Adolescent, maternal and Women's Health 1 Flashcards
1
Q
Define Non-volitional sex
A
Any sexual behaviour that violates a person’s right to choose freely when and with whom to have sex and what sexual behaviours to engage in.
2
Q
Subcategories of non/volitional sex
A
rape, forced sex, childhood sexual abuse, sexual violence, unwanted sex trafficking.
3
Q
consequences of poor sexual health
A
- Unplanned pregnancies and abortions
- Psychological consequences, including from sexual coercion and abuse
- Poor educational, social and economic opportunities for teenage mothers,
young fathers and their children - HIV transmission
- Cervical and other genital cancers
- Hepatitis, chronic liver disease and liver cancer
- Recurrent genital herpes
- Recurrent genital warts
- Pelvic inflammatory disease (subsequent ectopic pregnancies and infertility)
- Adverse pregnancy outcomes (maternal and neonatal)
4
Q
WHO Sexual health definition
A
A state of physical, mental and social well-being in relation to sexuality. it requires a respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and save sexual experiences, free of coercion, discrimination and violence
5
Q
prevention of poor sexual health
A
Prevention: ■ Contraception ■ HPV immunisation ■ HIV prevention ■ Education/ Health Literacy
6
Q
Clinicians role in preventing poor sexual health through contraception
A
Prevention:
■ Contraception
Clinicians’ role:
■ Provide information around contraception options
■ Educate patients about risks and consequences of unprotected sex
■ Facilitate prompt access to contraception and sexual health services
7
Q
Which preventative measure acts as protection against all STIs
A
Barrier protection prevents against all STls
Department of Health Survey:
■ 15-29 years old
■ 1/ 3 used barrier protection consistently
■ 71% thought barrier protection was the best form of
protection against all STls
8
Q
Population health approaches to sexual health?
A
- addresses knowledge gap
Prevention:
■ Education / health literacy
In 2019 was made compulsory for school pupils:
■ Primary Schools: Relationships Education
■ Secondary Schools: Relationships and Sex Education
9
Q
why is it important to prevent unplanned pregnancies
A
Preventing unintended pregnancies using contraception is essential for improving multiple health outcomes ■ 1 in 6 pregnancies are unplanned ■ More common in young, single women ■ Smoking, drug use and depression more common in women who report unplanned pregnancies
10
Q
Why is it important to address teenage pregnancies
A
= Conception under the age of 18 Majority unplanned ■ ■ 50% result in abortion ■ ■ Huge physical and psychological impact ■ ■ Less likely to finish education ■ Less likely to find employment ■ More likely to live in poverty ■ Higher risk of poor antenatal health ■ Lower birth weight babies Higher infant mortality rate ■ 3x more likely to suffer post-natal depression
11
Q
Which Individuals are more vulnerable
to coercive and exploitative sexual relationships
A
Conception under the age of 18: ■ In or leaving care ■ Homeless ■ Involved in crime ■ Low educational attainment ■ Social deprivation
12
Q
Which Individuals are more vulnerable to poor sexual health and
to coercive and exploitative sexual relationships
A
Conception under the age of 18: ■ In or leaving care ■ Homeless ■ Involved in crime ■ Low educational attainment ■ Social deprivation
13
Q
Approaches as clinician to sexual health
A
Non-judgmental
Empathetic
14
Q
specific preventative interventions targeting at risk groups in sexual health (HPV)
A
Girls and boys aged 12 to 13 years are offered the human
papillomavirus (HPV) vaccine as part of the NHS
immunisation programmes
The HPV vaccine helps protect against cancers caused by HPV, including:
■ Cervical cancer
■ Some mouth and throat (head and neck) cancers
■ Some cancers of the anal and genital areas
■ It also helps protect against genital warts
15
Q
specific preventative interventions targeting at risk groups in sexual health (HIV)
A
HIV prevention:
■ Pre-exposure prophylaxis (PrEP) is a course of HIV drugs
taken by a HIV negative person to lower the chance of
becoming infected with HIV in the future
■ Post exposure prophylaxis (PEP) is anti-HIV medication
that is prescribed to a HIV negative person, after a potential
exposure to HIV, to protect them from being infected with HIV
16
Q
How can we tackle stigma which arises when using specific preventative interventions
A
-Building an honest and open culture where people can make
