OBJECTIVES: We investigated how women, seeking care due to decreased movements, had paid attention to fetal movements and if the method of monitoring was associated with pregnancy outcome.

METHODS: A questionnaire was distributed to women from gestational week 28, who had sought care due to decreased fetal movements in Stockholm between January 1st and December 31st^, 2014. Women were included in the study if the examination did not reveal any signs of a compromised fetus requiring immediate intervention. Birth outcome and sociodemographic data were collected from the obstetric record register.

RESULTS: There were 29166 births in Stockholm in 2014, we have information from 2683 women who sought care for decreased fetal movements. The majority (96.6%) of the women stated that they paid attention to fetal movements. Some women observed fetal movements weekly (17.2%) and 69.5% concentrated on fetal movements daily (non-structured group). One in ten (9.9%) used counting methods daily for observing fetal movements (structured group). Women in the structured group more often had caesarean section before onset of labor (RR 1.6, 95% CI 1.2-2.2) and a lower risk of their baby being transferred to neonatal nursery (RR 0.25, 95% CI 0.03-0.94) compared to women in the non-structured group.

CONCLUSIONS: Women, who had a daily and structured approach to awareness of fetal movements, were more likely to have a caesarean section but their babies were less likely to be transferred to a neonatal nursery as compared with women who used a non-structured method daily.

OBJECTIVE: One key component in preventing unplanned pregnancies is to provide effective contraceptive counselling. This study aimed to investigate what characterises good contraceptive counselling from the woman's perspective.

METHODS: A qualitative study with a phenomenological approach. Twenty-four women aged 15-45 participated in semi-structured, individual, face-to-face interviews that lasted, on average, one hour. Data were analysed by latent content analysis.

RESULTS: One overall theme emerged, person-centred contraceptive counselling - an interactive process, with three main categories: (i) a trustworthy healthcare provider, (ii) creating a liaison and (iii) the right time and place.

CONCLUSIONS: The healthcare provider's attributes as well as what happened between the healthcare provider and the woman, and the surrounding context, had a bearing on the women's descriptions of good contraceptive counselling. The process of the counselling was described as more important than the actual outcome; thus, healthcare providers need to be aware that this seemingly straightforward consultation is rather multi-layered and has great health promoting potential.

Objectives

The aims of the study were to explore factors influencing the decision to continue or terminate pregnancy due to detection of fetal malformation following ultrasound examination, to elucidate the need for more information or other routines to facilitate the decision-making process and to assess satisfaction with the decision made.

Design

Descriptive study.

Setting

Four fetal care referral centres in Stockholm, Sweden.

Population

Pregnant women with a detected fetal malformation.

Methods

Data was collected by questionnaires. 134 women participated, 99 completing the questionnaire. Descriptive statistical analysis was performed.

Results

Both women who continued and those who terminated pregnancy based their decision on the severity of the malformation. Other reasons for terminating the pregnancy were aspects including socioeconomic considerations. None stated religious factors. The doctor at the fetal care unit also had an influence on the decision-making. The timeframe receiving information was regarded as long enough in duration but not the number of occasions. In both groups the women made the decision by themselves or together with their partners. The majority experienced that they had made the right decision. Women who terminated their pregnancy had a significant higher rate (51.2%) (p⩽ 0.004) of previous abortions than those in the continuing group (23.2%).

Conclusion

The decision to continue or terminate the pregnancy was to a great extent based on the severity of the malformation. Religious aspects did not seem to influence the decision. Many women expressed a need for additional occasion of information. The vast majority of women were satisfied with their decision.

BACKGROUND: There is evidence that continuity models of midwifery care benefit women and babies in terms of less birth interventions and higher maternal satisfaction. Studies about continuity models in a Swedish context are lacking.

OBJECTIVE: The aim of this study was to describe how women experience continuity of midwifery care in a Swedish rural area, and thereby provide a deeper understanding of what this care entails for women.

METHODS: A qualitative interview study using thematic analysis was carried out. Telephone interviews were conducted with 33 women who participated in a continuity of midwifery care project in a rural area of Sweden.

