion that abundant plasma cells present antigen in the inflamed CeD gut. Furthermore, 3.C11 specifically inhibited activation and proliferation of gluten-specific CD4 + T cells in vitro and in HLA-DQ2.5 humanized mice, suggesting a potential for targeted intervention without compromising systemic immunity., (Copyright © 2021 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Background In cardiovascular diseases, atherosclerotic disorder are the most frequent and important with respect to morbidity and mortality. Inflammation mediated by immune cells is central in all parts of the atherosclerotic progress, and further understanding of the underlying mechanisms is needed. Growing evidence suggests that deamination of adenosine-to-inosine in RNA is crucial for a correct immune response; nevertheless, the role of adenosine-to-inosine RNA editing in atherogenesis has barely been studied. Several proteins have affinity for inosines in RNA, one being ENDOV (endonuclease V), which binds and cleaves RNA at inosines. Data on ENDOV in atherosclerosis are lacking. Methods and Results Quantitative polymerase chain reaction on ENDOV mRNA showed an increased level in human carotid atherosclerotic plaques compared with control veins. Inosine-ribonuclease activity as measured by an enzyme activity assay is detected in immune cells relevant for the atherosclerotic process. Abolishing EndoV in atherogenic apolipoprotein E-deficient ( ApoE -/- ) mice reduces the atherosclerotic plaque burden, both in size and lipid content. In addition, in a brain stroke model, mice without ENDOV suffer less damage than control mice. Finally, lack of EndoV reduces the recruitment of monocytes to atherosclerotic lesions in atherogenic ApoE -/- mice. Conclusions ENDOV is upregulated in human atherosclerotic lesions, and data from mice suggest that ENDOV promotes atherogenesis by enhancing the monocyte recruitment into the atherosclerotic lesion, potentially by increasing the effect of CCL2 activation on these cells.

Aims: Immigrant women are at higher risk for gestational diabetes mellitus (GDM) than non-immigrant women. This study described the prevalence of GDM in immigrant women by maternal country of birth and examined the associations between immigrants' length of residence in Norway and GDM., Methods: This Norwegian national population-based study included 192,892 pregnancies to immigrant and 1,116,954 pregnancies to non-immigrant women giving birth during the period 1990-2013. Associations were reported as odds ratios (ORs) with 95% confidence intervals (CIs) using logistic regression models, adjusted for year of delivery, maternal age, marital status, health region, parity, education and income., Results: The prevalence and adjusted OR [CI] for GDM were substantially higher in immigrant women from Bangladesh (7.4%, OR 8.38 [5.41, 12.97]), Sri Lanka (6.3%, OR 7.60 [6.71, 8.60]), Pakistan (4.3%, OR 5.47 [4.90, 6.11]), India (4.4%, OR 5.18 [4.30, 6.24]) and Morocco (4.3%, OR 4.35 [3.63, 5.20]) compared to non-immigrants (prevalence 0.8%). Overall, GDM prevalence increased from 1.3% (OR 1.25 [1.14, 1.36]) to 3.3% (OR 2.55 [2.39, 2.71]) after 9 years of residence in immigrants compared to non-immigrant women. This association was particularly strong for women from South Asia., Conclusions: Gestational diabetes mellitus prevalence varied substantially between countries of maternal birth and was particularly high in immigrants from Asian countries. GDM appeared to increase with longer length of residence in certain immigrant groups., (© 2020 Diabetes UK.)

Background: Immigrant women are a vulnerable group within Norwegian prenatal care and have an increased risk of adverse pregnancy outcomes. The purpose of this exploratory literature review was to compile an overview of the available knowledge on the prenatal health of immigrant women in Norway., Evidence Base: The literature review covers 44 peer-reviewed articles on the prenatal health of immigrant women in Norway. The articles reflect a variety of study designs and were published in the period 2000-2019. Searches were conducted in MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, Maternity & Infant Care Database and SveMed+., Results: Frequently studied topics included gestational diabetes, obesity, hyperemesis gravidarum, preeclampsia and folate use. We found a considerable variation in the disease risk for different sub-groups of immigrants., Interpretation: Little research has been conducted on especially vulnerable immigrant groups, such as new arrivals, undocumented immigrants and refugees. We recommend that future studies consider using a qualitative research design that sheds light on the experiences of immigrant families, as well as intervention studies that test the effectiveness of measures for improving prenatal care.