informed and responsible choices about their sexual health
has been crucial to the success of these interventions - tackle stigma
17
Q
Essential components of maintaining sexual health of population
A
Test, Diagnose, Treat
- opportunistic approach
18
Q
Diagnosis of STIs highest in which groups
A
- highest in heterosexual people aged 15-24 years old
- BAME populations
- living areas of deprivation
- Men sex with men - MSM
19
Q
Most common STIs
A
Percentage of all new diagnosis of STIs
Chlamydia = 49%
Gonorrhoea = 15%
First episode genital warts = 11%
First episode genital herpes = 7%
20
Q
National Chlamydia screening programme
A
- Chlamydia most common STI especially amongst young people
- asymptomatic
- serious health consequences
- proactive and opportunistic approach
- screens for asymptomatic infections
21
Q
Gonorrhoea
A
common in MSM (male homosexuals)
- reemerged
- second most common STI diagnosis
- resistant to previous first-line antibiotic
- ongoing monitoring of anti-microbial resistance essential for effective treatment
22
Q
How to use MECC (make every contact count) principles in sexual health
A
■ Initiate conversations about sexual health ■ Increase screening uptake ■ Increasing subsequent diagnosis and treatment of STls
23
Q
Impact of open access to sexual health services that provide rapid treatment
A
- reduce the risk of STI complications and infection spread
- digital services reduce pressure on NHS
- online diagnostic test kits
NOTE: services may not spread equally across society
24
Q
Impact on lifestyle choices on sexual health
A
Smoking
Prolonged alcohol misuse
—->Sexual dysfunction
Stress Poor mental health Drug and alcohol use ----> Risky sexual behaviour, sexual assault, Drug and alcohol use inter-partner sexual violence
25
Summarise how sexual health behaviour can be improved from a clinician perspective
Sexual health behaviour is complex, and entirely
individual depending on lifestyles and circumstances
■ Opportunistic approach
■ Non-judgmental
■ Empathetic
■ Holistic
■ Informing patients and facilitating decisions/access to support and services
26
NATSAL SUMMARY
- 45000 respondents
- decline in age at first sexual intercourse
- increase in lifetime sexual partners
- varied sexual practices
- increasing acceptance of same sex partners
- increasing disapproval of non-exclusivity in marriage
- older people - lower satisfaction in health
- poor health - lower health satisfaction and decreased sexual activity
- only 25% of men and 20% of woman sough help when health affecting sex
- increased prevalence of HPV and increased risk of cervical cancer
- chlamydia peak in younger age groups - 1% of population
- gonorrhoea and HIV affect less than 0.1% and affected these with high risk factors\
- sexual health clinic attendance and HIV testing increased
- 16.2% unplanned pregnancies especially among 20-34 year olds
non volitional sex more in woman and at younger age - normally known by individual
- 33% of men and 42% of women told someone about non volitional sex
- only around 10% reported to police
- public health embrace change to ensure services are appropriate for lifestyle and consistent with definition of sexual wellbeing
27
What is the first stage for intervention when taking a life course approach
Pre-Conception
28
What is the most prevalent STI according to NATSAL?
HPV
29
Non-volitional sex is more common, though not exclusive to, one of the below groups. In which group is non-volitional sex more common?
Women
30
What are the main changes in attitudes to sex, according to the NATSAL video?
The data shows that people between 1990-2010 might be more sexually explorative than previous cohorts, with a decrease in age of first intercourse and and increase in sexual repertoire. There has also been a change in attitudes towards non-monogamous interactions. Do you think these trends will continue in the same way in the next NATSAL study?
31
Broader definition of sexual well-being
"Sexual and reproductive health is a state of physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction or infirmity.
Therefore, a positive approach to sexuality and reproduction should recognize the part played by pleasurable sexual relationships, trust and communication in promoting self-esteem and overall well-being.
All individuals have a right to make decisions governing their bodies and to access services that support that right.", and advocates for it's inclusion as a human right.