RESULTS: The overarching theme 'a longing for a sense of security', pervaded the three main themes: 'The importance of professional midwifery care', 'Continuity of midwifery - fulfilled expectations or full of disappointments' and 'New prerequisites - acceptable to some, but not a substitute for everyone', which explains different aspects affecting the feeling of security. The endeavour to feel secure during pregnancy, birth and postpartum was a continually recurring subject that cannot be overstated.

CONCLUSION: Continuity of midwifery care strengthened women's feelings of security during pregnancy, birth and postpartum. The deepened relationship developed over time was a central part of the positive aspects of the experience of continuity in midwifery care. Expectations and prerequisite circumstances are important to consider when developing and introducing new care models. Service providers and decision makers should pay attention to and prioritise this relational aspect when planning care for women during the childbearing period.

BACKGROUND: Midwifery continuity models are growing worldwide, but few such alternatives are available in Sweden. There is sparse knowledge about Swedish midwives' attitudes about midwifery continuity models.

AIM: The aim of this study was to explore Swedish midwives' attitudes toward continuity models. An additional aim was to evaluate the psychometric properties of a previously developed instrument measuring attitudes to continuity models.

METHODS: A cross-sectional survey of a national sample of 2537 midwives in Sweden. The participants completed a questionnaire online. A Principal component Analysis was performed to identify components in the instrument.

RESULTS: A fairly similar proportion of midwives worked in antenatal care (30.7%), intrapartum care (30.7%) and in other areas (31.1%). Many midwives (59%) agreed that continuity models should be available to women, but were not certain about if such models should be offered to all women or low risk women only. Two domains of the attitude scale were identified; Relationship-based Midwifery Continuity Models, and Practical and Organisational Aspects of Midwifery Continuity Models. Age, having children, marital status, length of work experience and place of work were associated with high agreement non the two components.

CONCLUSION: Many midwives in general held positive attitudes about continuity models. The relationship aspects were highly valued but midwives were also hesitant about the practical and organisational aspect of continuity models. Unbiased information to midwives about the pros and cons with continuity models should be offered, in order to limit misunderstandings about the model.

BACKGROUND: In many countries, various continuity models of midwifery care arrangements have been developed to benefit women and babies. In Sweden, such models are rare.

AIM: To evaluate two on-call schedules for enabling continuity of midwifery care during labour and birth, in a rural area of Sweden.

METHOD: A participatory action research project where the project was discussed, planned and implemented in collaboration between researchers, midwives and the project leader, and refined during the project period. Questionnaires were collected from participating women, in mid pregnancy and two months after birth.

RESULT: One of the models resulted in a higher degree of continuity, especially for women with fear of birth. Having a known midwife was associated with higher satisfaction in the medical (aOR 2.02 (95% CI 1.14-4.22) and the emotional (aOR 2.05; 1.09-3.86) aspects of intrapartum care, regardless of the model.

CONCLUSION: This study presented and evaluated two models of continuity with different on-call schedules and different possibilities for women to have access to a known midwife during labour and birth. Women were satisfied with the intrapartum care, and those who had had a known midwife were the most satisfied. Introducing a new model of care in a rural area where the labour ward recently closed challenged both the midwives' working conditions and women's access to evidence-based care.

BACKGROUND: Worries are common during pregnancy, but there is sparse knowledge of worries when the distance to hospital is long.

AIM: To assess the extent and content of worries during pregnancy. Another aim was to evaluate the psychometric properties of the Swedish version of the Cambridge Worry Scale.

METHOD: Cross-sectional study of 280 women recruited to a continuity project and completed a questionnaire in mid pregnancy.

RESULT: Women were most worried about something being wrong with the baby, giving birth and the risk of miscarriage. Women also reported worries about giving birth on the road or in the car. Two domains of the Cambridge Worry scale were identified; Socio-medical and health aspects and Socio-economic and relationship aspects. Women with high fear and depressive symptoms were most at risk for major worries.

CONCLUSION: Worries during pregnancy were mainly related to issues about pregnancy and birth, and specifically, to long distance to the labour ward. Women with depressive symptoms and fear of birth showed the highest levels of worries. When a woman expresses worries in connection to labour and birth, caregivers must be sensitive to the presence of underling fears or depressive symptoms and act to refer women to treatment or support.

