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  • 1.
    August, Furaha
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Univ Hlth & Allied Sci, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania..
    Pembe, Andrea B.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Univ Hlth & Allied Sci, Dept Obstet & Gynaecol, Dar Es Salaam, Tanzania..
    Mpembeni, Rose
    Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Axemo, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Norwegian Univ Sci & Technol, Dept Publ Hlth & Gen Practice, N-7034 Trondheim, Norway..
    Effectiveness of the Home Based Life Saving Skills training by community health workers on knowledge of danger signs, birth preparedness, complication readiness and facility delivery, among women in Rural Tanzania2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 129Article in journal (Refereed)
  • 2.
    Baker, Ulrika
    et al.
    Karolinska Inst, Widerstromska Huset, Dept Publ Hlth Sci Global Hlth Hlth Syst & Policy, Tomtebodavagen 18 A, S-17177 Stockholm, Sweden.;Karolinska Inst, Div Family Med, Dept Neurobiol Care Sci & Soc, Nobels Alle 12, S-14183 Huddinge, Sweden..
    Hassan, Farida
    Ifakara Hlth Inst, Plot 463 Kiko Ave,POB 78 373, Dar Es Salaam, Tanzania..
    Hanson, Claudia
    Karolinska Inst, Widerstromska Huset, Dept Publ Hlth Sci Global Hlth Hlth Syst & Policy, Tomtebodavagen 18 A, S-17177 Stockholm, Sweden.;London Sch Hyg & Trop Med, Dept Dis Control, London WC1E 7HT, England..
    Manzi, Fatuma
    Ifakara Hlth Inst, Plot 463 Kiko Ave,POB 78 373, Dar Es Salaam, Tanzania..
    Marchant, Tanya
    London Sch Hyg & Trop Med, Dept Dis Control, London WC1E 7HT, England..
    Peterson, Stefan Swartling
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Karolinska Inst, Widerstromska Huset, Dept Publ Hlth Sci Global Hlth Hlth Syst & Policy, Tomtebodavagen 18 A, S-17177 Stockholm, Sweden. ;Makerere Sch Publ Hlth, Kampala, Uganda..
    Hylander, Ingrid
    Karolinska Inst, Div Family Med, Dept Neurobiol Care Sci & Soc, Nobels Alle 12, S-14183 Huddinge, Sweden..
    Unpredictability dictates quality of maternal and newborn care provision in rural Tanzania: A qualitative study of health workers' perspectives2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, article id 55Article in journal (Refereed)
    Abstract [en]

    Background: Health workers are the key to realising the potential of improved quality of care for mothers and newborns in the weak health systems of Sub Saharan Africa. Their perspectives are fundamental to understand the effectiveness of existing improvement programs and to identify ways to strengthen future initiatives. The objective of this study was therefore to examine health worker perspectives of the conditions for maternal and newborn care provision and their perceptions of what constitutes good quality of care in rural Tanzanian health facilities. Methods: In February 2014, we conducted 17 in-depth interviews with different cadres of health workers providing maternal and newborn care in 14 rural health facilities in Tandahimba district, south-eastern Tanzania. These facilities included one district hospital, three health centres and ten dispensaries. Interviews were conducted in Swahili, transcribed verbatim and translated into English. A grounded theory approach was used to guide the analysis, the output of which was one core category, four main categories and several sub-categories. Results: `It is like rain' was identified as the core category, delineating unpredictability as the common denominator for all aspects of maternal and newborn care provision. It implies that conditions such as mothers' access to and utilisation of health care are unreliable; that availability of resources is uncertain and that health workers have to help and try to balance the situation. Quality of care was perceived to vary as a consequence of these conditions. Health workers stressed the importance of predictability, of `things going as intended', as a sign of good quality care. Conclusions: Unpredictability emerged as a fundamental condition for maternal and newborn care provision, an important determinant and characteristic of quality in this study. We believe that this finding is also relevant for other areas of care in the same setting and may be an important defining factor of a weak health system. Increasing predictability within health services, and focusing on the experience of health workers within these, should be prioritised in order to achieve better quality of care for mothers and newborns.

  • 3.
    Byrskog, Ulrika
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna.
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Allvin, Marie-Klingberg
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Being a bridge: Swedish antenatal care midwives' encounters with Somali-born women and questions of violence; a qualitative study2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, no 1, p. 1-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Violence against women is associated with serious health problems, including adverse maternal and child health. Antenatal care (ANC) midwives are increasingly expected to implement the routine of identifying exposure to violence. An increase of Somali born refugee women in Sweden, their reported adverse childbearing health and possible links to violence pose a challenge to the Swedish maternity health care system. Thus, the aim was to explore ways ANC midwives in Sweden work with Somali born women and the questions of exposure to violence.

    METHODS:

    Qualitative individual interviews with 17 midwives working with Somali-born women in nine ANC clinics in Sweden were analyzed using thematic analysis.

    RESULTS:

    The midwives strived to focus on the individual woman beyond ethnicity and cultural differences. In relation to the Somali born women, they navigated between different definitions of violence, ways of handling adversities in life and social contexts, guided by experience based knowledge and collegial support. Seldom was ongoing violence encountered. The Somali-born women's' strengths and contentment were highlighted, however, language skills were considered central for a Somali-born woman's access to rights and support in the Swedish society. Shared language, trustful relationships, patience, and networking were important aspects in the work with violence among Somali-born women.

    CONCLUSION:

    Focus on the individual woman and skills in inter-cultural communication increases possibilities of overcoming social distances. This enhances midwives' ability to identify Somali born woman's resources and needs regarding violence disclosure and support. Although routine use of professional interpretation is implemented, it might not fully provide nuances and social safety needed for violence disclosure. Thus, patience and trusting relationships are fundamental in work with violence among Somali born women. In collaboration with social networks and other health care and social work professions, the midwife can be a bridge and contribute to increased awareness of rights and support for Somali-born women in a new society.

  • 4.
    Carlsson, Tommy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Landqvist, Mats
    Södertörn Univ, Sch Culture & Educ, Stockholm, Sweden.
    Mattsson, Elisabet
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences. Ersta Skondal Univ Coll, Dept Hlth Care Sci, Stockholm, Sweden.
    Communication of support and critique in Swedish virtual community threads about prenatal diagnoses of fetal anomalies2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 199Article in journal (Refereed)
    Abstract [en]

    Background: A prenatal diagnosis of a fetal anomaly involves acute grief and psychological distress. The Internet has the potential to provide virtual support following the diagnosis. The overall aim was to explore communication of support and critique in Swedish virtual community threads about prenatal diagnoses of fetal anomalies.

    Methods: Systematic searches in Google resulted in 117 eligible threads. Fifteen of these were purposefully selected and subjected to deductive content analysis.

    Results:The virtual support involved mainly emotional support (meaning units n = 1,992/3,688, 54 %) and was described as comforting and empowering. Posters with experience of a prenatal diagnosis appreciated the virtual support, including the opportunity to gain insight into other cases and to write about one’s own experience. Critique of the decision to continue or terminate the pregnancy occurred, primarily against termination of pregnancy. However, it was met with defense.

    Conclusions: Peer support, mainly emotional, is provided and highly appreciated in threads about prenatal diagnoses of a fetal anomaly. Critique of the decision to terminate the pregnancy occurs in virtual community threads about prenatal diagnoses, but the norm is to not question the decision. Future studies need to investigate if virtual peer support promotes psychosocial function following a prenatal diagnosis and what medium would be most suitable for these types of supportive structures.

  • 5.
    Carlsson, Tommy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Marttala, Ulla Melander
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Languages, Department of Scandinavian Languages.
    Mattsson, Elisabet
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Psychology in Healthcare. Department of Health Care Sciences, Ersta Sköndal University College, Stockholm, Sweden.
    Ringnér, Anders
    Department of Nursing, Umeå University, Umeå, Sweden.
    Experiences and preferences of care among Swedish immigrants following a prenatal diagnosis of congenital heart defect in the fetus: a qualitative interview study2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, no 130Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Immigrants experience significant challenges when in contact with healthcare and report less satisfaction with maternity care compared to native Swedes. Research that gives voice to pregnant immigrant women and their partners following a prenatal diagnosis of a fetal anomaly is scarce. Thus, the aim of this study was to explore experiences and preferences of care following a prenatal diagnosis of congenital heart defect among Swedish immigrants.

    METHODS: Pregnant immigrants and their partners were consecutively recruited following a prenatal diagnosis of a congenital heart defect in the fetus. Nine respondents were interviewed in five interviews, four with the aid of a professional interpreter. The material was analyzed using manifest qualitative content analysis.

    RESULTS: The analysis resulted in five categories: 1) "Trustworthy information", 2) "Language barriers", 3) "Psychosocial situation", 4) "Peer support", and 5) "Religious positions".

    CONCLUSION: The potential need for interpreter services, visual information, psychosocial support, coordination with welfare officers, and respect for religious positions about termination of pregnancy are all important aspects for health professionals to consider when consulting immigrants faced with a prenatal diagnosis of fetal anomaly in the fetus. Peer support within this context needs to be further explored in future studies.

  • 6.
    Carlsson, Tommy
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare.
    Mattsson, Elisabet
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Psychology in Healthcare. Ersta Skondal Univ Coll, Dept Hlth Care Sci, SE-10061 Stockholm, Sweden.
    Emotional and cognitive experiences during the time of diagnosis and decision-making following a prenatal diagnosis: a qualitative study of males presented with congenital heart defect in the fetus carried by their pregnant partner2018In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 18, article id 26Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Expectant fathers consider the second-trimester obstetric ultrasound examination as an important step towards parenthood, but are ill prepared for a detection of a fetal anomaly. Inductive research is scarce concerning their experiences and needs for support. Consequently, the aim of this study was to explore the emotional and cognitive experiences, during the time of diagnosis and decision-making, among males presented with congenital heart defect in the fetus carried by their pregnant partner.

    METHODS:

    Twelve expectant fathers were consecutively recruited through two tertiary referral centers for fetal cardiology in Sweden, after they had been presented with a prenatal diagnosis of congenital heart defect in the fetus carried by their pregnant partner. The respondents were interviewed via telephone, and the interviews were analyzed using inductive qualitative content analysis.

    RESULTS:

    The respondents experienced an intense emotional shock in connection with detection. However, they set their own needs aside to attend to the supportive needs of their pregnant partner, and stressed the importance of an informed joint decision regarding whether to continue or terminate the pregnancy. When terminating the pregnancy, they experienced a loss of a wanted child, an emotionally intense termination procedure, needs of support neglected by professionals, and worries about the risk of recurrence in future pregnancies. When continuing the pregnancy, they tried to keep a positive attitude about the coming birth, but were simultaneously worried about the postnatal situation.

    CONCLUSIONS:

    The findings illustrate the importance of inclusive care and adequate follow-up routines for both expectant parents following a prenatal diagnosis. This includes the initial emotional shock, the decisional process, and depending on decision reached, the termination or continuation of the pregnancy. Expectant fathers presented with a fetal anomaly need adequate follow-up routines to address worries about risk of recurrence in future pregnancies and worries about the postnatal situation.

  • 7.
    Dahlqvist, Kristina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Obstetrics. Örnsköldsvik Hospital, Örnsköldsvik, Sweden.
    Jonsson, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Clinical Obstetrics.
    Neonatal outcomes of deliveries in occiput posterior position when delayed pushing is practiced: a cohort study2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, article id 377Article in journal (Refereed)
  • 8.
    Edqvist, Malin
    et al.
    Univ Gothenburg, Sahlgrenska Acad, Inst Hlth & Care Sci, Arvid Wallgrens Backe Hus 1,Box PO 457405 30, Gothenburg, Sweden..
    Blix, Ellen
    Oslo & Akershus Univ, Fac Hlth Sci, Res Grp Maternal Reprod & Childrens Hlth, Coll Appl Sci, Oslo, Norway..
    Hegaard, Hanne K.
    Copenhagen Univ Hosp, Rigshosp, Juliane Marie Ctr Women Children & Reprod, Res Unit,Womens & Childrens Hlth, Copenhagen, Denmark..
    Olafsdottir, Olöf Asta
    Univ Iceland, Fac Nursing, Dept Midwifery, Reykjavik, Iceland..
    Hildingsson, Ingegerd
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. Mid Sweden Univ, Dept Nursing, Sundsvall, Sweden..
    Ingversen, Karen
    Homebirth Assoc Sealand, Copenhagen, Denmark..
    Mollberg, Margareta
    Univ Gothenburg, Sahlgrenska Acad, Inst Hlth & Care Sci, Arvid Wallgrens Backe Hus 1,Box PO 457405 30, Gothenburg, Sweden..
    Lindgren, Helena
    Univ Gothenburg, Sahlgrenska Acad, Inst Hlth & Care Sci, Arvid Wallgrens Backe Hus 1,Box PO 457405 30, Gothenburg, Sweden.;Karolinska Inst, Dept Womens & Childrens Hlth, Stockholm, Sweden..
    Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 196Article in journal (Refereed)
    Abstract [en]

    Background: Whether certain birth positions are associated with perineal injuries and severe perineal trauma (SPT) is still unclear. The objective of this study was to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal injuries, SPT and episiotomy in different birth positions in four Nordic countries.

