Introduction Midwife has in Preventing Toxoplasmosis. Student ID: 3109169

Introduction to Psycho-Social
Perspectives of Childbearing and Childbirth.

 

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Preventing Toxoplasmosis in Pregnancy
and the Role the Midwife has in Preventing Toxoplasmosis.

 

Student ID: 3109169

 

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Toxoplasmosis is an infectious disease
caused by a single- celled parasite known as Toxoplasma Gondii (Atrid et al,
2001). There are around 350,000 cases a year in the UK but only 350 cases are
ever reported (NHS, 2017). In most people the immune system is strong enough to
fight off toxoplasmosis before the disease causes any serious illness or
symptoms. However, in some circumstances individuals do experience symptoms,
which are misinterpreted as being influenza (flu). This suggests the lack of
symptoms, or the misidentification of toxoplasmosis as the flu, leads to a
minimum number of diagnosis each year. While in most cases toxoplasmosis is
unthreatening to individuals, those with a weak immune system are at risk of
developing serious illness. Examples of which are ocular toxoplasmosis, cerebral
toxoplasmosis and congenital toxoplasmosis.

 

Pregnancy has been found to lower a woman’s
immune system, putting them at higher risk of contracting toxoplasmosis and
experiencing one of the serious illnesses associated with this risk. This
especially includes congenital toxoplasmosis where the health of the unborn
child is at risk. The parasite has been found to invade tissue and damage the
brain of a foetus or newborns (Findal et al, 2017). In some cases the disease,
if untreated, can cause miscarriage and newborn death (Prusa et al, 2017). Due
to these reasons prevention of toxoplasmosis needs to be promoted, especially
to pregnant women. Part of a midwife’s role is to promote health to expectant
mothers, following current research and recommendations from trust and national
guidelines (NICE, 2008), to ensure good health for mothers and babies. Midwives
are an expectant mothers main source of information and guidance, especially
throughout the antenatal period. Therefore, it is important midwives take this
opportunity to understand and advise pregnant women on how they can prevent
toxoplasmosis.

 

This essay will discuss toxoplasmosis,
preventions of the disease, the definition and role of health and health
promotion, and the role of the midwife in promoting prevention of
toxoplasmosis, specifically during antenatal consultations. This will be
presented by reviewing previous literature, applying Ewles and Simnett (2003)
Educational Approach and Antonovsky Salutogenesis (Benz et al, 2014).

 

The importance for preventing toxoplasmosis
in pregnant women is because of the risks the disease pose to the mother and to
the unborn child. The disease is most likely contracted and more dangerous when
people have a lowered immune system (e.g. undergoing chemotherapy, contracting
HIV or being pregnant). Thus when a woman becomes pregnant she is more likely
to be at risk of contracting toxoplasmosis, of which there are different types including
ocular toxoplasmosis, which causes scarring and inflammation in the eyes and
cerebral toxoplasmosis, where the brain swells causing headaches, poor
co-ordination and in some cases seizures (REFERENCE). Another form is
congenital toxoplasmosis, where toxoplasmosis can spread through the placenta
to the foetus possibly causing fluid on the baby’s brain (hydrocephalus),
epilepsy, brain damage, hearing loss, learning disabilities and cerebral palsy.
Congenital toxoplasmosis can also cause miscarriage or stillbirth. This form of
the disease only occurs if the woman becomes infected for the first time during
pregnancy or the weeks before conception. The risk of passing the infection on
to a foetus is around 10-15% if the mother contracts toxoplasmosis in the first
12-13 weeks of pregnancy and around 70% if the mother becomes infected from
week 26-28 onwards. This research suggests the congenital toxoplasmosis is more
likely to occur if the mother contracts the disease for the first time in the
later stages of pregnancy. Due to these reasons pregnant women need to be
informed and advised of the risks the disease poses for themselves and their
babies and most importantly what they can do to prevent the disease.

 

The Toxoplasma Gondii (t.gondii) parasite
is found in the faeces of infected cats and meat of infected animals. It is
also found in soil contaminated with cat faeces meaning produce grown in this
soil can carry the disease. Toxoplasmosis is only contracted via ingesting
contaminated food, such as unwashed fruit or vegetables, undercooked or raw
meat, contaminated meat, unpasteurised milk or cheeses and by drinking
contaminated water and by contaminated hands coming into contact with the
mouth. Prevention of the disease can be successful by being aware of the causes
and avoiding them. When a midwife has first contact with a pregnant woman,
usually at the booking appointment, a past history is discussed, including the woman’s
current lifestyle. During this appointment, prevention of toxoplasmosis should
be discussed along with other good health promotion to ensure a woman has a
safe and healthy pregnancy. Due to the damaging effects toxoplasmosis can
cause, midwifes need to be aware and ensure they inform mothers how they can
prevent toxoplasmosis.

