Morocco, officially the Kingdom of Morocco, is the northwesternmost country in the Maghreb region of North Africa. It overlooks the Mediterranean Sea to the north and the Atlantic Ocean to the west, and has land borders with Algeria to the east, and the disputed territory of Western Sahara to the south. Morocco also claims the Spanish exclaves of Ceuta, Melilla and Peñón de Vélez de la Gomera, and several small Spanish-controlled islands off its coast. It spans an area of 446,550 km2 (172,410 sq mi) or 710,850 km2 (274,460 sq mi), with a population of roughly 37 million. Its official and predominant religion is Islam, and the official languages are Arabic and Berber; the Moroccan dialect of Arabic and French are also widely spoken. Moroccan identity and culture is a vibrant mix of Berber, Arab, and European cultures. Its capital is Rabat, while its largest city is Casablanca.
In 2014, Morocco adopted a national plan to increase progress on maternal and child health. The Moroccan Plan was started by the Moroccan Minister of Health, Dr. El Houssaine Louardi, and Dr. Ala Alwan, WHO Regional Director for the Eastern Mediterranean Region, on 13 November 2013 in Rabat. Morocco has made significant progress in reducing deaths among both children and mothers. Based on World Bank data, the nation’s maternal mortality ratio fell by 67% between 1990 and 2010. In 2014, spending on healthcare accounted for 5.9% of the country’s GDP. Since 2014, spending on healthcare as part of the GDP has decreased. However, health expenditure per capita (PPP) has steadily increased since 2000. In 2015, the Moroccan health expenditure was $435.29 per capita. In 2016 the life expectancy at birth was 74.3, or 73.3 for men and 75.4 for women, and there were 6.3 physicians and 8.9 nurses and midwives per 10,000 inhabitants. In 2017, Morocco ranked 16th out of 29 countries on the Global Youth Wellbeing Index. Moroccan youths experience a lower self-harm rate than the global index by an average of 4 encounters per year.
PRETERM BIRTH RATES – Morocco
Rank: 160 – Rate: 6.7% Estimated # of preterm births per 100 live births
(USA – 12 %, Global Average: 11.1%)
Gravens By Design: The Importance of NICU Discharge Planning Guidelines and Standards
Vincent C. Smith, MD, MPH; Kristy Love; Erika Goyer, BA
When families reflect upon their experiences preparing to transition from the NICU (Neonatal Intensive Care Unit) to home, most families generally do not use the terms “joyful,” “easy,” “perfect,” or “stress-free.” More often, families use terms like “abrupt,” “sudden,” “lonely,” and “scary.” In truth, some families wonder if they even had a discharge preparation plan at all.
They, however, should have had a plan because the American Academy of Pediatrics (AAP) has set clear expectations. The AAP recommends that the transition to home occur when the infant achieves physiologic maturity, and there is an active program for parental involvement and preparation for care of the infant at home. (1) The AAP does not, however, provide much detail about the program for parental preparation. This may be the crux of the issue or source of the problem. While we know that parents need to be prepared, we have not put programs in place to prepare them.
The National Perinatal Association (NPA) hopes to help fill that gap. NPA formed an interdisciplinary work group that developed universal, adaptable, evidence-informed guidelines for NICU discharge preparation and transition planning in response to the unmet need for a program for thoughtful discharge preparation and transition planning. NPA hopes that NICU families and staff will find the guidelines beneficial, useful, and pertinent. Ideally, these guidelines will assist staff in providing clear and consistent messages of both action and guidance for parents and families and provide a systematic approach to required tasks and advanced planning of discharge teaching prior to their anticipated discharge. NPA hopes these guidelines will provide more uniformity in discharge preparation and reduce uncertainty and stress with the discharge preparation and transition planning process.
Using the guidelines
Smith et al. (2013) defined NICU discharge readiness as “the attainment of technical skills and knowledge, emotional comfort, and confidence with infant care by the infant’s primary caregivers at the time of discharge”; and NICU discharge preparation as “the process of facilitating discharge readiness to make the transition from the NICU to home successfully.” (2) Discharge readiness is the desired outcome, and discharge preparation is the process.
We understand that it is impossible to create a comprehensive discharge preparation and transition planning program that will work for every family in every NICU setting. Instead, we propose guidelines and recommendations that focus on content and process. We strived to create recommendations that are both general and adaptable while also being specific and actionable. Each NICU’s implementation of this guidance will depend on the unique makeup and skills of their team and the availability of local programs and resources. Our guidelines are divided into the following sections:
Basic information that emphasizes the content that every family will need, without taking into account each family’s and infant’s specific needs:
Discharge Education §Discharge Education Content § Family Preferred Educational Modality § Family Comprehension §Timing Of Discharge Education § Family Education Support
Discharge Planning Tools § Discharge Summary § NICU Roadmap § Discharge Planning Folder § Written Discharge Information § Supplemental Discharge Educational Materials § Journal
Discharge Planning Team § Infant Care Givers § Consistent Nursing Provider § Family Support People § Discharge Coordinator/Discharge Planner/Case Manager § Sibling Resources
Discharge Planning Process § Discharge Planning Timing § Discharge Planning Meeting § Discharge Planning Goals
Anticipatory guidance in the context of NICU discharge preparation and transition planning–refers to helping the family develop a realistic idea of what their life will be like with their infant. This means in the immediate future following discharge as well as over their life course:
Home and Family Life § Infant Behavior § Coping with a Crying Infant § Emergency Planning § Parental Mental Health § Paying for a NICU Stay
Family and Home Needs Assessment reviews family and home needs assessment to inform discharge planning § Family and Home Needs Assessment Process § Family And Home Needs Assessment Content
Transfer and Coordination of Care deliberate transfer and coordination of care from NICU providers to community providers and the medical home § Primary Care Involvement § Primary Care Contact § NICU Contact with the Family After Discharge § Parental Mental Health §Community Resources o Community Notification
Other Important Considerations examines some important topics to consider when doing discharge planning. We are mindful of families who are § Limited English proficient § Active military§Lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+)§headed o Disabled o Culturally and/or philosophically distinct in ways that need to be considered in NICU discharge transition planning.
Implications: This is a call to action. In implementing these guidelines, we need to address diversity, equity, inclusion, accessibility, and belonging. That may mean that policies need to change. Community connections may need to be adapted. “How we are” may need to change.