    Methods: A population-based prospective cohort study of planned home births in four Nordic countries. To assess medical outcomes a questionnaire completed after birth by the attending midwife was used. Descriptive statistics, bivariate analysis and logistic regression were used to analyze the data.

    Results: Two thousand nine hundred ninety-two women with planned home births, who birthed spontaneously at home or after transfer to hospital, between 2008 and 2013 were included. The prevalence of SPT was 0.7 % and the prevalence of episiotomy was 1.0 %. There were differences between the countries regarding all maternal characteristics. No association between flexible sacrum positions and sutured perineal injuries was found (OR 1.02; 95 % CI 0.86-1.21) or SPT (OR 0.68; CI 95 % 0.26-1.79). Flexible sacrum positions were associated with fewer episiotomies (OR 0.20; CI 95 % 0.10-0.54).

    Conclusion: A low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No associations were found between flexible sacrum positions and SPT. Flexible sacrum positions were associated with fewer episiotomies.

  • 9. Ekeus, Cecilia
    et al.
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Norman, Mikael
    Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, p. 36-Article in journal (Refereed)
    Abstract [en]

    Background: Few studies have focused on cerebral complications among newborn infants delivered by vacuum extraction (VE). The aim of this study was to determine the risk for intracranial haemorrhage and/or cerebral dysfunction in newborn infants delivered by VE and to compare this risk with that after cesarean section in labour (CS) and spontaneous vaginal delivery, respectively. Methods: Data was obtained from Swedish national registers. In a population-based cohort from 1999 to 2010 including all singleton newborn infants delivered at term after onset of labour by VE (n = 87,150), CS (75,216) or spontaneous vaginal delivery (n = 851,347), we compared the odds for neonatal intracranial haemorrhage, traumatic or non-traumatic, convulsions or encephalopathy. Logistic regressions were used to calculate adjusted (for major risk factors and indication) odds ratios (AOR), using spontaneous vaginal delivery as reference group. Results: The rates of traumatic and non-traumatic intracranial hemorrhages were 0.8/10,000 and 3.8/1,000. VE deliveries provided 58% and 31.5% of the traumatic and non-traumatic cases, giving a ten-fold risk [AOR 10.05 (4.67-21.65)] and double risk [AOR 2.23 (1.57-3.16)], respectively. High birth weight and short mother were associated with the highest risks. Infants delivered by CS had no increased risk for intracranial hemorrhages. The risks for convulsions or encephalopathy were similar among infants delivered by VE and CS, exceeding the OR after non-assisted spontaneous vaginal delivery by two-to-three times. Conclusion: Vacuum assisted delivery is associated with increased risk for neonatal intracranial hemorrhages. Although causality could not be established in this observational study, it is important to be aware of the increased risk of intracranial hemorrhages in VE deliveries, particularly in short women and large infants. The results warrant further studies in decision making and conduct of assisted vaginal delivery.

  • 10.
    Elden, Helen
    et al.
    Gothenburg Univ, Sahlgrenska Acad, Inst Hlth & Caring Sci, S-40530 Gothenburg, Sweden..
    Hagberg, Henrik
    Gothenburg Univ, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Perinatal Ctr,Dept Obstet & Gynecol,Inst Clin Sci, S-41685 Gothenburg, Sweden..
    Wessberg, Anna
    Gothenburg Univ, Sahlgrenska Acad, Inst Hlth & Caring Sci, S-40530 Gothenburg, Sweden..
    Sengpiel, Verena
    Gothenburg Univ, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Perinatal Ctr,Dept Obstet & Gynecol,Inst Clin Sci, S-41685 Gothenburg, Sweden..
    Herbst, Andreas
    Skane Univ Hosp, S-21428 Malmo, Sweden..
    Bullarbo, Maria
    Gothenburg Univ, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Perinatal Ctr,Dept Obstet & Gynecol,Inst Clin Sci, S-41685 Gothenburg, Sweden..
    Bergh, Christina
    Gothenburg Univ, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Dept Obstet & Gynecol,Inst Clin Sci,Reprod Med, S-41685 Gothenburg, Sweden..
    Bolin, Kristian
    Gothenburg Univ, Sch Business Econ & Law, Dept Econ & Stat, POB 640, S-40530 Gothenburg, Sweden..
    Malbasic, Snezana
    South Alvsborg Cty Hosp, Dept Obstet & Gynecol, S-50182 Boras, Sweden..
    Saltvedt, Sissel
    Karolinska Univ Hosp, Dept Obstet & Gynecol, S-17176 Stockholm, Sweden..
    Stephansson, Olof
    Karolinska Inst, Dept Med, Clin Epidemiol Unit, S-17176 Stockholm, Sweden.;Karolinska Univ Hosp, Dept Womens & Childrens Hlth, Div Obstet & Gynecol, S-17176 Stockholm, Sweden..
    Wikström, Anna-Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Ladfors, Lars
    Gothenburg Univ, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Perinatal Ctr,Dept Obstet & Gynecol,Inst Clin Sci, S-41685 Gothenburg, Sweden..
    Wennerholm, Ulla-Britt
    Gothenburg Univ, Sahlgrenska Univ Hosp, Sahlgrenska Acad, Perinatal Ctr,Dept Obstet & Gynecol,Inst Clin Sci, S-41685 Gothenburg, Sweden.;Karolinska Univ Hosp, Dept Obstet & Gynecol, S-17176 Stockholm, Sweden..
    Study protocol of SWEPIS a Swedish multicentre register based randomised controlled trial to compare induction of labour at 41 completed gestational weeks versus expectant management and induction at 42 completed gestational weeks2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 49Article in journal (Refereed)
    Abstract [en]

    Background: Observational data shows that postterm pregnancy (>= 42 gestational weeks, GW) and late term pregnancy (>= 41 GW), as compared to term pregnancy, is associated with an increased risk for adverse outcome for the mother and infant. Standard care in many countries is induction of labour at 42 GW. There is insufficient scientific support that induction of labour at 41 GW, as compared with expectant management and induction at 42 GW will reduce perinatal mortality and morbidity without an increase in operative deliveries, negative delivery experiences or higher costs. Large randomised studies are needed since important outcomes; such as perinatal mortality and hypoxic ischaemic encephalopathy are rare events. Methods/Design: A total of 10 038 healthy women >= 18 years old with a normal live singleton pregnancy in cephalic presentation at 41 GW estimated with a first or second trimester ultrasound, who is able to understand oral and written information will be randomised to labour induction at 41 GW (early induction) or expectant management and induction at 42 GW (late induction). Women will be recruited at university clinics and county hospitals in Sweden comprising more than 65 000 deliveries per year. Primary outcome will be a composite of stillbirth, neonatal mortality and severe neonatal morbidity. Secondary outcomes will be other adverse neonatal and maternal outcomes, mode of delivery, women's experience, cost effectiveness and infant morbidity up to 3 months of age. Data on background variables, obstetric and neonatal outcomes will be obtained from the Swedish Pregnancy Register and the Swedish Neonatal Quality Register. Data on women's experiences will be collected by questionnaires after randomisation and 3 months after delivery. Primary analysis will be intention to treat. The statistician will be blinded to group and intervention. Discussion: It is important to investigate if an intervention at 41 GW is superior to standard care in order to reduce death and lifelong disability for the children. The pregnant population, >41 GW, constitutes 15-20 % of all pregnancies and the results of the study will thus have a great impact. The use of registries for randomisation and collection of outcome data represents a unique and new study design.

  • 11.
    Elenis, Evangelia
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Svanberg Skoog, Agneta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Lampic, Claudia
    Karolinska Inst, Dept Neurobiol Care Sci & Soc, Solna, Sweden..
    Skalkidou, Alkistis
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Åkerud, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Sydsjö, Gunilla
    Linkoping Univ, Fac Hlth Sci, Dept Clin Expt Med, Obstet & Gynaecol, Linkoping, Sweden..
    Adverse obstetric outcomes in pregnancies resulting from oocyte donation: a retrospective cohort case study in Sweden2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 247Article in journal (Refereed)
    Abstract [en]

    Background: Oocyte donation has been associated to gestational diabetes, hypertensive disorders, placental abnormalities, preterm delivery and increased rate of caesarean delivery while simultaneously being characterized by high rates of primiparity, advanced maternal age and multiple gestation constituting the individual risk of mode of conception difficult to assess. This study aims to explore obstetrical outcomes among relatively young women with optimal health status conceiving singletons with donated versus autologous oocytes (via IVF and spontaneously). Methods: National retrospective cohort case study involving 76 women conceiving with donated oocytes, 150 nulliparous women without infertility conceiving spontaneously and 63 women conceiving after non-donor IVF. Data on obstetric outcomes were retrieved from the National Birth Medical Register and the medical records of oocyte recipients from the treating University Hospitals of Sweden. Demographic and logistic regression analysis were performed to examine the association of mode of conception and obstetric outcomes. Results: Women conceiving with donated oocytes (OD) had a higher risk of hypertensive disorders [adjusted Odds Ratio (aOR) 2.84, 95 % CI (1.04-7.81)], oligohydramnios [aOR 12.74, 95 % CI (1.24-130.49)], postpartum hemorrhage [aOR 7.11, 95 % CI (2.02-24.97)] and retained placenta [aOR 6.71, 95 % CI (1.58-28.40)] when compared to women who conceived spontaneously, after adjusting for relevant covariates. Similar trends, though not statistically significant, were noted when comparing OD pregnant women to women who had undergone non-donor IVF. Caesarean delivery [aOR 2.95, 95 % CI (1.52-5.71); aOR 5.20, 95 % CI (2.21-12.22)] and induction of labor [aOR 3.00, 95 % CI (1.39-6.44); aOR 2.80, 95 % CI (1.10-7.08)] occurred more frequently in the OD group, compared to the group conceiving spontaneously and through IVF respectively. No differences in gestational length were noted between the groups. With regard to the indication of OD treatment, higher intervention was observed in women with diminished ovarian reserve but the risk for hypertensive disorders did not differ after adjustment. Conclusion: The selection process of recipients for medically indicated oocyte donation treatment in Sweden seems to be effective in excluding women with severe comorbidities. Nevertheless, oocyte recipients-despite being relatively young and of optimal health status-need careful counseling preconceptionally and closer monitoring prenatally for the development of hypertensive disorders.

  • 12.
    Endler, Margit
    et al.
    Soder Sjukhuset, Karolinska Inst, Dept Clin Sci & Educ, Stockholm, Sweden.;Soder Sjukhuset, Dept Obstet & Gynecol, Sjukhusbacken 10, S-11883 Stockholm, Sweden..
    Saltvedt, Sissel
    Soder Sjukhuset, Karolinska Inst, Dept Clin Sci & Educ, Stockholm, Sweden.;Karolinska Univ Hosp, Dept Obstet & Gynecol, Stockholm, Sweden..
    Eweida, Mohamed
    Soder Sjukhuset, Karolinska Inst, Dept Clin Sci & Educ, Stockholm, Sweden..
    Åkerud, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Oxidative stress and inflammation in retained placenta: a pilot study of protein and gene expression of GPX1 and NF kappa B2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 384Article in journal (Refereed)
    Abstract [en]

    Background: Retained placenta is associated with severe postpartum hemorrhage. Its etiology is unknown and its biochemistry has not been studied. We aimed to assess whether levels of the antioxidative enzyme Glutathione Peroxidase 1 (GPX1) and the transcription factor Nuclear Factor kappa beta (NF kappa beta), as markers of oxidative stress and inflammation, were affected in retained placentas compared to spontaneously released placentas from otherwise normal full term pregnancies. Methods: In a pilot study we assessed concentrations of GPX1 by ELISA and gene (mRNA) expression of GPX1, NF kappa beta and its inhibitor I kappa beta alpha, by quantitative real-time-PCR in periumbilical and peripheral samples from retained (n = 29) and non-retained (n = 31) placental tissue. Results: Median periumbilical GPX1 concentrations were 13.32 ng/ml in retained placentas and 17.96 ng/ml in nonretained placentas (p = 0.22), peripheral concentrations were 13.27 ng/ml and 19.09 ng/ml (p = 0.08). Retained placental tissue was more likely to have a low GPX1 protein concentration (OR 3.82, p = 0.02 for periumbilical and OR 3.95, p = 0. 02 for peripheral samples). Median periumbilical GPX1 gene expressions were 1.13 for retained placentas and 0.88 for non-retained placentas (p = 0.08), peripheral expression was 1.32 and 1.18 (p = 0.46). Gene expressions of NF kappa beta and I kappa beta alpha were not significantly different between retained and non-retained placental tissue. Conclusions: Women with retained placenta were more likely to have a low level of GPX1 protein concentration in placental tissue compared to women without retained placenta and retained placental tissue showed a tendency of lower median concentrations of GPX1 protein expression. This may indicate decreased antioxidative capacity as a component in this disorder but requires a larger sample to corroborate results.

