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Abstract

Objective: To describe a cohort of women with a physical disability in various reproductive life stages to support the development of specific management targets, especially during the fertile stage. Design: Community survey. Population / Sample: We analysed data from 440 female participants with chronic spinal cord injury (SCI) aged over 16 years from the cross-sectional community survey of the Swiss Spinal Cord Injury Cohort Study (SwiSCI) in 2017. Methods: The full cohort was analysed using descriptive analysis. For women in the fertile reproductive life stage, a regression technique was used to identify the predictors of becoming a mother after SCI. Results: More than 50% of the sample were aged over 56, and approximately one fourth were in the fertile (16-45 years) age group. Motherhood after SCI was most prevalent in women with low and incomplete lesions and those who sustained an SCI at a young age. The chances of giving birth significantly decreased when sustaining an SCI after the age of 35. The mean age at first delivery after SCI (age 31.2±5 years) was five years higher compared to women with an SCI who gave birth before sustaining SCI (age 26.2±5 years). Conclusions: The study provides evidence for the need for tailored and specific lifespan adjusted obstetric and gynaecological services for women with SCI and for women with a disability in general.
Research Article
Clinical Obstetrics, Gynecology and Reproductive Medicine
Clin Obstet Gynecol Reprod Med, 2020 doi: 10.15761/COGRM.1000313 Volume 6: 1-7
ISSN: 2059-4828
Improving reproductive health care services for women
with a physical disability: Insights from a community
survey of women with spinal cord injury in Switzerland
Sue Bertschy1*, Cristina Ehrmann1,2, Petra Stute3, Dimitrios Skempes1,2, Franziska Maurer-Marti4, Armin Gemperli1,2, on behave of SwiSCI
study group#
1Swiss Paraplegic Research (SPF), 6207 Nottwil, Switzerland
2Department of Health Sciences and Medicine, University of Lucerne, 6000 Lucerne, Switzerland
3Department of Obstetrics and Gynecology, Inselspital, 3010 Bern, Switzerland
4Department of Obstetrics and Gynecology, Hospitals of Solothurn AG, 4500 Solothurn, Switzerland
#Membership of the SwiSCI Study Group is provided in the Acknowledgments.
Abstract
Objective: To describe a cohort of women with a physical disability in various reproductive life stages to support the development of specic management targets,
especially during the fertile stage.
Design: Community survey.
Population / Sample: We analysed data from 440 female participants with chronic spinal cord injury (SCI) aged over 16 years from the cross-sectional community
survey of the Swiss Spinal Cord Injury Cohort Study (SwiSCI) in 2017.
Methods: e full cohort was analysed using descriptive analysis. For women in the fertile reproductive life stage, a regression technique was used to identify the
predictors of becoming a mother after SCI.
Results: More than 50% of the sample were aged over 56, and approximately one fourth were in the fertile (16-45 years) age group. Motherhood after SCI was
most prevalent in women with low and incomplete lesions and those who sustained an SCI at a young age. e chances of giving birth signicantly decreased when
sustaining an SCI after the age of 35. e mean age at rst delivery after SCI (age 31.2±5 years) was ve years higher compared to women with an SCI who gave
birth before sustaining SCI (age 26.2±5 years).
Conclusions: e study provides evidence for the need for tailored and specic lifespan adjusted obstetric and gynaecological services for women with SCI and for
women with a disability in general.
Funding: is study has been nanced through the framework of the Swiss Spinal Cord Injury Cohort Study supported by the Swiss Paraplegic Foundation.
*Correspondence to: Sue Bertschy, Ph. D., SPF – Swiss Paraplegic Research,
Guido A. Zäch-Strasse 4 CH-6207 Nottwil, Switzerland, E-mail: sue.bertschy@
paraplegie.ch
Key words: spinal cord injury, gynecological services, fertility, motherhood,
management of women with a disability, life stages
Received: August 12, 2020; Accepted: October 01, 2020; Published: October
07, 2020
Introduction
Medical, demographic, and sociocultural shis require adjustments
of health systems to respond to the specic health needs of women with
physical disabilities (WPD).