We know that parents whose babies are admitted to the neonatal intensive care unit (NICU) need support. Whether their baby’s stay is brief or long, uncomplicated or complex, a NICU stay changes how they care for their infant and how they will parent once they are discharged.
If parents are going to become confident and competent caregivers for their infants, they need guidance and support. The education they receive while in the NICU cannot be limited to performing caregiving tasks. It has to expand to meet their need to become a parent to a medically-fragile child. It has to meet their social and emotional needs. It must welcome them into a community of parents and providers. This is what a smart, timely, coordinated NICU discharge preparation and transition planning program implemented by an interdisciplinary NICU team can deliver.
The guidelines are available as a supplement in the Journal of Perinatology and on the NPA.
Saad Lamjarred & Saber Rebai & RedOne – Sahra Sabahi | 2021 | السهرة صباحي
13,521,671 views Jul 10, 2021
Mortality, In-Hospital Morbidity, Care Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-2018
January 18, 2022
Edward F. Bell, MD1; Susan R. Hintz, MD, MS Epi2; Nellie I. Hansen, MPH3; et alCarla M. Bann, PhD3; Myra H. Wyckoff, MD4; Sara B. DeMauro, MD, MSCE5; Michele C. Walsh, MD, MS6; Betty R. Vohr, MD7; Barbara J. Stoll, MD8; Waldemar A. Carlo, MD9; Krisa P. Van Meurs, MD2; Matthew A. Rysavy, MD, PhD10; Ravi M. Patel, MD, MS8; Stephanie L. Merhar, MD, MS11; Pablo J. Sánchez, MD12; Abbot R. Laptook, MD7; Anna Maria Hibbs, MD, MSCE13; C. Michael Cotten, MD, MHS14; Carl T. D’Angio, MD15; Sarah Winter, MD16; Janell Fuller, MD17; Abhik Das, PhD18; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network
JAMA. 2022;327(3):248-263. doi:10.1001/jama.2021.23580
Question Among extremely preterm infants born at US academic medical centers between 2013 and 2018, what were mortality, in-hospital morbidity, and 2-year neurodevelopmental outcomes?
Findings In this observational study based on a prospective registry of 10 877 infants born at 22-28 weeks’ gestational age in 2013-2018 in 19 US academic medical centers, survival to discharge occurred in 78.3% and was significantly improved compared with a historical rate of 76.0% among infants born in 2008-2012. Among infants born at less than 27 weeks’ gestational age who survived to follow-up assessment at 2 years, 49.9% had been rehospitalized and severe neurodevelopmental impairment occurred in 21.2%.
Meaning Among extremely preterm infants born at US academic medical centers from 2013 to 2018, survival to discharge significantly improved compared with infants born in 2008-2012, but among those born at less than 27 weeks’ gestational age, rehospitalization and neurodevelopmental impairment at 2 years were common.
Importance Despite improvement during recent decades, extremely preterm infants continue to contribute disproportionately to neonatal mortality and childhood morbidity.
Objective To review survival, in-hospital morbidities, care practices, and neurodevelopmental and functional outcomes at 22-26 months’ corrected age for extremely preterm infants.
Design, Setting, and Participants Prospective registry for extremely preterm infants born at 19 US academic centers that are part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. The study included 10 877 infants born at 22-28 weeks’ gestational age between January 1, 2013, and December 31, 2018, including 2566 infants born before 27 weeks between January 1, 2013, and December 31, 2016, who completed follow-up assessments at 22-26 months’ corrected age. The last assessment was completed on August 13, 2019. Outcomes were compared with a similar cohort of infants born in 2008-2012 adjusting for gestational age.
Exposures Extremely preterm birth.
Main Outcomes and Measures Survival and 12 in-hospital morbidities were assessed, including necrotizing enterocolitis, infection, intracranial hemorrhage, retinopathy of prematurity, and bronchopulmonary dysplasia. Infants were assessed at 22-26 months’ corrected age for 12 health and functional outcomes, including neurodevelopment, cerebral palsy, vision, hearing, rehospitalizations, and need for assistive devices.
Results The 10 877 infants were 49.0% female and 51.0% male; 78.3% (8495/10848) survived to discharge, an increase from 76.0% in 2008-2012 (adjusted difference, 2.0%; 95% CI, 1.0%-2.9%). Survival to discharge was 10.9% (60/549) for live-born infants at 22 weeks and 94.0% (2267/2412) at 28 weeks. Survival among actively treated infants was 30.0% (60/200) at 22 weeks and 55.8% (535/958) at 23 weeks. All in-hospital morbidities were more likely among infants born at earlier gestational ages. Overall, 8.9% (890/9956) of infants had necrotizing enterocolitis, 2.4% (238/9957) had early-onset infection, 19.9% (1911/9610) had late-onset infection, 14.3% (1386/9705) had severe intracranial hemorrhage, 12.8% (1099/8585) had severe retinopathy of prematurity, and 8.0% (666/8305) had severe bronchopulmonary dysplasia. Among 2930 surviving infants with gestational ages of 22-26 weeks eligible for follow-up, 2566 (87.6%) were examined. By 2-year follow-up, 8.4% (214/2555) of children had moderate to severe cerebral palsy, 1.5% (38/2555) had bilateral blindness, 2.5% (64/2527) required hearing aids or cochlear implants, 49.9% (1277/2561) had been rehospitalized, and 15.4% (393/2560) required mobility aids or other supportive devices. Among 2458 fully evaluated infants, 48.7% (1198/2458) had no or mild neurodevelopmental impairment at follow-up, 29.3% (709/2419) had moderate neurodevelopmental impairment, and 21.2% (512/2419) had severe neurodevelopmental impairment.
Conclusions and Relevance Among extremely preterm infants born in 2013-2018 and treated at 19 US academic medical centers, 78.3% survived to discharge, a significantly higher rate than for infants born in 2008-2012. Among infants born at less than 27 weeks’ gestational age, rehospitalization and neurodevelopmental impairment were common at 2 years of age.