BACKGROUND: Three evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability.

METHODS: We estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD).

RESULTS: At baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives' participation time costs (56 %) for scenario 1 (collaborative), trainers' material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD.

CONCLUSION: Improving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.

BACKGROUND: Negative encounters in healthcare might affect women's health. During their reproductive life span, women are exposed to various health examinations, and have reported disrespectful care and obstetric violence. Such experiences might be a basis for fear of birth.

AIM: to explore and describe the prevalence, associated factors and experiences of previous negative healthcare encounters in women with fear of birth.

METHODS: A cross-sectional mixed-method study of 335 pregnant women with fear of birth. Data were collected by a questionnaire in mid-pregnancy, which included socio-demographic and obstetric background data as well as a question about the occurrence of previous negative experiences in healthcare.

RESULT: A previous negative experience of healthcare was found in 189 women (56.6%). The analysis of the women's comments regarding what caused their negative experiences generated three themes: disrespectful treatment and no one listened; painful, inadequate, or improper care; and impact of other people's stories.

CONCLUSION: This study showed that previous negative experiences in healthcare were common in women with fear of birth and the content of the encounters could be summarised as disrespectful care and obstetric violence. Women's previous encounters in healthcare might be an underlying reason for fear of birth and should be investigated. It is, therefore, of utmost importance to listen to women and their narratives in order to establish a trustful relationship and promote evidence-based, women-centred, respectful care, which is urgently needed.

OBJECTIVE: To investigate how fathers or partners perceive their roles as new parents when confronted with early breastfeeding challenges, how they navigate these difficulties, and the specific type of support they seek from the Child Health Care Centre (CHCC).

METHOD: In-depth, individual interviews conducted with 12 partners of women for whom breastfeeding was difficult. Reflexive thematic analysis was applied on the interview data.

RESULTS: Interviews resulted in three themes: 1) 'It is a revolutionary time to be a new father' represented a tumultuous time when fathers wanted to be involved in all decisions and part of a strong team with their partners. 2) 'When a breastfeeding problem arose'; fathers questioned the sovereignty of breast milk and began to seek more knowledge. They experienced a strong social norm about breastfeeding that led to feelings of guilt for their partners. They felt helpless when their partners suffered and lacked support. 3) 'Child Health Care Centre's duty'; was instrumental, as knowledge and competence were found to be important for trust. The fathers wanted concrete solutions to breastfeeding problems and more conversations of support with the CHCC nurse.

CONCLUSION: Well-educated fathers desire to protect their partners as they experience suffering due to a robust social norm telling them that breastfeeding is best. This can result in them starting to question the sovereignty of breast milk. Fathers need support to help their partners successfully during breastfeeding. They want counselling to strengthen their role as parents and help them build trusting teams with their partners.

INTRODUCTION: Although the prevalence of pain persisting after pregnancy or labour decreases with time, up to 35 % of women report pain 8 months to 12 years after childbirth. To prevent the development and reduce the impact of chronic pain, researchers and clinicians emphasize the importance of early diagnosis as well as timely and appropriate treatment. Previous studies have shown that when women with post-childbirth morbidities consult healthcare professionals during the first year following birth, their problems are often neglected, and they do not receive adequate treatment.

OBJECTIVE: To explore how women with pain persisting for eight months after childbirth experienced encounters with healthcare.

METHODS: A descriptive qualitative design with 20 face-to-face, semi-structured interviews. Data were analysed using inductive qualitative content analysis.

RESULTS: "Pain ignored by healthcare" was identified as an essential theme and included four categories: "Questioned pain experience," "Inadequate pain management," "Lost in healthcare," and "Insufficient postpartum care " CONCLUSION: The women experienced that their pain was often not recognized or adequately treated, but instead ignored or trivialized. Recurring were descriptions of experienced knowledge gaps among the healthcare providers regarding pain and its management. There was an overall desire among women for a well-defined and well-functioning chain of care with better accessibility and scope.

OBJECTIVE: To describe migrant women's experiences of bilingual community-based doulas (CBD) contribution to care in relation to labor and birth.