Literature suggests that not all women are
adequately informed about this preventable infectious disease. Knowledge of the
disease and its causes plays an essential role on the prevention of the
disease. One piece of research (Munoz-Zanzi, 2013) conducted a cross-sectional
serosurvey, where blood samples where taken and tested for toxoplasmosis from
people in urban slums, farms and rural villages in an area of Chile. Results
found 55.9%, over half, of the participants used were positive for
toxoplasmosis. More participants from the farms tested positive for
toxoplasmosis than those in rural villages and slums. The knowledge of
toxoplasmosis was also reviewed along with any preventive actions used. The
research found a lack of knowledge of the disease with the only noticeable
preventive technique being boiling hot water, however when the participants
were asked why they boil the water it was not specifically to prevent
toxoplasmosis. This research suggests when there is a lack of knowledge of
toxoplasmosis and how to prevent the disease, people are more likely to
contract the disease.

 

Other studies have shown when toxoplasmosis
and preventions are promoted the infectious disease is less likely found. Breugelmans,
M. (2004) conducted a study with three different conditions. Condition one, no
promotional information sent to pregnant women. The second condition, pregnant
women were sent a list of recommendations of how to avoid toxoplasmosis and the
third condition pregnant women were sent a leaflet with information of what
toxoplasmosis is and actions to prevent it. They found there was a reduction
rate of 92% of women found to have toxoplasmosis after receiving the leaflet
informing them of what toxoplasmosis is and how to prevent it. This research
suggests that informing women about the disease and its side effects and
informing them of the ways they can prevent contracting the disease the less
likely they are to contract this disease. This suggests that because they know
the dangers and possible outcomes of the disease they are more likely to
actively follow the preventions. Therefore evidence suggests the more informed
people are about the disease and the preventive actions the less likely they
are to contract the disease, emphasising the importance of promoting
toxoplasmosis preventions.

 

To promote positive promotion of health,
health itself along with health promotion definitions need to be considered and
reviewed. Collins Dictionary (2011) defines health as ‘the condition of the
body and the extent to which it is free from illness or is able to resist
illness’. The Medical Model states good health is when there is an absence of
disease, established by examining the individuals biological or physical state,
which requires diagnosis and in some cases a cure, to re-establish health. The
Medical Model supports Collins (2011) definition of health reinforcing the
definition that health should be defined as being without disease or illness.
However, this definition does not have holistic approach by ignoring other
aspects of an individual’s health, for example emotional and social health (Engel,
2012).

 

Due to these reason the World Health
Organisation, WHO, has redefined health as “a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity”
(WHO 1946). The Wellness model incorporates six dimensions, which are physical,
emotional/ mental, social, intellectual, occupational and spiritual health, and
states that concurrence across all of these areas makes an individual healthy.
The Wellness Model supports WHO’s definition that health is more than just the absence
of disease or infirmity (Hettler, 1976). Richard Smith (citied in Godlee, 2011)
suggests that the current accepted WHO definition of health needs updating because
it “would leave most of us unhealthy most of the time”. This is because
research has found that the definition does not contemplate the ever-changing
social circumstances and people’s ability to adapt in these circumstances.

 

DK Medical Dictionary (2013) defines Health
promotion as “programs designed to inform the public about health risks and
methods to prevent or reduce them; the programs are often targeted at specific
populations”. In the early 19th Century John Snow traced the source
of a Cholera outbreak to a single water pump in Soho and convinced the
residence to stop using the pump, which stopped the Cholera outbreak (Shiode et
al, 2015). This shows how by promoting specific health behaviours a whole
population health can be affected supporting the DK’s definition of health.

 

However DK’s definition does not encompass
the concept of the individuals in making a decision for their own health. WHO
(2005) defines health promotion as “The process of enabling people to increase
control over their health and it’s determinants, and thereby improve their
health”. The Health Belief Model (Chesnay & Anderson, 2015) suggests a
person will consider the perceived threat (developing congenital
toxoplasmosis), the perceived benefit of specific behaviour (not developing
congenital toxoplasmosis by avoiding cat faeces) and the individuals believe
they can initiate and maintain the specific behaviour to reduce their risk (believe
they can avoid cat faeces and lower risk of congenital toxoplasmosis)
(Becker’s, 1974). This undermines the DK’s definition of health promotion being
for a whole population but supports WHO’s definition that a person can have
more control over their choice of health control which makes them more likely
to improve their health.