Objective: To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway., Design: Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990-2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region., Main Outcome: Epidural analgesia for labour pain., Results: Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50-0.59) and Somalia (adjOR 0.63; CI 0.58-0.68) and highest in women from Iran (adjOR 1.32; CI 1.19-1.46) and India (adjOR 1.19; CI 1.06-1.33). Refugees (adjOR 0.83; CI 0.79-0.87) and newly arrived migrants (adjOR 0.92; CI 0.89-0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11-1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02-1.10) had higher odds., Conclusion: The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Migration is a risk factor for adverse neonatal outcomes. The various impacts of maternal origin have been reported previously. The aim of this study was to investigate associations between paternal origin and adverse neonatal outcomes in births to migrant and Norwegian-born women in Norway., Methods and Findings: This nationwide population-based study included births to migrant (n = 240,759, mean age 29.6 years [±5.3 SD]) and Norwegian-born women (n = 1,232,327, mean age 29.0 years [±5.1 SD]) giving birth in Norway in 1990-2016. The main exposure was paternal origin (Norwegian-born, foreign-born, or unregistered). Neonatal outcomes were very preterm birth (22+0-31+6 gestational weeks), moderately preterm birth (32+0-36+6 gestational weeks), small for gestational age (SGA), low Apgar score (<7 at 5 minutes), and stillbirth. Associations were investigated in migrant and Norwegian-born women separately using multiple logistic regression and reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs), adjusted for year of birth, parity, maternal and paternal age, marital status, maternal education, and mother's gross income. In births to migrant women, a foreign-born father was associated with increased odds of very preterm birth (1.1% versus 0.9%, aOR 1.20; CI 1.08-1.33, p = 0.001), SGA (13.4% versus 9.5%, aOR 1.48; CI 1.43-1.53, p < 0.001), low Apgar score (1.7% versus 1.5%, aOR 1.14; CI 1.05-1.23, p = 0.001), and stillbirth (0.5% versus 0.3%, aOR 1.26; CI 1.08-1.48, p = 0.004) compared with a Norwegian-born father. In Norwegian-born women, a foreign-born father was associated with increased odds of SGA (9.3% versus 8.1%, aOR 1.13; CI 1.09-1.16, p < 0.001) and decreased odds of moderately preterm birth (4.3% versus 4.4%, aOR 0.95; CI 0.91-0.99, p = 0.015) when compared with a Norwegian-born father. In migrant women, unregistered paternal origin was associated with increased odds of very preterm birth (2.2% versus 0.9%, aOR 2.29; CI 1.97-2.66, p < 0.001), moderately preterm birth (5.6% versus 4.7%, aOR 1.15; CI 1.06-1.25, p = 0.001), SGA (13.0% versus 9.5%, aOR 1.50; CI 1.42-1.58, p < 0.001), low Apgar score (3.4% versus 1.5%, aOR 2.23; CI 1.99-2.50, p < 0.001), and stillbirth (1.5% versus 0.3%, aOR 4.87; CI 3.98-5.96, p < 0.001) compared with a Norwegian-born father. In Norwegian-born women, unregistered paternal origin was associated with increased odds of very preterm birth (4.6% versus 1.0%, aOR 4.39; CI 4.05-4.76, p < 0.001), moderately preterm birth (7.8% versus 4.4%, aOR 1.62; CI 1.53-1.71, p < 0.001), SGA (11.4% versus 8.1%, aOR 1.30; CI 1.24-1.36, p < 0.001), low Apgar score (4.6% versus 1.3%, aOR 3.51; CI 3.26-3.78, p < 0.001), and stillbirth (3.2% versus 0.4%, aOR 9.00; CI 8.15-9.93, p < 0.001) compared with births with a Norwegian-born father. The main limitations of this study were the restricted access to paternal demographics and inability to account for all lifestyle factors., Conclusion: We found that a foreign-born father was associated with adverse neonatal outcomes among births to migrant women, but to a lesser degree among births to nonmigrant women, when compared with a Norwegian-born father. Unregistered paternal origin was associated with higher odds of adverse neonatal outcomes in births to both migrant and nonmigrant women when compared with Norwegian-born fathers. Increased attention to paternal origin may help identify women in maternity care at risk for adverse neonatal outcomes., Competing Interests: The authors have declared that no competing interests exist.