Whereas in the past women with WPD were seen by society as
“sexually unattractive” and stigmatised, recent advances in medicine
and non-discrimination policies have empowered WPD to participate
normally in daily life. Currently, WPD do not receive the same quality
of ObGyn care as non-disabled women [1]. Many health systems,
including those in high-income countries, are struggling to cope with
the health needs of the steadily growing number of WPD [2]. Services
on reproductive health are not routinely provided to WPD as part
of standard obstetric and gynaecological (ObGyn) health care. us,
WPD are less likely to receive preventive measures (e.g. pelvic exams,
PAP smears, mammograms), and counselling on family planning
(e.g., contraception, infertility treatment), pregnancy and menopause
[3,4].
Disabilities vary signicantly and while some health conditions
associated with disabilities result in poor health and extensive health
care needs, others do not. us, services need to be specically
tailored to individuals' health needs. For example, women with
neurological disorders, such as SCI, commonly suer from motor and
sensory impairments [5]. Due to the eects of such impairment (e.g.
temperature dysregulation, neurogenic bowel and bladder, altered
sexual response), women with SCI may experience greater severity
Bertschy S (2020) Improving reproductive health care services for women with a physical disability: Insights from a community survey of women with spinal cord
injury in Switzerland
Clin Obstet Gynecol Reprod Med, 2020 doi: 10.15761/COGRM.1000313 Volume 6: 2-7
a mother aer the SCI event with selected predictive variables: age
at injury, level of education, injury level and completeness, and birth
country. To account for item nonresponse (i.e., missing items of
predictive variables for a subset of participants), a random forest
imputation technique was used with the assumption that data were
missing at random [11]. For women who became mothers aer the
SCI, the timespan between the age at injury and the rst delivery was
displayed by cross plotting the age at injury and the age at delivery of
the rst child. Moreover, the ages at the rst and second deliveries aer
the SCI were cross-plotted. e data analyses were conducted using R
version 3.5.0.
Results
Total cohort of women with SCI from the 2017 community
SwiSCI survey
A total of 440 women with SCIs participated in the 2017 SwiSCI
cohort study. Reproductive behaviour and reproductive life stage
information is presented in Table 1. At the time of the survey, almost
one in four women (24%) was in the fertile stage. One in two women
was childless (n=205), while 64 women gave birth to their rst child
aer sustaining an SCI. Few women (n=8) delivered a child before and
aer the SCI event.
Figure 1 presents the percentage of women who delivered a child
aer the SCI event grouped by age at the time of injury. Only women
who provided information about their age at injury were considered
(n=402). Overall, 72 women had a delivery aer the SCI event. Of
those, nine (21%) women were aged 31-35 years, and two (5%) women
were aged 36+ years when sustaining an SCI.
Cohort of women in the fertile reproductive life stage at the
SCI event
Overall, 264 women were in the fertile life stage when they were
aected by an SCI. Of those, 124 women (47%) had children at a
mean age of rst delivery of 29 years (SD=6). In detail, mean age at
rst delivery was 26 years (SD=5) in women who had children before
the SCI event, 26 years (SD=7) in women who had children before and
aer the SCI event, and 31 years (SD=5) in women who delivered their
rst child aer the SCI event. Women who delivered their rst child
aer the SCI event had more years of education compared to women
with deliveries before the SCI those with deliveries before and aer the
SCI event. Of the entire cohort (n=264), almost three-quarters (74%)
were classied as paraplegia, and 60% had incomplete lesions. Most
women were born in Switzerland, long educated, and had a traumatic
SCI (Table 2).