  • 13.
    Eriksson, Leif
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Duc, Duong M
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Eldh, Ann Catrine
    Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet.
    Thanh, Vu Pham N
    Institute of Sociology, Public Health and Environment Depertment, Hanoi, Vietnam.
    Huy, Tran Q
    Nursing office, Department of Medical Services Administration, Ministry of Health Vietnam.
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Wallin, Lars
    School of Health and Social Studies, Dalarna University, SE-791 88, Falun.
    Lessons learned from stakeholders in a facilitation intervention targeting neonatal health in Quang Ninh province, Vietnam2013In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, p. 234-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In northern Vietnam the Neonatal health - Knowledge Into Practice (NeoKIP, Current Controlled Trials ISRCTN44599712) trial has evaluated facilitation as a knowledge translation intervention to improve neonatal survival. The results demonstrated that intervention sites, each having an assigned group including local stakeholders supported by a facilitator, lowered the neonatal mortality rate by 50% during the last intervention year compared with control sites. This process evaluation was conducted to identify and describe mechanisms of the NeoKIP intervention based on experiences of facilitators and intervention group members.

    METHODS: Four focus group discussions (FGDs) were conducted with all facilitators at different occasions and 12 FGDs with 6 intervention groups at 2 occasions. Fifteen FGDs were audio recorded, transcribed verbatim, translated into English, and analysed using thematic analysis.

    RESULTS: Four themes and 17 sub-themes emerged from the 3 FGDs with facilitators, and 5 themes and 18 sub-themes were identified from the 12 FGDs with the intervention groups mirroring the process of, and the barriers to, the intervention. Facilitators and intervention group members concurred that having groups representing various organisations was beneficial. Facilitators were considered important in assembling the groups. The facilitators functioned best if coming from the same geographical area as the groups and if they were able to come to terms with the chair of the groups. However, the facilitators' lack of health knowledge was regarded as a deficit for assisting the groups' assignments. FGD participants experienced the NeoKIP intervention to have impact on the knowledge and behaviour of both intervention group members and the general public, however, they found that the intervention was a slow and time-consuming process. Perceived facilitation barriers were lack of money, inadequate support, and the function of the intervention groups.

    CONCLUSIONS: This qualitative process evaluation contributes to explain the improved neonatal survival and why this occurred after a latent period in the NeoKIP project. The used knowledge translation intervention, where facilitators supported multi-stakeholder coalitions with the mandate to impact upon attitudes and behaviour in the communes, has low costs and potential for being scaled-up within existing healthcare systems.

  • 14.
    Esscher, Annika
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Binder-Finnema, Pauline
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Bødker, Birgit
    Department of Obstetrics and Gynaecology, Hillerød hospital, Denmark.
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Mulic-Lutvica, Ajlana
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Suboptimal care and maternal mortality among foreign-born women in Sweden: Maternal death audit with application of the 'migration three delays' model2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, p. 141-Article in journal (Other academic)
    Abstract [en]

    Background: Several European countries report differences in risk of maternal mortality between immigrants from low- and middle-income countries and host country women. The present study identified suboptimal factors related to care-seeking, accessibility, and quality of care for maternal deaths that occurred in Sweden from 1988-2010. Methods: A subset of maternal death records (n = 75) among foreign-born women from low- and middle-income countries and Swedish-born women were audited using structured implicit review. One case of foreign-born maternal death was matched with two native born Swedish cases of maternal death. An assessment protocol was developed that applied both the 'migration three delays' framework and a modified version of the Confidential Enquiry from the United Kingdom. The main outcomes were major and minor suboptimal factors associated with maternal death in this high-income, low-maternal mortality context. Results: Major and minor suboptimal factors were associated with a majority of maternal deaths and significantly more often to foreign-born women (p = 0.01). The main delays to care-seeking were non-compliance among foreign-born women and communication barriers, such as incongruent language and suboptimal interpreter system or usage. Inadequate care occurred more often among the foreign-born (p = 0.04), whereas delays in consultation/referral and miscommunication between health care providers where equally common between the two groups. Conclusions: Suboptimal care factors, major and minor, were present in more than 2/3 of maternal deaths in this high-income setting. Those related to migration were associated to miscommunication, lack of professional interpreters, and limited knowledge about rare diseases and pregnancy complications. Increased insight into a migration perspective is advocated for maternity clinicians who provide care to foreign-born women.

  • 15.
    Gagnon, Anita J
    et al.
    Ingram School of Nursing and Department of Obstetrics and Gynaecology, McGill University, Montreal, Quebec, Canada.
    DeBruyn, Rebecca
    Ingram School of Nursing, McGill University, Montreal, Quebec, Canada.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Gissler, Mika
    THL National Institute for Health and Welfare, Helsinki, Finland and NHV Nordic School of Public Health, Gothenburg, Sweden.
    Heaman, Maureen
    Faculty of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada.
    Jeambey, Zeinab
    Ingram School of Nursing, McGill University, Montreal, Quebec, Canada.
    Korfker, Dineke
    Netherlands Organization for Applied Scientific Research TNO, Department of Child Health, Leiden, Netherlands.
    McCourt, Christine
    Midwifery and Child Health, School of Community and Health Sciences, City University, London, UK.
    Roth, Carolyn
    School of Nursing & Midwifery, Faculty of Health, Keele University, Staffordshire, UK.
    Zeitlin, Jennifer
    INSERM, UMR S953 Epidemiological Research Unit on Perinatal Health and Women's and Children’s Health, Université Pierre et Marie Curie-Paris 6, Paris, France.
    Small, Rhonda
    Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
    Development of the Migrant Friendly Maternity Care Questionnaire (MFMCQ) for migrants to Western societies: an international Delphi consensus process.2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, no 1, p. 200-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Through the World Health Assembly Resolution, 'Health of Migrants', the international community has identified migrant health as a priority. Recommendations for general hospital care for international migrants in receiving-countries have been put forward by the Migrant Friendly Hospital Initiative; adaptations of these recommendations specific to maternity care have yet to be elucidated and validated. We aimed to develop a questionnaire measuring migrant-friendly maternity care (MFMC) which could be used in a range of maternity care settings and countries.

    METHODS: This study was conducted in four stages. First, questions related to migrant friendly maternity care were identified from existing questionnaires including the Migrant Friendliness Quality Questionnaire, developed in Europe to capture recommended general hospital care for migrants, and the Mothers In a New Country (MINC) Questionnaire, developed in Australia and revised for use in Canada to capture the maternity care experiences of migrant women, and combined to create an initial MFMC questionnaire. Second, a Delphi consensus process in three rounds with a panel of 89 experts in perinatal health and migration from 17 countries was undertaken to identify priority themes and questions as well as to clarify wording and format. Third, the draft questionnaire was translated from English to French and Spanish and back-translated and subsequently culturally validated (assessed for cultural appropriateness) by migrant women. Fourth, the questionnaire was piloted with migrant women who had recently given birth in Montreal, Canada.

    RESULTS: A 112-item questionnaire on maternity care from pregnancy, through labour and birth, to postpartum care, and including items on maternal socio-demographic, migration and obstetrical characteristics, and perceptions of care, has been created - the Migrant Friendly Maternity Care Questionnaire (MFMCQ) - in three languages (English, French and Spanish). It is completed in 45 minutes via interview administration several months post-birth.

    CONCLUSIONS: A 4-stage process of questionnaire development with international experts in migrant reproductive health and research resulted in the MFMCQ, a questionnaire measuring key aspects of migrant-sensitive maternity care. The MFMCQ is available for further translation and use to examine and compare care and perceptions of care within and across countries, and by key socio-demographic, migration, and obstetrical characteristics of migrant women.

  • 16.
    Haines, Helen M.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Rubertsson, Christine
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Pallant, Julie F.
    Hildingsson, Ingegerd
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    The influence of women's fear, attitudes and beliefs of childbirth on mode and experience of birth2012In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 12, p. 55-Article in journal (Refereed)
    Abstract [en]

    Background: Women's fears and attitudes to childbirth may influence the maternity care they receive and the outcomes of birth. This study aimed to develop profiles of women according to their attitudes regarding birth and their levels of childbirth related fear. The association of these profiles with mode and outcomes of birth was explored.

    Methods: Prospective longitudinal cohort design with self report questionnaires containing a set of attitudinal statements regarding birth (Birth Attitudes Profile Scale) and a fear of birth scale (FOBS). Pregnant women responded at 18-20 weeks gestation and two months after birth from a regional area of Sweden (n = 386) and a regional area of Australia (n = 123). Cluster analysis was used to identify a set of profiles. Odds ratios (95% CI) were calculated, comparing cluster membership for country of care, pregnancy characteristics, birth experience and outcomes.

    Results: Three clusters were identified - 'Self determiners' (clear attitudes about birth including seeing it as a natural process and no childbirth fear), 'Take it as it comes' (no fear of birth and low levels of agreement with any of the attitude statements) and 'Fearful' (afraid of birth, with concerns for the personal impact of birth including pain and control, safety concerns and low levels of agreement with attitudes relating to women's freedom of choice or birth as a natural process). At 18 - 20 weeks gestation, when compared to the 'Self determiners', women in the 'Fearful' cluster were more likely to: prefer a caesarean (OR = 3.3 CI: 1.6-6.8), hold less than positive feelings about being pregnant (OR = 3.6 CI: 1.4-9.0), report less than positive feelings about the approaching birth (OR = 7.2 CI: 4.4-12.0) and less than positive feelings about the first weeks with a newborn (OR = 2.0 CI 1.2-3.6). At two months post partum the 'Fearful' cluster had a greater likelihood of having had an elective caesarean (OR = 5.4 CI 2.1-14.2); they were more likely to have had an epidural if they laboured (OR = 1.9 CI 1.1-3.2) and to experience their labour pain as more intense than women in the other clusters. The 'Fearful' cluster were more likely to report a negative experience of birth (OR = 1.7 CI 1.02-2.9). The 'Take it as it comes' cluster had a higher likelihood of an elective caesarean (OR 3.0 CI 1.1-8.0).

    Conclusions: In this study three clusters of women were identified. Belonging to the 'Fearful' cluster had a negative effect on women's emotional health during pregnancy and increased the likelihood of a negative birth experience. Both women in the 'Take it as it comes' and the 'Fearful' cluster had higher odds of having an elective caesarean compared to women in the 'Self determiners'. Understanding women's attitudes and level of fear may help midwives and doctors to tailor their interactions with women.

  • 17.
    Högberg, Ulf
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Claeson, Catrin
    Karolinska Univ Hosp, Dept Obstet & Gynecol, S-17176 Solna, Sweden..
    Krebs, Lone
    Univ Copenhagen, Dept Obstet & Gynecol, Copenhagen, Denmark.;Holbaek Cent Hosp, Copenhagen, Denmark..
    Svanberg, Agneta Skoog
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Kidanto, Hussein
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynecol, Dar Es Salaam, Tanzania..
    Breech delivery at a University Hospital in Tanzania2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 342Article in journal (Refereed)
    Abstract [en]

    Background: There is a global increase in rates of Cesarean delivery (CD). A minor factor in this increase is a shift towards CD for breech presentation. The aim of this study was to analyze breech births by mode of delivery and investigate short-term fetal and maternal outcomes in a low-income setting.

    Methods: The study design was cross-sectional and the setting was Muhimbili National Hospital (MNH), Dar-es-Salaam, Tanzania. Subjects were drawn from a clinical database (1999-2010) using the following inclusion criteria: breech presentation, birth weight >= 2,500 g, single pregnancy, fetal heart sound at admission, and absence of pregnancy-related complication as indication for CD. Of 2,765 mothers who had a breech delivery, 1,655 met the inclusion criteria. Analyses were stratified by mode of delivery, taking into account also other birth characteristics. The outcome measures were perinatal death (stillbirths + in-hospital neonatal deaths) and moderate asphyxia. Maternal outcomes, such as death, hemorrhage, and length of hospital stay, were also described.

    Results: The CD rate for breech presentation increased from 28 % in 1999 to 78 % in 2010. Perinatal deaths were associated with vaginal delivery (VD) (adjusted odds ratio (aOR) 6.2; 95 % confidence interval (CI) 3.0-12.6) and referral (aOR 2.1; 95 % CI 1.1-3.9), but not with parity, birth weight, or delivery year. Overall perinatal mortality was 5.8 % and this did not decline, due to an increase in stillbirths among vaginal breech deliveries. Mothers with CD had more hemorrhage compared to those with VD. One mother died in association with CD, and one died in association with VD.

    Conclusion: A breech VD, compared to a breech CD, in this setting was associated with adverse perinatal outcome. However, despite a significant increase in CD rate, no overall improvement was observed due to an increase in stillbirths among VDs.