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Standard of Care to Incorporate Mental Health Care for NICU Families: TECaN Embarks on National Advocacy Campaign
Katie Hoge, MD, Ali Slone, MD, Ann Blake, MD, MPH
We are thrilled to announce the official launch of the Carousel Care Advocacy Campaign. This effort is led by the group TECaN (Training and Early Career Neonatologists), a subspecialty group of the American Academy of Pediatrics. This campaign focuses on the need for mental health care for NICU families throughout the NICU journey. We know that a need for mental health support for NICU families is a long-standing need preceding the COVID-19 pandemic; however, the advent of the pandemic has exacerbated these needs and brought the mental health concerns of families into sharper focus. We know from pre-pandemic research that about half of NICU parents at any given time suffer from anxiety or depression during a NICU stay and that a third of parents go on to develop PTSD after a NICU admission. We believe that the need is even higher with the onset of the pandemic and its numerous added challenges and burdens on families. Despite the high needs and impact on child and family outcomes, there is no universal NICU standard to address familial mental health. Due to this, TECaN has ambitiously resolved to take on the task of altering the standard of care within the NICU to include mental health care through all-around support and wellbeing for NICU families via the national advocacy campaign, Carousel Care (#CarouselCare).
TECaN is partnering with multidisciplinary experts from across the country to educate and empower NICU providers on addressing mental health needs for NICU families adequately. TECaN is teaming up with experts in Neonatology, Psychiatry, Psychology, Maternal, and Fetal Medicine, Palliative Care, Social Work, Child Life, Nursing, and NICU parents to create content and resources delivered throughout the campaign. The campaign, launched in October 2021, will continue to deliver content through live webinars (also viewable post live date) and supplemental materials, which can all be found on the campaign’s website through October 2022 (https:// http://www.aap.org/en/community/aap-sections/ sonpm/tecan/advocacy/). The content over the course of the year will be organized into four main phases.
Phase one focuses on the prenatal period for parents who learn that they may require a future NICU admission for their child’s survival and the general need for mental health resources from the start of the NICU journey. Webinars and supplemental materials found on our website will include topics on managing parental expectations and addressing emotional needs in the prenatal consult, understanding the scope of mental health challenges of NICU families, and special consideration populations of diversity, equity, and inclusion relating to NICU mental health. Live webinars will take place monthly from October 2021 through December 2021, and all webinars will be available for viewing on our website after their original air date.
Phase two of the campaign will focus on the time during a NICU admission. Topics will include mental health impacts upon the interrupted bonding of the parent-infant dyad, screening for parental mental health concerns throughout the NICU admission, and potential mental health interventions during the NICU stay. This content will be delivered beginning in January 2022 through March 2022.
Phase three will focus on the NICU discharge process and continuity of care after NICU admission. Topics will include establishing mental health resources for families post-discharge, comforting families during bereavement, and helping families thrive after the NICU. This content will be delivered beginning in April 2022 through June 2022.
The fourth and final phase of the campaign will focus on incorporating these new standards of care into NICUs across the country in a wide range of clinical settings with variable resources. Topics will include webinars on including NICU family mental health within your NICU and caring for the caregiver. In recognition of each unit’s unique challenges, we strive to provide means for all NICUs to consider adopting these changes into clinical practice. We also recognize that it is vital to support our team members’ mental health to care for families effectively. One cannot pour from an empty cup, so we will also address caring for ourselves as providers. This content will be delivered beginning in July 2022 through October 2022.
Preterm lung health study – Dr Shannon Simpson
Mar 22, 2018 Telethon Kids Institute
A Telethon Kids Institute study published today in The Lancet Child & Adolescent Health has found that survivors of very preterm birth face declining lung function as they get older, rather than growing out of any lung problems as previously believed. In the biggest study of its kind since significant improvements in neonatal critical care during the 1990s drastically improved the chances of survival for preterm babies, a team of researchers led by Dr Shannon Simpson spent eight years following the progress of 200 babies born at less than 32 weeks’ gestation, along with 67 controls born at full term.
When All Becomes New Book Trailer by Dr. Benjamin Rattray
Sep 1, 2021 Benjamin Rattray
Book trailer for When All Becomes New: A Doctor’s Stories of Life, Love, and Loss featuring Benjamin Rattray, writer and neonatologist.
Fertility Treatments Don’t Raise Odds for Smaller, Preemie Babies
January 12, 2022
Babies conceived through infertility treatment are more likely to be born early and small.
“Rather than the infertility treatment itself, our new findings highlight the importance of parents’ underlying fertility problems and health conditions, and infants’ birth characteristics, such as their birth order and whether they are a twin, on birth weight and pregnancy term,” said study co-author Alina Pelikh. She’s a research fellow at the University College London Center for Longitudinal Studies in the U.K., which worked in partnership with the University of Utah in Salt Lake City.
For the study, researchers analyzed data on 248,000 births in Utah.
They found that differences in birth weight and length of pregnancy between couples who conceived naturally and those who used in vitro fertilization (IVF), artificial insemination or fertility drugs were insignificant once family circumstances were taken into account.
The study focused on births in Utah between 2009 and 2017 and various indicators of mothers’ health, including pre-pregnancy body mass index (an estimate of body fat based on height and weight), blood pressure, age, education level and whether they had multiple births.
In all, about 5% of infants in the study were conceived through medically assisted reproduction (MAR).
Use of fertility-enhancing drugs was most common (60%), followed by assisted reproduction, including IVF (26%), and artificial insemination (14%).
Children who were conceived through MAR were 10% more likely to be born premature and had 9% greater odds of low birth weight compared to naturally conceived infants.
More invasive treatments — such as IVF and artificial insemination — were more strongly linked to adverse birth outcomes. Infants conceived using fertility drugs had outcomes more similar to those conceived naturally.
But differences in outcomes narrowed once the mothers’ health, parents’ social and economic background, and infants’ birth characteristics were factored in.
Drawing from a statewide database, researchers zeroed in on a subgroup who had given birth to children using both MAR and natural conception during different pregnancies.
“By comparing births from the same mother we were able to better isolate the impact on these births of medically assisted technologies,” said co-author Ken Smith, a professor of family studies and population science at the University of Utah.
The upshot: Once a mother’s age, pre-pregnancy BMI and infants’ birth characteristics were factored in, the siblings had similar pregnancy terms and birth weights.
That suggests that family circumstances and unobserved parental characteristics, such as genetic traits, are important when explaining the association between MAR and adverse birth outcomes.
“Obtaining similar results in highly diverse contexts — in terms of demographics, fertility rates and access to the medically assisted reproduction treatments — strengthens the argument that adverse birth outcomes among medically assisted reproduction conceived infants are unlikely to be driven by the reproductive technology itself,” said co-author Alice Goisis, an associate professor at the UCL Center for Longitudinal Studies.
“This new evidence can go on to enrich existing health guidance about the risks and benefits of infertility treatments, hopefully raising awareness among families who are thinking about using medically assisted reproduction to help them conceive,” she added.