Table 3 presents the results of the univariate (unadjusted model)
and multivariable (adjusted model) logistic analyses. e likelihood of
being a mother was signicantly associated with SCI aetiology and age
at injury. More specically, the chance of motherhood was signicantly
decreased by 61% in women with non-traumatic injury (OR 0.39; 95%
CI 0.16–0.84). Similarly, higher age at injury was associated with a
signicantly lower chance of motherhood (OR 0.94; 95% CI 0.91–0.97).
Figure 2 (A) shows the number of women by the age at SCI and the
age at rst delivery aer the SCI event. Overall, 72 women delivered
children aer the SCI event. e time between the SCI event and rst
delivery aer the SCI event ranged from 0 to 5 years in 34 women
(47%), from 6 to 10 years in 12 (17%), from 11 to 15 years in 16 (22%),
from 16 to 20 years in seven (10%), and 20+ years in three (4%). Forty-
two women with SCI before the age of 30 delivered their rst child
of symptoms (e.g. vaginal dryness or increased risk for osteoporosis)
or need tailored medications [6]. us, WPD require proper life stage
adjusted services and an interconnected health system for eective
disability management. Improving the process of care for women with
an SCI during their reproductive lifespan should lead to improvements
in many other conditions and lifespan needs as well. However, if le
unmanaged, adverse health outcomes could exacerbate existing co-
morbidities.
Currently, information from national surveys is not properly
disaggregated by disability status [7]. us, nationally representative
information related to reproductive health care for WPD (e.g. maternity
care) is lacking. e Swiss Spinal Cord Injury Cohort Study (SwiSCI) [8]
oers such data and the unique opportunity to study the reproductive
health and care of WPD. is is important since, individuals with SCI
constitute a highly representative group of people living with physical
disabilities. e aim of this study was to describe a cohort of WPD
(specically, with SCI) in various reproductive life stages to support
the development of specic management targets, especially during the
fertile life stage.
Methods
Study design and participants
is was a cross-sectional study of women with SCI who participated
in the community survey of the SwiSCI conducted in 2017 [8]. SwiSCI
is part of the International Spinal Cord Injury (InSCI) survey, an
initiative that coordinates community surveys on SCI in more than 20
countries [9]. Female Swiss residents with traumatic or non-traumatic
SCI were eligible and included in the study. Exclusion criteria were age
below 16 years, a new SCI in the context of end of life, an SCI due to
congenital conditions (e.g. spina bida), neurodegenerative disorders
(e.g. multiple sclerosis) or Guillain-Barre syndrome.
Measures
Demographic and injury characteristics: Self-reported
information on sex, age, education (years of formal education), etiology
(traumatic or non-traumatic), lesion level (paraplegia or tetraplegia),
lesion completeness (complete or incomplete), birth country, date of
SCI, language and SCI cause were collected.
Motherhood: Woman were asked to provide the date of delivery of
their biological children.
Statistical analysis
Total cohort of women with SCI in the 2017 community SwiSCI
survey: e reproductive life stages of women were categorised
according the STRAW staging system [10] as follows: fertile age: 16-
45 years; perimenopause/early postmenopause: 46-55 years; late
postmenopause I: 56-70 years; and late postmenopause II: 70+ years).
Additionally, the reproductive behaviour of women (being a mother
before SCI, being a mother aer SCI, being a mother before and aer
SCI, being childless) was described. Moreover, a pyramid chart was
used to illustrate the percentage of women having children aer an
SCI versus the percentage of women not having children aer an SCI,
stratied by age at SCI.