Background: This study compares subsequent birth outcomes in migrant women who had already had a child before arriving in Norway with those in migrant women whose first birth occurred in Norway. The aim of this study was to investigate the associations between country of first birth and adverse neonatal outcomes (very preterm birth, moderately preterm birth, post-term birth, small for gestational age, large for gestational age, low Apgar score, stillbirth and neonatal death) in parous migrant and Norwegian-born women., Methods: National population-based study including second and subsequent singleton births in Norway from 1990 to 2016. Data were retrieved from the Medical Birth Registry of Norway and Statistics Norway. Neonatal outcomes were compared between births to: 1) migrant women with a first birth before immigration to Norway (n = 30,062) versus those with a first birth after immigration (n = 66,006), and 2) Norwegian-born women with a first birth outside Norway (n = 6205) versus those with a first birth in Norway (n = 514,799). Associations were estimated as crude and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using multiple logistic regression., Results: Migrant women with a first birth before immigrating to Norway had increased odds of adverse outcomes in subsequent births relative to those with a first birth after immigration: very preterm birth (22-31 gestational weeks; aOR = 1.27; CI 1.09-1.48), moderately preterm birth (32-36 gestational weeks; aOR = 1.10; CI 1.02-1.18), post-term birth (≥42 gestational weeks; aOR = 1.19; CI 1.11-1.27), low Apgar score (< 7 at 5 min; aOR = 1.27; CI 1.16-1.39) and stillbirth (aOR = 1.29; CI 1.05-1.58). Similar results were found in the sample of births to Norwegian-born women., Conclusions: The increased odds of adverse neonatal outcomes for migrant and Norwegian-born women who had their first births outside Norway should serve as a reminder of the importance of taking a careful obstetric history in these parous women to ensure appropriate care for their subsequent pregnancies and births in Norway.

Endonuclease V (EndoV) is a conserved inosine-specific ribonuclease with unknown biological function. Here, we present the first mouse model lacking EndoV, which is viable without visible abnormalities. We show that endogenous murine EndoV cleaves inosine-containing RNA in vitro, nevertheless a series of experiments fails to link an in vivo function to processing of such transcripts. As inosine levels and adenosine-to-inosine editing often are dysregulated in hepatocellular carcinoma (HCC), we chemically induced HCC in mice. All mice developed liver cancer, however, EndoV-/- tumors were significantly fewer and smaller than wild type tumors. Opposed to human HCC, adenosine deaminase mRNA expression and site-specific editing were unaltered in our model. Loss of EndoV did not affect editing levels in liver tumors, however mRNA expression of a selection of cancer related genes were reduced. Inosines are also found in certain tRNAs and tRNAs are cleaved during stress to produce signaling entities. tRNA fragmentation was dysregulated in EndoV-/- livers and apparently, inosine-independent. We speculate that the inosine-ribonuclease activity of EndoV is disabled in vivo, but RNA binding allowed to promote stabilization of transcripts or recruitment of proteins to fine-tune gene expression. The EndoV-/- tumor suppressive phenotype calls for related studies in human HCC., (© The Author(s) 2020. Published by Oxford University Press on behalf of Nucleic Acids Research.)

Objective: To explore Somali women's experiences of antenatal care in Norway., Design: A qualitative study based on individual semi-structured interviews conducted either face-to-face or over the phone., Setting: Norway., Participants: Eight Somali-born women living in Norway., Key Findings: Four themes were generated from the analysis. From their experiences of antenatal care in Norway, the Somali women described: 1) when care was provided in a way that gained their trust, they made better use of the available health services, 2) the importance of continuity of care and of sharing commonalities with the caregiver, 3) a need for accessible information, specifically tailored to the needs of Somali women and 4) how culturally insensitive caregivers had a negative impact on the quality of care., Conclusion and Implications for Practice: The Somali women in this study were grateful for the care provided, although the quality of antenatal care did not always meet their needs. This study should serve as a reminder of the importance of establishing trust between the pregnant woman and the caregiver, strengthening interpretation services and assuring tailored information is available to Somali women at an early stage. The findings further suggest that antenatal care for Somali women may be improved by offering continuity of care and improving clinical and cultural skills in clinicians. Suggestions for practice, and future research, include initiating group antenatal care especially tailored to Somali women., Competing Interests: Declaration of Competing Interest None Declared., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

This study examines how preconception folic acid supplement use varied in immigrant women compared with non-immigrant women. We analyzed national population-based data from Norway from 1999-2016, including 1,055,886 pregnancies, of which 202,234 and 7,965 were to 1st and 2nd generation immigrant women, respectively. Folic acid supplement use was examined in relation to generational immigrant category, maternal country of birth, and length of residence. Folic acid supplement use was lower overall in 1st and 2nd generation immigrant women (21% and 26%, respectively) compared with Norwegian-born women (29%). The lowest use among 1st generation immigrant women was seen in those from Eritrea, Ethiopia, Morocco, and Somalia (around 10%). The highest use was seen in immigrant women from the United States, the Netherlands, Denmark, and Iceland (>30%). Folic acid supplement use increased with increasing length of residence in immigrant women from most countries, but the overall prevalence was lower compared with Norwegian-born women even after 20 years of residence (adjusted odds ratio: 0.63; 95% confidence interval: 0.60-0.67). This study suggests that immigrant women from a number of countries are less likely to use preconception folic acid supplements than non-immigrant women, even many years after settlement.