  • 18.
    Jonsson, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Induction of twin pregnancy and the risk of caesarean delivery: a cohort study2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 136Article in journal (Refereed)
    Abstract [en]

    Background: Complications are common in twin pregnancies and induction of labour is often indicated. Most methods for induction are used but data on risks related to induction methods are sparse. The aim of this study was to investigate the association between induction of labour and caesarean delivery in twin pregnancies, and to assess the influence of induction method. Methods: Cohort study of twin pregnancies >= 34 weeks, planned for vaginal delivery, from two University Hospitals in Sweden. Data were collected from medical records during the periods 1994 (Orebro) and 2004 (Uppsala) to 2013. During the study period there were 78,180 live born births and 1,282 were twin births. Women with previous caesarean section were excluded. Induction methods were categorized into amniotomy, oxytocin and cervical ripening (intra cervical Foley catheter or prostaglandin). Adjusted odds ratios (AOR) with 95 % confidence interval (CI) for caesarean section were calculated by logistic regression and were adjusted for parity, maternal age, gestational length, complications to the pregnancy, infant birth weight and year of birth. Spontaneous labour onsets were used as the reference group. The main outcome measure was caesarean section. Results: In 462 twin pregnancies, 220 (48 %) had induction of labour and 242 (52 %) a spontaneous labour onset. Amniotomy was performed in 149 (68 %) of these inductions, oxytocin was administered in 11 (5 %) and cervical ripening was used in 60 (27 %). The rate of caesarean sections was 21 % in induced and 12 % in spontaneous labours (p 0.01). The absolute risk of caesarean section following induction was: 15 % with amniotomy; 36 % with oxytocin and 37 % with Foley/prostaglandin. Induction of labour increased the risk of caesarean section by 90 % compared with spontaneous labour onset (AOR 1.9, 95 % CI 1.1-3.5) and, when cervical ripening was used, the risk increased more than two fold (AOR 2.5, 95 % CI 1.2-5.3). Conclusion: Induction of labour in twin pregnancies increases the risk of caesarean section compared with spontaneous labour onset, especially if Foley catheter or prostaglandins are required. However, approximately 80 % of induced labours are delivered vaginally.

  • 19.
    Kalliokoski, Paul
    et al.
    Primary Care Center Jakobsgårdarna, Jaxtorget 7A, Box 100 33 Borlänge S-781 10, Sweden.
    Bergqvist, Yngve
    Löfvander, Monica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Physical performance and 25-hydroxyvitamin D: a cross-sectional study of pregnant Swedish and Somali immigrant women and new mothers2013In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, article id 237Article in journal (Refereed)
    Abstract [en]

    Background:

    Severe vitamin D deficiency can impair muscle strength. The study aims were to examine physical performance in the hands and upper legs, and analyze plasma 25-hydroxyvitamin D (25(OH) D) concentrations in women with presumably low (veiled, Somali-born) and high levels (unveiled, Swedish-born).

    Methods:

    Women (n = 123, 58% Swedish) enrolled at a Swedish antenatal clinic, latitude 60 degrees N, were recruited. Plasma 25(OH) D was analyzed, measured as nmol/L, then categorized as <10 = undetectable, 10-24, 25-49, 50-74 or >75. Muscle strength was tested: maximal hand grip strength (in Newtons, N), and upper leg performance (categorized as able/unable to perform squatting, standing on one leg, standing from a chair, and lifting their hips). Social and anthropometric data were collected. Non-parametric statistics tested the data for differences in their ability to perform the tests across 25(OH) D categories. Undetectable values (< 10 nmol/L) were replaced with '9' in the linear correlation statistics. A final main effect model for grip strength (in N) was calculated using stepwise linear regression for independent variables: country of birth, 25(OH) D levels, age, height, weight, physical activity, lactation status, parity, and gestational age.

    Results:

    Somali participants (35%) had 25(OH) D levels of < 10 nmol/L, and 90% had < 25 nmol/L; 10% of Swedish participants had < 25 nmol/L of 25(OH) D, and 54% had < 50 nmol/L. Somali women had a relatively weak grip strength compared with Swedish women: median 202 N (inter-quartile range 167-246) vs. median 316 N (inter-quartile range 278-359), respectively. Somali women were also weak in upper leg performance: 73% were unable to squat, 29% unable to stand on one leg, and 21% could not lift their hips (not significant across 25(OH) D categories); most Swedish women could perform these tests. In the final model, grip strength (N) was significantly associated with 25(OH) D levels (B 0.94, p=0.013) together with Somali birth (B -63.9, p<0.001), age (B 2.5, p=0.02) and height (B 2.6, p=0.01).

    Conclusions:

    Many Somali women had undetectable/severely low 25(OH) D concentrations and pronounced hand and upper leg weakness; grip strength was strongly associated with 25(OH) D. Maternity health care personnel should be aware of this increased frequency and manage care accordingly.

  • 20.
    Kalliokoski, Paul
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Primary Hlth Care Ctr Jakobsgardarna, Jaxtorget 7A,Box 100 33, S-78110 Borlange, Sweden.
    Rodhe, Nils
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Bergqvist, Yngve
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Center for Clinical Research Dalarna.
    Löfvander, Monica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Karolinska Inst, Div Family Med, Dept Neurobiol Care Sci & Soc, Huddinge, Sweden.
    Long-term adherence and effects on grip strength and upper leg performance of prescribed supplemental vitamin D in pregnant and recently pregnant women of Somali and Swedish birth with 25-hydroxyvitamin D deficiency: a before-and-after treatment study2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 353Article in journal (Refereed)
    Abstract [en]

    Background: Muscular weakness and severe vitamin D deficiency is prevalent in Somali (veiled) pregnant women, Sweden. The study aims here were to explore adherence to prescribed supplemental vitamin D in new mothers with vitamin D deficiency and its effects on grip strength and upper leg performance in Somali (target group TG) and Swedish women (reference group RG) from spring through winter.

    Methods: A before-and after study was designed. A cross-sectional sample of women in antenatal care with serum 25-OHD <= 50 nmol/L were prescribed one or two tablets daily (800 or 1600 IU vitamin D3 with calcium) for 10 months. Reminders were made by Somali nurses (TG) or Swedish doctors (RG). Baseline and 10 month measurements of plasma nmol/L 25-OHD, maximal grip strength held for 10 s (Newton, N) and ability to squat (yes; no) were done. Total tablet intake (n) was calculated. Outcome variables were changes from baseline in grip strength and ability to squat. Predicting variables for change in grip strength and ability to squat were calculated using linear and binary regression in final models. Undetectable 25-OHD values (< 10 nmol/L) were replaced with '9' in statistic calculations.

    Results: Seventy-one women (46 TG, 1/3 with undetectable baseline 25-OHD; 25 RG) participated. At the 10-month follow up, 17% TG and 8% RG women reported having refrained from supplement. Mean 25-OHD increased 16 to 49 nmol/L (TG) and 39 nmol/L to 67 nmol/L (RG), (both p < 0.001). Grip strength had improved from 153 to 188 N (TG) (p < 0.001) and from 257 to 297 N (RG) (p = 0.003) and inability to squat had decreased in TG (35 to 9, p < 0. 001). Intake of number of tablets predicted increased grip strength (B 0.067, 95% CI 0.008-0.127, p = 0.027). One tablet daily (> 300 in total) predicted improved ability to squat (OR 16; 95% CI 1.8-144.6).

    Conclusions: Adherence to supplemental vitamin D and calcium should be encouraged as an even moderate intake was associated to improved grip strength and upper leg performance, which was particularly useful for the women with severe 25-OHD deficiency and poor physical performance at baseline.

  • 21.
    Karlstrom, Annika
    et al.
    Mid Sweden Univ, Dept Nursing, SE-70 Sundsvall, Sweden..
    Nystedt, Astrid
    Umea Univ, Dept Nursing, Umea, Sweden..
    Hildingsson, Ingegerd
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. Mid Sweden Univ, Dept Nursing, SE-70 Sundsvall, Sweden..
    The meaning of a very positive birth experience: focus groups discussions with women2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 251Article in journal (Refereed)
    Abstract [en]

    Background: The experience of giving birth has long-term implications for a woman's health and wellbeing. The birth experience and satisfaction with birth have been associated with several factors and emotional dimensions of care and been shown to influence women's overall assessment. Individualized emotional support has been shown to empower women and increase the possibility of a positive birth experience. How women assess their experience and the factors that contribute to a positive birth experience are of importance for midwives and other caregivers. The aim of this study was to describe women's experience of a very positive birth experience. Method: The study followed a qualitative descriptive design. Twenty-six women participated in focus group discussions 6-7 years after a birth they had assessed as very positive. At the time of the birth, they had all taken part in a large prospective longitudinal cohort study performed in northern Sweden. In the present study, thematic analysis was used to review the transcribed data. Results: All women looked back very positively on their birth experience. Two themes and six sub-themes were identified that described the meaning of a very positive birth experience. Women related their experience to internal (e.g., their own ability and strength) and external (e.g., a trustful and respectful relationship with the midwife) factors. A woman's sense of trust and support from the father of the child was also important. The feeling of safety promoted by a supportive environment was essential for gaining control during birth and for focusing on techniques that enabled the women to manage labour. Conclusion: It is an essential part of midwifery care to build relationships with women where mutual trust in one another's competence is paramount. The midwife is the active guide through pregnancy and birth and should express a strong belief in a woman's ability to give birth. Midwives are required to inform, encourage and to provide the tools to enable birth, making it important for midwives to invite the partner to be part of a team, in which everyone works together for the benefit of the woman and child.

  • 22.
    K.C, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nelin, Viktoria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Vitrakoti, Ravi
    Baral, Geha Nath
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Risk factors for antepartum stillbirth: a case-control study in Nepal2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 146Article in journal (Refereed)
    Abstract [en]

    Background: Globally, at least 2.65 million stillbirths occur every year, of which more than half are during the antepartum period. The proportion of intrapartum stillbirths has substantially declined with improved obstetric care; however, the number of antepartum stillbirths has not decreased as greatly. Attempts to lower this number may be hampered by an incomplete understanding of the risk factors leading to the majority of antepartum stillbirths. We conducted this study in a tertiary hospital in Nepal to identify the specific risk factors that are associated with antepartum stillbirth in this setting. Methods: This case-control study was conducted between July 2012 and September 2013. All women who had antepartum stillbirths during this period were included as cases, while 20 % of all women delivering at the hospital were randomly selected and included as referents. Information on potential risk factors was taken from medical records and interviews with the women. Logistic regression analysis was completed to determine the association between those risk factors and antepartum stillbirth. Results: During the study period, 4567 women who delivered at the hospital were enrolled as referents, of which 62 had antepartum stillbirths and were re-categorized into the case population. In total, there were 307 antepartum stillbirths. An association was found between the following risk factors and antepartum stillbirth: increasing maternal age (aOR 1.0, 95 % CI 1.0-1.1), less than five years of maternal education (aOR 2.4, 95 % CI 1.7-3.2), increasing parity (aOR 1.2, 95 % CI 1.0-1.3), previous stillbirth (aOR 2.6, 95 % CI 1.6-4.4), no antenatal care attendance (aOR 4.2, 95 % CI 3.2-5.4), belonging to the poorest family (aOR 1.3, 95 % CI 1.0-1.8), antepartum hemorrhage (aOR 3.7, 95 % CI 2.4-5.7), maternal hypertensive disorder during pregnancy (aOR 2.1, 95 % CI 1.5-3.1), and small weight-for-gestational age babies (aOR 1.5, 95 % CI 1.2-2.0). Conclusion: Lack of antenatal care attendance, which had the strongest association with antepartum stillbirth, is a potentially modifiable risk factor, in that increasing the access to and availability of these services can be targeted. Antenatal care attendance provides an opportunity to screen for other potential risk factors for antepartum stillbirth, as well as to provide counseling to women, and thus, helps to ensure a successful pregnancy outcome.

  • 23.
    Kc, Ashish
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). UN Childrens Fund, Nepal Country Off, UN House, Pulchowk, Nepal.
    Wrammert, Johan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Clark, Robert B
    Latter-day Saint Charities, Salt Lake City, UT, USA.
    Ewald, Uwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Målqvist, Mats
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Inadequate fetal heart rate monitoring and poor use of partogram associated with intrapartum stillbirth: a case-referent study in Nepal2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 233Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Newborns are at the greatest risk for dying during the intrapartum period, including labor and delivery, and the first day of life. Fetal heart rate monitoring (FHRM) and partogram use to track labor progress are evidence-based techniques that can help to identify maternal and fetal risk factors so that these can be addressed early. The objective of this study was to assess health worker adherence to protocols for FHRM and partogram use during the intrapartum period, and to assess the association between adherence and intrapartum stillbirth in a tertiary hospital of Nepal.

    METHODS: A case-referent study was conducted over a 15-month period. Cases included all intrapartum stillbirths, while 20 % of women with live births were randomly selected on admission to make up the referent population. The frequency of FHRM and the use of partogram were measured and their association to intrapartum stillbirth was assessed using logistic regression analysis.

    RESULTS: During the study period, 4,476 women with live births were enrolled as referents and 136 with intrapartum stillbirths as cases. FHRM every 30 min was only completed in one-fourth of the deliveries, and labor progress was monitored using a partogram in just over half. With decreasing frequency of FHRM, there was an increased risk of intrapartum stillbirth; FHRM at intervals of more than 30 min resulted in a four-fold risk increase for intrapartum stillbirth (aOR 4.17, 95 % CI 2.0-8.7), and the likelihood of intrapartum stillbirth increased seven times if FHRM was performed less than every hour or not at all (aOR 7.38, 95 % CI 3.5-15.4). Additionally, there was a three-fold increased risk of intrapartum stillbirth if the partogram was not used (aOR 3.31, 95 % CI 2.0-5.4).

    CONCLUSION: The adherence to FHRM and partogram use was inadequate for monitoring intrapartum progress in a tertiary hospital of Nepal. There was an increased risk of intrapartum stillbirth when fetal heart rate was inadequately monitored and when the progress of labor was not monitored using a partogram. Further exploration is required in order to determine and understand the barriers to adherence; and further, to develop tools, techniques and interventions to prevent intrapartum stillbirth.

    CLINICAL TRIAL REGISTRATION: ISRCTN97846009 .

