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Despite the consequences for women’s health, a repeat cesarean section (CS) birth after a previous CS is common in Western countries. Vaginal Birth After Cesarean (VBAC) is recommended for most women, yet VBAC rates are decreasing and vary across maternity organizations and countries. We investigated women’s views on factors of importance for improving the rate of VBAC in countries where VBAC rates are high. We interviewed 22 women who had experienced VBAC in Finland, the Netherlands, and Sweden. We used content analysis, which revealed five categories: receiving information from supportive clinicians, receiving professional support from a calm and confident midwife/obstetrician during childbirth, knowing the advantages of VBAC, letting go of the previous childbirth in preparation for the new birth, and viewing VBAC as the first alternative for all involved when no complications are present. These findings reflect not only women’s needs but also sociocultural factors influencing their views on VBAC.
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At the beginning of the twenty first century obesity entered Dutch maternity care as a ‘new illness’ challenging maternity care professionals in providing optimal care for women with higher BMI’s. International research revealed that obese women had more perinatal problems than normal weight women. However, the effect of higher BMIs on perinatal outcomes had never been studied in women eligible for midwife-led primary care at the outset of their pregnancy. In the context of the Dutch maternity care system, it was not clear if obesity should be treated as a high-risk situation always requiring obstetrician-led care or as a condition that may lead to problems that could be detected in a timely manner in midwife-led care using the usual risk assessment tools. With the increased attention on obesity in maternity care there was also increased interest in GWG. Regarding GWG in the Netherlands, the effect of insufficient or excessive GWG on perinatal outcomes had never been studied and there were no validated guidelines for GWG. A midwife’s care for the individual woman in the context of the Dutch maternity care system - characterised by ‘midwife-led care if possible, obstetrician-led care if needed’ - is hampered by the lack of national multidisciplinary consensus regarding obesity and weight gain. Obesity has not yet been included in the OIL and local protocols contain varying recommendations. To enable sound clinical decisions and to offer optimal individual care for pregnant women in the Netherlands more insights in weight and weight gain in relation to perinatal outcomes are required. With this thesis the author intends to contribute to the body of knowledge on weight and weight gain to enhance optimal midwife-led primary care for the individual woman and to guide midwives’ clinical decision-making.
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SummaryADHD and reificationThis thesis starts with a quote from eleven-year-old Sylvia, who thinks ADHD “is like a cancer (...) but you’re not going to die from it”. ADHD is no disease like cancer, but a con- cept from the Diagnostic and Statistical Manual of Mental Disorders (DSM), currently in its fifth edition. The DSM-5 defines ADHD with -partly overlapping- behavioral criteria such as “often has trouble waiting his/her turn” and “often interrupts or intrudes on others”. Thinking that the definitions in the DSM are concrete illnesses, such as Sylvia does, is acknowledged as a problematic phenomenon called reification. The most well- known mechanism of reification is called the “nominal fallacy”: naming behaviors carries the risk of thinking we have thereby explained them. In fact, constructs like ADHD only name these behaviors. However, confusing naming and explaining is just one of the mechanisms of reification. This thesis aims to answer the questions: how is ADHD reified in written discourse, and how often do these identified mechanisms of reification occur?Generalization and other mechanisms of reificationBesides confusing naming and explaining, generalizations can also lead to reification; particularly group-to-individual generalization. For instance, the authors of a large meta-analysis of brain-anatomy compared groups classified with ADHD with groups of “normal” individuals. They stated in their paper in 2017: “We confirm, with high-pow- ered analysis, that patients with ADHD have altered brains; therefore ADHD is a disorder of the brain. This message is clear for clinicians to convey to parents and patients”. The find- ings were in fact mere averages, and the case and control groups largely overlap. The authors wrongly suggest that all those classified with ADHD have different (smaller) brain parts. In fact, many with an ADHD classification have larger than average brain parts while many without an ADHD classification have brain parts that are smaller than average.There are many other reifying mechanisms. For instance, when reporting about case-control studies of neurophysiology and neurochemistry, researchers often select brain-images of the extremes from both samples. These images are then often pre- sented as allegedly representative of the brain activity and neurochemistry of a whole population of those classified with ADHD. In reality, case and control groups again show much overlap. Furthermore, brain activity differs strongly across people, regardless of an ADHD classification. Also within persons neurochemistry and physiology are not consistent through time.Medical jargon, for instance words like “symptom”, can also reify ADHD as the term implies that behaviors like interrupting others are the result of a disease or disorder. Speaking of criteria for ADHD is a more appropriate term, as this word refers to a stand- ard on which