Cohort of women in the fertile reproductive life stage at the SCI
event: Descriptive statistics were provided for demographics and injury
characteristics and grouped by reproductive behaviour. Univariate and
multivariable logistic regression analyses were performed to calculate
unadjusted and adjusted odds ratios (OR) of the likelihood of becoming
Bertschy S (2020) Improving reproductive health care services for women with a physical disability: Insights from a community survey of women with spinal cord
injury in Switzerland
Clin Obstet Gynecol Reprod Med, 2020 doi: 10.15761/COGRM.1000313 Volume 6: 3-7
Age/reproductive stage at survey participation (N (%)) Total
(N=440)
Children before SCI
(N=163)
Children after SCI
(N=64)
Children before
and after SCI
(N=8)
No children
(N=205)
Fertile Age, 16- 45 years 103 (24) 7 (7) 22 (21) 1 (1) 73 (71)
Peri-/Early postmenopause, 46-55 years 110 (25) 25 (23) 25 (23) 3 (3) 57 (52)
Late postmenopause I, 56-70 years 142 (32) 78 (55) 16 (11) 3 (2) 45 (32)
Late postmenopause II, 70+ years 85 (19) 53 (62) 1 (1) 1 (1) 30 (35)
Age at SCI (Mean (SD)) 38 (18) 53 (14) 22 (6) 32 (6) 31 (16)
Table 1. Reproductive life stages and reproductive behaviour of women participating in the SwiSCI community survey 2017
Total
(N=264)
Mothers (N=124)
Children before SCI
(N=52)
Children after SCI
(N=64)
Children before and
after SCI
(N=8)
No children
(N=140)
Language of the questionnaire
(N (%)) (Missing, N = 3)
German 189 (72) 38 (20) 52 (27) 5 (3) 94 (50)
French 66 (25) 13 (20) 10 (15) 3 (5) 40 (60)
Italian 9 (3) 1 (11) 2 (22) - 6 (67)
Country born (N (%)) (Missing, N = 2)
Foreigner 44 (17) 11 (25) 10 (23) 4 (9) 19 (43)
Swiss 218 (83) 40 (18) 53 (24) 4 (2) 121 (56)
Woman’s education (years) (Median, (Q1-Q3)) (Missing, N
= 12) 13 (12-17) 13 (10-14) 13 (12-16) 15 (13-17) 14 (12-17)
Woman’s education (N (%))
(Missing, N = 12)
0- 8 years 8 (3) 5 (62) - - 3 (38)
9- 12 years 73 (29) 18 (25) 21 (29) 2 (3) 32 (43)
13- 15 years 91 (36) 15 (17) 24 (27) 3 (3) 49 (53)
more 15 years 80 (32) 9 (11) 16 (20) 3 (4) 52 (65)
Aetiology (N (%)) (Missing, N = 3)
Traumatic 207 (79) 37 (18) 55 (27) 7 (3) 108 (52)
Traumatic SCI cause:
Sport accident 39 (15) 3 (8) 11 (28) 2 (5) 23 (59)
Accident at leisure activities 38 (14) 6 (16) 13 (34) - 19 (50)
Work accident 10 (4) 4 (40) 2 (20) - 4 (40)
Trac accident 87 (33) 14 (16) 23 (26) 4 (5) 46 (53)
Assault 10 (4) - 3 (30) - 7 (70)
Fall from less than 1m 6 (2) 2 (33) 2 (33) - 2 (33)
Fall from more than 1m 56 (21) 13 (23) 14 (25) 3 (5) 26 (47)
Surgical / medical complication 6 (2) 2 (33) 1 (17) - 3 (50)
Other cause 5 (2) - - - 5 (100)
Nontraumatic 54 (21) 15 (28) 8 (15) - 31 (57)
Nontraumatic SCI cause
Vertebral column degenerative disorder 17 (6) 5 (29) 2 (12) - 10 (59)
Tumour – benign 19 (7) 7 (37) 4 (21) - 8 (42)
Tumour - malign (cancer) 3 (1) 1 (33) - - 2 (67)
Vascular disorder 11 (4) 4 (36) 1 (9) - 6 (55)
Infection 8 (3) 1 (12) 1 (12) - 6 (75)
Other disease 5 (2) 2 (40) - - 3 (60)
SCI severity (N (%))
(Missing, N = 18)
Paraplegia complete 77 (31.3) 11 (14) 22 (29) 1 (1) 43 (56)
Paraplegia incomplete 106 (43.1) 6 (29) 3 (14) - 12 (57)
Tetraplegia complete 21 (8.5) 27 (25) 26 (25) 5 (5) 48 (45)
Tetraplegia incomplete 42 (17.1) 3 (7) 9 (21) 2 (5) 28 (67)
Table 2. Sociodemographic characteristics of fertile women (age 16-45 years) at the time of the SCI event
Abbreviation: Q1=rst quartile: 25% of data are smaller or equal to this value; Q3=third quartile: 75% of data are smaller or equal to this value.