32
What is a lifestyle course approach
- Pre conception is first stage for intervention
■ Pregnancy can be a time when mothers are amenable to change
■ Long lasting behaviour change
■ Impact positively on future health outcomes
33
Why is maternal nutrition important
Maternal nutrition plays a crucial role in
maintaining the health of the developing foetus
eg. obesity
some nutrients are essential and some to be avoided
34
Role of folic acid supplements in pregnancy
■ Folic acid 4oomcg OD recommended prior to conception and up to 12 weeks of pregnancy/ 40 to reduce the risk of neural tube defects such as spina bifida
(insert pic)
35
Role of vitamin D supplement in pregnancy
■ Vitamin D 1omcg OD throughout pregnancy and during breast feeding to promote bone health in foetus and reduce risk of rickets
36
Folate rich foods which can be recommended in consultations
```
Folate rich foods
■ Green leafy vegetables
■ Peas
■ Kidney beans
■ Chickpeas
```
37
Holistic approach to maternal health
advice on micronutrients, vitamins, minerals and macronutrients and healthy foods in consultation advising it will maintain their health and the babies
38
do mothers need to eat for two
No - common misconceptions to over eat
39
Benefit of physical activity. in pregnancy
Physical activity during pregnancy
is associated with decreased risk of:
■ Hypertension in pregnancy
■ Pre-eclampsia
■ Gestational diabetes
■ Reduced severity of depressive symptoms
- no evidence suggesting adverse effects of moderate intensity exercise in pregnancy
40
Why is reducing depressive symptoms in maternal health important
Reduced severity of depressive symptoms (1 in 5 woman experience a mental health problem during pregnancy or in first year following birth
- impact on mothers ability to bond with baby and attend child's needs (important for child development and forming secure attachment)
- insecure attachment impacts child's social and emotional development
41
Consequences of alcohol use in pregnancy
```
Drinking alcohol during pregnancy is associated with
■ Early miscarriage
■ Premature birth
■ Restricted growth
■ Still birth
■ Cognitive delay
■ Foetal alcohol spectrum disorders
■ Foetal alcohol syndrome
```
(usually irreversible problems but avoidable)
42
Presentation of foetal alcohol syndrome
Foetal Alcohol Syndrome characteristics
■ Small stature
■ Facial features
(microcephaly, microphthalmia, short palpebral fissures,
epicanthal folds, a small or flat midface, a flat elongated
philtrum, a thin upper lip, and a small chin)
■ Abnormal palmar creases
■ Cardiac defects
■ Joint contractures
■ Cognitive deficits
43
Recommendations for alcohol during pregnancy
avoid drinking any alcohol at all
44
EFFECTS of smoking in pregnancy
Mothers living in deprived areas are more likely to smoke
during pregnancy
11% of mothers smoke during pregnancy accounts for in a year:
-2200 premature births
-5000 miscarriages
- 300 perinatal deaths
increases low birth rate
respiratory conditions
and later development of diabetes, obesity, ENT problems
- tackle using brief interventions
45
What are the effects of the maternal microbiome on the foetus
```
Maternal Microbiome effects on foetus
■ Majority of microbes found in the gut
■ Interacts with the nervous system
■ Interacts with the immune system
■ Plays an important role in health and disease
```
Microbiome = genetic material of all microbes that live on
or within the human body
46
Factors influencing diversity and health of the microbiome
A healthy lifestyle can have a positive influence on the
microbiome
```
■ Genes
■ Age
■ Environment
■ Stress
■ Diet
■ Physical activity
```
47
How can maternal microbiome impact future health of the
| child?
In uterus - foetus exposed to maternal microbes and maternal microbial DNA
birth - baby exposed to vaginal microbes/skin microbes
breastfed babies - exposure to microbes in milk, milk ducts and skin
Mothers microbiome Colonises and influences diversity of baby gut microbiome
48
Impacting
factors
on gut
microbiome
```
Birthing process
Diet
Stress (exercise, metabolic, psychological)
Infant feeding method
Pharmaceuticals
Geography
Lifecycles stages
Physical activity
Illness
```
49
environmental factors of maternal and foetal health
Man-made
chemicals - Common uses (example when analysing newborn umbilical cords - 2 manmade chemicals used in food packaging found in 100% of cords)
Perfluoro-octane
sulfonate (PFOS) - Electronics, Textiles
Non-stick cookware
Perfluorooctanoate
(PFOA) - Carpets, Textiles, Leather, Household
Industrial cleaning products
50
crucial to consider in maternal and foetal health
socio-economic circumstances
screening
immunisation
breast feeding
A healthy lifestyle and environment are important for both
maternal and child health
51
Does diet including whether or not a baby is breastfed or given formula milk effect their microbiome. Why?