 

In 2005 the International Confederation of
Midwives (ICM) redefined the definition of being a midwife. Part of that
definition was ‘The midwife is recognised as a responsible and accountable
professional who works in partnership with women to give the necessary support,
care and advice during pregnancy…’ (Marshall, Myles, 2014). Therefore, part of
the role of a midwife will be to educate mothers of how to prevent
toxoplasmosis, support women into making the correct behavioural changes in
order to prevent the disease and advice them on their prevention options.  During pregnancy a woman’s entire health, the
six dimensions are affected. This includes their immune system being lowered
and their knowledge about health being altered. It is part of a midwife’s role
to promote normality of a healthy pregnancy, which can be successfully done by
effectively informing women to enable them to make a coherent and clear
decision about their health and pregnancy. Midwives need to take a holistic
approach to advising and supporting their clients. The holistic model explains
how the application of the six dimensions of wellness, mentioned earlier, can
allow an individual to contribute their own health. This is achieved through
allowing individuals to see how their own actions can affect their health in
order to be “healthy”(Hettler, 1976). For example, if they participate in
toxoplasmosis prevention behaviours then they are less at risk of contracting toxoplasmosis,
which can affect themselves or their unborn baby.

 

Antonovsky Salutogenesis (1993) is an
approach, which views each woman as unique and recognises the need for
woman-centred care. This approach looks at the prerequisites for successful
coping such as meaningfulness, manageability and

Comprehensibility. A woman will decide how
meaningful preventing toxoplasmosis is to her, how easy prevention will be to
prevent the disease and whether or not she has the correct amount of
information and resources to make the decision. Midwives can increase a woman’s
resources, by making sure she has access to the correct information to make an
informed decision, also by checking she has the ability to actively do the
prevention e.g. access to clean water. This will aid her manageability and meaningfulness
or toxoplasmosis.

 

Part of the ICM’s definition of the role of
the midwife is ‘the midwife has an important task in health counselling and
education, not only for the woman, but also within the family and community
(Marshall and Myers, 2005).  A midwife
must be knowledgeable, not only about toxoplasmosis and its prevention but
about the resources in the community such as the availability and accessibility
of information to all women. For example, creating health promotion posters, to
inform woman of the disease and how to prevent this. These could be displayed
in antenatal clinics, garden centres, pet stores and fresh food stores. This is
because women or family members who are in these areas, are likely to be
participating in the activities (e.g. if they are in a pet store they may have
a cat). By presenting information in these areas it can encourage woman to
consider their current behaviours, for instance may make them find someone else
to remove cat litter. By also presenting information in a variety of places
family or friends of pregnant woman may also see this and can also advice her. A
midwife should also have good communication skills with clients, this will
mainly be verbally but it is important they check all written information is also
well communicated. In the UK there is a diverse amount of cultures and
educational levels. Therefore something for midwives to consider is overcoming
communication barriers by, for example, using interpreters or creating posters
or leaflets about toxoplasmosis and prevention in different languages and using
simple language for all reading levels. By doing this all woman should be able
to be educated on the disease and can make an informed choice of whether or not
to participate in preventive behaviours.

 

In the UK the NHS provides free antenatal
care services, which includes a booking appointment, where a previous history
will be taken as well as information to help aid a healthy pregnancy, as well
as regular antenatal consultations. During the Booking appointment the role of
the midwife is to determine how at risk the mother is for various issues, such
as gestational diabetes or preeclampsia. This is done by taking a thorough
medical and lifestyle history of the woman and also included questions about first-degree
relatives health. During this time a midwife can take this opportunity to
determine the risk of toxoplasmosis. The woman may know whether she had
toxoplasmosis before or she may reveal lifestyle risks, for example if she is a
vegetarian her main source of food will be fruit and veg so will need to be
informed of how to safely prepare her food. The pregnant woman may also reveal
if she has any pets. The woman may also inform the midwife of any other immune
lowering disease she may have, such as HIV, which would mean she is even more
at risk of contracting toxoplasmosis since her immune system will be lowered
further when pregnant.