  • 24. Kelley, M
    et al.
    Rubens, C
    Rodriguez, Alina
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.
    Global report on preterm birth and stillbirth (6 of 7): erhical considerations2010In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 10, p. 6-6Article in journal (Refereed)
  • 25.
    Kidanto, Hussein L
    et al.
    Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Mogren, Ingrid
    Department of Clinical Science, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden.
    van Roosmalen, Jos
    Department of Obstetrics, Leiden University Medical Centre and Section of Health care and Culture, VU University Medical Centre, Amsterdam, The Netherlands.
    Thomas, Angela N
    Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania.
    Massawe, Siriel N
    Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Nystrom, Lennarth
    Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences, Umeå University, Umeå, Sweden.
    Lindmark, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Introduction of a qualitative perinatal audit at Muhimbili National Hospital, Dar es Salaam, Tanzania2009In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 9, p. 45-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Perinatal death is a devastating experience for the mother and of concern in clinical practice. Regular perinatal audit may identify suboptimal care related to perinatal deaths and thus appropriate measures for its reduction. The aim of this study was to perform a qualitative perinatal audit of intrapartum and early neonatal deaths and propose means of reducing the perinatal mortality rate (PMR).

    METHODS:

    From 1st August, 2007 to 31st December, 2007 we conducted an audit of perinatal deaths (n = 133) with birth weight 1500 g or more at Muhimbili National Hospital (MNH). The audit was done by three obstetricians, two external and one internal auditors. Each auditor independently evaluated the cases narratives. Suboptimal factors were identified in the antepartum, intrapartum and early neonatal period and classified into three levels of delay (community, infrastructure and health care). The contribution of each suboptimal factor to adverse perinatal outcome was identified and the case graded according to possible avoidability. Degree of agreement between auditors was assessed by the kappa coefficient.

    RESULTS:

    The PMR was 92 per 1000 total births. Suboptimal factors were identified in 80% of audited cases and half of suboptimal factors were found to be the likely cause of adverse perinatal outcome and were preventable. Poor foetal heart monitoring during labour was indirectly associated with over 40% of perinatal death. There was a poor to fair agreement between external and internal auditors.

    CONCLUSION:

    There are significant areas of care that need improvement. Poor monitoring during labour was a major cause of avoidable perinatal mortality. This type of audit was a good starting point for quality assurance at MNH. Regular perinatal audits to identify avoidable causes of perinatal deaths with feed back to the staff may be a useful strategy to reduce perinatal mortality.

  • 26.
    Kidanto, Hussein Lesio
    et al.
    Dept of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania.
    Mogren, Ingrid
    Dep of Clinical Science, Obstetrics and Gynaecology, Umeå University, Sweden.
    Massawe, Siriel N.
    Dept of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania.
    Lindmark, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Nyström, Lennarth
    Dept of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences, Umeå University, Sweden.
    Criteria-based audit on management of eclampsia patients at a tertiary hospital in Dar es Salaam, Tanzania2009In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 9, article id 13Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Criteria-based audits have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the introduction of a criteria-based audit in a tertiary hospital in an African setting, assesses the quality of care among eclampsia patients and discusses possible interventions in order to improve the quality of care. METHODS: We conducted a criteria based audit of 389 eclampsia patients admitted to Muhimbili National Hospital (MNH), Dar es Salaam Tanzania between April 14, 2006 and December 31, 2006. Cases were assessed using evidence-based criteria for appropriate care. RESULTS: Antepartum, intrapartum and postpartum eclampsia constituted 47%, 41% and 12% of the eclampsia cases respectively. Antepartum eclampsia was mostly (73%) preterm whereas the majority (71%) of postpartum eclampsia cases ware at term. The case fatality rate for eclampsia was 7.7%. Medical histories were incomplete, the majority (75%) of management plans were not reviewed by specialists in obstetrics, specialist doctors live far from the hospital and do not spend nights in hospital even when they are on duty, monitoring of patients on magnesium sulphate was inadequate, and important biochemical tests were not routinely done. Two thirds of the patient scheduled for caesarean section did not undergo surgery within agreed time. CONCLUSION: Potential areas for further improvement in quality of emergency care for eclampsia relate to standardizing management guidelines, greater involvement of specialists in the management of eclampsia and continued medical education on current management of eclampsia for junior staff.

  • 27.
    Kidanto, Hussein Lesio
    et al.
    Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Wangwe, Peter
    Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Kilewo, Charles D
    Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Nystrom, Lennarth
    Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Sweden.
    Lindmark, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Improved quality of management of eclampsia patients through criteria based audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. Bridging the quality gap2012In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 12, no 1, p. 134-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Criteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the use of a CBA to improve quality of care among eclampsia patients admitted at a University teaching hospital in Dar es Salaam Tanzania.

    OBJECTIVE:

    The prevalence of eclampsia in MNH is high ([almost equal to]6%) with the majority of cases arriving after start of convulsions. In 2004--2005 the case-fatality rate in eclampsia was 5.1% of all pregnant women admitted for delivery (MNH obstetric data base). A criteria-based audit (CBA) was used to evaluate the quality of care for eclamptic mothers admitted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania after implementation of recommendations of a previous audit.

    METHODS:

    A CBA of eclampsia cases was conducted at MNH. Management practices were evaluated using evidence-based criteria for appropriate care. The Ministry of Health (MOH) guidelines, local management guidelines, the WHO manual supplemented by the WHO Reproductive Health Library, standard textbooks, the Cochrane database and reviews in peer reviewed journals were adopted. At the initial audit in 2006, 389 case notes were assessed and compared with the standards, gaps were identified, recommendations made followed by implementation. A re-audit of 88 cases was conducted in 2009 and compared with the initial audit. RESULTS: There was significant improvement in quality of patient management and outcome between the initial and re-audit: Review of management plan by senior staff (76% vs. 99%; P=0.001), urine for albumin test (61% vs. 99%; P=0.001), proper use of partogram to monitor labour (75% vs. 95%; P=0.003), treatment with steroids for lung maturity (2.0% vs. 24%; P=0.001), Caesarean section within 2 hours of decision (33% vs. 61%; P=0.005), full blood count (28% vs. 93%; P=0.001), serum urea and creatinine (44% vs. 86%; P=0.001), liver enzymes (4.0% vs. 86%; P=0.001), and specialist review within 2 hours of admission (25% vs. 39%; P=0.018). However, there was no significant change in terms of delivery within 24 hours of admission (69% vs. 63%; P=0.33). There was significant reduction of maternal deaths (7.7% vs. 0%; P=0.001).

    CONCLUSION:

    CBA is applicable in low resource setting and can help to improve quality of care in obstetrics including management of pre-eclampsia and eclampsia.

  • 28.
    Koubaa, Saloua
    et al.
    Karolinska Inst, Dept Womens & Childrens Hlth, Stockholm, Sweden..
    Hallstrom, Tore
    Karolinska Inst, Div Psychiat, Dept Clin Neurosci, Stockholm, Sweden.;Univ Gothenburg, Sahlgrenska Acad, Div Psychiat & Neurochem, Dept Neurosci & Physiol, Gothenburg, Sweden..
    Brismar, Kerstin
    Karolinska Inst, Dept Mol Med & Surg, Stockholm, Sweden..
    Hellström, Per M.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Gastroenterology/Hepatology.
    Hirschberg, Angelica Linden
    Karolinska Inst, Dept Womens & Childrens Hlth, Stockholm, Sweden.;Karolinska Univ Hosp, Dept Obstet & Gynecol, SE-17176 Uppsala, Sweden..
    Biomarkers of nutrition and stress in pregnant women with a history of eating disorders in relation to head circumference and neurocognitive function of the offspring2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 318Article in journal (Refereed)
    Abstract [en]

    Background: Eating disorders during pregnancy can affect fetal growth and the child's early development, but the underlying mechanisms have not been elucidated. The aim of the present study was to investigate serum biomarkers of nutrition and stress in pregnant women with previous eating disorders compared to controls and in relation to head circumference and early neurocognitive development of the offspring. Methods: In a longitudinal cohort study, pregnant nulliparous non-smoking women with a history of anorexia nervosa (n = 20), bulimia nervosa (n = 17) and controls (n = 59) were followed during pregnancy and their children's growth and neurocognitive development were followed up to five years of age. We investigated maternal serum biomarkers of nutrition and stress (ferritin, cortisol, thyroid-stimulating hormone, free thyroxine, insulin, insulin-like growth factor I (IGF-I) and IGF binding protein 1) in blood samples collected during early pregnancy and compared between groups (ANOVA, LSD post-hoc test). The results were related to previous data on head circumference at birth and neurocognitive development at five years of age of the offspring (Spearman rank correlation or Pearson correlation test). Results: Serum levels of ferritin in the women with previous anorexia nervosa, but not in those with a history of bulimia nervosa, were significantly lower than in the controls (p < 0.01), and correlated strongly to impaired memory function in their children (rs = -0.70, p < 0.001). Maternal serum levels of free thyroxine were similar between groups but correlated positively to reduced head circumference at birth of the children in the bulimia nervosa group (r = 0.48, p < 0.05), and with the same tendency in the anorexia nervosa group (r = 0.42, p = 0.07), but not in the controls (r = 0.006). There were no significant differences in cortisol or the other biomarkers between groups. Conclusions: Low maternal serum ferritin in women with previous anorexia nervosa may be of importance for impaired memory capacity in the offspring at five years of age. Our results also indicate that thyroxin levels in pregnant women with previous eating disorders are positively associated with fetal head growth.

  • 29.
    Kullinger, Merit
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology. Vastmanland Cty Hosp, Clin Res Ctr, Vasteras, Sweden.;Vastmanland Cty Hosp, Dept Obstet & Gynecol, Vasteras, Sweden..
    Haglund, Bengt
    Karolinska Inst, Ctr Pharmacoepidemiol CPE, Dept Med, Stockholm, Sweden..
    Kieler, Helle
    Karolinska Inst, Ctr Pharmacoepidemiol CPE, Dept Med, Stockholm, Sweden..
    Skalkidou, Alkistis
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Effects of ultrasound pregnancy dating on neonatal morbidity in late preterm and early term male infants: a register-based cohort study2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 335Article in journal (Refereed)
    Abstract [en]

    Background: Assessing gestational age by ultrasound can introduce a systematic bias due to sex differences in early growth. Methods: This cohort study included data on 1,314,602 births recorded in the Swedish Medical Birth Register. We compared rates of prematurity-related adverse outcomes in male infants born early term (gestational week 37-38) or late preterm (gestational week 35-36), in relation to female infants, between a time period when pregnancy dating was based on the last menstrual period (1973-1978), and a time period when ultrasound was used for pregnancy dating (1995-2010), in order to assess the method's influence on outcome by fetal sex. Results: As expected, adverse outcomes were lower in the later time period, but the reduction in prematurity-related morbidity was less marked for male than for female infants. After changing the pregnancy dating method, male infants born early term had, in relation to female infants, higher odds for pneumothorax (Cohort ratio [CR] 2. 05; 95 % confidence interval [CI] 1.33-3.16), respiratory distress syndrome of the newborn (CR 1.99; 95 % CI 1.33-2. 98), low Apgar score (CR 1.26; 5 % CI 1.08-1.47), and hyperbilirubinemia (CR 1.12; 95 % CI 1.06-1.19), when outcome was compared between the two time periods. A similar trend was seen for late preterm male infants. Conclusion: Misclassification of gestational age by ultrasound, due to size differences, can partially explain currently reported sex differences in early term and late preterm infants' adverse neonatal outcomes, and should be taken into account in clinical decisions and when interpreting study results related to fetal sex.

  • 30.
    Lindgren, Anne
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Kristiansson, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Finger joint laxity, number of previous pregnancies and pregnancy induced back pain in a cohort study.2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, p. 61-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: General joint hypermobility is estimated to affect about 10% of the population and is a prerequisite of heritable connective tissue disorders where fragile connective tissue is a prominent feature. Pregnancy induced back pain is common whereas about 10% of women still have disabling pain several years after childbirth. The pathogenesis of the pain condition is uncertain, although several risk factors are suggested including general joint hypermobility. In the present study, the possible association of peripheral joint mobility in early pregnancy on the incidence of back pain with onset during pregnancy and persisting after childbirth was explored.

    METHODS: A cohort of 200 pregnant women recruited from antenatal health care clinics was assessed by questionnaire and clinical examination, including measurement of passive abduction of the left fourth finger, throughout pregnancy and at 13 weeks postpartum. Comparisons were made between women with and without back pain. Statistical tests used were χ2-test, t-test, Spearman correlation and multiple logistic regression.

    RESULTS: In the cohort, the mean passive abduction angle of the left fourth finger increased from 40.1° in early pregnancy to 41.8° at the postpartum appointment. At the postpartum appointment, women in the back pain group had a significantly larger mean passive abduction angle of the left fourth finger of 4.4°, twice as many previous pregnancies and deliveries, and more than twice as frequent back pain in previous pregnancy, as compared with women with no persistent back pain. A similar pattern was displayed in late pregnancy. In a multiple regression analysis, the passive abduction angle of the left fourth finger in early pregnancy and the number of previous pregnancies were positively, significantly and independently associated to the incidence of back pain in late pregnancy and postpartum.