a decision may be based, and the word does not suggest the behaviors are caused by an innate problem.Similarly, by using metaphors, such as comparing ADHD to a meat-cleaver that splits the brains of those with ADHD, agency is ascribed to the ADHD-concept as a real entity that does damage to the human brain. This reifies ADHD and such a metaphor may also create fear and stigma. Another reifying mechanism is the suggestion of causality when only correlation is empirically proven. It is often suggested that ADHD can cause academic failure and maladaptation to the point of delinquency. However, as for instance child maltreatment can cause problems of inattention and restless behaviors –for which the ADHD-con- cept merely provides a name- both ADHD and delinquency can be confounded by adverse circumstances.ADHD can also be reified by “textual silence”: omitting important information that shows the construct does not represent a steady and reliable disorder. For instance: birth-month studies reveal that normal, age-related behaviors tend to be “diagnosed” with ADHD and medically treated. Not mentioning this important information can leave the perception of ADHD as a concrete entity intact.How often do these reifying mechanisms occur?Using a sample of 43 academic textbooks used at universities in the Netherlands, this thesis aims to quantify the occurrence of reifying mechanisms such as textual silence in relation to genetics. For instance, roughly half of the textbooks mention 60-80% heritability estimates of twin/family and adoption studies that compare behaviors of relatives to estimate the influence of genetics. At the same time, these textbooks omit that the more precise molecular genetic studies reveal a low direct influence of genes of about 5%. Only a quarter of the textbooks mention the contrasting findings, which reveal that twin/family and adoption studies cannot separate genetic from environ- mental influences very well. A quarter of the textbooks do contrast the high outcome of twin/family/adoption studies and the limited effects according to molecular studies. This “missing heritability problem”, as it is known, is not mentioned explicitly as such.Generalizations are also a common mechanism of reification. Of 36 textbooks that discuss brain anatomy in relation to ADHD, 21 (58%) do not mention that empirical outcomes are mere average findings that have little bearing on individuals classified as having ADHD. Fifteen chapters on ADHD did place such findings in perspective, by referring, for instance, to the fact that such findings are mere group outcomes. Only 3 of those, however, clearly mentioned that those with ADHD do not necessarily have different brains, or that “normal” controls can also have different/smaller brains. Only one chapter on ADHD mentioned both: no single deficit is necessary or sufficient to explain all cases of ADHD. Additionally, none of the chapters mentioned sampling bias due to the use of “supernormal” controls on the one hand and “refined phenotypes”, rigorously screened ADHD cases, on the other.Background of reificationReification is a concept from scholars filed under the sociological school of “Conflict Theory” that sees the quest for power as a foundation of social relationships. Framing ADHD as a hardwired genetic and brain-based illness can privilege medical profes- sionals. When described by the catch-all concept that ADHD is at risk of becoming, everyday behaviors like interrupting others are framed as medical problems and not as a normal part of socialization. As a result, non-medical professionals, like teachers, may feel inept.Conflict Theory also addresses the monetary basis at the heart of the production of knowledge. Differences in the availability of monetary resources (e.g. from pharma- ceutical companies) might further tilt the power balance, such as by financing dedicated companies that help to prepare presentations, write scientific papers (ghost writing) and recruit opinion leaders. However, a conflict theoretical perspective seems limited to explain the passion of some of those who believe strongly in the biological approach. Financial incentives might not necessarily have preceded this enthusiasm, and many researchers do not receive industry funding.Philosophers such as Trudy Dehue and Charles Taylor bring an additional, more “functional” perspective to explain our contemporary eagerness to reify concepts such as ADHD. Dehue, for instance, states that as biological explanations of behavior, concepts like ADHD are functional by providing an excuse for the person one is, par- ticularly if one fails to meet the neo-liberal norm of being self-reliant and successful. Taylor traced one of the roots of this neo-liberal ideology, which he calls “disengaged reason” all the way back to the likes of Plato and Descartes. Disengaged reason means that humans can find true beliefs about the world when being disengaged from it and being disengaged from one’s emotions. This ideal is represented well by Descartes’ “I think therefore I am”.The success of science, partly founded on this notion of disengaged reason, eroded the influence of the church. The influence of the normative framework that the church provided eroded as well and created a void that, from a functional perspective, needed to be filled. Psychiatry rose to the occasion to help fill this void with its’ own psychiatric bible –as the DSM is often called. Perhaps unsurprisingly, psychiatry, as the new sci- ence-based norm-setting institution, is engrained with this ideal of disengaged reason.ADHD and the ideal of disengaged reasonI argue that the rationalistic norms strongly surface in the ADHD-concept. We expect children to control their impulses, be silent in their play and await their turn. Also in the way we study human behavior and “diagnose” children as having a neurodevelopmental