Bertschy S (2020) Improving reproductive health care services for women with a physical disability: Insights from a community survey of women with spinal cord
injury in Switzerland
Clin Obstet Gynecol Reprod Med, 2020 doi: 10.15761/COGRM.1000313 Volume 6: 4-7
Being a mother after the SCI event
Unadjusted model Adjusted model
95% CI 95% CI
OR Lower Upper p OR Lower Upper p
Age at injury 0.94 0.91 0.97 <0.001 0.94 0.91 0.97 <0.001
Country born 0.464 0.266
Foreigner 1 1
Swiss 0.76 0.38 1.58 0.65 0.31 1.39
Woman’s education (years) 0.99 0.92 1.07 0.910 0.98 0.90 1.06 0.745
Aetiology 0.015 0.044
Traumatic 1 1
Nontraumatic 0.39 0.16 0.84 0.39 0.15 0.88
SCI severity 0.312 0.177
Paraplegia complete 1 1
Paraplegia incomplete 0.32 0.07 1.04 0.32 0.07 1.08
Tetraplegia complete 0.86 0.46 1.62 1.26 0.64 2.48
Tetraplegia incomplete 0.87 0.38 1.95 1.03 0.42 2.46
Abbreviations: OR=odds ratio, CI=condence interval; p-values<0.05 are bolded.
Table 3. Multivariable regression analyses for the binary outcome “being a mother after the SCI event” (yes vs. no) (imputed dataset; n=264; unadjusted model and model adjusted for all
variables)
Figure 1. Pyramid displaying the percentage of women becoming mothers after the SCI grouped by age at SCI (N=402)
aer age 30. Of those, 15 women had a second child aer the age of 36
(Figure 2 (B)).
Discussion
Main ndings
To the best of our knowledge, this is the rst study to provide data on
reproductive behaviour in women with SCI. e chance of becoming a
mother aer SCI (n=440, 16%) was comparable to that found in previous
studies from other high-income countries, which make considerable
investments in rehabilitation and health care, with reported delivery
rates between 14 and 18% [12]. Time to rst delivery aer the SCI was
up to 5 years in almost 50% of the SCI women. Regarding predictors for
motherhood, young age at injury was signicant, similar to a previous
US study [13]. In our study, an additional signicant predictor for
motherhood aer SCI was sustaining a traumatic injury (e.g. trac
accidents and accidents during leisure activities). When comparing the
severity of SCI between the various studies some discrepancies appear.
For example, one retrospective cohort study involving 25 women with
SCI reported mainly those with complete lesions [14] became mother
aer SCI, while in our study mainly women with incomplete or low
lesions became mothers.
Age-related fertility decline is a general but oen neglected
phenomenon in women, with fertility declining with advancing age,
especially aer the mid-30s [15]. To date, there is no evidence showing
Bertschy S (2020) Improving reproductive health care services for women with a physical disability: Insights from a community survey of women with spinal cord
injury in Switzerland
Clin Obstet Gynecol Reprod Med, 2020 doi: 10.15761/COGRM.1000313 Volume 6: 5-7
that an SCI induces hormonal changes impacting fertility [16]. We
observed a similar pattern in our cohort, where women with an SCI gave
birth until the age of 44. However, we observed an important decrease
in a woman's chance of motherhood when sustaining the SCI aer the
age of 35. Moreover, in our cohort, more than 50% of the women with
SCI were above age 56 when participating in the survey, and so themes
such as menopause and related co-morbidities were predominant.