yes - Significant differences in the gut microbiome between breast fed and formula fed babies have been found. This is thought to result from breast feeding exposing the baby to the microbiome of the breast skin, nipple and ducts, and milk contents compared to less exposure for formula fed babies. Diet is also thought to impact on the health of the microbiome later in life.
52
Is the foetus exposed to maternal microbiome in foetus
yes - In utero the foetus is exposed to both microbial DNA and maternal microbes
53
Where and what is the microbiome
The microbiome consists of bacteria, fungi, parasites and viruses including their genes found co-existing throughout the human body.
This can also be found within and on all multicellular organisms, not just in the GI tract of humans.
Microbiota is the term usually used for a group of micro-organisms found within a certain environment. For example, the ‘gut microbiome’ refers to all microbes and their genetic material found in the gut, whereas ‘gut microbiota’ refers to the micro-organisms in the gut only.
54
Impact of delivery method of baby on microbiome influence
Babies born vaginally are initially colonised by organisms from the maternal vagina to which they are exposed during delivery.
Babies delivered via caesarean section are mostly colonised by maternal skin flora and tend to have significantly less diverse and fewer bacteria in their gut in early life compared with those delivered vaginally.
55
Immunomodulatory properties of microbiome
The microbiome curbs the growth of pathological microorganisms and has a role in balancing proinflammatory and anti-inflammatory signals.
56
Define microbiome
The microbiome is the trillions of bacteria, fungi, parasites and viruses and their own genetic material that co-exist on or inside our bodies.
57
name of relationship of microbiome with humans
For most, it is in a symbiotic relationship with human physiology and the environment, and it reacts depending what it is exposed to.
58
is there a perfect microbiome composition?
No - An individuals’ microbiome is entirely unique to them and changes in diversity and composition throughout the life course. There is not a definitive ‘healthy’ microbiome profile with variety found in healthy people but maintaining the diversity of species in the microbiome appears important.
59
largest microbiome? 2 most common microbiota present in gut? temporal vs spatial distribution? role of microbiome in gut?
- The GI tract microbiome is the largest and the large intestine constitutes over 70% of the microbiome
- Firmicutes and Bacteroidetes being the two main phyla present.
- There are temporal (oesophagus to colon) and spatial (luminal versus mucosal) differences in distribution of species throughout the GI tract.
- The GI tract microbiome derives it’s nutrition from host dietary intake and shed epithelial cells. Alongside sustaining itself, the gut microbiome is involved in a wide range of physiological processes
60
Metabolite Production by the gut microbiome
- producing secondary metabolites by
breaking down luminal compounds to more useful metabolites.
- detoxify ingested toxins to make these less harmful
- synthesising antimicrobial peptides.
- Dietary fibre and resistant starches broken down and fermented by enzymes
from the gut microbiome in the colon.
- Fermentation by Firmicutes, releases short chain fatty acids (SCFAs) - rich source of energy, lower the colon PH, maintain local homeostasis
61
Vitamin production by the gut microbiome
Vitamin K synthesis and several components of vitamin B
62
Role of PH in colon and SCFAs in metabolite production of microbiome
The pH in the colon dictates the
type of micro-organisms capable of surviving there and also interacts with both the immune
and nervous systems.
- SCFAs (particularly butyrate) play a vital role in maintaining local (gut) and systemic immune
homeostasis - play a role in gut-brain axis
63
The microbiome and the Immune system
-GI tract mucosal immune system must tolerate beneficial commensal
micro-organisms whilst simultaneously preventing overgrowth of pathogens to keep us healthy = helpful and protective
- Dendritic cells - detect ‘toxin’ such as
pathological organism entering the gut - help initiate an acute proinflammatory immune response to rid the body of the toxin.