METHODS: Mixed methods study combining quantitative data from 82 women who received CBD-support within a randomized controlled trial and qualitative data from semi-structured interviews with a sub-sample of 12 women from the same study arm. Descriptive analyses were used for quantitative data and content analysis for the manifest and latent content of the qualitative data. Quantitative findings were categorized according to qualitative findings.

RESULTS: The women expressed how CBDs played an essential role in the response to their basic emotional, informational, and physical support needs, when no other female family member was available. Three main categories emerged from the analysis of interviews: The doulas help women feel safe and calm - providing support before, during and after childbirth; The doulas' support role fills the void left by a deeply missed family, mother or sister; and The doulas assist women in achieving autonomy through communication support and advocacy. More than half of women reported feeling involved during labor and birth (56.8%), most valued CBD positively (such as being competent, calm, secure, considerate, respectful, encouraging, supportive) (40.8%-80.3%), that CBD had interpreted (75.6%), facilitated communication with the midwife (60,3%), comforted the woman (57.7%) and reduced anxiety (48,7%). Few reported negative CBD-characteristics (1.3-9.2%). Nevertheless, 61.7% of women felt frightened sometime during labor and birth, which made it even more important to them that the doula was there. Few women (21.8%) reported that the CBD had supported her partner but expressed so in the interviews.

CONCLUSION: Through an essential contribution in responding to migrant women's basic emotional, informational, and physical needs, bilingual community-based doulas have the potential to improve migrant women's experience of care during labour and birth. However, more focus on the quality of CBD-support to partners seem necessary.

BACKGROUND:

Shortening pre-hospital delay may decrease stillbirth rates and rates of babies born with a compromised health. Stillbirth may be preceded by a decrease in fetal movements. Mindfetalness has been developed as a response to the shortcomings of kick-counting for the monitoring of fetal movements by the pregnant woman. We do not know if practicing Mindfetalness may diminish pre-hospital delay. Nor do we know if practicing Mindfetalness may increase or decrease the percentage of women seeking health care for unfounded, from a medical perspective, worry for her fetus' well-being.

METHODS:

This article describes the rationale, study protocol and the randomization process for a planned study randomly allocating 40,000 pregnant women to receive, or not receive, proactive information about practicing Mindfetalness. The unit of randomization is 63 antenatal clinics in the Stockholm area. Midwives in the antenatal clinics randomized to Mindfetalness will verbally inform about practicing Mindfetalness, hand out brochures (printed in seven languages) and inform about a website giving information about Mindfetalness. Routine care will continue in the control clinics. All information for the analyses, including the main endpoint of an Apgar score below 7 (e.g., 0-6 with stillbirth giving a score of 0), measured five minutes after birth, will be retrieved from population-based registers.

RESULTS:

We have randomized 33 antenatal clinics to Mindfetalness and 30 to routine care. In two clinics a pilot study has been performed. One of the clinics randomly allocated to inform about Mindfetalness will not do so (but will be included in the intention-to-treat analysis). In October 2016 we started to recruit women for the main study.

CONCLUSION:

The work up to now follows the outlined time schedule. We expect to present the first results concerning the effects of Mindfetalness during 2018.

BACKGROUND: Migrant women are less likely to receive an individualized maternal care where they feel safe, informed and supported but few measures have been undertaken to meet their needs. In Södertälje municipality in Sweden, community-based antenatal care midwives identify migrant women and offer them and their partners language-assisted information and support through an individual two-hour-visit to the labor ward. The aim of the present study was to explore migrant women's experiences of antenatal care including receiving language-assisted information and support during pregnancy through a two-hour INFOR-visit to the labor ward.

METHODS: Semi-structured interviews were conducted with 10 non-Swedish speaking migrant women, using an interpreter. Interview analysis was conducted using reflexive thematic analysis.

RESULTS: The individualized support, including thorough information given with language support available, sufficient time for questions and discussion, and a caring approach - did appear to inform and reassure the women. Overall, they felt that they were seen and treated as individuals during both pregnancy and birth and that their specific needs were listened to and met by the health care providers. Having professional interpreters was seen as essential for receiving the right information, something achieved at the individual visit.