Preterm Birth Information for Education Professionals
11 January 2021 – E-learning resource focussing on preterm birth information recgonised with excellence award.
Camilla Gilmore and her colleagues in the Premature Infants’ Skills in Mathematics (PRISM) team, led by Professor Samantha Johnson (University of Leicester), were recently awarded a British Association of Perinatal Medicine (BAPM) Gopi Menon Award for ‘Excellence in Research or Innovation’ for the development of their PRISM e-learning resource for education professionals. The awards are given for excellence and contribution to patient and family care in the field of Perinatal Medicine.
The e-learning resource was co-designed with teachers, educational psychologists, parents of children born preterm, and young adults who were born preterm themselves, and comprises evidence-based information about what preterm birth is, how it may affect children’s development and learning, and what can be done to support them in the classroom. The resource has been evaluated and shown to significantly improve teachers’ knowledge of outcomes following preterm birth and their confidence in supporting preterm born children in the classroom.
Enter Below to review/access the five learning resources have been developed to improve your knowledge and confidence in supporting prematurely born children in the classroom.
Ventilation and respiratory outcome in extremely preterm infants: trends in the new millennium
Regin, Y., Gie, A., Eerdekens, A. et al. Ventilation and respiratory outcome in extremely preterm infants: trends in the new millennium. Eur J Pediatr (2022). https://doi.org/10.1007/s00431-022-04378-y
Ventilation and respiratory care have substantially changed over the last decades in extremely premature neonates but the impact on respiratory health remains largely unclear. To determine changes in respiratory care and disease frequency in extremely premature infants, a retrospective single-centre cohort study of extremely preterm infants was performed. All infants born alive between 24 + 0 and 27 + 6 weeks of gestation in 2000–2001 (Epoch 1), 2009–2010 (Epoch 2), and 2018–2019 (Epoch 3) were included. The primary outcome of this study was the incidence of bronchopulmonary dysplasia (BPD, diagnosed according to three different criteria) or death. Secondary outcomes included the usage of different ventilation modes, changes in pharmacotherapy, and the incidence of significant extra-pulmonary morbidities. A total of 184 neonates were included of whom 151 survived until 36 weeks of corrected GA (cGA). Oxygen or positive pressure dependence increased over time (26.1%, 41.7%, and 56.1% respectively), with higher adjusted odds in Epoch 3 for the composite outcome “BPD or death” (adjusted odds ratio: 2.55 [95%CI 1.19–5.61]). Severity-based definitions showed increasing trends in survivors only. Time spent on invasive mechanical ventilation was similar throughout the years, but the use of non-invasive ventilation significantly increased in Epoch 3 (32.0 [95%CI 25.0–37.0] vs 27.0 [95%CI 26.0–32.0] vs 53.0 [95%CI 46.0–58.0] days). Moreover, mortality-adjusted rates of severe IVH, NEC, or intestinal perforation and multiple sepsis tended to decrease.
Conclusion: In spite of significant clinical advancements and adherence to novel treatment guidelines in our neonatal intensive care unit, the incidence of BPD increased over time.
What is Known:
• Rates of BPD are stable or increase in population-based studies.
• Extremely preterm infants are particularly susceptible to developing BPD.
What is New:
• Despite increased use of evidence-based corticosteroid administration and early initiation of caffeine, the incidence of BPD has not decreased over the past decade.
• Increased usage of non-invasive ventilation is associated with an increase of BPD incidence
Medicaid, Doulas and Reducing Maternal and Infant Mortality Rates in the United States
Barb Himes, IBCLC, CD
First Candle’s mission is to reduce the rates of sleep-related infant mortality, which involves taking a hard look at maternal health – a critical gateway to infant health, and a reason why the American Academy of Pediatrics (AAP) includes in its infant safe sleep guidelines the recommendation that pregnant women seek out and obtain regular prenatal care. However, many factors interfere with maternal access to health care before, during, and after pregnancy, including racial/ethnic disparities and socioeconomics. Mortality rates due to pregnancy and birth complications are more than three times higher in Black than White women, and Black infants are more than twice as likely to be born prematurely or die within their first year of life than non Latinx white infants. Further complicating this is that women have also reported feeling they experience diminished autonomy or indifference in the provider-patient relationship, which could affect their outcomes and attitudes toward accessing care.
On the economic side, according to the Centers for Medicare and Medicaid Services (CMS), nearly two out of three adult women enrolled in Medicaid are of childbearing age, and Medicaid covers around 42% of births in the United States. Of those, whites make up 41.8% of women covered by Medicaid or the Children’s Health Insurance Program (CHIP), Hispanic women 28.1%, Black women 21.0%, and the rest Asian or native ethnicities.
In addition, only 21% of women in 2018 had a family income of 250% of the Federal Poverty Level (FPL) compared to 56.7% for women overall, and 20% had a family income of only 50 to 99% of the FPL. (2) The lack of financial resources can get in the way of access to health care to the degree needed throughout the birthing process and add to the risk of compromised health for infants.
But there is something that can address this combination of financial and social strain and help pregnant women get adequate care: make doulas part of the maternal health support network covered by Medicaid.
This approach advanced by the National Health Law Program’s Doula Medicaid Project monitors the status of Medicaid efforts regarding doula reimbursement in the United States, state by state. The ongoing-updated chart can be found at https://healthlaw.org/ doulamedicaidproject/. The program’s goal is to ensure that all pregnant enrollees in Medicaid who want access to a doula will have one.
According to the latest standings, there are currently four states (Oregon, New Jersey, Minnesota, Florida) where Medicaid is actively reimbursing for doula services, and eight states are putting Medicaid doula benefits in place. Ten states report action has been proposed but has made no progress, and those remaining have been taking steps related to care, such as setting up doula registries and certification programs.
This initiative matters because it contributes to maternal health care support, directly affecting maternal outcomes in at-risk populations and providing a method of care that fosters a level of trust that can enhance health care compliance to the benefit of mother and baby.
Doulas are a trained personal support system for expectant mothers and, depending upon the care plan, can be with the mother for prenatal and postpartum visits and the birth. Research studies indicate that doula support has contributed to better birth outcomes, reduced caesarian sections, advanced breastfeeding, and bolstered maternal emotional wellbeing. (3) They also serve mothers and their partners in their homes, literally meeting families where they live.
The Doula Medicaid Project is taking place as Medicaid itself continues its Maternal and Infant Health Initiative, working with states to increase the use and quality of postpartum care visits and decrease rates of caesarian sections in low-risk pregnancies, as well as increase well-child visits.