Strengths and limitations
is study is inherently subject to several limitations. First, despite
the rather extensive recruitment eorts, the obtained sample size of
women with SCI who became mothers aer the SCI event (n=72) was
relatively small. One reason for this might be that there is no national
registry for people with SCI. e SwiSCI cohort study, which collected
data from four Swiss rehabilitation centres, may not represent the whole
national SCI cohort and might thus underrepresent women with SCI,
the elderly and those with very low lesions (L1-S5) [17]. In addition,
this survey includes no further information about conceiving and
pregnancy outcomes. SwiSCI does not gather data on miscarriages,
pregnancy outcomes (e.g. premature or term births, caesarean
deliveries). Further, SwiSCI does not identify rst-time pregnancies,
whether women have diculty conceiving, or whether they used
assisted reproductive services to become pregnant. Finally, although
some relevant variables (e.g. educational status, SCI aetiology) were
considered for analysis, information on other potential predictors of
the likelihood of motherhood (e.g. marital status, work status, nances,
satisfaction with health and quality of life) were only available for the
3-month-period prior to the survey but not for the time of the delivery
or SCI event. Despite these shortcomings, this study oers insight not
only into fertile women but also in the entire cohort of women with
SCI, allowing the formulation of recommendations for policy and
service provision.
Interpretation
Our ndings show that women with SCI are represented in all
life stages, underlining the need for tailored services related to their
obstetric and gynaecological needs [3]. In our sample, one-fourth of
the women were in the fertile life stage, where counselling on family
planning, contraception, infertility/sterility treatment and pregnancy/
lactation is predominant. For example, contraception counselling
usually considers the females age, personal and family history, family
planning and the personal preferences. Counselling women with SCI
who are at additional increased risk for venous thromboembolism due
to their medical history, requires additional expertise. is because
they are not optimal candidates for combined oral contraception;
rather, they should be prescribed a non-hormonal or progestin-only
contraception [18].
Family planning decisions and health care service utilisation depend
on several individual factors as well as societal- and institutional-level
factors. In our study, only women with a lower incomplete lesion
became mothers. us, a womans personal characteristics (e.g. age,
education, health status, social identity) may interfere with health
care system structures and processes, creating a barrier to accessing
family planning services [19]. is potential barrier could be further
aggravated by environmental barriers, such as the lack of physical
accessibility [20]. Furthermore, institutional-level barriers, such as the
lack of national guidelines on reproductive care in WPD and issues
with insurance coverage and aordability, may present obstacles to the
development of high-quality, responsive gynaecological services.
However, most of the study participants were in the peri- and
postmenopausale life stage. In this stage, womens' service needs
change, with focus on acute menopausal symptom relief and long-
term prevention of chronic non-communicable diseases. At this
Figure 2. Graph shows the number of women by (A): age at SCI and age at rst delivery after SCI and (B) age at rst and second delivery after SCI
Bertschy S (2020) Improving reproductive health care services for women with a physical disability: Insights from a community survey of women with spinal cord
injury in Switzerland
Clin Obstet Gynecol Reprod Med, 2020 doi: 10.15761/COGRM.1000313 Volume 6: 6-7
age, menopause has usually occurred, and this may be associated
with various oestrogen deciency-related acute symptoms (e.g. hot
ushes, insomnia, depression, urogenital atrophy) and chronic health
conditions (e.g. osteoporosis, cardiovascular disease). For example,
due to estrogen deciency the risk of recurrent urinary tract infections
is increased in all menopausal women. In women with SCI, this risk
is already increased by self-catheterising. To avoid further risks, it is
preferable to initiate a local estrogen therapy [6].