 

Part of the antenatal booking appointment
is to give brief but informative information for during the woman’s pregnancy
to maintain or improve the clients health. This includes speaking about safe
sex during pregnancy, exercise, foods to avoid, food safety and hand hygiene
ect. This part of the appointment is also a good opportunity to discuss
toxoplasmosis and its preventions. Pereboom et al., 2013, conducted a
cross-sectional survey of pregnant women and their knowledge of toxoplasmosis
and other infectious disease. They found 75.3% of pregnant woman had heard
about toxoplasmosis with their main source of informing coming from health care
professionals, such as a midwife. However, respondents showed limited knowledge
of preventive practises of toxoplasmosis, suggesting women are informed about
toxoplasmosis and it’s risks but not how to prevent toxoplasmosis and lower their
risk. This suggests midwifes are effective at educating women of toxoplasmosis
and their risks, but need to focus time on explaining and informing women on
its preventions.

 

During every antenatal consultation the
wellbeing of the mother is observed. Firstly, the client’s urine and blood
pressure is checked for any abnormalities, as this can be an indication of
other problems. During this consultation the midwife has the opportunity to observe
the woman noticing any of the signs or symptoms of toxoplasmosis. While these
symptoms may also be associated with the flu, it is important the midwife
considers toxoplasmosis and follows the NICE Guidelines (2003) appropriately,
e.g. offering screening for the disease and informing women of toxoplasmosis so
the woman themselves feel empowered to make their own choice but also allows
them to question their health.

In conclusion, toxoplasmosis and its
preventions need to be promoted to ensure the safety of both mother and baby. If
prevention of toxoplasmosis does not take place pregnant women are more
susceptible to contract extreme cases of the disease such as ocular toxoplasmosis,
which causes scarring and inflammation in the eyes and cerebral toxoplasmosis,
where the brain swells causing headaches, poor co-ordination and in some cases
seizures. They are also more at risk at developing congenital toxoplasmosis,
which can have devastating consequences such as brain damage to the baby and in
some cases newborns death. Research has shown that by educating mothers and
communities they can make informed decisions to begin and maintain prevention
techniques of toxoplasmosis (Breugelmans, 2004). The midwife has an extremely
important role in this, which includes informing mothers in accessible ways,
e.g. posters and leaflets in different languages and reading levels, supporting
them through this time, encouraging them, giving them different coping
techniques along with empowering them throughout their pregnancy to prevent
toxoplasmosis. This is mainly achieved through the one to one antenatal
consultations. These consultations need to be seen as an opportunity to discuss
and help pregnant women to have a safe and healthy pregnancy, as well as giving
the Midwife an opportunity to observe any signs or symptoms that could mean
toxoplasmosis. In these circumstances it is the Midwifes role to offer
screening for the disease to establish the next step (NICE, 2003).

 

References:

 

Antonovsky, A. (1993) The implications of
Salutogenesis An Outsider’s View in Turnbull,A.P., Patterson,J.M., Behr, S.G.
et al (eds)

 

Becker, MH (1974) The health Belief Model
and personal Health Behaviour. New Jersey: Slack

 

Benz, C, Bull, T, Mittelmark, M, &
Vaandrager, L 2014, ‘Culture in salutogenesis: the scholarship of Aaron
Antonovsky’, Global Health Promotion, 21, 4, pp. 16-23, Education Research
Complete, EBSCOhost, viewed 8 January 2018.

 

Breugelmans, M, Naessens, A, & Foulon,
W 2004, ‘Prevention of toxoplasmosis during pregnancy–an epidemiologic survey
over 22 consecutive years’, Journal Of Perinatal Medicine, 32, 3, pp. 211-214,
MEDLINE, EBSCOhost, viewed 19 December 2017.

 

Chesnay, MD, Anderson BA (2015). Caring for
the Vulnerable. 4th ed. Burlington: Jones and Bartlett Publishers. 67-68.

 

Collins (2011.). Collins English dictionary
& thesaurus. Glasgow: HarperCollins. 235.

 

Downie, R, Tannahill, C, & Tannahill, A
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Engel, GL 2012, ‘The need for a new medical
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Ewles, L, & Simnett, I 2003, Promoting
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Findal, G, Helbig, A, Haugen, G, Jenum, P,
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gondii infection in pregnant women in Norway: twenty years of experience of
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Godlee, F 2011, ‘What is health?’, BASE,
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Hettler, B. (1976). The Six Dimensions of
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Last accessed 14th Jan 2018.

 

Kresser, C. (2015). What is Health?.
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Marshall, J, Raynor, M, & Myles, M
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Prusa, A, Kasper, D, Sawers, L, Walter, E,
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