disorder - based on splicing their behaviors and counting “symptoms”, we lean towards disengaged reason. A diagnosis does not require asking for a child’s motives for his/ her behavior. So, both the norms we bestow upon children via the ADHD-concept, and the norms we bestow upon ourselves by the way we try to classify them without the need to involve children themselves to give meaning to their behaviour, reflect the dominance of this disengaged reason in my view.ImplicationsSo, possibly we reify and fail to be objective to the disappointing outcomes of empirical studies with the ADHD construct due to our own narrow (institutional) interests. Or, possibly we have historically embedded high hopes for the success of psychiatry’s nor- mative framework. Either way, such interests or high hopes do not necessarily overlap with the interests of the child, which should be our primary concern. So finally, some political and practical implications are offered to safeguard the child’s best interest.Future studies based on this thesis could estimate the prevalence of reifying mech- anisms and could also include different domains of discourse besides textbooks. Ad- ditionally, institutional dependency on constructs from the DSM should be examined critically. For instance, scientific funding agencies should consider the pros and many limitations of the study into the highly reified classifications and consider alternative classifications, such as using Research Domain Criteria. Another possible approach to research and providing care is using a more tentative, back-and fourth, normalizing approach such as stepped diagnosis and stepped care. From a political point of view the high interdependence of science and commercially vested interest calls for reconsider- ation of how we can use financial resources. One longstanding idea is to concentrate these resources in a fund with representatives from different branches of industry, science and government.Finally, medically framing children’s restlessness that is associated with a plethora of problems -such as the contemporary schooling system, divorce, poverty, trauma and loss- makes it easy to forget such larger issues. To avoid this, we should seek refuge in the institute that aims to protect the child’s autonomy, agency and safety in the face of the many individual and collective challenges that our children are confronted with: The Convention on the Rights of the Child. This institution should also safeguard that our current healthcare system with its classifications is part of the solution and not part of the problem.
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Background and purposeWithin Northwest European Welfare states, there is a growing need for all social work professions to substantiate their work with research. The earliest notions of social street work origins from the end of the18th century by the British Salavation Army (Mikkonen et al., 2007). In the Netherlands it’s introduced from the United States (1960s), as a response to individuals and groups hanging around. Social street work is a low threshold and professional form of being there, performed in surroundings and situations where the target group is. It focusses on contact-making and staying in contact with individuals and marginalised groups, who otherwise are hard to reach, have lost their connection with society and have multiple problems. It’s a high appreciated practice, but it lacks a method that is substantiated with research (Morse et all, 1996; Kirkpatrick, 2000). In this paper we will present conceptual model of the method of social street work, that’s substantiated with experiences from professionals and the target group.MethodThis paper is based on a combination of literature review, document analysis, Delphi Method and an online questionnaire among the target group. The research is conducted at Streetcornerwork in Amsterdam. Streetcornerwork is the only organization in the Netherlands that provides social street work, since WWII. They employ 175 professional social street workers and has 43 years of experience in social street work.First, a theoretical model of social street work is developed bases on literature review, analyses of documents of the establishment (1970-1990)of social street work (Netherlands) and different attempts to describe the method (1991-2017). Second, the explanation model is strengthened with data from the online questionnaire among 1600 clients of Streetcornerwork. Third, the Delphi Method is used to validate the model with the tacit knowledge of 24 professionals.ResultsThe result is a conceptual model of the method of social street work that is substantiated with experiences from professionals and the target group. Characteristic is that it’s an open approach in contact with the target group which is highly dependent on context and has unpredictable character (Metz, 2016 , Andersson, 2011).The method social street work consists of 14 methodic principles,. Social street work contributesto the development of self-insight and general life skills, the restoration of the social network and the improvement of living conditions and the well-being of the target group. We also gain insight in the experienced contribution of social street work from persons in the environment of the target group (client system, neighborhood and institutional environment). This experienced contribution of social street work at theenvironment is divided into the direct contribution and the implicated contribution through the target group.Conclusions and implicationsThis conceptual model of the method of social street work contributes to a body of knowledge. We made tacit knowledge explicit and we can legitimize the profession of social street work. Because research is done in close collaboration with street workers, it also contributes to the development of their work.