Poor
diet or exposure to an unhealthy microbiome in the lumen ---> a low level, chronic
inflammatory state
- Dendritic cells constantly monitoring their environment and contents
within the gut (including the microbiota) and produce an appropriate immune response.
- Dendritic cells - pro-inflammatory or anti-inflammatory responses through cytokine
release and regulatory T cell production
unhealthy diet - damage the barrier between the
gut and rest of the body, - permeable --> ‘leaky’ gut.
--> harmful lipopolysaccharides (LPS’s) - outer coat of certain
types of microbiota crossing into the blood stream.
- LPS’s don’t cause
any damage, but if they cross over into the blood stream, this causes a stress and
inflammatory response.
- through direct and
indirect pathways regulates innate and adaptive immune cells.
64
The microbiome and the enteric and central nervous system
- brain and gut connection
- communication in the gut-brain axis - a two-way communication system and involves communication
via the enteral nervous system, central nervous system (via the vagus nerve) and via cytokines in the blood stream.
- brain can induce stress mediated changes in GI tract, eg. motility can change.
- GI tract can send stress mediated responses to the CNS
- The gut activation of neural afferent circuits of the brain, activate of mucosal immune response and produce metabolites that can travel via the blood stream to the brain. -->
influenced by the health and activity of the microbiome.
- involved in the metabolism of tryotphan --> involved in the
production of the neurotransmitter serotonin.
- Gut motility impacted by serotonin
65
how to begin conversation around physical activity in consultation
- summarises
- brief intervention
- SMART target
- advise on temperatures
- Asks permission to discuss physical activity
- Finds out what patient already knows
- Discusses benefits of PA (physical activity)in pregnancy (specific to her situation)
- Finds out about risks/barriers for the patient to being more active
- Explores patients motivations
- Identifying fears and barriers
- Screening for physical inactivity
- Positive reinforcement of current health behaviour and future plans
- Using positive and empowering approach
- Signposting to further resources
66
When to reassess physical activity use in Pregnancy
- Pre-eclampsia
- persistent bleeding
avoid high impact activities only in pregnancy
67
What is the Scot-PASQ (Scottish Physical Activity screening questionnaire)
The Scot-PASQ and GPPAQ are screening tools
| review brief interventions
68
Main barriers to physical activity in pregnancy
- Fear of harm to baby
- perceived lack of time
- fear of judgement
- perceived incapability
- No access to resources
69
Should mothers be active in pregnancy
yes - physical activity has multiple benefits in pregnancy.
-mothers should remain as physically active as possible during pregnancy
70
CMO guidelines for pregnant women
```
CMO guidelines
• Aim for at least 150 mins of moderate activity a week throughout pregnancy
• Home, leisure, out and about
• Muscle strengthening activities twice a week
• No evidence of harm
• More is better
• Don’t bump the bump
• Adapt to your body
```
```
benefits:
controls weight gain
improves fitness
reduce HBP
improves sleep
improves mood
prevents gestational diabetes
```
link to CMO infographic: https://icsm.insendi.com/programmes/aNpmyl7w1/courses/mKgWd7skY5/weeks/UWWUwpyRX/screens/t3_agIHKo
71
UK government definition of sex vs gender
sex - biological: determined by anatomy, chromosomes and hormones – male or female and assigned at birth.
Gender - social construct relating to behaviours. - Gender identity is a personal and internal perception of oneself. - Gender may not match the sex one is assigned at birth. Hence man or woman are terms that are commonly applied to gender (not sex).
72
Trend of life expectancy
life expectancy higher for females than males
trend stooling and declining for woman particularly those in deprived areas
73
Healthy life expectancy definition
- years lived in good health
| - been declining for woman since 2010
74
Inequalities related to woman across life course
Women are more likely to
• Move into residential care
• Provide informal, unpaid care for relatives and
children
• Be obese ---> Fat tissue is inflammatory, produces sex
hormones (oestrogen), produces growth
hormones (insulin, GF etc.)