In 2018, there were 17 maternal deaths for every 100,000 live births in the United States, a rate that is more than double that of most other developed countries, which have a more integrated system of physician and midwife support than the U.S. (4) Unlike midwives, doulas do not deliver babies. However, in this country, they share with midwives a history of providing maternal support decreased by regulations in the 20th century with the advent of physician-centric health systems.
There is room for both, and the expansion of Medicaid to cover doulas is a positive step toward improving maternal and infant health.
Preterm birth leads to impaired rich-club organization and fronto-paralimbic/limbic structural connectivity in newborns
Neuroimage. 2021 Jan 15;225:117440. doi: 10.1016/j.neuroimage.2020.117440. Epub 2020 Oct 8. PMID: 33039621
Prematurity disrupts brain development during a critical period of brain growth and organization and is known to be associated with an increased risk of neurodevelopmental impairments. Investigating whole-brain structural connectivity alterations accompanying preterm birth may provide a better comprehension of the neurobiological mechanisms related to the later neurocognitive deficits observed in this population. Using a connectome approach, we aimed to study the impact of prematurity on neonatal whole-brain structural network organization at term-equivalent age. In this cohort study, twenty-four very preterm infants at term-equivalent age (VPT-TEA) and fourteen full-term (FT) newborns underwent a brain MRI exam at term age, comprising T2-weighted imaging and diffusion MRI, used to reconstruct brain connectomes by applying probabilistic constrained spherical deconvolution whole-brain tractography. The topological properties of brain networks were quantified through a graph-theoretical approach. Furthermore, edge-wise connectivity strength was compared between groups. Overall, VPT-TEA infants’ brain networks evidenced increased segregation and decreased integration capacity, revealed by an increased clustering coefficient, increased modularity, increased characteristic path length, decreased global efficiency and diminished rich-club coefficient. Furthermore, in comparison to FT, VPT-TEA infants had decreased connectivity strength in various cortico-cortical, cortico-subcortical and intra-subcortical networks, the majority of them being intra-hemispheric fronto-paralimbic and fronto-limbic. Inter-hemispheric connectivity was also decreased in VPT-TEA infants, namely through connections linking to the left precuneus or left dorsal cingulate gyrus – two regions that were found to be hubs in FT but not in VPT-TEA infants. Moreover, posterior regions from Default-Mode-Network (DMN), namely precuneus and posterior cingulate gyrus, had decreased structural connectivity in VPT-TEA group. Our finding that VPT-TEA infants’ brain networks displayed increased modularity, weakened rich-club connectivity and diminished global efficiency compared to FT infants suggests a delayed transition from a local architecture, focused on short-range connections, to a more distributed architecture with efficient long-range connections in those infants. The disruption of connectivity in fronto-paralimbic/limbic and posterior DMN regions might underlie the behavioral and social cognition difficulties previously reported in the preterm population.
Tips to do well in the NICU
The NICU Doc – Jun 14, 2020
Do you want to know the tips to do well in the NICU? Wanna excel and blow away the attending and medical team? Are you a student or resident and you want to excel in your NICU rotation? Never taken care of preterm, premature or sick babies? Nervous about rounds in the NICU? You’re in the right place. Dr. Fort is an attending Neonatologist and I am ready to dish out the FIVE tips that will make you shine on rounds!. And stay until the end, for the BONUS tip you might not expect! Don’t forget to like and subscribe and hit notification button if you like this and want more videos. If there is a video you would like me to do, let me know in the comments section. Enjoy this video on Dr. Fort’s Baby Talk and Dad Jokes!
University Hospitals Investigates the Fundamentals of Labor to Prevent Preterm Birth
December 09, 2021
Innovations in Obstetrics & Gynecology | Fall 2021
Preterm birth impacts 10 to 15 percent of pregnancies in the United States and is the leading cause of neonatal mortality. While there are known risk factors and some therapies intended to prevent preterm birth, much remains unknown about its cause and how it can be prevented, says Sam Mesiano, PhD, Vice Chair of Research and Director of the Division of Research in the Department of Obstetrics and Gynecology at University Hospitals Cleveland Medical Center.
Mesiano, who is also the William H. Weir Professor of Reproductive Biology at Case Western Reserve University School of Medicine, leads a research team at University Hospitals that is trying to understand how the process of birth is controlled and use that knowledge to develop more effective therapies to prevent preterm birth.
Nature has provided some clues. Progesterone, often referred to as the pregnancy hormone, is essential for the establishment and maintenance of pregnancy. Clinical trials suggest that treating women with extra progesterone decreases the risk for preterm birth, and this therapy is administered in women with increased risk.
Mesiano’s team is exploring the mechanism by which progesterone acts to block labor and delivery and how its blocking actions are overcome to allow birth.
“We’re trying to tease out the molecular mechanism by which progesterone maintains pregnancy and how it acts on the uterus to keep it from contracting and to keep the cervix closed,” he says. “If we understand how progesterone blocks labor, then we can then start to tease out the signaling pathways that remove its blocking action and trigger labor.”
Some early studies suggested that boosting progesterone activity in pregnant women prevents preterm birth, but more research has since been done. Mesiano reasons that the blocking action of progesterone can be exploited with more potent synthetic compounds that mimic the action of a woman’s natural progesterone.
Uterine Tissue and Mouse Models
At UH, Mesiano is using uterine tissue, cell cultures and mouse models to understand the mechanisms behind labor and to develop novel progesterone-based therapies to prevent preterm birth. They can look at the muscle cells in human uterine tissue to help determine what keeps these cells relaxed and what causes them to contract. In mouse models, the research team is studying preterm birth and testing progesterone-like drugs that could prevent it.
A New Approach
While naturally occurring progesterone may not be the definitive answer to stopping preterm birth, understanding this hormone and altering it may be the key to doing so. In a recent study published in the American Journal of Obstetrics & Gynecology, Mesiano and his team demonstrated promising results with a different form of progesterone in a mouse model.
“We take the progesterone that nature has given us, and we modify it a little bit chemically to make a different structure that will act in a more robust way in the woman,” he says. “Our lead compound was effective at preventing preterm birth in mice treated to simulate human preterm birth, and we are excited to explore its mechanism of action.”
“It is exciting to have proof of concept that preterm birth can indeed be prevented with a progesterone-like compound,” Mesiano says. The team is in the process of obtaining funding to study the same protocol in rhesus monkeys.