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Nieuwe wetgeving voor jeugdzorg in Nederland heeft geleid tot de implementatie van teams, die geïntegreerde eerstelijns jeugdzorg bieden. Belangrijke doelen van de nieuwe Jeugdwet waren meer geïntegreerde, tijdige zorg en minder gebruik van intensieve vormen van zorg. Het doel van dit onderzoek was het bestuderen van veranderingen in het gebruik van jeugdzorg in de tijd en de rol van nieuw ingevoerde wijkgerichte ondersteuningsteams hierin. Patronen van jeugdzorggebruik veranderden naar meer lokaal geleverde primaire jeugdzorg, iets minder gespecialiseerde en iets meer residentiële jeugdzorg. Bovendien nam het jeugdzorggebruik onder jongere kinderen toe in de tijd. Deze trends komen deels overeen met de trends die de Jeugdwet beoogt. Er is weinig bewijs gevonden voor de rol van specifieke teamkenmerken op veranderingen in jeugdzorggebruik in de tijd.
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Studies of brain size of children classified with ADHD appear to reveal smaller brains when compared to ‘normal’ children. Yet, what does this mean? Even with the use of rigorously screened case and control groups, these studies show only small, average group differences between children with and without an ADHD classification. However, academic textbooks used in the Netherlands often portray individual children with an ADHD classification as having a different, malfunctioning brain that necessitates medical intervention. This conceptualisation of ADHD might serve professional interests, but not necessarily the interests of children.
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The professional growth of midwives, essential for optimizing midwifery leadership globally, can be enhanced through twinning collaborations. How twinning promotes growth is unclear. This case study explores how professional growth is affected by cultural differences between twins. We used a longitudinal qualitative design including data from open-ended questionnaires and focus groups. These data were analyzed using a content analysis. Our findings show that cultural differences were capable of both hindering and facilitating professional growth. Within the complex dynamics of twinning, professional growth was facilitated by twins’ preparedness to bridge cultural differences. Common goals positively influenced this process. Friction was more likely, and professional growth was hindered, when midwives were unprepared to bridge cultural differences. To optimize professional growth through twinning, we recommend a clear focus on common goals and consideration of the interaction between the length of a project and the extent of the cultural differences between twins.
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Background: Intellectual disability (ID) is a developmental disorder that causes considerably below-average intellectual performance and adaptive behaviour. In the context of the present study, families raising a child with ID are reported to experience multiple challenges that appear not to be well documented in Pakistan. Methods and procedures: Pakistan, which was conducted in Karachi, Pakistan, followed participatory action research, in which the researcher and participants examined their existing experiences of informal social support and then created, implemented, and evaluated actions to strengthen this informal social support. A total of five families (n = 25) participated in the study. These participating families comprise parents, siblings, and significant others, i.e., aunts, uncles, and grandparents, living with the child with ID. Families with children with ID were selected through a school for children with ID who are under 12 years old. This qualitative action research was conducted in two distinct parts, i.e., a) exploratory part and b) action part. This paper presents the findings of the first exploratory part of the study. Aim: The exploratory phase aimed to explore and examine the experiences and challenges families may experience with informal social support while caring for a child with an intellectual disability in Karachi, Pakistan. Findings: Parents often sacrifice their personal needs and aspirations for their children, leading to decreased tolerance and anxiety. Lack of communication, support, and assistance from family members is another significant issue. Stigmatisation and discrimination from school, relatives, and friends can cause depression and distress. The study emphasises the need for a unified and coordinated approach to support and care. Religious beliefs, siblings, and close friends provide comfort and well-being. When parents manage to connect with similar families, they have the opportunity to express a collective commitment to caregiving. Conclusion: To strengthen the situation, families propose enhancing intimacy and competency within homes and taking action at the governmental level. Governments must provide appropriate services, such as nurses supporting families, support groups, and religious traditions, to promote acceptance and holistic development for intellectually disabled children.
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