    CONCLUSIONS: Finger joint laxity as a reflection of constitutional weakness of connective tissue and number of previous pregnancies were associated with the development of back pain induced in pregnancy and persisting after childbirth. These factors may provide a foundation for development of targeted prevention strategies, but this have to be confirmed in future research including measurement of general joint laxity.

  • 31.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Kidanto, Hussein L.
    Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar es Salaam, Tanzania.
    Nystrom, Lennarth
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania2013In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, p. 107-Article in journal (Refereed)
    Abstract [en]

    Background: Rising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country. Methods: We conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age >= 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of obstetric groups, contribution to overall CS rate, perinatal mortality ratio, neonatal distress, and maternal mortality ratio. Time trends were analysed within the ten Robson groups, based on maternal and obstetric characteristics. We applied the chi(2) test for trend to determine whether changes were statistically significant. Odds ratios of CS were evaluated using multivariate logistic regression, accounting for maternal age, referral status, and private healthcare insurance. Results: We included 137,094 deliveries. The total CS rate rose from 19% to 49%, involving nine out of ten groups. Multipara without previous CS with single, cephalic pregnancies in spontaneous labour had a CS rate of 33% in 2009 to 2011. Adjusted analysis explained some of the increase. Perinatal mortality and neonatal distress decreased in multiple pregnancies (p < 0.001 and p = 0.003) and nullipara with breech pregnancies (p < 0.001 and p = 0.024). Although not statistically significant, there was an increase in perinatal mortality (p = 0.381) and neonatal distress (p = 0.171) among multipara with single cephalic pregnancies in spontaneous labour. The maternal mortality ratio increased from 463/100, 000 live births in 2000 to 2002 to 650/100, 000 live births in 2009 to 2011 (p = 0.031). Conclusion: The high CS rate among low-risk groups suggests that many CSs might have been performed on questionable indications. Such a trend may result in even higher CS rates in the future. While CS can improve perinatal outcomes, it does not necessarily do so if performed routinely in low-risk groups.

  • 32.
    Litorp, Helena
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Kidanto, Hussein L
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Rööst, Mattias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Abeid, Muzdalifat
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nyström, Lennarth
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, no 1, p. 244-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    The maternal near-miss (MNM) concept has been developed to assess life-threatening conditions during pregnancy, childhood, and puerperium. In recent years, caesarean section (CS) rates have increased rapidly in many low- and middle-income countries, a trend which might have serious effects on maternal health. Our aim was to describe the occurrence and panorama of maternal near-miss and death in two low-resource settings, and explore their association with CS complications.

    METHODS:

    We performed a cross-sectional study, including all women who fulfilled the WHO criteria for MNM or death between February and June 2012 at a university hospital and a regional hospital in Dar es Salaam, Tanzania. Cases were assessed individually to determine their association with CS. Main outcome measures included MNM ratio; maternal mortality ratio; proportion of MNM and death associated with CS complications; and the risk for such outcomes per 1,000 operations. The risk ratio of life-threatening CS complications at the university hospital compared to the regional hospital was calculated.

    RESULTS:

    We identified 467 MNM events and 77 maternal deaths. The MNM ratio was 36 per 1,000 live births (95% CI 33-39) and the maternal mortality ratio was 587 per 100,000 live births (95% CI 460-730). Major causes were eclampsia and postpartum haemorrhage, but we also detected nine MNM events and five deaths from iatrogenic complications. CS complications accounted for 7.9% (95% CI 5.6-11) of the MNM events and 13% (95% CI 6.4-23) of the maternal deaths. The risk of experiencing a life-threatening CS complication was three times higher at the regional hospital (22/1,000 operations, 95% CI 12-37) compared to the university hospital (7.0/1,000 operations, 95% CI 3.8-12) (risk ratio 3.2, 95% CI 1.5-6.6).

    CONCLUSIONS:

    The occurrence of MNM and death at the two hospitals was high, and many cases were associated with CS complications. The maternal risks of CS in low-resource settings must not be overlooked, and measures should be taken to avoid unnecessary CSs. More comprehensive training of staff, improved postoperative surveillance, and a more even distribution of resources within the health care system might reduce the risks of CS.

  • 33. Liyew, Ewnetu Firdawek
    et al.
    Yalew, Alemayehu Worku
    Afework, Mesganaw Fantahun
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Maternal near-miss and the risk of adverse perinatal outcomes: a prospective cohort study in selected public hospitals of Addis Ababa, Ethiopia.2018In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 18, article id 345Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Presence of maternal near-miss conditions in women is strongly associated with the occurrence of adverse perinatal outcomes, but not well-understood in low-income countries. The study aimed to ascertain the effect of maternal near-miss on the risk of adverse perinatal outcomes in Ethiopia.

    METHODS: A prospective cohort study was conducted in five public hospitals of Addis Ababa, Ethiopia. Women admitted from May 1, 2015 to April 30, 2016 were recruited for the study. We followed a total of 828 women admitted for delivery or treatment of pregnancy-related complications along with their singleton newborn babies. Maternal near-miss was the primary exposure and was ascertained using the World Health Organization criteria. Women who delivered without complications were taken as the non-exposed groups. The main outcome was adverse perinatal outcomes. Data on maternal near-miss and perinatal outcomes were abstracted from medical records of the participants. Exposed and non-exposed women were interviewed by well-trained data collectors to obtain information about potential confounding factors. Logistic regressions were performed using Stata version 13.0 to determine the adjusted odds of adverse perinatal outcomes.

    RESULTS: A total of 207 women with maternal near-miss and 621 women with uncomplicated delivery were included in the study. After adjusting for potential confounders, women with maternal near-miss condition had more than five-fold increased odds of adverse perinatal outcomes compared to women who delivered without any complications (AOR = 5.69: 95% CI; 3.69-8.76). Other risk factors that were independently associated with adverse perinatal outcomes include: rural residence, history of prior stillbirth and primary educational level.

    CONCLUSIONS: Presence of maternal near-miss in women is an independent risk factor for adverse perinatal outcomes. Hence, interventions rendered at improvement in maternal health of Ethiopia can lead to an improvement in perinatal outcomes.

  • 34. Lundqvist, Anette
    et al.
    Johansson, Ingegerd
    Wennberg, AnnaLena
    Hultdin, Johan
    Högberg, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Hamberg, Katarina
    Sandstrom, Herbert
    Reported dietary intake in early pregnant compared to non-pregnant women - a cross-sectional study2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, p. 373-Article in journal (Refereed)
    Abstract [en]

    Background: A woman's nutritional status before conception and during pregnancy is important for maternal health and the health of the foetus. The aim of the study was to compare diet intake in early pregnant women with non-pregnant women. Methods: Between September 2006 and March 2009, 226 women in early pregnancy were consecutively recruited at five antenatal clinics in Northern Sweden. Referent women (n = 211) were randomly selected from a current health screening project running in the same region (the Vasterbotten Intervention Program; VIP). We collected diet data with a self-reported validated food frequency questionnaire with 66 food items/food aggregates, and information on portion size, alcohol consumption, and supplement intake. Data were analysed using descriptive, comparative statistics and multivariate partial least square modelling. Results: Intake of folate and vitamin D from foods was generally low for both groups. Intake of folate and vitamin D supplements was generally high in the pregnant group and led to significantly higher total estimated intake of vitamin D and folate in the pregnant group. Iron intake from foods tended to be lower in pregnant women although iron supplement intake evened out the difference with respect to iron intake from foods only. Energy intake was slightly lower in pregnant women but not significant, a reflection of that they reported consuming significantly less of potatoes/rice/pasta, meat/fish, and vegetables (grams/day) than the women in the referent group. Conclusions: In the present study, women in early pregnancy reported less intake of vegetables, potatoes, meat, and alcohol than non-pregnant women. As they also had a low intake (below the Nordic Nutritional Recommendations) of folate, vitamin D, and iron from foods, some of these women and their unborn children are possibly at risk for adverse effects on the pregnancy and birth outcome.

  • 35.
    Malm, Mari-Cristin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Rådestad, Ingela
    Rubertsson, Christine
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Hildingsson, Ingegerd
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Lindgren, Helena
    Women's experiences of two different self-assessment methods for monitoring fetal movements in full-term pregnancy: a crossover trial2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, p. 349-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Low maternal awareness of fetal movements is associated with negative birth outcomes. Knowledge regarding pregnant women's compliance with programs of systematic self-assessment of fetal movements is needed. The aim of this study was to investigate women's experiences using two different self-assessment methods for monitoring fetal movements and to determine if the women had a preference for one or the other method.

    METHODS:

    Data were collected by a crossover trial; 40 healthy women with an uncomplicated full-term pregnancy counted the fetal movements according to a Count-to-ten method and assessed the character of the movements according to the Mindfetalness method. Each self-assessment was observed by a midwife and followed by a questionnaire. A total of 80 self-assessments was performed; 40 with each method.

    RESULTS:

    Of the 40 women, only one did not find at least one method suitable. Twenty of the total of 39 reported a preference, 15 for the Mindfetalness method and five for the Count-to-ten method. All 39 said they felt calm, relaxed, mentally present and focused during the observations. Furthermore, the women described the observation of the movements as safe and reassuring and a moment for communication with their unborn baby.

    CONCLUSIONS:

    In the 80 assessments all but one of the women found one or both methods suitable for self-assessment of fetal movements and they felt comfortable during the assessments. More women preferred the Mindfetalness method compared to the count-to-ten method, than vice versa.

  • 36.
    Mbekenga, Columba K
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Pembe, Andrea B
    Dept of Obstetrics and Gynaecology, School of Medicine, Muhimbili, University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Christensson, Kyllike
    Karolinska Institute, Stockholm, Sweden.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Olsson, Pia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Informal support to first-parents after childbirth: a qualitative study in low-income suburbs of Dar es Salaam, Tanzania2011In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 11, p. 98-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    In Tanzania, and many sub-Saharan African countries, postpartum health programs have received less attention compared to other maternity care programs and therefore new parents rely on informal support. Knowledge on how informal support is understood by its stakeholders to be able to improve the health in families after childbirth is required. This study aimed to explore discourses on health related informal support to first-time parents after childbirth in low-income suburbs of Dar es Salaam, Tanzania.

    METHODS:

    Thirteen focus group discussions with first-time parents and female and male informal supporters were analysed by discourse analysis.

    RESULTS:

    The dominant discourse was that after childbirth a first time mother needed and should be provided with support for care of the infant, herself and the household work by the maternal or paternal mother or other close and extended family members. In their absence, neighbours and friends were described as reconstructing informal support. Informal support was provided conditionally, where poor socio-economic status and non-adherence to social norms risked poor support. Support to new fathers was constructed as less prominent, provided mainly by older men and focused on economy and sexual matters. The discourse conveyed stereotypic gender roles with women described as family caretakers and men as final decision-makers and financial providers. The informal supporters regulated the first-time parents' contacts with other sources of support.

    CONCLUSIONS:

    Strong and authoritative informal support networks appear to persist. However, poverty and non-adherence to social norms was understood as resulting in less support. Family health in this context would be improved by capitalising on existing informal support networks while discouraging norms promoting harmful practices and attending to the poorest. Upholding stereotypic notions of femininity and masculinity implies great burden of care for the women and delimited male involvement. Men's involvement in reproductive and child health programmes has the potential for improving family health after childbirth. The discourses conveyed contradicting messages that may be a source of worry and confusion for the new parents. Recognition, respect and raising awareness for different social actors' competencies and limitations can potentially create a health-promoting environment among families after childbirth.

  • 37.
    Mgaya, Andrew H
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Department of Obstetrcs and Gynaecology, Muhimbili National Hospital, Tanzania.
    Litorp, Helena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Kidanto, Hussein L
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Reproductive and Child Health section, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania.
    Nyström, Lennarth
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Sweden.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 343Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting.

    METHODS: During 2013-2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. The effect of the implementations was assessed by the differences in percentage of standard diagnosis and management between the baseline and re-audit, using Chi-square test or Fisher's exact test, when appropriate.

    RESULTS: In the baseline audit and re-audit, 248 and 251 deliveries with a diagnosis of foetal distress were identified and audited, respectively. The standard of diagnosis increased significantly from 52 to 68 % (p < 0.001). Standards of management improved tenfold from 0.8 to 8.8 % (p < 0.001). Improved foetal heartbeat monitoring using a Fetal Doppler was the major improvement in diagnoses, while change of position of the mother and reduced time interval from decision to perform caesarean section to delivery were the major improvements in management (all p < 0.001). Percentage of cases with substandard diagnosis and management was significantly reduced in both referred public and non-referred private patients (all p ≤ 0.01) but not in non-referred public and referred private patients.

    CONCLUSION: The criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.