While plenty of work remains to be done before this research translates into real-world care, the compound being used in this research has already been in used in humans. It is approved in Europe for the treatment of gynecological disorders such as endometriosis and uterine fibroids. “It is an early stage drug repurposing project,” Mesiano says.
He is collaborating with experts in structural and organic chemistry at Case Western Reserve University to synthesize novel compounds that have the potential to be even more effective.
“We have a pipeline in place to test these compounds on cells and in mice, and we are now modifying what we have to see if we can improve effectiveness,” Mesiano says. “Our research wouldn’t happen as efficiently as it does if it were not for the academic environment that is built around the OB/GYN department at UH and the department of reproductive biology.”
Contact Mesiano at Sam.Mesiano@case.edu to learn more about his research on preterm birth.
Stress and social support among registered nurses in a level II NICU
Excessive occupational stress and the resulting burnout are a serious and widespread problem affecting nurses and other health care professionals (Buckley et al., 2020; Maslach and Leiter, 2017; West et al., 2016). Burnout is prevalent among staff in neonatal intensive care units (NICUs), particularly nurses (Rochefort and Clarke, 2010; Tawfik et al., 2017a). High levels of stress and burnout are not only detrimental to nurses’ own health and job satisfaction, but are also important factors contributing to high staff turnover, a chronic and costly problem in hospitals (Hayes et al., 2012). Deficiencies in the psychosocial work environment leading to overburdened staff and high turnover can also compromise patient safety and quality of care in the NICU (Lake et al., 2016; Profit et al., 2014; Rochefort and Clarke, 2010).
Workplace social support, i.e. various forms of assistance, resources or encouragement received from coworkers and supervisors, is a crucial element of a healthy psychosocial work environment (Kossek et al., 2011; Maslach and Leiter, 2017). Previous studies of nurses and other health care professionals show the importance of social support in enabling them to cope with the demands of their work, including emotional distress (Adriaenssens et al., 2015; Hamama et al., 2019; Winning et al., 2018).
Nurses in pediatric and neonatal care are exposed to particular stressors related to the emotional effects of caring for child patients and the complexity of working with families (Buckley et al., 2020; Larsonet al., 2017). In today’s family-centered neonatal care, patients’ parents are encouraged to be present at the unit as much as they can, and their involvement in all aspects of their child’s care is emphasized (Davidson et al., 2017). This model has benefits for families but can add to the complexity of nurses’ work (Coats et al., 2018; Jackson and Wigert, 2013).
Understanding the sources of stress to which neonatal nurses are exposed and the strengths and weaknesses of the social support available to them is a necessary foundation for targeted improvements to their work environment. However, research analyzing neonatal nurses’ work environment is scarce. In particular, to our knowledge, no study has explored the specific work environment of nurses in a level II NICU (special care nursery), where sick newborns who do not require ventilator therapy, including graduates from a level III NICU, are cared for. These units play an important role both medically and in preparing parents for the transition to caring for their infant independently at home, a process to which nurses contribute in crucial ways. In the pre- sent qualitative study we therefore aimed at describing the aspects of their work that nurses at a level II NICU perceived as important sources of stress, as well as the types of workplace social support available to them.
This study took place at a level II NICU in a Swedish university hospital, one of Northern Europe’s largest delivery hospitals. The unit has fourteen beds in single-family rooms as well as a room with four beds for continuous monitoring. The staff includes forty registered nurses. Some infants come to the unit directly after delivery, while others are graduates of the level III NICU at the same hospital.
All registered nurses who had worked at the unit for at least three months were eligible for participation in the study. A sample comprising nurses with various levels of experience and work schedules was sought. Thirteen nurses participated in the study, having given their informed consent. The participants had been registered nurses for be- tween 3 months and 38 years (median 6 years) and had worked in neonatal nursing for between 3 months and 38 years (median 2 years 9 months). Three worked exclusively night shifts, whereas others had a
Data collection took place in 2019. The level of staffing and other conditions at the unit at the time were as usual. Semi-structured interviews were conducted at the unit at a time convenient to the participant. The interviewer (first author) was external to the unit and previously unknown to the participants. Each interview began by asking for an account of how the participant perceived positive and negative aspects of working at the unit. After this, specific aspects of nurses’ work environment were covered based on the interview guide. Follow-up questions were asked as appropriate, for example to elicit specific examples. Care was taken to give participants time to elaborate on topics of special concern to them.
The duration of the interviews was 26–54 min (mean 42 min). The interviews were audio-recorded and transcribed verbatim. Data collection continued until data saturation was achieved.
Qualitative content analysis with an inductive approach as described by Graneheim and Lundman (2004) was performed. Meaning units aligned with the aim of the study were identified in the text and condensed to shorter textual units. Each condensed meaning unit was labeled with a code name. The initial coding covered all data relating to nurses’ psychosocial work environment. Further analysis focused on aspects of the data related to topics of stress and social support. Codes were grouped into categories, after which themes relating to nurses’ perceptions of stressors and forms of social support were identified.
Analysis resulted in three themes describing sources of stress and three themes describing sources of support,
Inexperienced nurses’ limited knowledge of neonatal care
The participants described work at the unit as highly demanding for inexperienced nurses, who mostly had no previous training or experience in neonatal or pediatric nursing. This gap between their initial level of competence and the demands of the work was seen as a major source of stress. After a six-week orientation and trainee period, new nurses were expected to work independently. This transition was pointed out as a particularly vulnerable period for inexperienced nurses, who still felt uncertain of their skills and lacked self-confidence.
“Even as a new graduate you’re expected to know everything both by parents and by colleagues, and maybe doctors and so on. […] So it’s incredibly stressful and hard on you psychologically to be new at this unit”. (Interview 5)
Working in single-family rooms was described as contributing considerably to the demands on new nurses, since it meant that they had to attend to patients and answer parents’ questions without the presence of a colleague. Single-family rooms were also seen as slowing new nurses’ learning process, since they impeded learning by observation.
Moreover, inexperienced nurses complained of considerable stress and apprehension due to a lack of previous notice as to when they would be assigned more advanced duties.
High and complex workload
Workload, both the sheer amount of work and the variety of tasks the nurses had to manage, was another important source of stress. Staffing at the unit was described as often barely adequate, meaning that nurses’ ability to manage their workload was highly vulnerable to unexpected events such as an influx of seriously ill patients or absences due to sickness among staff.