--> Promotes rapid cell division → Increases
cancer risk
• Breast and endometrial cancers have closest
link to obesity
• Have dementia --> Oestrogen protects brain cells but decreases
post menopause
• Be less physically active ---> Barriers = fear of judgement, lacking
confidence, lacking time
• Be misdiagnosed following MI – doctor bias
• Be unrepresented equally in research
• Have lower paid + lower skilled jobs – less likely to
be financially secure
• Women and men do different jobs
• Men hold more of the most senior roles
• Jobs done by women are undervalued
• Women pay a ’motherly penalty’ (lose jobs first)
• Experience violence against women and girls
• More likely to experience sexual/physical
abuse, neglect, domestic violence
75
Impact of good quality relationships on health in woman
Oxytocin released in response to social
connection, sex, labour + child birth
• Promotes social bonding, prosocial
behaviour, empathy, elevates mood,
reduced stress
- promotes good quality relationships -->
• Live longer + healthier lifestyle
- resilience and promotes recovery from illness
- vital source of social capital, allowing us to form bonds that provide emotional, cultural and socioeconomic support
• Suffer less from mental health issues +
better recovery from mental/physical
stressors
• Better cardiovascular health + stronger
immune system
• Lower severity of perceived physical pain
76
3 types of social connections (UCLA loneliness scale)
Intimate connections
- people who personally love and Support you
(eg, family, friends and partners)
Relational connections
- What are you see on a regular basis and may share an interest with
(eg. work colleagues)
Collective connections
- who share a common affiliation or group membership with you
(eg. people of faith group)
77
Evidence proven differences in relationship experience between men and women
W more likely to have broader/more intimate
friendships
• More likely to share personal matters +
feel more supported during stress
• W (and people of lower socio-economic status) more affected by –ve aspects of close
relationships
78
Types of Domestic abuse in woman
- woman more at risk
- exacerbated during pregnancy
- sexual, emotional, psychological or financial abuse.
79
Effects of domestic abuse in pregnancy
Domestic abuse during pregnancy causes long term psychological problems such as stress and anxiety in the mother, which can adversely impact the baby’s development. It also increases the risk of:
Miscarriage
Infection
Premature birth
Injury or death of the baby following birth.
80
how many woman experience domestic abuse or violence at some point in their life
1 in 4
81
What can exacerbate domestic abuse (percentage)
30% of domestic abuse starts in pregnancy and existing violence can be exacerbated
82
How many women die per week due to domestic violence
2 women die per week in the UK as a result of domestic violence
83
Impact of COVID19 and domestic abuse
Domestic violence has increased significantly during this pandemic. Government authorities across the world have reported significantly higher call rates to domestic violence helplines and increased demand for emergency shelter.
84
various ways in which intimate partner violence specifically can impact women’s health
mental health
- twice as likely to experience depression
- almost twice as likely to have alcohol use disorders
Sexual and Reproductive Health
- 16% more likely to have a low birth-weight baby
- 1.5 times more likely to acquire HIB and 1.5 times more likely to contract syphilis, chlamydia or gonorrhoea
```
Death and Injury
- 42% of women who have experienced
physical or sexual violence at the
hands of a partner have experienced
injuries as a result
- 38% of all murders of women globally were
reported as being committed by their
intimate partner
```
85
Recommendations to support women experiencing domestic abuse from NICE and the Department of Health offer
- Elicit information in a sensitive and empathetic manner
- Signpost to appropriate sources for guidance and safety
- Plan follow-up care with flexible appointments as needed, and refer to appropriate professionals, such as a domestic abuse support worker
- Address their fear of involvement of social or child protection services and reassure confidentiality where appropriate]
- Allow the patient to have autonomy over their decisions, without feeling pressured
- Respect their decisions and remain non-judgemental]
- Remind them that they are not alone in their experience and that there is always help available.
86
Key points
Key points
a. Sexual health issues are complex and highly individual, requiring a sensitive and
holistic approach.
b. A life course approach to health needs to start at the pre-conception stage in order to
tackle the impact of lifestyle, behaviour and environmental factors on maternal and
child health.
c. The gut microbiome plays an important role in health promotion and disease
prevention.
d. The recognition of and response to sex and gender differences in the context of
women’s health inequalities improves healthcare provision, health research and
population policies.