In Switzerland, some rst steps have been taken to improve
ObGyn health care services for women with SCI. For example, an
interdisciplinary international guideline on maternity care has recently
been published [21]. However, more needs to be done to address
the multifaceted barriers aecting WPD [20]. In this regard, specic
modules should be added to the standard gynaecological residency
curriculum along with continuous professional development courses
for practicing gynecologists. e goal is to establish the necessary
knowledge base for counselling women with disability-specic
complications [22]. Development of on-line training tools such as
videos explaining aspects of the gynaecological examination and care,
could aid providers in aligning their practice with best evidence and
help institute a culture of patient centeredness, respect for autonomy
and holistic care [23].
Health care providers and clinics could also take measures to make
their practice more accessible and inclusive by ensuring that equipment,
facilities and information are accessible to WPD. In Switzerland, the
umbrella organisation for disabled persons has developed a checklist
to assist health care providers in assessing physical accessibility
of their facilities and their conformance with national standards.
Finally, stereotypes and discriminatory attitudes against women with
disabilities must be eliminated through appropriate health professional
education and awareness. An overall national framework for improving
the reproductive health of women with disabilities and SCI would be in
alignment with WHO recommendations [24] and published evidence
[25] is needed to ensure that women with disabilities enjoy their
fundamental right to access reproductive and sexual healthcare.
Conclusion
Aer acquiring an SCI, the majority of women who became
mothers are those with low and incomplete lesions. Moreover, there
seem to be no fertility issues related to impairment or age other than
the biological age for motherhood. Women of all reproductive stages
were represented in this study, meaning that all women need to be
counselled with respect to their reproductive life stage (family planning,
contraception, infertility/sterility treatment, pregnancy/lactation,
peri- and postmenopause). In addition, a holistic, inter-professional
approach is needed to educate reproductive health professionals to
improve the quality of ObGyn care for women with SCI and disabilities
in general. Strengthening ObGyn services would likely result in cost
savings for the health system, improve individual health outcomes and
promote social inclusion and participation.
Author contributions
SB led the study design and contributed to the data analysis,
manuscript writing and revision. CE provided technical oversight of
the data analysis and validation and contributed to the manuscript
writing. PS contributed to the data interpretation, and manuscript
writing. DS and FM contributed to the data interpretation and
manuscript writing/revision. AG contributed to the study design and
manuscript revision.
Acknowledgments
We are grateful to all the participants of the SwiSCI survey for their
time and eort spent in responding to the questions. e members of
the SwiSCI Steering Committee are: Xavier Jordan, Fabienne Reynard
(Clinique Romande de Réadaptation, Sion); Michael Baumberger,
Hans Peter Gmünder (Swiss Paraplegic Center, Nottwil); Armin Curt,
Martin Schubert (University Clinic Balgrist, Zürich); Margret Hund-
Georgiadis, Kerstin Hug (REHAB Basel, Basel); Urs Styger (Swiss
Paraplegic Association, Nottwil); Daniel Joggi (Swiss Paraplegic
Foundation, Nottwil); NN (Representative of persons with SCI); Nadja
Münzel (Parahelp, Nottwil); Mirjam Brach, Gerold Stucki (Swiss
Paraplegic Research, Nottwil); Armin Gemperli (SwiSCI Coordination
Group at Swiss Paraplegic Research, Nottwil)..
Funding
is study has been nanced in the context of the Swiss Spinal
Cord Injury Cohort Study (SwiSCI) sponsored by the Swiss Paraplegic
Foundation.
Conicts of interest
None declared.
Details of ethics approval
e survey was approved by the local cantonal ethical committees of
Lucerne, Basel, Valais, and Zurich (reference numbers: 1008 [Luzern];
37/11 [Basel]; CCVEM 015/11 [Valais]; 2012–0049 [Zürich]). Informed
consent was obtained from all participants prior to their participation
in the survey.
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