Several participants said they often found it impossible to leave work on time. Also, the ever-present possibility of being contacted on a day off and asked to fill in for an absent colleague was mentioned as making it more difficult to relax and recover. While some participants said they mostly coped well with their workload, others said their work drained them of energy.
“My private life feels more like recharging to be able to cope with my job: pack lunches, sleep, stare at a wall, go to work”. (Interview 12)
Work at the unit was described as making high demands on nurses’ ability to prioritize and organize disparate tasks. Circumstances such as constantly having to check on alarms or lacking peace and quiet to focus on administrative tasks made it hard to concentrate on one thing at a time. Experienced nurses mentioned that they were expected to be more or less constantly available for advising less experienced coworkers; this was a significant addition to their workload.
Emotional intensity of work
Emotionally taxing situations that the participants had to deal with at work, in combination with their acute sense of responsibility for the patients and their families, could form significant emotional burdens although the patients at the unit were not critically ill. The extent to which participants felt emotionally affected by their work varied and was not seen as necessarily diminishing with experience.
While working with families was described as one of the most rewarding and meaningful aspects of nurses’ work, it also presented emotional challenges. The fact that parents were present most of the time accentuated the impact of their emotional state on nurses. In some cases, dealing with families’ transition from the level III NICU to the level II NICU and the expectations of staff that parents had formed at the level III NICU was an additional stress factor.
Certain families had a particularly marked emotional impact because of their exceptional distress or complicated psychosocial situation. At the same time, participants described the strain of having to control their own emotions in order to behave in a calm and professional manner in front of families. Some participants thought that nurses, especially less experienced ones, would have needed more support and guidance in how to deal with their own emotions in the face of families’ suffering.
A few participants expressed concern that patients’ safety might be at risk when nurses’ workload was at its most intense. More commonly, nurses were troubled by the feeling that patients’ families received less attention and support than they should have. Lacking time or ability to do as much for the families as they felt they ought to led, for some, to feelings of guilt and personal inadequacy. For some nurses this became a chronic source of frustration and ethical stress.
“It’s a word that unfortunately gets used quite a lot here when there’s been a lot to do, that you feel insufficient and that it’s … you haven’t been able to do all you wanted to. And that’s a dangerous feeling to go home with […] from what I’ve understood from the people who have quit since I started, it’s a pretty important part of [why they quit]”. (Interview 5)
Participants expressed a strong sense of the importance of their work and their responsibility for patients and patients’ families. For some, notably among less experienced nurses, this translated into stress and fear of what any negligence or error on their part could mean for the vulnerable infants and families. As a result, some nurses said they felt obliged, in practice, to exert themselves to the point of neglecting their own need of recovery.
Generally, the participants perceived the climate among staff at the unit as caring and supportive. The nurses at the unit were described as interested in each other’s well-being and active in helping their col- leagues. In general, participants said they felt valued by their colleagues and received positive feedback from them.
Several factors were seen as hampering access to support from col- leagues. At busy times all nurses might be too occupied with their own work to support colleagues. The physical layout of the unit, with single- family rooms behind closed doors, made it difficult to locate colleagues. For this reason, even when the unit was adequately staffed with nurses, nurses could be impeded from asking colleagues for help when they needed it. Further, some participants regretted that there was little opportunity for non-work-related exchanges that might have developed cohesion among coworkers or provided respite in the work day. Another hindrance mentioned by a number of participants was the lack of a private office for nurses. Finally, the high proportion of inexperienced nurses in the group meant that the need for support could be greater than the supply of colleagues able to provide it.
Support, including emotional support, from colleagues was viewed as an invaluable resource but one that was dependent on staff members’ individual initiative and good will, rather than an integral part of how work on the unit was organized.
“I think it saved me emotionally [as a new nurse] that I have colleagues who listen and show consideration […] It would have been much harder if there hadn’t been colleagues I could share things with, just briefly. I don’t think it’s really thought of as ‘support’ […] it’s more by good luck that the support is there”. (Interview 4)
About half of the participants described their first-line nurse man- agers as supportive, accessible and willing to listen to their concerns.
Night shift nurses, however, commented that they seldom saw or communicated with their nurse manager.
Some participants felt that management tended to be too quick to impose changes in the way things were done on the unit, for example if families complained about something, rather than listen to what nurses had to say about the matter.
Some participants said they received sufficient feedback from their managers, whereas others said they received very little and would have liked more. One participant felt that managers too easily tended to brush off new nurses’ anxiety about making mistakes by referring to the or- ganization’s responsibility for adverse events.
“[they tell you] ‘well, if anything were to happen it’s not your fault, it’s the organization’s since it’s understaffed’. And I thought, yeah but that doesn’t help me, I’m still the one who’s responsible […] I would feel just as awful anyway”. (Interview 13)
Nurse managers were described as caring about nurses’ well-being and fairly willing to provide support, e.g. by referring staff members experiencing excessive stress to occupational health services for counseling. Some participants felt that managers should have done more to address individual nurses’ stress levels before their situation became dire. But participants also saw managers as having a limited ability to make adaptations that might help nurses at risk of burnout.
Recent rapid turnover among management was seen by some as negatively impacting nurses’ confidence in their supervisors and their ability to count on supervisors’ support.
Recently the introduction program for new nurses had been expanded in order to provide increased support for new nurses. After their initial orientation and trainee period was over they continued to have access to a nurse mentor who was there was to offer guidance and act as a professional role model. The mentor was seen as an important resource but was not present at the unit full-time. Over the first year, new nurses also had access to small-group professional supervision in nursing care. Some participants wished that nurses with more experience had also had access to similar forms of support.
The organization was seen as fairly generous with opportunities for further training and development, which the participants appreciated and saw as a strength of their workplace.
“[On this point] I have to say I’m extremely positive, almost surprised […] I came here and almost immediately I got to take this course in neonatology, and it’s a lot of fun. And that also makes you feel appreciated, that they want to invest in you”. (Interview 10)
However, fewer forms of support and opportunities for development were available for the most experienced nurses.
“They’ve invested in new nurses above all, with a lot of training and opportunities to discuss and reflect [on their work] and so on. But we older nurses get forgotten […] Some of us have been working for a really long time and we also need a bit of attention and support”. (Interview 1)
A group reflection session for nursing staff, taking place at the end of each day shift, had recently been introduced. The sessions allowed staff to compare notes on how the day had gone and discuss issues of concern, for example challenging situations they had been involved in. This was described as a valuable means of coping with emotional stressors at work.
