Title. Expert intrapartum maternity care: a meta‐synthesis Aim.  This paper reports a meta‐synthesis exploring the accounts of intrapartum midwifery skills, practices, beliefs and philosophies given by practitioners working in the field of intrapartum maternity care who are termed expert, exemplary, excellent or experienced. Background.  Expertise in nursing and medicine has been widely debated and researched. However, there appear to be few studies of practitioners’ accounts of expertise in the context of maternity care. Given current international debates on the need to promote safe motherhood, and, simultaneously, on the need to reverse rising rates of routine intrapartum intervention, an examination of the nature of maternity care expertise is timely. Method.  A systematic review and meta‐synthesis were undertaken. Twelve databases and 50 relevant health and social science journals were searched by hand or electronically for papers published in English between 1970 and June 2006, using predefined search terms, inclusion, exclusion and quality criteria. Findings.  Seven papers met the criteria for this review. Five of these included qualified and licensed midwives, and two included labour ward nurses. Five studies were undertaken in the USA and two in Sweden. The quality of the included studies was good. Ten themes were identified by consensus. After discussion, three intersecting concepts were identified. These were: wisdom, skilled practice and enacted vocation. Conclusion.  The derived concepts provide a possible first step in developing a theory of expert intrapartum non‐physician maternity care. They may also offer more general insights into aspects of clinical expertise across healthcare groups. Maternity systems that limit the capacity of expert practitioners to perform within the domains identified may not deliver optimal care. If further empirical studies verify that the identified domains maximize effective intrapartum maternity care, education and maternity care systems will need to be designed to accommodate them.

BackgroundSimilar to global trends, neonatal mortality has fallen only slightly in Indonesia over the period 1990–2010, with a high proportion of deaths in the first week of life.ObjectiveThis study aimed to identify risk factors associated with neonatal deaths of low and normal birthweight infants that were amenable to health service intervention at a community level in a relatively poor province of Indonesia.DesignA matched case–control study of neonatal deaths reported from selected community health centres (puskesmas) was conducted over 10 months in 2013. Cases were singleton births, born by vaginal delivery, at home or in a health facility, matched with two controls satisfying the same criteria. Potential variables related to maternal and neonatal risk factors were collected from puskesmas medical records and through home visit interviews. A conditional logistic regression was performed to calculate odds ratios using the clogit procedure in Stata 11.ResultsCombining all significant variables related to maternal, neonatal, and delivery factors into a single multivariate model, six factors were found to be significantly associated with a higher risk of neonatal death. The factors identified were as follows: neonatal complications during birth; mother noting a health problem during the first 28 days; maternal lack of knowledge of danger signs for neonates; low Apgar score; delivery at home; and history of complications during pregnancy. Three risk factors (neonatal complication at delivery; neonatal health problem noted by mother; and low Apgar score) were significantly associated with early neonatal death at age 0–7 days. For normal birthweight neonates, three factors (complications during delivery; lack of early initiation of breastfeeding; and lack of maternal knowledge of neonatal danger signs) were found to be associated with a higher risk of neonatal death.ConclusionThe study identified a number of factors amenable to health service intervention associated with neonatal deaths in normal and low birthweight infants. These factors include maternal knowledge of danger signs, response to health problems noted by parents in the first month, early initiation of breastfeeding, and delivery at home. Addressing these factors could reduce neonatal deaths in low resource settings.

for the Western WA COVID-19 Expert Panel BACKGROUND: Washington State experienced the first major outbreak of COVID-19 in the US and despite a significant number of cases, has seen a relatively low death rate per million population compared with other states with major outbreaks, and has seen a substantial decrease in the projections for healthcare use, that is, "flattening the curve." This consensus report seeks to identify the key factors contributing to the effective health system disaster response in western WA. METHODS:A multidisciplinary, expert panel including individuals and organizations who were integral to managing the public health and emergency healthcare system response were engaged in a consensus process to identify the key themes and lessons learned and develop recommendations for ongoing management of the COVID-19 pandemic. RESULTS:Six key themes were identified, including early communication and coordination among stakeholders; regional coordination of the healthcare system response; rapid development and access to viral testing; proactive management of long-term care and skilled nursing facilities; proactive management of vulnerable populations; and effective physical distancing in the community. CONCLUSIONS: Based on the lessons learned in each of the areas identified by the panel, 11 recommendations are provided to support the healthcare system disaster response in managing future outbreaks.