Aim: To explore emergency medical technicians' experiences with unplanned births outside institutions., Design: A qualitative interview study., Methods: Individual semi-structured interviews with 12 emergency medical technicians in Norway. Systematic text condensation was used to analyse the data material., Results: Analysis showed that there is a mismatch between society's expectations about emergency medical technicians and the reality they encounter in out-of-hospital maternity care, that emergency medical technicians experience a general lack of training in caring for labouring women and that poor communication with other health professions challenges patient safety. The participants expressed how they do their best in caring for both mother and child, in spite of a lack of education, training and competence in assisting labouring women., Competing Interests: We have no conflicts of interest to disclose., (© 2019 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Background: Migrant women's overall increased risk of adverse pregnancy outcomes is well known. The aim of this study was to investigate possible associations between stillbirth and maternal country of birth and other migration related factors (paternal origin, reason for immigration, length of residence and birthplace of firstborn child) in migrant women in Norway., Methods: Nationwide population-based study including births to primiparous and multiparous migrant women (n = 198,520) and non-migrant women (n = 1,156,444) in Norway between 1990 and 2013. Data from the Medical Birth Registry of Norway and Statistics Norway. Associations were investigated by multiple logistic regression and reported as odds ratios (ORs) with 95% confidence intervals (CIs)., Results: Primiparous women from Sri-Lanka and Pakistan, and multiparous women from Pakistan, Somalia, the Philippines and Former Yugoslavia had higher odds of stillbirth when compared to non-migrant women (adjusted OR ranged from 1.58 to 1.79 in primiparous and 1.50 to 1.71 in multiparous women). Primiparous migrant women whose babies were registered with Norwegian-born fathers had decreased odds of stillbirth compared to migrant women whose babies were registered with foreign-born fathers (aOR = 0.73; CI 0.58-0.93). Primiparous women migrating for work or education had decreased odds of stillbirth compared to Nordic migrants (aOR = 0.58; CI 0.39-0.88). Multiparous migrant women who had given birth to their first child before arriving in Norway had higher odds of stillbirth in later births in Norway compared with multiparous migrant women who had their first child after arrival (aOR = 1.28; CI 1.06-1.55). Stillbirth was not associated with length of residence in Norway., Conclusions: This study identifies sub-groups of migrant women who are at an increased risk of stillbirth, and highlights the need to improve care for them. More attention should be paid to women from certain countries, multiparous women who had their first baby before arrival and primiparous women whose babies have foreign-born fathers.

Background: To investigate whether the occurrence of preeclampsia varied by maternal reasons for immigration., Methods: We included 1,287,270 singleton pregnancies (163,508 to immigrant women) in Norway during 1990-2013. Individual data were obtained through record linkage between the Medical Birth Registry of Norway and Statistics Norway. Analyses were performed for preeclampsia overall and in combination with preterm birth < 37 and < 34 weeks of gestation, referred to as preterm and very preterm preeclampsia. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using logistic regression with robust standard errors, adjusted for relevant covariates, including maternal income and education., Results: Preeclampsia was reported in 3.5% of Norwegian women and 2.5% of immigrants. Compared with Norwegian women, the adjusted OR for preeclampsia was lowest in labour immigrants (adjusted OR 0.55 [95% CI 0.49-0.62]), followed by family immigrants (0.62 [0.59-0.65]), immigrant students (0.75 [0.65-0.86]), refugees (0.81 [0.75-0.88]), and immigrants from other Nordic countries (0.87 [0.80-0.94]). Compared with Norwegian women, labour immigrants also had lower adjusted odds of preterm and very preterm preeclampsia, whereas refugees had increased adjusted odds of preterm and very preterm preeclampsia (< 37 weeks: 1.18 [1.02-1.36], and < 34 weeks: 1.41 [1.15-1.72])., Conclusions: The occurrence of preeclampsia was lower overall in immigrants than in non-immigrants, but associations varied by maternal reasons for immigration. Maternity caregivers should pay increased attention to pregnant women with refugee backgrounds due to their excess odds of preterm preeclampsia.