One of the most salient strengths of the work environment appreciated by the participants in our study was nurses’ positive attitude to- wards each other and their readiness to help and support colleagues.
Nevertheless, such collegial support was limited by a number of circumstances, including the single-family room layout of the unit. This layout offers parents in the NICU greater privacy and enables them to spend time with their infant, but it can also complicate nurses’ work. A novel finding in our study is the special impact of this layout on nurses just beginning independent work, who had few opportunities for learning by observation and felt it was daunting to work alone with families. Although some studies (Stevens et al., 2010) have shown enhanced workplace quality in a single-family room NICU layout, in our study the disadvantages of this environment were more evident, particularly for inexperienced nurses. More experienced nurses also regretted the obstacles to contact with colleagues. Similarly, in a previous study by Hogan et al. (2016), nurses in a single-family room level II NICU reported a sense of isolation. In view of our results, it would be important to organize nurses’ work in a way that facilitates communication and mutual support among nurses. The physical aspects of the workplace need to be taken into account, for example by providing ways to ensure nurses can find each other when needed and private office space for nurses. At the same time, informal collegial support cannot be a substitute for healthy organizational conditions such as an acceptable workload and adequate staffing.
We found that patients’ and families’ situation had a significant emotional impact on nurses although the infants cared for in a level II NICU are not normally critically ill. Participants mentioned the special impact of dramatic situations that were outside the normal routine at the unit and the need to be able to discuss these with colleagues. But they also spoke of the cumulative emotional impact of day-to-day work with patients and their families and a constant sense of responsibility that, for some nurses, shaded into a chronic feeling of inadequacy. Reflection sessions at the end of the day were an innovation that the nurses had found helpful as a way of coping with emotional stress. Opportunities for such sharing should be fostered, especially since a climate where staff can express their authentic feelings can protect health care staff from burnout caused by emotionally stressful encounters (Grandey et al., 2012). Our results also point to a need for training of nurses in dealing with emotionally taxing aspects of their work, something especially relevant within family-centered care where close communication with families is integral to nurses’ work.
The results of our study speak to the importance of adapting support to the needs of nurses at various stages of their career. Like previous studies (Labrague and McEnroe-Petitte, 2018), our results show new nurses’ particular vulnerability to stress. Apart from a general lack of experience, participants in our study provided information on specific difficulties for new nurses. For example, inexperienced nurses need to receive clear information on how their responsibilities will progress as they gain in competence. Not yet being well-versed in neonatal care is also liable to make prioritizing and organizing one’s own work harder, thus making work more stressful. This should be paid attention to in the training of new nurses. New nurses at the unit we studied appreciated having access to a nurse mentor whose job was specifically to support them. This type of mentorship seems worth investing in to provide assistance and security to new nurses.
At the same time, our results highlight the fact that nurses with extensive experience in neonatal care also have needs of support that should not be neglected, a little-studied area. Despite their competence, experienced neonatal nurses are also at risk for burnout, according to some studies even more so than less experienced colleagues (Tawfik et al., 2017b). In addition, they need professional stimulation and appreciation in order to feel that their work continues to be satisfying (Loft and Jensen, 2020). Because of their seniority and accumulated competence, their possible decision to leave can be especially disruptive for coworkers, including new nurses who rely on their teaching and support, as participants in our study noted. The value as well as the amount of the work that experienced nurses perform in teaching less experienced colleagues should receive recognition, and care should be taken that this task does not unduly increase their workload.
Since this was a study of one unit, care needs to be taken in applying the results to other contexts that may differ in various ways. For example, the hierarchy among Swedish hospital staff (e.g. between nurses and doctors or between nurses with different levels of expertise) is less pronounced than in many other countries, which could potentially have both positive and negative effects on nurses’ stress, e.g. by increasing their sense of influence in the workplace or by increasing their burden of individual responsibility. Sweden’s generous parental leave policy means that parents are free to spend large amounts of time at the unit, a factor likely to affect nurses’ work environment. Further, the unit we studied is part of a large university hospital, and nurses’ circumstances may differ from those at a smaller hospital providing less advanced care.
Working in single-family rooms presents particular stressors for neonatal nurses, especially those who are new to the job, and work should be organized in ways that counteract its isolating effect. While continuing their efforts to support new nurses, organizations should also pay attention to the needs of the most experienced nurses. The question of what factors help nurses feel that their work continues to be rewarding after many years merits further research. Neonatal nursing, involving close collaboration with families in distress, has a significant emotional impact on nurses, and there is a need to develop interventions to support and educate nurses in this aspect of their work.
A year in review: Physician leaders look back on 2021 | Moving Medicine for Dec. 22, 2021
Dec 22, 2021 American Medical Association (AMA)
As we look back on 2021, it’s difficult to put into words all that our nation’s physicians have experienced this past year. AMA CXO Todd Unger shares a special end-of-year feature where physicians answer three questions and tell their own stories of 2021 … in their words.
We recognize our preterm birth community within the migrant /refugee populations around the world. You are a valuable part of our family!
Unfortunately, we do not have the statistical information representing the actual percentage of preterm birth within this part of our community, but we know preterm birth is likely on the higher end of probability. Various field experts have suggested exposure to migration-related stress during pregnancy may lead to an increased risk of preterm birth.
Stress is a consistent and powerful force within the life experiences of a refugee/migrant journey and also within the journey of preterm birth family. We are hoping to promote research related to pre-verbal PTSD among our preterm birth community. PTSD is also a condition that does effect preemie parents as well. There are effective treatment options available for consideration by preemie parents, and providers are increasingly aware of parental exposure to PTSD and may be a good resource for support. Accessibility to these resources varies widely.
We are grateful for organizations such as the HERO2B Foundation that are raising awareness about PTSD among vulnerable and young populations. The impactful activities and valuable story-telling advocacy they are providing to youth and our global community is empowering. As highlighted in the HERO2B video above, our stories can inspire one our strength.
Preemies and their family members may benefit from hearing about their birth stories and the experiences and feelings their parents and family members endured and embraced along the path. Age appropriate sharing is encouraged. Storytelling in this capacity may be inspirational, educational and of benefit to all involved.
I Went Surfing In Morocco’s Hidden Magic Bay | Tastemade Travel
Jun 3, 2021 Tastemade Travel
Sierra takes us on a journey through Morocco and discovers a surfer’s paradise in Imsouane. Comment below what you want to see on our channel!