  • 38.
    Mgaya, Andrew
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynecol, POB 65000, Dar Es Salaam, Tanzania..
    Hinju, Januarius
    Benjamin Mkapa Referral Hosp, Dept Obstet & Gynecol, Dodoma, Tanzania..
    Kidanto, Hussein L.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Muhimbili Natl Hosp, Dept Obstet & Gynecol, POB 65000, Dar Es Salaam, Tanzania.;Muhimbili Univ Hlth & Allied Sci, Dept Obstet & Gynecol, Dar Es Salaam, Tanzania..
    Is time of birth a predictor of adverse perinatal outcome?: A hospital-based cross-sectional study in a low-resource setting, Tanzania2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, article id 184Article in journal (Refereed)
    Abstract [en]

    Background: Inconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes. Methods: A cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients' socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed for their association with time of delivery and prevalence of fresh stillbirth as a proxy for poor perinatal outcome at a significance level of p = 0.05. Results: Off-hour deliveries were nearly twice as likely to occur during the night shift (odds ratio (OR), 1.62; 95% confidence interval (CI), 1.50-1.72), but were unlikely during the evening shift (OR, 0.58; 95% CI, 0.45-0.71) (all p < 0.001). Neonatal distress (O.R, 1.48, 95% CI; 1.07-2.04, p = 0.02), early neonatal deaths (OR, 1.70; 95% CI, 1.07-2.72, p = 0.03) and fresh stillbirths (OR, 1.95; 95% CI, 1.31-2.90, p = 0.001) were more significantly associated with deliveries occurring during night shifts compared to evening and morning shifts. However, fresh stillbirths occurring during the night shift were independently associated with antenatal admission from clinics or wards, referral from another hospital, and abnormal breech delivery (OR 1.9; 95% CI, 1.3-2.9, p = 0.001, for fresh stillbirths; OR, 5.0; 95% CI 1.7-8.3, p < 0.001, for antenatal admission; OR, 95% CI, 1.1-2.9, p < 0.001, for referral form another hospital; and OR 1.6; 95% CI 1.02-2.6, p = 0.004, for abnormal breech deliveries). Conclusion: Off-hours deliveries, particularly during the night shift, were significantly associated with higher proportions of adverse perinatal outcomes, including low Apgar score, early neonatal death and fresh stillbirth, compared to morning and evening shifts. Labour room admissions from antenatal wards, referrals from another hospital and abnormal breech delivery were independent risk factors for poor perinatal outcome, particularly fresh stillbirths.

  • 39.
    Mohammadi, Soheila
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration. Shahid Beheshti Univ Med Sci, Infertil & Reprod Hlth Res Ctr, Tehran, Iran..
    Gargari Saleh, Soraya
    Shahid Beheshti Univ Med Sci, Infertil & Reprod Hlth Res Ctr, Tehran, Iran..
    Fallahian, Masoumeh
    Shahid Beheshti Univ Med Sci, Infertil & Reprod Hlth Res Ctr, Tehran, Iran..
    Källestål, Carina
    Ziaei, Shirin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Maternal and Reproductive Health and Migration.
    Afghan Migrants Face more Suboptimal Care than Natives: a Maternal Near-Miss Audit Study at University Hospitals in Tehran, Iran2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, article id 64Article in journal (Refereed)
    Abstract [en]

    Background: Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. Methods: An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined. Results: Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient-(31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM. Conclusions: Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.

  • 40.
    Musafili, Aimable
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Univ Rwanda, Paediatr & Child Hlth Dept, Kigali, Rwanda.
    Persson, Lars Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Baribwira, Cyprien
    Center for International Health, Education, and Biosecurity (CIHEB), Institute of Human Virology, University of Maryland, School of Medicine MGIC-Rwanda, Kigali, Rwanda.
    Påfs, Jessica
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Mulindwa, Patrick Adam
    Muhima District Hospital, Kigali, Rwanda.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Case review of perinatal deaths at hospitals in Kigali, Rwanda: perinatal audit with application of a three-delays analysis.2017In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, no 1, article id 85Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Perinatal audit and the three-delays model are increasingly being employed to analyse barriers to perinatal health, at both community and facility level. Using these approaches, our aim was to assess factors that could contribute to perinatal mortality and potentially avoidable deaths at Rwandan hospitals.

    METHODS: Perinatal audits were carried out at two main urban hospitals, one at district level and the other at tertiary level, in Kigali, Rwanda, from July 2012 to May 2013. Stillbirths and early neonatal deaths occurring after 22 completed weeks of gestation or more, or weighing at least 500 g, were included in the study. Factors contributing to mortality and potentially avoidable deaths, considering the local resources and feasibility, were identified using a three-delays model.

    RESULTS: Out of 8424 births, there were 269 perinatal deaths (106 macerated stillbirths, 63 fresh stillbirths, 100 early neonatal deaths) corresponding to a stillbirth rate of 20/1000 births and a perinatal mortality rate of 32/1000 births. In total, 250 perinatal deaths were available for audit. Factors contributing to mortality were ascertained for 79% of deaths. Delay in care-seeking was identified in 39% of deaths, delay in arriving at the health facility in 10%, and provision of suboptimal care at the health facility in 37%. Delay in seeking adequate care was commonly characterized by difficulties in recognising or reporting pregnancy-related danger signs. Lack of money was the major cause of delay in reaching a health facility. Delay in referrals, diagnosis and management of emergency obstetric cases were the most prominent contributors affecting the provision of appropriate and timely care by healthcare providers. Half of the perinatal deaths were judged to be potentially avoidable and 70% of these were fresh stillbirths and early neonatal deaths.

    CONCLUSIONS: Factors contributing to delays underlying perinatal mortality were identified in more than three-quarters of deaths. Half of the perinatal deaths were considered likely to be preventable and mainly related to modifiable maternal inadequate health-seeking behaviours and intrapartum suboptimal care. Strengthening the current roadmap strategy for accelerating the reduction of maternal and neonatal morbidity and mortality is needed for improved perinatal survival.

  • 41. Nystedt, Astrid
    et al.
    Hildingsson, Ingegerd
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Diverse definitions of prolonged labour and its consequences with sometimes subsequent inappropriate treatment2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, p. 233-Article in journal (Refereed)
    Abstract [en]

    Background: Prolonged labour very often causes suffering from difficulties that may have lifelong implications. This study aimed to explore the prevalence and treatment of prolonged labour and to compare birth outcome and women's experiences of prolonged and normal labour. Method: Women with spontaneous onset of labour, living in a Swedish county, were recruited two months after birth, to a cross-sectional study. Women (n = 829) completed a questionnaire that investigated socio-demographic and obstetric background, birth outcome and women's feelings and experiences of birth. The prevalence of prolonged labour, as defined by a documented ICD-code and inspection of partogram was calculated. Four groups were identified; women with prolonged labour as identified by documented ICD-codes or by partogram inspection but no ICD-code; women with normal labour augmented with oxytocin or not. Results: Every fifth woman experienced a prolonged labour. The prevalence with the documented ICD-code was (13%) and without ICD-code but positive partogram was (8%). Seven percent of women with prolonged labour were not treated with oxytocin. Approximately one in three women (28%) received oxytocin augmentation despite having no evidence of prolonged labour. The length of labour differed between the four groups of women, from 7 to 23 hours. Women with a prolonged labour had a negative birth experience more often (13%) than did women who had a normal labour (3%) (P < 0.00). The factors that contributed most strongly to a negative birth experience in women with prolonged labour were emergency Caesarean section (OR 9.0, 95% CI 1.2-3.0) and to strongly agree with the following statement 'My birth experience made me decide not to have any more children' (OR 41.3, 95% CI 4.9-349.6). The factors that contributed most strongly to a negative birth experience in women with normal labour were less agreement with the statement 'It was exiting to give birth' (OR 0.13, 95% CI 0.34-0.5). Conclusions: There is need for increased clinical skill in identification and classification of prolonged labour, in order to improve care for all women and their experiences of birthing processes regardless whether they experience a prolonged labour or not.

  • 42.
    Panda, Sunita
    et al.
    Trinity Coll Dublin, Sch Nursing & Midwifery, 2 Clare St, Dublin D02 CK80, Ireland.
    Daly, Deirdre
    Trinity Coll Dublin, Sch Nursing & Midwifery, 24 DOlier St, Dublin D02 T283, Ireland.
    Begley, Cecily
    Trinity Coll Dublin, Sch Nursing & Midwifery, 24 DOlier St, Dublin D02 T283, Ireland;Univ Gothenburg, Sahlgrenska Acad, Gothenburg, Sweden.
    Karlstrom, Annika
    Mid Sweden Univ, Dept Nursing, S-86170 Sundsvall, Sweden.
    Larsson, Birgitta
    Mid Sweden Univ, Dept Nursing, S-86170 Sundsvall, Sweden.
    Back, Lena
    Mid Sweden Univ, Dept Nursing, S-86170 Sundsvall, Sweden.
    Hildingsson, Ingegerd
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Mid Sweden Univ, Dept Nursing, S-86170 Sundsvall, Sweden.
    Factors influencing decision-making for caesarean section in Sweden - a qualitative study2018In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 18, article id 377Article in journal (Refereed)
    Abstract [en]

    Background: Rising rates of caesarean section (CS) are a concern in many countries, yet Sweden has managed to maintain low CS rates. Exploring the multifactorial and complex reasons behind the rising trend in CS has become an important goal for health professionals. The aim of the study was to explore Swedish obstetricians' and midwives' perceptions of the factors influencing decision-making for CS in nulliparous women in Sweden. Methods: A qualitative design was chosen to gain in-depth understanding of the factors influencing the decision-making process for CS. Purposive sampling was used to select the participants. Four audio-recorded focus group interviews (FGIs), using an interview guide with open ended questions, were conducted with eleven midwives and five obstetricians from two selected Swedish maternity hospitals after obtaining written consent from each participant. Data were managed using NVivo (c) and thematically analysed. Ethical approval was granted by Trinity College Dublin. Results: The thematic analysis resulted in three main themes; 'Belief in normal birth - a cultural perspective'; 'Clarity and consistency - a system perspective' and 'Obstetrician makes the final decision, but ...', and each theme contained a number of subthemes. However, 'Belief in normal birth' emerged as the core central theme, overarching the other two themes. Conclusion: Findings suggest that believing that normal birth offers women and babies the best possible outcome contributes to having and maintaining a low CS rate. Both midwives and obstetricians agreed that having a shared belief (in normal birth), a common goal (of achieving normal birth) and providing mainly midwife-led care within a 'team approach' helped them achieve their goal and keep their CS rate low.

  • 43.
    Pembe, Andrea Barnabas
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Carlstedt, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Urassa, David Paradiso
    Department of Community Health, Muhimbili University of Health and Allied Sciences.
    Lindmark, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nyström, Lennarth
    Department of Public Health and Clinical Medicine, Umeå University.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Quality of antenatal care in rural Tanzania: counselling on pregnancy danger signs2010In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 10, article id 35Article in journal (Refereed)
    Abstract [en]

    Background: The high rate of antenatal care attendance in sub-Saharan Africa, should facilitate information on signs of potential pregnancy complications and advice the women on referral where indicated. The aim of this study was to assess quality of antenatal care with respect to providers’ counselling of pregnancy danger signs and adherence to referral criteria in Rufiji district, Tanzania.

    Methods: A cross-sectional study was conducted in 18 primary health facilities. Thirty two providers were observed providing antenatal care to 438 pregnant women. Information on counselling on pregnancy danger signs and women’s use of health facility for delivery was collected by an observer. Exit interviews were conducted to 435 women.

    Results: One hundred and eighty five (42%) clients were not informed of any pregnancy danger signs. The most common pregnancy danger sign informed on was vaginal bleeding 50% followed by severe headache/blurred vision 45%. Maternal Child Health Aides (MCHAs) were three times more likely to inform a client of a danger sign than nurse auxiliaries (OR=3.7; 95% CI: 2.1-6.5) while public health nurses and registered/enrolled nurses were both two times more likely to inform on danger signs (OR=2.3: 95% CI: 1.3-4.3 and OR=2.4; CI: 1.4-4.2 respectively). Among grand multiparous and primigravida below 20 years identified on exit interview, 63% and 71% had been informed of the risk factors during the during interaction with providers.

    Conclusion: Two out of five clients were not counselled on danger signs of obstetric complication and not advised to use referral services, despite of having a risk factor. Nurse auxiliaries were less capable of counselling clients. Supportive supervision should be made to enhance counselling of danger signs and adherence to referral indications. Nurse auxiliaries should be encouraged and given chance for further training and upgrading to improve their performance and increase human resource for health.

  • 44.
    Pembe, Andrea
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Urassa, David
    Carlstedt, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Lindmark, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Nystrom, Lennarth
    Dept of Public Health and Clinical Medicine, Umeå University, SE-901 85, Umeå, Sweden.
    Darj, Elisabeth
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Rural Tanzanian women's awareness of danger signs of obstetric complications2009In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 9, no 12Article in journal (Refereed)
    Abstract [en]

    ABSTRACT: BACKGROUND: Awareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. The objectives of this study were to assess women's awareness of danger signs of obstetric complications and to identify associated factors in a rural district in Tanzania. METHODS: A total of 1118 women who had been pregnant in the past two years were interviewed. A list of medically recognized potentially life threatening obstetric signs was obtained from the responses given. Chi- square test was used to determine associations between categorical variables and multivariate logistic regression analysis was used to identify factors associated with awareness of obstetric danger signs. RESULTS: More than 98% of the women attended antenatal care at least once. Half of the women knew at least one obstetric danger sign. The percentage of women who knew at least one danger sign during pregnancy was 26%, during delivery 23% and after delivery 40%. Few women knew three or more danger signs. According to multivariate logistic regression analysis having secondary education or more increased the likelihood of awareness of obstetric danger signs six-fold (OR=5.8; 95% CI: 1.8-19) in comparison with no education at all. The likelihood to have more awareness increased significantly by increasing age of the mother, number of deliveries, number of antenatal visits, whether the delivery took place at a health institution and whether the mother was informed of having a risks/complications during antenatal care. CONCLUSION: Women had low awareness of danger signs of obstetric complications. We recommend the following in order to increase awareness of danger signs of obstetrical complications: to improve quality of counseling and involving other family members in antenatal and postnatal care, to use radio messages and educational sessions targeting the whole community and to intensify provision of formal education as emphasized in the second millennium development goal.