Apathy is one of the most prevalent and progressive psychiatric symptoms in Huntington's disease (HD) patients. However, preclinical work in HD mouse models tends to focus on molecular and motor, rather than affective, phenotypes. Measuring behavior in mice often produces noisy data and requires large cohorts to detect phenotypic rescue with appropriate power. The operant equipment necessary for measuring affective phenotypes is typically expensive, proprietary to commercial entities, and bulky which can render adequately sized mouse cohorts as cost-prohibitive. Thus, we describe here a home-built, open-source alternative to commercial hardware that is reliable, scalable, and reproducible. Using off-the-shelf hardware, we adapted and built several of the rodent operant buckets (ROBucket) to test Htt Q111/+ mice for attention deficits in fixed ratio (FR) and progressive ratio (PR) tasks. We find that, despite normal performance in reward attainment in the FR task, Htt Q111/+ mice exhibit reduced PR performance at 9-11 months of age, suggesting motivational deficits. We replicated this in two independent cohorts, demonstrating the reliability and utility of both the apathetic phenotype, and these ROBuckets, for preclinical HD studies.

Objective: To explore women's experiences with giving birth before arrival., Design: A qualitative interview study., Setting: Individual semi structured interviews with women from Western Norway conducted in their homes in 2015., Participants: 10 women who experienced BBA-births in 2014, or the beginning of 2015. Two primiparous and eight multiparous women participated in the study., Key Findings: Three themes were generated from the analysis. In the encounter with the healthcare services, the women described midwives as gatekeepers defining active labour. Giving birth before arrival was dramatic, but at some point fear of giving birth alone was replaced by feelings of coping, and in hindsight they felt empowered. The women described giving birth before arrival to be a special experience, but this was not always acknowledged by the midwives., Conclusion and Implications for Practice: The findings in this study question the cost-benefit of today's maternity care system pointing towards a more differentiated and decentralised care. To enhance patient safety adequate capacity of midwives in the maternity care is essential. Furthermore, good communication skills are key to improving practice and enhancing safety. Further research must be conducted., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Endonuclease V (EndoV) is an enzyme with specificity for inosines in nucleic acids. Whereas the bacterial homologs are active on both DNA and RNA, the mammalian variants only cleave RNA, at least when assayed with recombinant proteins. Here we show that ectopically expressed, as well as endogenously expressed human (h)EndoV, share the same enzymatic properties as the recombinant protein and cleaves RNA with inosine but not DNA. In search for proteins interacting with hEndoV, polyadenylate-binding protein C1 (PABPC1) was identified. The association between PABPC1 and hEndoV is RNA dependent and furthermore, PABPC1 stimulates hEndoV activity and affinity for inosine-containing RNA. Upon cellular stress, PABPC1 relocates to cytoplasmic stress granules that are multimolecular aggregates of stalled translation initiation complexes formed to aid cell recovery. Arsenite, as well as other agents, triggered relocalization also of hEndoV to cytoplasmic stress granules. As inosines in RNA are highly abundant, hEndoV activity is likely regulated in cells to avoid aberrant cleavage of inosine-containing transcripts. Indeed, we find that hEndoV cleavage is inhibited by normal intracellular ATP concentrations. The ATP stores inside a cell do not overlay stress granules and we suggest that hEndoV is redistributed to stress granules as a strategy to create a local environment low in ATP to permit hEndoV activity., (© 2016 by The American Society for Biochemistry and Molecular Biology, Inc.)

Endonuclease V (EndoV) is an enzyme with specificity for deaminated adenosine (inosine) in nucleic acids. EndoV from Escherichia coli (EcEndoV) acts both on inosines in DNA and RNA, whereas the human homolog cleaves only at inosines in RNA. Inosines in DNA are mutagenic and the role of EndoV in DNA repair is well established. In contrast, the biological function of EndoV in RNA processing is largely unexplored. Here we have characterized a second mammalian EndoV homolog, mouse EndoV (mEndoV), and show that mEndoV shares the same RNA selectivity as human EndoV (hEndoV). Mouse EndoV cleaves the same inosine-containing substrates as hEndoV, but with reduced efficiencies. The crystal structure of mEndoV reveals a conformation different from the hEndoV and prokaryotic EndoV structures, particularly for the conserved tyrosine in the wedge motif, suggesting that this strand separating element has some flexibility. Molecular dynamics simulations of mouse and human EndoV reveal alternative conformations for the invariant tyrosine. The configuration of the active site, on the other hand, is very similar between the prokaryotic and mammalian versions of EndoV.