BACKGROUND The Seattle, WA, area was ground zero for coronavirus disease 2019 (COVID‐19). Its initial emergence in a skilled nursing facility (SNF) not only highlighted the vulnerability of its patients and residents, but also the limited clinical support that led to national headlines. Furthermore, the coronavirus pandemic heightened the need for improved collaboration among healthcare organizations and local and state public health. METHODS The University of Washington Medicine's (UWM's) Post‐Acute Care (PAC) Network developed and implemented a three‐phase approach within its pre‐existing network of SNFs to help slow the spread of the disease, support local area SNFs from becoming overwhelmed when inundated with COVID‐19 cases or persons under investigation, and help decrease the burden on area hospitals, clinics, and emergency medical services. RESULTS Support of local area SNFs consisted of the following phases that were implemented at various times as COVID‐19 impacted each facility at different times. Initial Phase: This phase was designed to (1) optimize communication, (2) review infection control practices, and (3) create a centralized process to track and test the target population. Delayed Phase: The goals of the Delayed Phase were to slow the spread of the disease once it is present in the SNF by providing consistent education and reinforcing infection prevention and control practices to all staff. Surge Phase: This phase aimed to prepare facilities in response to an outbreak by deploying a "Drop Team" within 24 hours to the facility to expeditiously test patients and exposed employees, triage symptomatic patients, and coordinate care and supplies with local public health authorities. CONCLUSIONS The COVID‐19 Three‐Phase Response Plan provides a standardized model of care that may be implemented by other health systems and SNFs to help prepare and respond to COVID‐19. J Am Geriatr Soc 68:1155–1161, 2020.

BackgroundAltered DNA methylation of imprinted genes has been implicated in a range of cancers. Imprinting is established early in development, and some are maintained throughout the life course in multiple tissues, providing a plausible mechanism linking known early life factors to cancer risk. This study investigated methylation status of seven imprinted differentially methylated regions—PLAGL1/ZAC1, H19-ICR1, IGF2-DMR2, KvDMR-ICR2, RB1, SNRPN-DMR1 and PEG3—in blood samples from 189 women with the most common type of invasive breast cancer (invasive ductal carcinoma—IDC), 41 women with in situ breast cancer (ductal carcinoma in situ—DCIS) and 363 matched disease-free controls.ResultsThere was no evidence that imprinted gene methylation levels varied with age (between 25 and 87 years old), weight or height. Higher PEG3 methylation was associated with an elevated risk of IDC (odds ratio (OR) 1.065; 95 % confidence interval (CI) 1.002, 1.132; p = 0.042) and DCIS (OR 1.139; 95 % CI 1.027, 1.263; p = 0.013). The effect was stronger when in situ and invasive breast cancer were combined (OR 1.079; 95 % CI 1.020, 1.142; p = 0.008). DCIS breast cancer risk increased with higher KvDMR-ICR2 methylation (OR 1.395; 95 % CI 1.190, 1.635; p < 0.001) and lower PLAGL1/ZAC1 methylation (OR 0.905; 95 % CI 0.833, 0.982; p = 0.017). In a combined model, only KvDMR-ICR2 methylation remained significantly associated.ConclusionsThese findings may help to improve our understanding of the aetiology of breast cancer and the importance of early life factors in particular. Imprinting methylation status also has the potential to contribute to the development of improved screening and treatment strategies for women with, or at risk of, breast cancer.