  • 45. Perera, Dinusha
    et al.
    Lund, Ragnhild
    Swahnberg, Katarina
    Schei, Berit
    Infanti, Jennifer J
    'When helpers hurt': women's and midwives' stories of obstetric violence in state health institutions, Colombo district, Sri Lanka.2018In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 18, no 1, article id 211Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The paper explores how age, social position or class, and linguistic and cultural background intersect and place women in varying positions of control and vulnerability to obstetric violence in state health institutions in Colombo district, Sri Lanka. Obstetric violence occurs during pregnancy, childbirth and the immediate postpartum period; hence, it is violence that directly affects women. The authors aim to break the traditional culture of silence around obstetric violence and bring attention to the resulting implications for quality of care and patient trust in obstetric care facilities or providers.

    METHODS: Five focus group discussions were held with 28 public health midwives who had prior experience working in labor rooms. Six focus group discussions were held with 38 pregnant women with previous childbirth experience. Additionally, 10 of the 38 women, whom felt they had experienced excessive pain, fear, humiliation, and/or loss of dignity as patients in labor, participated in individual in-depth interviews. An intersectional framework was used to group the qualitative data into categories and themes for analysis.

    RESULTS: Obstetric violence appears to intersect with systems of power and oppression linked to structural gender, social, linguistic and cultural inequities in Sri Lanka. In our dataset, younger women, poorer women, and women who did not speak Sinhala seemed to experience more obstetric violence than those with relevant social connections and better economic positions. The women in our study rarely reported obstetric violence to legal or institutional authorities, nor within their informal social support networks. Instead, they sought obstetric care, particularly for childbirth, in other state hospitals in subsequent pregnancies.

    CONCLUSIONS: The quality of obstetric care in Sri Lanka needs improvement. Amongst other initiatives, policies and practices are required to sensitize health providers about the existence of obstetric violence, and repercussions are required for abusive or discriminatory practices. The ethics of care should be further reinforced in the professional training of obstetric health providers.

  • 46.
    Påfs, Jessica
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Musafili, Aimable
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). Univ Rwanda, Sch Med, Dept Pediat & Child Hlth, Coll Med & Hlth Sci, POB 217 Butare, Huye, Rwanda.
    Binder-Finnema, Pauline
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Klingberg-Allvin, Marie
    School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Rulisa, Stephen
    Department of Obstetrics & Gynecology, College of Medicine and Health Sciences, School of Medicine, University of Rwanda, Kigali; Univ Teaching Hosp Kigali, Dept Clin Res, BP 655, Kigali, Rwanda.
    Essén, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Beyond the numbers of maternal near-miss in Rwanda - a qualitative study on women's perspectives on access and experiences of care in early and late stage of pregnancy2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 257Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Rwanda has made remarkable progress in decreasing the number of maternal deaths, yet women still face morbidities and mortalities during pregnancy. We explored care-seeking and experiences of maternity care among women who suffered a near-miss event during either the early or late stage of pregnancy, and identified potential health system limitations or barriers to maternal survival in this setting.

    METHODS: A framework of Naturalistic Inquiry guided the study design and analysis, and the 'three delays' model facilitated data sorting. Participants included 47 women, who were interviewed at three hospitals in Kigali, and 14 of these were revisited in their homes, from March 2013 to April 2014.

    RESULTS: The women confronted various care-seeking barriers depending on whether the pregnancy was wanted, the gestational age, insurance coverage, and marital status. Poor communication between the women and healthcare providers seemed to result in inadequate or inappropriate treatment, leading some to seek either traditional medicine or care repeatedly at biomedical facilities.

    CONCLUSION: Improved service provision routines, information, and amendments to the insurance system are suggested to enhance prompt care-seeking. Additionally, we strongly recommend a health system that considers the needs of all pregnant women, especially those facing unintended pregnancies or complications in the early stages of pregnancy.

  • 47.
    Saeedi, Maryam
    et al.
    Orebro Univ, Orebro Univ Hosp, Orebro, Sweden.
    Hanson, Ulf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Orebro Univ Hosp, Sch Med Hlth & Sci, Dept Obstet & Gynecol, Orebro, Sweden.
    Simmons, David
    Orebro Univ Hosp, Sch Med Hlth & Sci, Dept Obstet & Gynecol, Orebro, Sweden;Western Sydney Univ, Macarthur Clin Sch, Campbelltown, NSW, Australia.
    Fadl, Helena
    Orebro Univ Hosp, Sch Med Hlth & Sci, Dept Obstet & Gynecol, Orebro, Sweden.
    Characteristics of different risk factors and fasting plasma glucose for identifying GDM when using IADPSG criteria: a cross-sectional study2018In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 18, article id 225Article in journal (Refereed)
    Abstract [en]

    Background: The Swedish National Board of Health and Welfare (SNBHW) recommended the new diagnostic criteria for GDM based upon Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study thresholds. Due to limited knowledge base, no recommendations were made on GDM screening. The aim of this study is to evaluate test characteristics of risk factors and fasting blood glucose as screening tests for diagnosing GDM using diagnostic thresholds based upon HAPO study 1.75/2.0 (model I/II respectively) odds ratio for adverse pregnancy outcomes.

    Methods: This cross-sectional, population-based study included all pregnant women who attended maternal health care in Orebro County, Sweden between the years 1994-96. A 75 g OGTT with capillary fasting and 2-h blood glucose was offered to all pregnant women at week 28-32. Risk factors and repeated random glucose samples were collected. Sensitivity, specificity and predictive values of blood glucose were calculated.

    Results: Prevalence of GDM was 11.7% with model I and 7.2% with the model II criteria. Risk factors showed 28%, (95% CI 24-32) and 31%, (95% CI 25-37) sensitivity for model I and II respectively. A fasting cut off >= 4.8 mmol/l occurred in 24% of women with 91%, (95% CI 88-94) sensitivity and 85%, (95% CI 83-86) specificity using model I while a fasting cut off >= 5.0 mmol/l occurred in 14% with 91%, (95% CI 87-94) sensitivity and 92%, (95% CI 91-93) specificity using model II.

    Conclusion: Risk factor screening for GDM was found to be poorly predictive of GDM but fasting glucose of 4.8-5. 0 mmol/l showed good test characteristics irrespective of diagnostic model and results in a low rate of OGTTs.

  • 48.
    Shaheen, Rubina
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Persson, Lars-Åke
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
    Ahmed, Shakil
    Streatfield, Peter Kim
    Lindholm, Lars
    Cost-effectiveness of invitation to food supplementation early in pregnancy combined with multiple micronutrients on infant survival: analysis of data from MINIMat randomized trial, Bangladesh2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 125Article in journal (Refereed)
    Abstract [en]

    Background: Absence of cost-effectiveness (CE) analyses limits the relevance of large-scale nutrition interventions in low-income countries. We analyzed if the effect of invitation to food supplementation early in pregnancy combined with multiple micronutrient supplements (MMS) on infant survival represented value for money compared to invitation to food supplementation at usual time in pregnancy combined with iron-folic acid. Methods: Outcome data, infant mortality (IM) rates, came from MINIMat trial (Maternal and Infant Nutrition Interventions, Matlab, ISRCTN16581394). In MINIMat, women were randomized to early (E around 9 weeks of pregnancy) or usual invitation (U around 20 weeks) to food supplementation and daily doses of 30 mg, or 60 mg iron with 400 mu gm of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 mu gm of folic acid. In MINIMat, EMMS significantly reduced IM compared to UFe60F (U plus 60 mg iron 400 mu gm Folic acid). We present incremental CE ratios for incrementing UFe60F to EMMS. Costing data came mainly from a published study. Results: By incrementing UFe60F to EMMS, one extra IM could be averted at a cost of US$907 and US$797 for NGO run and government run CNCs, respectively, and at US$1024 for a hypothetical scenario of highest cost. These comparisons generated one extra life year (LY) saved at US$30, US$27, and US$34, respectively. Conclusions: Incrementing UFe60F to EMMS in pregnancy seems worthwhile from health economic and public health standpoints.

  • 49.
    Sjömark, Josefin
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Reproductive Health.
    Parling, Thomas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Reproductive Health. Karolinska Inst, Ctr Psychotherapy Educ & Res, Stockholm Hlth Care Serv, Stockholm Cty Council, Liljeholmstorget 7B, SE-11364 Stockholm, Sweden;Karolinska Inst, Dept Clin Neurosci, Liljeholmstorget 7B, SE-11364 Stockholm, Sweden.
    Jonsson, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Skoog Svanberg, Agneta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Reproductive Health.
    A longitudinal, multi-centre, superiority, randomized controlled trial of internet-based cognitive behavioural therapy (iCBT) versus treatment-as-usual (TAU) for negative experiences and posttraumatic stress following childbirth: the JUNO study protocol2018In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 18, article id 387Article in journal (Refereed)
    Abstract [en]

    Background: About one-third of women report their childbirth as traumatic and up to 10% have severe traumatic stress responses to birth. The prevalence of Posttraumatic stress disorder following childbirth (PTSD FC) is estimated to 3%. Women with PTSD FC report the same symptoms as other patients with PTSD following other types of trauma. The effect of psychological treatment for women with PTSD FC has only been studied in a few trials. Similarly, studies on treatment needs for women not diagnosed as having PTSD FC but who nevertheless face psychological problems are lacking. Methods/design: Women who rate their overall birth experience as negative on a Likert scale, and/or had an immediate caesarean section and/or a major postpartum haemorrhage are randomized to either internet delivered cognitive behaviour therapy (iCBT) plus treatment as usual (TAU) or TAU. The iCBT is to be delivered in two steps. The first step consists of six weekly modules for both the woman and her partner (if they wish to participate) with minimal therapeutic support. Step 2 consists of eight weekly modules with extended therapeutic support and will be offered to participants whom after step 1 report PTSD FC. Assessments will be made at baseline, 6 weeks, 14 weeks, and at follow-ups at 1, 2, 3 and 4 years after baseline. The primary outcome measures are symptoms of posttraumatic stress and depression. Secondary outcomes are quality of life, parent-child bonding, marital satisfaction, coping strategies, experience regarding the quality of care received, health-related quality of life, number of re-visits to the clinic and number of appointments for counselling during the 4 years' period after the negative childbirth experience, time until the woman gets pregnant again, and the type of birth in the subsequent pregnancy. A health economic evaluation in the form of a cost utility analysis will be conducted. Discussion: This study protocol describes a randomized controlled trial that will provide information about the effectiveness of iCBT in women with negative experiences, posttraumatic stress, and PTSD FC.

  • 50.
    Soederberg, Malin
    et al.
    Institution of Reproductive Health, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden.
    Lundgren, Ingela
    Institute of Health and Care Sciences, The Sahlgrenska Academy at University of Gothenburg, Sweden..
    Christensson, Kyllike
    Institution of Reproductive Health, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden.
    Hildingsson, Ingegerd
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Attitudes toward fertility and childbearing scale: an assessment of a new instrument for women who are not yet mothers in Sweden2013In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 13, p. 197-Article in journal (Refereed)
    Abstract [en]

    Background: Women in high-resource countries often postpone childbearing. Postponed childbearing may lead to increased health risks for both mother and child and may also result in childlessness. Attitudes among men and women about fertility and childbearing have been studied in different phases of fertile life, but instruments that assess attitudes toward fertility and childbearing among women without children are lacking. The aim of this study is to develop and evaluate a specific instrument, the Attitudes toward Fertility and Childbearing Scale (AFCS), to assess and compare attitudes toward fertility and childbearing using a national sample of Swedish women, who are not yet mothers. Methods: This study reports on the development of a new instrument and was carried out in three steps: (1) Statements were constructed based on two qualitative studies; (2) Data were collected through web-based questionnaires, and (3) Data were analyzed using statistical tests for construct validity with exploratory factor analysis, internal consistency reliability, and comparative statistics. Student's t-test and analysis of variance (ANOVA) were performed to analyze differences between the components and background characteristics. One hundred and thirty-eight women participated; they were 20-30 years of age, not mothers, and able to read and speak Swedish. Results: The instrument showed acceptable sample adequacy, factorability, and reliability using Cronbach's alpha. Three components were revealed, each one representing a specific underlying dimension of the construct: 1) importance of fertility for the future (Cronbach's a, 0.901); 2) childbearing as a hindrance at present (Cronbach's a, 0.908); and 3) social identity (Cronbach's a, 0.805). Women who were students scored higher in importance of fertility for the future than did women who were unemployed. Women living in metropolitan areas and larger cities were more likely to score highly in childbearing as a hindrance at present than women living in middle-sized cities or in the countryside. Women in the age group from 25-26 agreed to the largest extent with childbearing as a hindrance at present. Conclusions: The instrument shows acceptable factorability and reliability. Three components were found to be the best solution. Further evaluation is necessary.

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