CONCLUSIONS: The findings from this study provide evidence that a two-hour-visit to the labor ward during pregnancy has potential to empower migrant women during pregnancy and birth and to improve their experiences of maternity care. The two-hour-visit is a relatively simple intervention with the potential of not only improving migrant women's experiences of pregnancy and birth, but also their medical outcomes.

Aim

The objective was to examine lifetime exposure to violence, physical and sexual, among women seeking termination of pregnancy (TOP) and its association with socio-demographic factors, PTSD, symptoms of anxiety and depression.

Design

The design of the study was a Swedish multi-centre study targeting women requesting TOP.

Methods

All women requesting TOP with a gestational length less than 12 pregnancy weeks were approached for participation in the study. The questionnaire comprised the following research instruments: Screen Questionnaire-Post traumatic Stress Disorder (SQ-PTSD) and Hospital Anxiety and Depression Scale (HADS). The response rate was 57% and the final sample was 1514 women. Descriptive and analytic statistics were applied.

Results

Lifetime exposure to violence was common among women seeking abortion. Exposure to violence was associated with low education, single marital status, smoking and high alcohol consumption. Exposure to violence was associated with the occurrence of signs of PTSD and symptoms of anxiety and depression. Among those having PTSD, all had been exposed to sexual violence and almost all had been exposed to physical violence, while for those with symptoms of anxiety and depression almost half had been exposed to either physical or sexual violence.

Conclusion

Exposure to physical and sexual abuse was common among women requesting TOP, and was strongly associated with the occurrence of PTSD, symptoms of anxiety and depression. This underscores the importance for health professionals to recognize and offer support to those women exposed to violence.

Today, student midwives in Sweden spend half of their midwifery education at various internships. Practice reality demonstrates that there is an insufficient number of preceptors for the students, and the workload is demanding. Therefore, the present study aimed to explore the experiences of final term Swedish students during their midwifery internship and whether other paedagogical learning experiences beyond the apprenticeship model were included. A cross-sectional survey was distributed to 288 final year midwifery students at all universities offering the midwifery programme in Sweden. This paper focuses on open-ended questions, which were answered by 108 students, and analysed inductively via thematic analysis. Students described an intensive period with pressure during their internship. They expressed a desire for fewer parallel tasks and a better-structured internship. Students revealed that it was both a challenge and stressful to be under constant high performance while practising clinically. Furthermore, students described feelings of competition towards fellow peers in regard to attaining the final number of 50 assisted births. As to the paedagogical methods, the classical preceptorship model with a one-to-one student-preceptor relationship was predominately used. Preceptors were perceived as crucial role models. However, this learning experience was considered suboptimal for learning in the event where preceptors were not engaged or felt insecure regarding their knowledge, or if the preceptor was changed. For the students, the most optimal setting would be if preceptors were selected, trained, and supported in their role to supervise students, instead of being assigned any available preceptor, who was, at times, not a midwife.

OBJECTIVE: To investigate the prevalence and severity of haemorrhoids after birth among first-time mothers in relation to management during the second stage of labour and to describe the women's experiences with haemorrhoids.

METHOD: A mixed method explanatory sequential design was used. Nulliparous women were allocated to an intervention group for whom the second-stage of labour practice followed the MIMA model (Midwives management during second stage of labour) or to a control group for whom standard-care practice was followed. Data were collected three weeks and 1.5 years after birth.

RESULT: A total of 496 (82.1%) women responded to the questionnaire three weeks after birth, 120 (70%) responded to the questionnaire 1.5 years after the birth. The women in the intervention group had fewer symptoms from haemorrhoids three weeks after birth compared to the women in the control group (adj. OR 0.6 95% CI 0.4-0.9). Half of the women in the intervention and control group (50.8%) who reported problems with haemorrhoids three weeks after birth still experienced problems after 1.5 years. The majority of all women did not seek medical care due to their symptoms. The women who described that they experienced haemorrhoids as a problem after birth felt neglected by the healthcare system.

CONCLUSION: A substantial percentage of women had symptoms from haemorrhoids after birth. Many of these women felt that their problems were neglected. Women who experienced a slow birth of the baby's head and spontaneous pushing suffered less from haemorrhoids 3 weeks after birth.